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CAM You can Use: Preventing Headaches. Kathi J Kemper, MD, MPH General Pediatrics, Integrative Medicine 2 nd Opinion Clinic (Monday mornings) 716-9640. Disclaimer.

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cam you can use preventing headaches

CAM You can Use: Preventing Headaches

Kathi J Kemper, MD, MPH

General Pediatrics, Integrative Medicine

2nd Opinion Clinic (Monday mornings)


  • I have no conflicts of interest to report regarding this presentation; I published a CME article on this topic with MedScape for which my institution received payment
  • The presentation includes no description of any proprietary items for screening, diagnosis, or treatments

By the end of this session, participants will be able to

  • Counsel patients on dietary modifications to prevent headaches
  • Discuss the scientific evidence about the effectiveness of stress management practices in preventing headaches
  • Find evidence-based resources about the effectiveness of acupuncture in preventing headaches (See AAP Section for Complementary and Integrative Medicine; join the listserv)
  • NOT focused on diagnosis or medications
  • Common! (in teens, > 4 HA in past month by 6% males; 14% females) (Linet. JAMA, 1989)
  • 90% Migraine or Tension-Type Headache
  • 10% other : sinusitis, eye, trauma, ice cream, cervicogenic, myofascial pain, TMJ, hemorrhage, infection, pseudotumor, vasculitis, tumor,
cam use for tension type ha
CAM Use for Tension-Type HA
  • 40% used CAM
  • 60% did not tell MD (how many MD’s asked?)
  • Types of CAM
    • Chiropractic 21%
    • Acupuncture 17%
    • Massage 17%

Rossi et al. Headache 46:622-631, 2006

* CAM – Complementary or Alternative Medicine, somewhat outdated and useless term

cam at unc for headache
CAM at UNC for Headache
  • Biofeedback (thermal, muscular, heart rate variability, autonomic)
  • Hypnotherapy
  • Osteopathy
  • Acupuncture
  • Mindfulness Meditation
  • Herbal and supplement counseling
prevention options
Prevention options







prevention health promotion lifestyle
Prevention/health promotion lifestyle
  • Avoid triggers!
  • Nutrition and supplements
  • Exercise/sleep
  • Environment
  • Stress management
lifestyle avoid triggers
  • Non-modifiable: genetics, gender, weather
  • Semi-modifiable: air pollution (including tobacco smoke, CO, SO2, NO2), menses
  • Modifiable

- Lack of sleep

- Missing meals

    • Allergens
    • Foods – tyramine containing, nuts, cheese, smoked fish, artificial sweeteners, nitrate preservatives, MSG, caffeine withdrawal
    • Stress – physical, psychological


diet avoid food allergens
Diet: Avoid Food Allergens
  • Clinical trial of 43 patients
  • Allergy skin testing
  • 69% responded to diet modification (p<0.005)
  • People with IgE-specific food allergy benefited more from the elimination diet than people with negative skin tests.

Mansfield L et al.. Ann Allergy, 2004

diet and migraine
Diet and Migraine
  • Regularization of meals
  • Normalize blood sugar (glycemic index)
  • Elimination Diet 1: Caffeine, cheese, nuts, chocolate, shellfish, onions, aspartame, wine, beer, dairy, processed meats
  • Elimination Diet 2: Lamb and rice – add back
  • Reduction in omega-6 fatty acids – red meats, fast food
  • Increase in omega-3 fatty acid intake-fish oil
dietary supplements
Dietary Supplements
  • B vitamins
  • Minerals: calcium, magnesium
  • Fatty acids/fish oil
  • CoQ10
  • Melatonin
supplements b vitamins
Supplements: B vitamins
  • B2
    • Migraine sufferers suspected of having a mitochondrial defect -> impaired O2 utilization
    • Riboflavin (B2) is the precursor to key molecules in the electron transport chain in the mitochondria
    • 200 mg BID with meals for 3 months -> 68% reduction in migraine attacks in RCT (next slide)
    • Side effect: yellow urine

Schoenen. Neurology, 1998; Sandor. Headache, 2000; Magis. Headache, 2007

  • B6 essential in converting tryp to serotonin
    • More than 100 mg daily -> nausea, abd pain, sleepiness, lower B12 levels; >1000 mg daily -> sensory neuropathy
high dose riboflavin vs placebo
* High Dose Riboflavin vs. Placebo

