Temperature biofeedback and relaxation training in the treatment of migraine headaches

In a previous controlled group outcome study, a comparison of temperature biofeedback with progressive relaxation indicated that relaxation training was more effective in reducing migraine headache activity at the end of treatment. However, follow-up data obtained at 1, 2, and 3 months after the completion of treatment showed no difference between the two groups on any dependent measure. In the current study, 18 of 26 subjects who completed treatment in the original investigation collected headache data and completed a headache questionnaire I year subsequent to the conclusion of treatment in order to evaluate the long-term effectiveness of the two treatments. The results indicated that gains achieved in the reduction of headaches during both treatments were maintained at a 1-year follow-up. With the exception of medication consumption (for which relaxation training led to better long-term results) the 1-year follow-up data reveal no differential efficacy for temperature biofeedback or progressive relaxation in treating migraine headaches.     

Long-term maintenance of improvements achieved with (abortive) pharmacological and nonpharmacological treatments for migraine: preliminary findings

This report presents the first prospective comparison of the long-term maintenance of reductions in recurrent migraine headaches achieved with (abortive) pharmacological and nonpharmacological (combined relaxation training and thermal biofeedback training) treatments. Nineteen of 21 (90%) successfully treated patients (50% or greater reduction in headache activity) were contacted for follow-up evaluation 3 years later. Migraine sufferers who had been treated with ergotamine were less likely to still be relying on the treatment they had received and more likely to have additional medical treatment for their headaches and to be using prophylactic or narcotic medication than were migraine sufferers who had been treated with relaxation/biofeedback training. However, daily headache recordings revealed that patients in both treatment groups continued to show lower headache activity at 3-year follow-up than prior to treatment. Although preliminary, these findings raise the possibility that improvements achieved with nonpharmacological treatment are more likely to be maintained without additional treatment than are similar improvements achieved with abortive pharmacological treatment.     

Long-term maintenance of improvements achieved with (abortive) pharmacological and nonpharmacological treatments for migraine: Preliminary findings

This report presents the first prospective comparison of the long-term maintenance of reductions in recurrent migraine headaches achieved with (abortive) pharmacological and nonpharmacological (combined relaxation training and thermal biofeedback training) treatments. Nineteen of 21 (90%) successfully treated patients (50% or greater reduction in headache activity) were contacted for follow-up evaluation 3 years later. Migraine sufferers who had been treated with ergotamine were less likely to still be relying on the treatment they had received and more likely to have additional medical treatment for their headaches and to be using prophylactic or narcotic medication than were migraine sufferers who had been treated with relaxation/biofeedback training. However, daily headache recordings revealed that patients in both treatment groups continued to show lower headache activity at 3-year follow-up than prior to treatment. Although preliminary, these findings raise the possibility that improvements achieved with nonpharmacological treatment are more likely to be maintained without additional treatment than are similar improvements achieved with abortive pharmacological treatment.A Baker Award from Ohio University provided support for the original outcome study.Abgelo Theofanous with R. L. Associates (Ann Arbor).     

Multimodal biofeedback in the treatment of migraine

The purpose of this study was twofold: (a) to compare the effects of three behavioral strategies for the relief of migraine, and (b) to examine different combinations of the treatments to assess the effectiveness of multimodal biofeedback with this problem. Twenty-four volunteer migraine sufferers not on medication, and with at least weekly occurrence of headaches, participated in the study. Results indicated that (a) subjects who learned temporal cooling, frontalis relaxation, and progressive muscular relaxation exhibited the best success with headache relief; (b) control subjects, who did not show the same psychophysiological changes as experimental subjects, reported no headache relief; and (c) subjects in the group with only relaxation exercises performed similarly to control subjects and reported no headache relief.     

