Refractory Headache or Refractory Patient? Issues of Locus of Control in Chronic Daily Headache (CDH)

  • Sarah E. TrostEmail author
  • Matthew T. Seipel
  • Emily J. Kalscheur
  • Rebecca C. Anderson


Both patient and provider should not underestimate the important role of the patient to exert agency or control over his or her own health. This chapter reviews the psychological construct of locus of control (LOC) as it applies to the treatment and management of CDH. Beginning with an overview of LOC and the related concept of self-efficacy, the chapter explores how these constructs have been measured and applied to understand the CDH population. In particular, research suggests that internal LOC and high self-efficacy are associated with favorable treatment outcomes for modifiable health behaviors of benefit to CDH patients. Two psychological treatments to enhance patient internal LOC and self-efficacy – cognitive-behavioral therapy (including biofeedback and use of relevant assessment tools) and motivational interviewing – are addressed. The chapter concludes with a discussion of suggestions for providers to increase their own LOC and self-efficacy in treating the CDH population, and concepts are illustrated with a case study.


Chronic daily headache (CDH) Refractory headache Refractory patient Locus of control (LOC) Health locus of control (HLOC) Headache-specific locus of control (HSLC) Self-efficacy Cognitive-behavioral therapy (CBT) Biofeedback Motivational interviewing Patient-provider collaboration Patient-provider frustration 



The authors wish to thank Annette Wilson, Ph.D., for her contributions to the chapter, in particular the results of her biofeedback study.

Correspondence regarding this chapter should be addressed to Sarah E. Trost, Pain Management Center, Department of Anesthesiology, Medical College of Wisconsin, 959 N. Mayfair Rd., Wauwatosa, WI 53226.


  1. 1.
    Rotter JB. Social learning and clinical psychology. New York (NY): Prentice-Hall; 1954.CrossRefGoogle Scholar
  2. 2.
    Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychol Monogr. 1966;80(1):1–28.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Wallston KA, Wallston BS. Who is responsible for your health? The construct of health locus of control. In: Sanders GS, Suls JM, editors. Social psychology of health and illness. Hillsdale (NJ): Lawrence Erlbaum; 1982. p. 65–95.Google Scholar
  4. 4.
    Wallston BS, Wallston KA, Kaplan GD, Maides SA. Development and validation of the health locus of control (HLC) scale. J Consult Clin Psychol. 1976;44(4):580–5.CrossRefPubMedGoogle Scholar
  5. 5.
    Wallston KA, Wallston BS, DeVellis R. Development of the multidimensional health locus of control (MHLC) scales. Health Educ Monogr. 1978;6(1):160–70.CrossRefPubMedGoogle Scholar
  6. 6.
    Berglund E, Lytsy P, Westerling R. The influence of locus of control on self-rated health in context of chronic disease: a structural equation modeling approach in a cross sectional study. BMC Public Health. 2014;14(1):492–500.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Grotz M, Hapke U, Lampert T, Baumeister H. Health locus of control and health behaviour: results from a nationally representative survey. Psychol Health Med. 2011;16(2):129–40.CrossRefPubMedGoogle Scholar
  8. 8.
    O’Hea EL, Grothe KB, Bodenlos JS, Boudreaux ED, White MA, Brantley PJ. Predicting medical regimen adherence: the interactions of health locus of control beliefs. J Health Psychol. 2005;10(5):705–17.CrossRefPubMedGoogle Scholar
  9. 9.
    Milte CM, Luszcz MA, Ratcliffe J, Masters S, Crotty M. Influence of health locus of control on recovery of function in recently hospitalized frail older adults. Geriatr Gerontol Int. 2015;15(3):341–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Cassidy T, Hilton S. Family health culture, health locus of control and health behaviours in older children. J Pediatric Med Care. 2017;1(1):4–9.Google Scholar
  11. 11.
