A randomized controlled trial of an internet-based treatment for chronic headache

Chronic headache is a significant public health problem in Western nations. Although controlled trials demonstrate the efficacy and cost-effectiveness of face-to-face behavioral therapy, most headache sufferers have limited access to these treatments. Delivery of behavioral interventions using Internet technology has the potential to reach a larger number of headache sufferers and reduce the burden of disease. This randomized controlled study evaluated an Internet-delivered behavioral regimen composed of progressive relaxation, limited biofeedback with autogenic training, and stress management versus a symptom monitoring waitlist control. Treatment led to a significantly greater decrease in headache activity than symptom monitoring alone. Thirty-nine percent of treated individuals showed clinically significant improvement on self-report measures of headache symptoms at post-treatment. At two-month follow-up, 47% of participants maintained improvement. Treatment had a significant impact on general headache symptoms and headache-related disability. There was a 35% within-group reduction of medication usage among the treated subjects. The Internet program was more time-efficient than traditional clinical treatment. Treatment and follow-up dropout rates, 38.1% and 64.8%, respectively, were typical of behavioral self-help studies. This approach to self-management of headache is promising; however, several methodological and ethical challenges need to be addressed.     

BIOFEEDBACK AND RATIONAL-EMOTIVE THERAPY IN THE MANAGEMENT OF MIGRAINE HEADACHE

Twenty-four migraine patients were randomly assigned to one of four conditions: (a) self-monitoring of headache activity (waiting list), (b) frontalis EMG biofeedback, (c) digit temperature biofeedback, and (d) digit temperature biofeedback plus Rational-Emotive Therapy (RET). Bidirectional control over the target physiological response was assessed through a reversal design in each session. Following at least a four-week baseline, the three biofeedback groups received 8 to 10, 30-minute sessions of bidirectional biofeedback training, scheduled twice a week. Subjects in the combined digit temperature biofeedback plus RET group received three 40-minute sessions of RET as an addition to the third, fifth, and seventh biofeedback sessions. Records of daily home practice were kept throughout treatment and three-month followup. Subjects on the waiting list monitored headaches for at least five months, corresponding to “baseline”, “treatment”, and three-month followup. Digit temperature biofeedback alone and in conjunction with RET did not prove to be more effective than the control conditions. All the EMG subjects reduced headache activity to two-thirds or less of the baseline level by the third month of followup. Bidirectional digit temperature performance did not improve with training, was demonstrated in only 33% of the biofeedback sessions, was not maintained over time, and was unrelated to improvement in headache activity. EMG subjects reported biofeedback performance to be an easier task and met the performance criterion on 85% of the sessions. The frequency of home practice contributed over 55% of the variance in retrospective estimates of headache improvement but was not related to changes in daily records of headache activity.     

BEHAVIORAL MANAGEMENT OF EXERCISE TRAINING IN VASCULAR HEADACHE PATIENTS: AN INVESTIGATION OF EXERCISE ADHERENCE AND HEADACHE ACTIVITY

A behavioral package was used to shape and maintain the adherence of 5 subjects with vascular headache to a program of aerobic exercise training. Repeated measures of exercise behavior were examined through the use of a bidirectional changing criterion design. Repeated measures of headache activity were also collected. Results demonstrated a functional relationship between the behavioral package and exercise adherence, because all 5 subjects showed exercise behavior that matched bidirectional changing exercise criteria. The results also indicated clinically significant collateral reductions in vascular headache activity in 4 subjects. Subjects whose aerobic fitness levels were not masked by vasoactive medication also showed measurable increases in aerobic fitness. The results are discussed in terms of the methodology used to demonstrate a functional relationship between the adherence package and exercise behavior and the possible mechanism(s) by which aerobic exercise activity might affect vascular headache activity.     

The relationship between frontalis muscle activity and self-reports of headache pain

The relationship between levels of frontalis muscle activity and self-reports of pain was evaluated in two studies. In Study I frontalis muscle activity and self-reports of pain collected during biofeedback treatment of muscular contraction headache clients were correlated. In Study II frontalis EMG activity was increased and decreased using biofeedback techniques while concurrent reports of headache pain were recorded. The results of Study I indicated a significant relationship between EMG activity and reported headache pain for only two of the five subjects studied. The biofeedback procedures in Study II were associated with reliable increases and decreases in EMG activity. Concordance between EMG and pain reports occurred only during the EMG increase condition. Overall correlations were significant for one of the 2 subjects. The results suggest that EMG activity may not be sufficient to account for pain reports in all chronic headache clients, and variables other than EMG activity may be influencing reports of pain in some patients.     

