Biofeedback as a Treatment for Migraine

February 2000; Volume 3: 20-22

By V. Jane Kattapong, MD, MPH

Look into the depths of your own soul and learn first to know yourself, then you will understand why this illness was bound to come upon you and perhaps you will thenceforth avoid falling ill.

Sigmund Freud, MD

One of the Difficulties of Psychoanalysis

Migraine headache is an extremely common disorder, and the prevalence is reportedly increasing.1 At some point in their lives, up to 15% of the world’s population suffers from migraine. Migraine headache continues to be undertreated, resulting in temporary disability, lost work days, and decreased quality of life. In fact, many migraineurs have never been diagnosed and have never received treatment.

Reasons for not seeking treatment include reluctance to rely on pharmaceutical agents, which may have side effects, be costly, or lead to dependence. Employing nonpharmacologic treatment can circumvent these obstacles to obtaining migraine relief and may help migraineurs help themselves.

Migraine Risk Factors

Many risk factors, including diet and environmental factors, play a role in the genesis of migraine episodes in those who are susceptible. Skipping meals, weather changes, and high altitude may trigger migraine. In addition, lifestyle factors that can trigger migraines include changes in sleep pattern or amount of sleep; stress or the stress letdown that occurs after a positively or negatively stressful event; exposure to bright light, fluorescent light, or sunlight; loud noises; strong odors; or overuse of headache medication.

Mechanism of Action

Nonpharmacologic treatments, more so than pharmacologic treatments, may allow migraineurs to be in control of their headaches,2 since nonpharmacologic treatments are self-directed, in contrast to the external control imposed by pharmacologic agents.

Nonpharmacologic treatments of migraine include biofeedback and relaxation. The mechanism for their effectiveness is not well understood.3 Of these two techniques, a greater body of literature has accumulated regarding outcomes from biofeedback.4 One possible mechanism for the effectiveness of biofeedback is a decrease in sympathetic outflow or stabilization of autonomic nervous system activity, and a resulting improvement in migraine activity.5 However, since a dose-response relationship between the effectiveness of biofeedback and headache relief has not been proven,6 an alternative hypothesis is that biofeedback brings migraine relief through implicating conditioned relaxation.7

What is a possible mechanism for the effectiveness of biofeedback?

a. Decrease in sympathetic outflow

b. Increase in autonomic nervous system activity

c. Conditioned relaxation

d. a and c

e. All of the above.


What Is Biofeedback?

Biofeedback techniques take advantage of the fact that patients can be made aware of measurable aspects of physiologic function which are potential indicators of migraine susceptibility. Provision of this information enables patients to attempt consciously to alter these physiologic functions.

There are several varieties of biofeedback. Thermal biofeedback, frontalis EMG biofeedback, and cephalic vasomotor feedback are among the varied types of techniques that have been employed to alter physiologic manifestations of migraine. Chapman believes that biofeedback is most likely to be effective in younger patients who are not habituated to analgesics.8 Thus it seems likely that biofeedback will differentially benefit some subgroups of patients more than others.

Thermal Biofeedback

Thermal biofeedback involves obtaining skin temperature measurements, usually from the finger, and conveying this information to the patient. The goal of thermal biofeedback is to teach the migraineur to raise the peripheral finger and hand temperature.8 In essence, the technique teaches cognitively controlled handwarming.

Frontalis EMG Biofeedback

EMG biofeedback uses EMG data to provide patients with measurements of the intensity of muscle contraction. These data are then used to induce a decrease in intensity of muscle contraction.

Cephalic Vasomotor Feedback

Cephalic vasomotor feedback utilizes photoplethysmography to present a visual representation of temporal artery blood-volume pulse amplitude. As the signal width varies with vasodilatation and vasoconstriction, patients are asked to cause the signal to become more narrow. Guided imagery, such as description and visualization of traversing a tunnel, and methods of positive reinforcement may be employed to enhance results.2

Procedure

Biofeedback training sessions usually are provided by psychologists or other practitioners who have had counseling training.9 However, no license is required for health professionals who utilize biofeedback techniques. Sessions may take 30-60 minutes, and typically 4-16 sessions are given.10 During the course of the sessions, patients are taught techniques that they can perform on their own.

What are some specific techniques utilized for biofeedback?

a. Thermal biofeedback

b. Frontalis EMG biofeedback

c. Cephalic vasomotor biofeedback

d. All of the above.


Clinical Trials

Numerous controlled trials have reported a therapeutic effect of thermal biofeedback for migraine sufferers.11 One uncontrolled comparison study of biofeedback and relaxation found biofeedback to be more effective.4 In a nonrandomized study of 27 adult migraine patients, the effectiveness of thermal biofeedback, frontalis EMG biofeedback, and relaxation training was compared.4 A total of 24 training and maintenance sessions were given to each patient, with subsequent follow-up for up to six months. Significant longitudinal improvements in headache frequency were demonstrated in all three groups.4

In a randomized, eight-month trial of psychological and pharmacological treatment of pediatric migraine, 43 German schoolchildren received either psychological treatment or pharmacologic treatment with metoprolol, a beta blocker.2 Those receiving psychological treatment were separated into two groups: those receiving biofeedback from cephalic vasomotor training and those receiving relaxation training.

