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A REVIEW OF BIOFEEDBACK THERAPY AS TREATMENT FOR MIGRAINE HEADACHES
By: Caroline Dickens
29 September 2009
The jackhammer pounding between your temples. The slicing pain that radiates between your eyes at the slightest sound or glimpse of light. The nausea that floods your body upon any sudden movement. These symptoms are all too familiar to the 28 million people who suffer from sporadic or chronic migraines in the United States (http://www.webmd.com/migraines-headaches/migraines-headaches-migraines). The incapacitation that results from a severe migraine headache is enough to inspire desperation in even the most composed individual, oftentimes sending him or her to the Internet in an anxious attempt to seek relief from the pain by any means possible. As a chronic migraine sufferer myself, I can vouch for the plethora of information available on alternative treatments to migraine headaches that can be found on the World Wide Web, and as any discerning individual knows, it is necessary to validate the information found in such a manner.
One of the most prominent behavior medicine treatments highlighted on the internet is biofeedback therapy, and the goal of this paper is to scrutinize and critique the claims made online about the efficacy of this particular therapy as well as review a small sample of the existing literature expounding upon the treatment’s effectiveness in controlled studies. I have selected four websites to analyze, two of which are general information websites produced by individuals (i.e., self-help articles) and two websites affiliated with official institutions (The Mayo Clinic and Creighton University) in an attempt to broadly encompass the range of information that can be found on the Internet regarding biofeedback and migraine treatment. I have also selected four scholarly articles to analyze (either primary research reports on the effectiveness of biofeedback therapy on the treatment of migraines or reviews of individual studies previously performed).
WHAT IS BIOFEEDBACK?
Biofeedback is an alternative behavioral treatment that is designed to lessen the effects of pain on the body (within the purview of this paper, the pain caused by migraines) by gradually coaching an individual to control specific seemingly involuntary bodily functions such as brain activity, blood pressure, muscle tension, heart rate, skin temperature, and sweat gland activity (www.mayoclinic.com/health/biofeedback/SA00083/FLUSHCACHE=0&UPDATEAPP=false).
Biofeedback therapy is based upon the supposition that mind can control matter—that a person can learn how his or her body responds to different stressors and eventually how to control those responses by concentrated power of will (http://www.relieve-migraine-headache.com/biofeedback-migraine.html). The process of biofeedback therapy usually falls under the framework of multiple 30 to 60 minute sessions led by a biofeedback therapist, who uses monitoring equipment to measure the patient’s internal bodily functions in relation to migraine stress. Electrodes are attached to the patient’s body and the different bodily functions are recorded and analyzed by the therapist. To accompany the recording process, the patient is presented with audible or visible feedback (i.e., beeps or flashes of light) coordinated with specific body responses (such as heart rate or muscle contraction) (www.mayoclinic.com/health/biofeedback/SA00083/FLUSHCACHE=0&UPDATEAPP=false). The patient is then coached on how to control those responses during the session and charged with practicing the control at home to reap the full benefits of the therapy (http://headache.emedtv.com/migraines/biofeedback-for-migraines.html).
TYPES OF BIOFEEDBACK THERAPY
There are several different types of biofeedback, including (but not necessarily limited to) electromyogram biofeedback (EMG) (in which electrodes are placed on the body to alert the patient to targeted muscle tension), temperature biofeedback (in which electrodes placed on the hands or feet alert the patient to low body temperature readings, indicating possible stress), galvanic skin response training (in which sensors monitor the sweat glands and levels of perspiration, indicating anxiety levels) and electroencephalogram biofeedback (in which electrodes measure brain waves related to different mood states) (http://www.mayoclinic.com/health/biofeedback/SA00083/FLUSHCACHE=0&UPDATEAPP=false). However, according to eMedTV.com, the two most popular techniques are the electromyogram and temperature (thermal) biofeedback therapy (http://headache.emedtv.com/migraines/biofeedback-for-migraines.html). In all of the techniques, the patient is trained to respond to the data provided by the sensors and counteract the effects of stress and pain on the body (i.e.: in thermal biofeedback training, the patient is trained to raise his or her body temperature as a response to the reading of the electrode clamped to his or her hand or foot).
INTERNET CLAIMS REGARDING THE SUCCESS OF BIOFEEDBACK IN TREATING MIGRAINES
Of the several websites analyzed for this paper, all conclude unequivocally that biofeedback is indeed at least a moderately successful treatment for migraine headaches. Some sites make strongly worded claims regarding such success. For example, as eMedTV states,
… studies have shown that when practiced regularly, biofeedback techniques can achieve significant reductions in headache activity. In migraine sufferers, EMG biofeedback has reduced headache activity by approximately 55 percent. Thermal biofeedback, when combined with relaxation training, reduced headache activity by about 35 percent (http://headache.emedtv.com/migraines/biofeedback-for-migraines.html).