    Bergvik S, Sørlie T, Wynn R. Coronary patients who returned to work had stronger internal locus of control beliefs than those who did not return to work. Br J Health Psychol. 2012;17(3):596–608.CrossRefPubMedGoogle Scholar
  12. 12.
    Keedy NH, Keffala VJ, Altmaier EM, Chen JJ. Health locus of control and self-efficacy predict back pain rehabilitation outcomes. Iowa Orthop J. 2014;34:158–65.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Aarts JW, Deckx L, Abbema DL, Tjan-Heijnen VC, Akker M, Buntinx F. The relation between depression, coping and health locus of control: differences between older and younger patients, with and without cancer. Psychooncology. 2015;24(8):950–7.CrossRefPubMedGoogle Scholar
  14. 14.
    Ahmedani BK, Peterson EL, Wells KE, Rand CS, Williams LK. Asthma medication adherence: the role of god and other health locus of control factors. Ann Allergy Asthma Immunol. 2013;110(2):75–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Martin NJ, Holroyd KA, Penzien DB. The headache-specific locus of control scale: adaptation to recurrent headaches. Headache. 1990;30(11):729–34.CrossRefPubMedGoogle Scholar
  16. 16.
    VandeCreek L, O’Donnell F. Psychometric characteristics of the headache-specific locus of control scale. Headache. 1992;32(5):239–41.Google Scholar
  17. 17.
    Grinberg AS, Seng EK. Headache-specific locus of control and migraine-related quality of life: understanding the role of anxiety. Int J Behav Med. 2017;24(1):136–43.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    French DJ, Holroyd KA, Pinell C, Malinoski PT, O'donnell F, Hill KR. Perceived self-efficacy and headache-related disability. Headache. 2000;40(8):647–56.CrossRefPubMedGoogle Scholar
  19. 19.
    Seng EK, Holroyd KA. Dynamics of changes in self-efficacy and locus of control expectancies in the behavioral and drug treatment of severe migraine. Ann Behav Med. 2010;40(3):235–47.CrossRefPubMedGoogle Scholar
  20. 20.
    Seng EK, Buse DC, Klepper JE, J Mayson S, Grinberg AS, Grosberg BM, et al. Psychological factors associated with chronic migraine and severe migraine-related disability: an observational study in a tertiary headache center. Headache. 2017;57(4):593–604.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Nash JM, Williams DM, Nicholson R, Trask PC. The contribution of pain-related anxiety to disability from headache. J Behav Med. 2006;29(1):61–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Scharff L, Turk DC, Marcus DA. The relationship of locus of control and psychosocial-behavioral response in chronic headache. Headache. 1995;35(9):527–33.CrossRefPubMedGoogle Scholar
  23. 23.
    Heath RL, Saliba M, Mahmassani O, Major SC, Khoury BA. Locus of control moderates the relationship between headache pain and depression. J Headache Pain. 2008;9(5):301–8.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191–215.CrossRefPubMedGoogle Scholar
  25. 25.
    Judge TA, Erez A, Bono JE, Thoresen CJ. Are measures of self-esteem, neuroticism, locus of control, and generalized self-efficacy indicators of a common core construct? J Pers Soc Psychol. 2002;83(3):693–710.CrossRefPubMedGoogle Scholar
  26. 26.
    Luszczynska A, Schwarzer R. Multidimensional health locus of control: comments on the construct and its measurement. J Health Psychol. 2005;10(5):633–42.CrossRefPubMedGoogle Scholar
  27. 27.
    O'Leary A. Self-efficacy and health: behavioral and stress-physiological mediation. Cognit Ther Res. 1992;16(2):229–45.CrossRefGoogle Scholar
  28. 28.
    Lefebvre JC, Keefe FJ, Affleck G, Raezer LB, Starr K, Caldwell K, et al. The relationship of arthritis self-efficacy to daily pain, daily mood, and daily pain coping in rheumatoid arthritis patients. Pain. 1999;80:425–35.CrossRefPubMedGoogle Scholar
  29. 29.
