The Effectiveness of a Group-Based Acceptance and
Commitment Additive Therapy on Rehabilitation of Female
Outpatients With Chronic Headache: Preliminary Findings
Reducing 3 Dimensions of Headache Impacthead_21921..14
Hadi Mo’tamedi, MD; Payman Rezaiemaram, MS; Abaas Tavallaie, MD
Objective.—Examine whether acceptance and commitment additive therapy is effective in reducing the experience of
sensory pain, disability, and affective distress because of chronic headache in a sample of outpatient Iranian females.
Background.—Chronic headaches have a striking impact on sufferers in terms of pain, disability, and affective distress.
Although several Acceptance and Commitment Therapy outcome studies for chronic pain have been conducted, their findings
cannot be completely generalized to chronic headaches because headache-related treatment outcome studies have a different
emphasis in both provision and outcomes. Moreover, the possible role of Iranian social and cultural contexts and of gender-
consistent issues involved in Acceptance and Commitment Therapy outcomes deserve consideration.
Methods.—This study used a randomized pretest–post-test control group design. The sample was selected from consecu-
tive female outpatients with chronic headache, attending and/or referred to a headache clinic in a governmental hospital from
April 2011 to June 2011. In total, 80 female outpatients were interviewed, and after implementing inclusion/exclusion criteria,
thirty females were considered eligible to participate in the study. Half (n = 15) were randomly selected to participate in the
treatment group. Four participants of this group failed to complete the treatment sessions (n = 11). The Acceptance and
Commitment Therapy group received the medical treatment as usual and 8 sessions of Acceptance and Commitment Therapy.
The other half (n = 15) served as the control group that received only medical treatment as usual.The short form of McGill pain
questionnaire, the migraine disability assessment scale, and the trait subscale of the state-trait anxiety inventory were admin-
istered, which operationalized 3 dimensions of impact of chronic headache, sensory pain, disability, and emotional distress,
respectively, to explore the impact of recurrent headache episodes. Pretest and post-test measures on these 3 dimensions of
impact were the primary outcome measures of this study.Analyses of covariance with the pretreatment score used as a covariate
were conducted on pain intensity, degree of disability, and level of affective distress before and after therapy to assess
therapeutic intervention effectiveness.
Results.—Chronic tension type of headache (63%) and chronic migraine without aura (37%) were the headache types
reported by the participants. Data analyses indicated the significant reduction in disability (F[1,29] = 33.72, P < .0001) and
affective distress (F[1,29] = 28.27, P < .0001), but not in reported sensory aspect of pain (F[1,29] = .81, P = .574), in the
treatment group in comparison with the control group.
Research Committee, University of Welfare and Rehabilitation Sciences, Tehran, Iran (P. Rezaiemaram); Behavioral Sciences
Research Center, Baqiyatallah Medical University, Tehran, Iran (A. Tavallaie).
Address all correspondence to P. Rezaiemaram, Student Research Committee, University of Welfare and Rehabilitation Sciences,
Tehran 18359-95199, Islamic Republic of Iran, email: email@example.com
Accepted for publication April 18, 2012.
Conflict of Interest: The authors report no conflict of interest.
Published by Wiley Periodicals, Inc.
© 2012 American Headache Society
Conclusions.—The effectiveness of a brief acceptance and commitment additive therapy in the treatment of Iranian
outpatient females with chronic headache represents a significant scientific finding and clinical progress, as it implies that this
kind of treatment can be effectively delivered in a hospital setting.
Key words: headache impact, pain intensity, disability, affective distress, outpatient female, Acceptance and Commitment
Abbreviations: ACT Acceptance and Commitment Therapy, ANCOVA analysis of covariance, CBT Cognitive Behavioral
Therapy, ITT intent-to-treat, LOCF last observation carried forward, MIDAS migraine disability assessment
scale, MPQ-SF McGill pain questionnaire-short form, MTAU medical treatment as usual, STAI-T state-trait
anxiety inventory-trait subscale
In contemporary societies, headaches are the
most frequent pains in Western societies.1In the
Iranian population, also, the average prevalence of
migraine and tension-type headache are lower than
Western countries but higher than previous studies
conducted in other Asian countries like Turkey and
Korea.2Headaches in women as compared with
men are much more highly experienced in Western
countries3-7and in Iran1as well. Considering the
World Health Organization’s ranking of causes of dis-
ability, headache disorders are among the 10 most
disabling conditions for both genders and rank
among the 5 most disabling conditions for women.1
Primary (migraine and tension-type) headaches
are a complex conditions with organic,8-10psycho-
logical,11,12and social7aspects. Therefore, a biopsy-
chosocial framework that takes into account the
multidimensional nature of the problem as well as the
multidirectional relationships between these factors
in the explanation of chronic headaches11is a prom-
ising theoretical approach. Also, gender differences
regarding chronic headaches and related factors have
been found to be affected by organic, psychological,
and social aspects.7
The conceptualization of the multidimensional
nature of pain has remarkable impact on the con-
ceptualization of headache.13In brief, within this
framework, headache has been defined by 3 major
dimensions: (1) pain, (2) disability, and (3) affective
To date, in order to reduce headache and related
impacts, a variety of psychological interventions have
been developed in Western countries, of which,
behavior therapies,both traditional behavior therapy,
such as biofeedback16,17and relaxation training18
(so-called, first generation therapies), and cognitive
therapies19(also known as second generation thera-
(CBT),20-25independently or in various combinations
have been reported to be effective in treating head-
ache. In Iran, Mohammadi and colleagues have
shown that cognitive behavioral group therapy is
effective in the treatment of recurrent headaches.26
In fact, CBT has become the dominant paradigm in
psychological treatments for many of the chronic
medical conditions involving chronic pains.27None-
theless,some problems have emerged that undermine
this paradigm28-31and have resulted in the emergence
of new techniques that together conform the third
generation of CBTs.
