S2:Ep22 – Biofeedback for Migraine and Anxiety: A Proven Therapy
Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease. This episode is brought to you by our generous sponsor, Lundbeck.
In this jam-packed episode, Dr. Christopher Rhyne, of the Diamond Headache Clinic, explains this drug-free technique that can aid in managing migraine attacks. Biofeedback uses body sensors and guided relaxation to train patients to control autonomic responses such as heart rate, muscle tension, and body temperature.
Lundbeck is a global pharmaceutical company that is committed to improving the lives of people living with brain diseases. Lundbeck is pleased to offer a treatment option for migraine prevention. To learn more, visit LundbeckUS.com.
Molly O’Brien: Hi there and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re talking all about biofeedback for migraine. What is it? Does it work? How does it work? So to help us answer all those questions and more, I’d like to introduce headache medicine doctor Dr. Christopher Rhyne.
Thanks so much for joining us.
Dr. Christopher Rhyne: Hey, Molly. How’s it going? Good to see you.
Molly: Good to see you as well.
And Dr. Rhyne is joining us from the Diamond Headache Clinic. So let’s jump right in, but before we get into all those details, we’ll start off with the basics. What is biofeedback?
Dr. Rhyne: So biofeedback is a fantastic tool, and not just for headache pain — although we certainly do use it — but for several different ailments. Basically, it’s a psychophysiological sort of combination tool that works through using several different types of sensors that are placed on a patient, guided relaxation with a professional who understands how to apply biofeedback techniques, and then that data being gathered and shared with the patient during the course of these different sessions in order for that patient to better manage some of their autonomic pieces of themselves, things like heart rate or blood pressure, in a way that shows them how to more appropriately control things like pain, levels of constipation, jaw pain — I mean, you name it.
There’s several different applications to it, and it’s this neat way where we can take the way that we think and the way that we sort of understand what’s going on with our bodies and see it in real time in a way that helps us better control these pieces of ourselves that, for a lot of us, we think we have no control over. And biofeedback’s really a neat way to see how much we can do within that space to improve sort of our overall treatment goals for whatever those conditions are that we’re applying biofeedback to.
Molly: And I really do want to dive into that control aspect a little bit later on. But, again, we’re going to start with the basics. So —
Dr. Rhyne: Absolutely, yeah.
Molly: Some people might have heard of biofeedback. Some people may have heard of CBT, or cognitive behavioral therapy. And then some of the things you’re saying almost sound like meditation. Are these all related? Are they different? And how does biofeedback differ from those other ones?
Dr. Rhyne: I would probably put meditation outside of that bucket a little bit further, but cognitive behavioral therapy, CBT, and biofeedback are generally short-term strategies for an individual goal. So we’re going to work through the trauma of the car accident that I was in or the way that I respond to stress from work, and maybe CBT is going to be a tool that we use to do that specific task; where you’re going to use biofeedback to help you manage the way that your neck behaves, the muscles of your neck behave, as your migraine headache comes on. It’s a specific task, a specific goal in treatment that we would want to use biofeedback for, depending on how it’s applied, and CBT really fits in that same bucket.
The way that that happens is a little different. We’re going to use physical tools — sensors, computers, and guidance from a professional on how to use those tools and gather data during the course of a biofeedback session. CBT isn’t necessarily going to have things like that, and it’s going to be really more a curriculum and a therapeutic approach that a healthcare provider would offer to a client or a patient.
The notion in cognitive behavioral therapy is that what I’m going to do is I’m going to take something that I think is beyond my control and I’m simply responding to — I like stress at work. I think everybody — right now, especially — understands that really well. So, man, I always get a headache because of the stress that I experience at work.
And so the thought there is, Well, hold on. You’re having an emotional response to an external force, this stress that you perceive internally at work. And so let’s work together and talk through and work with CBT approaches to sort of better understand the way that you’re internalizing this external stimulus, this stress response that you’re having. And perhaps if we do a better job of that, we’ll have less of a physical response to that experience. And we start to internalize and accept what’s going on, and we say, “Actually, you know what, it’s not the stress. Yeah, it’s there. It’s the way I respond to the stress that’s the thing.” And now we can work on the way I respond to the stress and hopefully get a better outcome.
So that’s CBT sort of in a nutshell, where biofeedback is going to be, “Man, when I get stressed at work, I always get a headache. So I do my biofeedback sessions to better understand the way that my heart rate picks up when I’m stressed, the way that the muscles on the back of my neck stiffen up and become tender and painful when I’m stressed, the way that my blood pressure picks up, that I get my sweaty palms,” these other pieces that, again, are physiological responses. And rather than sort of looking maybe to the emotional piece or the emotional response to that external stimuli, I’m internalizing my physical response to that stimulus.