Biofeedback control of migraine headaches: a comparison of two approaches

In order to assess the relative effectiveness of finger warming and temporal blood volume pulse reduction biofeedback in the treatment of migraine, 22 female migraine patients were assigned to one of three experimental conditions: temporal artery constriction feedback, finger temperature feedback, or waiting list. Biofeedback training consisted of 12 sessions over a 6-week period. All patients completed 5 weeks of daily self-monitoring of headache activity (frequency, duration, and intensity) and medication before and after treatment. Treatment credibility was assessed at the end of Sessions 1, 6, and 12. Results showed that temporal constriction and finger temperature biofeedback were equally effective in controlling migraine headaches and produced greater benefits than the waiting list condition. Power analyses indicated that very large sample sizes would have been required to detect any significant differences between the two treatment groups. No significant relationships were found between levels of therapeutic gains and levels of thermal or blood volume pulse self-regulation skills. Likewise, treatment outcome was not found to be related to treatment credibility. Further analyses revealed that changes in headache activity and medication were associated with changes in vasomotor variability. Because blood volume pulse variability was not significantly affected by biofeedback training, questions about its role in the therapeutic mechanism are raised.     

Biofeedback applications to migraine and tension headaches: A double-blinded outcome study

The efficacy of progressive relaxation, fingertip temperature training, and EMG training of the frontalis muscles was tested against chronic migraine and tension headaches in a double-blinded 3×2 design. All 56 subjects reported being conditioned in the course of the nine 1/2-hour training sessions. Detailed records of perceived severity and duration of the headaches were maintained by the subjects before the study and for at least 3 months after the training period. While even a conservativeF revealed a diminution of perceived severity, of hours/month of headache, and of an index conceived by Budzynski, Stoyva, Adler, and Mullaney (1973), across time, at beyond the .05 level of significance, no specific treatment emerged as clearly most effective for either type of headache. Over time, however, progressive relaxation was not as good as the other procedures in reducing the number of hours/month of headache.     

Comparison of Biofeedback and Relaxation in the Treatment of Pediatric Headache and the Influence of Parent Involvement on Outcome

The relative efficacy of EMG-frontalis feedback and progressive relaxation was examined in children with tension-type or combined headaches (8–14 yrs. old). Furthermore, the influence of parent involvement, in the form of a three-session educational approach, on training outcome was systematically explored (2 × 2 factor design). Fifty children took part in the study, 40 were randomly assigned to the four different treatment conditions, 10 children participated in the self-monitoring control group. The training comprised 6 sessions of 1 hr each in the relaxation treatment and 12 sessions of 1/2 hr duration in the biofeedback group. Headache diaries were kept by children and parents for 4-week period prior to therapy, and for a similar length of time at post-treatment and follow-up (6 months). Multivariate analyses of variance on the headache diary data yield no significant main or interaction effects of treatment format or of parent involvement, but only a main effect of period, indicating a general efficacy of the four treatment conditions. At follow-up the reduction of headache activity is even more prominent. A different evaluative approach points to the superiority of biofeedback revealing a mean effect size for biofeedback training that reflects a good to excellent improvement rate. Correlations between headache data from children and parents are high.     

Blood volume pulse biofeedback in the treatment of migraine headache: A controlled evaluation

In order to evaluate the specific effects of blood volume pulse (BVP) biofeedback in the treatment of migraine headaches, 21 female migraine patients were randomly assigned to one of three experimental conditions: temporal artery constriction feedback, temporal artery dilation feedback, or waiting list. Biofeedback training consisted of 15 sessions over an 8-week period. All patients completed 5 weeks of daily self-monitoring of headache activity and medication before and after treatment. Results showed that constriction and dilation biofeedback were equally effective in controlling migraines and produced greater benefits than the waiting-list condition. No significant relationships were found between therapeutic gains and BVP self-regulation skills. However, further analyses revealed that changes in headache activity and medication were associated with changes in vasomotor variability. The current rationale for the use of BVP biofeedback in the treatment of migraine is questioned and a new one is proposed.     

An integrated blood volume pulse biofeedback system for migraine treatment

A blood volume pulse (BVP) biofeedback system is described that integrates BVP amplitude to provide a signal appropriate for auditory feedback. In comparison to binary BVP feedback methods, this integrated system offers the advantages of continuous feedback and increased scoring ease. The validity of this system was established by correlating the integrated BVP output with trough-to-peak measurements of the raw BVP signal during unassisted relaxation and temporal BVP biofeedback with eight migraine headache patients. Within-subject correlations of the integrated and raw BVP outputs ranged from .82 to .98 (X=.95). Although the integrated method admits unwanted BVP changes in rate, correlation analyses showed this confound factor to be small. Increments in biofeedback training effects were observed during the treatment course. Substantive migraine relief was achieved by the end of treatment and therapeutic gains were maintained at 1-year follow-up. In conclusion, it appears that this method successfully presents continuous auditory feedback from an integrated BVP signal resulting in therapeutic benefits to migraineurs.     

