**5. Biofeedback and neurofeedback in the treatment of migraine**

Biofeedback is a noninvasive method of measurement of physiological functions. Precise instruments measure the slightest changes of different body functions—which are then in a clear and understandable manner shown in the form of feedback. The person gets an insight into what is going on inside the body and thus learns to change patterns of behavior to improve health and performance. Any changes that are wanted are rewarded, which leads to learning of the new patterns of behavior [31]. Biofeedback is a common intervention in pain management. For migraine treatment, the most frequently used biofeedback methods have been peripheral skin temperature biofeedback, blood-volume-pulse feedback, and electromyography feedback [31]. Neurofeedback is a method of obtaining feedback on brain processes, that is, a type of training that observes wave activity and is presented to the individual through the screen through video games. It is based on the measurement of specific brain activity patterns that are characteristic of certain cognitive processes or conditions such as attention, concentration, depression, insomnia, anxiety, fears, stress, headache, or migraine. The neurofeedback method functions as a "mirror that you hold in front of the brain." It gives information on how the brain works. That way the brain can train to function better. It is possible to alleviate feelings of anxiety and anger and increase self-esteem, concentration, and organizational skills. According to symptoms and problems that a person could have, neurofeedback could be used to increase self-esteem and concentration and decrease anxiety and anger. Brain activity can be targeted by the brain function that we call neuroplasticity. Neuroplasticity refers to the ability to change brain activity over time and represents one of the fundamental parts of the human evolution process and is found to be the basis of some mental and health disorder acquisition.

seriously affect the amount and quality of sleep. Neurofeedback training can reduce anxiety

Biofeedback and Neurofeedback in the Treatment of Migraine

http://dx.doi.org/10.5772/intechopen.76534

9

Some studies have shown that using biofeedback can reduce the occurrence of a migraine or reduce the strength of the pain. A German meta-analysis of the efficacy of biofeedback for migraine—account 55 studies—showed medium effect size for all biofeedback interventions and proved stable over an average follow-up phase of 17 months. The frequency of migraine attacks and perceived self-efficacy demonstrated the strongest improvements. Blood-volumepulse feedback yielded higher effect sizes than peripheral skin temperature feedback and

Sharff et al. [33] conducted a study to examine the effects of hand-warming biofeedback, as compared to hand-cooling biofeedback and no treatment at all. Sharff et al. found that the children who were in the hand-warming biofeedback group improved more than the com-

Results from a study conducted by Grazzi et al. [34] suggest that the use of biofeedback in combination with medication is more successful than medication alone in treating migraines. Results showed a relapse rate of 42.1% (16 of 38) for participants in the medication only group vs. a relapse rate of only 12.5% (2 of 16) for the medication plus biofeedback group at year 3 of follow-up. This study, therefore, suggests that a combination of medication and biofeedback rather than either by itself may perhaps be the best means of treating migraines, specifically

Vasudeva [35] conducted a study to examine whether migraine sufferers who experienced aura reacted differently to biofeedback/relaxation than those without and if this was accounted for by blood flow velocity. The results have shown the biofeedback group experienced a decline in the severity of their migraine pain and reported about using less medication to treat/control the pain. Furthermore, no association between biofeedback-assisted relaxation and blood flow velocity was found. Therefore, this study provides corroborating evidence for the notion that biofeedback is an effective treatment for migraines. Another migraine study with 62% of participants using neurofeedback reported major or total improvement in their migraines [36]. Per the study, most patients had long histories of migraines and had tried multiple pharmaceutical treatments prior to trying neurofeedback. Most were on medications during the study. Participants took part in an average of 40 sessions over 6 months. For neurofeedback training, they used a different site such as temporal locations (T3, T4), central areas (C3, C4), frontal areas (F3, F4), prefrontal areas (FP1, FP2), and parietal areas (P3, P4) for typically one to two sessions at each location. Seventy percent of the 37 participants showed a 50% or greater reduction in the frequency of their migraines, and only 16% failed to improve at all. Of those who improved, 62% reported major or total improvement in their migraines. The goal of neurofeedback, however, is to reduce, on an ongoing basis, the number and intensity of migraines. Based on these results—and on clinical experience from clinicians around the country—neurofeedback offers the potential for significant relief for anyone still struggling with migraines.