So they certainly can help each other out, but they’re really focused, and it’s really applied mindfulness, if there’s a catchphrase that people think about with mindfulness. So the notion there is I’m going to think very clearly about both my physical and emotional response, depending on which tool we’re using, whether it’s biofeedback or CBT.
Meditation is about walking away from the mindfulness. It’s about emptying yourself. It’s about trying to remove that clutter, which can still offer a therapeutic benefit in a different way. And I would probably argue that once people have CBT and biofeedback in a really good place for them where they’re seeing therapeutic benefit and they’re seeing improvements, that maybe the master class is moving into a guided meditation that’s more than just relaxation. That really is you gaining better management over our modern-day brains that are constantly trying to jump to the next thing and think through things. So I hope that helps kind of suss out the sort of quiet differences between each one of those.
Molly: I think that’s a good way to put it, that CBT and biofeedback can hold hands, and then meditation, you’re kind of taking it to that next level.
So, again, we’re going to focus mainly on biofeedback today, so we’re super excited to get into this. There are multiple types of biofeedback. Can you walk us through a few of the most common ones that are used for migraine?
Dr. Rhyne: Probably the most common that we do is an EMG form, where we’re using electrodes on particular muscle groups, especially in the neck, bottom of the skull, upper back, shoulders sometimes even, and even the frontalis, the forehead, where we’re measuring to see tension and tightness that are taking place during the onset of a migraine, during the course of a migraine. Because this tool’s not just necessarily about keeping headaches from showing up, but also working through how we mindfully, with these techniques, chase a headache away, and so having the capacity to understand in real time what your body’s doing, rather than sort of just taking your hands off the wheel and saying, “Well, I’m having a headache. I guess this is just how it goes.” This is the impact of biofeedback with guided relaxation and then measuring that.
So with EMG, they’ll use those electrodes to physically measure the electrical activity in those muscle groups, and we can show a patient in real time, “I know it feels like it’s tight or it feels like it’s not tight, but this is what’s really going on right now in these muscle groups.” And we can show them that in real time.
Other pieces, too — there’s thermal forms, where we can use heat sensors, particularly on the hands, to show changes in body temperature. We have the capacity with that to, again, show that you’re having this heightened response to a particular situation and work to physically show them that they can, with the right guidance, work to either increase or decrease the temperature of that probe. And they can see that there are actual controls that you can have over some of these autonomic features that you didn’t think you could. I mean, a lot of us probably don’t think that they can raise or lower the temperature of their hands with guided relaxation techniques and focus, but you can.
Other pieces that we probably use less — blood pressure, heart rate variability are other pieces that we can measure too, again with different types of sensors — very important in the management of anxiety, which does have a tremendous relationship to migraine and migraineurs. So in sort of a back-door way, managing anxiety with some of that testing will ultimately improve response to headache and overall clinical outcomes for headache patients. So that’s a place that can be really good for patients to start with and focus on.
Molly: I mean, it sounds a little mind-blowing that I could actually control the temperature of my hands regardless of the situation that I’m in. So it sounds awesome, and we’re going to get into the fact that how does it work, and does it work?
But first, can you walk us through maybe what a typical treatment is like for a patient coming in? Do they need to — I mean, do they have to be in the midst of a migraine attack? Is it better to not be in the midst of an attack? Walk us through what it’s like and what people could expect.
Dr. Rhyne: No, you don’t have to be headache-free to start learning how to do this or to apply this, and if you are in the midst of terrible headaches or really chronified headaches, this is a tool that you can start right now. And I would really advise that you do. For those viewers who are out there wondering when they should pull the trigger on seeking this out or seeking this as a therapeutic option for them, I can’t support it enough in the benefits that we see for our patients who are brand-new to it and really kind of get their feet wet before they leave the unit and then continue that therapy as an outpatient.
So what do we need to do? What do we need to expect when we come into that treatment plan with biofeedback? We want you to show up probably with an open mind. I think your sentiment that you brought is a fair one, right? We are not levitating monks sitting in a biofeedback suite, and we — what is it? Light as a feather, stiff as a board? That’s not what’s going on in a biofeedback suite. What it really comes down to is understanding the component of your sympathetic nervous system as it relates to your autonomic function in a stress environment.
So your sympathetic nervous system, fight or flight or freeze — they’ve added that part to it too. Everybody’s heard of fight or flight before. It is — to some degree, in really simple terms — your lizard brain taking over. If a bear kicked in that beautiful glass door behind you, you’re not going to be considering the meaning of life. You’re not going to be wondering about what we’re having for dinner tonight. Your focus is going to be solely on this threat. Your stomach is going to stop digesting your lunch. Your hair, skin, nails stop growing. All of the nonessential functions in your body will stop.
