Headache is the most common pain complaint(11) and the most frequent medical problem seen in medical clinics(7). Most experts(3) believe that the majority of headaches are muscle tension-type. Although nearly all of the headache literature treats biofeedback and relaxation therapy as separate interventions, most clinicians combine both procedures when treating their tension headache patients.
::::::::John G. Arena, Ph.D.,
Glenda M. Bruno, R.N., M.S., Andrew G. Brucks, M.S.
Pain Evaluation and Intervention Program
Department of Veterans Affairs Medical Center
College of Georgia Augusta, Georgia
Headache is the most common pain complaint(11) and the
most frequent medical problem seen in medical clinics(7).
Most experts(3) believe that the majority of headaches are
muscle tension-type. Community-based epidemiological studies
have found that 14% of men and 29% of women have had
headaches either every few days or headaches which
significantly bothered them(9).
Tension headache is generally described as a bilateral
dull ache, pressure or cap-like pain that is usually located
in the forehead, neck and shoulder regions. The headache
typically occurs from two to seven days a week and can last
from one hour to all day; a small proportion of tension
headache sufferers have continuous headache. Migraine
headache, on the other hand, is described as a unilateral
pain, generally accompanied with nausea and vomiting, with
the pain characterized as throbbing or pulsating. Clinicians
who deal with headache patients should use a standardized set
of inclusion and exclusion criteria for diagnosis such as
specified by the Ad Hoc Committee on the Classification of
Headache(1) or the newer Ad Hoc Committee of the
International Headache Society(2).
of Chronic Tension Headache
Behavioral treatments for chronic tension headache have
been found to be as effective as pharmacological
interventions(8). Although nearly all of the headache
literature treats biofeedback and relaxation therapy as
separate interventions, most clinicians combine both
procedures when treating their tension headache patients.
A study by Holroyd and his colleagues(10), detected no
significant difference between subjects who trained to
increase or decrease their muscle tension levels; high
success feedback groups showed substantially greater
improvements in headache activity (53%) than low success
groups (26%). This study demonstrated the importance that
cognitive mediating factors such as perceived success and
self efficacy play in biofeedback training, and the enhanced
awareness of ones level of muscle tension during
non-biofeedback periods. Thus, the emphasis on biofeedback
training with tension headache should focus on skill
acquisition and the therapist-patient relationship.
Initially, place the two active sensors approximately in
the center of the forehead in line with the pupil of the
respective eye. The reference (ground) sensor is placed
between the two active sensors (figure 1). We recommend the
use of disposable EMG sensors to insure against infection. A
reading of less than 2 microvolts generally indicates a
fairly relaxed muscle group. If the level starts off and
remains low even during stress provoking imagery or
discussion, or after the patient has gone through an adequate
course of forehead EMG biofeedback and little change in
headache activity is noted, advance to the shoulder and neck
regions (figure 2). Palpation for muscular tenderness may
also be used in the selection of electrode placement sights.
To decrease patient anxiety, refer to the electrodes as
sensors, and indicate that EMG only senses electrical
activity and does not send current through the body.
Settings on the MyoTrac(TM):
- Set the OFF/CONT/THR switch to continuous
- Set the gain switch to x10, or to x1 if the muscle
activity is less than 10 uV.
- Set the threshold setting so that the bargraph
reading is near the yellow LED.
- Set internal switches to OFF/OFF/ABV/WIDE
- For clinical use, a computerized EMG system such as
the MyoDac2(TM), MyoTrac2(TM), ProComp(TM) or FlexComp/DSP(TM) provides either bargraph or
polygraph displays, as well as full database
functions which allow the storage of patient
information and session data.
We say something like this: "Its
traditionally been assumed that the type of headache
you have - tension headache - is caused by very high
levels of muscle tension in your forehead, neck and
shoulder areas. These muscles have been tense for a
long time. Through biofeedback training, you will
learn to both be aware of and decrease your muscle
tension levels at any time. When you do this, its
hoped that you will get a decrease in your
We next give the patient a number of possible
strategies to choose from. We emphasize that learning
the biofeedback response is purely an idiosyncratic
process and that what works for others may not work
for them. We customarily describe 6 possible
biofeedback strategies outlined in Table 1 (figure
In the first session, we usually tell the patient
to pick only one strategy and stick with it the
entire session. We keep the initial session short - a
3-5 min. adaptation period (Just sit quietly with
your eyes closed) and a maximum of 12 min. of
biofeedback. (In latter sessions, we increase the
biofeedback portion to a maximum of 25 min.) We
emphasize that learning to relax muscles at will can
be a difficult response to learn and that it may take
some time before they can lower their forehead muscle
tension reliably; we tell them not to get discouraged
if they cannot control their EMG levels immediately.
We instruct the patients to let the response occur
rather than make it occur, to be passive rather than
try to force their forehead muscles to relax. We let
them choose which type of visual and auditory
feedback they like. At the end of the biofeedback
session when the sensors are removed and the sessions
data is saved, we inquire as to which strategy was
employed and the patients perception as to how
effective it was. We also get a self report of
relaxation, muscle tension and pain levels on a 1-10
scale prior to and following the session. If using a
computer, we review the actual minute by minute
printout of the data with the patient. Throughout
this review we attempt to impart to the patient the
most positive feeling of success gained, based on the
realities of the sessions data. The number of
sessions may run from 10 to as many as 24.
