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Wake Forest Baptist Medical Center
Mindfulness & Meditation
Rebecca Erwin Wells, MD, MPHAssociate Professor, Neurology
Founder & Director, Headache Program at Wake Forest Baptist
Associate Director-Clinical Research, Center for Integrative Medicine
Wake Forest Baptist Health
@RebeccaWellsMD
Wake Forest Baptist Medical Center
Disclosures
• No Financial Disclosures
Wake Forest Baptist Medical Center
Objectives
• Define mindfulness and mindfulness meditation
• Examine the evidence for mindfulness for headaches
• Describe the neuroscience of meditation
• Discuss how to apply this knowledge into the clinical practice of
headache medicine
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Wake Forest Baptist Medical Center
Objectives
• Define mindfulness and mindfulness meditation
• Examine the evidence for mindfulness for headaches
• Describe the neuroscience of meditation
• Discuss how to apply this knowledge into the clinical practice of
headache medicine
Wake Forest Baptist Medical Center
Meditation
• Self-regulation of attention and awareness
• Types
• Concentration Meditation
• Mindfulness Meditation
• Cultivate attention & awareness
Wake Forest Baptist Medical Center
What is Mindfulness?
• “The awareness that arises through
• Paying attention
• On purpose
• In the present moment
• Non-judgmentally”
-Jon Kabat Zinn
Awareness
Mindfulness
AcceptancePresent Moment
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Historical Perspective
• Long historical roots (religious)
• Stress Reduction Clinic 1979
• Research
• Media
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Mindfulness-Based Stress
Reduction (MBSR)
• Standardized 8 weekly 2 hr classes + home
• Body scan, sitting meditation, yoga, mindfulness
• Teaches:
• Focus on present moment
• Practice without judgment
Wake Forest Baptist Medical Center
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Number of Media Articles Relative
to Meditation Published by Year
Lauricella S, J Relig Health 2016.
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A Mindful Moment
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Objectives
• Define mindfulness and mindfulness meditation
• Examine the evidence for mindfulness for headaches
• Describe the neuroscience of meditation
• Discuss how to apply this knowledge into the clinical practice of
headache medicine
Wake Forest Baptist Medical Center
Wake Forest Baptist Medical Center
Stress & Headaches
• Stress # 1 reported migraine trigger (60%)
• Meta-analysis of 7187 migraineurs
• HPA axis: hypothalamic-pituitary-adrenal
• Cortisol
• Autonomic Nervous
• Epinephrine, NE
Peroutka SJ, 2014
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Behavioral & Mind/Body Treatments
Behavioral
• Cognitive behavioral therapy (CBT)
• Stress management
• Coping skills
• Biofeedback
• Relaxation training
Mind/Body
• Meditation, Yoga, Tai Chi
• Guided Imagery
• Biofeedback
• Hypnosis
• Qi gong
• Deep Breathing Exercises
• Progressive Relaxation
Headache 2012;52;S2:70-75.
Wake Forest Baptist Medical Center
Prevalence of Mind/Body Use
among Adults with Severe HA
Wells et al. Headache 2011.
0 5 10 15 20 25 30
Deep Breathing exercises
Meditation
Yoga
Progressive relaxation
Guided Imagery
Biofeedback
Percent
<1%
17%
9%
6%
4%
24%
Medicines
• Side effects
• Not 100% effective
• Not always ideal:
• Co-morbidities
• Pregnant
• Breastfeeding
Mind-Body
• Congruent-beliefs
• Few side effects
• Concurrent- medicines
• Address other factors
playing a role
Non-Drug Treatment Options Needed
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• ≥18 yo with 4-14 Migraines/mo x 1yr (ICHD-II)
• Randomize to mindfulness meditation or control group
• Before and after, evaluated:
• HA frequency, severity
• QOL and well-being
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Continued
daily
headache
logs
Assessed For Eligibility-Phone Screen (n=111)
Assessed For Eligibility-In-Person Screen (n=29)
Excluded (n=82)
Maintained 28 day headache
log
Excluded (n=10)
Randomized (n=19)
Allocation
Wait-list usual care (n=9)
Follow-up
Analysis(n=10)
(n=10)
(n=9)
(n=9)
MBSR (n=10)
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Results• Although underpowered, migraines were
• Less frequent by 1.4/mo d=0.32
• Less severe (0-10) by 1.3 d=0.61
• Shorter by 3 hrs* d=0.75
• Lower Disability scores*
• MIDAS -13 d=1.37
• HIT-6 -5 d=0.91
• Self efficacy & mindfulness improved* (d=0.8)
*Statistically significant
• Qualitative Analyses:
• ↓Emotional reactivity
• ↓ Pain catastrophizing
• ↑Pain acceptance
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Potential Mechanisms of Meditation
on Migraine Pain
• Non-reactive approach to life stressors
• Decreases emotional reactivity
• Decreases affective response to stress
• Practice non-judgmental awareness of sensory events
• Detached observation of sensory experiences (pain)
• Reducing affective>sensory component of pain
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Headache
Threshold
Individual Baseline } Lowered
Baseline
} Raised
Threshold
A
B
Wells, RE Headache 2012.