The Mayo Clinic takes a slightly less certain stance on the effectiveness of the treatment (while still espousing its general success), allowing that the treatment may or very well may not be effective for some people:
Many people who've tried it can't explain how they're able to control their bodies, yet experience improvement in their symptoms. Biofeedback may enable you to reduce the amount of medication you take, or even help a condition that hasn't responded well to medication (http://www.mayoclinic.com/health/biofeedback/SA00083/FLUSHCACHE=0&UPDATEAPP=false).
Other sites simply state that “plenty of studies” (or another variant of the word “plenty”) prove that the treatment is effective, especially for people who prove intolerant of other types of medication and therapy (http://altmed.creighton.edu/migraine/biofeedback.htm).
All of the sites advocate approaching a healthcare professional before beginning a biofeedback regimen and finding a certified practitioner of biofeedback therapy, though both of the individually created websites highlight no negatives to the treatment and the professionally-affiliated sites do offer at least one specific negative to the therapy. The Mayo Clinic warns that biofeedback “…should generally not be used…if [a patient has] depression, psychosis, or another major mental health disorder” and that “…biofeedback can potentially interfere with some medications, such as insulin, so patients with diabetes should exercise extra caution [when entering into a biofeedback program] (http://www.mayoclinic.com/health/biofeedback/SA00083/FLUSHCACHE=0&UPDATEAPP=false).” In the same vein of critique, Creighton University’s website highlights the fact that there is no licensing requirement and thus no regulation for administering biofeedback therapy, the poor stigma associated with psychology, and the small amount of studies that advocate that biofeedback alone is a successful treatment for migraines as potential negatives of the therapy (http://altmed.creighton.edu/migraine/biofeedback.htm).
ANALYSIS OF INTERNET CLAIMS
As noted more generally in the introduction, the types of websites used for this analysis span those made by individuals (relieve-migraine-headache.com), those still produced privately but with claims of being peer-reviewed by staff physicians (eMedTV.com), and those produced by and affiliated with professional institutions, namely the Mayo Clinic and Creighton University. It seems logical that the websites affiliated with the Mayo Clinic and Creighton University would provide more reliable information than the individually produced sites, though the peer-review process and medically based opinions provided by eMedTV.com appear to ensure relatively dependable informational claims as well.
Relieve-migraine-headache.com exists solely as an informative site whose motive for providing information about biofeedback is the education and potential aid of the site’s visitors. The site itself stands to reap no benefit from providing the information it includes in its description of biofeedback therapy; therefore it can be assumed that the information presented carries no specific bias or slant. Not surprisingly, the website cites only two specific sources of information in its claims about biofeedback’s effectiveness, and those are the Association for Applied Psychophysiology and Biofeedback and an individual study report. The website simply states that the Association for Applied Psychophysiology and Biofeedback has “found biofeedback to be most helpful for: migraine (adult and child), tension headache (adult and children), muscle related face pain, irritable bowel syndrome, chest pain from breathing patterns, posture related pain ((http://www.relieve-migraine-headache.com/biofeedback-migraine.html)” and that if the viewer of the website is interested in learning more about migraines and biofeedback for children and adolescents he or she should consult the listed article. There is no other mention of specific studies to corroborate relieve-migraine-headache.com’s claims regarding the definition and effectiveness of biofeedback. Thus, it can be argued that the serious lack of substantive evidentiary support for the claims made on relieve-migraine-headache.com greatly undermines the credibility of both the site and its informational content.
In comparison, eMedTV.com is a privately produced medical information portal whose goal is to provide accurate and reliable medical information to its clients. In general, the greatest benefit this site stands to enjoy from providing accurate information is the advertising revenue garnered by securing repeat visitors to the site; therefore it can be assumed that a substantive effort has been made to insure the accuracy of its information and claims. In fact, eMedTV.com claims that all of the informational articles it presents are repeatedly peer-reviewed and placed under rigorous medical review by their on-staff physicians, physical therapists, and pharmacists. However, when citing informational sources, eMedTV.com merely refers to “a headache specialist” and “a number of studies (http://headache.emedtv.com/migraines/biofeedback-for-migraines-p2.html);” hardly specific citations to substantiate their claims to the lay reader. Without specific proof being provided by the site, it can only be fairly concluded that the information is more than likely reliable, but still questionable in its complete accuracy.
