The use of EMG biofeedback
for the treatment
of chronic tension headache.
- John G. Arena, Ph.D.,
Glenda M. Bruno,
Andrew G. Brucks, M.S.
- Pain Evaluation and Intervention
Program Department of Veterans Affairs Medical Center
and Medical 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
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
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.
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
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
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, 717-718, 1988.
- Ad Hoc Committee on the Classification
of Headache. Classification of headache. Journal of the American Medical
Association, 179, 127-128, 1962.
- 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
- 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.
- 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.
- 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.
- Bakal, D.A. Psychology and Health, Second
Edition, Springer Publishing Company, New York, 1992.
- Blanchard, E.B. Psychological Treatment
of Benign Headache Disorders. Journal of Consulting and Clinical Psychology,
Vol. 60, No. 4, 537-551, 1992.
- Dupuy, H.J., Engel, A., Devine, B.K.,
Scanlon, J., Querec, L. Selected Symptoms of Psychological Stress, US
Public Health Service Publication #1000, Series 11, #37. National Center
for Health Statistics. 1977.
- 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 Biofeedback Training: Cognitive
Changes Underlying Improvements in Tension Headache. Journal of Consulting
and Clinical Psychology, Volume 52, 1039-1053, 1984.
- Peatfield, R. Headache. New York, Springer,
- Schwartz, M.S. Biofeedback: A Practitioners
Guide. New York: Guiliford Press, 1987.
1997 The Biofeedback Federation of Europe