BRIEF REPORT:
BIOFEEDBACK-PSYCHOTHERAPY FOR THE TREATMENT OF HEADACHES: A 5-YEAR FOLLOW-UP Charles Spencer Adler, M.D. Sheila Morrissey Adler, Ph.D. Presented at the Bergen Migraine Symposium, June, 1975 Accepted for publication: 6/21/76 SYNOPSIS A psychodynamic approach to the use of biofeedback with chronically disabled headache patients was effective in 86% causing a 75-100% reduction of headache frequency which has persisted over a 5-year period. (Headache 16: 189-191, 1976) THE PRINCIPLES of biofeedback have been known for centuries and date back at least as far as the ancient Greek myth of Narcissus, who looked at his reflection in a pool and thus, received the first biofeedback. While it is hoped that medicine today won't be transfixed like Narcissus by the momentary visage it sees, biofeedback does seem to be offering exceptional promise against certain recalcitrant maladies such as headache. Biofeedback is a tool which supplements traditional tools. It is not a theory and does not replace or invalidate any old theories, though it can be used to test their premises. We have treated headaches with biofeedback for seven years. The first two years yielded promising results in a research setting; we have now used this method in a clinical setting. This report deals with the first 58 headache patients. The results in these patients have been similar to those in nearly 200 subsequent patients treated by us. This is a retrospective analysis, and no controls were used. Some recurring psychological conflicts in headache patients were observed and will be commented on. METHODS Patients studied had terminated all treatment between three and one-half to five years before follow-up. They were asked about current headache frequency and intensity, recent medication use, current status of physiologic control in their lives, and significant changes in functional adaptation to life. There were 22 common and classic migraine patients; 19 muscle contraction (tension) headache patients; 12 mixed migraine and tension headaches, and 5 cluster headache patients. Mean age was 37 years, mean frequency of headache was three times per week, and average duration of headaches prior to treatment was 18 years. All patients had medical treatment before biofeedback therapy; 50% additionally had visited diagnostic centers in other states. Almost all were on medication, and the majority were taking narcotic in combination with analgesics or ergot compounds (30 patients used ergots regularly; 38 used minor tranquillizers regularly). Many patients had learned to treat the anticipation of a headache with drugs, and when they first entered treatment had no motivation to abstain from medication. After ascertaining that a thorough medical workup had been performed, biofeedback training began. For tension headache electromyographic feedback was used. For migraine or mixed headaches, after an initial period of EMG feedback, temperature feedback training was given. Cluster headaches also were treated with temperature feedback training. With experience, it
became apparent that for continued improvement it was essential to treat all aspects of the patient and his headache, including social, psychological, and physiologic contexts. The aim of treatment was to resolve disordered function of the psychologic and somatic components of headache. Psychotherapy was indicated for three-quarters of the patients. Much of this therapy was interpretive work with feedback participating in the interpretive process. This involved arousing the patient's curiosity about emotional and ideational concomitants of sudden physiologic shifts on the instrument used suggesting increased anxiety. At the end of the hour, a detailed inquiry was made on how internal cognitive and ideational maneuvers had affected the feedback during the session. Sometimes biofeedback treatment had to be interrupted for a time and more classic psychotherapeutic sessions substituted. Sessions were at least twice weekly and varied in number from five to sixty. It was not possible to predict the number of sessions needed on the basis of diagnosis alone. The degree of disruption of psychosomatic functioning was a more reliable criterion. During biofeedback training, an attempt was made to teach the technique of "passive concentration" on specific regions of the body and to discourage attitudes of active striving on the machine that are inimical to relaxation. RESULTS At follow-up, 42% of the patients had either no headaches or only very occasional ones. An additional 44% had 10 to 25% of the original headache frequency. Major improvement (75-100% remission) was therefore present in 86% of patients. Two patients stopped treatment; the others were either slightly improved or unchanged. The results at follow-up were similar to those recorded in the charts at the end of treatment. The success rate for tension headaches was 88%; for migraine, 81%; mixed headache, 60%; and cluster headache, 60%. Seven of the classic migraine patients reported intermittent prodromal symptoms which could last from minutes to hours. They found it necessary to focus attention on raising their hand temperature to ensure that headache did not develop. When a migraine attack did occur after termination of treatment, sometimes ergot compounds either took longer to work or were ineffective. Most of the patients who did not improve were in the group that did not receive psychotherapy. It was frequently learned that patients had not "confessed" their full medication use during the initial stages of therapy due to fear of it being abruptly discontinued. Over half had been taking Valium. Five migraine patients who had irregular menstrual cycles spontaneously reported the onset of regular menses during the course of biofeedback treatment. The possibility exists of hypothalamic reorganization from vascular re-training with consequent beneficial neuro-endocrine effects. DISCUSSION In our opinion, the essential factor in the maintained improvement was the therapeutic interweaving of both psychologic and physiologic facets of headache. Although biofeedback is an exciting innovation in the treatment of headache, its effectiveness is limited if isolated from the psychogenic aspects of chronic headache and from the full range of traditional medical therapies, including appropriate medications. We have observed that specific psychologic processes are potentiated by the relaxation which occurs with biofeedback treatment. Unresolved grief, repressed rage, and latent thanatophobia were often uncovered.
Because the biofeedback instrument is often viewed as an extension of the therapist, interpersonal factors in biofeedback treatment weigh heavily in the patient's willingness to internalize and use the "physiologic insight" that the instrument provides. The prevalence of previous unsuccessful psychotherapy in the patients, however, indicates the limitations of therapeutic relationships devoid of physiologic information in the treatment of psychophysiologic disorders. Reprint requests to: Charles S. Adler, M.D. 955 Eudora Street, Suite 1605 Denver, Colorado 80220 U.S.A.
