CEPHALIC VASOMOTOR AND ELECTROMYOGRAPHIC FEEDBACK IN THE TREATMENT OF COMBINED MUSCLE CONTRACTION AND MIGRAINE HEADACHES IN A GERIATRIC CASE

SYNOPSIS
The effects of cephalic vasomotor response (CVMR) feedback and electromyographic (EMG) feedback on control of CVMR, frontalis EMG and temporal artery vasospasms in muscle contraction and migraine headaches were investigated in a 67 year old woman. Systematic reductions in EMG activity were not achieved during EMG feedback. The frequency of temporal artery vasospams declined. No changes in amplitude of blood volume pulse (BVP) were observed during EMG feedback. A decrease in headache activity was associated with EMG feedback which may have been due to the reduction in temporal artery vasospasms. A treatment withdrawal condition was introduced after six EMG feedback sessions during which an increase in headache activity occurred. When CVMR feedback was introduced, the patient achieved significant BVP reductions. This control was related to the largest reduction in headache frequency and duration. Ratings representing subjective perception of the degree of disability because of headache also decreased during EMG feedback, CVMR feedback, and follow-up. At follow-up, there was a moderate increase in headache activity which was partially attributed to limited home practice.
This case demonstrates the successful use of biofeedback therapy in the treatment of combined vascular and muscle contraction headaches in an elderly patient and suggests that age not be a criterion for eliminating patients from this treatment. In addition, this case further supports the use of cephalic vasomotor feedback as an alternative to temperature training in the treatment of migraine.     

Enhanced Performance Feedback to Strengthen Biofeedback Treatment Outcome With Childhood Migraine

Recent research has indicated that both the magnitude and frequency of performance feedback may be important variables in the biofeedback treatment of headaches. The purpose of this research was to determine whether the qualitative and/or quantitative enhancement of performance feedback could improve the efficacy of thermal biofeedback as a treatment for childhood migraine. In a time-lagged control design, six children with migraine headaches were exposed to thermal biofeedback training and then provided performance feedback reflecting moderate and high success, and, if needed, increased feedback frequency. In four of six subjects, clinically significant reductions in headache activity corresponded directly with the addition of feedback suggesting marked improvement in handwarming relative to peers, even when no improvement in handwarming had actually occurred. In two other subjects, clinically significant changes in headache activity were reported only after performance feedback frequency was increased. The results support the importance of attending to both qualitative and quantitative parameters of feedback as well as skill acquisition during thermal biofeedback treatment of children with migraine.     

Psychophysiological Reactivity in Migraine Following Biofeedback

SYNOPSIS
Biofeedback training is assumed to attenuate the psychophysiological effects of cognitive stressors. This study compared the effects of four varieties of biofeedback, namely, frontalis EMG, finger temperature, skin conductance, and false EMG feedback, in the treatment of severe migraine headache. Before and after treatment there was a psychophysiological assessment during attempted relaxation and during exposure to a variety of cognitive stressors. There was a statistically and clinically significant reduction in headache activity after treatment, with the four procedures being equally effective. Frontalis EMG biofeedback was superior to finger temperature, skin conductance, and false EMG biofeedback as a means of reducing scalp muscle tension, and showed some generalization to other physiological measures. There was no evidence that the physiological effects of the cognitive stressors were modified by any of the biofeedback procedures.     

Differential Efficacy of Biofeedback in Headache

SYNOPSIS
This paper presents a retrospective study of 84 headache patients seen in the Behavioural Medicine Unit of Sunnybrook Medical Centre, of whom 53 were treated with biofeedback.
Of the 84 patients assessed, half were tension headache and half were migraine. Both groups were treated in one of three ways:
1. Frontal EMG FB only.
2. Hand skin temperature (HST) only.
3. EMG FB followed by HST FB.
Assessment results showed the migraine group to have longer headache histories and more severe headaches than the tension group. The tension group had significantly higher frontal muscle tension than the migraine group, while the migraine group had significantly colder peripheral hand temperature. No differences were found in psychometric assessment data.
EMG feedback results showed significant decreases in frontal EMG for both headache groups. Both groups showed a moderate improvement in headache at the end of treatment.
HST feedback treatment results showed significant increases in peripheral temperature and a significant improvement in headache for those migraine patients who achieved a pre-determined criterion level of performance. Non-significant increases in skin temperature occurred for the tension headache group. HST feedback after EMG feedback did not provide further improvement for the tension group. The results are discussed in the context of the differential effects of treatment and highlight the importance of a "trials to criterion" training paradigm.     

