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A randomized controlled trial of an internet-based treatment for chronic headache
Abstract
Chronic headache is a significant public health problem in Western nations. Although controlled trials demonstrate the efficacy and cost-effectiveness of face-to-face behavioral therapy, most headache sufferers have limited access to these treatments. Delivery of behavioral interventions using Internet technology has the potential to reach a larger number of headache sufferers and reduce the burden of disease. This randomized controlled study evaluated an Internet-delivered behavioral regimen composed of progressive relaxation, limited biofeedback with autogenic training, and stress management versus a symptom monitoring waitlist control. Treatment led to a significantly greater decrease in headache activity than symptom monitoring alone. Thirty-nine percent of treated individuals showed clinically significant improvement on self-report measures of headache symptoms at post-treatment. At two-month follow-up, 47% of participants maintained improvement. Treatment had a significant impact on general headache symptoms and headache-related disability. There was a 35% within-group reduction of medication usage among the treated subjects. The Internet program was more time-efficient than traditional clinical treatment. Treatment and follow-up dropout rates, 38.1% and 64.8%, respectively, were typical of behavioral self-help studies. This approach to self-management of headache is promising; however, several methodological and ethical challenges need to be addressed.
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“Internet-based self-help interventions for chronic pain have been shown to be effective for a number of pain conditions, including headache,35 non-headache chronic pain,36 and rheumatoid arthritis, osteoarthritis, or fibromyalgia.37”
From An Online Self-help CBT Intervention for Chronic Lower Back Pain (2012) · cites this paper as [35]
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Emmelkamp, P. M. G., David, D., Beckers, T., Muris, P., Cuijpers, P. J., Lutz, W., Andersson, G., Araya, R., Rivera, R. M. B., Barkham, M., et al. (2013) · International Journal of Methods in Psychiatric Research · doi:10.1002/mpr.1411 · Cited by 183
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BackgroundAn Online Self-help CBT Intervention for Chronic Lower Back Pain
Carpenter, K. M., Stoner, S. A., Mundt, J. M., & Stoelb, B. (2012) · The Clinical Journal of Pain · doi:10.1097/ajp.0b013e31822363db · Cited by 157
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“More recent published research includes a few studies on Internet intervention for recurrent headache in adults and children (Andersson, Lundström, & Ström, 2003; Devineni & Blanchard, 2005; Hicks, Baeyer, & McGrath, 2004; Ström, Pettersson, & Andersson, 2000).”
BackgroundChronic Health Conditions and Internet Behavioral Interventions
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“…4 wk 45 1, 3, 6 + 1: Internet (107) 2: Control (106) Bickel et al (2008)54 (USA) Opioid dependents RCT, 23 wk 1, 3, 8 + 1: Internet (45) 1:38 2: Face-to-face (45) 2:47 3: Standard care (45) 3:42 Devineni and Blanchard (2005)49 (USA) Chronic headache RCT, 4 wk, 2-mo F/U 38 1,2 + 1: Internet (39) 2.”
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“Devineni and Blanchard 49 studied an Internet intervention for chronic headache and reported 38% dropout rate; however, compared with symptom monitoring alone, the intervention group reported significantly greater decrease in headache activity.”
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“…small) randomized controlled trials for stress-management (Zetterqvist et al., 2003), tinnitus (Andersson et al., 2002; Kaldo-Sandstrom et al., 2004), headache (Andersson et al., 2003; Devineni & Blanchard, 2005) chronic back pain (Buhrman et al., 2004) and complicated grief (Wagner et al., 2006).”
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“The 30 studies encompassed 61 arms: 23 internet-delivered arms [5-9,15,34,36,37,46,57-69]; 2 telephone [35,70]; 1 mobile app [71]; 2 virtual reality [14,72]; 1 videoconferencing [15]; 1 interactive voice response [12]; 25 control; and 13 enhanced controls (Table 2).”
