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Badretal.
Egypt J Neurol Psychiatry Neurosurg (2025) 61:19
https://doi.org/10.1186/s41983-025-00947-8
RESEARCH
Ecacy ofelectromyographical (EMG)
andthermal biofeedback inmanagement
ofmigraine
Marwa Y. Badr1* , Elsayed A. E. Gad2, Hossam Eldin F. Alsawi2, Mohamed A. Abd El‑Hay2, Mohamed M. Pasha3,
Asmaa A. E. Belal1 and Fatma A. El Deeb2
Abstract
Background There are many effective treatments for migraine, ranging from medication to self‑help and behavioral
therapy. However, the treatment with medication only is not effective in many cases and has many side effects. There
is a need for other therapies combined with medication. This work aimed to evaluate the efficacy of EMG and ther‑
mal biofeedback in management of migraine in comparison with drugs. The study was conducted on 45 patient
with migraine diagnosed according to The International Classification of Headache Disorders 3rd edition. The patients
were divided into three matched groups: Group (A): 15 patients treated with drugs (propranolol) only. Group (B): 15
patients treated with EMG and thermal biofeedback therapy only. Group (C): 15 patients treated with both drugs
and biofeedback therapy. The patients were assessed before and after therapy by Migraine Disability Assessment
Scale (MIDAS).
Results Migraine Disability Assessment Scale (MIDAS) after 2.5 months of treatment was comparable between Group
I and group II and significantly higher in group I and group II than group III. EMG score was similar between group II
and group III at 1st session, 2nd session, 3rd session, 5th session, 7th session, 8th session, 9th session and 10th session
and higher significantly in group II than group III at 4th session and 6th session. EMG score increased in both groups
within time. Temperature score was comparable between both group II and III at all sessions.
Conclusions EMG and thermal biofeedback is effective treatment of migraine disorder.
with non‑significant difference in improvement from propranolol. EMG and thermal biofeedback combined with pro‑
pranolol are more effective than either of them alone in management of migraine.
Keywords Migraine, Electromyography (EMG), Thermal biofeedback, Propranolol
Background
Migraine is a throbbing or pulsing headache that is fre-
quently unilateral and linked with nausea, vomiting,
hypersensitivity to light, sound, and odours, disturbed
sleep, and sadness. Attacks are frequently repeated [1].
In Egypt, about 10.51% of people have migraines. e
female-to-male migraine patient ratio is 2.4:1, and it is
highest among people aged 20–40. Some individuals get
multiple headaches every month, while others encounter
only a few migraines in their lives [2].
Open Access
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The Egyptian Journal of Neurology,
Psychiatry and Neurosurgery
*Correspondence:
Marwa Y. Badr
drmoroneuro@yahoo.com
1 Neurology Unit, Neuropsychiatry Department, Faculty of Medicine,
Tanta University, Tanta, Egypt
2 Psychiatry Unit, Neuropsychiatry Department, Faculty of Medicine, Tanta
University, Tanta, Egypt
3 Neuropsychiatry, Ministry of Health, Cairo, Egypt
Page 2 of 8
Badretal. Egypt J Neurol Psychiatry Neurosurg (2025) 61:19
ere are many effective treatments for migraine, rang-
ing from medication to self-help and behavioral therapy.
However, the treatment with medication only is not
effective in many cases and has many side effects. ere
is a need for other therapies combined with medication
[3, 4].
Recent research supporting the efficacy of Electromyo-
graphy (EMG) and thermal biofeedback therapy in man-
agement of migraine [5]. Biofeedback is a technique in
which individuals are trained to enhance their health by
learning to manage involuntary body functions, such as
heart rate, muscle tension, blood pressure, and skin tem-
perature [6].
Biofeedback is a successful treatment for numerous
disorders, but it is mostly used to treat hypertension, ten-
sion headaches, migraines, attention deficit hyperactivity
(ADHD), depression and obsessive compulsive disorder
[7].
Many trials and studies were made about the effective-
ness of biofeedback in migraine therapy. A meta-analysis
showed that efficacy of EMG biofeedback in reduction of
migraine pain ranged between 45 and 65% [8].
is work aimed to evaluate the efficacy of electromyo-
graphy (EMG) and thermal biofeedback in management
of migraine in comparison with drugs.
