Biofeedback-assisted relaxation in migraine headache: relationship to cerebral blood flow velocity in the middle cerebral artery

sEMG Biofeedback for Episodic Migraines: A Pilot Randomized Clinical Trial

The aim of this study was to assess the feasibility and potential effectiveness of a 6-week virtual sEMG biofeedback intervention for patients with episodic migraines. Patients with episodic migraines were randomized to treatment with a novel surface EMG (sEMG) at-home biofeedback device or a treatment as usual control group; they completed validated baseline and post-intervention assessments of migraine related disability (migraine-specific quality of life, anxiety and depression). Participants also underwent a series of Quantitative Sensory Testing (QST) procedures referring to several different tests that quantitatively assess responses to mechanical stimuli during two separate visits (baseline and post intervention). No adverse events were reported during the study. Compared to the treatment as usual comparison group, patients in the sEMG biofeedback group reported lower migraine disability (p < 0.05). Compared to baseline, participants in the sEMG biofeedback group demonstrated statistically significant reductions in anxiety (p < 0.01), and significant increases in quality of life (p < 0.001), and significant decreases in temporal summation (p < 0.05) assessed by QST. No significant changes were observed in any of the outcomes in the control comparison group (p > 0.05). No significant changes were observed in migraine frequency in either of the two groups (p > 0.05). In addition, mediation analyses revealed that changes in migraine related quality of life mediated group effects on changes in migraine disability. Virtual sEMG biofeedback shows promise as a potential therapy for reducing disability, anxiety and depression and improving quality of life in individuals with episodic migraines. These results demonstrate the feasibility of a digital intervention for migraines and set the basis for conducting a future, larger scale randomized controlled trial to confirm these preliminary findings.

Pupil Size Changes as an Active Information Channel for Biofeedback Applications

Pupil size is usually regarded as a passive information channel that provides insight into cognitive and affective states but defies any further control. However, in a recent study (Ehlers et al. 2015) we demonstrate that sympathetic activity indexed by pupil dynamics allows strategic interference by means of simple cognitive techniques. Utilizing positive/negative imaginings, subjects were able to expand pupil diameter beyond baseline variations; albeit with varying degrees of success and only over brief periods. The current study provides a comprehensive replication on the basis of considerable changes to the experimental set-up. Results show that stricter methodological conditions (controlled baseline settings and specified user instructions) strengthen the reported effect, whereas overall performance increases by one standard deviation. Effects are thereby not restricted to pupillary level. Parallel recordings of skin conductance changes prove a general enhancement of induced autonomic arousal. Considering the stability of the results across studies, we conclude that pupil size information exceeds affective monitoring and may constitute an active input channel in human-computer interaction. Furthermore, since variations in pupil diameter reliably display self-induced changes in sympathetic arousal, the relevance of this parameter is strongly indicated for future approaches in clinical biofeedback.

Psychological interventions for migraine: a systematic review

Migraine causes major health impairment and disability. Psychological interventions offer an addition to pharmacotherapy but they are not currently recommended by the National Institute of Clinical Excellence (NICE) or available in the National Health Service. We aimed to systematically review evidence on the efficacy of psychological interventions for migraine in adults. A search was done of MEDLINE, psychINFO, http://www.opengrey.eu , the meta-register of controlled trials and bibliographies. Twenty-four papers were included and rated independently by two people using the Yates scale, which has 35 points. Cochrane recommendations are that high quality reports score above the mid-point (18 points). Methods used in 17/24 papers were rated 'high quality'. However, frequently descriptions of key areas such as randomisation methods were omitted. Eighteen studies measured effects of psychological interventions on headache-related outcomes, fifteen reporting significant improvements, ranging 20-67 %. Interventions also produced improvements in psychological outcomes. Few trials measured or reported improvement in disability or quality of life. We conclude that evidence supports the efficacy of psychological interventions in migraine. Over half of the studies were from the USA, which did not provide universal health care at the time of the study, so it is difficult to generalise results to typical populations in receipt of publically funded health services. We agree with the NICE recommendation that high quality pragmatic randomised controlled trials are needed in the UK.