One of the most well-established third-wave
therapies is Acceptance and Commitment Therapy
(ACT – pronounced as single word,“act,” not as ini-
tials,“A-C-T”).32This therapy is based on Relational
Frame Theory.33ACT proposes that psychological
inflexibility,which refers to an individual’s inability to
connect with the present moment fully and mindfully,
make“suffering”prolonged through 2 factors:(1) the
psychological processes of experiential avoidance,
and (2) cognitive fusion.32,34Experiential avoidance is
a process whereby an individual deliberately attempts
to change the form or frequency of private experi-
ences (eg, bodily sensations, emotions, thoughts,
memories, behavioral predispositions), and the con-
texts in which they occur regardless of the social,
emotional, cognitive, and behavioral consequences
that may result.28,32,35,36Cognitive fusion, which sup-
ports experiential avoidance, occurs when an indi-
vidual’s verbal processes (ie, thoughts) markedly
regulate inappropriately overt behavior in ineffective
ways.30,37When these processes dominate an indi-
vidual’s experience, this can result in psychological
Although there are many similarities between
traditional CBT perspective and ACT, 2 fundamental
differences between these 2 therapies are worth men-
tioning. First, from a traditional CBT perspective, the
main problem of a client is assumed to be the aversive
psychological experience (eg, a severe headache and
related thoughts and memories) per se.38As a result,
CBT techniques (eg,relaxation and breathing retrain-
ing) are typically used in conjunction to teach patients
to exert control over cognitive responses and lower
headache-related variables themselves. In ACT,
however, therapeutic efforts are targeted to enhance
the processes of responding to such negative cogni-
tive experiences through psychological flexibility,as a
conscious human being, and to change or persist in
behavior that is in line with identified values.32
Second, the processes underlying CBT inter-
ventions are not clear.30,31,39Following the “entire
intervention packages” approach like some of CBT
therapies, it is not possible to identify what compo-
nents of the package are effective and what com-
ponents are inert or harmful. Nor it allows for iden-
tification of how packages are similar or different.
Hence, particular packages of CBT can include
specific components that differ substantially from one
treatment to another.31In contrast, ACT is clearly
a process-oriented therapy aimed at promoting psy-
chological flexibility through 6 interrelated core pro-
cesses. A brief description of each one of these core
processes is delineated in Table 1.
It is through the synergistic interacting effect of
core processes that ACT facilitates the development
of larger patterns of effective action linked to chosen
values.These core processes are grouped into 2 major
overlapping groups, Mindfulness and acceptance
skills – acceptance, cognitive defusion, being present,
and self-as-context processes – and Commitment and
behavior change skills – involving being present,
self-as-context, values, and committed action pro-
cesses.28,30For example, mindfulness connects to the
values and commitment component ofACT,in that it
allows the regulation of action that is informed by
needs, feelings, values, and their fit with the current
Recent reviews of interventions and research
studies implemented for the management of diverse
chronic pain conditions suggest that ACT could help
in dealing with this perplexing health condition.41-50
For instance, McCracken and Zhao-O’Brien propose
that people with pain lose contact with what they
want in life beyond relief from pain (psychological
inflexibility), and this process leads to disability
and reduced quality of life.51Notwithstanding the
numerous outcome studies that are supportive of
the effectiveness of ACT-consistent interventions
in decreasing chronic pain-induced problems, such
findings cannot be completely generalized to chronic
headache conditions because as Morley and col-
leagues noted, headache-related treatment outcome
research has a different emphasis in both treatment
provision and outcomes.52Moreover, Martin and
MacLeod after review of related literature suggested
that the philosophy of behavioral management of
headache triggers should be replaced with coping
with headache triggers as they include both avoid-
ance and approach/confront strategies.12Among
the so-called third-generation
mindfulness-based stress reduction has been investi-
Table 1.—Brief Description of 6 Core Process in Acceptance
and Commitment Therapy
Core ProcessBrief Description
Acceptance The willingness to have and accept private
experiences without needless defense.
Taking perspective from their own private
events, noticing them for what they are
(thoughts, feelings, memories, etc), and not
as barriers for action.
The state that can enable one to perceive
accurately what is happening when in
contact with the present moment.
The awareness of client’s “observing self,” or
Directions in life that individuals choose to
guide their behavior.
Behaving in accordance with personally
valued directions for the fulfillment of
goals coherent with such directions.
gated in chronic headache conditions.53-55Therefore,
ACT as an additive acceptance-based therapy merits
examination in improving sufferings because of recur-
Because of the scarcity of research studies, it is
not possible to make a strong case for the effects of
gender and ethnicity in Iran;26however, in Western
countries, pain-related parameters have been found
to be affected by gender pain-related factors10,56and
ethnicity.56,57Moreover, the effectiveness of ACT in
the treatment of pain is limited to Western popula-
tions, and the possibility of delivery in a hospital
setting with limited psychiatric and psychological
facilities remains to be investigated.
Considering the theoretical and empirical argu-
ments advanced earlier, the purpose of the present
preliminary study was to examine the effectiveness of
a group-based 8-session protocol of ACT49in manag-
ing 3 dimensions of headache impact – pain,disability,
and affective distress – in a group of Iranian outpa-
tient females with chronic headache. It was hypoth-
esized that acceptance and commitment additive
therapy focused on acceptance, mindfulness, and
values will be effective in managing the perception of
pain intensity, mainly of the sensory type, disability,
and affective distress.
This study used a randomized pretest–post-test
control group design.ACT was compared in an addi-
tive treatment design with medical treatment as usual
(MTAU).42Prophylactic medication therapy was per-
mitted, stable, continued throughout the treatment,
and tracked.All participants were blind to the treat-
the intervention was not blinded to treatment condi-
clinic for headache administered by a governmental
hospital, which operates on an outpatient basis. The
principal investigator was a certified psychiatrist with
In addition, the hospital staff possessed the training
and experience for delivering the therapy.
Participants.—The sample was selected from con-
secutive female outpatients seeking treatment and
included 30 Iranian outpatient females complain-
ing from a long-lasting headache attending and/or
referred to anspecialized
Baqiyatallah Hospital at Tehran. Patients were told
that at the conclusion of the study, they will receive a
brochure containing information about headache and
rationale for psychological treatment.Selection crite-
ria,which was based mostly onThorn and colleagues’
work,24included (1) having a diagnoses of primary
chronic (migraine and tension-type) headache (ie, a
headache occurring on ?15 days/month on average
for >3 months), according to the second edition of
International Classification of Headache Disorders,58
involving chronic tension-type headache and chronic
migraine without aura (diagnostic criteria for head-
ache were evaluated by the first and third authors
separately, and only outpatients who received the
same diagnosis by both evaluators were selected to
participate in the study.);(2) no history of seizure and
facial neuralgia; (3) age range of 19-55 years; (4) no
history of severe mental disorders or current sub-
stance abuse; and (5) adequate skill of reading Farsi
language for completing the questionnaires of the
study. In this study, because of its preliminary nature,
a small sample size was utilized.