Biofeedback control of migraine headaches: A comparison of two approaches

In order to assess the relative effectiveness of finger warming and temporal blood volume pulse reduction biofeedback in the treatment of migraine, 22 female migraine patients were assigned to one of three experimental conditions: temporal artery constriction feedback, finger temperature feedback, or waiting list. Biofeedback training consisted of 12 sessions over a 6-week period. All patients completed 5 weeks of daily self-monitoring of headache activity (frequency, duration, and intensity) and medication before and after treatment. Treatment credibility was assessed at the end of Sessions 1, 6, and 12. Results showed that temporal constriction and finger temperature biofeedback were equally effective in controlling migraine headaches and produced greater benefits than the waiting list condition. Power analyses indicated that very large sample sizes would have been required to detect any significant differences between the two treatment groups. No significant relationships were found between levels of therapeutic gains and levels of thermal or blood volume pulse self-regulation skills. Likewise, treatment outcome was not found to be related to treatment credibility. Further analyses revealed that changes in headache activity and medication were associated with changes in vasomotor variability. Because blood volume pulse variability was not significantly affected by biofeedback training, questions about its role in the therapeutic mechanism are raised.This research was supported in part by grants from the Quebec Ministry of Education and the Quebec Ministery of Social Affairs to the first author, and an award from the Medical Research Council of Canada to the second author. The authors are indebted to Drs. Frank Andrasik, Howard Barbaree, Edward Blanchard, Martin Ford, and Patrick McGrath, as well as to two anonymous reviewers, for their helpful comments on an earlier draft of this paper.     

Blood volume pulse biofeedback treatment of chronic cluster headache

Behavioral interventions shown to be clinically effective in the treatment of migraine headache have generally not been employed for cluster headache. Herein, we report on the treatment of a severe case of chronic cluster headache with a common method of migraine treatment, temporal blood volume pulse (BVP) biofeedback. The patient was a 61-year-old male, medically diagnosed as suffering from chronic cluster headaches for over 20 years. Following an 18-day baseline, 14 BVP biofeedback sessions were conducted over a 7-week period. By the last 2 weeks of treatment, there was a 70% reduction in daily headache frequency and a 45% decrease in headache severity. Improvement was maintained at 1, 3, 6, 12, and 21 months follow-up. Large decreases in the consumption of migraine abortives, narcotic analgesics, and antiemetics were also observed. These encouraging results call for further evaluation of the efficacy of BVP biofeedback treatment of chronic cluster headache.This research was supported in part by the Psychological Services Center, Memphis State University. Portions of this article were presented at the meeting of the Society of Behavioral Medicine, Chicago, March 1982.     

Effectiveness of multiple muscle-site EMG biofeedback and relaxation training in reducing the aversiveness of cancer chemotherapy

A 44-year-old female cancer patient was given progressive muscle relaxation training and multiple muscle-site EMG biofeedback to reduce the conditioned negative responses she had apparently developed to her chemotherapy treatments. Following three baseline chemotherapy sessions, the patient was given relaxation training and biofeedback during four consecutive chemotherapy treatments and was asked to practice her relaxation skills daily in the hospital or at home. After the patient felt able to relax on her own, relaxation training and biofeedback were terminated and three follow-up sessions were held. Results indicated that during the chemotherapy sessions in which the patient received relaxation training and biofeedback, she showed reductions in physiological arousal (EMG, pulse rate, systolic blood pressure, and diastolic blood pressure) and reported feeling less anxious and nauseated. Moreover, these changes were maintained during the follow-up sessions. These results suggest that relaxation training plus multiple muscle-site biofeedback may be an effective adjunctive procedure for reducing some of the adverse side effects of cancer chemotherapy.     

