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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 ...

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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 
                    S72    CLEVELAND CLINIC JOURNAL OF MEDICINE         VOLUME 77 • SUPPLEMENT 3         JULY 2010
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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 
                                                                 CLEVELAND CLINIC JOURNAL OF MEDICINE         VOLUME 77 • SUPPLEMENT 3         JULY 2010    S73
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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
                                             Downloaded from www.ccjm.org on September 26, 2022. For personal use only. All other uses require permission.
                                                                                                                                                                                  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
                                            Downloaded from www.ccjm.org on September 26, 2022. For personal use only. All other uses require permission.
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...Frank andrasik phd distinguished university professor department of psychology senior research scientist florida institute for human machine cognition west pensacola fl biofeedback in headache an overview approaches and evidence abstract training meditation etc as well cogni related to therapy fall tive behavioral stress coping the second category into two broad categories general techniques takes a different approach applying that seek often augmented by relaxation based strategies more directly target aberrant physiology under methods linked pathophysiology lying specifi c types this latter has use assisted focused chiefl y on migraine its variants been evaluated article reviews supportive each extensively expert panels meta analyses taken together these indicate various forms identifi es select areas future attention are effective tension type base outcomes with rival medication combining can enhance despite have over past several ef cacy many patients fails bring decades evaluation...

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