About 4 of 5 of people who have tension and migraine headaches which did not start with trauma can reduce their headache frequency, intensity, and duration by an average of about 80% (with many having no remaining headache activity for at least 10 years) by using biofeedback based behavioral interventions.

“Tension” headaches originating from muscles kept too tense for too long anywhere in the head and neck -especially including the jaws. People who have muscle related pain usually cannot tell how tense their painful muscles are as well as people without muscle related pain. The inability to accurately relate actual levels of muscle tension to sensations from the muscles leads to muscles being kept tenser than necessary for longer than necessary given the task at hand. Muscles kept only five percent tenser than necessary for less than a half hour longer than necessary leads to pain which can be sustained for an entire day.

Biofeedback devices record tension in the muscles generating the pain and show those levels to the patient. The patient learns to associate actual levels of tension with sensations from the muscles so muscles are kept appropriately relaxed. Most people learn to recognize their levels of tension and to automatically keep them at appropriate levels. This eliminates or vastly reduces head area pain from this source. People who successfully learn this skill and apply it eliminate or vastly reduce the intensity, duration, and frequency of their tension headaches.

“Migraine” headaches usually begin during adolescence or young adulthood with no obvious initiating incident. They may begin abruptly or gradually and may or may not be related to sexual maturity. These are the type of migraine headaches which can be effectively prevented through behavioral techniques such as biofeedback. Migraine-like headaches which begin with trauma such as an auto accident or which come in clusters usually cannot be effectively treated through behavioral interventions.

 Nearly all people with migraine headaches have less near-surface blood flow to the fingers and toes (and sometimes noses) than those who do not have migraine headaches. As all of the heat emanating from the fingers and toes is generated by near surface blood flow, these people tend to have relatively cool extremities. Biofeedback devices can accurately record the temperature of the fingers (or any other body part) and show the temperature to patients so they can learn to recognize and then control finger temperature sufficiently to maintain normal levels of finger temperature. People who can learn this skill and maintain normal levels of fingertip temperature do not get migraine headaches as often or as severely as previously. Many entirely eliminate their headaches. Most also significantly decrease or eliminate their need for migraine medications.

People who do not learn to control their muscle tension or finger blood flow do not change their headache activity.

The evidence supporting the effectiveness of biofeedback (frequently used in conjunction with related techniques such as progressive muscle relaxation training) for the treatment of tension and non-traumatic origin migraine headaches is very strong. Numerous controlled studies with reasonably large numbers of patients and long follow-ups (of up to ten years) show that biofeedback is highly efficacious for these types of headaches with about 4 of 5 people showing an average of an 80% reduction in headache activity. The evidence supporting this assertion and the reviews of the peer reviewed literature are summarized below.

Other types of headaches, such as those caused by trigger points and nerve over-reactivity cannot be treated effectively with behavioral interventions.

For information about biofeedback:

To watch a slide show on biofeedback, go to www.biofeedbacktraining.org. On the home page’s left column, scroll down to “biofeedback info and equipment” then click on “what is biofeedback”. This will lead you to the slide show.

THERAPISTS: If you are a therapist and would like to find out more about how to treat headaches using behavioral interventions such as biofeedback, please contact us at contact@behavmedfoundation.org or look at the courses on the web site www.biofeedbacktraining.org.   

PATIENTS: If you have migraine or tension headaches and would like to look into biofeedback based interventions, go to the web site www.bcia.org to locate a certified biofeedback practitioner near you.   

Evidence that psychophysiological interventions are effective for treating migraine and tension headaches including muscle tension related jaw pain

(This material is abstracted from the book “Pain assessment and intervention from a psychophysiological perspective” by R. Sherman, 2012.)

            A discussion of head area pain caused by sustained tension in the jaw muscles is incorporated into this section because sustained tension in the jaw is nearly always accompanied by headaches which extend across the forehead. This is because the temporal muscles tense concurrently with the masseters.

          Numerous clinical and controlled studies demonstrate that psychophysiological interventions including biofeedback (e.g. Blanchard and Andrasik 1984, Blanchard 1992), autogenic exercises (e.g. Linden 1994), and progressive muscle relaxation training (e.g. Jacobson 1970) are effective for the treatment of both migraine and tension headache among adults and children. Blanchard (1992) wrote an excellent review of biofeedback interventions for headaches. The outcome criteria for large studies required decreases in intensity, duration, and frequency of at least 50% with changes in use of medication factored in. Long term follow‑up studies show that the treatments are effective for at least five years. Comparative studies show that biofeedback is at least as or more effective than standard interventions. Blanchard et al (1987) have demonstrated that three week pre and post treatment baselines are adequate for evaluating the initial effects of any intervention on headache activity. Thus, most of the studies in the literature actually have sufficient baseline and follow-up periods to give a reasonable idea of their initial success rate. Pollard and Katkin (1984) were able to show that the effects of biofeedback for jaw muscle problems are not due to the placebo effect.

