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-
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Frame Theory.33ACT proposes that psychological
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connect with the present moment fully and mindfully,
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a process whereby an individual deliberately attempts
to change the form or frequency of private experi-
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memories, behavioral predispositions), and the con-
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emotional, cognitive, and behavioral consequences
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