The efficacy and cost-effectiveness of minimal-therapist-contact, non-drug treatments of chronic migraine and tension headache

Mindfulness in migraine: A narrative review

Introduction: Migraine is the second leading cause of disability worldwide, yet many patients are unable to tolerate, benefit from, or afford pharmacological treatment options. Non-pharmacological migraine therapies exist, especially to reduce opioid use, which represents a significant unmet need. Mindfulness-based interventions (MBI) have potential as a non-pharmacological treatment for migraine, primarily through the development of flexible attentional capacity across sensory, cognitive, and emotional experiences.Areas covered: The authors review efficacy and potential mechanisms of MBIs for migraine, including mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).Expert opinion: While most mindfulness research studies for migraine to date have been pilot trials, which are small and/or lacked rigor, initial evidence suggests there may be improvements in overall headache-related disability and psychological well-being. Many research questions remain to help target the treatment to patients most likely to benefit, including the ideal dosage, duration, delivery method, responder characteristics, and potential mechanisms and biomarkers. A realistic understanding of these factors is important for patients, providers, and the media. Mindfulness will not 'cure' migraine; however, mindfulness may be an important tool as part of a comprehensive treatment approach to help patients 'mindfully' engage in valued life activities.

Psychological therapies for the prevention of migraine in adults

BACKGROUND

Migraine is a common neurological problem associated with the highest burden amongst neurological conditions in terms of years lived with disability. Medications can be used as prophylaxis or rescue medicines, but are costly and not always effective. A range of psychological interventions have been developed to manage migraine.

OBJECTIVES

The objective was to evaluate the efficacy and adverse events of psychological therapies for the prevention of migraine in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL from their inception until July 2018, and trials registries in the UK, USA, Australia and New Zealand for randomised controlled trials of any psychological intervention for adults with migraine.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of a psychological therapy for people with chronic or episodic migraine, with or without aura. Interventions could be compared to another active treatment (psychological or medical), an attention-placebo (e.g. supportive counselling) or other placebo, routine care, or waiting-list control. We excluded studies where fewer than 15 participants completed each arm.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and outcome data at post-treatment and the longest available follow-up. We analysed intervention versus control comparisons for the primary outcome of migraine frequency. We measured migraine frequency using days with migraines or number of migraine attacks measured in the four weeks after treatment. In addition, we analysed the following secondary outcomes: responder rate (the proportion of participants with a 50% reduction in migraine frequency between the four weeks prior to and the four weeks after treatment); migraine intensity; migraine duration; migraine medication usage; mood; quality of life; migraine-related disability; and proportion of participants reporting adverse events during the treatment. We included these variables, where available, at follow-up, the timing of which varied between the studies. We used the GRADE approach to judge the quality of the evidence.

