In thermal biofeedback, a person works with a therapist and a sensitive
instrument, to learn to mentally raise hand temperature. The learning
is surprisingly rapid, usually within the first 3 sessions. Children
with migraines seem to benefit from biofeedback as well (Hermann, Kim,
& Blanchard, 1995).
Effectiveness
By 1990, there had been 60 studies, involving over 2440 patients,
of the effectiveness of thermal biofeedback in preventing migraines.
The effectiveness is approximately equal to that of propranolol: Roughly
45% of participants have at least a 50% decrease in migraine frequency.
Moreover, there is preliminary evidence that the combined effects
of propranolol and thermal biofeedback are greater than the individual
effects, with between 75% and 93% of patients obtaining at least a
50% reduction in migraine frequency (Holroyd, et al., 1995; Mathew,
1981). The combined treatments may help break the pain cycle, allowing
success with lower doses of propranolol (Holroyd, et al., 1995).
Surface EMG
Biofeedback
Overview
In this modality, a sensitive instrument is used to give a person
feedback about levels of muscle tension at their jaw, forehead, temples,
neck, and/or shoulders. With coaching and feedback it is relatively
straightforward to learn to reduce the muscle tension. Often, concurrent
involvement in physical therapy is helpful.
Effectiveness
By 1994, there had been 78 studies, involving over 2860 patients,
of behavioral treatment for tension-type headache. The combination
of surface EMG biofeedback and training in deep relaxation appears
to be the most effective behavioral approach, with an approximately
60% reduction in total headache activity (Bogaards & ter Kuile, 1994).
In this approach, an individual learns to mentally bring about
a state of deep relaxation, essentially at will, using imagery, focused
attention, increased awareness of the sensations of tension and relaxation.
Relaxation skills seem to be a bit more useful when combined with
biofeedback, but this issue is not settled in the literature.
Cognitive Stress
Management Skills
Overview
In this approach, individuals learn to maximize the effectiveness
of their skills for dealing with stresses. This increases self-confidence,
and maximizes the probability that the stressor will be resolved.
Effectiveness
By 1994, there had been 15 studies on cognitive therapy for tension-type
headache. It appears to lead to an approximately 53% reduction in
total headache activity (Bogaards & ter Kuile, 1994; McCrory, Penzien,
Rains & Hasselblad, 1996). In a direct comparison, it was more effective
than EMG biofeedback and relaxation for people who were also attempting
to deal with high levels of daily stresses (Tobin, et al., 1988).
Trigger Identification
and Management
Overview
In retrospective studies, the most important migraine triggers
have been stress, hormones (perimenstrual and mid-cycle migraines),
exercise, and disrupted sleep and eating times (Rains & Penzien, 1996;
Robbins, 1994). In addition, a number of substances found in foods
have been suspected of causing migraines, leading to recommendations
that specific trigger foods be avoided, such as alcoholic beverages
and particularly red wine, caffeine, aged cheeses, citrus fruits,
chocolate, MSG and hydrolyzed vegetable protein (Constantine & Scott,
1994). Behavioral skills are useful for adopting a more regular lifestyle
and for managing stresses, as well as for identifying and eliminating
any dietary triggers.
Effectiveness
For dietary triggers, the outcome literature consists mostly of
case studies and small-scale clinical trials (e.g., Radnitz, Blanchard,
& Bylina, 1990). Within the limits of this design, the results have
been encouraging. It seems likely that dietary triggers are a significant
factor for only a small minority of people with migraines (e.g., Hanington
& Harper, 1968; Nicolodi & Sicuteri, 1999). However, for people who
fall in this category, dietary management may be an important component
of treatment. For lifestyle triggers, there does not yet seem to be
a relevant outcome literature, but of course there are strong rational
reasons for believing that their modification will help prevent migraines.
Pain Coping
Skills
Overview
Pain is a significant stress that can interfere with a person's
well-being, school, job, and family activities. Sometimes fear of
having a severe headache is disruptive by itself. In the worst case
this leads to a vicious cycle, in which thinking about headaches,
stress from them, and sometimes overuse of symptomatic medications
leads to still more headaches. Chronic pain treatment consists of
a set of cognitive and behavioral skills for regaining confidence
in one's ability to cope with the headaches, and for minimizing the
impact of headaches.
Effectiveness
By 1999, there had been approximately 30 controlled trials of
cognitive-behavioral treatment for various chronic pain conditions
(Morley, Eccleston, & Williams, 1999). These show that behavioral
treatment is superior to standard alternative treatments in reducing
pain and increasing cognitive coping. Behavioral treatment is alternative
to waiting list controls on a number of dimensions, including pain
level, mood, activity, and functioning. This refers to pain conditions
in general. However, we have no reason to believe that chronic daily
headaches would be less susceptible than other conditions to behavioral
treatment.
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