    Buckelew SP, Parker JC, Keefe FJ, Deuser WE, Crews TM, Conway R, et al. Self-efficacy and pain behavior among subjects with fibromyalgia. Pain. 1994;59(3):377–84.CrossRefPubMedGoogle Scholar
  30. 30.
    Litt MD. Self-efficacy and perceived control: cognitive mediators of pain tolerance. J Pers Soc Psychol. 1988;54(1):149–60.CrossRefPubMedGoogle Scholar
  31. 31.
    Wilcox S, Schoffman DE, Dowda M, Sharpe PA. Psychometric properties of the 8-item english arthritis self-efficacy scale in a diverse sample. Arthritis. 2014;2014:1–8.CrossRefGoogle Scholar
  32. 32.
    Martin NJ, Holroyd KA, Rokicki LA. The headache self-efficacy scale: adaptation to recurrent headaches. Headache. 1993;33(5):244–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Seng EK, Nicholson RA, Holroyd KA. Development of a measure of self-efficacy for acute headache medication adherence. J Behav Med. 2016;39(6):1033–42.CrossRefPubMedGoogle Scholar
  34. 34.
    Peck KR, Smitherman TA. Mediator variables in headache research: methodological critique and exemplar using self-efficacy as a mediator of the relationship between headache severity and disability. Headache. 2015;55(8):1102–11.CrossRefPubMedGoogle Scholar
  35. 35.
    Nicholson RA, Smith TR. Predicting self-efficacy, satisfaction with care, and headache impact among migraine sufferers in a primary care setting. Headache. 2006;46(5):874.CrossRefGoogle Scholar
  36. 36.
    Nicholson RA, Houle TT, Rhudy JL, Norton PJ. Psychological risk factors in headache. Headache. 2007;47(3):413–26.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Parsons T. The sick role and the role of the physician reconsidered. Milbank Mem Fund Q Health Soc. 1975;53(3):257–78.CrossRefPubMedGoogle Scholar
  38. 38.
    Heidarnia MA, Heidarnia A. Sick role and a critical evaluation of its application to our understanding of the relationship between physicians and patients. Novel Biomed. 2016;4(3):126–34.Google Scholar
  39. 39.
    Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153–66.CrossRefPubMedGoogle Scholar
  40. 40.
    Turner JA, Romano JM. Cognitive-behavioral therapy for chronic pain. In: Loeser JD, Bonica JJ, editors. Bonica’s management of pain. 3rd ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2001. p. 1751–8.Google Scholar
  41. 41.
    Penzien DB, Andrasik F, Freidenberg BM, Houle TT, Lake AE, Lipchik GL, et al. Guidelines for trials of behavioral treatments for recurrent headache, first edition, American headache society behavioral clinical trials workgroup. Headache. 2005;45(S2):S110–32.CrossRefPubMedGoogle Scholar
  42. 42.
    Jacobson E. Progressive relaxation: a physiological and clinical investigation of muscular state and their significance. Chicago (IL): University of Chicago Press; 1938.Google Scholar
  43. 43.
    Blanchard EB, Andrasik F. Biofeedback treatment of vascular headache. In: Hatch JP, Fisher JG, Rugh J, editors. Biofeedback studies in clinical efficacy. New York (NY): Plenum Press; 1987. p. 1–79.Google Scholar
  44. 44.
    Blanchard EB, Andrasik F, Ahles TA, Teders SJ, O’Keefe D. Migraine and tension headache: a meta-analytic review. Behav Ther. 1980;11(5):613–31.CrossRefGoogle Scholar
  45. 45.
    Nestoriuc Y, Martin A, Rief W, Andrasik F. Biofeedback treatment for headache disorders: a comprehensive efficacy review. Appl Psychophysiol Biofeedback. 2008;33(3):125–40.CrossRefPubMedGoogle Scholar
  46. 46.