MAIN RESULTS

We found 21 RCTs including 2482 participants with migraine, and we extracted meta-analytic data from 14 of these studies. The majority of studies recruited participants through advertisements, included participants with migraine according to the International Classification of Headache Disorders (ICHD) criteria and those with and without aura. Most intervention arms were a form of behavioural or cognitive-behavioural therapy. The majority of comparator arms were no treatment, routine care or waiting list. Interventions varied from one 20-minute session to 14 hours of intervention. No study had unequivocally low risk of bias; all had at least one domain at high risk of bias, and 20 had two to five domains at high risk. Reporting of randomisation procedures and allocation concealment were at high or unclear risk of bias. We downgraded the quality of evidence for outcomes to very low, due to very serious limitations in study quality and imprecision. Reporting in trials was poor; we found no preregistrations stipulating the outcomes, or demonstrating equivalent expectations between groups. Few studies reported our outcomes of interest, most only reported outcomes post treatment; follow-up data were sparse.Post-treatment effectsWe found no evidence of an effect of psychological interventions for migraine frequency in number of migraines or days with migraine (standardised mean difference (SMD) -0.02, 95% confidence interval (CI) -0.17 to 0.13; 4 studies, 681 participants; very low-quality evidence).The responder rate (proportion of participants with migraine frequency reduction of more than 50%) was greater for those who received a psychological intervention compared to control: 101/186 participants (54%) with psychological therapy; 37/152 participants (24%) with control (risk ratio (RR) 2.21, 95% CI 1.63 to 2.98; 4 studies, 338 participants; very low-quality evidence). We found no effect of psychological therapies on migraine intensity (SMD -0.13, 95% CI -0.28 to 0.02; 4 studies, 685 participants). There were no data for migraine duration (hours of migraine per day). There was no effect on migraine medication usage (SMD -0.06, 95% CI -0.35 to 0.24; 2 studies, 483 participants), mood (mean difference (MD) 0.08, 95% CI -0.33 to 0.49; 4 studies, 432 participants), quality of life (SMD -0.02, 95% CI -0.30 to 0.26; 4 studies, 565 participants), or migraine-related disability (SMD -0.67, 95% CI -1.34 to 0.00; 6 studies, 952 participants). The proportion of participants reporting adverse events did not differ between those receiving psychological treatment (9/107; 8%) and control (30/101; 30%) (RR 0.16, 95% CI 0.00 to 7.85; 2 studies, 208 participants). Only two studies reported adverse events and so we were unable to draw any conclusions.We rated evidence from all studies as very low quality.Follow-upOnly four studies reported any follow-up data. Follow-ups ranged from four months following intervention to 11 months following intervention. There was no evidence of an effect on any outcomes at follow-up (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review identified 21 studies of psychological interventions for the management of migraine. We did not find evidence that psychological interventions affected migraine frequency, a result based on four studies of primarily brief treatments. Those who received psychological interventions were twice as likely to be classified as responders in the short term, but this was based on very low-quality evidence and there was no evidence of an effect of psychological intervention compared to control at follow-up. There was no evidence of an effect of psychological interventions on medication usage, mood, migraine-related disability or quality of life. There was no evidence of an effect of psychological interventions on migraine frequency in the short-term or long-term. In terms of adverse events, we were unable to draw conclusions as there was insufficient evidence. High and unclear risk of bias in study design and reporting, small numbers of participants, performance and detection bias meant that we rated all evidence as very low quality. Therefore, we conclude that there is an absence of high-quality evidence to determine whether psychological interventions are effective in managing migraine in adults and we are uncertain whether there is any difference between psychological therapies and controls.

Smartphone-based migraine behavioral therapy: a single-arm study with assessment of mental health predictors

Progressive muscle relaxation (PMR) is an under-utilized Level A evidence-based treatment for migraine prevention. We studied the feasibility and acceptability of smartphone application (app)-based PMR for migraine in a neurology setting, explored whether app-based PMR might reduce headache (HA) days, and examined potential predictors of app and/or PMR use. In this single-arm pilot study, adults with ICHD3 migraine, 4+ HA days/month, a smartphone, and no prior behavioral migraine therapy in the past year were asked to complete a daily HA diary and do PMR for 20 min/day for 90 days. Outcomes were: adherence to PMR (no. and duration of audio plays) and frequency of diary use. Predictors in the models were baseline demographics, HA-specific variables, baseline PROMIS (patient-reported outcomes measurement information system) depression and anxiety scores, presence of overlapping pain conditions studied and app satisfaction scores at time of enrollment. Fifty-one patients enrolled (94% female). Mean age was 39 ± 13 years. The majority (63%) had severe migraine disability at baseline (MIDAS). PMR was played 22 ± 21 days on average. Mean/session duration was 11 ± 7 min. About half (47%) of uses were 1+ time/week and 35% of uses were 2+ times/week. There was a decline in use/week. On average, high users (PMR 2+ days/week in the first month) had 4 fewer days of reported HAs in month 2 vs. month 1, whereas low PMR users (PMR < 2 days/week in the first month) had only 2 fewer HA days in month 2. PROMIS depression score was negatively associated with the log odds of using the diary at least once (vs. no activity) in a week (OR = 0.70, 95% CI = [0.55, 0.85]) and of doing the PMR at least once in a week (OR = 0.77, 95% CI = [0.68, 0.91]). PROMIS anxiety was positively associated with using the diary at least once every week (OR = 1.33, 95% CI = [1.09, 1.73]) and with doing the PMR at least once every week (OR = 1.14 [95% CI = [1.02, 1.31]). In conclusion, about half of participants used smartphone-based PMR intervention based upon a brief, initial introduction to the app. App use was associated with reduction in HA days. Higher depression scores were negatively associated with diary and PMR use, whereas higher anxiety scores were positively associated.

