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At Health Psych Maine we provide a biobehavioral, non-drug approach to prevent and manage migraine, tension-type, and chronic daily headache. Our goal is to understand the headaches in terms of their underlying biology, risk factors, and trigers and to impart skills for managing and preventing them. Biofeedback is a key component of treatment.
Behavioral treatment can also help to:
These skills are intended for chronic benign headaches:
At Health Psych Maine, after an initial interview, questionnaires and biofeedback assessment, we will work with you to identify the best treatments for your headaches. Treatment is designed to be time and cost-effective, and is generally 5-6 sessions in total.
For more detailed information about specific topics,
please search Dr. Borkum's textbook or browse its table of contents.
In the American Academy of Neurology guidelines, biofeedback, relaxation training, and cognitive-behavioral therapy are empirically supported for the prevention of migraines, with grade A evidence.
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).
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).
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.
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.
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.
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).
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.
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 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.
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.