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By Jessica Fear
According to the American Migraine Study II (Lipton, Diamond, Reed, Diamond & Stewart, 2001), approximately 28 million Americans are affected by migraines. In 1989, approximately 38% of survey participants were diagnosed with migraines, compared with 48% in 1999. Since migraines are a major cause of absenteeism from work (costing employers $13 billion per year! [Lipton et al., 2001]) and can significantly disrupt normal family-life, this increase is troubling. In their study, Lipton et al. mailed 20000 self-report headache questionnaires to a representative sampling of households. Using the International Headache Society criteria, researchers then diagnosed and classified respondents based on whether or not they suffered from migraines.
Results showed that only about half of the survey participants who met criteria for migraines had been previously diagnosed as such. Thus, it appears that many Americans are suffering through a debilitating condition without a proper diagnosis. For those who are properly diagnosed, there are many treatment options available. One treatment option, which has become increasingly popular over the past decades, is the use of biofeedback to prevent and treat migraines. A general search of the world-wide web reveals that biofeedback is effective in decreasing the severity, duration, and frequency of migraines, with only one web site contradicting this claim (http://www.migraines.org/treatment/treatalt.htm). Furthermore, the scientific, rigorous studies of these claims substantiate the efficacy of biofeedback on migraine intensity, confirming the claims of the general websites.
What is a Migraine? (symptoms and theories of causation)
The intense pain of a migraine can last anywhere from a few hours to several days (National Headache Foundation [NHF]: “Migraine Headaches and Treatment” http://www.headaches.org/consumer/educationmoduleindex.html# ). Migraine symptoms include: intense, pulsating pain, nausea, dizziness, vomiting, sensitivity to light, sensitivity to sound, experiencing blind spots, and seeing flashing lights or lines (NHF). Symptoms can come on suddenly or can be preceded by an aura. An aura basically refers to the sensory or visual distortions that can accompany migraines, such as blind spots or flashing lights. An aura serves to warn of an impending migraine, and disappears with initial pain of the migraine itself (NHF).
*Migraines lead to absenteeism from work and disruptions in family-life*
There are two main theories which explain the cause of migraine pain. The more prevalent theory is the vascular or blood flow explanation. According to Webster (2001; accessed at: http://www.desertskypress.com/files/migraine1.pdf ), arteries within the head constrict (vasoconstriction), decreasing blood flow to some brain cells, which therefore affects sight and motor sensations. At the end of vasoconstriction the arteries dilate (vasodilation), creating a situation wherein the vessels press on the adjacent nerves, causing the intense pain of the migraine (NHF: “Migraine Headaches and Treatment”).
A second, neurological theory, suggests that migraines are caused by changes in chemicals in the brain which engender changes in the vascular system (NHF: “Migraine Headaches and Treatment”). Specifically, serotonin is an important neurotransmitter which appears to regulate messages regarding the contractions and dilations of the blood vessels, and is therefore thought to be important in migraines (NHF: “Migraine Headaches and Treatment). Interestingly, positron emission tomography (PET) scans have shown both changes in chemicals and blood vessels in the brain. As a result, there are still many unanswered questions regarding the causes of migraines. However, according to the National Headache Foundation (“Migraine Headaches and Treatment”), 80% of migraine sufferers have a family history of migraines, and women are three times more likely to suffer from migraines than men. This data implies that a genetic component or a predisposition for migraines may exist, and more research needs to be done to determine the concrete cause(s) of this condition.
What is Biofeedback?
There are automatic functions in our body that occur outside of our conscious awareness. For instance, an individual does not think about the process of breathing or having to breathe in and out every few seconds, they just naturally do so. In a similar fashion, other functions such as heart rate and skin temperature work on an automatic basis. “Simply put, biofeedback is a means for gaining control of your body processes to increase relaxation, relieve pain, and develop healthier, more comfortable life patterns” (http://www.bio-medical.com/homeuse-home.cfm). Essentially, biofeedback equipment allows an individual to monitor their body’s automatic activities, particularly their reactivity to stress. The idea behind biofeedback is that once an individual learns how to monitor their body’s reactions, they can learn how to alter them. For example, the individual can consciously learn how to monitor and change their heart rate and skin temperature.
