Biofeedback and Neurofeedback in the Treatment of Migraine

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Chapter 1
Biofeedback and Neurofeedback in the Treatment of
Migraine
Ivana Zivoder, Sanja Martic-Biocina and
Ana Vodanovic Kosic
Additional information is available at the end of the chapter
http://dx.doi.org/10.5772/intechopen.76534
Provisional chapter
DOI: 10.5772/intechopen.76534
© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Biofeedback and Neurofeedback in the Treatment of
Migraine
IvanaZivoder, SanjaMartic-Biocina and
Ana VodanovicKosic
Additional information is available at the end of the chapter
Abstract
Biofeedback is a noninvasive method of measurement of physiological functions where
precise instruments measure the slightest changes in body functions. Many of the stud-
ies have shown that using biofeedback can reduce the occurrence of migraine or reduce
the strength of the pain. Some results from a study suggest that the use of biofeedback
in combination with medication is more successful than medication alone in treating
migraines. Also, holistic approach by using behavioral technic is necessary to provide
maximal results by methods. To more precisely work with patients who suer from a
migraine, it is also important to know the pathophysiology of a migraine. According to
relevant research, we combined biofeedback treatment that consisted of a combination of
three forms of biofeedback treatment: neurofeedback, breathing, and vascular biofeed-
back. Combination of treatments in 25 sessions helped the patient with a long history of
a severe migraine. Further research of patients suering from a migraine with dierent
treatment protocols is needed to establish the method.
Keywords: biofeedback, neurofeedback, migraine treatment, pathophysiology,
breathing technique
1. Introduction
Migraine headache is one of the most common headaches in the general population, 15% suf-
fering from the European Union population [1] which with disabling symptoms signicantly
decreases the quality of life of the patients [2]. According to the International Classication
of Headache Disorders [3], a chronic migraine is a type of a primary headache occurring in
15 or more days per month for more than 3 months, in which more than 8 days per month of
© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

headache meet the criteria for a migraine with or without aura or respond to specic migraine
treatment. Not only in Europe, but also in the world, migraine has today a high incidence. The
prevalence of a migraine in Europe is 15%—ranges depending on the individual countries,
12–27.5% [1]. According to data published in 2006, Croatia, with Germany and Denmark, has
the highest prevalence of migraine in Europe [1].
Migraine is a disabling neurological condition characterized by episodic aacks of usually
unilateral headache, with pulsating character and light and sound intolerance, associated
with nausea and vomiting. The tendency to suer from a migraine has a genetic compo-
nent, but aacks can be triggered by a series of internal and external factors. Two types of
migraine have been described: episodic migraine (EM) (with subtypes migraine with aura
and migraine without aura)—in which a typical headache occurs on fewer than 15 days per
month—and chronic migraine (CM) with headaches in 15 or more days per month for at least
3 months [3]. It is not rare that an episodic migraine has progression to a chronic migraine.
The development of a chronic migraine has been associated with the presence of many risk
factors: female sex, older age, low level of education, low-income populations, predisposition
for anxiety, depression, sleep apnea or snoring, overweight, history of frequent headache,
stressful life events or major life changes, asthma, allergic rhinitis, and caeine consumption
[4]. Because of all these facts about migraines, it is not dicult to think about complexity and
longevity of the treatment. Also, many of people who suer from migraine in their life use
more than one treatment to get beer results, which is reduced pain and number of migraines.
For more than four decades, many dierent experts have been trying to nd the best way to
treat a migraine. Because the causes of migraine are not fully claried as well as the physiol-
ogy of migraine, so no unique treatment has yet been conceived.
The annual costs of migraine such as diagnosis, treatment, reduced productivity, and absence
from work are estimated to be 5 billion euros in the European Union [5]. It follows from the
above that a migraine is not only a medical but also a socioeconomic problem. Apart from the
economic, the lack of inuence of migraine is manifested in the social sphere. This recurrent
disease signicantly reduces the quality of life of the diseased, as it limits them to perform
daily activities. This directly aects both the near and the outer environment and above all the
patient’s family. Thus, the consequences of a migraine are reected in all areas of life—fam-
ily, professional, and social—resulting in dissatisfaction with their own achievements in all
these spheres and creating a sense of ineciency and intolerance, creating a vicious cycle with
negative consequences [2]. Therefore, the comprehensive approach to solving this problem is
very important, and education, of both the general population and the patients, and raising
health care to a higher level, with ongoing support for migraine-sick patients, are indispens-
able for shaping a healthier society.
