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FRANK ANDRASIK, PhD
Distinguished University Professor, Department of Psychology,
Senior Research Scientist, Florida Institute for Human & Machine Cognition,
University of West Florida, Pensacola, FL
Biofeedback in headache:
An overview of approaches and evidence
ABSTRACT training, meditation, etc) as well as training in cogni-
Biofeedback-related approaches to headache therapy fall tive and behavioral stress coping. The second category
into two broad categories: general biofeedback techniques takes a different approach, applying techniques that seek
(often augmented by relaxation-based strategies) and more directly to target the aberrant physiology under-
methods linked more directly to the pathophysiology under- lying specifi c headache types. This latter category has
lying headache. The use of general biofeedback-assisted focused chiefl y on migraine headache and its variants.
relaxation techniques for headache has been evaluated This article reviews the supportive evidence for each
extensively by expert panels and meta-analyses. Taken category of biofeedback approaches to headache therapy
together, these reviews indicate that (1) various forms of and identifi es select areas for future research attention.
biofeedback are effective for migraine and tension-type EVIDENCE BASE FOR GENERAL BIOFEEDBACK
headache; (2) outcomes with biofeedback rival outcomes TECHNIQUES IN HEADACHE
with medication therapy; (3) combining biofeedback Biofeedback-assisted relaxation approaches for headache
with medication can enhance outcomes; and (4) despite have been evaluated extensively over the past several
effi cacy in many patients, biofeedback fails to bring decades. These evaluations have consisted of two basic
signifi cant relief to a sizeable number of headache patients. types—comprehensive reviews by expert panels, and
Biofeedback methods that more directly target headache meta-analytic statistical analyses—as detailed below.
pathophysiology have focused chiefl y on migraine. These
headache-specifi c approaches include blood volume pulse Expert panel reviews
biofeedback, which has considerable supportive evidence, A wide variety of groups have assessed biofeedback and
and electroencephalographic feedback. related relaxation-based procedures by reviewing all
relevant published studies according to rigorous pre-
iofeedback has long been employed for helping determined criteria. These groups include the National
ameliorate symptoms of recurrent headache; Institutes of Health, the Canadian Headache Society,
seminal work was performed in the late 1960s the American Psychological Association, the Society
1,2
Band fi rst reported in the early 1970s. This early of Pediatric Psychology, the Association for Applied
work focused mainly on electromyography (EMG) or Psycho physiology and Biofeedback, and the US Head-
muscle tension and hand temperature. Today a greater ache Consortium.
array of approaches are available, and they fall within The 2000 evidence review by the latter group, the
two broad categories: (1) biofeedback-assisted relaxation 4
US Headache Consortium, merits particular mention,
and (2) specifi c or more specialized approaches.3
for several reasons. First, their review was sponsored by
The fi rst category employs the two types of biofeed- diverse medical societies—namely, the American Acad-
back mentioned earlier (EMG and thermal feedback), as emy of Family Physicians, American Academy of Neu-
well as feedback on sweat gland activity, to counteract rology, American Headache Society, American College
the sympathetic nervous arousal that occurs in response of Emergency Physicians, American College of Physi-
to stress for a host of disorders, not just headache. These cians–American Society of Internal Medicine, Ameri-
types of biofeedback are commonly augmented with can Osteopathic Association, and National Headache
a variety of allied relaxation-based strategies (guided Foundation. Second, this review panel applied objec-
imagery, diaphragmatic or paced breathing, autogenic tive criteria, grading the evidence quality as A, B, or C
(see Table 1 for details). Third, the panelists examined
Dr. Andrasik reported that he has no fi nancial relationships that pose a poten- a diverse array of behavioral and physical treatments
tial confl ict of interest with this article. (acupuncture, transcutaneous electrical nerve stimula-
doi:10.3949/ccjm.77.s3.13 tion, occlusal adjustment, cervical manipulation, and
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ANDRASIK
TABLE 1 TABLE 2
Treatment recommendations on behavioral and Patient characteristics for which behavioral treatments
physical treatments for migraine from US Headache for migraine may be particularly well suited*
4
Consortium evidence-based guidelines
Preference for a nondrug approach
Relaxation training, thermal biofeedback combined with Intolerance of, or medical contraindication to, drug treatment
relaxation training, electromyographic biofeedback, and
cognitive-behavioral therapy may be considered as treatment Absent or minimal response to drug treatment
options for prevention of migraine (Grade A evidence*) Pregnancy, plans to become pregnant, or current nursing status
Behavioral therapy (ie, biofeedback, relaxation) may be History of long-term, frequent, or excessive use of analgesic or
combined with preventive drug therapy to achieve additional other acute medications that aggravate headache symptoms
clinical improvement for migraine relief (Grade B evidence*) or are reducing medication effectiveness
Evidence-based recommendations are not yet possible on the Presence of signifi cant life stress or lack of adequate stress-
use of hypnosis, acupuncture, transcutaneous electrical nerve coping skills
stimulation, cervical manipulation, occlusal adjustments, or
hyperbaric oxygen as preventive or acute therapy for migraine 4
(Grade C evidence*) *From US Headache Consortium evidence-based guidelines.
