Journal of Consulting and Oinical Psychology Copyright 1988 by the American Psychological Association, Inc

1988. Vol. 56, No. 4,621-623 0022-006X/88/S00.75

Exploration of the Type A Behavior Pattern

in Chronic Headache Sufferers

Neil B. Rappaport David P. McAnulty and Phillip J. Brantley

University of Alabama at Birmingham Louisiana State University

Several recent studies have indicated a relation between the Type A behavior pattern (TABP) and
headache occurrence. Researchers have also noted descriptive similarities between Type A character-
istics and characteristics associated with the "migraine personality." To date, no prospective study
has examined whether the characteristics ascribed to migraine sufferers in fact comprise the TABP.
Sixty participants (30 migraine, 30 tension headache) provided full headache histories, completed
the Jenkins Activity Survey, and were diagnosed according to Ad Hoc Committee on Classification
of Headache criteria. Approximately 53% of migraine participants were classified as Type A com-
pared with only 231 of tension headache participants, and this difference was statistically significant.

Cardiologists Friedman and Rosenman were the first to con-
ceptualize the coronary-prone behavior pattern now referred to
as Type A (Friedman & Rosenman, 1959). Their initial formu-
lation of the Type A behavior pattern (TABP) included descrip-
tions of individuals who displayed overtly competitive strivings
for achievement, aggressiveness, time urgency, and easily
aroused hostility (Matthews & Haynes, 1986). Although the
original conceptualization grew from their clinical practice
with relatively young survivors of myocardial infarction, em-
pirical studies have since documented the link between the
TABP and coronary heart disease (CHD) (Haynes, Feinleib, &
Kannel, 1980; Jenkins. Zyzanski. & Rosenman. 1976; Rosen-
man etal., 1975).
Although the underlying biological mechanisms that link the
TABP to the development of CHD have not yet been delineated,
most researchers are currently investigating cardiovascular
hyperreactivity patterns (Roskies et al., 1986). It has been hy-
pothesized that frequent sympathetic-adrenomedullary activa-
tion could be the major etiological component in the develop-
ment of CHD in Type A individuals (Krantz & Manuck, 1984).
In addition, both headache researchers and practitioners who
investigate the biological mechanisms involved in migraine
headache have pointed toward a similar vascular dysregulation
(Adams, Feuerstein, & Fowler, 1980; Diamond & Dalessio,
1978).
Descriptions of the "migraine personality" and of those char-
acteristics usually ascribed to the Type A individual are similar
in several ways.
Migraine sufferers are characterized by irritability, compul-
sivity, rigidity, perfectionism, inhibited expressions of anger and
hostility, preoccupation with achievement, the tendency to
dominate theirenvironment, and the inability to feel tired (Dia-
mond & Dalessio, 1978; Bihldorf, King, & Parnes, 1971). Clas-
Correspondence concerning this article should be addressed to Neil
B. Rappaport, Division of General and Preventive Medicine, University
of Alabama at Birmingham, 60S Medical Education Facility. University
Station, Birmingham, Alabama 35294.
sic Type A individuals are characterized by extreme strivings
for success, constant time pressure, chronic restlessness and im-
patience, feelings of fierce competitiveness, and irritable and
hostile attitudes toward others (Jenkins, Zyzanski, & Rosen-
man, 1979).
To date, only two studies have explored the relation between
TABP and headache. Hicks and Campbell (1983) published a
brief report that surveyed college students to collect their self-
estimates of headache frequency. Results demonstrated a rela-
tion between Type A, as measured by the Jenkins Activity Sur-
vey (JAS), and headache frequency. Woods, Morgan, Day,
Jefferson, and Harris (1984), in addition to replicating Hicks
and Campbell's survey results with female undergraduates,
provided further evidence by using data collected archivally
from a clinical population; 75% of headache patients (seen in
private practice) scored above the mean for the norm group on
the JAS. Although both of these studies were methodologically
unsophisticated, they did suggest some relation between the
JAS and headache occurrence or frequency. The purpose of this
study was to recruit a sample of migraine and tension headache
sufferers and to examine (prospectively) whether a high propor-
tion of them were Type A individuals. It was hypothesized that a
larger proportion of migraine headache compared with tension
headache individuals would match the Type A classification.
Method
Students were recruited through newspaper advertisements and refer-
rals from the medical community. Demographically. most of our partic-
ipants (30 migraine and 30 tension headache sufferers) were married
(61%), White (87%), adult (mean age = 38.8 years, range = 18-66)
women (77°o), and most were educated (41°fc had college degrees).
Headache groups differed only on sex, with more men in the muscle
contraction group, x2( 1 A' = 60) = 5.96, p < .02; 10% of the migraine
participants compared with 36.6% of the tension headache participants
were men.
All participants were diagnosed by a board-certified neurologist and
a doctoral candidate in clinical psychology with several years of experi-
ence in headache research using the diagnostic criteria of the Ad Hoc
Committee on Classification of Headache (1962) for purposes of diag-