*Monitoring your temperature with a thermometer is a simple form of biofeedback*
For individuals with migraines, biofeedback relates back to the vascular theory of the causes of migraines. The rationale behind biofeedback as a treatment for migraines is embedded in the vascular theory; that migraines are a result of the processes of vasoconstriction and vasodilation mentioned earlier. This theory further suggests that the blood flow during migraines has been increased to certain areas in the head and decreased to the extremities. Therefore, if a migraine sufferer can modify the temperature of another body part (e.g. their hands) through biofeedback, then the blood flow will automatically increase to the extremities and decrease to the “strained” vessels in the head. When the vasodilation/swelling of the blood vessels begins to diminish, the throbbing, pulsating, head pain disappears (http://www.holistic-online.com/Remedies/migraine/mig_biofeedback.htm; Webster, 2001) and the treatment has proven effective.
Types of Biofeedback
There are many different types of biofeedback. EMG biofeedback provides information regarding muscle tension, whereas thermal biofeedback (referred to as temperature biofeedback and handwarming biofeedback, interchangeably) and blood flow biofeedback both provide information regarding blood flow. The latter two methods of biofeedback are suggested treatments for migraine sufferers. Essentially, regardless of the type of biofeedback implemented, training in this treatment begins with the equipment. An individual is hooked up to sensors, which depict their body’s physiology on a computer screen. This then allows the individual to monitor their automatic processes on the screen. Eventually, the individual will be able to recognize/become aware of their body’s reactions without the equipment.
Temperature biofeedback assumes that the colder the temperature of the skin, the less blood that is flowing to this area. For this form of biofeedback, a temperature wire is attached to one of the individual’s fingers. In contrast, the ability to measure blood flow directly requires the use of a photoplethysmograph. However, according to Webster (2001), temperature biofeedback and use of a photoplethysmograph have produced identical results. This suggests that temperature biofeedback, which is much less expensive, may be the most practical means of learning biofeedback. For this form of biofeedback, the patient concentrates on warming their hands, in an attempt to increase blood flow to this area. Webster suggests that by practicing this form of biofeedback, the vascular system can actually be retrained, potentially preventing future migraines.
According to Webster (2001), a migraine sufferer who practices this form of biofeedback for 20-30 minutes 2 to 3 times a week, will learn the skills necessary to decrease the severity of a migraine attack and even prevent an attack (if the technique is employed during the “aura” phase).
Is biofeedback an effective treatment for migraines?
The current scientific literature regarding the use of biofeedback to treat migraines is remarkably consistent with the popular claims on the world-wide web (e.g., the National Headache Foundation website: http://www.headaches.org/). Many controlled studies have been conducted to assess the efficacy of biofeedback on both adults and children with migraines. Results from these studies suggest that biofeedback, especially temperature biofeedback, is effective in treating episodes of migraine pain, as well as preventing future episodes from occurring.
For instance, in a pilot study (Powers, Mitchell, Byars, Bentti, LeCates, et al., 2001), 20 children who had been clinically diagnosed with migraines underwent a one-hour session of what was termed “biofeedback-assisted relaxation training (BART)”. During this time, children were taught relaxation techniques while there “peripheral body temperature” (PBT) was recorded. The results of the study showed that children were able to raise their PBT after BART, and that headache severity, frequency, and duration decreased. “In general, 85% of parents reported that their child was functioning “better” at T2 [after BART] as compared with T1 [before BART]” (Powers, et al.). A brief summary of this study and its results, originally published in Neurology, can be found at: http://www.findarticles.com/p/articles/mi_m0BJI/is_4_31/ai_71900903.
Another study examined the efficacy of biofeedback in three case studies, two of which involved migraine sufferers (Earles, Folen, & James, 2001). A unique component to this study was that patients and physicians communicated via videophone during their biofeedback training sessions. Results indicated that drastic improvements occurred in all three cases treated with biofeedback. Specifically, the two migraine sufferers both reported at least a 50% reduction in the severity and number of migraines experienced after treatment (Earles, et al.). However, results of this study should be interpreted cautiously; case studies are not done in controlled environments, they are not always replicable, and they are hard to generalize to society as a whole. This study therefore needs replication with a prospective design and a greater number of case studies in order to create more interpretable results.
