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Biofeedback Treatment for Headache Disorders: A Comprehensive Efficacy Review

Abstract

The aim of the present review was to critically evaluate the documented evidence regarding the efficacy of biofeedback for the two most prevalent headache conditions––migraine and tension-type headache. Drawing upon two recently published meta-analyses, data from 150 outcome studies, including randomized controlled trials as well as uncontrolled quasi-experimental designs, were screened. Of these, 94 studies were selected for inclusion according to predefined criteria. Meta-analytic integrations were carried out separately for the two conditions of interest. The main results were medium-to-large mean effect sizes for biofeedback in adult migraine and tension-type headache patients. Treatment effects remained stable over an average follow-up period of 14 months, both in completer and intention-to-treat analyses. Headache frequency was the primary outcome variable and showed the largest improvements. Further significant effects were shown for perceived self-efficacy, symptoms of anxiety and depression, and medication consumption. Reduced muscle tension in pain related areas was observed in electromyographic feedback for tension-type headache. Biofeedback was more effective than waiting list and headache monitoring conditions in all cases, while electromyographic feedback for tension-type headache showed additional significant effects over placebo and relaxation therapies. Levels of efficacy (migraine: efficacious, level 4; tension-type headache: efficacious and specific, level 5) and recommendations for future research are provided.

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Fig. 1
Fig. 2

Notes

  1. 1.

    Studies with children and adolescents resulted in a significantly different average effect size (see Nestoriuc et al. 2008) and were therefore excluded from further analyses in this review. Hence, all results presented in this white paper review apply to adult headache patients.

  2. 2.

    Average effect sizes from .2 to .5 are considered small effects, average effect sizes from .5 to .8 are considered medium and average effects over .8 are considered large effects (Cohen 1988).

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Author information

Correspondence to Yvonne Nestoriuc.

Additional information

This paper was prepared as a White Paper review, according to the template guidelines developed by the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neurofeedback and Research (ISNR).

Appendices

Appendix A

List of studies included in the efficacy review (* Indexed studies are included in both meta-analyses for migraine and TTH).

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Appendix B

Study Coding Scheme

Identification: Identification number, coder, author, country, publishing journal, year of publication; Methodology: design, number of BFB and control groups, measurement points, type of outcome variables, use of a structured headache diary, number of weeks of diary assessment at pre, post and follow-up measurement, number of participants, number of dropouts, research hypothesis, statistical data for the calculation of effect sizes; Subjects: diagnosis, diagnostic instruments, additional diagnostic information, patient characteristics (age, years with headache, gender); Treatment: type of biofeedback intervention, additional relaxation training during biofeedback, feedback modality, type of control intervention, treatment setting, treatment documentation (number and duration of sessions, treatment manual), changes in medication.

Validity Assessment Scale

Internal Validity: Design, treatment allocation, dropout, type of outcome variables; External validity: time points, patient characteristics; Construct validity: treatment documentation, diagnose, medication status, blinding; Statistical conclusion validity: number of participants, statistics for effect size calculation.

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Nestoriuc, Y., Martin, A., Rief, W. et al. Biofeedback Treatment for Headache Disorders: A Comprehensive Efficacy Review. Appl Psychophysiol Biofeedback 33, 125–140 (2008) doi:10.1007/s10484-008-9060-3

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Keywords

  • Migraine
  • Tension-type headache
  • Biofeedback
  • Relaxation
  • Treatment efficacy
  • Meta-analysis
  • White paper