From some studies, in the electrophysiological activities of migraine sufferers, there are certain abnormalities, so it is understandable that interventions using EEG may be beneficial

and strengthen the brain activity that will help us sleep again well.

parison groups and sustained this improvement for up to 6 months later.

electromyography feedback [32].

transformed migraines.

Before training the target change activity in the brain, it is necessary to see what the initial activity is. Electrical activity in the brain is recorded with electroencephalograph, or EEG. The program analyzes brain activity through brain waves and uses, as well as feedback data presented through video games (motion of missiles, cars, changing image size, etc.). Brain activity by measuring brain waves is monitored via a computer interface, whereby the neurofeedback trainer follows brain activity and the client looks at his screen where he traces his brain activity in the form of video games and sound signals. If we want to achieve that the brain produces more rapid waves (important for mental functions and attention), when brain activity is increased precisely at those frequencies, the client will get better in the game or gain more points. If activity increases with slow-wave frequencies (those we want to reduce), then the success in the game will be weaker. Gradually, the brain will react more and more to these instructions and learn a new pattern of brain activity. The client does not have to think about the process of controlling activity that occurs at a subconscious level. The client just needs to relax and let the brain use its own ability to self-regulate. Observing brain activity information through real-time senses is what makes neurofeedback unique and successful. While some aspects of neurofeedback are automated using modern computer technology, each brain is unique, and each individual situation is different. It is therefore very important that the trained neurofeedback therapist takes an individual approach to the treatment of each client.

Focus and emotional balance are important to outstanding performance in all areas of our work and activities. By training certain brain wave patterns in certain areas, we can develop the skill of entering the "zone," at those times when it is most important for us to be excellent and regardless of the circumstances in which we are located. We must not forget that one of the most important preconditions for excellence is a quality dream. Stress and anxiety can seriously affect the amount and quality of sleep. Neurofeedback training can reduce anxiety and strengthen the brain activity that will help us sleep again well.

in a clear and understandable manner shown in the form of feedback. The person gets an insight into what is going on inside the body and thus learns to change patterns of behavior to improve health and performance. Any changes that are wanted are rewarded, which leads to learning of the new patterns of behavior [31]. Biofeedback is a common intervention in pain management. For migraine treatment, the most frequently used biofeedback methods have been peripheral skin temperature biofeedback, blood-volume-pulse feedback, and electromyography feedback [31]. Neurofeedback is a method of obtaining feedback on brain processes, that is, a type of training that observes wave activity and is presented to the individual through the screen through video games. It is based on the measurement of specific brain activity patterns that are characteristic of certain cognitive processes or conditions such as attention, concentration, depression, insomnia, anxiety, fears, stress, headache, or migraine. The neurofeedback method functions as a "mirror that you hold in front of the brain." It gives information on how the brain works. That way the brain can train to function better. It is possible to alleviate feelings of anxiety and anger and increase self-esteem, concentration, and organizational skills. According to symptoms and problems that a person could have, neurofeedback could be used to increase self-esteem and concentration and decrease anxiety and anger. Brain activity can be targeted by the brain function that we call neuroplasticity. Neuroplasticity refers to the ability to change brain activity over time and represents one of the fundamental parts of the human evolution process and is found to be the basis of some