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“…Floyd & Rokke, 2004; Frazer, Christensen & Griffiths, 2005; Jamison & Scogin, 1995); post-traumatic stress (Ehlers et al., 2003); headaches (Devineni & Blanchard, 2005; Strom, Pettersson & Andersson, 2000); migraines (McGrath et al., 1992); problem drinking (Apodaca & Miller, 2003);…”
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“In 12 studies [35, 37–39, 42–45, 48–51], the subjects were representative of the population; in four studies [36, 40, 41, 47], they were not, and in one study [46], representativeness could not be determined (see Table 4).”
InfluentialAndersson, G., Estling, F., Jakobsson, E., Cuijpers, P., & Carlbring, P. (2011) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2010.529457 · Cited by 102
“There are now several Internet applications in areas such as mood disorders (Andersson & Cuijpers, 2009) and health conditions, among them irritable bowel syndrome (Ljótsson et al., 2010), headache (Devineni & Blanchard, 2005), and diabetes (Tate, Jackvony, & Wing, 2003).”
Efficacy of psychological treatment for headache disorder: a systematic review and meta-analysis
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Internet-based randomized controlled trials: a systematic review
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“…Emails, Homework or answering questions, Questionnaires to target information or feedback Conversation with facilitator 5 8 weeks Yes Primary +++− (Devineni and Blanchard, 2005)a US Migraine 39/47 Post-diagnosis, average time specified: I:88% C:79% NR No No Yes Module learning 4 4 weeks No…”
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Use of Handheld Wireless Technology for a Home-based Sickle Cell Pain Management Protocol
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“…have the potential to overcome numerous barriers that limit the usefulness of traditional clinic-based interventions, including limited access to care due to rural location or travel difficulties and lack of trained intervention staff (Devineni & Blanchard, 2005; Jerome & Zaylor, 2000).”
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“In addition to the programs described above, we identified 11 other guided programs that have targeted adults with pain, including headache pain [61–64], back pain [65–67], arthritis pain [54], mixed pain syndromes [68, 69], and self-reported chronic pain [70] [see [34,35] for systematic reviews of this literature].”
BackgroundA randomized trial of telemedicine for migraine management
Friedman, D. I., Rajan, B., & Seidmann, A. A. (2019) · Cephalalgia · doi:10.1177/0333102419868250 · Cited by 76
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“…(Lorig et al., 2002; Winzelberg et al., 2000), several researchers have demonstrated challenges in retention of participants for online health research (Bull et al., 2004a; Devineni & Blanchard, 2005; Gray et al., 2000; McKay, Feil, Glasgow, & Brown, 1998; Strom, Pettersson, & Andersson, 2000).”
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“Treatments included an Internet-based self-help program with therapist-initiated telephone contacts [20], videotape training intended to promote self-efficacy [36], an Internet-based education program [33], yoga [34], and home-based training by lay providers with migraine [35].”
Psychological interventions for migraine: a systematic review
Sullivan, A., Cousins, S., & Ridsdale, L. (2016) · Journal of Neurology · doi:10.1007/s00415-016-8126-z · Cited by 73
Colin, M., Lih, Y. S., Elizabeth, M. R., & Lynlee, W. C. (2007) · Behavior Research Methods · doi:10.3758/bf03193023 · Cited by 68
“In keeping with the views of other researchers who have adapted quite different types of psychological procedures for use on the Internet (e.g., Devineni & Blanchard, 2005; Luce et al., 2005), we believe that such a form of delivery affords significant practical advantages.”
BackgroundInfluentialJacob, E., Duran, J., Stinson, J., Lewis, M. A., & Zeltzer, L. K. (2012) · Journal of the American Academy of Nurse Practitioners · doi:10.1111/j.1745-7599.2012.00754.x · Cited by 66
“…interventions have been reported to decrease barriers to continuity of care such as limited access to care as a result of distant location or travel difficulties and lack of trained knowledgeable healthcare providers with expertise in SCD (Devineni & Blanchard, 2005; Jerome & Zaylor, 2000).”