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Wakehealth.edu/BeInvolved/Migraine
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• 31K Views
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Jacob, JAMA 2016.
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Objectives
• Define mindfulness and mindfulness meditation
• Examine the evidence for mindfulness for headaches
• Describe the neuroscience of meditation
• Discuss how to apply this knowledge into the clinical practice of
headache medicine
Wake Forest Baptist Medical Center
What happens physiologically with
meditation?
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Mindfulness Meditation--
Beyond Relaxation
• Attention regulation
• Body awareness
• Emotion regulation
• Non-reactivity
• Meta-cognition
Kabat-Zinn 1982; Zeidan 2011; Goldin 2010; Farb 2012;
Hoge 2013; Kerr 2013; Creswell 2014.
The Psychological Effects of Meditation
• Improves well-being
• Decreases perceived stress
• Reduces recurrence of depression and levels of
anxiety
Grossman et al. 2004; Chiesa, Serretti. 2009;
Teasdale et al. 2000; Kabat-Zinn et al. 1992.
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Possible Mechanisms of Meditation
• Decrease depression and anxiety
• Improve coping skills
• Improve locus of control, self-efficacy
• Decrease stress hormones
• Increase parasympathetic tone
• Create changes in the brain
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Neuroplasticity
•The brain is built to change in
response to experience and
training
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Structural Differences
Ott, U., Hölzel, B.K., & Vaitl, D. Brain structure and
meditation. How spiritual practice shapes the brain.
Neuroscience, Consciousness and Spirituality:
Proceedings of the Expert Meeting in
Freiburg/Breisgau 2008.
•Lazar et al. 2005.
•Pagnoni & Cekic. 2007.
•Hölzel et al. 2008.
•Vestergaard-Poulsen et al.2009.
•Luders et al. 2009.
Activation during Meditation
• Prefrontal
• Anterior Cingulate
• Insula
• Hippocampus
• Thalamus
• Putamen
• Parietal
Lou et al. Human Brain Mapping 1999.
Lazar et al. NeuroReport 2000.
Newberg et al Pscych Res
Neuroimaging 2001.
Brefczynski-Lewis et al. PNAS 2007.
Farb et al. SCAN 2007.
Creswell et al. Psychosom Med 2007.
Tang et al. PNAS 2009.
Pagnoni et al. PLoS One 2008.
Lutz et al. NeuroImage 2009.
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• 16 subjects learned to meditate
• MRIs before & after
• Increased concentration of gray matter in hippocampus
The Impact of Meditation on the Brain
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Prefrontal Cortex
Parietal
Cortex
Hippocampus
AmygdalaThalamus
Cingulate Cortex• Attention
• Concentration
• Emotional regulation
• Sensory/
spatial
recognition
• Learning & memory
• Emotional regulation
• Cortical-subcortical
• Cognitive & affective
response
• Mediates stress-
related behavior
• Fear
• Attention
• Executive function
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Insula
• Body
Awareness
• Empathy
• Awareness of
consciousness
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Pain Mechanisms:
Psychophysical Pain Responses
• Using thermal heat to evoke pain, measuring:
• Pain intensity-sensory
• Pain unpleasantness-affective
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Pain decreased after learning to meditate ↓Pain unpleasantness (57%) & intensity (40%)
Meditation related pain relief
Directly related to brain regions
Important for understanding pain
Journal of Neuroscience, April 6, 2011
Wake Forest Baptist Medical Center
The Journal of Neuroscience, March 16, 2016.