Before training the target change activity in the brain, it is necessary to see what the initial activity is. Electrical activity in the brain is recorded with electroencephalograph, or EEG. The program analyzes brain activity through brain waves and uses, as well as feedback data presented through video games (motion of missiles, cars, changing image size, etc.). Brain activity by measuring brain waves is monitored via a computer interface, whereby the neurofeedback trainer follows brain activity and the client looks at his screen where he traces his brain activity in the form of video games and sound signals. If we want to achieve that the brain produces more rapid waves (important for mental functions and attention), when brain activity is increased precisely at those frequencies, the client will get better in the game or gain more points. If activity increases with slow-wave frequencies (those we want to reduce), then the success in the game will be weaker. Gradually, the brain will react more and more to these instructions and learn a new pattern of brain activity. The client does not have to think about the process of controlling activity that occurs at a subconscious level. The client just needs to relax and let the brain use its own ability to self-regulate. Observing brain activity information through real-time senses is what makes neurofeedback unique and successful. While some aspects of neurofeedback are automated using modern computer technology, each brain is unique, and each individual situation is different. It is therefore very important that the trained neurofeedback therapist takes an individual approach to the treatment of each client. Focus and emotional balance are important to outstanding performance in all areas of our work and activities. By training certain brain wave patterns in certain areas, we can develop the skill of entering the "zone," at those times when it is most important for us to be excellent and regardless of the circumstances in which we are located. We must not forget that one of the most important preconditions for excellence is a quality dream. Stress and anxiety can

mental and health disorder acquisition.

8 Biofeedback

Some studies have shown that using biofeedback can reduce the occurrence of a migraine or reduce the strength of the pain. A German meta-analysis of the efficacy of biofeedback for migraine—account 55 studies—showed medium effect size for all biofeedback interventions and proved stable over an average follow-up phase of 17 months. The frequency of migraine attacks and perceived self-efficacy demonstrated the strongest improvements. Blood-volumepulse feedback yielded higher effect sizes than peripheral skin temperature feedback and electromyography feedback [32].

Sharff et al. [33] conducted a study to examine the effects of hand-warming biofeedback, as compared to hand-cooling biofeedback and no treatment at all. Sharff et al. found that the children who were in the hand-warming biofeedback group improved more than the comparison groups and sustained this improvement for up to 6 months later.

Results from a study conducted by Grazzi et al. [34] suggest that the use of biofeedback in combination with medication is more successful than medication alone in treating migraines. Results showed a relapse rate of 42.1% (16 of 38) for participants in the medication only group vs. a relapse rate of only 12.5% (2 of 16) for the medication plus biofeedback group at year 3 of follow-up. This study, therefore, suggests that a combination of medication and biofeedback rather than either by itself may perhaps be the best means of treating migraines, specifically transformed migraines.

Vasudeva [35] conducted a study to examine whether migraine sufferers who experienced aura reacted differently to biofeedback/relaxation than those without and if this was accounted for by blood flow velocity. The results have shown the biofeedback group experienced a decline in the severity of their migraine pain and reported about using less medication to treat/control the pain. Furthermore, no association between biofeedback-assisted relaxation and blood flow velocity was found. Therefore, this study provides corroborating evidence for the notion that biofeedback is an effective treatment for migraines. Another migraine study with 62% of participants using neurofeedback reported major or total improvement in their migraines [36]. Per the study, most patients had long histories of migraines and had tried multiple pharmaceutical treatments prior to trying neurofeedback. Most were on medications during the study. Participants took part in an average of 40 sessions over 6 months. For neurofeedback training, they used a different site such as temporal locations (T3, T4), central areas (C3, C4), frontal areas (F3, F4), prefrontal areas (FP1, FP2), and parietal areas (P3, P4) for typically one to two sessions at each location. Seventy percent of the 37 participants showed a 50% or greater reduction in the frequency of their migraines, and only 16% failed to improve at all. Of those who improved, 62% reported major or total improvement in their migraines. The goal of neurofeedback, however, is to reduce, on an ongoing basis, the number and intensity of migraines. Based on these results—and on clinical experience from clinicians around the country—neurofeedback offers the potential for significant relief for anyone still struggling with migraines.