    Nestoriuc Y, Reif W, Martin A. Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J Consult Clin Psychol. 2008;76(3):379–96.CrossRefPubMedGoogle Scholar
  47. 47.
    Grazzi L, Andrasik F, D’Amico D, Leone M, Usai S, Kass SJ, et al. Behavioral and pharmacologic treatment of transformed migraine with analgesic overuse: outcome at 3 years. Headache. 2002;42(6):483–90.CrossRefPubMedGoogle Scholar
  48. 48.
    Andrasik F. Behavioral treatment of migraine: current status and future directions. Expert Rev Neurother. 2004;4(3):403–13.CrossRefPubMedGoogle Scholar
  49. 49.
    Holroyd KA, France JL, Cordingley GE, Rokicki LA, Kvaal SA, Lipchik GL, et al. Enhancing the effectiveness of relaxation-thermal biofeedback training with propranolol hydrochloride. J Consult Clin Psychol. 1995;63(2):327–30.CrossRefPubMedGoogle Scholar
  50. 50.
    Wilson AM. Heart rate variability biofeedback training as an intervention for chronic pain. PhD [dissertation]. Milwaukee (WI): Marquette University; 2017.Google Scholar
  51. 51.
    Nicholson R, Nash J, Andrasik F. A self-administered behavioral intervention using tailored messages for migraine. Headache. 2005;45(9):1124–39.CrossRefPubMedGoogle Scholar
  52. 52.
    Cano-Garcia FJ, Rodriguez-Franco L, Lopez-Jimenez AM. A shortened version of the headache-specific locus of control scale in Spanish population. Headache. 2010;50(8):1335–45.CrossRefPubMedGoogle Scholar
  53. 53.
    Sullivan M, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7(4):524–32.CrossRefGoogle Scholar
  54. 54.
    Terkawi AS, Sullivan M, Abolkhair A, Al-Zhahrani T, Terkawi RS, Alasfar EM, et al. Development and validation of Arabic version of the pain catastrophizing scale. Saudi J Anaesth. 2017;11(S1):S63–70.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Cho S, Kim HY, Lee JH. Validation of the Korean version of the pain catastrophizing scale in patients with chronic non-cancer pain. Qual Life Res. 2013;22(7):1767–72.CrossRefPubMedGoogle Scholar
  56. 56.
    Bansal D, Gudala K, Lavudiya S, Ghai B, Arora P. Translation, adaptation, and validation of Hindi version of the pain catastrophizing scale in patients with chronic low back pain for use in India. Pain Med. 2016;17(10):1848–58.CrossRefPubMedGoogle Scholar
  57. 57.
    Suren M, Okan I, Gokbakan AM, Kaya Z, Erkorkmaz U, Arici S, et al. Factors associated with the pain catastrophizing scale and validation in a sample of the Turkish population. Turk J Med Sci. 2014;44(1):104–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Lopes RA, Dias RC, Queiroz BZ, Rosa NM, Pereira Lde S, Dias JM, et al. Psychometric properties of the Brazilian version of the pain catastrophizing scale for acute low back pain. Arq Neuropsiquiatr. 2015;73(5):436–44.CrossRefPubMedGoogle Scholar
  59. 59.
    Pallegama RW, Ariyawardana A, Ranasinghe AW, Sitheeque M, Glaros AG, Dissanayake WP, et al. The Sinhala version of the pain catastrophizing scale: validation and establishment of the factor structure in pain patients and healthy adults. Pain Med. 2014;15(10):1734–42.CrossRefPubMedGoogle Scholar
  60. 60.
    Meroni R, Piscitelli D, Bonetti F, Zambaldi M, Cerri CG, Guccione AA, et al. Rasch analysis of the Italian version of pain catastrophizing scale (PCS-I). J Back Musculoskelet Rehabil. 2015;28(4):661–73.CrossRefPubMedGoogle Scholar
  61. 61.