An online self-help CBT intervention for chronic lower back pain

OBJECTIVES

Research has shown that cognitive and behavioral therapies can effectively improve quality of life in chronic pain patients. Unfortunately, many patients lack access to cognitive and behavioral therapy treatments. We developed a pilot version of an interactive online intervention to teach self-management skills for chronic lower back pain, a leading cause of disability and work absenteeism. The objective of this randomized, controlled trial was to evaluate its efficacy.

METHODS

Individuals with chronic lower back pain were recruited over the Internet, screened by phone, and randomly assigned to receive access to the intervention (Wellness Workbook; WW) either immediately (intervention group) or after a 3-week delay (wait-list control). Participants (n=141, 83% female, 23% minority) were asked to complete the WW over 3 weeks. Self-report measures of pain, disability, disabling attitudes and beliefs, self-efficacy for pain control, and mood regulation were completed at baseline, week 3, and week 6.

RESULTS

Controlling for baseline individual differences in the outcome measures, multivariate analysis of covariance revealed that, at week 3, the intervention group scored better than the wait-list control group on all outcomes, including pain severity ratings. At week 6, after both groups had been exposed to the WW, there were no differences between groups.

DISCUSSION

Use of this pilot intervention seems to have had positive effects on a number of pain-related outcomes, including disability. Future research will evaluate the effectiveness of the completed intervention, with particular attention to quality of life and disability.

Behavioral treatments of chronic tension-type headache in adults: are they beneficial?

To assess the efficacy of behavioral treatments in patients with tension headache. Medline, Cinahl, EMBASE, and the Cochrane library were searched from inception to October 2007 and reference lists were checked. We selected randomized trials evaluating behavioral treatments (e.g., relaxation, electromyographic [EMG] biofeedback, and cognitive behavioral training) in patients with tension-type headache (TTH). We assessed the risk of bias using the Delphi list and extracted data from the original reports. A qualitative analysis was carried out. We found 44 trials (2618 patients), which were included in this review, of which only 5 studies (11.4%) were considered to have low risk of bias. Most trials lacked adequate power to show statistical significant differences, but frequently, recovery/improvement rates did not reach clinical relevance. In 8 studies, relaxation treatment was compared with waiting list conditions, and in 11 studies, biofeedback was compared with waiting list conditions, both showing inconsistent results. On the basis of the available literature, we found no indications that relaxation, EMG biofeedback, or cognitive behavioral treatment is better than no treatment, waiting list, or placebo controls.

The burden of migraine in the United States: current and emerging perspectives on disease management and economic analysis

OBJECTIVES

Migraine is often perceived as a low-impact condition that imposes a limited burden to society and the health-care system. This study reviews the current understanding of the burden of migraine in the U.S., the history of economic understanding of migraine treatment and identifies emergent trends for future studies evaluating clinical and economic outcomes of migraine treatment.

METHODS

This study traced the history of economic articles published on migraine by performing a literature search using PubMed MEDLINE database and ancestral searches of relevant articles. The intention was not to provide an exhaustive review of every article or adjudicate between studies with different findings.

RESULTS

Migraine affects millions of individuals worldwide, generally during the most productive years of a person's life. Studies show that migraineurs are underdiagnosed, undertreated, and experience substantial decreases in functioning and productivity, which in turn translates into diminished quality of life for individuals, and financial burdens to both health-care systems and employers. Economic evaluations of migraine therapies have evolved with new clinical developments beginning with cognitive-behavioral therapy, introduction of triptans, concern over medication overuse, and emergence of migraine prophylaxis. Now recent clinical studies suggest that migraine may be a progressive disease with cardiovascular, cerebrovascular, and long-term neurologic effects.

CONCLUSIONS

Migraine imposes a substantial burden on patients, families, employers and societies. The economic standards by which migraine and treatment are evaluated have evolved in response to clinical developments. Emerging evidence suggests that migraine is a chronic and progressive disease. If confirmed, approaches to acute and prophylactic treatments and economic evaluations of migraine treatment may require major reconsideration.

