Biofeedback and cognitive behavioural approaches to migraine: what we know and what we don't

“The neurologist told me to see a psychologist as well. I could almost hear the chair creak behind me as I stood up. As if I were making the migraine up.”

I hear this sentence often, in different versions. Someone who has had migraine for years has tried all sorts of things, spent countless days in a darkened room, and finally received a diagnosis confirming that the pain is not imagined. Then the doctor refers them to someone who works with thoughts and feelings. It is understandable that this sounds like a step backwards — as if they were back at the beginning, where people told them to worry less.

In fact it is exactly the other way round. Being referred for psychological treatment in migraine does not mean the illness is psychological. It means the doctor knows the research. In this post I will explain what biofeedback and cognitive behavioural approaches to migraine are, what we know about them and what we do not — and where they fit alongside the treatment your doctor leads.

First: migraine is a neurological disease

I want to be clear, because this is where things often get stuck. Migraine is not a psychosomatic symptom. It is a neurological disease with a hereditary basis, in which the brain is more sensitive to changes in the body and the environment. According to the largest global study of disease burden, roughly one person in seven has it, and it is among the illnesses that take the most healthy years of life from people.

Diagnosis is made and treatment is led by a doctor — your GP and, for frequent or difficult attacks, a neurologist. I do not write about medication in this post; that is not my field, and it is something you decide with your doctor. Biofeedback and cognitive behavioural approaches are not a replacement for that treatment. They are an additional branch that works at the other end: on how the body reacts to strain, how you think about pain and how you live with the illness.

I wrote about relaxation techniques you can learn yourself in What helps with migraine besides medication: relaxation techniques with evidence. Here I continue with two approaches that are usually led by a professional. I should also say this: I do not provide biofeedback or cognitive behavioural therapy myself. My training is in relational family therapy. I write about them because they are among the best-researched psychological approaches to migraine, and because you deserve to know they exist.

What biofeedback is

The word means something like “feedback about the body”. A sensor is attached to your body to measure a bodily process — finger temperature, muscle tension, heart rhythm — and a computer shows it to you in real time as a graph, a sound or a colour on the screen. Meanwhile you try to change that process: warm your hands, soften your forehead, steady your pulse. Because you can see what works as it happens, you learn much faster than you would without the device. The goal is that, over time, you can do the same without it.

Biofeedback for migraine had an interesting beginning. In the late 1960s, researchers at the Menninger Clinic in the United States noticed that a participant who had learned to warm her hands also found her headache easing during practice. This led to thermal biofeedback — hand-warming training — which is still the most researched form in migraine today. When the nervous system calms, the blood vessels in the hands widen and the fingers warm up. Finger temperature is therefore a good, visible marker of calming down.

Two other forms are also used: EMG biofeedback, which measures muscle tension in the forehead, neck and shoulders and is well supported especially in tension-type headache, and heart rate variability biofeedback, which is linked to calming via the vagus nerve. I briefly explain what vagal tone means and why it matters under vagal tone. This form has been studied less in migraine than thermal and EMG biofeedback.

What we know about biofeedback in migraine

The most comprehensive review of the research was published in 2007 by Yvonne Nestoriuc and Alexandra Martin. In a meta-analysis they pooled studies of biofeedback in migraine and found a medium-sized effect: after training, people had noticeably less frequent attacks, and the effect held over follow-up periods of several months after training ended. A year later, in a broader review with colleagues, they concluded that biofeedback for migraine and tension-type headache meets the criteria for an efficacious treatment.

That is encouraging, but it is also worth knowing what the research does not tell us. Most studies are small and older, and many were carried out when the medicines for preventing migraine were different from today’s. It is not entirely clear how much of the effect came from the device itself and how much from the fact that a person regularly stopped, calmed down and paid attention to their body. Some researchers believe part of the effect lies in a sense of control: when you see that you can change your body at least a little, the helplessness that migraine brings is reduced.

In Slovenia, biofeedback is not available everywhere. If you are interested, it is best to ask your GP or neurologist whether it is offered anywhere near you — and to be cautious about offers promising that your migraine will “disappear”. No serious research promises that.

Cognitive behavioural approaches: what is actually done

Cognitive behavioural therapy (CBT) is a structured approach that works with the links between thoughts, emotions, bodily reactions and behaviour. In migraine it does not try to convince a person that they are not in pain. A programme usually includes several parts:

• Self-monitoring. A diary of attacks, sleep, meals, stress and thoughts, from which patterns emerge.
• Relaxation skills. Often progressive muscle relaxation or breathing, sometimes combined with biofeedback.
• Working with thoughts. Recognising thoughts that ramp up tension — “it’ll ruin the week again”, “I mustn’t cancel”, “I have to finish everything before it gets me”.
• Handling triggers and rhythm. Regular meals, sleep, breaks — and thinking through which triggers are really worth avoiding.
• A plan for attacks. What you do at the first signs, so that an attack does not take you by surprise and wreck the whole day.

