Efficacy of biofeedback

THE EFFICACY OF BIOFEEDBACK IN TREATING MIGRAINE HEADACHE: Martyn R. Thomas, M.A., C.Psych.Assoc. and Associates Migraine headache is a physiological disorder, which is generally characterized by intense unilateral pain accompanied by nausea, vomiting, dizziness and increased sensitivity to light, smell or sound. Migraine headache may or may not be preceded by aura. Of the various types of migraine, migraine without aura (common migraine) accounts for about 90 percent, whereas migraine with aura (classic migraine) accounts for only about 10 percent of the migraine population. (Purdy, 1992). Prevalence rates indicate that migraine is a very common disorder. Purdy (1992) estimates that migraine accounts for about 10-20 percent of general headaches in an adult population. Findlay (1991) found that approximately 3.2 million Canadians, or 17 percent of the adult population, suffer from migraine. Migraine headache is both debilitating and distressing to the migraine sufferer. The disorder is thought to result from changes in central neural processes and corresponding neurotransmitters which induce changes in cerebral blood flow (vasoconstriction followed by vasodilation). The resulting headache pain and accompanying symptoms are often so severe that migraine sufferers feel the need to withdraw from normal activities. Findlay (1991) found that 75 percent of migraine sufferers indicated that they had to withdraw from their normal activities when experiencing a migraine. Research has investigated both pharmacological and nonpharmacological Pharmacological therapy generally falls into three broad categories, namely abortive, prophylactic and palliative treatments (Blanchard & Andrasik, 1987). Abortive treatment serves to abort or terminate the headache after it has begun and typically includes Ergot derivatives. Prophylactic treatment attempts to prevent the onset of a headache and generally requires daily intake of medications such as beta blocking agents including Propranolol. Tricyclic antidepressants, such as Amitriptyline and Ergot derivatives, have also been used for migraine prophylaxis. Palliative treatment attempts to lessen the distress of headache pain once it arrives, and includes the use of sedatives, analgesic hypnotics, and antiemetics (Dalessio, 1980). Although reasonable treatment success has been achieved with medication, pharmacological intervention is not effective for all migraine sufferers and many clients display concern over taking medication for a prolonged period of time. Additionally, many prescribed medications have various adverse side effects including nausea, vomiting, fatigue, depression and weight gain. Prolonged use of Ergotamine preparations can also lead to Ergotamine dependency (Saper, 1987). Furthermore, the possibility of rebound head ache must be considered where long term, frequent analgesic use is involved. In recent years, Sumatriptan (Imitrex) became available to the migraine sufferer. Sumatriptan is thought to abort a migraine attack by selectively preventing vasodilation in neurogenically activated cranial blood vessels (Purdy, 1992). Although clinical trials have demonstrated the efficacy of Sumatriptan in the symptomatic treatment of acute migraine, adverse side effects have been reported, including injection-site reactions, nausea or vomiting, feelings of heaviness, fatigue or malaise and weakness. As well, there is some concern that Sumatriptan is not as selective in constricting only cranial blood vessels as originally reported (Regus, 1993). In view of the concerns associated with the pharmacological treatment of migraine, alternative treatment methods have been introduced. Biofeedback, a nonpharmacological intervention, has been shown to be an effective prophylactic treatment when conducted by appropriately trained professionals. Treatment of migraine with either thermal biofeedback (Blanchard & Andrasik, 1987), autogenic training (Sargent et al., 1986), cephalic EMG biofeedback (Sargent et al., 1986) has been found to be superior to headache monitoring alone. Blanchard & Andrasik (1987) defined success as a 50 percent reduction in headache frequency and intensity following treatment. Biofeedback/pharmacotherapy comparisons have been conducted. Sovak, Kunzel, Sternback & Dalessio (1981) compared Propranolol and analgesic use to 8-10 session of thermal biofeedback with autogenic training. Based on a criterion of at least 50 percent reduction in headache frequency, intensity, and duration, the treatments were found to be equivalent. Mathew (1981) compared biofeedback-based therapy to abortive and analgesic therapy, or Propranolol and Amitriptyline. Results indicated that biofeedback was significantly better than the combination of abortive and analgesic medications but poorer than Propranolol or Amitriptyline treatment. Holroyd & Penzien (1990) integrated the results from 25 clinical trials which evaluated the effectiveness of Propranolol and 35 clinical trials which evaluated the effectiveness of relaxation and biofeedback training in treating migraine. Meta analysis revealed substantial empirical support for the effectiveness of both Propranolol and relaxation/biofeedback training, but did not support the superiority of one treatment over the other. More recently, Thomas et. al. (1995) reported the results of a preliminary program evaluation of a four week bio-behavioural program for migraine (which included respiration and hand skin temperature biofeedback). The results showed that 67% of the 60 migaineurs participating in the program reported less frequent headache while 75% reported reduced intensity. With empirical