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“…caregiving (Marziali & Donahue, 2006), overweight (Williamson et al., 2005), depression (Andersson et al., 2005), panic disorder (Klein, Richards, & Austin, 2006), poor diets (Papadaki & Scott, 2005), breast cancer (Winzelberg et al., 2003), and chronic headache (Devineni & Blanchard, 2005).”
Behavioral Approaches to the Treatment of Migraine
Holroyd, K., & Drew, J. B. (2006) · Seminars in Neurology · doi:10.1055/s-2006-939920 · Cited by 65
Multimodal behavioral treatment of migraine: An Internet-administered, randomized, controlled trial
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“A further, purely Internetbased study on chronic headache included one group with migraine/mixed headache and one with solely tension-type headache (28).”
Experiences of telemedicine in neurological out‐patient clinics during the COVID‐19 pandemic
Kristoffersen, E. S., Sandset, E. C., Winsvold, B. S., Faiz, K. W., & Storstein, A. M. (2020) · Annals of Clinical and Translational Neurology · doi:10.1002/acn3.51293 · Cited by 61
Psychological therapies for the prevention of migraine in adults
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“Multimodal including PMR + biofeedback RCT (delayed tx control which later crossed over) Devineni, 2005 [52] N = 139 (age not specified) Internetbased promotion channels e.”
BackgroundA Vertical VAS is a Valid Instrument for Monitoring Headache Pain Intensity
Lundqvist, C., Benth, J. Š., Grande, R., Aaseth, K., & Russell, M. (2009) · Cephalalgia · doi:10.1111/j.1468-2982.2008.01833.x · Cited by 56
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Non-Pharmacological Pain Management
Geziry, A. E., Toble, Y. M. R. A., Kadhi, F. A., & Nobani, M. P. A. M. A. (2018) · IntechOpen eBooks · doi:10.5772/intechopen.79689 · Cited by 64
“Other trials are ongoing that utilizes phone applications in other conditions like chronic back pain and neck pain [14, 22].”
Backgroundde Boer, M. J., Versteegen, G. J., Vermeulen, K. M., Sanderman, R., & Struys, M. M. R. F. (2014) · European Journal of Pain · doi:10.1002/ejp.509 · Cited by 51
“…outcomes was reported in Internet-based treatment for chronic pain (Ruehlman et al., 2012), chronic back pain (Buhrman et al., 2004, 2011; Carpenter et al., 2012), chronic headache (Strom et al., 2000; Devineni and Blanchard, 2005) and fibromyalgia (Lorig et al., 2008; Williams et al., 2010).”
BackgroundAn e-health solution for people with alcohol problems.
Gustafson, D. H., Boyle, M. G., Shaw, B. R., Isham, A., Mctavish, F. M., Richards, S., Schubert, C. J., Levy, M., & Johnson, K. (2011) · Europe PMC (PubMed Central) · Cited by 50
Woodford, J., Farrand, P. A., Bessant, M., & Williams, C. M. (2011) · Contemporary Clinical Trials · doi:10.1016/j.cct.2011.04.013 · Cited by 48
Sex Therapy through the Internet for Men with Sexual Dysfunctions: A Pilot Study
van Diest, S. L., van Lankveld, J. J. D. M., Leusink, P., Slob, A. K., & Gijs, L. A. C. L. (2007) · Journal of Sex & Marital Therapy · doi:10.1080/00926230601098456 · Cited by 48
“…for example, in the treatment of chronic headache, depression, panic disorder, and social phobia, post-traumatic stress disorder and tinnitus (Devineni & Blanchard, 2005; Ström et al., 2001, 2004; Christensen et al., 2004; Carlbring et al., 2003, 2005; Andersson et al., 2006; Lange et al.,…”