Materials.—All the scales were translated into
Farsi, the official Iranian language, then back-
translated into English. The back-translated version
was then compared with the original one. Adjust-
ments were made to make sure that the translated
Farsi version reflected the original meanings.Then,as
a pilot test, this Farsi versions were administered in a
group of outpatients with chronic headache (N = 84),
and their reliabilities was investigated.
McGill Pain Questionnaire-Short Form.—This
instrument was used to measure female outpatients’
perception of the intensity of their pain considering
sensory-physical and affective dimensions.59The
McGill pain questionnaire-short form (MPQ-SF) is a
self-report questionnaire consisting of 15 items. It
consists of 2 subscales that measure sensory and
affective dimensions of the pain perception. The
MPQ-SF is a reliable and valid instrument.59,60The
level of intensity of pain in the sensory dimension was
the main outcome measure in this study based on the
3-dimensional model of chronic headache.14The
affective perception of the intensity of pain was a
secondary outcome measure. In the pilot test, the
internal consistency reliability of the Farsi version
was good for the sensory dimension (a = 0.82) and
the affective dimension (a = 0.74). The MPQ-SF
pretest evaluation provided the baseline scores on
pain intensity perception frequency and severity.
instrument was used to measure the extent to which
the experience of recurrent headaches impacts on the
normal and adaptive functioning of the female out-
patients, specifically the degree of interference in
daily, vocational, and social activities brought by
headache.61Level of disability was the 1 of the 3
primary outcome measures in this study. It has a high
internal consistency (a = 0.83) and adequate test–
retest reliability (j = 0.84,P < .01),and comparison of
the migraine disability assessment scale (MIDAS)
with 90-day diary records and medical diagnostic
evaluation has confirmed its validity.61Also, in the
current study, this measure was scored based on a
30-day interval. In the pilot test, the internal consis-
tency reliability of the Farsi 30-day version was good
(a = 0.79). The MIDAS pretest evaluation provided
the baseline scores on impact frequency and severity
in terms of disability.
State-Trait Anxiety Inventory-Trait.—This mea-
sure is a 20-item self-report inventory.62This inven-
tory assesses the general disposition to experience
affective distress by the female outpatients. In the
present research,the trait subscale (state-trait anxiety
inventory-trait [STAI-T]) was used as the third
primary measure of the study because of the fact that
trait anxiety is the best indicator of affective distress
according to Holroyd and colleagues’ 3-dimensional
model of headache impact.14It has a high internal
consistency (a = 0.92) and adequate test–retest reli-
ability (j = 0.86, P < .01).62In the pilot test, the inter-
nal consistency reliability of the Farsi version was
good (a = 0.82). The level of emotional distress was
the main outcome measures in this study. STAI-T
pretest evaluation provided the baseline scores on
affective distress impact frequency and severity.
Procedure.—Ethical approval was obtained from
the Board of Advanced Studies and Research of the
University of Social Welfare and Rehabilitation Sci-
ences in Tehran, which was responsible for the super-
vision of the present study. The outpatients were
informed about the purpose of the study,their right to
either consent or refuse to participate, and to with-
draw from the study at any point in time. The
researchers made clear that withdrawal would not in
any way affect their treatment. It was also explained
that the information they would share during the
study would remain confidential.
The 80 consecutive clients were interviewed in
the hospital’s headache clinic testing room. Of them,
30 outpatients who met the aforementioned selection
criteria were invited for participation.After providing
written informed consent, the chosen participants
(n = 30) were assigned randomly into 2 groups (each
group comprising 15 participants). Participants were
asked to keep medications stable and to discontinue
other psychological therapies during the treatment
(ie, fairly control of medical and other concomitant
treatments according to the psychotherapy outcome
received the MTAU,which was labeled as the MTAU
group, and the other group, the group-based ACT,
which was labeled as the ACT group, in addition to
MTAU,received an 8-weekly sessions for 2 months.A
brief orientation ofACT was given to each individual
participant of theACT group.Four participants of the
ACT group failed to complete the treatment because
of several reasons including busy work (2 patients),
family involvement (1 patient), and difficulties in
commuting to the location of the treatment meetings
(1 patient).The study was completed with 26 partici-
pating patients (15 in the MTAU group and 11 in the
Information was obtained on demographic vari-
ables, including headache type, marital status, age,
education,headache frequency,duration of headache,
and chronicity of headache. All participants in both
groups completed the 3 aforementioned self-report
measures at the beginning and end of the treatment
(duration between pretreatment and post-treatment
measurements was 8 weeks).The baseline assessment
period and the outcome assessment period took 2
days. The present study does not report follow-up
Every week,the medications for 1-week use were
delivered in the clinic by the third author to partici-
pants in both groups. In addition, in weekly 1-hour
sessions, the participants in the MTAU group were
given the opportunity to speak with the therapist
(second author) and other participants about the
problems they experienced with medication use, as
well as other psychological problems. The therapist
also provided problem-solving guidance to the par-
ticipants about the problems brought about (merely
in an intimate and empathic relationship and guid-
ance, and not a psychological intervention). Medica-
tion was also delivered to theACT group participants
before each session of ACT, and if needed, partici-
pants spoke about medication problems in that
session. Furthermore, to ensure the accurate use of
drugs, in every dose, the second author contacted all
participants and asked them about their drug use.