Autogenic Feedback in the Treatment of Two Children with Migraine Headache

Autogenic feedback was used to treat two subjects, ages 12 to 14, suffering form migraine headache. A multiple baseline across subjects design was used to evaluate treatment outcome. Marked improvement was displayed on all three measures of headache activity for both subjects by the end of treatment and was maintained throughout the follow-up period. These results are comparable to those obtained when similar procedures are applied to chronic adult headache sufferers and suggest that continued investigation is warranted.     

Temperature self-regulation and relaxation with migraine patients and normals

Ten migraine headache subjects and 10 non-migraine subjects were divided equally into two groups: a progressive relaxation group and a finger temperature biofeedback group. Finger temperature, temporal artery pulse amplitude and forehead blood flow were monitored for all subjects during two baseline and six treatment sessions.

The biofeedback group achieved greater (albeit low magnitude) increases in finger temperature than the relaxation group, but no improvement in headache activity was obtained. However the relaxation group improved significantly in terms of headache intensity.

There was no significant difference in the ability to achieve finger temperature control, nor in stability point temperatures, between the migraine and non-migraine subjects.

No systematic relationship was found between finger temperature, forehead blood volume and temporal artery pulse amplitude. Possible mechanisms of the therapeutic effects of finger temperature training are examined in the light of these results.     

Restless legs syndrome and drug-induced akathisia in headache patients

The purpose of the research presented in this article was to characterize restless leg syndrome (RLS) in a headache population and correlate treatment induced risks with dopamine blockers. Fifty patients with severe headache who were admitted to an outpatient infusion center were enrolled. The diagnosis of RLS was established using the International Restless Leg Syndrome Study Group criteria. Patients were screened for baseline akathisia using an akathisia scale and reexamined for akathisia after receiving intravenous infusion with one of four dopamine receptor blocking agents as treatment for their headaches. A change from baseline to post-infusion assessment of two points on a global assessment of akathisia was considered positive for drug-induced akathisia. Our results indicated that 41 (82%) of patients had episodic or chronic migraine. The rest had new daily persistent headache, cluster, or posttraumatic headache. Seventeen subjects (34%) met the criteria for RLS. Nineteen (38%) of the subjects developed drug-induced akathisia. Thirteen (76.5%) of the subjects with RLS developed akathisia compared with only 6 of the 33 (18.2%) without RLS (P<.0001). Finally, we concluded that headache patients with RLS are at a greatly increased risk of developing drug-induced akathisia when treated with intravenous dopamine receptor blocking agents.     

Electromyographic and vasomotor activity in tension, migraine, and combined headache patients: The influence of postural variation

Electromyographic (EMG) and temporal artery vasomotor activity was evaluated in three groups of headache patients (tension, migraine and combined) and nonheadache control subjects while in reclining, sitting and standing positions. Analysis of the EMG data revealed that at all measurement sites (bilateral frontalis, bilateral trapezius) the three headache groups demonstrated significantly higher levels than the nonheadache group but did not differ from each other. A secondary analysis of the trapezius EMG data revealed that a large percentage of headache patients had “normal” EMG levels in the reclining position but showed abnormalities in the sitting and standing positions. Analysis of the left temporal artery vasomotor activity revealed that all three headache groups vasoconstricted to a significantly greater extent than the nonheadache group in the sitting and standing positions. However, a diagnosis by position interaction was found for the right temporal artery with the migraine group demonstrating a unique pattern of activity.     

Stress reactivity and perception of pain among tension headache sufferers

Twenty-one tension headache sufferers and 21 control subjects were exposed to a series of psychological stressors and an ischemic pain task, involving a tourniquet around the arm. Compared to control subjects, headache patients showed higher heart rates and evidence of more prolonged vasoconstriction in the hands and the ear lobe. No between-group differences in EMG were found, however. Headache patients rated the tourniquet as more painful than did control subjects, and described themselves as more anxious, angry, and depressed. The pattern of results is consistent with the interpretation that headache patients are emotionally and autonomically hyperreactive to pain and to psychological stress.     

Medlemsaktivitet i BTF

Abstract

EMG-biofeedback assisted relaxation training was used in the treatment of tension headache. Two groups of subjects were treated with either a “standard biofeedback” method, or a “biofeedback with generalization training” method. The latter included procedures which were aimed at maximizing voluntary control of frontal muscle activity in the absence of external feedback, as well as the ability to use the self-regulation skills in every-day life. The results indicated that only the “standard biofeedback” group showed evidence of increased relaxation abilities. However, these greater achievements were not accompanied by comparable superiority regarding headache decreases. These results are discussed and some hypothetical explanations are put forward.     