From some studies, in the electrophysiological activities of migraine sufferers, there are certain abnormalities, so it is understandable that interventions using EEG may be beneficial at migraines [37, 38]. For example, a study in children with a migraine, with or without aura, shows an increase in frequency theta compared to the control group [37]. One of the used neurofeedback protocols for a migraine emphasizes the brain activity reward of 12–15 HZ at T3 and T4 sites [37]. Siniatchkin et al., in their research, showed a significant reduction of migraine in 10 young people after 10 sessions of neurofeedback in central frontal and central areas by teaching them control of sporadic cortical potential activity that represents cortical sensitivity and reactivity [39]. Michael Tansey in his work with four people with migraine after neurofeedback training in the central frontal and central area showed a decrease in low frequency that became less dominant and strengthened faster frequency [40]. Also, neurofeedback training includes a newer method called hemoencephalography (HEG) that is used on the frontal lobe with gaining information on heat value and learning to increase the frontal temperature or forehead temperature [41]. The elevation of PIR HEG signals reflects the composite thermal activity generated by vascular supply, vascular return, and brain cell activity. Changes of the heat signal from the underlying prefrontal cortex reflect the degree of engagement and increase of neuronal activity. This method also, according to literature, helped to reduce migraine pain as well as the frequency of their headaches in people with migraine diagnoses [37, 41, 42].

our decades of use, we thought that it is a good choice to work with a migraine. After neurofeedback, breathing training with the diaphragm lasted for 10–15 min with the aim of relaxing the body through muscle relaxation and breathing training that would lead to vasodilation and relaxation of the whole body by stimulating the parasympathetic action of the autonomic nervous system. Subsequently, we have been using vasoconstriction-vasodilation training with the aim of enabling a person to learn that vasoconstriction occurs when a migraine occurs. The training is done in such a way that the sensor is set to a. temporalis with a signal that must be at least 10 μV. During the 21-min training sessions, we had 4-min vasoconstriction training and 1-min relaxation training alternate. Choosing all three training sessions at the same time was to prompt positive changes in pain reduction as well as

Biofeedback and Neurofeedback in the Treatment of Migraine

http://dx.doi.org/10.5772/intechopen.76534

11

The reason for choosing that particular way of training (neurofeedback, breathing, vasoconstriction training) was to have one relaxation training between two difficult pieces of training. It is not so easy to work one hour and a half with maximum work of the person. We also could recommend monitoring peripheral temperature as a secondary parameter during vasoconstriction training, but we did not consider it necessary to include it because the effectiveness of the training achieves vasodilation, that is, a certain blood flow, which also increases the peripheral temperature. Of course, it would be useful to put the sensor in peripheral temperature for future research. We did not use EMG biofeedback, it was not necessary in this particular case. HEG would certainly be useful as a method and probably use it to have it in the software. The device we used in training was NEXUS-10 MARK II and software BIOTRACE+,

The training lasted 4 months during which the person came two to three times a week for complete training; breathing training was used daily. During the 4 months, a headache diary was also conducted. During the training session, there was no migraine, or a headache was on

Implementation of neurofeedback was by using protocols that are determined individually according to the initial assessment, and mean duration of each session was 30 min. Electrode position was according to the international 10–20 systems, and frequency bands were inhibited or rewarded. Administered protocols were on Cz, C4, and C3. Neurofeedback was used to increase sensory motor rhythm (SMR) in the sensory-motor area, to decrease high beta activities and to learn to maintain a relaxed state with a clear focus and concentration. Below is a description of the neurofeedback training with a detailed performance about working on

Cz: inhibition of theta waves (4–9 Hz), strengthening of SMR and beta waves (12–15 Hz), and

C4: inhibition of theta waves (4–9 Hz), strengthening of SMR and beta waves (12–15 Hz), and

C3: inhibition of theta waves (4–9 Hz), strengthening of SMR and beta waves (14–18 Hz), and

individual points according to the international 10–20 systems:

inhibition of high beta (22–30 Hz)—ten sessions.

inhibition of high beta (22–30 Hz)—seven sessions.

inhibition of high beta (22–30 Hz)—eight sessions.

migraine rates.

of the Dutch company Mind Media.

pain scale 3, on the scale of 1–10.

According to relevant research, we started a combined biofeedback treatment as a combination of three forms of biofeedback treatment: neurofeedback, breathing, and vascular biofeedback. After an initial assessment and extensive interview, we decided together with the person to combine multiple treatments at one visit. First, we did neurofeedback treatment, followed by breathing with the diaphragm for 10 min and then vascular training, with the aim of learning to achieve vasoconstriction. Treatments started at the beginning of September 2015 and completed at the end of December 2015. During the treatment, a headache diary was conducted by the person.