Group-BasedACT Intervention.—An experienced
graduate hospital staff certified psychologist (second
author) administered the ACT to a group of 15
female outpatients.An 8-weekly session group-based
ACT-oriented protocol,49which was designed to be
theoretically consistent with third-wave treatments
generally and with ACT specifically, was conducted
for 2 months. On the average, each session lasted 90
minutes. The intervention49aimed at identifying the
following specific goals of treatment: (1) building
awareness of the difficulty in effectively controlling
pain sensations; (2) improving engagement in mean-
ingful and effective activities even with continued
pain and distress; (3) decreasing pain- and distress-
avoidant behaviors; (4) identification of and engage-
ment in actions consistent with personally relevant
values and goals; and (5) improving present-focused
awareness and mindfulness of thoughts, feelings, and
physiological sensations.49The main topics of each
session depicted in Table 2 are in agreement with
ACT group-based manual.49Although each session
had an organizing topic (refer toTable 2),these topics
were addressed throughout the therapy sessions in a
flexible manner.49As depicted inTable 2,mindfulness
practice was performed in every session, excluding
the first and final sessions. The adapted Farsi ACT
protocol used in this intervention and based on
Vowles and colleagues’ manual,49is available from
the authors upon request. Fidelity to the treatment
manual and treatment adherence was checked using
weekly supervision of each session.All sessions were
(audio) recorded, then the first author evaluated the
contents using a detailed checklist associated to each
session.This checklist was designed using the content
of the treatment manual. As such, the authors were
successful in delivering the therapy as intended.
Patients’ compliance with the procedural require-
ments, mainly homework, of the intervention, as
depicted in Table 2, was followed up in each session.
Each session began with addressing the previous
session and its homework.
Statistics.—Collected data were analyzed with
SPSS 17 software (SPSS,Inc.,Chicago,IL,USA).Fre-
quencies and percentages were applied for descrip-
tion of categorical variables, and mean and standard
deviation (SD) were applied for description of inter-
val variables. Between-group differences in demo-
graphic variables were computed with the Fisher’s
exact probability, and between-group mean differ-
ences were computed with independent-samples
t-test for interval variables. In all earlier cases, signifi-
cance of 2-tailed tests was interpreted at P < .05.
Analyses of covariance (ANCOVAs) with the pre-
treatment scores entered as a covariate were applied
to evaluate the effectiveness ofACT on pain intensity,
degree of disability, and level of emotional distress of
the women participants. In all ANCOVAs, signifi-
cance of 1-tailed tests was interpreted at P < .05.
ANCOVA has more statistical power than ANOVA
to detect changes from pretreatment in randomized
designs.64Moreover,effect sizes of the outcomes were
calculated. Generally, the effect size for the pretest–
post-test control group design is defined as the differ-
ence between the standardized mean change for the
treatment and control groups.65Morris compared 3
formulas of effect-size estimation for the pretest–
post-test control group design (dppc). The results
supported Carlson and Schmidt’s66formula (an esti-
mation of effect size based on the pooled pretest SD)
as the best choice.65Therefore,the current study used
this formula for effect-size estimation.
A flow diagram of outpatients in each stage of
the study, including the number of patients assessed,
enrolled, and allocated to each condition, from the
specialized headache clinic from Baqiyatallah Hos-
pital in which this study was conducted, is depicted
in the Figure. The sample was selected from con-
secutive female outpatients with recurrent headache,
attending and/or referred to Baqiyatallah Hospital
Specialized Headache Clinic from April 2011 to
The reported results are based on intent-to-treat
(ITT) analyses with 4 dropouts in the analyses. ITT
analyses were conducted by having the last observa-
tion carried forward (LOCF) for the outcome data
when data were missing at the post-treatment mea-
surements (eg, because of dropout). For this analysis,
pretreatment scores of dropouts were moved forward
to subsequent assessments (post-treatment).
Baseline clinical characteristics and demographics by
condition are depicted in Table 3.The majority of the
outpatient women was middle-aged, single, and had
completed high school. According to information
registered in each participant’s hospital portfolios,
the average headache frequency in the total sample
Table 2.—Overview of Treatment Sessions (This Table Is Adopted From Vowles and Colleagues,49as Well as
Session Objectives and ContentHomework
(1)(A) Review treatment history, and evaluate it in terms of how it has worked
relative to patient’s goals and expectations. (B) Introduce the possibility
that change is possible but perhaps not through symptom reduction.
– Increasing flexibility by addressing
clients’ change agenda and
encourage completing the
– A brief mindfulness exercise.
(2) (A) Review interactions among thoughts, feelings, and action that cause
vicious cycles. (B) Exercises to attempt to control thoughts and/or emotions.
Review patient experiences about the difficulty inherent in control
attempts. (C) Introduce the idea that changes in action may mean changes
that directly contribute to meaningful and successful living (ie, values), not
changes in stubborn avoidant behavior. (D) Introductory mindfulness
practice consisting of 2 short exercises (sitting and breathing) and 1 longer
(A) Values clarification exercises. Emphasis on identification and awareness.
(B) Mindfulness practice of breathing. Emphasis on awareness and “just
noticing,” including noticing distractions.
(A) Continued values clarification. (B) Discussion of barriers and exercises
exploring possibilities for values-based action even with aversive
experiences. (C) Introduction to effective goal setting, as related to values.
(D) Awareness of body sensations exercise.
(A) Discussion of activity pacing and activity cycling. (B) Exercises to raise
awareness of language-based influences on action. Purpose is to highlight
opportunities for choosing to behave in ways (in)consistent with identified
values. (C) Awareness exercise (breathing or body awareness).
– Ask participants to check-in with
themselves several times a day and
record experiences on a daily basis.
– Complete the Values Rating Form.
– Practice mindfulness daily.
– Ask patients to identify 3 values, 3
related goals, and 3 actions for each
– Work regarding committed action
and to allow for barriers to come up
and be identified.
– Provide cues for being mindful of
– Request simple behavior record.
(6) (A) Continued discussion of willingness to have discomfort in the service of
meaningful living. (B) “Thought watching” exercise. Discussion in middle
or at end of exercise to explore experience of honest, nonavoidant
observation. (C) Discussion of pain medications and effective
(A) Awareness. Exercise, pertaining to the ways in which humans add
additional, often unnecessary, distress onto already distressing situations.
(B) Continued discussion of willingness, especially related to meaningful
living. (C) Walking mindfulness exercise, preferably outside of treatment
(A) Values clarification exercise, emphasizing commitment and future
planning. (B) Preparation for “relapses” and “set-backs.”
– Begin to move participants closer to
independently making decisions on
– More work on generalization.
– Identify specific homework with
specific individuals, if necessary.