Psychological risk factors in headache

Headache is a chronic disease that occurs with varying frequency and results in varying levels of disability. To date, the majority of research and clinical focus has been on the role of biological factors in headache and headache-related disability. However, reliance on a purely biomedical model of headache does not account for all aspects of headache and associated disability. Using a biopsychosocial framework, the current manuscript expands the view of what factors influence headache by considering the role psychological (i.e., cognitive and affective) factors have in the development, course, and consequences of headache. The manuscript initially reviews evidence showing that neural circuits responsible for cognitive-affective phenomena are highly interconnected with the circuitry responsible for headache pain. The manuscript then reviews the influence cognitions (locus of control and self-efficacy) and negative affect (depression, anxiety, and anger) have on the development of headache attacks, perception of headache pain, adherence to prescribed treatment, headache treatment outcome, and headache-related disability. The manuscript concludes with a discussion of the clinical implications of considering psychological factors when treating headache.

Cognitive-Behavioral self-help for chronic pain

Cognitive behavioral self-help is a potentially cost-saving method of delivering evidence-based treatment to a wide range of chronic pain patients. This article provides a rationale for self-help and focuses on the effectiveness of self-help in the management of chronic pain, which typically includes some degree of lay leader or professional facilitation. The evidence for these treatments is generally positive (e.g., reductions in pain and pain-related disability) across such illnesses as arthritis, back pain, headache, and temporomandibular joint disorders. When implementing self-help, professionals need to consider individual differences in suitability for using a self-management treatment and evaluate the outcome in the context of a stepped care approach. This article uses three case examples to illustrate the use of cognitive behavioral self-help delivered in the care of scleroderma patients.

A pilot study of feasibility and efficacy of telemedicine-delivered psychophysiological treatment for vascular headache

Headache is a common complaint. Psychological treatment has been effective in managing the symptoms of vascular (migraine and combined migraine-tension) headache. Traditional office-based treatment may be inconvenient for many patients in terms of time and travel constraints, thereby limiting access. Telemedicine has emerged as a promising delivery medium to address these barriers to access. However, the efficacy of remotely delivered treatment for vascular headache remains untested. This case series is a preliminary evaluation of effectiveness and feasibility of an analogue telemedicine system for delivery of psychophysiological treatment for vascular headache. Three of four subjects showed improvement. These findings are encouraging for follow-up study of the clinical utility and broader viability of headache treatment via distance technology.

Headache in pregnancy

Headache is a frequent symptom in women of childbearing age and during pregnancy. Benign and pathologic headaches may change in response to changes in estrogen after conception. Expected patterns of change are described for headaches that occur commonly during pregnancy. In addition, although treatment options are limited during pregnancy, a variety of effective medication and nonmedication treatments are available and should be offered to women with benign headaches that persist into the second trimester of pregnancy.

Internet-based treatment of headache: does telephone contact add anything?

OBJECTIVE

To study the contribution of therapist-initiated telephone contact in the treatment of recurrent headache via the Internet.

BACKGROUND

Internet-based cognitive behavioral self-help is a promising new venue for the treatment of recurrent headache. While cost-effective, there are indications that this modality may be associated with high dropout rates.

DESIGN AND METHODS

The role of therapist-initiated contact was investigated in a randomized controlled trial in which 44 self-recruited headache sufferers were randomized to either a Web-based self-help program with e-mail support or to a group receiving, in addition, weekly individual telephone calls. An additional 8 control subjects were recruited to receive similar treatment outside of the study.

RESULTS

Dropout rates were 29% in the telephone support group and 35% in the control group, suggesting that the telephone calls did not affect dropout. Results showed significant reductions in headache-related disability, depression, maladaptive coping strategies, and perceived stress but little to indicate any superior performance in the Internet-only group and little improvement in the headache index. In short, therapist-initiated telephone calls did not influence the results.

CONCLUSIONS

Internet-based treatment for headache is not affected by minimal therapist-initiated telephone contact.