The children were asked to complete headache diaries including entries regarding quality, duration, frequency, and intensity of headaches. Relaxation training was the most effective treatment (P = 0.04) and metoprolol was the least effective, with biofeedback intermediate in effectiveness. However, in a comparison of pre- and post-treatment data, children treated with cephalic vasomotor feedback demonstrated significant improvements in headache frequency, headache duration, and mood.

The usefulness of biofeedback technique as an adjunctive and alternative therapy for pregnant mi-graineurs is accepted in the medical literature.10 Relatively few pharmacologic treatments are believed to be safe. With this constraint in place, biofeedback has taken on more importance as a therapeutic option among practitioners of standard medical therapy.

In a controlled study involving 30 pregnant women with a history of migraines, Marcus found that women taught to engage in relaxation and biofeedback experienced an 81% decline in headache intensity and frequency, compared to a 33% decline in controls (although it is unclear if the differences reached statistical significance).12 The beneficial effects of this nonmedical treatment persisted for up to one year following delivery.13

Biofeedback Performance Feedback

Utilizing an intriguing paradigm, Allen and Shriver7 investigated the possibility that outcome in childhood migraine could be improved with enhanced performance feedback. This study used a time-lagged control design in which children who were migraineurs were taught thermal biofeedback techniques, and then subsequently were given feedback that reflected successful employment of these techniques. Only a few patients were studied. Four of six children subjectively experienced a significant reduction in headache, even when no objective improvement occurred in biofeedback response, as measured by improvement in handwarming. These findings suggest that providing patients with encouraging feedback regarding their performance of biofeedback techniques can enhance the headache relief they experience.

Adverse Effects

No adverse effects have been reported.

Conclusion

Most migraineurs will never be entirely free of headaches, so the goal of migraine management is to keep headaches manageable. When this goal is achieved, patients can expect to have minimal, if any, disruption of their lives caused by migraines.

Although the effectiveness of biofeedback and relaxation are probably comparable, limited evidence suggests greater effectiveness for biofeedback. The key appears to be to help migraineurs control their headaches. This empowerment can help migraineurs stay active and productive at home and at work. Specific populations that have been studied and found to have a beneficial response from biofeedback include adults, pediatric patients, and pregnant patients. While it may not be possible to prevent headaches entirely, making use of biofeedback techniques should help enable prevention of disability from migraines.

Recommendation

There is no reason not to recommend that all migraineurs learn biofeedback techniques for migraine reduction. Biofeedback techniques have no reported side effects, and can be employed both on a regular basis and when environmental or psychosocial factors result in susceptibility to a migraine attack.

How great a decline in headache frequency might be experienced by pregnant women who practice biofeedback?

a. 12%

b. 36%

c. 81%

d. 100%


Dr. Kattapong is a neurologist and principal in MediCat Consulting, a health services consulting firm in Tucson.

References

1. Lipton RB, Stewart WF. Epidemiology of migraine and other primary headache disorders. In: Gorelick PB, Alter M, eds. Handbook of Neuroepidemiology. New York: Marcel Dekker, Inc., 1994:357-377.

2. Sartory G, et al. A comparison of psychological and pharmacological treatment of pediatric migraine. Behav Res Ther 1998;36:1155-1170.

3. Reid GJ, McGrath PJ. Psychological treatments for migraine. Biomed Pharmacother 1996;50:58-63.

4. LaCroix JM, et al. Biofeedback and relaxation in the treatment of migraine headaches: Comparative effectiveness and physiological correlates. J Neurol Neurosurg Psychiatry 1983;46:525-532.

5. Sargent J, et al. Results of a controlled, experimental, outcome study of nondrug treatments for the control of migraine headaches. J Behav Med 1986;9:291-323.

6. Morrill B, Blanchard EB. Two studies of the potential mechanisms of action in the thermal biofeedback treatment of vascular headache. Headache 1989;29:169-176.

7. Allen KD, Shriver MD. Enhanced performance feedback to strengthen biofeedback treatment outcome with childhood migraine. Headache 1997;37:169-173.

8. Chapman SL. A review and clinical perspective on the use of EMG and thermal biofeedback for chronic headaches. Pain 1986;27:1-43.

9. Hartz A. Biofeedback for treatment of chronic insomnia. Altern Med Alert 1998;1:103-106.

10. Blanchard EB, et al. A controlled evaluation of the addition of cognitive therapy to a home-based biofeedback and relaxation treatment of vascular headache. Headache 1990;30:371-376.

11. Blanchard EB, et al. A controlled evaluation of thermal biofeedback and thermal biofeedback combined with cognitive therapy in the treatment of vascular headache. J Consult Clin Psychol 1990;58:216-224.

12. Marcus DA, et al. Nonpharmacological management of headaches during pregnancy. Psychosom Med 1995;57:527-535.

13. Scharff L, et al. Maintenance of effects in the nonmedical treatment of headaches during pregnancy. Headache 1996;36:285-290.