— = not applicable.
was 17.46 days over the last month before beginning
treatment (17.78 in the MTAU group and 18.14 in
the ACT group). Mean duration of headache (ratio
of headache hours/headache days) in the total
sample was 5.4 hours per day (5.1 in the MTAU
group and 5.7 in the ACT group). All of them had a
relatively short history of headache experiences of
approximately 4 years. The diagnosed headache
types were chronic tension-type headache (63% of
the total sample, 67% of the MTAU group, and 53%
of the ACT group) and chronic migraine without
aura (37% of the total sample, 33% of the MTAU
group, and 47% of the ACT group). In pretreatment
measurement, a large percentage of female outpa-
tients reported experiencing sensory aspect of pain
(46% of the total sample, 40% of the MTAU group,
and 54% of the ACT group) and affective aspect of
pain (38% of the total sample, 33% of the MTAU
group, and 45% of the ACT group) above the mean
of total sample, severe pain disability (50% of the
total sample, 46% of the MTAU group, and 54% of
the ACT group), and moderate levels of anxiety
(65% of the total sample, 67% of the MTAU group,
and 64% of the ACT group). In post-treatment mea-
surement, sensory aspect of pain (46% of the total
sample, 33% of the MTAU group, and 64% of the
ACT group) and affective aspect of pain (54% of the
total sample, 87% of the MTAU group, and 10% of
the ACT group) above the mean of the total sample,
severe pain disability (31% of the total sample, 40%
of the MTAU group, and 18% of the ACT group),
and moderate levels of anxiety (50% of the total
sample, 80% of the MTAU group and 10% of the
ACT group) were also observed.
There were no significant differences between 2
groups in the demographic variables, especially with
regards to age, education, headache chronicity that
are identified in the literature as background vari-
ables correlated with pain outcomes.67-69
According to the results, 45% of the ACT group
(19% oftotal sample)
improvement in terms of 3 outcome measures: pain
(both sensory and affective aspects), disability, and
affective distress; however, such a simultaneous
improvement was not seen in the MTAU group. Fur-
thermore,23% of the total sample (7% of the MTAU
group and 45% of the ACT group), who reported
severe disability in the pretreatment measurement,
showed moderate disability in the post-treatment
Table 4 outlinesthe
ANCOVAs of 3 dimensions of headache impact with
the pretreatment score used as the covariate. Sepa-
rate LOCF analyses were computed with pretreat-
ment scores of dropouts (4 participants) moved
means(M), SD, and
Randomized Group Assignment
McGill & MIDAS & STAI-T
(n = 15)
(n = 15)
(N = 30)
ACT + MTAU
(n = 11)
(n = 15)
McGill & MIDAS & STAI-T
Specialized Headache Clinic
Evaluation of the Selection
(N = 80)
(N = 50)
Figure.—Flow diagram of outpatients through each stage of
the study. ACT = Acceptance and Commitment Therapy;
MIDAS = migraine disability
medical treatment as usual; STAI-T = state-trait anxiety
assessment scale; MTAU =
forward to subsequent assessments (post-treatment)
for each headache pain dimension.
The comparisons between the MTAU and the
ACT groups in post-treatment measurements con-
trolling for pretreatment measurements give evi-
dence for the effectiveness of ACT, as statistically
significant findings were obtained with primary and
secondary outcome measures in affective dimension
of pain intensity (F[1,29] = 10.14, P = .003), disability
(MIDAS scores) (F[1,29] = 33.72, P < .0001), and
Table 3.—Comparison of Group Scores of Background Variables and Headache Characteristics in the MTAU (n = 15) and the
ACT (n = 15) Groups
(n = 15)
(n = 15)
Headache diagnosis frequency (%)
Chronic migraine (without aura)
Marital status frequency (%)
(n = 15)
(n = 15)
(df = 28)
Age (years), M (SD)
Education (years), M (SD)
Headache frequency, M (SD)
Duration of headache, M (SD)
Headache chronicity (years), M (SD)
ACT = Acceptance and Commitment Therapy; M = mean; MTAU = medical treatment as usual; SD = standard deviation.
Table 4.—Means (M), Standard Deviations (SD) of Outcome Variables at Pretreatment and Post-Treatment for Each Groups,
Analyses of Covariance (ANCOVAs) for Mean Scores on Outcome Variables With Pretreatment Score Used as a Covariate,
and Effect Sizes
Variable (Scoring Range)Group
Pretreatment Post-Treatment ANCOVA
Effect SizeM (SD) M (SD)
Pain intensity (McGill)
Sensory dimension (0-33)MTAU
Affective dimension (0-12)10.14.003 1.35
Disability (MIDAS) (0-30)33.72
Distress (STAI-T) (20-80)28.27
ACT = Acceptance and Commitment Therapy; MIDAS = migraine disability assessment scale; MTAU = medical treatment as
usual; STAI-T = state-trait anxiety inventory-trait subscale.
affective distress (STAI-T score) (F[1,29] = 28.27,
P < .0001). However, no significant findings were
obtained for the sensory dimension of pain intensity
(F[1,29] = 0.81, P = .574).
The effect sizes were large for affective distress
(dppc= 2.54), affective dimension of pain intensity
(dppc= 1.35), and disability (dppc= 0.93). However,
effect size for the sensory dimension of pain intensity
was small (dppc= 0.28).
The current preliminary study was aimed at
examining the effectiveness of a group-based accep-
tance and commitment additive therapy in reducing
the experience of pain, disability, and affective dis-
tress due to recurrent headache episodes, in a sample
from a population of outpatient Iranian women.
Statistically significant, this study supports the
effectiveness of a brief time group ACT in treating
hospital-based outpatient recurrent headache. Spe-
cifically, in reference to research objectives and
hypotheses, this intervention significantly promoted
participants’ perception of pain intensity in terms of
affect as well as individual functioning (reducing dis-
ability) and affective adjustment (decreased affective
distress).The intensity of sensory dimension of pain,a
primary outcome measure, in the ACT group was
decreased, but results did not reach significance.