The incidence of migraine before puberty is greater in boys than in girls [6]. It grows up to
12 years in both sexes and is the highest in the age range of 30–40 years. After puberty, the ratio
changes and increases in favor of women and with 40 is 3.5:1. After 40 years, the strength of the
symptoms is reduced (except for women in perimenopause), and the beginning of migraine
headaches in the fties is rare [7]. The prevalence of migraine is higher in the case of white
races than in black races and, on the other hand, is proportional to the socioeconomic status [6].
Migraine is a disease with many faces. The most common form is migraine without aura, occur-
ring in about 80% of patients, while migraine with aura occurs in about 20% of the patients [8].
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2. Pathophysiology of migraine
Pathogenesis of a migraine has long been a subject of discussion among scientists. It has been
considered that typical headaches are caused by intracranial vasodilation preceded by vaso-
constriction causing aura—vascular theory. Today it is known that this is not the case, and
although new ndings have emerged, the exact mechanism and genetic determinants are
not yet fully claried. The admied neurovascular theory states that causes of migraine lie in
neurogenic processes, followed by secondary changes in brain perfusion [7].
For a long time, it was thought that the cause of the aura, which precedes headaches, is cere-
bral vasoconstriction. Today, this theory is denied, and the aura is explained by neural dys-
function rather than ischemia due to vasoconstriction. The process of cortical widespread
depression, described in 1944 by Brazilian scientist Leão, is now associated with the emer-
gence of visual aura [9]. It is a self-stimulating process that is thought to be due to hyperexcit-
ability of the brain.
There is a release of potassium and neuroexcitatory amino acids of glutamate from neuronal
endings, whereby the surrounding tissue depolarizes and then a longer period of neuronal
activity is observed. Impulses travel by tissue at a rate of 2–6 mm/min—which is the rst fea-
ture to retrieve parallel with the rate of appearance, progression, and spread of characteristic
visual auric symptoms. During this process, there are also molecular events that cause sterile
inammation and changes in brain perfusion. During the aura seizures, studies using posi-
tron emission tomography showed initial hyper-phase, followed by reduced cortical blood
ow caused by reduced metabolism due to depolarization and associated decreased neuronal
activity. Changing the blood ow in the post-anterior direction is followed by the spread of
the impulse through the cortex and is not anatomically linked to the site and during the cere-
bral blood vessels [10].
During the functional magnetic resonance imaging study, blood oxygenation was found to be
initially increased, followed by a decrease in oxidative clearance in the occipital cortex, which
ranged at 3–6 mm/min—which may again be related to the appearance of visual symptoms of
aura [11]. In addition to being associated with oligemia, corticosteroid depression also inu-
ences the trigeminal activation of the trigeminovascular system and changes the permeability
of the blood-brain barrier and thus generates migraine headaches [12]. Cortical widespread
depression leads to activation of trigeminovascular aerent bers. Because of this activation,
prolonged blood ow increases through the middle meningeal artery and extravasation of
plasma proteins in the pituitary mater. There is the opening of the neuronal panicles and the
release of proinammatory cytokines. Consequently, there is a sterile inammation and pain
that aects the brain veins [12].
2.1. Pathogenesis of migraine headaches
When trigeminal ganglion stimulation occurs, neuropeptides are released that are key to the
emergence of neurogenic inammation. The key substances are P and calcitonin gene-related
peptide (CGRP) [13, 14]. Substance P is released primarily from thin non-ligated C bers,
while CGRP releases A and C bers. They, within neurogenic inammation, cause vasodila-
tion (CGRP), protein extravasation, and dural mast cell activation.
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There is the release of ions, cytokines, and other inammatory mediators in the environment of
sensory bers that inject the brain envelope. Due to the presence of these substances, prolonged
activation of peripheral nociceptors occurs, which is eventually perceived as pain. Neurogenic
inammation prolongs and enhances migraine headaches. Because of inammation, there is
also sensitization [13, 14]. Sensitization of neurons and neural bers indicates an increase in their
susceptibility. The threshold is lowered, and the magnitude of irritability and area of the irrita-
ble area grow [12]. Because of this, the weaknesses of the stimuli at perhaps atypical sites can be
perceived as pain. Spontaneous neuronal activation also occurs. There are two forms—periph-
eral and central sensitization. In peripheral sensitization, it is about capturing primary aerent
neurons, while in central sensitization, it is more susceptible to “higher” neurons—those in the
trigeminal nucleus and other parts of the brain stem and hemisphere. Sensitization is believed
to be responsible for many of the clinical symptoms of migraine. Pulsating pain, strengthening
pain due to physical activity, hyperalgesia, and allodynia are associated with sensitization.
