**4. Treatment of a migraine**

Migraine headache therapy according to European Federation of Neurological Societies (EFNS) recommendations' indication for individual drugs was elaborated according to EFNS guidelines at three levels [22]:

• Level A—the drug is effective, ineffective, or harmful, as demonstrated by at least one convincing first-level research (prospective, randomized, double-blind clinical study in a representative population sample or systematic review of prospective, randomized, doubleblind clinical studies in a representative sample of populations) or with two consistent, convincing second-level studies (prospective, cohort, double-blind research in a representative sample of populations or randomized, controlled research in a representative population sample).

twice a month or more often, abortive treatment is inadequately effective, and common, long-

Biofeedback and Neurofeedback in the Treatment of Migraine

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

7

It is important to emphasize that the introduction of prophylactic therapy should be discussed with the patient, who should be familiar with the possible adverse effects of therapy and adapt the drug and the dose to each individual patient [26]. The main goals of prophylactic therapy are to reduce the incidence and duration of headaches, improve the quality of life of patients, and prevent progression of transient episodic to chronic migraines. Prophylactic therapy should also be introduced if the patient is suffering from a specific form of migraine that can lead to permanent neurological damage, hemiplegic migraine, basilar migraine, persistent aura without migraine infarction, and migraine infarction [27]. Pregnancy is recommended only for magnesium and metoprolol [28], and flunarizine, propranolol, or topiramate may be used in childhood and adolescence [26]. In the prophylactic treatment of migraine, certain drugs are used such as antihypertensive, antidepressant, antiepileptic, and nonsteroi-

In addition to drug therapy, preventive procedures include life-changing practices that include sleep hygiene, regular meals, exercise, and avoiding known trigger for reducing migraine frequency. Using techniques such as relaxation exercises, cognitive-behavioral techniques, biofeedback, acupuncture, and transcutaneous electrical stimulation of the nerve (TENS) can

According to preventive treatment, it is recommended in patients with high frequency of migraine attacks (usually more than 4–5 days per month)—which is always the case in a chronic migraine, but also when attacks are rare, but very severe and disabling (intense pain), or when patients have contraindications or no response to triptans [29]. Relaxation training and biofeedback focus on the perception of pain, biofeedback training focus on the physical response involved in pain persistence, and cognitive-behavioral techniques target the experience of feeling pain. Knowing the factors that produced chronic headaches may allow the patient to modulate the pain. Patients are taught self-regulation techniques to enhance individual control of pain and coping strategies for a chronic headache and reduce migrainerelated stress [30]. In the treatment of a migraine, we can certainly combine different methods. Some people can take certain analgesics only in the period of headaches; some take preventive therapy. With the use of nonpharmacological treatments such as biofeedback, according to our experience, the analgesia is gradually diminishing. The use of multiple combinations of treatments always goes on the assumption that a combination of multiple treatments will

**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

lasting, and unpleasant aura occurs [26].

dal anti-inflammatory drugs.

**4.3. Non-pharmacological prophylactic treatment of migraine**

also contribute to the prevention of migraine headaches [23].

sooner and faster produce better results.


#### **4.1. Abortive migraine therapy**

Abortive migraine therapy involves interrupting the headaches in a short time. The choice of the drug and the way it is administered depend on the clinical picture; the strength of a headache; whether it is associated with additional symptoms, such as nausea and vomiting; and the health of the patient itself—the presence of cardiovascular and/or other illness—and pregnancy. Symptomatic therapy works best if early, immediate headaches are given, with a larger dose being more effective than many smaller ones [23]. In the treatment of weaker to moderate headaches without nausea and vomiting, the nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for oral use. If a headache is followed by nausea and vomiting, the NSAID and antiemetics are used parenterally [24]. Moderate to severe headaches without nausea and vomiting are treated with specific drugs—triptans in oral or triptan combinations and NSAIDs (sumatriptan and naproxen) [24]. A moderate to severe headache with nausea and vomiting indicated the use of triptan subcutaneously or intranasally [23].

If the number of headaches varies from attack to attack, the patients are taught and prescribed two or more drugs, either orally or parenterally, which they use as needed [25].

Pregnancy is contraindicated in the use of all medicines used to treat a migraine except paracetamol and aspirin and ibuprofen in the second trimester. Triptans may be used with specialist consensus and if the risk to the child for attack and vomiting is greater than the risk of using triptan [26]. Ibuprofen and paracetamol from the NSAID group, domperidone from the antiemetic group and sumatriptan nasally from the triptan group [26], may be used for childhood treatment and adolescent treatment.

#### **4.2. The prophylactic treatment of migraine**

The prophylactic treatment of migraine is prescribed to patients to prevent or reduce the incidence and strength of symptoms. Prophylactic migraine treatment should be initiated if headaches significantly reduce the quality of life (family and professional), headaches occur twice a month or more often, abortive treatment is inadequately effective, and common, longlasting, and unpleasant aura occurs [26].