Physiological changes after biofeedback and relaxation training for multiple-pain tension-headache patients

This paper is concerned with the psychophysiology of "muscle-contraction" headaches in a group of Compensation patients suffering from multiple pain problems in addition to headaches. A total of 55 of these patients were divided into 4 groups which received frontalis EMG biofeedback, relaxation training, combined biofeedback-relaxation training, or no treatment. Differences were observed among the 3 experimental treatments and the control group with respect to headache changes, but there were no differences among groups with respect to the changes observed in four underlying physiological responses as a function of time or practice. While the subjects who showed the largest changes in headache characteristics were those who exhibited the largest decreases in frontalis EMG, these were also the subjects whose initial frontalis EMG levels were the highest. It is concluded that, in keeping with a growing literature, the link between frontalis EMG and "muscle-contraction" headaches is a tenuous one and that the changes brought about in headache symptomatology through biofeedback or relaxation training are most likely attributable to a generalization of feelings of mastery over the environment or of self-efficacy brought about in the subjects through apparent success at the task.     

Long-term follow-up of migraine treatment: do the effects remain up to six years?

Fifty migraine subjects (constituting 79% of the originally treated sample) participated in a follow-up study to 6 yr after the end of treatment. Subjects had been treated with different forms of biofeedback methods (skin temperature, BVP of the temporal artery) and applied relaxation training. The assessment included 4 weeks of continuous self-monitoring of headache activity and medication usage, as well as a retrospective self-rating scale. The main results indicated that, on a group basis, headache reductions achieved at the end of treatment persisted for up to 6 yr, and were indeed enhanced during the follow-up period.     

Medikamentenübergebrauchs­kopf­schmerz

Prospective longitudinal studies clearly demonstrate a causal relationship between the overuse of painkillers and migraine relievers and chronic headache. Overuse of any acute headache medication is the main factor in about 30-50% cases for chronic headache, and thus chronic headaches may be attributed to overuse. The prevalence of medication overuse headache (MÜKS, Eng: medication overuse headache, MOH) is likely to be around 3%.The diagnostic criteria of MOH are: Headache more than 15 days per month, Regular overuse of one or more drugs for acute symptomatic headache treatment of over more than 3 months, Headache has developed or is aggravated during medication overuseHeadache disappears or reverts to its initial level within 2 months after discontinuation of the drug overuse. Clinically, it is usually a “mixed” holocranial headache that is no longer consistent with a migraine or tension headache. The so-called “swing model” has proven itself in the context of psychoeducation. If painkiller withdrawal is not possible, in the outpatient setting, then a stationary multimodal withdrawal therapy should also be considered.     

The refractory headache patient--II. High medication consumption (analgesic rebound) headache

'Analgesic rebound headache' is identified by habituation of an individual to pain reducing medication, the exacerbation of headache pain a few hours after medication consumption and a marked increase in headache frequency and intensity for several weeks after medication is discontinued. We describe three studies undertaken to clarify the existence and characteristics of this proposed headache syndrome. In Study 1 we compared a group of headache sufferers who consume large amounts of analgesic medications to headache sufferers who did not consume excessive analgesics. It was found that the two groups did not differ on age, duration of headache problem or gender. However, the groups did differ on subjective headache pain (with the high medicators experiencing more headache pain than low medicators) and diagnosis (with high medicators being more likely to have a muscle contraction component to their headaches). In an analysis of drug use within the high medication group, it was found that 91% were taking some kind of analgesic and that a majority (84%) were taking more than one type of medication. In Study 2 we found that the group of high medicators were not as successful in reducing headache activity as a result of a self-regulatory behavioral treatment as the matched controls. Furthermore, there was a direct relationship between reduction and treatment success in the high medication consuming population. Lastly, in Study 3 we examined the current psychological functioning of the two groups; no differences were found between the two groups indicating the lack of 'addictive' personality characteristics as an explanation for the high medicating population. These findings all support the existence of a sub-population of headache sufferers who consume excessive amounts of analgesic medication and who are relatively refractory to behavioral treatment.     

Clinical effects of biofeedback treatment in migraine: The relation to achieved self-control and pretreatment predictors

Abstract

Factors contributing to the headache reduction six months after treatment of sixty-three migraine subjects were examined in three different studies. Subjects had originally been treated with either peripheral skin temperature biofeedback, biofeedback for blood-volume-pulse amplitude of the temporal artery, or applied relaxation. In Study 1 it was found that biofeedback subjects who had achieved self-control of the trained physiological parameter had significantly greater headache reductions than “nonlearners”. In Studies 2 and 3, potential predicting factors of clinical effects were studied. Age and whether subjects had achieved self-control emerged as (weak) predictors in different analyses using discriminant analysis. Using “PLS” (partial least squares projections to latent structures) a model emerged which gave a more complex picture, and which might indicate for example that there are different sets of factors which predict success and predict nonsuccess in treatment.     