Our treatment goals were an improvement of the quality of life and increase in everyday functioning by reducing the symptoms related to the primary diagnoses.

Before we started treatment, we have done an initial assessment which included:


With neurofeedback as a method, we chose to train a relaxed focus or sensorimotor rhythm (SMR) with maintaining muscular relaxation and reducing the internal anxiety and tensions most commonly occurring in the fast beta activity (high beta amplitude) above 22 Hz and may be associated with stress as well as other psychological events. Given that it was a young person, but also loads with her law study, the idea was to strengthen the relaxed focus with neurofeedback and reduce internal tension. Along with the effectiveness of neurofeedback that we have been able to see in improving performance as well as at some difficulties during our decades of use, we thought that it is a good choice to work with a migraine. After neurofeedback, breathing training with the diaphragm lasted for 10–15 min with the aim of relaxing the body through muscle relaxation and breathing training that would lead to vasodilation and relaxation of the whole body by stimulating the parasympathetic action of the autonomic nervous system. Subsequently, we have been using vasoconstriction-vasodilation training with the aim of enabling a person to learn that vasoconstriction occurs when a migraine occurs. The training is done in such a way that the sensor is set to a. temporalis with a signal that must be at least 10 μV. During the 21-min training sessions, we had 4-min vasoconstriction training and 1-min relaxation training alternate. Choosing all three training sessions at the same time was to prompt positive changes in pain reduction as well as migraine rates.

at migraines [37, 38]. For example, a study in children with a migraine, with or without aura, shows an increase in frequency theta compared to the control group [37]. One of the used neurofeedback protocols for a migraine emphasizes the brain activity reward of 12–15 HZ at T3 and T4 sites [37]. Siniatchkin et al., in their research, showed a significant reduction of migraine in 10 young people after 10 sessions of neurofeedback in central frontal and central areas by teaching them control of sporadic cortical potential activity that represents cortical sensitivity and reactivity [39]. Michael Tansey in his work with four people with migraine after neurofeedback training in the central frontal and central area showed a decrease in low frequency that became less dominant and strengthened faster frequency [40]. Also, neurofeedback training includes a newer method called hemoencephalography (HEG) that is used on the frontal lobe with gaining information on heat value and learning to increase the frontal temperature or forehead temperature [41]. The elevation of PIR HEG signals reflects the composite thermal activity generated by vascular supply, vascular return, and brain cell activity. Changes of the heat signal from the underlying prefrontal cortex reflect the degree of engagement and increase of neuronal activity. This method also, according to literature, helped to reduce migraine pain as well as the

frequency of their headaches in people with migraine diagnoses [37, 41, 42].

functioning by reducing the symptoms related to the primary diagnoses.

Before we started treatment, we have done an initial assessment which included:

conducted by the person.

10 Biofeedback

• Structured interview.

• Measuring of baseline EEG (one channel, Cz).

According to relevant research, we started a combined biofeedback treatment as a combination of three forms of biofeedback treatment: neurofeedback, breathing, and vascular biofeedback. After an initial assessment and extensive interview, we decided together with the person to combine multiple treatments at one visit. First, we did neurofeedback treatment, followed by breathing with the diaphragm for 10 min and then vascular training, with the aim of learning to achieve vasoconstriction. Treatments started at the beginning of September 2015 and completed at the end of December 2015. During the treatment, a headache diary was

Our treatment goals were an improvement of the quality of life and increase in everyday

• Analyses of medical documentation (conducted diagnostic and therapeutic procedures).

With neurofeedback as a method, we chose to train a relaxed focus or sensorimotor rhythm (SMR) with maintaining muscular relaxation and reducing the internal anxiety and tensions most commonly occurring in the fast beta activity (high beta amplitude) above 22 Hz and may be associated with stress as well as other psychological events. Given that it was a young person, but also loads with her law study, the idea was to strengthen the relaxed focus with neurofeedback and reduce internal tension. Along with the effectiveness of neurofeedback that we have been able to see in improving performance as well as at some difficulties during The reason for choosing that particular way of training (neurofeedback, breathing, vasoconstriction training) was to have one relaxation training between two difficult pieces of training. It is not so easy to work one hour and a half with maximum work of the person. We also could recommend monitoring peripheral temperature as a secondary parameter during vasoconstriction training, but we did not consider it necessary to include it because the effectiveness of the training achieves vasodilation, that is, a certain blood flow, which also increases the peripheral temperature. Of course, it would be useful to put the sensor in peripheral temperature for future research. We did not use EMG biofeedback, it was not necessary in this particular case. HEG would certainly be useful as a method and probably use it to have it in the software. The device we used in training was NEXUS-10 MARK II and software BIOTRACE+, of the Dutch company Mind Media.