    Kroner-Herwig B, Maas J. The German pain catastrophizing scale for children (PCS-C) - psychometric analysis and evaluation of the construct. Psychosoc Med. 2013;10:Doc07.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Sole E, Castarlenas E, Miro J. A Catalan adaptation and validation of the pain catastrophizing scale for children. Psychol Assess. 2016;28(6):e119–26.CrossRefPubMedGoogle Scholar
  63. 63.
    McWilliams LA, Kowal J, Wilson KG. Development and evaluation of short forms of the pain catastrophizing scale and the pain self-efficacy questionnaire. Eur J Pain. 2015;19(9):1342–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Nishigami T, Mibu A, Tanaka K, Yamashita Y, Watanabe A, Tanabe A. Psychometric properties of the Japanese version of short forms of the pain catastrophizing scale in participants with musculoskeletal pain: a cross-sectional study. J Orthop Sci. 2017;22(2):351–6.CrossRefPubMedGoogle Scholar
  65. 65.
    Lundahl B, Moleni T, Burke BL, Butters R, Tollefson D, Butler C, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Edu Couns. 2013;93(2):157–68.CrossRefGoogle Scholar
  66. 66.
    Stevens J, Hayes J, Pakalnis A. A randomized trial of telephone-based motivational interviewing for adolescent chronic headache with medication overuse. Cephalalgia. 2014;34(6):446–54.CrossRefPubMedGoogle Scholar
  67. 67.
    Rollnick S, Miller WR, Butler CC. Motivational interviewing in health care: helping patients change behavior. New York (NY): Guilford Press; 2008.Google Scholar
  68. 68.
    Miller W, Rollnick S. Motivational interviewing: preparing people for change. New York (NY): Guilford Press; 2002.Google Scholar
  69. 69.
    Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychother Theor Res Pract. 1982;19(3):276–88.CrossRefGoogle Scholar
  70. 70.
    Miller W, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York (NY): Guilford Press; 1991.Google Scholar
  71. 71.
    Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician. 2005;72(10):2063–8.PubMedGoogle Scholar
  72. 72.
    Cottrell CK, Drew JB, Waller SE, Holroyd KA, Brose JA, O’Donnell FJ. Perceptions and needs of patients with migraine: a focus group study. J Fam Pract. 2002;51(2):142–7.PubMedPubMedCentralGoogle Scholar
  73. 73.
    Loder E. The approach to the difficult patient. Handb Clin Neurol. 2010;97:233–8.CrossRefPubMedGoogle Scholar
  74. 74.
    Cho SJ, Chu MK. Risk factors of chronic daily headache or chronic migraine. Curr Pain Headache Rep. 2015;19(1):465.CrossRefPubMedGoogle Scholar
  75. 75.
    Grazzi L. Behavioural approach to the “difficult” patient. Neurol Sci. 2008;29(S1):S96–8.CrossRefPubMedGoogle Scholar
  76. 76.
    Rains JC, Lipchik GL, Penzien DB. Behavioral facilitation of medical treatment for headache–part 1: review of headache treatment compliance. Headache. 2006;46(9):1387–94.CrossRefPubMedGoogle Scholar
  77. 77.
    Wilson AM, Melchert T, Anderson RC. Biofeedback facilitates greater pain control in a diverse sample of patients with chronic pain. Unpublished manuscript. 2018.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Sarah E. Trost
    • 1
    Email author
  • Matthew T. Seipel
    • 2
  • Emily J. Kalscheur
    • 1
    • 3
  • Rebecca C. Anderson
    • 1
  1. 1.Department of AnesthesiologyMedical College of WisconsinMilwaukeeUSA
  2. 2.Department of PsychologyIowa State UniversityAmesUSA
  3. 3.Department of PsychologyRosalind Franklin University of Medicine and ScienceNorth ChicagoUSA

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