Pregnancy and chronic headache

Headache patterns in women change in relation to fluctuations in oestrogen levels. Increasing oestrogen levels in early pregnancy offer a protective effect against headache, particularly for women with migraine. However, some women continue to experience troublesome headache throughout pregnancy. Headache persisting at the end of the first trimester will usually continue without improvement for the remainder of pregnancy and should be treated. Safe and effective acute care treatment options include paracetamol, opioids and anti-emetics. The use of triptans during pregnancy is controversial and not broadly recommended. Safe and effective preventive treatments include relaxation, biofeedback, beta-blockers, some antidepressants and gabapentin in early pregnancy.

The effect of home training with direct blood pressure biofeedback of hypertensives: a placebo-controlled study

BACKGROUND

Home training in self-lowering of blood pressure using continuous blood pressure feedback has not previously been reported. Enhancement of laboratory-learned skills was hypothesized on the basis of outcomes from other intellectual, emotional and physical endeavours.

OBJECTIVE

To examine the supplementary effect of home blood pressure biofeedback training.

DESIGN

Thirty unmedicated, mild hypertensives participated in a randomized, double-blinded, modified contingency placebo-controlled study.

METHOD

After suitable screening and baseline blood pressure measurements subjects undertook eight laboratory biofeedback sessions and then 12 home training sessions over 4 weeks using continuous finger blood pressure monitoring.

RESULTS

In the laboratory those being administered active therapy (n=16) lowered systolic pressures by 5 +/- 5.4 mmHg compared with a lowering of 4 +/- 4.2 mmHg with placebo (NS). During the fourth week at home lowering for the active group (11 +/- 8 mmHg) was greater than that with placebo (4 +/- 6.2 mmHg, P=0.017). Arm-cuff blood pressures were not statistically different for groups and with time but that of the active group was lower by 9 +/- 15.4/7 +/- 10.2 mmHg, which is a clinically relevant change, after home biofeedback.

CONCLUSIONS

The efficacy of self-lowering of systolic blood pressure in mild hypertensives by continuous feedback was enhanced by 6 mmHg with 4 weeks of practice at home. Standard arm-cuff blood pressure was reduced by a clinically relevant amount. The home environment proved cost effective for this 'high-tech' approach.

A retrospective, follow-up study of biofeedback-assisted relaxation therapy in patients with posttraumatic headache

Although biofeedback in the treatment of migraine and tension-type headache has been widely researched, there is little research examining biofeedback therapy in posttraumatic headache (PTH). In this retrospective study, 40 subjects with PTH who had received biofeedback-assisted relaxation at our headache clinic were questioned at least 3 months following the completion of therapy. Subjects were queried about improvements in headache, increases in ability to relax and cope with pain, and overall benefits, lasting effectiveness, and continued use of biofeedback in daily life. Results indicate 53% reported at least moderate improvement in headaches; 80% reported at least moderate improvement in ability to relax and cope with pain; 93% found biofeedback helpful to some degree; 85% felt headache relief achieved through biofeedback had continued at least somewhat; and 95% stated they were continuing to use biofeedback skills in daily life. A correlation analysis revealed a negative relationship between response to biofeedback and increased chronicity of the disorder. In other words, the more chronic the disorder, the poorer the response to treatment. A stepwise regression analysis found that chronicity of the disorder and number of treatment sessions significantly affected response to treatment. Data suggest that biofeedback-assisted relaxation should at least be considered when planning treatment strategies for posttraumatic headache.

Nonpharmacological management of headaches during pregnancy

Concerns about the effects of maternal medications on the growing baby limit the use of medication treatment for benign conditions, such as recurring headaches, during pregnancy and lactation. Nonpharmacological therapies hold particular promise for pregnant women due to the limited medication options. No controlled studies, however, have reported on the efficacy of nonpharmacological treatments for pregnant women. The first study evaluated the effectiveness of a combined nonpharmacological treatment (CT) consisting of relaxation, skin-warming biofeedback, and physical therapy for pregnant women with chronic headaches. In a second study, the CT protocol was compared with an attention control (AC) that received headache education and skin-cooling biofeedback. The first study resulted in significant symptom improvement in 79% of subjects, with an overall 72.9% reduction in headaches. In the second study, both groups improved with treatment; however the CT group was more likely to experience significant headache relief (72.7%) than the AC group (28.6%, chi 2(1) = 4.97, p < .03). Significant improvement was maintained at a 6-month follow-up for over 50% of patients. It is concluded that the combined nonpharmacological treatment was more effective than an attention control in reducing headaches during pregnancy. This treatment was effective regardless of predisposing variables.

