Chronic Tension
Headache
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 and Medical College of Georgia Augusta, Georgia
Introduction
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).
Treatment 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.
EMG Biofeedback
Training
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.
Initial Session
Strategies
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 headaches."
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 3).
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.
Coaching and Therapist Attitude
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 prepared for:
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.
Homework
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
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.
Biofeedback 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.
Conclusion
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.
References
1.
Ad Hoc Committee of the International Headache
Society. Classification of headache. Journal of American Medical Association,
179, 717-718, 1988.
2.
Ad Hoc Committee on the Classification of
Headache. Classification of headache. Journal of the American Medical
Association, 179, 127-128, 1962.
3.
Andrasik, F. & Blanchard, E.B. Biofeedback
treatment of muscle contraction headache. In Hatch, J.P., Fisher, J.G., Rugh,
J.D., (eds.) Biofeedback: Studies in Clinical Efficacy. NY: Plenum Press, 1987.
4.
Arena, J.G., Hannah, S.L., Bruno, G.M. &
Meador, K.J. Electromyographic biofeedback training for tension headache in the
elderly: A prospective study. Biofeedback and Self-Regulation, 4, 379-390,
1991.
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Arena, J.G., Hannah, S.L., Bruno, G.M., Smith,
J.D. & Meador, K.J. Effect of movement and position on muscle activity in
tension headache sufferers during and between headaches. Journal of
Psychosomatic Research, 35, 187-195, 1991.
6.
Arena, J.G., Hightower, N.E. & Chang, G.C.
Relaxation therapy for tension headache in the elderly: A prospective study.
Psychology and Aging, 3, 96-98, 1988.
7.
Bakal, D.A. Psychology and Health, Second
Edition, Springer Publishing Company, New York, 1992.
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Blanchard, E.B. Psychological Treatment of
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60, No. 4, 537-551, 1992.
9.
Dupuy, H.J., Engel, A., Devine, B.K., Scanlon,
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10. Holroyd,
K.A., Penzien, D.B., Hursey, K.G., Tobin, D.L., Rogers, L., Holm, J.E.,
Marcille, P.J., Hall, J.R. & Chila, A.G. Change Mechanisms in EMG
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Copyright, 1997 The Biofeedback Foundation of Europe