To begin with, the lack of effect of the treatment
in the present study with respect to reduction of
sensory pain perception needs to be addressed.In the
present study, the sensory dimension of pain was not
found to be sensitive to treatment intervention,
although the affective aspect of the perception of pain
significantly decreased in the ACT group. As it is
known, theoretically, according to ACT assumptions,
ACT should not necessarily result in decreases of
pain intensity as one of its main emphasis is the cre-
ation and/or increase of the acceptance of aversive
experiences (such as chronic headache) and commit-
ment to adaptive, flexible, and value-based activities,
despite the presence of such upsetting experiences
(eg,an unrelenting pain) and their psychological con-
sequents.Perhaps as a consequence of this theoretical
stand,ACT was not originally designed for the treat-
ment of pain. When the ACT model is applied to
chronic pain,however,it is designed to move patients
away from a focus on pain intensity toward a focus on
its unnecessary interference with living.31,51So,both in
terms of theoretical grounds as well as actual treat-
ment characteristics, the reduction of pain is not a
logically expected outcome of ACT. For instance,
mindfulness-based interventions have not been found
to be effective in the reduction of pain severity.53-55
Rosenzweig et al,55for example,studied mindfulness-
based stress reduction for chronic pain conditions
among various types of chronic pains of which
patients with chronic headache/migraine experienced
the smallest improvement in headache pain.55Also,
Nash-Mc Feron53examined the effects of mindfulness
training in chronic headache patients based on 3
dimensions, pain, health-related quality of life, and
sense of control. His findings indicate that mindful-
ness training resulted in improvement of quality of
life and sense of control but not in the reduction of
perceived pain.53Thus, the lack of effectiveness of
ACT in the present study in the reduction of the
perception of sensory pain severity precludes the
assumption that treatment of chronic pain is best con-
ceived of as the shift away from pain to nonpain
aspects of life but rather supports a shift away from a
search for a cure alternatively replacing this motiva-
tional stand with an acknowledgment that pain may
not change. This emphasis may be related to ACT
reduction of participants’ perception of pain intensity
in terms of affect.
With respect to 2 other dimensions of chronic
headache impact, that of disability and affective dis-
tress, it is notable that ACT in the present study was
effective in the reduction of disability as well as affec-
tive distress, and these intervention outcomes are
very important because the participants at pretest
rated in the highest ranges of disability severity,
although affective distress felt within a moderate
Although the present study successfully demon-
strated the effectiveness of an ACT group interven-
tion, it has some limitations. To begin with, the ACT
protocol used in the present study was developed for
chronic pain conditions, and in this study, it was
adapted for the first time to headache pain.Therefore,
lack of attention to some dimensions deemed in
important in headache research is apparent. For
instance, homework used in this intervention did not
provide for the inclusion of headache diaries.Second,
there was nearly a 33% difference between the 2
groups in therapy hours (approximately, 8 hours in
MTAU group vs 12 hours in ACT group) because of
absence of enough physical accommodations for
setting up meetings and visits. Such difference in
amount of therapy is in itself a threat to the internal
validity of the study, although it is commonly found
even in well-designed studies of third-wave therapies
(for more information, see Öst’s review study63). A
third limitation relates to the fact that concomitant
medication was allowed, and thus, the efficacy of the
behavioral intervention cannot be isolated and evalu-
ated independently from the impact of the medica-
tion. The present behavioral trial then looked at the
additive effects of behavioral treatment concurrent to
prophylactic medication, thereby threatening the
internal validity of the study. Notably, however, disal-
lowing outpatients’ ongoing prophylactic medication
therapy may adversely impact patient recruitment,
may prolong the investigation with washout periods,
and may exacerbate the patient’s headache severity
during baseline.Additionally,the period between pre-
measurement and post-measurement was only 2
months, and the trial was modest in size and included
mixed headache groups. Future studies need to
address these issues.
In terms of recommendations for future research,
the authors suggest replicating this study using
adequate sample sizes. It is also recommended that
future studies be conducted with this treatment pro-
tocol with a group composed of Iranian males with
chronic headache, and the results are compared with
treatment outcomes of Iranian women.
In addition, future research needs to continue
the search for specific mechanisms of change in the
ACT process related to different types of chronic
headache conditions, controlling for chronic head-
In summary, the findings of the present study
indicate that among Iranian outpatient females suf-
fering from chronic headache, ACT was effective
mainly on 2 dimensions of headache impact (disabil-
ity and emotional distress),ACT effectiveness on pain
as far as it involves the sensory dimension of pain was
not supported; however, it significantly affected the
affective dimension of pain. A significant number of
Iranian women outpatients were found to be experi-
encing the impact of chronic headache. Hence, ACT
operating within a hospital-based center appears to
be an effective intervention with this challenging
Acknowledgments: The authors would like to thank
Professor Kevin Vowles, who facilitated the manual for
the implementation of group-based ACT brief interven-
tions. Also, the authors would like to acknowledge the
contribution of Professor Maria E. Aguilar-Vafaie, who
helped in the translation of measures and preparation of
this manuscript.Last,but not least,the authors appreciate
the collaboration of Baqiyatallah Hospital and the clinic
directors and staff.
STATEMENT OF AUTHORSHIP
(a) Conception and Design
Hadi Mo’tamedi; Payman Rezaiemaram; Abaas
(b) Acquisition of Data
Hadi Mo’tamedi; Payman Rezaiemaram
(c) Analysis and Interpretation of Data
(a) Drafting the Article
Hadi Mo’tamedi; Payman Rezaiemaram
(b) Revising It for Intellectual Content
Hadi Mo’tamedi; Payman Rezaiemaram; Abaas
(a) Final Approval of the Completed Article
Hadi Mo’tamedi; Payman Rezaiemaram; Abaas
1. Stovner LJ, Hagen K, Jensen R, et al. The global
burden of headache:A documentation of headache
prevalence and disability worldwide. Cephalalgia.
2. Ayatollahi SMT,Sahebi L,Haghighi AB.Epidemio-
logic and clinical characteristics of migraine and
tension-type headaches among hospitals staffs of
Shiraz (Iran).Acta Medica Iranica.2009;47:115-120.
3. Celentano DD, Linet MS, Stewart WF. Gender dif-
ferences in the experience of headache.Soc Sci Med.
4. Evans RW, Mathew NT. Hand Book of Headache.
Philadelphia: Lippincott Williams & Wilkins; 2000.