A retrospective,follow-up study of biofeedback-assisted relaxation therapy in patients with posttraumatic headache

Although biofeedback in the treatment of migraine and tension-type headache has been widely researched, there is little research examining biofeedback therapy in posttraumatic headache (PTH). In this retrospective study, 40 subjects with PTH who had received biofeedback-assisted relaxation at our headache clinic were questioned at least 3 months following the completion of therapy. Subjects were queried about improvements in headache, increases in ability to relax and cope with pain, and overall benefits, lasting effectiveness, and continued use of biofeedback in daily life. Results indicate 53% reported at least moderate improvement in headaches; 80% reported at least moderate improvement in ability to relax and cope with pain; 93% found biofeedback helpful to some degree; 85% felt headache relief achieved through biofeedback had continued at least somewhat; and 95% stated they were continuing to use biofeedback skills in daily life. A correlation analysis revealed a negative relationship between response to biofeedback and increased chronicity of the disorder. In other words, the more chronic the disorder, the poorer the response to treatment. A stepwise regression analysis found that chronicity of the disorder and number of treatment sessions significantly affected response to treatment. Data suggest that biofeedback-assisted relaxation should at least be considered when planning treatment strategies for posttraumatic headache.We wish to express our appreciation to Sandra Tomlinson Becky Kinloch, and C. M. Bundrick for their assistance in this project.     

Change Mechanisms Associated with Combined Relaxation/EMG Biofeedback Training for Chronic Tension Headache

Therapeutic mechanisms hypothesized to underlie improvements in tension headache activity achieved with combined relaxation and eleclromyographic (EMG) biofeedback therapy were examined. These therapeutic mechanisms included (1) changes in EMG activity in frontal and trapezii muscles, (2) changes in central pain modulation as indexed by the duration of the second exteroceptive silent period (ES2), and (3) changes in headache locus of control and self-efficacy. Forty-four young adults with chronic tension-type headaches were assigned either to six sessions of relaxation and EMG biofeedback training (N = 30) or to an assessment only control group (N = 14) that required three assessment sessions. Measures of self-efficacy and locus of control were collected at pre- and posttreatment, and ES2 was evaluated at the beginning and end of the first, third, and lost session. EMG was monitored before, during, and following training trials. Relaxation/EMG biofeedback training effectively reduced headache activity: 51.7% of subjects who received relaxation/biofeedback therapy recorded at least a 50% reduction in headache activity following treatment, while controls failed to improve on any measure. Improvements in headache activity in treated subjects were correlated with increases in self-efficacy induced by biofeedback training but not with changes in EMG activity or in ES2 durations. These results provide additional support for the hypothesis that cognitive changes underlie the effectiveness of relaxation and biofeedback therapies, at least in young adult tension-type headache sufferers.     

Comprehensive surgical treatment of migraine headaches

The purpose of this study was to investigate the efficacy of surgical deactivation of migraine headache trigger sites. Of 125 patients diagnosed with migraine headaches, 100 were randomly assigned to the treatment group and 25 served as controls, with 4:1 allocation. Patients in the treatment group were injected with botulinum toxin A for identification of trigger sites. Eighty-nine patients who noted improvement in their migraine headaches for 4 weeks underwent surgery. Eighty-two of the 89 patients (92 percent) in the treatment group who completed the study demonstrated at least 50 percent reduction in migraine headache frequency, duration, or intensity compared with the baseline data; 31 (35 percent) reported elimination and 51 (57 percent) experienced improvement over a mean follow-up period of 396 days. In comparison, three of 19 control patients (15.8 percent) recorded reduction in migraine headaches during the 1-year follow-up (p < 0.001), and no patients observed elimination. All variables for the treatment group improved significantly when compared with the baseline data and the control group, including the Migraine-Specific Questionnaire, the Migraine Disability Assessment score, and the Short Form-36 Health Survey. The mean annualized cost of migraine care for the treatment group (925 dollars) was reduced significantly compared with the baseline expense (7612 dollars) and the control group (5530 dollars) (p < 0.001). The mean monthly number of days lost from work for the treatment group (1.2) was reduced significantly compared with the baseline data (4.41) and the control group (4.4) (p = 0.003). The common adverse effects related to injection of botulinum toxin A included discomfort at the injection site in 27 patients after 227 injections (12 percent), temple hollowing in 19 of 82 patients (23 percent), neck weakness in 15 of 55 patients (27 percent), and eyelid ptosis in nine patients (10 percent). The common complications of surgical treatment were temporary dryness of the nose in 12 of 62 patients who underwent septum and turbinate surgery (19.4 percent), rhinorrhea in 11 (17.7 percent), intense scalp itching in seven of 80 patients who underwent forehead surgery (8.8 percent), and minor hair loss in five (6.3 percent). Surgical deactivation of migraine trigger sites can eliminate or significantly reduce migraine symptoms. Additional studies are necessary to clarify the mechanism of action and to determine the long-term results.     