Relaxation und Biofeedback in der Behandlung von chronischem Kopfschmerz bei Kindern und Jugendlichen

The first studies on psychological treatment of pediatric headache appeared about 10 years ago; most of them were published in Anglo-American journals. This review focuses on relaxation training and biofeedback (EMG and hand temperature feedback) as the psychological interventions most often used in pediatric migraine and tension headaches. The results of randomized group studies, which were mostly well-controlled, on the efficacy of relaxation therapy (n=12) now allow a rather optimistic prognosis on the feasibility of this intervention. Most studies demonstrate clinically relevant reductions of headache frequency after training. Biofeedback studies are methodologically less well controlled and although positive effects have been observed, e.g., in single case studies, the relative usefulness of biofeedback has yet to be determined. Deficits in research on the psychological treatment of headache in children and adolescents are described, new research issues are discussed and recommendations for more systematic research are given.     

Progressive Relaxation und EMG-Biofeedback in der Therapie von chronischem Kopfschmerz bei Kindern

A group study on the comparative efficacy of EMG biofeedback and progressive relaxation is presented. Sixteen children aged between 8 and 14 years with chronic tension headache and combined headache participated in the study. Six sessions of relaxation training and 12 (shorter) biofeedback sessions were held with each child. Both treatments had excellent results, which were apparent directly after training. All but one child benefited to a clinically significant extent from the treatment, with a reduction of more than 50% in headache frequency. Other variables indicate further positive effects of treatment (e.g., medication consumption, absence from school). After 6 months of follow-up the children treated by relaxation had achieved event further reductions in headache activity. Suggestions for further improvement in the clinical and economic efficiency of treatment formats are presented, and perspectives for future research are discussed.     

Do the effects of cognitive therapy endure? A two-year follow-up of tension headache sufferers treated with cognitive therapy or biofeedback

This report presents findings from a two-year follow-up of chronic tension headache sufferers treated either with stress-coping training (cognitive therapy, N = 11) or electromyographic biofeedback (N = 8). Clients who had received stress-coping training reported that two years following treatment they continued to use the coping strategies they had been taught, and daily headache recordings indicated they were still significantly improved ( p < .005). About one-half of the clients treated with biofeedback were substantially improved following treatment, with the remaining clients showing minor improvements or increases in headache symptoms. These mixed outcomes were still evident at two-year follow-up, with three of four clients maintaining improvements and the remaining clients showing, at best, minor reductions in headache symptoms. This longterm maintenance of treatment gains following stress-coping training suggests that cognitive therapy deserves the increased attention of investigators interested in the long-term maintenance of therapeutic gains.Grants from NIMH supported the original treatment study (1-R03-MH28939-1) and facilitated preparation of this report (1-F32-MH08327-01).     

Long-term efficacy of combined relaxation: biofeedback treatments for chronic headache.

Thirty-four patients having chronic idiopathic headaches participated in a long-term study comparing autogenic relaxation training alone (REL) with combinations of relaxation and electromyographic biofeedback (REL + EMG) or relaxation and temperature biofeedback (REL + TEMP). Assignment to treatment conditions was balanced on demographics and clinical characteristics, as well as headache classification according to muscle contraction or vascular headache symptomatology. The results indicate that REL + TEMP produced no additional improvements over REL following the 8-week treatment program, or at 6-month, or 12-month follow-up. However, REL + EMG produced significantly greater reductions in headache activity measures than the REL and REL + TEMP conditions at all post-treatment time points. Headache activity continued to improve over the follow-up period independent of treatment condition. These data indicate that EMG biofeedback augments long-term clinical improvements in headache patients who undergo autogenic relaxation training.     