Energy and adrenaline, cortisol, races through you, particularly to your arms and legs, so that you can either punch that bear in the nose or run from it or both. That’s the only thing that your body’s going to focus on. And so this is that stress response, that sympathetic nervous system. So your blood pressure comes up, your heart rate comes up, you start sweating more, you start breathing faster, you start doing all of things that we measure with biofeedback.
And we see that stress response. That’s what we’re seeing in this situation. Fantastic. So this is a wonderful tool to have. This stress response is an unbelievable tool to have if you run into a bear every once in a while. Great tool to have, wonderful, will keep us alive, is a fantastic, awesome piece of the way that human beings are made.
But for migraineurs and for people who suffer with other conditions where biofeedback’s helpful too or that have a large autonomic response, their bear’s in the room all the time. And so because of that, they can never ever get ahold of it, and worse, they go further and they say, “All right, fantastic. So this is my day. I’m a chronic migraineur. I’ve got headaches every day.” And they throw their hands up in the air, and this is what their expectation is of their day.
And so our neck’s tight and stiff all the time. My pressure’s a little bit higher when I have pain. I constantly have cortisol rushing through me, so now we have this stimulus over time that promotes depression and anxiety, which furthers my experience with migraine, all of these things taking place. The notion of both CBT, really, and the medications that we use, honestly, and biofeedback, too, is can we get ahold of that mechanism? Can we try to stop this sort of circle of stress, stress response, re-stress, and the symptoms that are associated in between?
So a great number of the medications that we use short-circuit the neurochemicals that promote that stress response or short-circuit the autonomic signals that create that stress response. And then working with professionals can also change the way we experience or see that stress response. So that’s the notion and the way that it works.
So it does seem really pie-in-the-sky, but I think everybody’s had the experience where they’ve been startled. You’re not scared for the rest of the evening. Why not? Because you calm down, because you realized it wasn’t that big of a deal. It was a scary movie, or it was just a trip through the haunted house, that there’s nothing to be afraid of, I guess is sort of the best way to think about it on the back end. Now, you were petrified when they jumped out of the bushes or whatever they did during the haunted house, but not later.
And, really, in a simple way, that’s the approach that we’ll take in thinking about where biofeedback can fit in, is to give you the tools to calm down, to understand how to manage these pieces of yourself. And it’s a task. This isn’t easy, but it’s certainly something that has results and is effective, for sure.
Molly: So tell us a little bit about how does it work, does it work. If you’re going into treatment, it doesn’t seem like something you can pick up just like this. Do you need to practice? Tell us a little bit more about that.
Dr. Rhyne: Yeah, I think from patient to patient, again, based on how skeptical they are sometimes of it, to be totally honest, which is fair, they may need more or less coaxing or experience or success with it before they’ll recognize the value, which is totally fair. But most sessions, maybe 30 to 60 minutes. It depends, again, on age, capacity, what we’re working towards, how severe the symptoms are.
They’ll come in. Oftentimes, especially early on, whoever’s working with them through the experience will explain to them exactly what’s going — we’re putting sensors on people. It’s strange. And so to make them feel more comfortable about what’s going on, “Why is this on my finger? Why am I wearing this sort of heart rate monitor around my waist?” or “Why are these stickers on my forehead?” So getting them comfortable with that process.
It’s private, oftentimes. Most biofeedback suites are very mellow, low light, kind of that spa feel, Enya in the background kind of deal — maybe not.
Molly: Love Enya.
Dr. Rhyne: Yeah, but very soothing, very quiet, very comfortable in order to get patients to let their guard down enough that we can start to take them through those relaxation exercises, get that data coming back on those sensors, and then walk them through how to approach adjusting that data through their force of thought.
The expectation on whether or not it works — it does. How long it takes, again, to some degree, depends on what you’re working toward, how successful other adjunct therapies are. But there are hundreds of clinical studies that have shown that biofeedback is effective. We typically see in the meta-analysis of that, maybe 45 to 60 percent of the folks who’ve continued biofeedback or the practices of biofeedback after relatively extensive treatment, and really understanding and buying in and building out these non-pharmaceutical approaches to medicine, continue to have significant reductions in the frequency and intensity of their headache, statistically significant — for all my statistics fans out there — improvement in their overall headache pain.
That cannot be said for all practitioners of biofeedback. There is a level of — certain quality and experience that we’d want to have. I think that’s probably fair with any type of therapy like this, that you would want to have somebody who’s experienced and knows what they’re doing, has appropriate equipment, and the experience of walking people through difficult things, like chronic migraine, for example.
But, yeah, it works, and it works well, on the order of some of the other preventative medicines that we see, medicines like propranolol, for example. That has been sort of a gentle, maybe not super effective, but a longstanding first-line medication for the prevention. Amitriptyline, another medicine — the namesake of our clinic, Dr. Seymour Diamond, who did a lot of the initial research on amitriptyline way back when — biofeedback has equally efficacious prevention data as those two medications. So not only does it work, but it can work as well as some of the stuff that might be in your medicine cabinet.