Evaluation of home-based thermal biofeedback treatment of pediatric migraine headache

Sixteen children and adolescents with migraine headache were treated with thermal biofeedback. Seven were seen individually in the clinic while the other nine participated in a limited-contact, partly home-based regimen. Evaluation of headache diary data from 4-week monitoring periods before and after treatment showed significant (p less than .01) reduction in headaches, with no significant difference in efficacy between the two conditions.     

A study of physician attitude on biofeedback

A study of physician attitudes on biofeedback was conducted among members of the Harris County Medical Society, Harris County, Texas. The sample was drawn to match the proportionate representation in the society by speciality. Findings indicated that over 62% of the respondents had little knowledge of biofeedback, over 86% did not use biofeedback in their practice, 21.7% referred patients for biofeedback, and 47.1% were undecided whether insurance coverage should be provided. For specific disorders, adjunct treatment was the most recommended category for migraine and muscle contraction headaches, relaxation training for anxiety and tension, pain management, and essential hypertension. Responses were also analyzed by speciality category.     

Behavioral management of recurrent headache: three decades of experience and empiricism

In the past three decades, behavioral interventions (chiefly relaxation, biofeedback, and stress-management) have become standard components of the armamentarium for management of migraine and tension-type headaches. Meta-analytic literature reviews of these behavioral interventions have consistently identified clinically significant reductions in recurrent headache. Across studies, behavioral interventions have yielded approximately 35–50% reduction in migraine and tension-type headache activity. Although we have only recently begun to directly compare standard drug and nondrug treatments for headache, the available evidence suggests that the level of headache improvement with behavioral interventions may rival those obtained with widely used pharmacologic therapies in representative patient samples. In recent years, some attempts have been made to increase the availability and cost effectiveness of behavioral interventions through alternative delivery formats and mass communications. Recent developments within diagnosis and classification are summarized, pointing out implications for behavioral researchers. Select future directions are discussed, which include impact of the triptans, cost and cost effectiveness, and integration of behavioral treatments into primary care settings, the place where the great majority of headache sufferers receive treatment.     

Stress management techniques: Are they all equivalent,or do they have specific effects?

This article evaluates the hypothesis that various stress management techniques have specific effects. Studies comparing various techniques are reviewed, as well as previous literature reviews evaluating the effects of individual techniques. There is evidence that cognitively oriented methods have specific cognitive effects, that specific autonomic effects result from autonomically oriented methods, and that specific muscular effects are produced by muscularly oriented methods. Muscle relaxation and/or EMG biofeedback have greater muscular effects and smaller autonomic effects than finger temperature biofeedback and/or autogenic training. EMG biofeedback produces greater effects on particular muscular groups than progressive relaxation, and thermal biofeedback has greater finger temperature effects than autogenic training. Disorders with a predominant muscular component (e.g., tension headaches) are treated more effectively by muscularly oriented methods, while disorders in which autonomic dysfunction predominates (e.g., hypertension, migraine headaches) are more effectively treated by techniques with a strong autonomic component. Anxiety and phobias tend to be most effectively treated by methods with both strong cognitive and behavioral components.This work was supported by grants Nos. HL-34336 and HL-44097 from the Heart, Lung, and Blood Institute of the National Institutes of Health. Material in this article has been condensed and updated from three chapters in Lehrer, P. M., and Woolfolk, R. L. (1993).Principles and practice of stress management, Vol. 2, New York: Guilford Press.     

The treatment of cluster headache with relaxation and thermal biofeedback

Eleven patients with episodic cluster headache were assessed and offered a treatment program consisting of 8 weeks of training in abbreviated progressive relaxation followed by 12 sessions of thermal biofeedback. Four dropped out before treatment began. Of the seven who completed the full treatment regimen, three (27% of initial sample) reported some degree of improvement when their next cluster bout occurred. In no one was the disorder eliminated.This research was supported by a grant from the National Institute of Neurological and Communicative Disorders and Stroke, NS-15235.