Furthermore, Sharff, Marcus, and Masek (2002) conducted a study to examine the effects of handwarming biofeedback, as compared to handcooling biofeedback and no treatment at all. In their study, Sharff et al. randomly assigned 36 children into one of the three treatment groups. The handwarming group then received four one-hour sessions within a 6 week time-frame, which included cognitive behavioral stress management training and 30 minutes of handwarming biofeedback training. The handcooling group also received four one-hour sessions within a 6 week time-frame, which included 30 minutes of handcooling biofeedback training. The control group was exposed to neither treatment. Sharff et al. found that the children who were in the handwarming biofeedback group improved more than the comparison groups, and sustained this improvement for up to 6 months later. However, a potential confound in the results of this study exist due to the fact that the children in the handwarming biofeedback group also received stress management training, whereas the handcooling biofeedback group did not. Replication of this study without this added advantage is needed to confirm that their results were indeed due to the handwarming biofeedback, and not the stress management training or the combination of the two.
Beyond examining the effect of biofeedback alone, results from a study conducted by Grazzi, Andrasik, D’Amico, Leone, Usai, et al. (2002) suggest that the use of biofeedback in combination with medication is more successful than medication alone in treating migraines. In their study, they examined 61 participants who were classified as having “transformed migraines,” meaning a previous history of migraines which led to chronic daily headaches. These participants were quasi-randomized (people who lived farther away were not forced to participate in the biofeedback training and could be in the medication only group) into a combined medication/biofeedback group and a medication only group. Results showed a relapse rate of 42.1% (16 of 38) for participants in the medication only group vs. a relapse rate of only 12.5% (2 of 16) for the medication plus biofeedback group at year 3 of follow-up. This study therefore suggests that a combination of medication and biofeedback rather than either by itself may perhaps be the best means of treating migraines, specifically transformed migraines. However, a fundamental flaw in the methodology of this study lies in the fact that they did not have a biofeedback only group. Future studies need to examine how effective biofeedback is alone when compared with biofeedback plus medication, and medication only in the treatment of migraines.
Finally, Vasudeva, Claggett, Tietjen, and McGrady (2002) conducted a study to examine whether migraine sufferers who experienced aura reacted differently to biofeedback/relaxation than those without, and if this was accounted for by blood flow velocity. In this study, forty participants were randomly assigned to either the biofeedback treatment group or the control group. The biofeedback group then underwent 12 fifty-minute sessions of biofeedback assisted relaxation therapy. The researchers included both EMG biofeedback and thermal biofeedback over the course of the sessions. The results show that post-treatment, the biofeedback group experienced a decline in the severity of their migraine pain and also reported using less migraine medication to treat/control the pain. Additionally, migraine sufferers with aura reacted similarly to migraine sufferers without aura; no significant differences were found in how the two groups responded to biofeedback. Furthermore, no association between biofeedback-assisted relaxation and blood flow velocity was found. Therefore, this study provides corroborating evidence for the notion that biofeedback is an effective treatment for migraines.
In conclusion, both general information websites and scientific literature support the use of biofeedback as an effective treatment for migraine headaches. While this technique may be more time-consuming (at least initially) for the migraine sufferer than simply taking analgesic medication, the long-term preventative benefits in terms of decreased severity, frequency, and duration suggest that this treatment is worth the time and effort it takes to master the techniques involved.
Sharff, L., Marcus, D.A., & Masek, B.J. (2002). A controlled study of minimal-contact thermal biofeedback treatment in children with migraine. Journal of Pediatric Psychology, 27, 109-119.
Lipton, R.B., Diamond, S., Reed, M., Diamond, M.L., & Stewart, W.F. (2001). Migraine diagnosis and treatment: Results from the American Migraine Study II. Headache, 41, 638-645.
Powers, S.W., Mitchell, M.J., Byars, K.C., Bentti, A.L., LeCates, S.L., & Hershey, A.D. (2001). A pilot study of one-session biofeedback training in pediatric headache. Neurology, 56, 133.
Grazzi, L., Andrasik, F., D’Amico, D., Leone, M., Usai, S., Kass, S.J., & Bussone, G. (2002). Behavioral and pharmacologic treatment of transformed migraine with analgesic overuse: Outcome at 3 years. Headache, 42, 483-490.
Vasudeva, S., Claggett, A.L., Tietjen, G.E., & McGrady, A.V. (2003). Biofeedback-assisted relaxation in migraine headache: Relationship to cerebral blood flow velocity in the middle cerebral artery. Headache, 43, 245-250.
Earles, J., Folen, R.A., & James, L.C. (2001). Biofeedback using telemedicine: Clinical applications and case illustrations. Behavioral Medicine, 27, 77-82.
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