* Grade A: Multiple well-designed randomized controlled trials (RCTs) revealing
a consistent pattern of positive fi ndings. Grade B: Some supportive evidence or with various prophylactic medications for migraine
from RCTs, but not optimal support (often because RCTs were few or fi ndings and tension-type headaches in adults and in children
were judged to be inconsistent). Grade C: Consensus on the recommendation 7
achieved among consortium members in the absence of acceptable RCTs. and adolescents. The most recent meta-analysis, by
8
Nestoriuc et al, focused extensively on biofeedback and
will be discussed in detail here.
hyperbaric oxygen) previously identifi ed in a technical Nestoriuc et al identifi ed and screened 150 clinical
review prepared for the Agency for Health Care Policy trials, including randomized controlled trials and quasi-
5 8
and Research, a review that included detailed meta- experimental designs. Ninety-four of these trials met
analyses as well. Fourth, the panel’s main objective was predefi ned inclusion criteria (headache diagnostic crite-
to provide scientifi cally sound and clinically relevant ria specifi ed, biofeedback evaluated as treatment alone
practice guidelines for use in primary care settings. or in combination with behavior therapy, outcome
Table 1 summarizes the consortium’s resulting treat- assessed using a structured headache diary, 5 or more
ment recommendations on behavioral and physical patients per condition, and suffi cient data to permit
4 calculation of effect sizes). It was possible to include a
treatments for migraine. The consortium also prepared a suffi cient number of studies to permit comparisons with
list of special indicators for behavioral treatment, which
4 two types of control groups: waiting list and placebo.
are summarized in Table 2. Thus, strong support was For migraine, biofeedback treatment yielded small to
garnered for thermal and EMG biofeedback for migraine, medium effects overall compared with waiting-list con-
and this support is consistent with fi ndings from many trol and placebo, although these effects failed to reach
meta-analyses addressing not only migraine but also statistical signifi cance. For tension-type headache,
tension-type headache (see next section). The panelists biofeedback treatment yielded a medium to large effect
noted that there was insuffi cient information for recom- compared with waiting-list control and a medium effect
mending which type of treatments to pursue for specifi c compared with placebo, both of which were statistically
patients, a conclusion that holds true to the present. 8
signifi cant.
Meta-analytic reviews The accompanying fi gures provide a more detailed
The other major type of evaluation applied to bio- snapshot of results from the meta-analysis by Nestoriuc
feedback for headache is more quantitative in nature, et al. Figure 1 shows effect sizes in terms of headache
applying meta-analytical statistical analyses to avail- pain for various biofeedback treatments for migraine.