Methods
is randomized open-label double-blind interventional
pilot study was carried out on 45 patients with migraine
diagnosed according to e International Classification
of Headache Disorders 3rd edition (International Head-
ache Society Criteria For Migraine, 2018), recruited from
outpatient clinic of Tanta University Hospital and Psychi-
atry, Neurology and Neurosurgery Centre, Tanta Univer-
sity [9]. e present work was conducted from April 2022
to December 2022. e patients’ informed written con-
sent was acquired after a full explanation of the benefits
and pitfalls of the procedure. e research was conducted
with the approval of the Tanta University Hospitals Ethi-
cal Committee (approval code: 35804/9/22).
Exclusion criteria Patients who could not read and
write because there are several tests on the apparatus
require literate ones. Patients with concomitant medi-
cal illness that may cause headache e.g. sinusitis, errors
of refraction and glaucoma. Patients who received any
behavioral treatment for migraine before to assess the
success of the current treatment.
Randomization and blindness: 45 cases were randomly
classified into three groups equally by a computer-gener-
ated sequence into opaque sealed envelopes. Group (A):
15 patients treated for the first time with beta blockers in
the form of propranolol. e dose ranged between 40 and
80mg with a mean of 60 ± 5mg/day. e duration was
two and half months.
Group (B): 15 patients submitted to management by
EMG and thermal biofeedback training; 10 sessions
ranged from 20 to 30min twice weekly. Group (C): 15
patients subjected to both propranolol (40–80 mg per
day for two and half months) and biofeedback train-
ing; 10 sessions ranged from 20 to 30min twice weekly.
e study was open-label due to different treatment
strategies.
All studied groups were submitted to the following
before and after treatment: clinical study: medical history
and examination. Assessment of severity of migraine by
Migraine Disability Assessment Scale (MIDAS) [10].
Biofeedback training was done in Psychiatry, Neurol-
ogy and Neurosurgery center of Tanta University. Appa-
ratus: e Flex Comp Infiniti encoder model 5A7550. e
Flex Comp Infiniti encoder is a ten-channel, multi-modal
machine for computerized real-time psychophysiology,
biofeedback, and data gathering. It features ten secured
sensor pin inputs. e Flex Comp Infiniti encoder is
able to provide a vast array of objective physiological
indicators utilised in ergonomics, observing in clinical,
and biofeedback, and can serve as a supplement to user
assessment, diagnosis, and rehabilitation, Fig.1 [11, 12].
Procedure of EMG biofeedback training (Fig. 2): the
sessions were conducted in a 3 × 5 square meter room
that was poorly illuminated throughout training. e
individual was seated in a semi-recumbent position in a
comfortable reclining chair. Explain to the patient how
biofeedback training proceeds. Frontalis muscle was used
for biofeedback training. Swab the electrode sites with
alcohol. e two active electrodes were attached in the
approximate center of the forehead 46 mm above a hori-
zontal template reference line that intersected the mid-
line of each subject’s pupils, and 40mm to either side of a
vertical midline nose reference. A single ground or refer-
ence electrode was attached midway between the active
horizontal electrodes.
After that we instruct the subject to relax for about
5min before we do the training to get the base line of
the subject. We provide the subjects with a variety of
relaxation techniques from which they can select as: in
calming imagery, the patient imagines a pleasing scene.
is sentence is repeated over and over again; it contains
soothing terms. e most helpful phrases are those that
patients come up with on their own.
During deep breathing, the patient closes his or her
eyes and focuses on relaxed, slow, and fairly deep dia-
phragmatic breathing while repeating a relaxing word
like ‘‘relax’’ or ‘‘peaceful’’ while exhaling. Some patients
report that concentrating on a colour or really play-
ing a game in their head, like cards or basketball, helps
Page 3 of 8
Badretal. Egypt J Neurol Psychiatry Neurosurg (2025) 61:19
to reduce muscle tension. Each session consists of
20–30min as other world research as follows: 5min to
prepare the patient. 10–15 min for muscle relaxation
Training recording. 5min for relaxation. Number of ses-
sions: twice weekly for 5weeks, i.e., total sessions were
10.