The training lasted 4 months during which the person came two to three times a week for complete training; breathing training was used daily. During the 4 months, a headache diary was also conducted. During the training session, there was no migraine, or a headache was on pain scale 3, on the scale of 1–10.

Implementation of neurofeedback was by using protocols that are determined individually according to the initial assessment, and mean duration of each session was 30 min. Electrode position was according to the international 10–20 systems, and frequency bands were inhibited or rewarded. Administered protocols were on Cz, C4, and C3. Neurofeedback was used to increase sensory motor rhythm (SMR) in the sensory-motor area, to decrease high beta activities and to learn to maintain a relaxed state with a clear focus and concentration. Below is a description of the neurofeedback training with a detailed performance about working on individual points according to the international 10–20 systems:

Cz: inhibition of theta waves (4–9 Hz), strengthening of SMR and beta waves (12–15 Hz), and inhibition of high beta (22–30 Hz)—ten sessions.

C4: inhibition of theta waves (4–9 Hz), strengthening of SMR and beta waves (12–15 Hz), and inhibition of high beta (22–30 Hz)—seven sessions.

C3: inhibition of theta waves (4–9 Hz), strengthening of SMR and beta waves (14–18 Hz), and inhibition of high beta (22–30 Hz)—eight sessions.

**Figure 1.** Vascular training with BVP sensor on a. temporalis (session 2).

**5.1. Breathing technique**

is often not recognized or affected by them.

**Figure 3.** Vascular training with BVP sensor on a. temporalis (after 3 months).

body to function normally, it is necessary to balance both systems.

Breathing is a willing and reluctant function, which means we can, but we do not have to pay attention to breathing. Breathing is under control of the breathing center located in the extended spinal cord, which means that the breathing takes place without our influence. It is controlled by an autonomic nervous system that manages various functions in the body and

Biofeedback and Neurofeedback in the Treatment of Migraine

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How then to affect the function of breathing? Breathing can be controlled by a conscious mechanism of breathing an attempt to relax the body and slow down the physiological processes. Today, when the challenges—and therefore stressors—in everyday life are very intense, body relaxation for the sake of health is very important. People who use certain breathing techniques feel their benefit. They are more relaxed, they feel happier, and they do not feel in their own body of great pressures of everyday life. To explain why breathing is important and how it affects a person, we need to look at the vascular system that is also affected by the autonomic nervous system. The most frequent changes due to the great pressures in life most people feel in that system. Mostly, it is a disruption of heartburn, accelerated breathing, a sense of losing air, and "kicking in the heart"—all these are symptoms that lead to bad feelings and the inability to function every day. Common respiratory changes are associated with retardation or acceleration of the bloodstream and are caused by the sympathetic and parasympathetic autonomic nervous system. The first accelerates it, and the other serves to slow down all the functions in the body. The same happens with breathing—in the sympathetic work of the autonomic nervous system, the breathing is faster, shallow, and irregular, while in the parasympathetic effect, breathing is slower, which most commonly occur during rest and sleep without our influence. For the

**Figure 2.** Vascular training with BVP sensor on a. temporalis (after 1 month).

Implementation of biofeedback included vascular training which means 25 sessions of vascular training on a. temporalis, learning the modality of vasoconstriction and vasodilatation. Each training session was 30 min. We used the device that had the vascular training. The goal was to have the amplitude of BVP signal smaller at training phase than relax phase. The results of the few training we shown in **Figures 1**–**3**.

**Figure 3.** Vascular training with BVP sensor on a. temporalis (after 3 months).