Schoenen J et al. Effectiveness of high-dose riboflavin in migraine prophylaxis: a randomized controlled trial. Neurology 50(2): 466-70; 1998.

supplements minerals
Supplements: Minerals
  • Calcium for PMS-related migraines
    • 44% of boys and 58% of girls 6-11 insuff
    • 64% of boys and 87% of girls 12-19 insuff
  • Ensure 1200- 1500 mg daily

Thys-Jacobs. J Am Coll Nutr, 2000

  • Magnesium (1 gram iv acutely) or 300 – 500 mg daily po to prevent (soy beans, black beans, tofu, seeds, nuts, whole grains, shellfish)

Mauskop. Headache, 2002; Pfaffenrath. Cephalgia, 1996

Mazzotta. Cephalgia, 1999; Wang, Headache, 2003

Peikert. Cephalgia, 1996; Facchinetti F, Headache, 1991

magnesium mechanism
* Magnesium - mechanism
  • Ionized magnesium levels low in 50% of MHA patients
  • Migraines associated with platelet aggregation, serotonin release
  • Magnesium reduces platelet aggregation
  • Magnesium decreases the affinity of serotonin for vascular receptor sites
  • Magnesium acts as an NMDA receptor (glutamate receptor) antagonist
    • NMDA receptors & pain transmission
    • Inhibits one type of neuronal spreading depression in experimental models

* OPTIONAL SLIDE – for participant reference

consequences of reduced mg
* Consequences of Reduced Mg++
  • Vasoconstriction of scalp arteries
  • Reduced affinity of serotonin receptors
  • Lower threshold for activation of N-methyl- d-aspartate receptors
  • Enhanced platelet aggregation and serotonin release
trials with mg supplements
* Trials with Mg++ Supplements
  • An infusion of 1.0 g of magnesium sulfate in 40 patients with acute migraine
    • 52% responded to therapy
    • 86% of the responders had low serum ionized Mg++ levels
    • 16% of the non-responders had low serum ionized Mg++ levels.

Mauskop A. Alternative therapies in headache – Is there a role? Medical Clinics of North America 85(4): 1077-84; 2001.

trials with mg supplements1
* Trials with Mg++ Supplements
  • Four trials with oral magnesium supplementation
  • Three of the four showed efficacy
  • The one negative trial used a poorly absorbed magnesium salt which resulted in diarrhea
current use of mg supplements
*Current Use of Mg++ Supplements
  • 500 mg/day K+ Mg++ aspartate
  • Avoid combining with Fe, Ca, Zn
  • May cause temporary diarrhea
  • Magnesium gluconate – an alternate
  • Menstrual migraine – months to benefit

Mann, Doug et al. “Migraine and Tension-Type Headache.” Integrative Medicine. Ed. David Rackel MD. Philadelphia: Sanders, 2006 143-156.


Omega-6 Fatty Acids

Omega-3 Fatty Acids

Linoleic Acid (18:2n-6)

a-Linolenic Acid (18:3n-3)

∆-6 Desaturase

(GLA)γ -Linolenic Acid (18:3n-6)

Stearidonic Acid (18:4n-3)


(DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6)

Eicosatetraenoic Acid (20:4n-3)

∆-5 Desaturase


(AA)Arachidonic Acid (20:4n-6)

(EPA) Eicosapentaenoic Acid (20:5n-3)




Leukotriene 5-series

Prostaglandins E3

Thromboxanes A3

∆-6 Desaturase


Leukotriene 4-series

Prostaglandins E2

Thromboxanes A2



(DHA) Docosahexaenoic Acid (22:6n-3)

changing fatty acid intake omega 6 omega 3
Changing Fatty Acid Intake:Omega 6: Omega 3
  • Prehistoric ~ 1900 ~ 2000
  • 1:1 4:1 25:1

n-6 fats

n-3 fats

why efa imbalance in us
Why EFA Imbalance in US?
  • Diet is high in Omega-6 and low in Omega-3 (previously 1:1 ratio, now 20:1)
  • Hydrogenated oils
  • Enzyme cofactor deficiency (B-3, B-6, Biotin, C, Zinc, Magnesium)
  • Genetic polymorphism (biochemical individuality)
  • Hyperinsulinism from high glycemic load diet (increase DGLA to AA)
  • Increased stress -> increased demands.
fatty acids omega 3s
Fatty acids: Omega 3s
  • Popular approach to decreasing inflammation
  • Open studies suggest it helps reduce headaches; doses 1-3 grams daily
  • RCTs – mixed results; olive oil may not be a placebo!
  • Supplements – generally free from mercury, dioxins, PCBs; palatable

