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​Evidenced- Based Guidelines For Migraine Headache: Behavioral and Physical Treatments US Headache Consortium: American Academy of Family Physicians American Academy of Neurology American College of Emergency Physicians American College of Physicians-American Society of Internal Medicine HEADACHE In a consortium of seven major medical groups drew together experts to recommend specific treatments for migraine headache. The second article is a review of biofeedback treatment of headache.


Evidenced- Based Guidelines For Migraine Headache:

Behavioral and Physical Treatments

US Headache Consortium:

American Academy of Family Physicians

American Academy of Neurology

American College of Emergency Physicians

American College of Physicians-American Society of Internal Medicine



Behavioral therapies may be particularly well suited as treatment options for headache sufferers who have one or more of the following characteristics:

    1. patient preference for nonpharmachological intervention;

    2. poor tolerance for specific pharmacological treatments;

    3. medical contraindications for specific pharmacological treatments;

    4. insuffiecient or no response to pharmacological treatment;

    5. pregnancy, planned pregnancy, or nursing;

    6. history of long-term, frequent, or excessive use of analgesic or acute medications that can aggravate hadache problems; and

    7. significant stress or deficient stress-coping skills


Aims of the Guideline

The objective of the US Headache Consortium is to develop scientifically sound, clinically relevant practice guidelines on chronic headache in the primary care setting. These headache guidelines review the evidence published in the literature and propose diagnostic and therapeutic recommendations to improve the care and satisfaction of migraine patients.

Specific Treatment Recommendations


Relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback, and cognitive-behavioral therapy may be considered as treatment options for prevention of migraine (Grade A)*. Specific recommendations regarding which of these to use for specific patients cannot be made.

*Quality of evidence A. Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings.

Biofeedback Can Help Headache Sufferers

Donald Moss , PhD President, Association for Applied Psychophysiology and Biofeedback

Frank Andrasik , PhD Senior Research Scientist, Institute for Human and Machine Cognition, University of West Florida, Pensacola

Angele McGrady , PhD Professor, Dept of Psychiatry, and Director, Complementary Medicine Center, Medical College of Ohio

John D. Perry , PhD M.Div. Psychologist (ret.), Webmaster,

Steven M. Baskin , PhD, Director, New England Institute for Behavioral Medicine, Stamford, Connecticut

The Human and Economic Costs of Headache

Headaches take a tremendous toll in human suffering, and cost employers millions of dollars each year in absenteeism, disability, and lost productivity. Headaches affect 91 % of males and 96 % of females in the course of their lifetimes. Chronic headaches are challenging to treat, accounting for about 18 million medical visits per year, and many patients continue to suffer in spite of extensive and expensive treatment (McGrady, Andrasik, Davies, et al, 1999).

The Efficacy of Biofeedback for Headache

We believe that Dr. Mullally is wrong, based on an abundance of research studies and clinical reports. Three decades of clinical practice and research have shown repeatedly that biofeedback can be helpful for patients with migraine, tension headache and mixed headache. Several authors have described effective treatment programs, typically including combinations of EMG biofeedback, thermal biofeedback, relaxation training, and cognitive behavioral interventions for tension type and migraine headache (McGrady, Andrasik, Davies, et al. 1999; Degood, Manning, Middaugh, & Davies, 1997; Schwartz, 1995a; Schwartz, 1995b). Patients routinely report reduced intensity or frequency of headache, and some report a complete remission, with a corresponding decrease in medication use.

Many other research investigations have shown clear benefits either from biofeedback alone, or from a combination of biofeedback with other treatments. Several meta-analyses (Blanchard, Andrasik, Ahles, Teders, & O’Keefe, 1980; Blanchard & Andrasik, 1987; Bogaards & ter Kuile, 1994; Haddock, Rowan, Andrasik, Wilson, Talcott, & Stein, 1997; Holroyd & Penzien, 1986, 1990; McCrory et al. 1996) and even more research reviews summarize the positive outcomes available for both tension and migraine headache. An NIH panel on the efficacy of behavioral and relaxation therapies for chronic pain found that EMG biofeedback was more effective than psychological placebo and equally effective to relaxation therapies for tension headache (NIH Technology Assessment Panel, 1996). McGrady, Andrasik, Davies et al (1999) refer to over 100 empirical studies judging the efficacy of biofeedback and behavioral therapies for headache. Their review finds approximately a 50 % reduction in head pain following biofeedback/relaxation therapy and stress management training.

The National Headache Foundation has published Standards of Care for Headache Diagnosis and Treatment, which state that "biofeedback has been shown to be an excellent treatment in the long term management of migraine and tension-type headache disorders (NHF, 1999, p. 17)." The Agency for Health Care Policy and Research commissioned a meta-analysis of the available reports on behavioral interventions for migraine. Thermal biofeedback, relaxation therapy, and cognitive-behavioral therapies were found to be at least moderately effective for migraine, by comparison to waiting-list controls (Goslin, Gray, McCrory, et al, 1999). Another meta-analysis showed moderate effectiveness for EMG biofeedback, relaxation therapy, and cognitive-behavioral therapy in alleviating tension-type headache (McCrory, Penzien, Rains, et al, 1996). The meta-analysis by Holroyd and Penzien (1990) showed biofeedback/relaxation to be identical in effectiveness to propranolol, to date the most researched prophylaxis for migraine. Both of these treatments in turn significantly surpassed placebo and no treatment.

Qualitative Advantages of Biofeedback Treatment

Biofeedback also has particular advantages over most medical treatments for headaches. Not only can it produce long-term remission of symptoms, but it does so without side effects. On the contrary, common side effects of medical treatments of headache include weight gain, sedation, and impaired concentration, and headache medications frequently lose their effectiveness over time. There is even preliminary evidence to suggest that successful treatment with biofeedback and relaxation can result in substantial cost savings (Blanchard, Jaccard, Andrasik, Guarnieri, & Jurish, 1985).

Conclusion: Biofeedback Can Help Headache Sufferers

Clinical experience and research show that headaches remain a challenge for the physician and the patient. Many patients continue to suffer daily severe pain, in spite of heroic treatment regimens. Health care cannot afford to dismiss any intervention that benefits large groups of patients with "modest" improvement, and occasional patients with dramatic improvements. It is irresponsible for Dr. Mullally to dismiss biofeedback overall, simply because one study of patients in an intensive headache program failed to show added benefit. It would be more responsible to limit one's conclusions to the conditions of this specific study. Mullally's study apparently showed that severe headache patients, who have already had a wide variety of interventions in an intensive six-week program, showed no benefit from the addition of biofeedback to their program.

Null results from Mullally's one small study do not negate the large quantity of other clinical and experimental research showing that biofeedback can effectively help many patients suffering from headache. For many patients, with mild to severe tension or migraine headache, biofeedback remains a valuable and risk-free approach to treatment.


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