able studies to determine the range and mean level of Figure 2A shows effect sizes for all biofeedback treat-
clinical effects across pooled studies. Biofeedback and ments combined for migraine, while Figure 2B shows
related approaches to headache have been subject to an effect sizes for EMG biofeedback alone for tension-type
extensive number of quantitative reviews, the fi rst being headache (this was the only type of biofeedback with
6 a suffi cient number of studies in tension-type headache
published in 1980. Since then, approximately 15 other
quantitative reviews have compared behavioral treat- to permit analysis). Both panels of Figure 2 show effect
ments with one another, with various placebo conditions, sizes on the four main pain outcome measures used in
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BIOFEEDBACK IN HEADACHE
Medication index (k = 51) ◆
EEG-FB, skin conductance (k = 7) ◆ Headache index (k = 46) ◆
EMG-FB (k = 7) ◆ Intensity (k = 39) ◆
TEMP-FB (k = 19) ◆ Duration (k = 30) ◆
Frequency (k = 33) ◆
TEMP-FB + RT/EMG-FB (k = 35) ◆
BVP-FB (k = 16) ◆ A 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2
Mean weighted effect sizes (migraine)
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
Mean weighted effect sizes (migraine) Medication index (k = 18) ◆
Headache index (k = 30) ◆
BVP-FB = blood volume pulse feedback; EEG-FB = electroencephalographic feedback; Intensity (k = 27) ◆
EMG-FB = electromyographic feedback; RT = relaxation training; TEMP-FB = peripheral Duration (k = 13) ◆
skin temperature feedback Frequency (k = 28) ◆
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2
FIGURE 1. Mean weighted effect sizes (and 95% confi dence B Mean weighted effect sizes
intervals) for migraine pain for various biofeedback methods from a (tension-type headache)
8
meta-analysis of studies of biofeedback treatment for migraine. FIGURE 2. Mean weighted effect sizes (with 95% confi dence inter-
(k = number of independent effect sizes entered into the calculation)
With kind permission from Springer Science+Business Media: vals) for various headache outcome measures from a meta-analysis
Applied Psychophysiology and Biofeedback, “Biofeedback treatment 8
of studies of biofeedback treatment for headache. Results are for
for headache disorders: a comprehensive effi cacy review,” volume 33, all biofeedback procedures combined in the treatment of migraine
2008, p. 131, Nestoriuc Y, Martin A, Rief W, Andrasik F, fi gure 1. (A) and for electromyo graphic biofeedback alone in the treatment of
tension-type headache (B). (k = number of independent effect sizes
headache research, along with reductions in medica- entered into the calculation)
tion (considered a behavior motivated by pain). Figure With kind permission from Springer Science+Business Media:
Applied Psychophysiology and Biofeedback, “Biofeedback treatment
3 shows effect sizes from biofeedback on the secondary for headache disorders: a comprehensive effi cacy review,” volume 33,
outcome measures of anxiety, depression, and self- 2008, p. 131, Nestoriuc Y, Martin A, Rief W, Andrasik F, fi gure 2.
effi cacy, again for all biofeedback procedures for migraine
and for EMG biofeedback alone for tension-type head- one investigation suggests that biofeedback may
ache. These latter results show that biofeedback has the 14
be of particular value to a subset of patients.
added advantage of favorably affecting cognitive and 5) Although not reviewed here, the outcome effects
emotional functioning.8
from biofeedback seem to endure for extended
Additionally, Holroyd and colleagues have con- 15
periods, whether booster treatments are provided
ducted a number of meta-analyses and randomized con- 16
or not.
trolled trials that compare behavioral and prophylactic 6) Although biofeedback has been shown to be effec-
pharmacologic treatments, as well as their combina- tive for a number of patients, a sizeable number of
tion.9–13
These reviews and studies have consistently patients do not achieve signifi cant relief.
shown that outcomes for the individual treatments are
similar in magnitude and that the combination of both Remaining questions and challenges
behavioral and pharmacologic treatment leads to even Unfortunately, little attention has been devoted to iden-
greater effects—a conclusion tentatively offered by the tifying variables predictive of outcome. Certain head-
4
US Headache Consortium back in 2000. ache types—chronic forms of headache (presence of pain
15 days per month), headaches associated with the
Interim conclusions menstrual cycle, headaches accompanied by medication
Consideration of the fi ndings from individual studies overuse (of ergotamine, triptans, analgesics, or opioids),
and reviews discussed, plus those not singled out here, posttraumatic headaches, and cluster headaches—have
leads to the following conclusions: shown minimal response to biofeedback alone.
1) Various forms of biofeedback are effective for Headaches complicated by medication overuse are
migraine and tension-type headache. particularly diffi cult to treat. The fi rst order in treatment
2) Outcomes with these forms of biofeedback rival is to have the patient withdrawn from the offending
outcomes with medication alone. agents, which often requires a brief hospitalization, after
3) Combining biofeedback with medication can which a more appropriate course of treatment is begun.