5. Mannix LK, Diamond M, Loder E. Women and
headache:A treatment approach based on life stage.
Cleve Clin J of Med. 2002; 69:488-500.
6. Peterlin BL, Gupta S, Ward TN, MacGregor A. Sex
matters: Evaluating sex and gender in migraine and
headache research. Headache. 2011;51:839-842.
7. Smitherman TA, Ward TN. Psychosocial factors of
relevance to sex and gender studies in headache.
8. Ashina S, Bendtsen L, Ashina M. Pathophysiology
of tension-type headache. Curr Pain Headache Rep.
9. Masoud AA. Study on relation between attacks of
migraine headache and serum-magnesium level.
Iranian J Publ Health. 2003; 32:27-30.
10. Shyti R, de Vries B, Maagdenberg AM. Migraine
genes and the relation to gender. Headache. 2011;
11. Nicholson RA, Houle TT, Rhudy JL, Norton PJ.
Psychological risk factors in headache. Headache.
12. Martin PR, MacLeod C. Behavioral management
of headache triggers: Avoidance of triggers is an
inadequate strategy. Clin Psychol Rev. 2009;29:483-
13. Holroyd KA, Stensland M, Lipchik GL, Hill KR,
O’Donnell FS, Cordingley G. Psychosocial corre-
lates and impact of chronic tension-type headaches.
14. Holroyd KA, Malinoski P, Davis MK, Lipchik GL.
The three dimensions of headache impact: Pain,
disability and affective distress. Pain. 1999;83:571-
15. Broadbenta E, Niederhofferb K, Haguec T, Cortera
A, Reynoldsa L. Headache sufferers’ drawings
reflect distress, disability and illness perceptions.
J Psychosom Res. 2009; 66:465-470.
16. Nestoriuc Y, Rief W, Martin A. Meta-analysis of
biofeedback for tension-type headache: Efficacy,
specificity,and treatment moderators.J Consult Clin
17. Nestoriuc Y, Martin A. Efficacy of biofeedback for
migraine:A meta-analysis. Pain. 2007;128:111-127.
18. Teders SJ, Blanchard EB, Andrasik F, Jurish SE,
Neff DF, Arena JG. Relaxation training for tension
effectiveness of a minimal therapist contact versus a
therapist delivered procedure. Behav Ther. 1984;
19. Holroyd KA, Andrasik F, Westbrook T. Cognitive
control of tension headache. Cogn Ther Res. 1977;
20. Nash J, Walker B, Gordon N, Nicholson R. Cogni-
tive behavioral group treatment for disabling head-
ache. Pain Med. 2004; 5:178-186.
21. Holroyd KA, Andrasik FA. Cognitive-behavioral
approach to recurrent tension and migraine head-
ache. In: Kendall PC, ed. Advances in Cognitive-
Behavioral Research andTherapy.Vol.1.NewYork,
NY: Academic; 1982:275-320.
22. Johnson PR, Thorn BE. Cognitive behavioral
treatment of chronic headache: Group versus indi-
vidual treatment format. Headache. 1989;29:358-
23. Richardson GM, McGrath PJ. Cognitive-behavioral
therapist-contact approach versus a clinic-based
approach. Headache. 1989;29:352-357.
24. Thorn BE,Pence LB,Ward LC,et al.A randomized
clinical trial of targeted cognitive behavioral treat-
ment to reduce catastrophizing in chronic headache
sufferers. J Pain. 2007; 8:938-949.
25. Bakal DA,Demjen S,Kaganov JA.Cognitive behav-
ioral treatment of chronic headache. Headache.
26. Mohammadi N, Sajadinejad MS, Taghavi MR, Ash-
jazadeh N. Effects of cognitive-behavioral group
therapy on recurrent headaches in Iranian culture.
Psychol Rep. 2008;103:893-898.
27. White CA. Cognitive Behavioral Therapy for
Chronic Medical Problems: A Guide to Assessment
and Treatment in Practice. New York: John Wiley &
Sons Ltd; 2001.
28. Hayes SC. Acceptance and Commitment Therapy
and the new behavior therapies:Mindfulness,accep-
tance, and relationship. In: Hayes SC, Follette VM,
Linehan MM, eds. Mindfulness and Acceptance:
Expanding the Cognitive-Behavioral Tradition. New
York: The Guilford Press; 2004:1-29.
29. Hayes SC. Acceptance and Commitment Therapy,
relational frame theory,and the third wave of behav-
ioral and cognitive therapies. Behav Ther. 2004;
30. Hayes SC,Luoma BJ,Bond FW,Masuda A,Lillis J.
Acceptance and Commitment Therapy: Model, pro-
cesses and outcomes. Behav Res Ther. 2006; 44:1-25.
31. Vowles KE,Thompson M.Acceptance and Commit-
ment Therapy for chronic pain. In: McCracken LM,
ed. Mindfulness andAcceptance in Behavioral Medi-
cine: Current Theory and Practice. Oakland: New
Harbinger Press; 2011:31-60.
32. Hayes SC, Strosahl K, Wilson KG. Acceptance and
Commitment Therapy:An Experiential Approach to
Behavior Change. New York: Guilford Press; 1999.
33. Hayes SC, Barnes-Holmes D, Roche B. Relational
Frame Theory: A Post-Skinnerian Account of
Human Language and Cognition. New York:
Plenum Press; 2001.
34. Hayes SC, Strosahl KD, Bunting K, Twohig M,
Wilson KG. What is Acceptance and Commitment
Therapy? In: Hayes SC, Strosahl KD, eds. A Practi-
cal Guide to Acceptance and Commitment Therapy.
New York: Springer-Verlag; 2004:1-29.
35. Blackledge JT, Hayes SC. Emotion regulation in
Acceptance and Commitment Therapy. Psychother
Pract. 2001; 57:243-255.
36. Wilson KG, Murrell AR. Values-centered interven-
tions: Setting a course for behavioral treatment. In:
Hayes SC, Follette VM, Linehan M, eds. Mindful-
ness and Acceptance: Expanding the Cognitive
BehavioralTradition.NewYork:The Guilford Press;
37. Pierson HM, Bunting K. Smith AA, Gifford EV,
Hayes SC. A Functional Approach to Measuring
Therapists’ Adherence and Competence in Accep-
tance and Commitment Therapy (ACT). Boston:
Meeting ofAssociation for BehaviorAnalysis;2004.