support for the short-term efficacy of biofeedback in the treatment of migraine, researchers have examined long term effectiveness. Lisspers (1990) conducted a follow-up study of migraineurs who were successfully treated with biofeedback and relaxation training. The results indicated, on a group basis, that headache reductions achieved at the end of treatment persisted for up to 6 years and were enhanced during the follow-up period. Holroyd, Holm, Penzien, Cordingley, Hursey, Martin and Theofanous (1989) compared the long term effectiveness of pharmacological (Ergotamine) to nonpharmacological (relaxation/biofeedback training) treatment approaches. At 3 months, both Ergotamine and relaxation/biofeedback training yielded similar improvements in migraine activity. Successfully treated patients in both treatment groups maintained these improvements in migraine activity. Successfully treated patients in both treatment groups maintained these improvements at a 4-month follow-up evaluation. At a 3-year follow-up of successfully treated patients, Holyroyd et al. (1989) found that both groups reported lower headache activity than prior to treatment. However, those who had been treated with Ergotamine were more likely to have additional medical treatment than those who had been exposed to relaxation/biofeedback training. Based on their results, Holroyd et al. (1989) proposed that improvements achieved through relaxation/biofeedback training are more likely to be maintained without the need for additional treatment, while the same may not be true for Ergotamine treatment. More research is needed to support the above contention. Another issue which is important in evaluating the efficacy of biofeedback in the treatment of migraine is learning. Most studies of biofeedback and headache do not evaluate the degree to which individuals in the biofeedback group actually learn physiological control. It is likely that some develop good control while others do not. This is likely to dilute the effect of biofeedback on headache when the data is averaged together. Thomas et. al. (1993), reported that migraineurs who developed good control (as determined by a performance score derived from each training session) showed double the improvement of poor control subjects. Moreover, the good control subjects were using less analgesic medication at the end of the study while the poor control subjects were using more. In conclusion, migraine headache is a distressing and often debilitating physiological disorder for which there is no available cure at present. Although there are a variety of treatments available, no one treatment is effective for all individuals. Biofeedback has been demonstrated to be an effective drug free approach to treating migraine. The efficacy of biofeedback compares adequately to that of drug therapy, but without the potentially adverse side effects. Finally, empirical support for the long term effectiveness of biofeedback is accumulating. However, it must be emphasized that just as pharmacological intervention is not effective for every migraine sufferer, biofeedback is similarly not effective for every migraineur. Rather, biofeedback represents an effective non-drug alternative for the treatment of migraine. References
Blanchard, E.B. & Andrasik, F. (1987). Biofeedback treatment of vascular headache. In J. P. Hatch, J. G. Fisher & J. D. Rugh (Eds), Biofeedback: Studies in Clinical Efficacy. New York: Plenum Press, 1-49. Dalessio, D. J. (1980). Wolff’s headache and other head pain (4th ed). New York: Oxford University Press. Gautherier, J., Doyon, J., Lacroix, R. & Drolet, M. (1983). Blood volume pulse biofeedback in the treatment of migraine headache: A controlled evaluation. Biofeedback and Self-Regulation, 8, 427-442. Holroyd, K. A., Holm, J. F., Penzien, D. B., Cordingley, G. E., Hursey, K. G., Martin, N. J. & Theofanous, A. (1989). Long term maintenance of improvements achieved with (abortive) pharmacological and nonpharmacological treatments for migraine: Preliminary findings. Biofeedback and Self-Regulation, 14, 301-308. Holroyd, K. A & Penzien, D. B. (1990). Pharmacological versus non-pharmacological prophylaxis of recurrent migraine headache: A meta-analytic review of clinical trials. Pain, 42, 1-13. Lisspers, J. (1990). Long-term follow-up of migraine treatment: Do the effects remain up to 6 years? Behaviour Research and Therapy, 28, 313-322. Mathew, N. T. (1981). Prophylaxis of migraine and mixed headache. A randomized controlled study. Headache, 21, 105-109. Purdy, R. A. (1992). Migraine: A Handbook for Pharmacists. Toronto: Grosvenor House Press Inc. Regush, N. (May, 1993). No pain, no gain. Saturday Night, 5, 26-32, 71. Saper, J. R. (1987). Ergotamine dependency - a review. Headache, 27, 435-438. Sargent, J., Solbach, P., Coyne, L., Spohn, H. & Segerson, J. (1986). Results of a controlled, experimental, outcome study of non-drug treatments for the control of chronic migraine headaches. Journal of Behavioural Medicine, 9, 291-323. Sovak, M., Kunzel, M., Sternbach, R. A. & Dalessio, D. J. (1981). Mechanism of the biofeedback therapy of migraine: Volitional manipulation of the psychophysiological background. Headache, 21, 89-92. Thomas, M.R., Hollander, S., Kostecki-Dillon, T., Ridgley, B., & Knoke, D. (1995) Brief bio-behavioural intervention for migraine headache: A preliminary program evaluation. International Headache Congress, Toronto, Ontario. Thomas, M. R., & Mizener, D. (1993). Hand temperature biofeedback training for migraine headache: Self regulation or false positive? International Headache Congress, Paris, France.

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