            Middaugh and her group (e.g. Middaugh and Morrisette 1999) combine stretching exercises with EMG biofeedback to optimize results for those patients shown to have postural problems such as forward head thrust. These protocols have been presented at numerous workshops (e.g. Middaugh 2003) but are not presented here as special, hands-on training is needed to teach them to patients. The forward head thrust exercises presented in Appendix H are frequently effective for controlling these problems – especially if combined with use of ice and warm packs. In the absence of poor posture, there is no evidence that any of the physiotherapy modalities including manipulation are effective in helping tension headache (Lenssinck et al 2004).

             Headache activity is usually defined as a composite of headache duration, frequency, and intensity.  Many studies have been published which show that people with tension

and migraine headaches can be taught to control their muscle tension. For most of the subjects, this results in a significant decrease in the frequency, intensity and duration of headaches (Adler 1976, Budzynski et al 1973, Cox 1975, Hutchings et al 1975, Sherman 1982). For example, Adler (1976), compared a combination of temperature biofeedback and relaxation training with ergotamine. Three years after treatment, 19 of the 21 patients successfully treated with biofeedback had not received other treatments and still showed reduced headache activity. Most of those who had received ergotamine had gone on to a succession of other drugs and treatments but most continued to show at least some reduced headache activity.  

             Sherman (1982) and many others (e.g., Jurish et al 1983, Teders et al 1984) have shown that people can be trained to control their muscle tension to reduce their pain at home without having to be treated at a hospital.  The work on comparative efficacy of biofeedback for the treatment of migraine and tension headache has been extensively reviewed elsewhere (e.g. Shellenberger et al 1994, Holroyd et al 1989).

             Blanchard (1992) reviewed the use of biofeedback for treatment of benign headache disorders. This review details the effectiveness of biofeedback treatments for headache and described their acceptance.  He concluded that biofeedback treatments of headache are well‑established based upon a fairly large literature of controlled evaluations.  Moreover, these treatments have gained widespread acceptance in the medical world specializing in headache.  The effects hold up over long‑term follow‑up, the side effects tend to be positive (reduced anxiety and depression), and the treatments can be readily adapted to more cost‑effective formats.  Blanchard and Andrasik’s 1985 review of all of the publications in the area at that time indicated an average degree of improvement of 56% (range of 14% to 100%) for tension headaches and 48% (range of 16 to 70%) with migraine headaches. Teders et al (1984) found that about 63 percent of subjects showed improvement (26% slight, 37% over 50% decrease in headache activity). Blanchard et al (1982) found about the same rate of improvement with 12% of subjects showing slight improvement (20 to 49% decrease in headache activity) and 52 percent showing significant improvement (50% or greater decrease in headache activity).

     Typical studies such as that by Grazzi et al (1990) show gains maintained at one year follow-up of ten children treated for tension headaches. Sliver et al (1979) showed similar finding as long ago as the 1970s. Hermann and Blanchard (2002) reviewed the effectiveness of biofeedback for children’s headaches and found a high level of effectiveness. Penzien et al (2002) reviewed the overall effectiveness of behavioral treatments (biofeedback, relaxation training, stress control training) for headaches and found that the techniques are highly efficacious. Eccleston et al (2002) performed a meta-analysis of these therapeutic approaches for children with headaches and confirms that well designed, controlled studies indicate excellent effectiveness.

             Other reviews and metaanalyses confirming the efficacy of behavioral / biofeedback based interventions for headache include Rains et al (2008), Nestoriuc and Martin (2007) for migraines, and Nestoriuc et al (2008) for all headaches, and Nestoriuc (2008) for tension headaches. The later meta-analysis (Nestoriuc et al 2008) investigated the short- and long-term efficacy, multidimensional outcome, and treatment moderators of biofeedback as a behavioral treatment option for tension-type headache. A literature search identified 74 outcome studies, of which 53 were selected according to predefined inclusion criteria. Meta-analytic integration resulted in a significant mediumto-large effect size (d 0.73; 95% confidence interval  0.61, 0.84) that proved stable over an average follow-up phase of 15 months. Biofeedback was more effective than headache monitoring, placebo, and relaxation therapies. The strongest improvements resulted for frequency of headache episodes. Further significant effects were observed for muscle tension, self-efficacy, symptoms of anxiety, depression, and analgesic medication. Moderator analyses revealed biofeedback in combination with relaxation to be the most effective treatment modality; effects were particularly large in children and adolescents. In intention-to-treat and publication-bias analyses, the consistency of these findings was demonstrated. It is concluded that biofeedback constitutes an evidence-based treatment option for tension-type headache.

            There is solid literature showing that volume of blood flow in the temporal arteries is related to onset of migraines and change in pain during a migraine. This was established as early as 1982 by Allen & Mills (J Psychosom Res. 1982;26(2):133-40) .

Thus, biofeedback of temporal artery blood volume recorded using a photoplethysmograph mounted over the temporal artery is a reasonable approach to treating migraines.

Several studies have successfully used it for just this purpose.

Two of these were controlled studies (Lisspers & Ost and Gauthier et al). However, the author has not found any large clinical studies with long term follow-ups using this technique.

             Blanchard et al (1982) found that 36 percent of tension headache patients and 44 percent of migraine headache patients who did not respond to ten sessions of relaxation training (spread over eight weeks) did respond to biofeedback. This change could have been due to further treatment or the difference between the two treatments.   