Harel. J Adolesc Health, 2002

Pradalier. Cephalgia, 2001

Puel. Br J Nutr, 2004

coenzyme q 10
Coenzyme Q-10
  • Open label, 150 mg qd - for 3 months
  • 62% had > 50% reduction in number of HA days
  • Migraine Days: 7.34 -> 2.95/mo
  • Frequency: 4.85 -> 2.81/month
  • No side effects; except pain in pocketbook

Rozen and Silberstein, Cephalalgia 22: 137-141, 2002

melatonin and headache
Melatonin and Headache
  • Mechanism
    • Potentiates GABA; Modulates Ca entry in to vascular smooth muscle cells
    • Modulates 5HT2 receptor – like B- blockers; Inhibits the synthesis of prostaglandin E2 - inflammation mediator
  • Melatonin low and out of phase in menstrual migraine, chronic daily headache, migraine, status and cluster HA
  • Effective preventive for cluster HA and HA associated with delayed sleep-phase syndrome
melatonin sleep phase delay or cluster ha
Melatonin: Sleep phase delay or cluster HA
  • Corrects delayed sleep-phase syndrome
  • An alternative to benzodiazepines
  • Dosing 6-12 mg one hour before bed
  • Few side effects
  • ConsumerLab reviews show consistent quality

Rozen. Headache, 2006

Vogler. CNS Drugs, 2006

Rozen, Neurology, 2003

Pringsheim. Headache, 2002

Miano. Neurol Sci, 2008 – PEDIATRIC STUDY

lifestyle stress management
Lifestyle: Stress management
  • Stress is common
  • Stress triggers/worsens pain
  • Managing stress: exercise, sleep, nutrition, mind/emotion/body/spirit
    • Biofeedback
    • Hypnosis
  • Reducing stress helps 50% - 70% of headache sufferers

Stress and Physiological Activation

High Arousal/High Energy


Low Arousal/Low Energy


Institute of HeartMath

biofeedback what and why
Biofeedback-What and why?

Use of electronic equipment to measure and feed back information about physiologic functions—which are then modulated in desirable direction

Goal-balancing ANS (& CNS) activity

“video-games for your body” kid-friendly

2007 meta-analysis showed > 50 controlled trials of BF for HA; EFFECTIVE!

Strong treatment effect that persists for over 12 months after training

Allen Pediatr Ann, 2004

Kaushik R. Complement Ther Health Med, 2005

Trautman. Cephalgia, 2006

Nestoriuc. Pain, 2007

biofeedback example
*Biofeedback - Example
  • Blanchard - 116 patients with migraine
  • Assigned to either thermal biofeedback, thermal biofeedback with relaxation training, or pseudomeditation, headache monitoring
  • Six month follow-up
  • 51% of the subjects in the thermal biofeedback groups improved in frequency compared to 5% and 22% for the monitoring and pseudomeditation groups

Blanchard E et al.. J Consult Clin Psychol; 1990.

biofeedback modalities
Biofeedback Modalities

Home or Office Use

Peripheral Temperature

Heart Rate Variability

Surface EMG

Skin Conductance

biofeedback temperature

Theory-the more relaxed, the lower sympathetic nervous system activity, the more peripheral blood flow, hands and feet warm up


Dermatherm Bands Sharn, Incorporated


Digital Temp Portable Units

heart rate variability hrv
*Heart Rate Variability(HRV)



76 BPM

83 BPM

70 BPM

m Volts


.793 sec.

.726 sec.

.859 sec.







2.5 seconds of heart beat data

hypnosis guided imagery
Hypnosis/Guided Imagery

Hypnosis: An altered state of awareness usually but not always involving relaxation during which the participant can give himself/herself suggestions for desired changes to which he/she is more likely to respond that in their usual state of awareness.

Guided Imagery: A technique that involves using the imagination and mental images to promote relaxation, changes in attitude or behavior, and encourages physical healing. AKA- visualization.

children enjoy it
Children Enjoy It

To teach self hypnosis for a specific purpose (such as reduction of pain or elimination of a habit) involves helping young children focus on their natural thinking styles.