BackgroundMcCombie, A., Gearry, R., Andrews, J., Mikocka-Walus, A., & Mulder, R. (2015) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-015-9420-0 · Cited by 42
“Conversely, no effects of CCBT were found in studies of chronic headache (Devineni & Blanchard, 2005; see row 14 of Table 1), migraine (Hedborg and Muhr, 2011; see row 15 of Table 1), erectile dysfunction (Andersson et al., 2011; see row 1 of Table 1), early stage breast cancer (Owen et al., 2005;…”
BackgroundSelf-Management of Wellness and Illness in an Aging Population
Mitzner, T. L., McBride, S. E., Barg‐Walkow, L. H., & Rogers, W. A. (2013) · Reviews of Human Factors and Ergonomics · doi:10.1177/1557234x13492979 · Cited by 48
Clickety-click: E-Mental Health Train on Track
Griffiths, K. M., Farrer, L. M., & Christensen, H. M. (2007) · Australasian Psychiatry · doi:10.1080/10398560601123716 · Cited by 39
(2020) · Deakin Research Online (Deakin University) · Cited by 41
Cognitive‐Behavioral self‐help for chronic pain
Buenaver, L. F., McGuire, L., & Haythornthwaite, J. A. (2006) · Journal of Clinical Psychology · doi:10.1002/jclp.20318 · Cited by 41
Terpstra, J. A., van der Vaart, R., van Beugen, S., van Eersel, R. A., Gkika, I., Erdős, D., Schmidt, J., Radstake, C., Kloppenburg, M., van Middendorp, H., et al. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100587 · Cited by 38
“Furthermore, this also implied that pain conditions with a potentially different pain intensity and pain frequency (such as headache [Andersson et al., 2003; Devineni and Blanchard, 2005] vs.”
BackgroundPreventing Chronic Pain: A Human Systems Approach—Results from a Massive Open Online Course
Fricton, J., Anderson, K., Clavel, A. L., Fricton, R., Hathaway, K. M., Kang, W., Jaeger, B. A., Maixner, W. D., Pesut, D. J., Russell, J., et al. (2015) · Global Advances in Health and Medicine · doi:10.7453/gahmj.2015.048 · Cited by 39
Kleiboer, A., Sorbi, M., van Silfhout, M., Kooistra, L., & Passchier, J. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.07.009 · Cited by 37
“The results were promising, particularly concerning psychological benefits (Andersson et al., 2003; Bromberg et al., 2012; Devineni & Blanchard, 2005; Nicholson et al., 2005; Trautmann & Kr€oner-Herwig, 2010).”
BackgroundManagement of Persistent Cognitive Symptoms After Sport-Related Concussion
Sohlberg, M. M., & Ledbetter, A. K. (2016) · American Journal of Speech-Language Pathology · doi:10.1044/2015_ajslp-14-0128 · Cited by 37
Fernandez, M. I., Warren, J. C., Varga, L. M., Prado, G. J., Hernández, N., & Bowen, G. S. (2007) · Journal of Ethnicity in Substance Abuse · doi:10.1300/j233v06n02_09 · Cited by 35
“…et al., 2002; Ross et al., 2000; Strom, Pettersson, & Andersson, 2004; Christensen, Griffiths, & Jorm, 2004; Strom, Pettersson, & Andersson, 2000; Devinini & Blanchard, 2004; Rhodes, 2004; Brown, Winzelberg, Abascal, & Taylor, 2004; Linke, Brown, & Wallace, 2004; Escoffery, McCormick, & Bateman,…”
Behavioral treatment of headaches: extending the reach
Andrasik, F. (2012) · Neurological Sciences · doi:10.1007/s10072-012-1073-2 · Cited by 34
Psychologische Therapie der Migräne
Fritsche, G., Kröner‐Herwig, B., Kropp, P. A., Niederberger, U., & Haag, G. (2013) · Der Schmerz · doi:10.1007/s00482-013-1319-9 · Cited by 33
Chronic daily headache: diagnosis and management.