2.2. Genetics of a migraine
The association of genetic factors with the onset of a migraine has been rst proven in patients
with familial hemiplegic migraine (FHM). This is a migraine subtype where an aura appears to
be fully reversible motor deciency [12]. There are three types of family hemiplegic migraines:
• FHM1 is linked to the mutation of the CACNA1A gene, located on chromosome 19p13.1,
and encodes for the α1 subunit of the P/Q calcium channel neurons [15]. The P/Q calcium
channel manifests multiple expressions in the central nervous system, regulates serotonin
and glutamate release in central and peripheral synapses, and is associated with increased
susceptibility to cortical widespread depression [16]. With the mutation of this gene, epi-
sodic ataxia type 2, paroxysmal disorder causing cerebellar ataxia, migraine-like symp-
toms, nystagmus, and cerebellar atrophy [17] are associated.
• FHM2 occurs due to the mutation of the ATP1A2 gene encoding the α2 subunit of Na/K
ATPase. This gene is found on the 1q23 chromosome, and the mutation causes reduced
ATPase oligodendrocyte activity and decreased anity for potassium ions, leading to the
reduced removal of the same from the extracellular space and reduction of retention of
glutamate from the synaptic cracks [18]. The elevated concentration of potassium ions and
glutamate in the extracellular space results in hyperexcitability of the brain [16]. Because
of the emergence of isolated FHM, it is also possible to combine with cerebellar symptoms,
childhood convulsions, and the emergence of mental retardation epilepsy [19].
• The FHM3 mutation aects the SCN1A gene (on the second chromosome), which encodes
the Nav1.1 voltage channel. The Nav1.1 voltage channel is key to generating and spread-
ing neuronal action potential, and genetic mutation causes excessive activation of action
potentials and can alleviate cortical widespread depression through several mechanisms:
high trigger rates can lead to increased extracellular potassium concentrations and further
depolarization and increase the release excitatory neurotransmier glutamate [15]. In addi-
tion to being associated with the emergence of family hemiplegic migraine, this gene is also
recognized as a cause of generalized convulsion in adult and childhood epilepsy [16], gen-
eralized epilepsy with febrile convulsions, and myoclonic epilepsy in early childhood [20].
Biofeedback4

Discovery of the mutations of these genes explains very few migraine cases, but their detection is
very important for a beer understanding of pathogenesis [21]. Other forms of migraine are most
likely to be complicated genetic disorders, where multiple genes are responsible for the occur-
rence of migraine and in which the gene base is intertwined with environmental factors [12].
3. Diagnosis of a migraine
Diagnosis of a migraine is based on the clinical picture or diagnostic criteria set by the
Headache Classication Commiee of the International Headache Society [3]. There are two
types of a migraine—migraine without aura and migraine with aura. Headaches that occur 15
or more days a month for more than 3 months and 8 or more days of migraine headache are
diagnosed with chronic migraine [3].
Specic diagnostic tests for migraine do not exist, and image methods are in most cases
not necessary. According to the American Academy of Neurology, the use of radiographic
image methods (MSCT, MR) is recommended only if an abnormal neurological status is
found and in patients with an atypical clinical history of headaches or headaches that can-
not be classied into either a migraine headache or some other primary headache [15].
Dierential diagnosis of a migraine without aura includes primarily tensile headache,
whereas the dierential diagnosis of migraine with aura also involves transitory ischemic
aack and partial epileptic seizure. At the seing of diagnosis of a migraine can help pres-
ence of auras (the presence of positive phenomena following negative phenomena), the
sequence of their occurrence, progression, duration, and possibly the existence of associ-
ated symptoms [12].