Behavioral and prophylactic pharmacological intervention studies of pediatric migraine: an exploratory meta-analysis

In this review, the effectiveness of behavioral and pharmacological treatments for pediatric migraine was quantitatively summarized following the meta-analytic approach outlined by Hedges and Olkin (1985). A first meta-analysis based on treatment outcome within treatment conditions revealed that thermal biofeedback and interventions combining biofeedback and progressive muscle relaxation seem to be significantly more efficacious than other behavioral treatment modalities, psychological and drug placebo, and the more commonly used prophylactic drug regimens. Though there is some evidence suggesting good effectiveness of propranolol, the lack of systematic data precludes more definitive conclusions. A second meta-analysis that included only studies providing data on the comparison between control versus active treatment conditions replicated the initial findings only partially. In the light of the relative small number of studies that met basic inclusion requirements, the methodological flaws of many studies, and the under-representation of certain treatment types, conclusions regarding differential effectiveness of the treatment types have to be drawn with caution. Overall, our findings clearly demonstrate the need for direct comparisons between behavioral and pharmacological treatments and the need for more theory-driven research in order to determine the most promising treatment approaches for pediatric migraine.

Cost-effectiveness of home relaxation training for tension headaches

Taped home relaxation training was evaluated in a single-case replication design across three patients suffering from tension headaches. Data from daily headache diaries indicated that headache frequency decreased substantially for two of the patients. For the third patient who reported almost continual headache pain, intensity was reduced by over 50%. When compared with results of our previous research taped home relaxation training appeared as effective as (and therefore, more cost-effective than) live clinic relaxation training.

Relaxation training as a treatment for irritable bowel syndrome

Although there have been many successful, controlled demonstrations of the clinical efficacy of multicomponent treatments for irritable bowel syndrome (IBS), in the present study we sought to evaluate a single component of many of these regimens, relaxation training. Eight IBS patients received a 10-session (over 8 weeks) regimen of abbreviated progressive muscle relaxation with regular home practice while 8 comparable patients merely monitored GI symptoms. Based on daily GI symptom diaries collected for 4 weeks before and 4 weeks after treatment (or continued symptom monitoring), the Relaxation condition showed significantly (p = .05) more improvement on a composite measure of primary GI symptom reduction than the Symptom Monitoring condition. Fifty percent of the Relaxation group were clinically improved at the end of treatment.

Neglected topics in chronic pain treatment outcome studies: determination of success

Although literature on chronic pain treatment outcome has made substantial strides in improving the quality of the studies reported, there remain a number of factors that lead to qualification of the generally positive results. In the two previous papers in this series a set of migrating factors was discussed, namely, representativeness of the samples treated in these outcome studies, relapse, and non-compliance with therapeutic recommendations. Additional limitations include the lack of agreement on the criteria on which to base evaluation of the success of treatment outcome and the percentage of treated patients included in follow-up data. In this paper, the most common methods for determining success are described (group effects based on standard and quasi-standard outcome measures). The limitations of this approach are discussed and alternative strategies are presented that focus not only on traditional criteria based on group means but on additional criteria including: (a) importance of change (i.e., clinical vs. statistical significance), (b) proportion of patients who improve, (c) cost, (d) efficiency in treatment delivery, (e) and consumer acceptance and satisfaction.

Biofeedback treatments of essential hypertension

Fifteen years of research in the self-regulatory treatment of hypertension by the author is summarized. A model relating expectations, task performance, home practice, and biochemical variables to the thermal biofeedback treatment of hypertension is presented.

