Efficacy of Biofeedback for Migraine: A Meta-Analysis
Yvonne Nestoriuc and Alexandra Martin
Philipps-University of Marburg, Section for Clinical Psychology and Psychotherapy, Gutenbergstr. 18, 35032 Marburg, Germany
Received 16 June 2006; revised 10 August 2006; accepted 5 September 2006. Available online 2 November 2006.
Published in: Pain, 2007; 128(1-2):111-127.
In this article, we meta-analytically examined the efficacy of biofeedback (BFB) in treating migraine. A computerized literature search of the databases Medline, PsycInfo, Psyndex and the Cochrane library, enhanced by a hand search, identified 86 outcome studies. A total of 55 studies, including randomized controlled trials as well as pre–post trials, met our inclusion criteria and were integrated. A medium effect size (95% CI = 0.52-0.64) resulted for all BFB interventions and proved stable over an average follow-up phase of 17 months. Also, BFB was more effective than control conditions. Frequency of migraine attacks and perceived self-efficacy demonstrated the strongest improvements. Blood-volume-pulse feedback yielded higher effect sizes than peripheral skin temperature feedback and electromyography feedback. Moderator analyses revealed BFB in combination with home training to be more effective than therapies without home training. The influence of the meta-analytical methods on the effect sizes was systematically explored and the results proved to be robust across different methods of effect size calculation. Furthermore, there was no substantial relation between the validity of the integrated studies and the direct treatment effects. Finally, an intention-to-treat analysis showed that the treatment effects remained stable, even when drop-outs were considered as nonresponders.
Keywords: Migraine; Biofeedback; Behavioral Therapy; Meta-analysis
Biofeedback Treatment for Headache Disorders:
A Comprehensive Efficacy Review
Yvonne Nestoric, Alexandra Martin, Winfried Rief, Frank Andrasik
Abstract: The aim of the present review was to critically evaluate the documented evidence regarding the efficacy of biofeedback for the two most prevalent headache conditions-- migraine and tension-type headache. Drawing upon two recently published meta-analyses, data from 150 outcome studies, including randomized controlled trials as well as uncontrolled quasi-experimental designs, were screened. Of these, 102 studies depicting data from over 3500 headache patients were selected for inclusion according to predefined criteria. The average chronicity of migraine and tension-type headache was over 14 years. Meta-analytic integrations were carried out separately for the two headache conditions of interest. The main results were robust medium-to-large mean effect sizes for biofeedback in adult migraine and tension-type headache patients, both adults and geriatric. Treatment effects remained stable over an average follow-up period of 14 months, both in completer and intention-to-treat analyses. Headache frequency was the primary outcome variable and showed the largest improvements. Further significant effects were shown for perceived self-efficacy, symptoms of anxiety and depression, and medication consumption. Reduced muscle tension in pain related areas was observed in electromyographic (EMG) feedback for tension-type headache. Biofeedback was more effective than waiting list and headache monitoring conditions in all cases, while EMG feedback for tension-type headache showed additional significant effects over placebo and relaxation therapies.
Although effective for both types of headache, biofeedback treatment was somewhat more effective for tension-type headache than for migraine. This is likely because the most common form of biofeedback applied to tension-type headaches (i.e., electromyographic (EMG) biofeedback) was more directly related to the known cause of the headache-- muscle tension. The most commonly used forms of biofeedback to treat migraine headaches was skin temperature (TEMP) and electrodermal response (EDR) and these are related more to a reduction of sympathetic arousal of the autonomic nervous system.
Levels of efficacy (migraine: efficacious, level 4; tension-type headache: efficacious and specific, level 5) and recommendations for future research are provided.
Published in: Applied Psychophysiology & Biofeedback (2008), Vol. 33, No. 3, pp.125-140.
Biofeedback Treatments for Headache
Overview Efficacy: Numerous controlled, clinical, comparative, and long term follow-up studies have proven beyond any doubt that biofeedback can reduce and cure tension and migraine headaches among adults and children. Several medical groups strongly recommend using biofeedback before or instead of medications. This therapy is rated as efficacious and specific (level 4 on a scale of 1 to 5 with 5 being the best).
Why biofeedback would help this problem: Tension headaches are usually caused by muscles in the neck, shoulders, jaws and other facial structures being kept too tense for too long. These muscles may become too tense because some people can not recognize the actual level of tension in painful muscles, because of postural problems while working, over-reactions by the muscles to stress, poor habits, etc. Psychophysiological assessments can identify which muscles are not functioning correctly and what circumstances lead to the incorrect patterns of tension. Biofeedback of muscle tension is used to train people to recognize actual levels of tension and to correct these levels in conjunction with relaxation training. Temperature biofeedback for migraine headaches work through a similar chain of logic.
Brief summary of evidence supporting the efficacy of biofeedback for headache: There are simply too many studies to note even a fraction of them. Yucha and Gilbert (2004) and Sherman (2004) reviewed the studies supporting efficacy of this therapy and found a plethora of fine work ranging from double blind controlled studies to clinical studies.
Comparative studies show that biofeedback is as good or better than any medication. Long term follow-up studies show that the treatments last for most people as long as they continue to practice the techniques learned during therapy. People who had biofeedback therapy were more likely to continue to use it than people taking any particular medication were likely to continue taking that medication. Pain from jaw problems is treated effectively if the pain is due to problems in the muscles but not if the problem is in the jaw joint itself.