Kids move in and out of altered states and imaginary activities all the time. Think IMAGINARY PLAY!

The child is in control.

We serve as the teacher or coach.

Offer choices and options.

The child can use this skill when he or she chooses.

Ask that parents not remind the child to practice self hypnosis; it’s up to the child/adolescent

hypnosis prevention
Hypnosis – Prevention
  • Meta-analysis – strong evidence of benefits for tension HA (Hammond. Int J Clin Exp Hypnosis, 2007)
  • Better than wait-listed controls for migraine prevention (Melis. Headache, 1991)
  • Superior to propranolol or placebo in juvenile classic migraine prevention (next slide)
hypnosis headache
Hypnosis : Headache
  • Children 6 to 12 years with classic migraine
  • RXT: propanolol vs. placebo for 3 months each
  • Then hypnosis training
  • Placebo: 13.3 HA/ 3 mos
  • Propanolol: 14.9 HA/3 mos
  • Hypnosis: 5.8 HA/3 mos (P<0.05)

Olness. Pediatrics. 1987

Hammond: Int J Clin Exp Hypn. 2007

hypnosis misconceptions
* Hypnosis Misconceptions

Patient is under control of the hypnotherapist

Patient is unaware of surroundings and/or activities around him/her

Patients defenses are impaired (there is improved access to subconscious material)

Symptoms are masked

Patient can be forced to do things they would not normally do

contraindications to hypnosis
Contraindications to Hypnosis

Ignoring underlying disorder

Used for fun or entertainment

The problem is more effectively treated with another modality

Patient is psychotic, acutely depressed

Patient (child) does not want to engage in hypnosis (but parent wants them to)

mind body autogenic training
Mind-Body: Autogenic Training
  • Form of hypnosis
  • Repeat phrases
    • My hands and arms are heavy and warm
    • My legs and feet are heavy and warm
    • My heartbeat is calm and regular
    • My breathing is easy and free
    • My forehead is cool
    • My belly is relaxed
  • Reduces need for headache medication
  • Reduces frequency of migraine attacks

Zsombok. Headache, 2003

Juhasz. Headache, 2007

massage for migraines
Massage for Migraines
  • Massage improves blood flow and decreases inflammation, relaxes muscles, reduces stress, provides tangible social support
  • Can combine with physical therapies such as ice, heat; aromas (peppermint)
  • RCT for migraines showed significantly decreased frequency and improved sleep

Lawler SP. Ann Behav Med, 2006

Pieovesan. Arq Neuropsiquiatr, 2007

  • Commonly used
  • Older studies support use of chiropractic in migraine; frequency and severity were reduced
  • Little other evidence supporting use in headache of different types

Tuchin. Australas Chiropr Osteopathy, 1997

Parker. Aust NZ J Med, 1978

osteopathy headache
Osteopathy - Headache
  • Five of six studies showed positive results for tension, cervicogenic and post-traumatic HA
  • No studies specifically for migraine
  • No control groups or long term results
  • Two of 6 studies: results comparable to TCA

Hoyt. J Am Osteopath Assoc, 1979

Fernandez-de-las-Penas. J Orthop Sports Phys Ther, 2006

Bronfort. J Manipulative Phys Ther, 2001

acupuncture for chronic daily headache unc study
Acupuncture for Chronic Daily Headache – UNC study
  • RCT of usual medical care (UMC) vs UMC + acupuncture
  • Medical care alone: no change
  • Medical care +acupuncture
    • Improvement in headache impact (function)
    • Improvement in general mental health domains (SF-36)
    • 3.7 times >likely to report reduced suffering

Coeytaux R. Headache, 2005

Gottschling. Pain, 2008 – PEDIATRIC STUDY LASER ACUP.