Procedure of thermal biofeedback training (Fig.3): the
sessions were conducted in a 3 × 5 square meter room
that was poorly illuminated. e subject was seated in a
comfortable reclining chair in a semi recumbent position.
Explain to the patient how biofeedback training pro-
ceeds. e temperature sensors attached to the palmar
or dorsal surface of any finger. e patient was told to
try to rise the temperature of his extremities by imagin-
ing that he is in a sunny place, and he is getting sweaty or
take a hot path or in a hot river. Each session consists of
20min as follows: 5min for prepare the patient. 10min
for increasing temperature training, 5min for relaxation.
Number of sessions: twice weekly for 5weeks, i.e., total
sessions were 10.
Fig. 1 Biofeedback apparatus
Fig. 2 EMG biofeedback training
Page 4 of 8
Badretal. Egypt J Neurol Psychiatry Neurosurg (2025) 61:19
e primary outcome was the mean values of Migraine
Disability Assessment Scale (MIDAS) among the studied
groups of patients with migraine before and after 1 and
half months of follow-up. e secondary outcomes were
measurements of Electromyography (EMG) score and
temperature score.
e sample size computation was done by G *
Power3.1.9.2 (Universitat Kiel, Germany). We performed
a pilot study (five cases in each group) and we set up that
the mean (± SD) of MIDAS after two and half months in
follow-up was11.9 ± 2.55 in Group I, 10.5 ± 3.27 in Group
II and was8.1 ± 2.63 in Group III. e sample size was
based on the following considerations: 0.52 effect size,
95 confidence limit, 80 power of the study, group ratio
11 and two cases were added to each group to overcome
dropout. thus, we signed 15 cases in each group.
Statistical analysis was done by SPSS v27 (IBM ©,
Armonk, NY, USA). Shapiro–Wilks test and histograms
were operated to assess the normality of the allocation
of data. Quantitative parametric data were presented
as mean and standard deviation (SD) and compared
between both groups employing unpaired student t test
and compared between the three groups using ANOVA
(F) test with post hoc test (Tukey). Qualitative variables
were presented as frequency and percentage (%) and
analyzed using the Chi-square test or Fisher’s exact test
when applicable. A two-tagged P value < 0.05 was consid-
ered statistically significant (13,14).
Results
Demographic results: Age and sex were insignificantly
different between the 3 groups, Table1.
Migraine Disability Assessment Scale (MIDAS) results:
MIDAS before treatment was insignificantly different
among the 3 groups. MIDAS after 2.5 months of treat-
ment was insignificantly different between Group I and
group II and significantly higher in group I and group II
than group III (P value = 0.003 and 0.031, respectively),
Table2.
EMG and temperature scores results: EMG score
was insignificantly different between both groups(II,
III) at 1st session, 2nd session, 3rd session, 5th session,
7th session, 8th session, 9th session and 10th session
and significantly higher in group II than group III at
Fig. 3 Thermal biofeedback training
Table 1 Demographic information of the studied groups
Information are displayed as mean ± SD or frequency (%)
Group I (n = 15) Group II (n = 15) Group III (n = 15) P value
Age (years) 27.5 ± 6.79 32.3 ± 5.28 28.6 ± 5.87 0.089
Sex Male 6 (40%) 8 (53.33%) 9 (60%) 0.537
Female 9 (60%) 7 (46.67%) 6 (40%)
Page 5 of 8
Badretal. Egypt J Neurol Psychiatry Neurosurg (2025) 61:19
4th session and 6th session (P value = 0.047 and 0.024,
respectively). ere was a gradual decrease in EMG
score during biofeedback training in both groups II and
III with significant difference which means improve-
ment (P value < 0.001), Fig.4.
Temperature score was insignificantly different
between both groups at 1st session, 2nd session, 3rd
session,4th session,5th session, 6th session, 7th ses-
sion, 8th session, 9th session and 10th session. ere
was a gradual increase in temperature score during
biofeedback training in both groups II and III which
means improvement with significant difference p: 0.001
(p < 0.05), Fig.5.