38. Bromberg J, Wood ME, Black RA, Surette DA,
Zacharoff KL, Chiauzzi EJ. Randomized trial of a
Web-based intervention to improve migraine self-
39. Rosen GM, Davison GC. Psychology should list
empirically supported principles of change (ESPs)
and not credential trademarked therapies or other
treatment packages. Behav Modif. 2003; 27:300-
40. Brown KW, Ryan RM, Creswell JD. Mindfulness:
Theoretical foundations and evidence for its salu-
tary effects. Psychol Inq. 2007; 18:211-237.
41. Asmundson GJG, Hadjistavropolous HD. Accep-
new ground.Cogn Behav Pract.2006;3:178-181.
42. Dahl J, Wilson KG, Nilsson A. Acceptance and
Commitment Therapy and the treatment of persons
at risk for long-term disability resulting from stress
and pain symptoms:A preliminary randomized trial.
Behav Ther. 2004; 35:785-801.
43. McCracken LM,Gutiérrez-Martinez O.Processes of
change in psychological flexibility in an interdiscipli-
nary group-based treatment for chronic pain based
on Acceptance and Commitment Therapy. Behav
Res Ther. 2011; 49:267-274.
44. McCracken LM, MacKichan F, Eccleston C. Con-
textual cognitive-behavioral therapy for severely
disabled chronic pain sufferers: Effectiveness and
clinically significant change.Eur J Pain.2007;11:314-
45. McCracken LM,Vowles
complex, long standing chronic pain: A preliminary
analysis of treatment outcome in comparison to a
waiting phase. Behav Res Ther. 2005; 43:1335-1346.
46. Veehof MM, Oskam
Bohlmeijer ET. Acceptance-based interventions for
the treatment of chronic pain: A systematic review
and meta-analysis. Pain. 2011;152:533-542.
47. Vowles KE, McCracken LM. Acceptance and
values-based action in chronic pain:A study of effec-
tiveness and treatment process. J Consult Clin
Psychol. 2008; 76:397-407.
48. Vowles KE,McCracken LM,Eccleston C.Processes
of behavior change in interdisciplinary treatment of
chronic pain: Contributions of pain intensity, catas-
trophizing,and acceptance.Eur J Pain.2007;11:779-
49. Vowles KE, Wetherell JL, Sorrell JT. Targeting
acceptance, mindfulness, and values-based action in
chronic pain:Findings of two preliminary trials of an
outpatient group-based intervention. Cogn Behav
Pract. 2009; 16:49-58.
50. Wicksell RK, Ahlqvist J, Bring A, Melin L, Olsson
improve functioning and life satisfaction in people
with chronic pain and whiplash-associated disorders
(WAD)? A randomized controlled trial. Cogn
Behav Ther. 2008; 37:169-182.
51. McCracken LM, Zhao-O’Brien J. General psycho-
logical acceptance and chronic pain: There is more
to accept than the pain itself. Eur J Pain. 2010;
52. Morley S, Eccleston C, Williams A. Systematic
review and meta-analysis of randomized controlled
trials of cognitive behavior therapy and behavior
therapy for chronic pain in adults, excluding head-
ache. Pain. 1999;80:1-13.
53. Nash-Mc Feron DE. Mindfulness in the treatment
of chronic headache pain. [dissertation]. Seattle:
Seattle Pacific University; 2006.
54. Sun TF,Kuo CC,Chiu NM.Mindfulness meditation
in the control of severe headache.Chang Gung Med
55. Rosenzweig S, Greeson JM, Reibel DK, Green JS,
Jasser SA, Beasley D. Mindfulness-based stress
reduction for chronic pain conditions: Variation in
treatment outcomes and role of home meditation
practice. J Psychosom Res. 2010;68:29-36.
56. Coghill RC. Individual differences in the subjective
experience of pain: New insights into mechanisms
and model. Headache Curr. 2010;50:1531-1535.
57. Carod-Artal FJ, V’azquez-Cabrera C. Headache
medicine in Brazil:Research submissions an anthro-
pological study about headache and migraine in
native cultures from central and South America.
58. International Headache Society. The international
classification of headache disorders, 2nd ed. Ceph-
alalgia. 2004;24(Suppl. 1):1-160.
59. Melzack R. The McGill pain questionnaire: Major
properties and scoring methods. Pain. 1975;1:277-
60. Melzack R, Katz J. The McGill pain questionnaire:
Appraisal and current status. In: Turk DC, Gatchel
RJ, eds. Psychological Approaches to Pain Manage-
ment: A Practitioner’s Handbook, 2nd edn. New
York: Guilford; 2001:35-52.
61. Stewart WF, Lipton RB, Dowson AJ, Sawyer J.
Development and testing of the migraine disabi-
lity assessment (MIDAS) questionnaire to assess
62. Spielberger CD, Gorsuch RL, Lushene R, Vagg
RK, Jacobs GA. State-Trait Anxiety Inventory for
Adults. Palo Alto, CA: Consulting Psychologists;
63. Öst LG. Efficacy of the third wave of behavioral
therapies: A systematic review and meta-analysis.
Behav Res Ther. 2008; 46:296-321.
64. Van Breukelen GJ. ANCOVA versus change from
baseline: More power in randomized studies, more
bias in nonrandomized studies. J Clin Epidemiol.
65. Morris SB. Estimating effect sizes from pretest-
posttest-control group designs. Organ Res Methods.
66. Carlson KD, Schmidt FL. Impact of experimental
design on effect size: Findings from the research
literature on training. J Appl Psychol. 1999; 84:851-
67. Samwel H. Chronic Pain Treatment: From Psycho-
logical Predictors to Implementation. Wageningen,
Netherlands: Pensen avd Looyen BV; 2008.
68. Schütze R, Rees C, Preece M, Schütze M. Low
mindfulness predicts pain catastrophizing in a
fear-avoidance model of chronic pain. Pain. 2010;
69. Nash JMDMW, Nicholson R, Trask PC. The contri-
bution of pain-related anxiety to disability from
headache. J Behav Med. 2006;29:61-67.