Finally, an analysis of the two professionally affiliated websites, mayoclinic.com and Creighton University’s altmed.com, provides an interesting comparison in the documented reliability of the information presented on the two sites. Both sites are, again, predominantly informational sites that do not stand to reap any substantial benefits from providing accurate information other than maintaining the credibility of the institution and, in the Mayo Clinic’s case, possibly enticing the viewer to approach the clinic for treatment; therefore, there would be no perceived reason for the sites to present biased and/or false information. Interestingly, the Mayo Clinic relies on the credibility of its name alone in validating the information presented on its webpage as it merely cites the author of the article on biofeedback as “Mayo Clinic Staff” without providing any other specific evidentiary support throughout its explanation of biofeedback and its effectiveness/possible benefits. Creighton University does not cite specific sources for its information, either, though it does provide a table summarizing several empirical studies of biofeedback as a migraine treatment. This table greatly increases the reliability of the information found on altmed.com, and I also feel that the reputation of the Mayo Clinic is enough to carry the credibility of the information presented on its site as well.
SCHOLARLY LITERATURE REVIEW
SUMMARY OF RESEARCH
In one study, Alvin Lake, Joseph Rainey, and James D. Papsdorf (1979) chose to examine whether digit temperature biofeedback alone or in conjunction with Rational Emotive Therapy was a more effective migraine treatment than either EMG biofeedback or self-monitoring headache frequency and intensity, dividing 24 migraine patients into one of three experimental groups receiving only digit temperature biofeedback, only EMG biofeedback, or a combination of digit temperature feedback and RET and one control group (which merely self-monitored for the duration of the program). Each experimental group provided baseline headache activity reports on a scale of 1 to 5 in intensity and duration for at least four weeks and then participated in eight treatment sessions at a frequency of two sessions per week before participating in a follow up session three months after the termination of the study. The researchers found that 12 of the 18 subjects receiving some variant of biofeedback therapy (either digit temperature biofeedback, EMG biofeedback, or digit temperature biofeedback in conjunction with Rational Emotive Therapy) showed improvement in their experience of migraine headaches (after collapsed analysis, biofeedback in general was found to be better at mediating headaches than self-monitoring alone), but after separate analysis, only the EMG treatment was found to be truly superior to self-monitoring. Further, the paper’s authors point out that patients who received some sort of biofeedback training experienced an overall 46% decrease in headache activity while the patients who merely self-monitored experienced an overall 17% increase in headache activity (Lake et al., 1979).
In their 1983 article, Biofeedback and Relaxation in the Treatment of Migraine Headaches: Comparative Effectiveness and Physiological Correlates, J. Michael LaCroix, Melissa Clarke, J. Carson Bock, Neville Doxey, Anne Wood, and Sandra Lavis asked a similar research question to that of Lake and his colleagues, detailing their comparative study of the effectiveness of thermal biofeedback, frontalis biofeedback, and relaxation training in mediating the intensity and frequency of migraine headaches. 27 migraine-suffering patients were divided into three groups by the order they were recommended to the study program, and each group underwent a cycle of 18 training and six text sessions in which they were exposed to either thermal biofeedback, frontalis biofeedback, or relaxation training. At the conclusion of the program the patients were asked to rate the improvement of their headache symptoms and frequency on a five-point scale ranging from “no change” to “symptom free,” answers that were then compared to the patients’ baseline headache descriptors determined by an interview process prior to the beginning of the study. LaCroix et al. found that the patients in the thermal biofeedback group improved the most initially and maintained those improvements for up to six months following the treatment program and that the patients in both the EMG and relaxation training treatments showed less improvement, with the EMG patients’ improvement remaining steady over the next six months after the treatment cycle and the relaxation training showing further improvement over the next six months (LaCroix et al., 1983).
A third study performed by Michael J. Cohen, David L. McArthur, and William H. Rickles in 1980 further supports the claim that biofeedback is a successful form of migraine headache mediation. In this particular study, 42 patients selected based on their documented evidence of a history of migraine headaches were divided between four different experimental groups, each receiving one of four treatments: finger temperature warming biofeedback training (using a differential finger forehead procedure), frontalis EMG relaxation training, Alpha brain wave enhancement training, or vasoconstriction of scalp arteries in the temporal area. Prior to the beginning of the training sessions, each patient provided 8 weeks’ worth of headache charting. Following this initial baseline analysis, the patients participated in 24 biofeedback training sessions over an eight to 10 week period, after which they reported back to the lab at the one, two, three, and six month mark for further interview. The patients continued their headache charting throughout the training period and concluded the charting one year after the training period. From the data collected, Cohen and his colleagues determined that biofeedback training alone had a positive effect on migraine headaches, given that all groups demonstrated an approximate 20% reduction in the average number of headaches experienced from pre-treatment to eight weeks post-treatment (which was either maintained or enhanced even further at the 32 week post-treatment mark) (Cohen et al., 1980).