Molly: It’s pretty fascinating to know that there are multiple studies on this and we’re still getting high efficacy. So there’s something there. For those who might have a hard time grasping their head around it, it’s there. So that’s pretty cool.
Dr. Rhyne: I want to tell your viewers: so I am an army veteran, blue-blood guy. I’m a Bears fan here in Chicago. I’ve got two sons, and we do guy stuff. And I know that biofeedback can feel very hippie-dippie, thinking about this. You know, like, okay, and get out the bongo drums and the daisy chains.
It’s not. It’s not. It’s real stuff, and I think as people who cope with significant levels of chronic pain — cancer patients, chronic migraineurs, fibromyalgia patients — who use biofeedback on a regular basis to cope with function and do the things with their day that they’d rather be doing besides hurting, you start to see how hardcore it is, that these people are using their mind to control the way their body responds to stress. It’s unbelievable. It is tremendous amounts of work, really, really talented professionals, and cutting-edge science that are basically teaching us how to regain control over our bodies, in particular, our autonomic system.
Molly: And like you said, the science is there. The data is there. So that brings us to just kind of some nitty-gritty stuff we want to get into. Is biofeedback right for everyone, and with that, are there any side effects or interactions that people might need to know about?
Dr. Rhyne: First, the side effect or safety profile that we would look at with it is fantastic. I mean, the biggest drawback is that to do this well, it’s a time investment. It is. And that, oftentimes, in medicine in the modern day sometimes is a financial investment too. So those are real considerations for people.
Whether biofeedback is approved — is a cute work that insurance companies use — depends. It depends on your plan, how much it would cost. We typically can use health savings accounts, things like that, those types of funds to be able to support the cost. Depending on the practitioner, the location, all of this changes. So I know if you have viewers who are interested in trying to find out whether or not they can do it, I’d really advise that they get in touch with their insurance plan and have that conversation — there are codes for it; it is real — so that they can ask and see what that would be for them, given their situation.
As far as physical dangers, almost none. I mean, really, as long as you don’t trip over any of the sensors while you’re trying to walk out of the session, you should be okay. But, yeah, you really don’t see anything. There is nothing that pokes the skin, goes under the skin, nothing like that.
Molly: You mentioned a little bit about insurance, and, obviously, it’s different everywhere cost-wise. But can you give us a ballpark, an idea of cost if insurance doesn’t cover it? And then the other side of that, do most insurances do?
Dr. Rhyne: It really is a mixed bag. I actually even took some time in preparation for talking to you to go look to see where some of our local carriers are at with it. It seems to me that oftentimes, they’re sort of viewing it the way that they view physical therapy, where you have so many sessions and there may be a co-insurance or a co-payment associated with that. Depends where you are with your deductible how much your out-of-pocket would be. So there are tons of moving parts as far as that’s concerned.
I did, again, some research on individuals who, whether they’re good at it or not, were stating that they do biofeedback anywhere from 100 to $150 a session, up to quite a bit more than that for cash. Some of that depends on time too. Are you doing a 30-minute session? Are you doing 60?
And for those reasons, I guess, the other sort of cursory — warning’s too strong of a word, but thought to sort of give to your viewers is to say, “Hey, if you’re really interested in this, do your homework.” If you jump on Google and you type in “who does biofeedback near me?” Oh, Biofeedback Johnny’s up the street. Yes, biofeedback’s good, but maybe Johnny’s not that great.
So look and find somebody who knows what they’re doing. Because of the broad application of biofeedback in several different pieces of medicine — dentistry, occupational and physical therapy — you’ll have a lot of different kinds of providers that can do that work. So I think being really clear about what you want to apply biofeedback to, and then finding the right person. For headaches, come to a headache clinic or a pain clinic that does it. If you’ve got TMJ, maybe the folks out of your dentist’s office are good. Maybe that’s a place to go.
Molly: So we’re wrapping things up here on this episode of Spotlight on Migraine, a fantastic discussion about biofeedback with Dr. Christopher Rhyne, of the Diamond Headache Clinic.
Dr. Rhyne, thanks so much again for joining us today.
Dr. Rhyne: Molly, thank you so much. I really appreciate you, your team, and the work that you guys do.
Molly: So kind of you. Thank you.
Well, again, that wraps up this episode of Spotlight on Migraine. I’m Molly O’Brien, with the Association of Migraine Disorders. And if you want any more information on migraine or possible treatments, head over to our website at MigraineDisorders.org. Thanks again, and we’ll see you next time.
This podcast is sponsored in part by Lundbeck.
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