BIOFEEDBACK-PSYCHOTHERAPY FOR THE TREATMENT OF HEADACHES: A 5-YEAR FOLLOW-UP Charles Spencer Adler, M.D. Sheila Morrissey Adler, Ph.D. Presented at the Bergen Migraine Symposium, June, 1975 Accepted for publication: 6/21/76 SYNOPSIS A psychodynamic approach to the use of biofeedback with chronically disabled headache patients was effective in 86% causing a 75-100% reduction of headache frequency which has persisted over a 5-year period. (Headache 16: 189-191, 1976) THE PRINCIPLES of biofeedback have been known for centuries and date back at least as far as the ancient Greek myth of Narcissus, who looked at his reflection in a pool and thus, received the first biofeedback. While it is hoped that medicine today won't be transfixed like Narcissus by the momentary visage it sees, biofeedback does seem to be offering exceptional promise against certain recalcitrant maladies such as headache. Biofeedback is a tool which supplements traditional tools. It is not a theory and does not replace or invalidate any old theories, though it can be used to test their premises. We have treated headaches with biofeedback for seven years. The first two years yielded promising results in a research setting; we have now used this method in a clinical setting. This report deals with the first 58 headache patients. The results in these patients have been similar to those in nearly 200 subsequent patients treated by us. This is a retrospective analysis, and no controls were used. Some recurring psychological conflicts in headache patients were observed and will be commented on. METHODS Patients studied had terminated all treatment between three and one-half to five years before follow-up. They were asked about current headache frequency and intensity, recent medication use, current status of physiologic control in their lives, and significant changes in functional adaptation to life. There were 22 common and classic migraine patients; 19 muscle contraction (tension) headache patients; 12 mixed migraine and tension headaches, and 5 cluster headache patients. Mean age was 37 years, mean frequency of headache was three times per week, and average duration of headaches prior to treatment was 18 years. All patients had medical treatment before biofeedback therapy; 50% additionally had visited diagnostic centers in other states. Almost all were on medication, and the majority were taking narcotic in combination with analgesics or ergot compounds (30 patients used ergots regularly; 38 used minor tranquillizers regularly). Many patients had learned to treat the anticipation of a headache with drugs, and when they first entered treatment had no motivation to abstain from medication. After ascertaining that a thorough medical workup had been performed, biofeedback training began. For tension headache electromyographic feedback was used. For migraine or mixed headaches, after an initial period of EMG feedback, temperature feedback training was given. Cluster headaches also were treated with temperature feedback training. With experience, it
became apparent that for continued improvement it was essential to treat all aspects of the patient and his headache, including social, psychological, and physiologic contexts. The aim of treatment was to resolve disordered function of the psychologic and somatic components of headache. Psychotherapy was indicated for three-quarters of the patients. Much of this therapy was interpretive work with feedback participating in the interpretive process. This involved arousing the patient's curiosity about emotional and ideational concomitants of sudden physiologic shifts on the instrument used suggesting increased anxiety. At the end of the hour, a detailed inquiry was made on how internal cognitive and ideational maneuvers had affected the feedback during the session. Sometimes biofeedback treatment had to be interrupted for a time and more classic psychotherapeutic sessions substituted. Sessions were at least twice weekly and varied in number from five to sixty. It was not possible to predict the number of sessions needed on the basis of diagnosis alone. The degree of disruption of psychosomatic functioning was a more reliable criterion. During biofeedback training, an attempt was made to teach the technique of "passive concentration" on specific regions of the body and to discourage attitudes of active striving on the machine that are inimical to relaxation. RESULTS At follow-up, 42% of the patients had either no headaches or only very occasional ones. An additional 44% had 10 to 25% of the original headache frequency. Major improvement (75-100% remission) was therefore present in 86% of patients. Two patients stopped treatment; the others were either slightly improved or unchanged. The results at follow-up were similar to those recorded in the charts at the end of treatment. The success rate for tension headaches was 88%; for migraine, 81%; mixed headache, 60%; and cluster headache, 60%. Seven of the classic migraine patients reported intermittent prodromal symptoms which could last from minutes to hours. They found it necessary to focus attention on raising their hand temperature to ensure that headache did not develop. When a migraine attack did occur after termination of treatment, sometimes ergot compounds either took longer to work or were ineffective. Most of the patients who did not improve were in the group that did not receive psychotherapy. It was frequently learned that patients had not "confessed" their full medication use during the initial stages of therapy due to fear of it being abruptly discontinued. Over half had been taking Valium. Five migraine patients who had irregular menstrual cycles spontaneously reported the onset of regular menses during the course of biofeedback treatment. The possibility exists of hypothalamic reorganization from vascular re-training with consequent beneficial neuro-endocrine effects. DISCUSSION In our opinion, the essential factor in the maintained improvement was the therapeutic interweaving of both psychologic and physiologic facets of headache. Although biofeedback is an exciting innovation in the treatment of headache, its effectiveness is limited if isolated from the psychogenic aspects of chronic headache and from the full range of traditional medical therapies, including appropriate medications. We have observed that specific psychologic processes are potentiated by the relaxation which occurs with biofeedback treatment. Unresolved grief, repressed rage, and latent thanatophobia were often uncovered.
Because the biofeedback instrument is often viewed as an extension of the therapist, interpersonal factors in biofeedback treatment weigh heavily in the patient's willingness to internalize and use the "physiologic insight" that the instrument provides. The prevalence of previous unsuccessful psychotherapy in the patients, however, indicates the limitations of therapeutic relationships devoid of physiologic information in the treatment of psychophysiologic disorders. Reprint requests to: Charles S. Adler, M.D. 955 Eudora Street, Suite 1605 Denver, Colorado 80220 U.S.A.
