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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

rewells@wakehealth.edu

@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

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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

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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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336-705-2396Help4Migraines@wakehealth.edu

Wakehealth.edu/BeInvolved/Migraine

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In one week:

• 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

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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

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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?

rewells@wakehealth.edu

@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

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How to Learn More

(Ideas, NOT endorsements)

Apps

Mindfulness Training App

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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

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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.