Effects of Frontalis EMG Biofeedback and Diazepam in the Treatment of Tension Headache

SYNOPSIS
Frontalis EMG biofeedback and diazepam treatments were compared in tension headache patients; headache scores (intensity and frequency) and frontalis EMG were used as control parameters. The study, conducted in a double blind manner, was split in three equal observation periods (4 weeks): baseline, treatment and follow-up. Four patient groups were chosen, two of which received placebo treatment. In both true conditions, biofeedback and diazepam, treatment effects differentiated from placebo groups; with diazepam the strongest results upon headache and frontalis EMG were observed during treatment, which, however, were lost at the follow-up period; biofeedback although with weaker effects during treatment showed, at follow-up, a long lasting reduction of headache scores even when frontalis activity reached baseline levels; in the false biofeedback group some decrease of EMG activity during treatment and of headache intensity at follow-up were also observed. The data suggest that biofeedback is a complex learning situation, where several uncompletely known factors are possibly at work; it also raises the possibility of a complex relation between frontalis muscular activity and headache since a simple linear relation of both variables was not observed.     

Some Benefits of High Frontalis Tension in Tension Headache Sufferers

SYNOPSIS
Although the relationship between EMG levels and tension headache remains unclear, elevated frontalis EMG levels in tension headache sufferers are usually assumed to be part of the debilitating experience of headache. Elevated tension levels are seldom considered in an activation-type framework. Consequently, headache patients are encouraged to relax in almost all situations. Two experiments were performed to examine whether tension headache sufferers showed any benefits from elevated tension levels during periods demanding a sustained level of cognitive efficiency. Headache subjects were compared with non-headache subjects during discrimination and reaction time task performance across three levels of frontalis tension. Both groups' performance improved under increasing tension conditions relative to the low tension condition. In both experiments improvement was noted as a reduction in the most extreme scores, reflecting possible "mental blocks". In Experiment 2 median reactions times were also affected. In Experiment I the variation in reaction time scores across the tension levels was greater in the headache group than the non-headache group. Even when the optimal level of tension varied across task difficulty levels, low frontalis tension was never the optimal condition. It was concluded that tension headache prone individuals being treated by relaxation or biofeedback techniques need to be informed about the increased tendency towards slower responding under conditions of frontalis relaxation.     

Comprehensive Biofeedback Versus Self-Monitored Relaxation in the Treatment of Tension Headache

SYNOPSIS
Muscle contraction headaches have been demonstrated to significantly decrease following EMG biofeedback as well as general relaxation practice. This study contrasted the efficacy of a comprehensive biofeedback and stress management strategy and a self-monitored home relaxation program in the treatment of 20 tension headache sufferers. The results suggested that while both treatment strategies successfully increased patients' ability to relax and reduce frontalis EMG levels, only the comprehensive biofeedback program was successful in reducing reports of headache pain and feelings of psychological distress. The findings support the utility of a headache treatment model beginning with simple relaxation and progressing on a case by case basis to more comprehensive tension and stress management strategies (like EMG biofeedback and cognitive stress coping techniques) only when the less costly relaxation proves ineffective in altering subjective feelings of pain or distress.     

Two Studies of the Potential Mechanisms of Action in the Thermal Biofeedback Treatment of Vascular Headache

Sixty vascular headache sufferers who underwent a standard protocol treatment of progressive relaxation and thermal biofeedback with autogenic training were studied for changes in hand temperature (the targeted response) and heart rate (a non-targeted response) to determine how such physiological change relates to reduction in headache activity. Overall, regardless of degree of improvement, subjects showed a significant, positive change over time in their ability to increase hand temperature. It was also found that inability to handwarm at session one of thermal biofeedback training was predictive of treatment success, as was the ability to achieve a fingertip temperature of at least 96.0 degrees F at any point in thermal biofeedback training. In addition, it was found that migraine headache sufferers who were treatment successes had significantly lowered their heart rates from pre- to post-treatment assessment.     