Witt. Cephalgia, 2008 – COST EFFECTIVENESS

acupuncture mechanism of action
*Acupuncture: Mechanism of Action
  • The documented effects of acupuncture include:
  • 1) Release of opioids in the central nervous system
  • 2) Changes in regulation of blood flow, blood pressure, body temperature, and alterations in immune function.
mechanism of action
*Mechanism of Action
  • Functional MRI: Single point stimulation
    • Activation of occipital lobes with lateral foot VA1 stimulation
    • Reduction in limbic structure activity with true acupuncture (pressure sensation)
    • Activation of somatosensory cortex with sham point activation or painful response to needling
mechanism of action biomedicine
*Mechanism of Action: Biomedicine
  • Release of opioid-like substances into CSF
  • Substance P, neurokinin A, neuropeptide Y
  • Serotonergic and dopaminergic systems activated
  • Descending pain inhibitory systems activated
  • Thalamic relay nuclei inhibition
  • Dorsal root entry zone inhibition
acupuncture for headache
*Acupuncture for Headache
  • 5 or more weekly 20-40 minute sessions
  • Electrical stimulation
  • Prolonged benefit after 6-10 weeks
  • 70% respond to acupuncture -frequency

Morrisey, H et al. Headache 43, 221-228, 2003


Vincent C. A controlled trial of the treatment of migraine by acupuncture. Clinical Journal of Pain. 5(4): 305-12; 1989.

acupuncture migraine reviews involving 1000 patients
Acupuncture – MigraineReviews involving > 1000 patients
  • Acupuncture benefits adults and pediatric patients in preventing migraines
  • NOT for acute treatment
  • 1-2 treatments weekly for 4-6 weeks
  • Effects last at least 6 months
  • Side effects rare

Melchart et al. Cephalalgia, 1999

Manias.The Clinical Journal of Pain, 2000


Healing Touch

And Therapeutic Touch

biofield therapies
Biofield Therapies
  • Rapid increase in use and availability of Healing Touch, Therapeutic Touch, Reiki, QiGong, Polarity Therapy
  • RCT showed decreased tension headache pain with TT

Keller E. Nurs Res, 1986

herbs in migraine
Herbs In Migraine
  • Feverfew – yes for prevention if you can get British and use it daily
  • Valerian –to help with sleep
  • Petasites (Butterbur) – yes for prevention if you can get quality product
* Feverfew
  • Feverfew (Tanacetum parthenium)
  • 270 adult migraine patients
  • 70% reduction in intensity and frequency of migraine
  • Other trials have not been as promising but all show benefit of feverfew > placebo
  • Variability in quality of products!

Murphy J et al.. Lancet 1988.

Ernst E et al.. Public Health Nutrition .2000.

  • Significant reduction in frequency, not in duration
  • No head to head studies with other modalities
  • Dosing: 125mg/day of the dried leaf standardized to a minimum 0.2% parthenolide
  • Maximum effect after 4-6 weeks
  • Adverse effects: Aphthous ulcers and gastrointestinal side effects in 5-15%
  • Avoid abrupt cessation: agitation & increased HA
  • Contraindicated during pregnancy
  • Used for sleep, anxiety
  • 150-300 mg of dried root hs or tid
  • Few side effects
  • Avoid prolonged use – rebound headache
  • Used during headache
  • Smells very bad
petasites hybridus root extract
Petasites hybridus Root Extract
  • Large, 3arm, dose-finding RCT (Lipton, Neurology, 2004)
  • Reduced frequency by more than 50% in 68% of those with highest doses.
  • Few dropouts.
  • Two other confirmatory studies, one in children.

Acupressure / acupuncture

Self care



acupressure resources
Acupressure resources
  • (korean hand acu)
  • course)
  • and certification)
hrv biofeedback resources
* HRV Biofeedback - Resources and training)

self care training resources
Self-Care Training Resources


Be the Boss of Your Body” Series

“Ways to Wellness” Videos

Music and Recorded Relaxation Exercises****

Home Computer Biofeedback Fun

web resources
Web Resources
  • AAP Section on CHIM
    • Will post this presentation
  • Integrative Pediatrics Council
    • CAM bibliography
    • IPC Network
training and certification
Training and Certification

Society For Developmental and Behavioral Pediatrics Annual Pediatric Hypnosis Training

American Society for Clinical Hypnosis

Society for Clinical and Experimental Hypnosis

International Society for Hypnosis

Academy for Guided Imagery

text resources
Text Resources

Culbert & Olness, ed: Integrative Pediatrics

In press, March 2009 (Oxford University Press)

Loo: Integrative Medicine for Children (2008)

Rosen & Riley, ed: Complementary and Alternative Medicine, Pediatric Clinics of North America (December 2007)

Schwartz & Andrasik: Biofeedback: A Practitioners Guide

Shannon: Handbook of Complementary and Alternative Therapies in Mental Health

Schnaubelt: Medical Aromatherapy

Reed Gach: Acupressure Potent Points


PCIM Director: Kemper

Medical School:

Arcury (Family Med)

Avis (Public Health)

Chilton (Phys/Pharm)

Curl (Orthopedics)

Tegeler (Neurology)

Stant: newsletter/Web


Atkinson (Business Dev.)