Also, at diagnostic, it is very important to take an extensive interview to get detailed informa-
tion on all spheres of life of the person with migraine (frequency, pain, time of occurrence,
association with other events, relationship with some period of time, place of appearance
of pain and description of pain, susceptibility to events in their own surroundings—greater
expectations of oneself or others—sensitivity to criticism, events that could have caused
migraines). Being a good listener to hear all the details of the person with migraine is of cru-
cial importance because it also depends on proposing the possible treatment. After an initial
interview where we collect all the necessary information, we shall decide together with the
person about how to treat a migraine. For biofeedback as a method of treatment, it is very
important to nd out how much the person is motivated to invest in and separate the time
they will devote to these treatments. At some people, it is still a bigger motive to take some
medications that will quickly solve their problem.
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]:
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• Level A—the drug is eective, ineective, or harmful, as demonstrated by at least one con-
vincing rst-level research (prospective, randomized, double-blind clinical study in a rep-
resentative population sample or systematic review of prospective, randomized, double-
blind clinical studies in a representative sample of populations) or with two consistent,
convincing second-level studies (prospective, cohort, double-blind research in a represen-
tative sample of populations or randomized, controlled research in a representative popu-
lation sample).
• Level B—the drug is probably eective, inecient, 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
of the treatment of the patient).
• Level C—the drug is probably eective, ineective, or harmful this is proven by at least
two-level three trials.
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 eective than many smaller ones [23]. In the treatment of weaker to
moderate headaches without nausea and vomiting, the nonsteroidal anti-inammatory 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 specic 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 aack to aack, 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 aack 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 signicantly reduce the quality of life (family and professional), headaches occur
Biofeedback6

twice a month or more often, abortive treatment is inadequately eective, and common, long-
lasting, and unpleasant aura occurs [26].
It is important to emphasize that the introduction of prophylactic therapy should be dis-
cussed with the patient, who should be familiar with the possible adverse eects of therapy
and adapt the drug and the dose to each individual patient [26]. The main goals of prophylac-
tic 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 suering from a specic form of migraine
that can lead to permanent neurological damage, hemiplegic migraine, basilar migraine, per-
sistent aura without migraine infarction, and migraine infarction [27]. Pregnancy is recom-
mended only for magnesium and metoprolol [28], and unarizine, 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-
dal anti-inammatory drugs.
4.3. Non-pharmacological prophylactic treatment of migraine
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 aacks (usually more than 4–5 days per month)—which is always the case in a
chronic migraine, but also when aacks 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 experi-
ence 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 indi-
vidual control of pain and coping strategies for a chronic headache and reduce migraine-
related stress [30]. In the treatment of a migraine, we can certainly combine dierent methods.
Some people can take certain analgesics only in the period of headaches; some take preven-
tive 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 beer results.
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 dierent body functions—which are then
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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 paerns of behavior
to improve health and performance. Any changes that are wanted are rewarded, which leads
to learning of the new paerns 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 elec-
tromyography feedback [31]. Neurofeedback is a method of obtaining feedback on brain pro-
cesses, 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 specic brain
activity paerns that are characteristic of certain cognitive processes or conditions such as
aention, 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 beer. 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.
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 neu-
rofeedback 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 aention), when brain
activity is increased precisely at those frequencies, the client will get beer 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 paern 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 dierent. 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 paerns 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
Biofeedback8

seriously aect the amount and quality of sleep. Neurofeedback training can reduce anxiety
and strengthen the brain activity that will help us sleep again well.
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 ecacy of biofeedback for
migraine—account 55 studies—showed medium eect size for all biofeedback interventions
and proved stable over an average follow-up phase of 17 months. The frequency of migraine
aacks and perceived self-ecacy demonstrated the strongest improvements. Blood-volume-
pulse feedback yielded higher eect sizes than peripheral skin temperature feedback and
electromyography feedback [32].
Shar et al. [33] conducted a study to examine the eects of hand-warming biofeedback, as
compared to hand-cooling biofeedback and no treatment at all. Shar et al. found that the
children who were in the hand-warming biofeedback group improved more than the com-
parison 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, specically
transformed migraines.
Vasudeva [35] conducted a study to examine whether migraine suerers who experienced aura
reacted dierently to biofeedback/relaxation than those without and if this was accounted for
by blood ow 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/con-
trol the pain. Furthermore, no association between biofeedback-assisted relaxation and blood
ow velocity was found. Therefore, this study provides corroborating evidence for the notion
that biofeedback is an eective 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 phar-
maceutical 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 dierent 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 neu-
rofeedback, 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—neu-
rofeedback oers the potential for signicant relief for anyone still struggling with migraines.