Mean change between 1st session and 10th session
of EMG score was insignificantly different between
Group II and Group III (P value = 0.731). Mean change
between 1st session and 10th session of temperature
score was significantly higher in group III than group II
(P value = 0.033), Table3.
Discussion
Migraine remains the second leading cause of disability
worldwide [1]. Inappropriate management of migraine
attacks has a significant socioeconomic impact and also
raises the likelihood of chronic types of migraine [15].
e cases were assessed before and after treat-
ment by MIDAS. After treatment, MIDAS scores were
taken as quantitative measurements of improvement
of migraine patients. Results were consistent with the
clinical finding and showed that improvement occurred
in the three groups of patients where there was insignif-
icant difference between patients treated by proprano-
lol (group I) and those treated by biofeedback (group
II).
Patients received both types of treatment (group III)
showed more significant improvement, and this was
supported by Sovak and colleagues [16] who made a
comparison between propranolol treatment against
thermal biofeedback (8–10 sessions) with autogenic
Table 2 MIDAS before and after two and half months in follow‑up of the studied groups
* Signicant as P value ≤ 0.05, Information are displayed as mean ± SD, MIDAS migraine disability assessment scale
Group I (n = 15) Group II (n = 15) Group III (n = 15) P value Post Hoc
Before treatment 17.9 ± 3.52 21.3 ± 4.42 19.7 ± 4.06 0.079
After 2.5 months
of treatment 11.9 ± 2.55 10.5 ± 3.27 8.1 ± 2.63 0.002* P1 = 0.201
P2 = 0.003*
P3 = 0.031*
Fig. 4 EMG score during sessions of biofeedback for migraine patients in group II and group III
Page 6 of 8
Badretal. Egypt J Neurol Psychiatry Neurosurg (2025) 61:19
training. ere was a reduction of 50% in migraine fre-
quency, severity, and duration.
erapeutic efficacy of migraine treatment was
enhanced by and equivalent to both treatments (drugs,
biofeedback). Our results were supported by a study
done by Grazzi, and colleagues.[17], who suggested that
the utilization of biofeedback (thermal and EMG) com-
bined with pharmacological treatment was more efficient
than drugs only in migraines management. In their study,
61 patients were categorised as having ‘‘transformed
migraines,’’. ese participants were randomly assigned to
either a medication-plus-biofeedback group or a medica-
tion alone group. At the third year of monitoring, partici-
pants in the medication group had a relapse rate of 42.1%
(16 of 38) compared to 12.5% (2 of 16) in the medication
combined with biofeedback group.
Analysis of the results showed that in group I (treated
by propranolol HCL only) improvement was about 40%
and this agreed with Linde and colleagues [18] who
stated that there was a strong evidence that proprano-
lol was more effective than placebo for the treatment of
migraines in the short term. Propranolol appeared to be
as effective and safe as other migraine prevention medi-
cations [18].
On the other hand, Lipton and colleagues [19] stated
that it became clearly apparent, that drugs were not ther-
apeutically successful in every patient and that responses
depend in part at least, on factors other than the drugs
itself.
In this study, results of group II (EMG and thermal
biofeedback) improvement were about 45% and this was
in agreement Gray and colleagues [20] who stated that
deep muscle relaxation was accompanied by a decrease
in autonomic arousal levels and the achievement of a
deep muscle relaxation state generally resulted in unique
and pleasurable states that were highly motivated and
reinforcing.
Also, Claghom and colleagues [21] reported that ther-
mal biofeedback was effective in regulating regional cere-
bral blood flow in patients with migraine. Twelve sessions
on 58 patients with migraine, twice sessions per week
with follow-up for 6months show reduction of headache
activity by 55%.
