1. 2009;12;1005-1011Efficacy of Biofeedback in the Treatment of Migraine and Tension Type Headaches
   Randomized Trial
   William J. Mullally, MD, Kathryn Hall, MS, RNCS, ANP-BC, and Richard Goldstein, PhD.

BACKGROUND: Biofeedback is an established non-pharmacologic technique commonly used in the treatment of migraine and tension type headaches. Multiple published studies have suggested that biofeedback is effective in reducing the frequency and severity of headaches, often allowing patients to decrease their dependence on medication. Studies have also suggested that biofeedback may effect a decrease in medical utilization.

OBJECTIVE: Assess the efficacy of biofeedback in reducing the frequency and severity of migraine and tension type headaches.

DESIGN: Randomized, prospective, single blind, single center controlled trial.

METHODS: Sixty-four patients with migraine with or without aura and/or tension type headaches, by ICHD-1 criteria, age 18 to 55, who had suffered from headaches for more than one year, were entered into the study. Patients were randomly assigned to receive biofeedback in addition to the basic relaxation instruction or relaxation techniques alone. All patients received instruction in pain theory. Biofeedback training consisted of 10 50-minute sessions utilizing standard EMG feedback from the frontalis and trapezius muscles and temperature from the third finger of the dominant hand. Visual and auditory feedback was provided. Thirty-three patients were assigned to receive biofeedback plus the relaxation techniques and 31, the relaxation techniques alone.

All patients were asked to respond to periodic questionnaires for 36 months. The primary analysis was an intention-to-treat (ITT) analysis. The subsidiary analyses were not and the 11 subjects (7 in the relaxation alone and 4 in the biofeedback group) who received no treatment at all were analyzed and the results were qualitatively the same.

RESULTS: Patients who completed the program with education in pain theory and relaxation techniques showed a statistically significant decrease in the frequency and severity of the headaches in the first 12 months that continued to 36 months. Biofeedback provided no additional benefit, specifically no change in the frequency or severity of the headaches. After 3 months 48% of those in the relaxation group reported fewer severe headaches, while 35% of those in the biofeedback group reported fewer severe headaches; after 6 months, 52% of those in the relaxation group reported fewer severe headaches as compared with 57% reporting fewer severe headaches in the biofeedback group.

The number of medications used by the patients and the utilization of medical care decreased in both groups over 36 months suggesting a regression to the mean.

LIMITATIONS: Compliance was an issue throughout the study. Patients dropped out from the outset and that increased over time. Recovery of questionnaires was difficult and fewer were completed at each 3-month interval. Lack of a large control group who did not receive biofeedback or instruction in relaxation techniques.

CONCLUSION: Biofeedback is an extremely costly and time-consuming treatment modality that, in our study, provided no additional benefit when compared to simple relaxation techniques alone, in the treatment of migraine and tension type headaches in adults.