Table 1 Description of activities in each therapy session

First session

Therapeutic agreement and psychoeducation

 1. Forming a therapeutic agreement between patients and the therapist regarding number of therapy sessions and their durations, the process of treatment, and confidentiality issues

 2. Educating patients about the nature and causes of headaches and its comorbid psychological disorders and discussing definition of anxiety

 3. Explaining the importance of completing homework at home, and providing instructions on homework,

 4. Giving homework to patients on self-monitoring (recording dates of experiencing headaches, duration of the pain, and its severity based on a scale from 0 to 10; rating the average daily anxiety level on a scale of 0 to 100)

 5. Asking patients to provide a list of situations that are associated with distressing anxiety for them

 6. Briefly explaining the content of the next session

Second session

Educating relaxation training and hierarchy of behavioral avoidance

 1. Educating relaxation techniques and preparation of hierarchy of behavioral avoidance for the better management of headache and anxiety responses

 2. Evaluating patients’ homework on self-monitoring and analyzing headache triggers

 3. Explaining the components of anxiety to patients

 4. Giving homework to patients on relaxation exercises

 5. Giving homework to patients on self-monitoring

 6. Briefly explaining the content of the next session

Third session

Automatic negative thoughts and guided imagery

 1. Evaluating patients’ problems in practicing relaxation techniques and preparing a hierarchy of behavioral problems as an important part of the treatment

 2. Discussing the importance of thoughts and educating how to identify automatic negative thoughts

 3. Giving homework to patients on recognizing and recording automatic negative thoughts

 4. Evaluating headache and anxiety daily diary recorded by the patient

 5. Delivering a CD containing audio on guided imaginary to patients to practice with at home

 6. Briefly explaining the content of the next session

Fourth session

Cognitive restructuring

 1. Ensuring that the patients have performed their self-monitoring homework and relaxation exercises

 2. Assessing automatic thoughts identified by patients during the past week

 3. Educating patients on how to challenge automatic thoughts

 4. Educating patients on cognitive errors and helping them to identify such errors

 5. Addressing patients’ ambiguities

 6. Briefly explaining the content of the next session

Fifth session

Problem solving skills and distraction technique

 1. Evaluating patients’ improvements in performing homework

 2. Educating problem solving skill and using role-playing techniques

 3. Educating distraction technique to reduce overthinking

 4. Giving homework on problem solving and distraction skills

 5. Briefly explaining the content of the next session

Sixth session

Exposure and cognitive restructuring

 1. Evaluating problem solving homework, assessing learned skills and the way patients apply them in their daily lives

 2. Educating self-directed exposure to patients and giving them homework on this skill

 3. Educating advanced cognitive reconstruction steps and encouraging patients to apply them in real life situations

 4. Extensive focusing on daily general stress level instead of targeting a special problem

 5. Summarizing the session and addressing patients’ ambiguities

 6. Briefly explaining the content of the next session

Seventh, Eighth, and Ninth session

Advanced cognitive restructuring, stress management, assertiveness skills training, preparation for therapy termination

 1. Evaluating self-monitoring homework, exposure, and cognitive reconstruction of patients to ensure their proper learning and applying them by patients in their lives

 2. guiding patients in cognitive reconstruction processes

 3. Educating stress management, assertiveness skills, and the ability to say “No”

 4. Advising patients to continue cognitive reconstruction homework, stress management techniques, and assertiveness skills in appropriate situations

 5. preparing patients for the last therapy session

Tenth session

Relapse prevention and therapy termination

 1. Evaluating patients’ performances in stress management and assertiveness skills

 2. Encouraging patients to continue doing homework and rewarding themselves

 3. Educating patients to administer the learned therapeutic techniques in case of disease recurrence

 4.Summarizing previous sessions and getting feedback from patients on different therapy sessions and effectiveness of the learned techniques

 5. Discussing with patients about the new perspectives they need to learn about themselves and their problems

 6. Congratulating patients on completing therapy sessions and acknowledging their participation in the program