Johnson (Operations/Nursing)

Parker (Home & Community)

Small (Quality)

Snelgrove (Operations)

Yates (Pastoral Care)

Zachary: (meetings)


Program leaders

Bailey: Ambience Sound/Music

Best Health

Black: ActionHealth/ Farmer’s Market

Dailey/McCarty: Meditation

Danhauer: Yoga

Feldman: Guided imagery

Kilbourne: Green Initiative

LaRose: HM – Hospital

Larrimore – Healing Touch/HeartMath

McClenny – Arts

Melcher – Massage

NW Area Health Education Center

Pashayan: Hypnosis

Sackett – RN Research

Wilson – Recreation/Aqua

Woodard - Nutrition

Zachary – Healthy Living

Julie Milunic: Advisory Board

Library Staff: resources

Mark Wright: PR and Marketing


Medical School:

how behavioral medicine
How: Behavioral Medicine
  • Identify the goal
  • Consider various strategies
  • Pick a strategy
  • Identify a small, achievable step that the patient and family can support
  • Explore pros and cons of change
  • Anticipate barriers; identify resources
  • Plan rewards/celebrations!
  • Re-evaluate; take the next step
goal setting
  • Pick a POSITIVE goal
    • E.g., healthier lifestyle.
example healthier lifestyle
Example: Healthier lifestyle

To promote

Better mood

Better focus or concentration

Greater calm More resilience

More cheerfulness Greater adaptability

More confidence More creative

More clarity

Better memory

More harmonious relationships

Higher self esteem

More consistent with personal values


pick a specific strategy
Pick a specific strategy
  • More exercise
  • Better nutrition
  • Judicious use of supplements
  • Better sleep
  • Healthier environment
  • Stress management; biofeedback; journal; meditation
  • Use medication
  • Massage, psychotherapy, acupuncture or other professional help
identify a small achievable step
Identify a small, achievable step
  • Rome was not built in a day; habits are not changed overnight: BABY STEPS.
  • For exercise, go from sedentary, to 5 minute walks with the dog 5 days a week.
  • Be specific (with or without an MP3 player; with or without a friend; regardless of weather?; distance vs. time)
how important is this to you
How important is this to you?

0 1 2 3 4 5 6 7 8 9 10

Not Very

Why did you pick that number and not a lower number? (e.g. a 7 instead of a 5)

Asking this question helps the patient/family provide their own rationale for why this is important. They talk themselves into it!

how confident are you that you can do this for one month
How confident are you that you can do this for one month?

0 1 2 3 4 5 6 7 8 9 10

Not Very

If they pick an 8 or higher (pretty confident), proceed with next step of making a chart and planning rewards and follow-up.

If they pick a number less than 8,

“What would it take for you to go from the number you picked to a higher number?” Begin to explore their ambivalence…. It’s OK to be ambivalent about change!

identify barriers and resources
In addition to (cons listed above), what other barriers or challenges might you anticipate as you try to make this change? Need new tennis shoes; need leash; need pooper-scooper

What resources do you have/need to help you make this change? Will Mom commit to getting new shoes, leash, etc. ? Will the child want/need a reminder? Is it helpful for Dad to do that? Do they need a chore chart? A calendar?

Identify Barriers and Resources
plan celebrations rewards
Plan celebrations/rewards
  • Pick a tangible reward and timing (will it be offered after week 1, 2, 3, 4?)
  • Samples: new walking shoes; Support the patient’s choices.
  • Emphasize the importance of the reward/celebration. If the patient says they expect “good” behavior, suggest they consider celebrating it (instead of rewarding it).
follow up
Follow- up in 4-6 weeks.

Ask patient to bring chart and say you plan to be proud of them (build expectation of success) and will ask them what they’d like to do for next step (involve them in problem solving).

Do it!

Follow Up
behavioral medicine
Behavioral Medicine
  • Identify the goal
  • Consider various strategies
  • Pick a strategy
  • Identify a small, achievable step that the patient can embrace
  • Explore pros and cons of change
  • Anticipate barriers; identify resources
  • Plan rewards/celebrations!
  • Re-evaluate; take the next step