It is important to emphasize that the introduction of prophylactic therapy should be discussed with the patient, who should be familiar with the possible adverse effects of therapy and adapt the drug and the dose to each individual patient [26]. The main goals of prophylactic therapy are to reduce the incidence and duration of headaches, improve the quality of life of patients, and prevent progression of transient episodic to chronic migraines. Prophylactic therapy should also be introduced if the patient is suffering from a specific form of migraine that can lead to permanent neurological damage, hemiplegic migraine, basilar migraine, persistent aura without migraine infarction, and migraine infarction [27]. Pregnancy is recommended only for magnesium and metoprolol [28], and flunarizine, propranolol, or topiramate may be used in childhood and adolescence [26]. In the prophylactic treatment of migraine, certain drugs are used such as antihypertensive, antidepressant, antiepileptic, and nonsteroidal anti-inflammatory drugs.

#### **4.3. Non-pharmacological prophylactic treatment of migraine**

• Level A—the drug is effective, ineffective, or harmful, as demonstrated by at least one convincing first-level research (prospective, randomized, double-blind clinical study in a representative population sample or systematic review of prospective, randomized, doubleblind clinical studies in a representative sample of populations) or with two consistent, convincing second-level studies (prospective, cohort, double-blind research in a representative sample of populations or randomized, controlled research in a representative popu-

• Level B—the drug is probably effective, inefficient, or harmful, as proven by at least one persuasive research other levels or superior trials of the three (all other controlled studies in the representative sample of the population where the expected outcome is independent

• Level C—the drug is probably effective, ineffective, or harmful this is proven by at least

Abortive migraine therapy involves interrupting the headaches in a short time. The choice of the drug and the way it is administered depend on the clinical picture; the strength of a headache; whether it is associated with additional symptoms, such as nausea and vomiting; and the health of the patient itself—the presence of cardiovascular and/or other illness—and pregnancy. Symptomatic therapy works best if early, immediate headaches are given, with a larger dose being more effective than many smaller ones [23]. In the treatment of weaker to moderate headaches without nausea and vomiting, the nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for oral use. If a headache is followed by nausea and vomiting, the NSAID and antiemetics are used parenterally [24]. Moderate to severe headaches without nausea and vomiting are treated with specific drugs—triptans in oral or triptan combinations and NSAIDs (sumatriptan and naproxen) [24]. A moderate to severe headache with nausea

If the number of headaches varies from attack to attack, the patients are taught and prescribed

Pregnancy is contraindicated in the use of all medicines used to treat a migraine except paracetamol and aspirin and ibuprofen in the second trimester. Triptans may be used with specialist consensus and if the risk to the child for attack and vomiting is greater than the risk of using triptan [26]. Ibuprofen and paracetamol from the NSAID group, domperidone from the antiemetic group and sumatriptan nasally from the triptan group [26], may be used for

The prophylactic treatment of migraine is prescribed to patients to prevent or reduce the incidence and strength of symptoms. Prophylactic migraine treatment should be initiated if headaches significantly reduce the quality of life (family and professional), headaches occur

and vomiting indicated the use of triptan subcutaneously or intranasally [23].

two or more drugs, either orally or parenterally, which they use as needed [25].

childhood treatment and adolescent treatment.

**4.2. The prophylactic treatment of migraine**

lation sample).

6 Biofeedback

of the treatment of the patient).

two-level three trials.

**4.1. Abortive migraine therapy**

In addition to drug therapy, preventive procedures include life-changing practices that include sleep hygiene, regular meals, exercise, and avoiding known trigger for reducing migraine frequency. Using techniques such as relaxation exercises, cognitive-behavioral techniques, biofeedback, acupuncture, and transcutaneous electrical stimulation of the nerve (TENS) can also contribute to the prevention of migraine headaches [23].

According to preventive treatment, it is recommended in patients with high frequency of migraine attacks (usually more than 4–5 days per month)—which is always the case in a chronic migraine, but also when attacks are rare, but very severe and disabling (intense pain), or when patients have contraindications or no response to triptans [29]. Relaxation training and biofeedback focus on the perception of pain, biofeedback training focus on the physical response involved in pain persistence, and cognitive-behavioral techniques target the experience of feeling pain. Knowing the factors that produced chronic headaches may allow the patient to modulate the pain. Patients are taught self-regulation techniques to enhance individual control of pain and coping strategies for a chronic headache and reduce migrainerelated stress [30]. In the treatment of a migraine, we can certainly combine different methods. Some people can take certain analgesics only in the period of headaches; some take preventive therapy. With the use of nonpharmacological treatments such as biofeedback, according to our experience, the analgesia is gradually diminishing. The use of multiple combinations of treatments always goes on the assumption that a combination of multiple treatments will sooner and faster produce better results.