Studies do not support the efficacy of biofeedback for all kinds of headaches. The evidence supporting its use with migraines brought on by trauma, cluster headaches, and menstrual headaches is much weaker. There is no evidence supporting its effectiveness for trigeminal neuralgia, jaw joint problems, etc.
Passive Infrared Hemoencephalography:
Four Years and 100 migraines
Jeffrey A. Carmen, PhD
This paper reports Dr. Carmen’s experience in treating 100 migraine sufferers (64 F, 36 M; aged 8-67 years) over a period of four years using passive Infrared Hemoencephalography (pIR HEG) biofeedback. All patients met the criteria for at least one of the categories set forth in the International Headache Society (IHS, 1988) classification criteria for headache disorders for primary migraine.
All patients were treated using the pIR HEG system in 30-minute sessions. A central forehead placement (approximately FPz) was used for the sensor assembly for all patients. Patients were trained to increase prefrontal cortical blood perfusion under the sensor assembly. Changes in headache patterns were examined. After two years, an infrared video imaging system was added to the data collection process and was used to examine 61 of the 100 patients. Infrared forehead images were captured at the start and end of each training session to examine changes in prefrontal cortical brain activity.
Over 70% of the 100 patients included in this report obtained improved control over their migraine headaches and 4% regarded themselves as “completely cured”. Over 90% of the 76 patients who completed at least six pIR HEG biofeedback training sessions reported significant improvements in their migraines. None of the 24 patients who dropped out of treatment before completing six training sessions obtained any improvement in their headaches. No patients reported a worsening of their headaches with treatment. Typically, the intensity of headache pain decreased some weeks or months before the frequency of headaches became less.
pIR HEG biofeedback training of increased blood perfusion in the prefrontal lobe appears to have a strong impact on migraine headaches, even for people who have not had a positive response to medication. Headache response by the end of six sessions appears to be a good predictor of the probability of improvement. Only 11% of patients who failed to note significant improvement in six or fewer sessions obtained improvement in seven or more.
The positive effects on migraine management after exposure to the HEG system when the sensor assembly is placed in the center of the forehead take place in a manner consistent with a global increase in the amount of control generated by the inhibitory and regulatory functions of the prefrontal cortex.
The current working hypothesis is that the improved control over migraine headaches in response to frontal HEG biofeedback training represents a strengthening of the inhibitory control exerted by the prefrontal cortex over the brainstem migraine generator.
Published In: Journal of Neurotherapy, 2004, 8(3):23-51.
Electroencephalography (EEG) Neurofeedback, Hemoencephalography (HEG) Neurofeedback,
and Thermal Biofeedback with 37 Migraineurs
Deborah Stokes, PhD and Martha Lappin, PhD
Neurofeedback Consultants Alexandria, VA and Action Research
and Technical Solutions Inc., Reston, VA.
Source: Biomed Central: Behavioral and Brain Functions, 2010, 6:9
Traditional biofeedback has grade A evidence for effectively treating migraines. Two newer forms of biofeedback, electroencephalography (EEG) neurofeedback and hemoencephalography (HEG) neurofeedback were combined with thermal handwarming biofeedback to treat 37 migraineurs in a clinical outpatient setting.
The objectives of this study are to ascertain the effectiveness of two types of neurofeedback (EEG & HEG) with one type of conventional peripheral biofeedback to treat migraines and to stimulate future research in using neurofeedback to treat migraines.
Thirty-seven migraine patients (29 F, 8 M) aged 9-79 years were given neurofeedback treatment sessions combined with thermal biofeedback. Persons with fewer than 1 or more than 20 migraines per month were excluded from the study. All patients met HIS-diagnosis of migraine with or without aura. Most patients had long, stable histories of migraine and had tried multiple pharmaceutical treatments prior to neurotherapy. About one-third of the patients had migraine with aura, and about three-fourths reported experiencing other kinds of headaches as well as migraines or one or more other significant conditions such as depressed mood, anxiety, sleep problems, or poor mental focus.
The study involved treatment using EEG neurofeedback, pIR HEG neurofeedback, and thermal handwarming biofeedback training for an average of 40 sessions over an average span of 6 months. Patients were treated with an average of 30 half-hour long frequency-based EEG neurofeedback sessions and 10 pIR HEG neurofeedback sessions at least twice weekly. Thermal biofeedback training for handwarming was used simultaneously with the EEG neurofeedback during all sessions and all patients were given simple thermal biofeedback units to use at home between in-clinic training sessions.
Patients kept daily headache diaries a minimum of two weeks prior to treatment and throughout treatment showing symptom frequency, severity, duration and medications taken. Treatments were conducted an average of three times weekly over an average span of six months. Headache diaries were examined after treatment and a formal interview was conducted. After waiting an average of 14.5 months (range 6 to 24 months) following treatment, an independent research consulting firm conducted follow-up interviews by telephone with all patients in order to ascertain duration of treatment effects.
Of the 37 migraine patients treated, 26 patients or 70% experienced at least a 50% reduction in frequency of their headaches. Pre-treatment mean frequency of migraines was 7.6 per month (SD = 1.5) and dropped to 2.9 migraines per month (SD = 2.8) at follow-up. Only 16% of the patients failed to improve at all. No patients experienced a worsening of their headaches. As well, a majority of the patients also experienced moderate to major improvement in other problem symptoms such as depression, anxiety, sleep problems, and poor mental focus.
What is EEG Neurofeedback?
What is HEG Neurofeedback?
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