621
622 BRIEF REPORTS
Table I
Distribution of JAS Groups Among Headache Diagnoses
Headache diagnosis
Migraine Tension
(« = 30) (« = 30)
Jas group
Type A 16 53.33 7 23.33
TypeX 9 30.00 13 43.33
TypeB 5 16.67 10 33.33
Note. JAS = Jenkins Activity Survey.
nostic group assignment. For those cases in which the physician and
psychologist could not agree on a diagnosis (usually due lo poor or inad-
equate reports of headache symptomatology), participants were re-
ferred for treatment elsewhere. All subjects agreed to participate in a
neurological screening to rule out any physical abnormalities that may
have accounted for their pain. The screening included either a CAT
scan, a skull X ray, or an electroencephalogram. Individuals meeting
the Ad Hoc Committee on Classification of Headache criteria and re-
porting a minimum of three headaches per week (for muscle contrac-
tion headache) or two headaches per month (for migraine headache)
were included in the study. Subjects who met criteria for mixed head-
ache were excluded from the present study. Other exclusionary criteria
included diagnosed sinus headaches, temporomandibular joint (TMJ)
pain, structural damage (e.g., pinched nerve or concussion), or a history
of major psychiatric illness (e.g., psychosis). Subjects were also excluded
if they tested positive on one of the neurological screening tests.
All participants were administered the JAS (Jenkins et al., 1979) on
their inclusion in the study. Participants were asked to monitor their
headache activity for 8 consecutive weeks.
Subjects scoring in the 75th percentile or higher on the Type A scale
were classified as Type A. Headache sutferers scoring at or below the
25th percentile were classified as Type B. Those participants whose
score fell between these two cutoffs were classified as Type X (i.e., pos-
sessing some characteristics of both types). The mean percentile for in-
dividuals diagnosed with migraine and tension headache was 62.5 and
50.7, respectively.
Results and Discussion
A chi-square analysis was used to determine if the distribu-
tion of Types A, B. and X differed for migraine and tension
headache sufferers. Results showed that there were significantly
more Type A individuals in the migraine group, \~(2 Ar = 60) =
5.92, p < .05. Table I contains the distributions.
Mean measures of headache intensity, assessed on a 1-10 rat-
ing scale, were computed for each participant. The average
number of headaches per 4-week period (headache frequency)
was also recorded for each individual (days with headache = 0-
28). These two head pain parameters were analyzed by a 2 X
3 (Headache Diagnosis x JAS Group) completely randomized
multivariate analysis of variance (MANOVA). The results indi-
cated significant differences for JAS group, multivariate F(4,
108) = 2.76, p < .03, and headache diagnosis, multivariate F(2,
53) = 7.03, p < .002. The interaction was not significant.
A follow-up two-way analysis of variance (ANOVA) for head-
ache intensity revealed significant differences for JAS group.
F(2, 54) = 3.76. p < .03. A two-way ANOVA for headache fre-
quency indicated a significant difference for headache group
only, f\ 1,54) = 14.27, p < .0007. Post hoc analysis for headache
intensity means revealed that Type B participants (M = 3 . 1 )
reported headaches of milder intensity than did Type X (M =
4.1) and Type A (M = 3.9) participants. For headache fre-
quency, tension headache sufferers (M = 20.9) reported signifi-
cantly more headaches than migraine headache sufferers
( A / = 12.4).
The significant difference between tension and migraine
headache sufferers on frequency is not surprising due to the cri-
teria of the study. However, the lack of a difference between Type
A and Type B participants does not replicate earlier results
(Hicks & Campbell, 1983; Woods etal., 1984). Further exami-
nation of headache frequency in Type A and Type B individuals
is needed.
More interesting were the results of the headache intensity
analyses: Type B participants reported significantly less intense
head pain compared with Type A and Type X participants.
Based on previous laboratory findings that demonstrated the
Type A individual's tendency to suppress the reporting of physi-
cal complaints and symptoms (Hart, 1983; Matthews & Carra,
1982), one would expect results in the opposite direction. These
results need further replication outside of the laboratory set-
ting.
This exploratory investigation examined the distribution of
the TABP within a chronic headache population. It was hypoth-
esized that there would be a high prevalence of Type A individu-
als in the migraine population. Results demonstrated that well
over 50°i> of those diagnosed with migraine headaches were in
fact Type A individuals; tension headache sufferers generated a
more normal distribution across the Type A, Type B, and Type
X classifications. The results of this investigation begin to clar-
ify the controversy surrounding the migraine personality. In
past investigations, researchers have attempted to report
differences using measures of psychopathology and have usually
come up with nonsignificant results.