Pharmacological versus non-pharmacological prophylaxis of recurrent migraine headache: a meta-analytic review of clinical trials

In order to generate information about the relative effectiveness of the most widely used pharmacological and non-pharmacological interventions for the prophylaxis of recurrent migraine (i.e., propranolol HCl and combined relaxation/thermal biofeedback training), meta-analysis was used to integrate results from 25 clinical trials evaluating the effectiveness of propranolol and 35 clinical trials evaluating the effectiveness of relaxation/biofeedback training (2445 patients, collectively). Meta-analysis revealed substantial, but very similar improvements have been obtained with propranolol and with relaxation/biofeedback training. When daily recordings have been used to assess treatment outcome, both propranolol and relaxation/biofeedback have yielded a 43% reduction in migraine headache activity in the average patient. When improvements have been assessed using other outcome measures (e.g., physician/therapist ratings), improvements observed with each treatment have been about 20% greater. In both cases, improvements observed with propranolol and relaxation/biofeedback have been significantly larger than improvement observed with placebo medication (14% reduction) or in untreated patients (no reduction). Meta-analysis thus revealed substantial empirical support for the effectiveness of both propranolol and relaxation/biofeedback training, but revealed no support for the contention that the two treatments differ in effectiveness. These results suggest that greater attention should be paid to determining the relative costs and benefits of widely used pharmacological and non-pharmacological treatments.

Evaluation of home-based thermal biofeedback treatment of pediatric migraine headache

Sixteen children and adolescents with migraine headache were treated with thermal biofeedback. Seven were seen individually in the clinic while the other nine participated in a limited-contact, partly home-based regimen. Evaluation of headache diary data from 4-week monitoring periods before and after treatment showed significant (p less than .01) reduction in headaches, with no significant difference in efficacy between the two conditions.

The refractory headache patient--I. Chronic, daily, high intensity headache

Two studies on patients with Chronic, Daily, High Intensity Headache (CDHIHA) are presented. In the first, their response to various self-regulatory (biofeedback, relaxation) treatments was compared to that of case controls matched for age, duration and Ad Hoc Committee diagnoses who had 1-2 headache-free days per week (Group II) and 3-5 headache-free days per week (Group III). The CDHIHA patients had a significantly poorer response to treatment (12.7 vs 49.8% improvement for Groups II and III combined). In the second study, the psychological profiles of an enlarged sample of CDHIHA patients were compared to matched case controls from Group II and Group III. The CDHIHA patients tended to be more anxious, more hysterical and to have more non-headache somatic complaints than Groups II and III combined.

Prediction of early termination from the self-regulatory treatment of chronic headache

The ability of demographic, psychological testing and history information to predict which patients will terminate early from nonpharmacological treatment of headache (relaxation and biofeedback) was tested. Information from each of these areas was initially examined for differences between dropouts and treatment completers using univariate analyses. These analyses were followed by a canonical discriminate function analysis that predicted whether patients would complete treatment or drop out. Information from the three predictor sets combined resulted in 77.4% of the patients being correctly classified.

Evaluation of a minimal-therapist-contact thermal biofeedback treatment program for essential hypertension

We compared a clinic-based regimen of 16 individual sessions (2 per week) of thermal biofeedback with a largely home-based regimen of 5 sessions (spread over 8 weeks) for the treatment of essential hypertension in patients who required at least two drugs to maintain control of blood pressure (BP). On the basis of the clinical end point of being successfully withdrawn from the second stage medication while BP remained under control, the clinic-based regimen (5 of 9) was superior (chi less than (1) = 4.0, p less than .05) to the home-based regimen (1 of 9). Internal analyses point to more frequently obtaining a hand temperature of at least 95 degrees F by the office-based patients as possibly the reason for the difference.

Cost effectiveness of biofeedback and behavioral medicine treatments: a review of the literature

This paper reviews multicomponent behavioral medicine studies that contain cost-effectiveness and or cost-benefit data relevant to the field of biofeedback and relaxation training, primarily when assisted by biofeedback, with or without stress management, in the treatment of psychosomatic illness and pain. A model for evaluating biofeedback treatment is presented. Cost-effectiveness data concerning reduction in physician visits and/or medication use, decrease in medical care costs to patients, reduction in hospital stays and rehospitalization, reduction of mortality, and enhanced quality of life are reviewed. Evidence suggests that multicomponent behavioral medicine treatments are cost-effective on all dimensions reviewed. Cost/benefit ratios range between 1:2 and 1:5, with a median of 1:4. Evidence that could increase the cost effectiveness of biofeedback is reviewed.