Cognitive control of tension headache

This study assessed the effectiveness of a cognitively oriented stress coping training program designed to provide skills for coping with daily life stresses as a treatment for tension headache. Thirty-one community residents with chronic tension headaches were assigned to stress-coping training (N =10),to biofeedback training (N =11),or to a waiting-list control group (N =10).Treatment procedures were accompanied by counterdemand instructions designed to minimize the influence of implicit demands for improved performance. Although only the biofeedback training group showed reductions in frontalis electromyographic activity, only the stress-coping training group showed substantial improvement on daily recordings of headache. These results were interpreted as providing support for a cognitive approach to the treatment of tension headache. Questions concerning the part played by nonspecific treatment factors in biofeedback training were also raised. Appreciation is expressed to Dale Mattmiller, M.D., Jerry Noble, and Cheryl Richards, who assisted with the carrying out of this experiment. Grants from the Ohio University Research Committee and NIMH (1-R03-MH28939-1) to the senior author provided support for this study.     

A Critical Analysis of the Traditional Tension Headache Model

SYNOPSIS
Electromyographic (EMG) biofeedback is frequently used as the behavioral therapy of choice to reduce the severity of tension headache. In this review, it becomes evident that despite biofeedback's widespread use, other behavioral therapies which are not as hardware-dependent are as effective as biofeedback training in relieving headache pain. In addition, several theoretical concerns are raised here since the assumptions upon which EMG biofeedback therapy is justified may not be valid. Finally, recommendations for dealing with tension headache are made, based on the evidence provided by studies of behavioral intervention therapies.     

EMG Activity in Pericranial Muscles During Postural Variation and Mental Activity in Healthy Volunteers and Patients With Chronic Tension Type Headache

EMG activity was recorded over frontalis, temporalis and trapezius muscles in a supine position, a standing position and during a mental task in 32 female patients suffering from chronic tension-type headache and in 20 healthy volunteers. Measurements in patients were made before and after biofeedback therapy. All EMG levels were on average significantly higher in patients than in controls. 62.5% of patients had at least one abnormal EMG level, but only 34% were beyond the normal range, if 1 muscle and 1 recording condition was considered. EMG levels were not correlated with headache severity, anxiety or response to biofeedback treatment. It is therefore suggested that pericranial EMG activity is not pathogenetic in chronic tension type headache, but merely one of several pathophysiologic changes, that are produced by a central dysfunction.     

Pain Response to Voluntary Muscle Tension Increases and Biofeedback Efficacy in Tension Headache

SYNOPSIS
The hypothesis that patients reporting an association between head pain and voluntary muscle tension increases could react more positively to EMG biofeedback was evaluated in 33 tension headache sufferers involved in a program of six training sessions and of a follow-up two months later. These patients were taught to increase their frontal muscle tension over 10 μvolts through biofeedback for a period of one minute at the first session and of two minutes at the second one. According to their subjective pain response, 14 patients were considered to show a positive association between head pain and muscle tension increases while the 19 others did not show such an association. The group of patients with a positive association between head pain and muscle tension showed a rapid symptomatic improvement which was partially lost as the training progressed, while the other reported a more linear gradual improvement. At follow-up, there was no difference in headache, drug usage and frontal EMG between the two groups. The differences in the shapes of the symptomatic responses are discussed in terms of patients' expectations from the training.     