Yancey, J. R., Sheridan, R., & Koren, K. G. (2014) · PubMed · Cited by 32
Owen, J. E., Bantum, E. O., Criswell, K. R., Bazzo, J., Gorlick, A., & Stanton, A. L. (2013) · Journal of Behavioral Medicine · doi:10.1007/s10865-013-9509-6 · Cited by 32
“This has been true for online interventions for cancer patients and survivors (David et al., 2011; Gustafson et al., 2001; Winzelberg et al., 2003) and interventions for a wide range of other health conditions (Berman et al., 2009; Devinini & Blanchard, 2005; Strom et al., 2000).”
BackgroundInforming the development of an Internet-based chronic pain self-management program
Gogovor, A., Visca, R., Auger, C., LeBlanc, L. B., Symeonidis, I., Poissant, L., Ware, M. A., Shir, Y., Viens, N., & Ahmed, S. (2016) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2016.10.005 · Cited by 32
Messer, D., Horan, J. J., Turner, W., & Weber, W. (2016) · AERA Open · doi:10.1177/2332858415625188 · Cited by 30
“Relaxation training was selected as a high-demand control because it too is amenable to online delivery and focuses on similar outcomes (Beatty & Lambert, 2013; Devineni & Blanchard, 2005; Vincent & Lewycky, 2009).”
BackgroundPsychological therapies for the prevention of migraine in adults
Sharpe, L., Williams, A. C. D. C., Martin, P. R., Nicholas, M. K., Welgampola, M. S., McPhee, I., Baillie, A., Dudeney, J. E., & McGuire, B. E. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012295 · Cited by 28
Development, standardisation and pilot testing of an online fatigue self-management program
Ghahari, S., Packer, T. L., & Passmore, A. E. (2009) · Disability and Rehabilitation · doi:10.1080/09638280902751956 · Cited by 29
“The internet constitutes a widely available and affordable instructional medium that can help overcome some of the barriers to delivery of effective selfmanagement programs [22] and improve equity of access.”
BackgroundRecruitment to Online Therapies for Depression: Pilot Cluster Randomized Controlled Trial
Jones, R. B., Goldsmith, L., Hewson, P., & Williams, C. J. (2013) · Journal of Medical Internet Research · doi:10.2196/jmir.2367 · Cited by 28
“Ways of addressing this include online advertising through search engines such as Google AdWords (AdWords) [13-19], advertising on social media sites [20], “snowballing” on social media sites [21], getting websites of other organizations to add links (weblinks) [22], using offline via mass media [23], or via practitio…”
BackgroundMethodYeh, M., Hung, Y.-L., Chen, H., Lin, J., & Wang, Y.-J. (2013) · Evidence-based Complementary and Alternative Medicine · doi:10.1155/2013/316212 · Cited by 27
“…were for harmonizing and improving endocrine and uterine function [40], kidney and liver were for normalizing qi and blood and restoring organ function [41], shenmen was for alleviating pain and for sedation [29], and central rim was for dredging the meridian and normalizing circulation [42].”
BackgroundFlynn, N. (2019) · International Journal of Clinical and Experimental Hypnosis · doi:10.1080/00207144.2019.1612674 · Cited by 28
“The medication index score (MIS) used in this study is based loosely on that employed by Devineni and Blanchard (2005) in their randomized controlled trial of an internet-based treatment for chronic headache.”
MethodSorbi, M. J., Kleiboer, A. M., van Silfhout, H., Vink, G., & Passchier, J. (2014) · Cephalalgia · doi:10.1177/0333102414547137 · Cited by 26
“A reduction 50% in attack frequency was adopted as clinically significant change or treatment responder rate, in accordance with other studies (12,17,19,20,22).”