On studying group III [managed by both electromyo-
graphy (EMG) and thermal biofeedback and propranolol]
improvement was about 60%. Two studies assessed the
advantages of combined propranolol with the thermal
Fig. 5 Temperature score during sessions of biofeedback for migraine patients in group II and group III
Table 3 Mean change between 1st session and 10th session of
EMG and temperature score of the studied groups
* Signicant as P value ≤ 0.05, Information are displayed as mean ± SD, EMG
score: electromyography score
Group II (n = 15) Group III (n = 15) P value
EMG score 1.87 ± 2.39 2.13 ± 1.77 0.731
Temperature score 0.87 ± 2.92 2.8 ± 1.61 0.033*
Page 7 of 8
Badretal. Egypt J Neurol Psychiatry Neurosurg (2025) 61:19
biofeedback/relaxation training. Olness and colleagues
[22]. e researchers investigated the efficacy of ther-
mal biofeedback training with and without propranolol
(60–180mg/dl). Propranolol significantly improved the
efficacy of thermal biofeedback training on measures of
migraine activity, analgesic medication utilisation, and
quality of life.
On the contrary of this study, Holroyd and colleagues
[23] found that, propranolol HCL alone was more effec-
tive than biofeedback training, and the combined treat-
ment was roughly as effective.
Our results showed that EMG biofeedback was ben-
eficial in treatment of migraine and this effect could be
explained by one of the three assumptions: first, it was
efficient for teaching deep muscle relaxation. It had been
found that EMG biofeedback training was comparable
or even superior to conventional relaxation techniques
for creating muscular relaxation in normal subjects and
migraine patients [24, 25]. e second hypothesis is that
the effect of EMG biofeedback-assisted relaxation would
extend to muscle groups other than those for which bio-
feedback was provided and/or to other response sys-
tems that represented generally calmness [26]. ird, it
was assumed that successful EMG biofeedback-assisted
relaxation training would result in the development of an
antistress responses. e notion was that when a person
was confronted with a stressful circumstance, he or she
would be able to utilise relaxation techniques to counter-
act the arousal [27].
ere are several limitations in this study; first, the
time period of this study was relatively short. Migraine is
a disease with a variable course in which symptoms wax
and wane, and psychophysiological treatment may have
a delayed effect; hence, we require a longer length for
follow-up. Second, our sample size was relatively limited
and did not adequately represent the migraine commu-
nity as a whole. ird, the absence of a biofeedback con-
trol group. Finally, we did not know exactly if biofeedback
training affects frequency or severity of migraine. We
expect that this study will create interest in doing larger-
scale controlled investigations of non-invasive neuro-
therapies for the treatment of migraine and other chronic
and/or progressive illnesses.
Conclusion
As with medications, EMG and thermal biofeedback
treatment was found to alleviate headaches in migraine
patients. ese findings indicate that biofeedback may be
an effective nonpharmacological treatment for migraine
patients and thus decrease the need for pharmacological
treatment and its side effects and improve the quality of
life.
Abbreviations
EMG Electromyography
MIDAS Migraine disability assessment scale
Acknowledgements
The authors thank all patients for giving consent for publication of the data
and the healthy control subjects for participation in this study.
Author contributions
FE conceptualized the study. EG, HA, MA, MP, AB and MB have given inputs in
study design. FE collected the information. MB analyzed the information and
composed the primary draft of the manuscript and all co‑authors contributed
to the basic review of information analysis and manuscript composing. MB
will act as a guarantor for this paper. All authors have examined and asserted
the manuscript.
Funding
This research did not get any particular grant from funding organizations in
the public, commercial, or not‑for‑profit divisions.
Availability of data and materials
All information created or analysed during this study is included in this pub‑
lished article [and its supplementary data records].
Declarations
Ethics approval and consent to participate
The study protocol followed was reviewed, approved by the Research Eth‑
ics Committee of Faculty of Medicine, Tanta University have hence been
performed in agreement with the moral standards laid down within the 1964
Affirmation of Helsinki. A detailed clarification about the study was given by
the principal investigator after which they gave consent for publication. All
the patients included in this research gave composed informed consent to
publish the information contained in this study. All moral standards were kept
up. Any unexpected risks that showed up during the research will be clarified
to the subjects and the moral committee on time. There were satisfactory
measures to keep the security of members and privacy of the data. Ethics
approval code 35804/9/22.
Consent for publication
Written informed consent for publication was obtained by all patients
included in this study.
Competing interests
The authors announced that they have no known competing budgetary
interface or individual connections that might have shown up to impact the
work detailed in this paper.
Received: 3 January 2024 Accepted: 10 March 2025
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