Relationship between self-reported intensity of headache and magnitude of surface EMG

The study was designed to examine the relationship between self-reported intensity of headache and surface EMG. 98 patients, diagnosed by their neurologists with "muscle-contraction headaches" (tension-type headaches) were referred to evaluate their suitability for biofeedback therapy. At the time of examination, they were asked to rate their average headache intensity on a 10-point scale. Surface EMG data were collected to assess actual muscle contraction. Analysis indicated that among patients diagnosed with muscle contraction headache, there is a positive significant correlation between self-reported intensity of headache and actual muscle-contraction. The current data lend support to the hypothesis that the tension in the headaches currently described as "tension-type" may in fact refer to actual muscular tension or contraction.     

Pain,emotion, and the situational specificity of catastrophising

Two studies were designed to explore the cross-situational nature of catastrophising and the emotions associated with pain and catastrophising. The crosssituational consistency of catastrophising in response to a finger-pressure procedure and during an episode of headache pain was examined in the first study. The second study examined differences between catastrophisers and noncatastrophisers with respect to state and trait measures of positive and negative emotions. Results of study one indicated that almost half of the subjects remained consistent in their classification as catastrophiser or noncatastrophiser in both pain situations. The majority of subjects that switched classification changed from being classified as catastrophisers during the headache experience to noncatastrophisers during the finger-pressure procedure. Results of the second study indicated that catastrophisers experienced significantly greater fear, sadness, anger, hostility, guilt, disgust, and shame during the finger-pressure procedure as compared to noncatastrophisers. Unexpectedly, catastrophisers were not a homogeneous group in regard to the pattern of negative emotions reported. Catastrophisers with headaches experienced greater sadness in response to finger-pressure pain than catastrophisers without headaches. Theoretical and clinical implications of these findings are discussed.     

情景变换诱发已消退恐惧记忆重现的神经环路

暴露疗法是治疗创伤后应激障碍的主要行为疗法。当被试反复暴露于可引起恐惧反应的条件刺激(如白噪音), 但却不伴有非条件刺激(如足底电击)时, 恐惧记忆将被消退, 形成消退记忆。但恐惧记忆并未从根本上被擦除, 当被试在消退训练以外的情景暴露于条件刺激时, 已消退的恐惧记忆将会重现。海马、内侧前额叶皮层、杏仁核等脑区及其相互连接的神经环路是情景诱发恐惧记忆重现的生理基础。情景变化诱发恐惧记忆重现过程中, 海马可能是通过直接投射至杏仁核基底核、杏仁核外侧核或通过边缘前皮质间接调控杏仁核基底核、杏仁核外侧核的功能, 产生恐惧反应。     

The Headache Symptom Questionnaire: Discriminant classificatory ability and headache syndromes suggested by a factor analysis

A brief Headache Symptom Questionnaire was administered to 129 chronic headache Sufferers. The questionnaire accurately classified 68.42% of headache subjects in their proper diagnostic category, comparable to, but statistically less accurate than, the 86.4% agreement between expert headache diagnosticians using clinical interviews. Results of a factor analysis of the Headache Symptom Questionnaire lend support for their being two commonly accepted global headache categories—vascular/migraine and muscle contraction—and one headache dimension concerned with duration of headache pain. Combined migraine-muscle contraction headache was found to be related more to migraine than to muscle contraction headache, and cluster headaches emerged as a separate clinical entity, not loading positively on any factor and loading negatively on all three.This research was supported in part by Grant NS-15235 from the National Institute of Neurological and Communicative Disorders and Stroke.     

Pain-elicited responses and their role in predicting future pain duration and severity.

The first objective of this study was to carry out a prospective investigation of the behavioral and affective responses to headache pain over a 72 hr period. A sample of 74 headache sufferers provided self-reported ratings of affective and behavioral responses as measured by a composite of standardized questionnaires. Highly significant and clinically meaningful levels of both types of responses were found on the headache day. Interestingly, significant levels of behavioral and affective disturbances were also reported 24 hr after pain termination, indicating that responses to pain actually outlasted pain perception by at least 1 day. The second goal of this study was to investigate whether affective or behavioral responses were predictors of future pain intensity, duration or severity. A smaller sample of 25 subjects provided ratings on two sequential headaches. A series of time-lag analyses indicated that, unlike behavioral responses, strong affective responses during a given episode were associated with subsequently longer and more severe headaches. These results suggest that affective pain-elicited responses may be a risk factor for suffering a worse headache during the episode that follows.