Psychological Treatments and Psychotherapies in the Neurorehabilitation of Pain: Evidences and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

BACKGROUND

It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams.

OBJECTIVES

To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases.

METHODS

A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions.

RESULTS

The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive-Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post-Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache.

CONCLUSIONS

Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the paper.

A systematic review of the psychosocial difficulties relevant to patients with migraine

Migraine is a common disease which causes significant burden to individuals, in terms of personal suffering and activity reduction, and to societies, in terms of disease cost. The purpose of this study is to identify the most relevant psychosocial difficulties related to migraine, the variables associated with them and the most relevant determinants of their evolution over time. MEDLINE and PsychINFO were searched for studies published in English between 2000 and 2010 that examined psychosocial difficulties in persons with migraine with and without aura, from clinical trials and observational studies. Information on the description of each difficulty, its determinants of onset and change over time and associated variables were extracted and categorized at a higher level. In total, 34 difficulties have been collected from 51 papers: the most frequent were reduced vitality and fatigue, emotional problems, pain, difficulties at work, general physical and mental health, social functioning and global disability. Evidence exists that pharmacological treatments have an impact toward improvement in patients’ difficulties, in particular emotional problems, physical and mental health, difficulties with employment and global disability. Migraine treatments and decreased headaches frequency are the major determinants of improvements in psychosocial difficulties, while no information is available for determinants of worsening; understanding the role of such factors is of primary public health relevance, given the high prevalence and the relevant personal and societal costs of migraine.

Relationship between biofeedback and oxidative stress in patients with chronic migraine

Chronic migraine (1.5.1) is burdened with headache-related disability. During noxious stimulation, changes of cerebral blood flow enhance the release of oxygen free radicals that react with nitric oxide (NO). We investigated the role of biofeedback in limiting migraine disability by influencing oxidative stress. Peroxides, NO and superoxide dismutase (SOD) were analysed in 20 female subjects with chronic migraine and in 20 female healthy controls before and after biofeedback sessions. NO(x) levels (23.7 +/- 4.2 vs. 34.9 +/- 4.6 microm; P < 0.05) and SOD activity (6.5 +/- 1.0 vs. 8.0 +/- 0.7 U/ml; P < 0.05) were lower in migraine sufferers before treatment than in healthy controls, whereas peroxide levels (145.8 +/- 40.3 vs. 78.0 +/- 20.0 microm; P < 0.05) were higher in migraine sufferers before treatment than in healthy controls. In migraine sufferers NO(x) levels (23.7 +/- 4.2 vs. 31.3 +/- 7.1 microm; P < 0.05) and SOD activity (6.5 +/- 1.0 vs. 7.9 +/- 0.9 U/ml; P < 0.05) were lower before than after treatment, whereas peroxide levels (145.8 +/- 40.3 vs. 82.4 +/- 21.1 microm; P < 0.05) were higher before than after treatment. SOD serum activity correlated positively with NO(x) serum levels and negatively with peroxide serum levels in healthy controls and in chronic migraine sufferers before and after biofeedback. The mean Migraine Disability Assessment Score before biofeedback sessions was higher than after treatment (36.9 +/- 13.9 vs. 18.8 +/- 10.4; P < 0.001). The effectiveness of biofeedback in limiting chronic migraine may be related to muscular relaxation associated with decreased oxidative stress accompanied by psychological well-being.

Craniomandibular muscles, intraoral orthoses and migraine

Intraoral splints are effective in migraine prevention. In this review, changes in the quality of life of migraineurs treated with a palatal nonoccluding splint were measured. Using the Migraine Specific Quality of Life Instrument (Version 2.1), it was found that the palatal nonoccluding splint significantly improved the quality of life of migraineurs. The role of the craniomandibular muscles in the pathophysiology of migraine is also discussed.

Alternative therapies in the management of headache and facial pain

Complementary therapies are now becoming the rule rather than the exception in the management of headache and facial pain. It is incumbent on physicians to be aware of and to have a working knowledge of these increasingly popular modalities.