Significant findings in this study support the proposition that
the original conceptualization of Type A behavior (i.e., coro-
nary-prone behavior) needs to be broadened to include other
vascular dysfunctions (Woods et al., 1984). Future studies are
needed to replicate and extend these findings to support the
concept of a vascular-prone behavior pattern. The results of this
study imply that those individuals who possess Type A features
may beat risk for other disorders (particularly vascular) in addi-
tion to the coronary problems that have previously been docu-
mented. The notion that a behavior pattern can function as a
risk factor for a disease process was recently expressed by Fried-
man and Booth-Kewley (1987). In their meta-analytic review
of personality characteristics and disease, they concluded that
an individual's pattern of behavior "may function like diet: Im-
balances can predispose one to all sorts of diseases" (p. 552).
Because of the exploratory nature of this investigation, the
JAS was used as the only measure of Type A due mainly to time
and financial constraints. Follow-up investigations in the area
might choose to utilize the JAS in addition to the Structured
Interview (Rosenman. 1978), which is still the benchmark cri-
teria in Type A research.
Future studies need to determine if the features and psycho-
 BRIEF REPORTS
logical descriptors of these Type A headache individuals differ
from those of Type A populations that have already been stud-
ied in large trials (e.g., the Western Collaborative Group Study,
the Framingham Study). Because the hypothesized underlying
biological mechanism for these two populations seems to be
vascular, the investigation of differential psychophysiological
reactivity patterns (particularly of vascular activity) between
migraine headache sufferers who are and are not Type A indi-
viduals would be of interest.
References
Adams, H. E.. Feuerstein, M.. & Fowler. J. L. (1980). The migraine
headache: A review of parameters, theories, and interventions. Psy-
chological Bulleiin, 87, 217-237.
Ad Hoc Committee on Classification Of Headache. (1962). Classifica-
tion of headache. Journal of the American Medical Association, 179,
717-718.
Bihldorf J. P.. King, S. H., & Parnes, L. R. (1971). Psychological factors
in headache. Headache. II. 117-127.
Diamond, S.. & Dalessio, D. J. 11978). The practicing physician's ap-
proach lo headache (2nd ed.). Baltimore, MD: Williams & Wilkins.
Friedman, H. S., & Booth-Kewley, S. (1987). The disease prone person-
ality: A meia-analytic view of the construct. American Psivhologist,
«.S39-555.
Friedman, M., & Rosenman. R. H. (1959). Association of specific overt
behavior pattern with blood and cardiovascular findings. Journal of
ihe American Medical Association, 169, 1286-1296.
Hart. K. E. (1983). Physical symptom reporting and health perception
among Type A and B college males. Journal of Human Stress. 9, 17-
22.
Haynes, S. G., Feinleib, M.. & Kannel, W. B. (1980). The relationship
of psychosocial factors to coronary heart disease in the Framingham
Study III: Eight-year incidence of coronary heart disease. American
Journal of Epidemiology, I I I , 37-59.
623
Hicks, R. A., & Campbell, J. (1983). Type A-B behavior and self-esti-
mates of the frequency of headaches in college students. Psychological
Reports, 52.912.
Jenkins, C. D., Zyzanski. S. J.. & Rosenman, R. H. (1976). Risk of new
myocardial infarction in middle-aged men with manifest coronary
heart disease. Circulation, 53, 342-347.
Jenkins, C. D., Zyzanski, S. J., & Rosenman, R. H. (1979). Manual for
the Jenkins Activity Survey. New York: Psychological Corporation.
Krantz. D. S., & Manuck, S. B. (1984). Acute psychophysiological reac-
tivity and risk of cardiovascular disease: A review and methodologic
critique. Psychological Bulletin. 96. 436-464.
Matthews, K. A., & Carra, J. (1982). Suppression of menstrual distress
symptoms: A study of Type A behavior. Personality and Social Psy-
chology Bulletin, 8, 146-151.
Matthews, K. A., & Haynes. S. G. (1986). Type A behavior pattern and
coronary disease risk: Update and critical evaluation. American Jour-
nal of Epidemiology. 123, 923-960.
Rosenman, R. H. (1978). The interview method of assessment of the
coronary-prone behavior pattern. In T. P. Dembroski, S. M. Weiss,
J. L. Shields, S. G. Haynes, & M. Feinleib (Eds.), Coronary-prone
behavior New York: Springer-Verlag.
Rosenman, R. H., Brand, R. J., Jenkins, C. D., Friedman, M., Straus,
R., & Wurm. M. (1975). Coronary heart disease in the Western Col-
laborative Group Study: Final follow-up experience of 8.5 years.
Journal of the American Medical Association, 233. 872-877.
Roskies, E., Seraganian, P., Oseasohn, R., Hanley. J. A., Collu, R., Mar-
tin, N.. & Smilga, C. (1986). The Montreal Type A Intervention Proj-
ect: Major findings. Health Psychology. 5. 45-69.
Woods. P. J.. Morgan. B. T., Day, B. W, Jefierson, T., & Harris, C.
(1984). Findings on a relationship between Type A behavior and
headaches. Journal of Behavioral Medicine. 7, 277-286.
Received June 29, 1987
Revision received December 15, 1987
Accepted January 12, 1988 •