BackgroundResultInfluentialTowards eHealth to support the health journey of headache patients: a scoping review
van de Graaf, D. L., Schoonman, G. G., Habibović, M., & Pauws, S. C. (2020) · Journal of Neurology · doi:10.1007/s00415-020-09981-3 · Cited by 27
Johnson, E., Corrick, S., Isley, S., Vandermeer, B., Dolgoy, N., Bates, J., Godfrey, E., Soltys, C., Muir, C., Vohra, S., et al. (2024) · PLOS Digital Health · doi:10.1371/journal.pdig.0000435 · Cited by 24
“(e.g., Parkinson’s disease) [52,53,59,62,63,66,71,80,82,83,85–91] followed by cardiovascular conditions (e.g., heart failure) (7, 12”
Noser, A. E., Gibler, R. C., Ramsey, R. R., Wells, R. E., Seng, E. K., & Hommel, K. A. (2022) · Headache The Journal of Head and Face Pain · doi:10.1111/head.14392 · Cited by 25
Inflammatory Bowel Diseases-related Disability: Risk Factors, Outcomes, and Interventions
Tse, C. S., Hunt, M. G., Brown, L. A., & Lewis, J. D. (2023) · Inflammatory Bowel Diseases · doi:10.1093/ibd/izad182 · Cited by 23
Williams, M. L., Bowen, A. M., & Ei, S. (2008) · Health Promotion Practice · doi:10.1177/1524839908324783 · Cited by 24
Gewirtz, A., & Minen, M. (2019) · Current Pain and Headache Reports · doi:10.1007/s11916-019-0739-3 · Cited by 22
Dudeney, J., Sharpe, L., McDonald, S., Menzies, R. E., & McGuire, B. (2022) · Headache: The Journal of Head and Face Pain · doi:10.1111/head.14260 · Cited by 26
Huguet, A., Stinson, J., MacKay, B., Watters, C. R., Tougas, M. E., White, M., & McGrath, P. J. (2014) · Pain Research and Management · doi:10.1155/2014/631638 · Cited by 22
“The Internet holds promise for revolutionizing the way treatment of recurrent pain conditions is given and received (8-11).”
BackgroundGriffiths, F. E., Armoiry, X., Atherton, H., Bryce, C., Buckle, A., Cave, J. A. K., Court, R. A., Hamilton, K., Dliwayo, T. R., Dritsaki, M., et al. (2018) · Health Services and Delivery Research · doi:10.3310/hsdr06090 · Cited by 22
Metadata
- Authors
- Devineni, T., & Blanchard, E. B.
- Affiliations
- Conemaugh Health System (US)
- University at Albany, State University of New York (US)
- Corresponding author
- Devineni, Trishul
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2005-03
- Volume
- 43
- Issue
- 3
- Pages
- 277-292
- ISSN
- 0005-7967 (ISSN-L)
- OpenAlex
- W2009393470
- Cited by
- 203
- References
- 27
- Citations by year
- 2026: 4 · 2025: 2 · 2024: 3 · 2023: 8 · 2022: 6 · 2021: 6 · 2020: 7 · 2019: 10 · 2018: 7 · 2017: 6 · 2016: 16 · 2015: 7 · 2014: 17 · 2013: 13 · 2012: 12
- FWCI
- 4.17
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Neurological Disorders and Stroke (R01NS033072, NS-33072)
- Topics
- Health Sciences › Medicine › Clinical Neurology › Migraine and Headache Studies
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Dentistry › Oral Surgery › Temporomandibular Joint Disorders
- Keywords
- chronic headache, internet-delivered treatment, behavior therapy, progressive muscle relaxation, biofeedback, autogenic training, stress management, headache-related disability, medication reduction, self-management, treatment discontinuation, waitlist control
- MeSH terms
- Adult, Autogenic Training, Behavior Therapy, Biofeedback, Psychology, Cost-Benefit Analysis, Female, Humans, Male, Migraine Disorders, Patient Dropouts, Relaxation Therapy, Stress, Psychological, Treatment Outcome, Telemedicine, Tension-Type Headache, Internet, Headache Disorders
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