Finally, to round out the literature review of this paper, I have chosen to recapitulate a general literature review of the effectiveness of biofeedback therapy entitled Effectiveness of Biofeedback for Treating Migraine and Tension Headaches: A Review of the Evidence by David S. Holmes and Thomas G. Burish (1983). Holmes and Burish summarized an impressively large number of empirical studies performed to evaluate the effectiveness of finger temperature biofeedback and temporal artery pulse biofeedback in treating migraine headaches and the effectiveness of EMG biofeedback and EEG-alpha biofeedback in treating tension-type headaches. Interestingly, unlike the previous three articles mentioned in this paper, Holmes and Burish determined from their meta-analysis that neither finger temperature biofeedback nor temporal artery pulse biofeedback demonstrated any significant effectiveness in mediating migraine headaches and that EMG biofeedback demonstrated only moderate effectiveness in treating tension-type headaches, similar to the effects achieved by relaxation therapy and the general placebo effect (Holmes & Burish, 1983).
ANALYSIS OF SCHOLARLY RESEARCH FINDINGS
There are several caveats to these studies that an individual interested in pursuing biofeedback therapy should bear in mind before blindly accepting the conclusions to which each article arrives. Most importantly, of the three independent research reports summarized in this paper, only one (Cohen et al., 1980) utilizes a specially controlled study design. By not allowing for a controlled comparison, it is nearly impossible to determine whether the effects obtained in the experiment are in fact due to the successful implementation of the various methods of biofeedback therapy or another third confounding variable, such as the placebo effect. The studies also employ very small sample sizes, making it difficult (if not inappropriate) to extend the conclusions drawn from the experiment to the general population. Likewise, with the exception of Cohen et. al (1980), the studies limit their experimental timeframe and follow up periods to only a few months, further limiting the generalized conclusions that can be drawn regarding the long-term effectiveness of biofeedback therapy in treating migraine headaches.
Therefore, it appears that the conclusions drawn by Holmes and Burish’s literature review (1980) are markedly more reliable than those reached by the individual empirical studies discussed in this paper, as the authors take such shortcomings as listed in the previous paragraph into account when evaluating the strength of the conclusions reached by the previous studies upon which the article focuses its attention. Holmes and Burish determine that little reliably proven information exists to substantiate the claim that biofeedback therapy is an effective treatment of migraine headaches. This is testament enough to the fact that more carefully controlled studies of the subject should be performed.
After careful consideration, it appears that all but one of the pieces of literature examined in this paper confirm, at least to some degree, the effectiveness of biofeedback therapy in treating migraines, and, consequently, remain in general concordance with the opinions espoused by the websites featured in this paper. However, the broad weaknesses of the designs of the experimental studies highlighted in this work are great enough to cast doubt upon the accuracy of such claims, allowing merely for the assumption that the improvements in headache experience are at least attributable to the psychological placebo effect associated with biofeedback therapy. In conclusion, this author contends that biofeedback therapy appears to be a relatively harmless alternative treatment for migraine headaches that is worth considering, but that solidly supporting evidence of the treatment’s effectiveness should be found before a patient commits to such therapy.
Biofeedback. (n.d.). Retrieved October 3, 2009, from http://altmed.creighton.edu/migraine/biof eedback.htm
Biofeedback Migraine Treatment - What You Need to Know. (n.d.). Retrieved October 3, 2009, from http://www.relieve-migraine-headache.com/biofeedback-migraine.html
Biofeedback: Using Your Mind to Improve Your Health: In Depth-Mayo Clinic. (2008, January 21). Retrieved October 3, 2009, from http://www.mayoclinic.com/health/biofeedback/ SA00083/FLUSHCACHE=0&UPDATEAPP=false
Cohen, M. J., McArthur, D. L., & Rickles, W. H. (1980). Comparison of Four Biofeedback Treatments for Migraine Headache: Physiological and Headache Variables. Psychosomatic Medicine, 42(5), 463-480.
Holmes, D. S., & Burish, T. G. (1983). Effectiveness of Biofeedback for Treating Migraine and Tension Headaches: A Review of the Evidence. Journal of Psychosomatic Research, 27(6), 515-532.
LaCroix, J. M., Clarke, M. A., Bock, J. C., Doxey, N., Wood, A., & Lavis, S. (1983). Biofeedback and relaxation in the treatment of migraine headaches: comparative effectiveness and physiological correlates. Journal of Neurology, Neurosurgery, and Psychiatry, 46, 525-532.
Lake, A., Rainey, J., & Papsdorf, J. D. (1979). Biofeedback and Rational-Emotive Therapy in the Management of Migraine Headache. journal of Applied Behavioral Analysis, 12(1), 127 140.
Schoenstadt, A. (2007, May 4). Biofeedback for Migraines. Retrieved October 3, 2009, from http ://headache.emedtv.com/migraines/biofeedback-for-migraines.html
WebMD: Better Information. Better Health.. (n.d.). Retrieved October 3, 2009, from www.w ebmd.com/migraines-headaches/migraines-headaches-migraines
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