From some studies, in the electrophysiological activities of migraine suerers, there are cer-
tain abnormalities, so it is understandable that interventions using EEG may be benecial
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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 signicant
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 hemo-
encephalography (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 reects the composite thermal activity generated by vascular
supply, vascular return, and brain cell activity. Changes of the heat signal from the under-
lying prefrontal cortex reect 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].
According to relevant research, we started a combined biofeedback treatment as a combina-
tion of three forms of biofeedback treatment: neurofeedback, breathing, and vascular bio-
feedback. 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:
• Analyses of medical documentation (conducted diagnostic and therapeutic procedures).
• Structured interview.
• Measuring of baseline EEG (one channel, Cz).
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 eectiveness of neurofeedback
that we have been able to see in improving performance as well as at some diculties during
Biofeedback10

our decades of use, we thought that it is a good choice to work with a migraine. After neu-
rofeedback, 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 vaso-
dilation and relaxation of the whole body by stimulating the parasympathetic action of the
autonomic nervous system. Subsequently, we have been using vasoconstriction-vasodila-
tion 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 train-
ing sessions at the same time was to prompt positive changes in pain reduction as well as
migraine rates.
The reason for choosing that particular way of training (neurofeedback, breathing, vasocon-
striction training) was to have one relaxation training between two dicult 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 vasocon-
striction training, but we did not consider it necessary to include it because the eectiveness
of the training achieves vasodilation, that is, a certain blood ow, which also increases the
peripheral temperature. Of course, it would be useful to put the sensor in peripheral tempera-
ture for future research. We did not use EMG biofeedback, it was not necessary in this par-
ticular 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 inhib-
ited 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.
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Implementation of biofeedback included vascular training which means 25 sessions of vas-
cular 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 1. Vascular training with BVP sensor on a. temporalis (session 2).
Figure 2. Vascular training with BVP sensor on a. temporalis (after 1 month).
Biofeedback12

5.1. Breathing technique
Breathing is a willing and reluctant function, which means we can, but we do not have to
pay aention 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 inuence. It is
controlled by an autonomic nervous system that manages various functions in the body and
is often not recognized or aected by them.
How then to aect the function of breathing? Breathing can be controlled by a conscious mecha-
nism of breathing an aempt 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
benet. 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 aects a person, we
need to look at the vascular system that is also aected 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 blood-
stream and are caused by the sympathetic and parasympathetic autonomic nervous system.
The rst 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 eect, breathing
is slower, which most commonly occur during rest and sleep without our inuence. For the
body to function normally, it is necessary to balance both systems.
Figure 3. Vascular training with BVP sensor on a. temporalis (after 3 months).
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Experts engaged in the vascular system of research have found that reducing cardiac vari-
ability leads to a greater inclination to the bloodstream disease, and deaths are also more
common. Also, biofeedback use aims to increase heart rate variability by using breathing tech-
niques. So, breathing is a tool that we use not only to relax but to inuence the well-being
of the bloodstream system. The breathing used in the training itself is breathing with the
diaphragm (breathing with belly) that breathes the lowest part of the respiratory system—the
diaphragm—as we show in Figure 4.
Breathing training at a migraine was used by breathing with the diaphragm in the duration of
minimum 10 min at one session. The person had instructions to use this breathing also at home at
least once a day taking care that the breathing is taking place without the inuence of external dis-
tractors. Breathing technique is a recommended method for relaxation and to reduce stress which
is important for people with a migraine. Breathing with the diaphragm is the healthiest breathing
we can use. The aim is to provide the best possible exchange of oxygen and carbon dioxide. The
body of the belly breathing curves upward, so that the lower part of the chest is enlarged and the
lower part of the lung lls with air, as the belly breathes. With this breathing, we get a full eect:
the fullness of the ribs, the bones, the spine, and the scurvy and thus the higher lung capacity.
In people who are often aected by dierent stressors, the use of breathing techniques is
of utmost importance. Breathing encourages the parasympathetic action of the autonomic
nervous system that slows down and relaxes our body. Breathing is a mechanism that aects
HRV and changes that will lead to optimum functioning of the individual.
The daily use of breathing with the diaphragm for at least 10 min leads to the stimulation of
protective mechanisms in our body and the creation of so-called protective “receptors” that
protect the body from long-term adverse eects of stress. Below is a detailed description of
breathing by using the diaphragm.