Electromyographic (EMG) feedback in chronic musculoskeletal pain: a controlled trial

The literature regarding the application of EMG feedback training in musculoskeletal pain disorders is reviewed. A within-subject control trial of EMG feedback using a counterbalanced design in patients with chronic musculoskeletal pain is reported here. Eighteen subjects (12 females and 6 males) were studied in terms of subjective reports of pain and EMG activity measurement under standardised conditions. Both EMG feedback and a control condition were active in reducing subjective pain levels, which increased during a waiting list conditions in certain sequences. EMG activity declined during both EMG feedback and control conditions but only EMG feedback resulted in an orderly reduction in EMG baseline measurements with a highly significant linear trend when presented before the control condition in sequence. A significant correlation between subjective pain levels and surface EMG activity was found. These data suggest that EMG feedback is superior to a control condition in training muscle relaxation but not in reducing subjective pain levels despite a high correlation between these two parameters. Non-specific factors may well affect pain scores and further research is required before the specific biofeedback training effect can be accepted as superior to its non-specific effects in reducing subjective pain.     

Lack of Concordance Between Changes in Headache Activity and in Psychophysiological and Personality Variables Following Treatment

SYNOPSIS
Hypotheses about the involvement of physiological and personality mechanisms in the relation between stress and headache have not yet been tested in a pretreatment-post-treatment treatment design though many behavioral techniques are based on these notions. Effects of four treatments (stress-coping, stress-coping including finger temperature biofeedback, stress-coping including temporal vasoconstriction biofeedback and waiting list-control) were analysed in migraine patients with regard to headache measures, psychophysiological functioning and personality variables. In tension headache patients three treatments were compared (stress-coping, stress-coping including frontalis EMG biofeedback, and waiting list-control). Changes neither in physiological nor in personality measures showed concurrency with changes in headache variables. Our results do not confirm the hypothesis of a mediating role between stress and headache for temporal artery and frontal muscle stress responses in migraine patients and tension headache patients, respectively. Neither was the notion of involvement of personality change in headache improvement sustained.     

Cognitive changes accompanying headache treatment: The use of a thought-sampling procedure

Thirty-six community residents with mixed headache symptomatology were assigned either to a group receiving cognitive-behavioral treatment or to a waiting list control. Treatment focused explicitly upon training subjects to manage headache attacks more effectively. During a baseline assessment and following completion of treatment, all participants self-monitored cognitive activity during headache and kept a written record of headache symptoms. Cognitions were obtained by means of a thought-sampling procedure in which subjects provided a series of cognitive reports during each headache episode. Headache cognitions were scored on five cognitive measures developed in a preliminary study. In comparison with controls, treated subjects appraised headache attacks in a more positive manner and reported more frequent occurrence of coping thoughts of a problem-solving nature. Changes in cognitive appraisal were also correlated with reductions in headache intensity following treatment. In addition, prior to treatment, reported levels of pain intensity appeared to be related to cognitive activity during headache. The findings provide support for a multidimensional model of pain and suggest that treatment effectiveness may be mediated by changes in particular cognitive reactions to headache.This paper is based upon portions of a doctoral dissertation submitted by the first author, under supervision of the second author, to Queen's University, 1985. The research was supported in part by funding provided by the Medical Research Council of Canada. Appreciation is expressed to Marlies Sudermann, Carol Harris, and Zindel Siegal for their assistance.     

A Controlled Evaluation of the Addition of Cognitive Therapy to a Home-Based Biofeedback and Relaxation Treatment of Vascular Headache

Seventy-six patients with vascular (migraine or mixed migraine and tension) headache (HA) participated in a controlled evaluation of a minimal-therapist-contact, largely home-based, treatment program which combined relaxation (R) training with thermal biofeedback (TBF). One group received TBF + R administered in 3 office visit over 8 weeks, supplemented by audio tapes and manuals. A second group received the TBF + R plus instruction in cognitive stress coping techniques, all of which was administered in 5 office visits over 8 weeks. A third group monitored headache activity for 8 weeks. Evaluations, based on 4 weeks of HA diary at pre-treatment and after treatment, revealed significantly greater reductions in HA activity and medication consumption for both treated groups than the HA monitoring controls who did not change. Significantly more of the treated patients had clinically significant reductions in HA activity than the controls. The two treated groups did not differ on any measure.