• Meditation ↓ Pain Intensity & Unpleasantness
• Naloxone failed to reverse these findings
• No differences in meditation + naloxone vs.
meditation + saline
• Mindfulness meditation does NOT rely on
endogenous opioid mechanisms to ↓ pain
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Wake Forest Baptist Medical Center
Objectives
• Define mindfulness and mindfulness meditation
• Examine the evidence for mindfulness for headaches
• Describe the neuroscience of meditation
• Discuss how to apply this knowledge into the clinical practice of
headache medicine
Wake Forest Baptist Medical Center
When to Consider
• Medications not working
• Medication overuse
• Interested in non-drug approaches
• Build self-efficacy: empower, active
• Address other factors playing a role
• Stress, anxiety
What are the Barriers & Risks?
Barriers
• Time
• Energy
• Commitment
• Teacher/training
• Costs
Risks/Side Effects
• Generally safe
• Rare cases: psychosis
-Psych history
• Paradoxical tension/anxiety
• Musculoskeletal
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Where do I go to get started? • Local psychologist/therapist
• Local Classes
• Stress reduction
• Meditation, yoga, tai chi, etc.
• Retreats centers
• CDs, books, apps, websites
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Mindfulness in Medicine
• Being present: attention
• Non-judgment
• Acceptance
• Understanding of patients as people
• Awareness of patient’s and own emotions
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JAMA. 2009;302(12):1284-1293.
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Practicing Mindfulness with My Patients
• Room with patient: my presence
• Specific phrases of compassion
• “I Honor…”
• Don’t “look ahead”
• Work space environment
• Botox, occipital nerve block procedures
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Final Tips and Pearls• Stress can be a potential trigger for migraines
• Mindfulness meditation may be helpful
• Potential for significant improvement
• With broad benefits, narrow harms
• Additional research pending
• Neuroscientific evidence suggests meditation may impact brain areas
important for pain
• Practicing mindfulness may enhance providers’ well-being
Wake Forest Baptist Medical Center
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Wake Forest Baptist Medical Center
Objectives
• Define mindfulness and mindfulness meditation
• Examine the evidence for mindfulness for headaches
• Describe the neuroscience of meditation
• Discuss how to apply this knowledge into the clinical practice of
headache medicine
Acknowledgements
Wake Forest Baptist Medical Center
Research Support
• NIH National Center For Complementary & Integrative Health (NCCIH)
K23AT008406
• American Pain Society Sharon S. Keller Chronic Pain Research Grant
• National Research Service Award T32AT000051 from NCCAM at the
NIH
• 2011 American Headache Society Fellowship Award
• National Institutes of Health (NIH) Loan Repayment Program
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Any questions?
@RebeccaWellsMD
Wake Forest Baptist Medical Center
Appendix
Wake Forest Baptist Medical Center
How to Learn More
(Ideas, NOT endorsements)
Training/Courses for Providers
Websites
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Wake Forest Baptist Medical Center
How to Learn More
(Ideas, NOT endorsements)
Retreats
Wake Forest Baptist Medical Center
How to Learn More
(Ideas, NOT endorsements)
Apps
Mindfulness Training App
Wake Forest Baptist Medical Center
57 How to Learn More-(Ideas, NOT Endorsements)
Books
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Results
Improvements in:
• Mindfulness
• Burnout
• Empathy
• Physician Belief scale
• Total mood disturbance
• Personality factors
(conscientiousness,
emotional stability)
Mindfulness correlated with:
• Total mood
• Physician empathy,
perspective taking
• Decreased burnout
• Personal Factors
58
JAMA. 2009;302(12):1284-1293.
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Positive Effects for Providers
• Enjoyment
• Sense of Control
• Personal Meaning
• “Being present” correlates more with meaning
in work than diagnostic and therapeutic
triumphs
Horowitz 1995
West et al. JAMA Intern Med 2014.
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Mindfulness Research Supports the
Provider’s Wellbeing
Improves Positive
• Empathy
• Self-compassion
• Positive affect
• Life satisfaction
• Mood
Reduces Negative
• Stress
• Ruminative thoughts & behaviors
• Burnout
• Anxiety
• Depression
• Emotional exhaustion
Burton, et al. Stress Health 2016.
Lamothe et al. Complement Ther Med 2016.
Irving et al. Complementary Therapies in Clinical Practice, 2009.