5.2. Instruction for breathing training—10 min
1. Take a comfortable position and remove anything that sticks around you.
2. Relax the upper body muscles (face, neck, shoulders, upper back, arms).
Figure 4. “Breathe in” with the diaphragm.
Biofeedback14

3. If you are feeling comfortable, place your palms on the belly, at the height of the navel.
4. Close your eyes and relax your body.
5. Slowly breathe through your nose counting in yourself by three, inating your belly as if
you were blowing a balloon (Figure 5).
6. Try to keep the rest of the body relaxed and not lift it up.
7. It is important that you take as much air as is enough to ll your belly.
8. When you are breathing out, open your mouth slightly, and slowly exhale by counting to
six (until you breathe all the air) (Figure 6).
Only the body will stimulate your next breath and repeat the cycle. Exercise at least once a
day. You can use it several times if you feel the need for relaxation.
6. Results and discussion
According to the treatment of the person with a migraine, we have done a total of 25 treat-
ments. Three modalities were used at each treatment: neurofeedback, vascular training,
and breathing techniques. Duration of one treatment was 1 h and 30 min. The training
sessions were done 2–3 times per week. The results were a reduction in the frequency of
migraine aacks, as well as a reduction in pain severity during the aacks. The reduction
in the frequency of migraine aacks and in the strength of pain was gradual. In September,
Figure 5. Slowly “breathe in” through your nose about 3 seconds and inate your belly such as balloon.
Figure 6. With open mouth slightly, and slowly exhale by counting to six (until you out all the air).
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the person had nine migraines, with pain ranges between 8 and 9. In October, the person
had six migraine aacks (3 less), pain strengths from 5 to 8. In November there were ve
migraine aacks, with a pain score from 2 to 7. In December the number of migraine aacks
was four, which is a reduction in frequency by more than 50% since the beginning of the
training in September. The pain strength was from 3 to 5, which is also a reduction of more
than 40% from September. The person learned to apply the vasoconstriction method when
she was experiencing migraine, which reduced the strength of the pain. Also, breathing
technique became normal training used daily. The ecacy of biofeedback is evident in the
application of the method, for the reduction of a migraine as well as pain relief. Within
4 months of treatment, the person had fewer migraine aacks, and the pain was reduced to
such extent that it did not require the use of analgesics. Our experience has shown that it is
important to take a good initial assessment and know all relevant information of a migraine
as well as to the person itself and to agree with the person on possible treatment goals as
well as the incidence of arrivals. The emphasis is on the motivation of the person as well
as encouraging motivation, which is always it happens as the frequency and strength of
headaches are reduced.
7. Conclusion
Our case study has shown the good curative potential of biofeedback and neurofeedback
treatments at a migraine. We conrmed earlier research results that dierent types of bio-
feedback methods could have some benets to people with migraine. Also, we gave some
our way of training. Combination of treatments (neurofeedback, breathing, and vascular
training) in 25 sessions helped the female patient with a long history of a severe migraine.
Further research of patients suering from migraine with dierent treatment protocols
is needed to establish the method. Therefore, a comprehensive approach to solving this
problem is very important, and education, to both the general population and the patients,
and the raising of health care to a higher level, with ongoing support for patients suering
from a migraine, are indispensable for the formation of a healthier society. Combination of
pharmacologic and behavioral treatments such as relaxation training and cognitive behav-
ior therapy can lead to faster and beer results with people who suer from migraine
[43, 44]. Empirically validated behavioral treatments include biofeedback training; relaxation
training, combinations of the two, stress management training, and cognitive behavioral
therapy could be helpful for people with migraine headache. According to earlier research
and our case, we could have recommended a dierent type of biofeedback methods such
as temperature, vascular training, neurofeedback, HEG, and EMG biofeedback. The choice
is depending on therapist and client with migraine. Migraines as a disease with many faces
need the multidisciplinary and combined approach which provides the possibility of faster
achievement of the goals of a therapist and a person with a migraine, which are a reduction
pain and the number of migraines. By achieving these goals, we enable a person to have a
good and quality life.
Biofeedback16

Author details
Ivana Zivoder1,2*, Sanja Martic-Biocina3 and Ana Vodanovic Kosic2
*Address all correspondence to: ivana.zivoder@gmail.com
1 Department of Nursing, University North, Varazdin, Croatia
2 Mens Sana d.o.o., Zagreb, Croatia
3 Psychiatric Clinic Vrapce, Zagreb, Croatia
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