enhance outcomes. Unfortunately, relapse is high. Mindful of this, we con-
4) Outcomes from biofeedback are similar to those ducted an investigation that assigned 61 consecutive
obtained with other behavioral approaches. patients who had undergone a course of inpatient with-
Whether biofeedback has a unique advantage over drawal to either medication alone or medication plus
other similar approaches is not known, but at least biofeedback-assisted relaxation training to determine if
S74 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • SUPPLEMENT 3 JULY 2010
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ANDRASIK
Anxiety (k = 7) ◆ 100 Relapse
Depression (k = 6) ◆ 90
Self-efficacy (k = 7) ◆ No relapse
80
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 70
A Mean weighted effect sizes (migraine)
60
Anxiety (k = 9) 50
◆ 40
Depression (k = 5) ◆
Self-efficacy (k = 5) ◆ 30
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 20
Mean weighted effect sizes 10
B (tension-type headache) 0
Medication alone Medication + biofeedback
FIGURE 3. Mean weighted effect sizes (with 95% confi dence (n = 38) (n = 16)
intervals) for secondary outcome measures related to cognitive and FIGURE 4. Percentage of migraine patients who relapsed to
emotional function from a meta-analysis of studies of biofeedback
8 analgesic overuse at 3-year follow-up after being assigned to either
treatment for headache. Results are for all biofeedback procedures medication therapy alone or medication therapy combined with
combined in the treatment of migraine (A) and for electromyo graphic biofeedback-assisted relaxation to combat initial analgesic overuse.
biofeedback alone in the treatment of tension-type headache (B). 17
(k = number of independent effect sizes entered into the calculation) Data are from a study by Grazzi et al.
With kind permission from Springer Science+Business Media:
Applied Psychophysiology and Biofeedback, “Biofeedback treatment EEG-based methods
for headache disorders: a comprehensive effi cacy review,” volume 33, The next most investigated approach involves electro-
2008, p. 131, Nestoriuc Y, Martin A, Rief W, Andrasik F, fi gure 2. encephalographic (EEG) biofeedback, of which there
17 are two types. The fi rst derives from research investi-
such training could enhance outcome. At 1-year fol- gating links between certain EEG frequency bands and
low-up evaluation, the two patient groups showed simi- 19
lar levels of improvement. However, at 3-year follow-up, the experience of pain. This research suggests that the
patients receiving biofeedback showed more sustained experience of pain is associated with lower amplitudes
improvements and, most importantly, had lower rates of slow brain wave activity (delta, theta, and alpha) and
of relapse back to analgesic overuse (Figure 4). Thus, higher amplitudes of faster brain wave activity (beta).
biofeedback seemed to help these patients cope more Several uncontrolled series suggest that EEG biofeedback
effectively over the long term. Unfortunately, we did may be of value, but more well-controlled investigations
not collect suffi cient data over the intervening 2 years, are needed before further statements can be made.
so we could not determine with precision what medi- The second line of EEG research takes a differ-
ated this differential outcome. ent approach, focusing on the contingent negative
variation response (CNV). The CNV is a slow corti-
EVIDENCE BASE FOR HEADACHE-SPECIFIC cal event-related potential that examines EEG activity
BIOFEEDBACK APPROACHES occurring between presentation of a warning stimulus
and an imperative stimulus (in this case 3 seconds
As noted above, a number of biofeedback approaches later), a stimulus requiring a response by the individual.
have been suggested that are tied more directly to the This potential is related to the level of excitability upon
underlying physiology of headache. activation in the striato thalamocortical loop, refl ecting
different stages of information processing.20 Studies in
Blood volume pulse biofeedback child and adult migraineurs reveal that these patients
One of these approaches, blood volume pulse (BVP) bio- have a heightened response to novel stimuli and do
feedback, has undergone a suffi cient number of trials to not habituate as readily over repeated trials as do non-
21
be included in the recent meta-analysis by Nestoriuc et migraineur controls. The CNV is believed to refl ect
8 anticipation of a migraine attack because its amplitude
al mentioned earlier. This approach involves monitoring
blood fl ow in the temporal artery and providing feedback and habituation patterns change during the headache-
to patients to enable them to decrease or constrict blood free interval. Abnormalities gradually increase in the
18 days before a migraine attack, with the most pronounced
fl ow. This approach, when fi rst envisioned, was viewed
22
as the nondrug counterpart to the abortive agent ergota- changes occurring just prior to the attack.
mine. Although BVP biofeedback is not very common On the basis of these etiopathologic fi ndings, Sini-
8 atchkin et al conducted an initial test to determine
in clinical practice, the meta-analysis by Nestoriuc et al
found it to produce the greatest effect size of the biofeed- whether child migraineurs could learn, via biofeedback,
back methods assessed for migraine relief (Figure 1). to change their CNV activity and whether such learning
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • SUPPLEMENT 3 JULY 2010 S75
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