     Hutching and Reinking (1976) compared the effectiveness of (a) autogenic exercises, (b) EMG biofeedback, and (c) a combination of both interventions for reduction of tension headaches among eighteen subjects and found that EMG biofeedback worked best. Silver et al (1979) found no difference between progressive muscle relaxation training and temperature biofeedback for migraine headaches upon one year follow-up. Daly et al (1983) did not find any difference in the efficacy of (a) fingertip temperature biofeedback, (b) progressive relaxation, and (c) EMG biofeedback from the frontal area for either tension or migraine headaches. At three month follow-up the progressive relaxation group had not maintained its effects quite as well as the other two but all groups showed highly significant success with only one patient in each group getting worse.

     Hart and Cichanski (1981) found that 20 tension headache sufferers treated with EMG biofeedback from either the frontal area or the neck did about as well in reducing headache activity but that the neck feedback group showed a greater decrease in medication use. Wauquier et al (1995) found that groups of 23 and 25 migraine headache patients did better with temperature biofeedback and relaxation training than with relaxation training alone. 

     Linden’s 1994 review of the German literature on autogenic training provides convincing evidence that this technique produces results at least as good as the better known progressive muscle relaxation exercises. However, Stetter and Kupper’s (2002) recent meta-analysis did not find as firm support for use of the technique. It is well worth learning this simple training regime and using it with patients who prefer more structure in their awareness exercises.

             There is considerable evidence that psychophysiological interventions do not work well with cluster headaches (e.g. Blanchard et al 1982). Ham and Packard found that biofeedback helped about 53% of patients with posttraumatic headache.

             Psychophysiological Interventions for Muscle Tension Related Orofacial Pain (Including Bruxism) are generally highly effective. Crider et al (2005) reviewed the literature supporting the efficacy of biofeedback for TMD and determined that it is efficacious. Glaros et al (2007) found that behavioral interventions for TMD were as effective as splint therapy. Reviews of the literature by many authors incuding Crider et al (2005), Glaros and Glass (1993), Glaros and Lausten (2002), Hatch et al (1987), and Gevirtz et al (1995) provide sufficient convincing detail and analyses of numerous clinical and several controlled studies to reach the firm conclusion that:

          (1) Surface muscle tension biofeedback from the masseters and/or frontal area and muscle tension recognition and control training exercises are effective in reducing pain from objectively diagnosed, muscle related jaw area pain problems.

          (2) Both objective finding upon examination, electromyographic activity, and pain decrease and remain improved during six month or longer follow‑ups.

          (3) Comparative studies show that biofeedback is at least as effective as splints and other standard techniques.

             The author’s studies clearly demonstrated that psychophysiological interventions are ineffective for head area pain caused by jaw joint (TMJ) problems and for sustained masseter muscle tension resulting from splinting to prevent painful motion of the jaw. Thus, it is imperative that a good differential diagnoses be made prior to initiating treatment.

             Glaros and Glass (1993) summarized the history of treatment attempts beginning with Gessell’s 1975 study of twenty-three patients with myofascial pain. Each was given between three and fourteen sessions of EMG biofeedback training from the masseter and temporalis muscles. Fifteen of the twenty-three subjects showed a clinically positive response.  Carlson and Gale (1977) conducted a single group trial in which eleven patients with TMJ were given biofeedback for between six and eighteen sessions. At the end of treatment eight reported no pain. Five still had no pain after one year. This is long enough for the placebo effect to have worn off so the therapy was probably effective.

     More recent studies included larger sample sizes, control groups, limited follow-ups, and outcome measures which included dental examinations and EMG levels. Stenn et al (1979) found that progressive relaxation training, EMG feedback from the masseter muscles, sensory awareness training, and coping skills training all helped MPD patients. However, the entire study only had thirteen subjects so partialling out the effects is difficult. The three month follow-up was too short to permit evaluation of long term effectiveness.  Dalen et al (1986) compared EMG biofeedback with a waiting list control and had a six month follow-up which showed continuing effectiveness of the treatment.

     Several comparative studies have been performed. Dahlstrom et al (1982) found that EMG biofeedback was as good as splint therapy and that gains were maintained upon one year follow-up (Dahlstrom and Carlsson 1984). Crockett et al (1986) compared (1) bite splints combined with physiotherapy, (2) biofeedback and relaxation training, and (3) transcutaneous nerve stimulation. None of the groups in this small study (seven subjects per group) were superior and no follow-up was performed. Hijzen et al (1986) found that EMG feedback (in which people were trained to recognize and control the amount of EMG produced) was more  effective than splint therapy in reducing pain and increasing mouth opening with both being more effective than no therapy. The splint group was more effective at reducing joint sounds. No follow-up was reported.    

     Flor and Birbaumer (1993) divided twenty-one patients with muscle related jaw pain into three groups: EMG biofeedback from the masseters, standard dental treatment (bite plates, dental work, massage), and cognitive-behavioral therapy. The biofeedback group showed the most change and was the only group to maintain the improvement at 24 month follow-up.

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