Figure 3. Table 1.
The first, and most important thing for a
therapist to determine about coaching, is whether a
patient wants and could benefit from coaching. This
is truly idiosyncratic. There are three general
situations during EMG biofeedback that you have to be
Situation 1 - The patient has decreased forehead
muscle tension levels. Possible responses are:
a) Thats fantastic! Keep up the good work. I want
you to remember what you are doing now so you can
tell me at the end of the session. Real good! Try to
get it even lower. Situation 2 - The patient has not
been able to decrease forehead muscle tension levels.
Possible responses are: Thats OK. Its as important to
find out what makes it go up as it is to find out
what makes it go down. I want you to remember what
youre doing now so you can tell me at the end of the
session. Thats OK. You can only go up so far before
you have to start going down. You seem to be going
up; you might want to switch to a different strategy.
Situation 3 - The patient seems frustrated or appears
to be trying too hard. Possible responses are: Thats
to be expected. Remember, I told you that this is a
very difficult response to get. If it was easy, you
wouldnt need me or the machines. Lets take a break.
Sometimes all you need is a few minutes to clear your
mind and then you come back like gangbusters. You may
want to think of yourself as a scientist, who
dispassionately tests theories and tosses them in or
out depending on whether or not they work. As a rule,
we would suggest that coaching be done in a limited
basis, as this will help to generalize the response
to the real world, for in everyday situations
patients do not have a therapist accompanying them.
It is imperative for the therapist to convey as
enthusiastically as possible to the patient that he
or she is doing well in the biofeedback session.
Home practice has traditionally been considered an
essential aspect of all psychophysiological
interventions for chronic tension headache(8,12).
Home practice can be conducted in many ways: The
simplest form of homework is to instruct the patient
to practice the office strategy that seemed to work
the best at home and in other real world locations
such as the job, supermarket, etc. (we usually
instruct them to do so at least four times a day).
The use of a home practice EMG unit, such as the MyoTrac(TM), is also quite helpful. An important
application for the MyoTrac(TM) EMG is to use it in
situations which generally initiate headaches. For
example, computer operators might monitor muscle
activity while typing, using the delayed threshold
function (internal switch positions at OFF/ON/ABV/WIDE) which provides a tonal warning only
when the threshold level has been exceeded for more
than 4 seconds. In this way, maintained muscle
tension is minimized, while appropriate low levels of
muscle activity is reinforced.
Generalization involves preparing the patient to
carry the learning that may have occurred during the
biofeedback session into the real world. The most
common method, by far, is a self control condition
which is interspersed between a baseline and a
feedback condition. The self control condition
involves asking the patient to control the desired
psychophysiological response (e.g., "Please try
to lower your forehead muscle tension") without
any feedback. If the patient can control the
response, the clinician may assume that there has
been between-session learning (i.e., generalization).
Another method of testing for generalization is to
present a pre- and post-treatment stressor to the
patient and, if there is less arousal during and
after a stressor in the post treatment, the clinician
may infer that generalization has occurred. A third
way of preparing the patient to generalize the
biofeedback response is to try to make the office
biofeedback training as close to real world
situations as possible, such as switching to an
uncomfortable chair or standing during the session.
for tension headache in the elderly
Based upon the research (4,5,6) and our clinical
experience we would suggest the following when
working with the elderly tension headache patient:
First, to be certain that the patient understands the
therapists instructions, we would suggest requesting
each patient to verbally repeat each sessions
instructions. Second, therapists should talk at a
somewhat slower rate than usual to insure that
rationale and instructions are comprehended. Third,
the therapist should make every attempt to simplify
the instructions and, especially, to avoid the use of
sophisticated language or jargon. Fourth, a brief
summary of previously imparted information should be
given at subsequent sessions to aid patients in
retaining details. Fifth, turn up the biofeedback
auditory feedback volume to ensure the patient can
hear it, or use an earphone. We would also suggest
moving the visual feedback monitor closer to ensure
that the patient does not have to strain to see it.
Finally, be patient with the elderly headache
sufferer. Spend some extra time listening; do not
communicate a desire to hurry the session. Schedule
appointments for 10 minutes longer than usual.
A biofeedback - behavioral program to assist
headache patients to decrease both the severity and
frequency of headaches has been described. The
program includes in-clinic training as well as the
inclusion of EMG portable home trainers to provide
reinforcement of behavioral and muscle control
strategies in the real world.
- Ad Hoc Committee of the International
Headache Society. Classification of headache.
Journal of American Medical Association, 179,
- Ad Hoc Committee on the Classification of
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- Andrasik, F. & Blanchard,
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Reprinted from The
Biofeedback Foundation of Europe
Lead Psychologist Veterans Administration Medical Center in Augusta, Georgia, President, Association for Applied Psychophysiology and Biofeedback