On triggers, the Australian psychologist Paul Martin made an interesting point: strictly avoiding every possible trigger may, in the long run, increase sensitivity to them and shrink your life. It does not apply to every trigger or to everyone, but the idea is worth considering — much as with anxiety, where avoidance helps today and fences in your life tomorrow.

Anyone who knows cognitive behavioural therapy for insomnia (CBT-I) will recognise a similar logic: the work is not about making the symptom disappear through willpower, but about changing the habits and thoughts that keep it going.

What the research shows about CBT in migraine

One of the best-known studies was carried out with children and adolescents with chronic migraine. In 2013, Scott Powers and colleagues published a randomised trial in JAMA in which all participants received the same medication prescribed by a doctor; half also had CBT, and the other half had education sessions about headache. By the end of treatment, 66 per cent of the young people in the CBT group had at least halved their number of headache days, compared with 36 per cent in the comparison group.

In adults, a well-known study is the one by Kenneth Holroyd and colleagues from 2010. People with frequent migraine received optimised treatment for attacks and then either a preventive medicine, a behavioural programme, both, or neither. The combination of preventive medicine and behavioural programme did best. The message matters: it is not a question of “pills or psychology”, but of the two approaches complementing each other. I wrote about a similar dilemma in anxiety in Therapy or medication for anxiety: what the research shows.

Thoughts about pain are not guilt, they are part of a cycle

When CBT works with thoughts, people often misunderstand it: as if they had to “think positive” and are in pain because they think the wrong way. That is not it. Migraine pain is real and thoughts do not create it. But it can be accompanied by thoughts that ramp up tension, fear and withdrawal — catastrophising is the technical term. Research on chronic pain shows that people who experience pain more catastrophically more often report greater disability — not necessarily stronger pain, but more of their life taken by it. There is more on this in migraine in Migraine and pain catastrophising: what the research shows.

Working with thoughts is not about arguing with them, but about noticing them as thoughts rather than facts. An approach I find especially close to my heart is described in How to notice a thought instead of following it: an introduction to cognitive defusion. The thought “I can’t bear this” can be loud and still not be a prediction.

When the doctor refers you “to a psychologist”

Let us go back to the sentence from the opening. The conversation might go something like this (a composite, not a real person):

“I don’t think he believes me. I think he thinks I’m oversensitive.”
“Did he tell you why he’s suggesting psychological help?”
“To help me with stress. But everyone has stress, and they don’t have migraine.”
“That’s true. And migraine didn’t come from stress. But what do you think happens to your stress when you live in fear of the next attack?”
“… It grows. More every week.”

That is the heart of it. Migraine is not caused by stress, but migraine itself is a major source of stress. Unpredictable attacks, cancelled plans, the feeling of being a burden to others, fear of the next attack — all of this creates tension that can add to the load. Psychological treatment steps into exactly that cycle. Not because the cause is in your head, but because part of what you can influence is there.

Exercise: from the first sign to your response

This is not CBT, but it is a simple exercise in the spirit of self-monitoring, which is part of every such programme. Do it for two to three weeks, after every attack or after every day when you felt something building up.

1. Write down when you noticed the first signs. The time, where you were, what you were doing. You are not looking for someone to blame, just recording.
2. Write down what was happening in the last few days. Sleep, meals, your menstrual cycle if relevant, workload, tension in relationships — and also whether stress had recently eased.
3. Write down your first thought at the first signs. Word for word, as it came: “No, not now”, “It’ll last three days again”, “I still have to finish this”.
4. Write down what you did. Did you act straight away as agreed with your doctor, push on, cancel plans, hide from others?
5. After two weeks, read it all together. Which pattern keeps repeating? Where could you do something differently next time — not to prevent the attack by willpower, but so that it takes less from you?

Your notes can also be valuable for your doctor. You will find a short tool for recording bodily reactions under diary of bodily signs.

Where these approaches are not the answer

They are not a substitute for medical care. If your attacks are frequent, getting worse or changing, or if you are taking medication for attacks more and more often, your first port of call is a doctor. A sudden, extremely severe headache, a headache with neurological symptoms such as weakness on one side of the body, speech problems or confusion, or a headache with fever and a stiff neck needs immediate help — call 112 (the emergency number in Slovenia and across the EU).

They do not help everyone. Research reports averages, and with every approach there are people for whom there is no effect or only a small one. That does not mean you did not try hard enough.

They are not always accessible. Biofeedback needs equipment and a trained practitioner, and CBT for migraine needs a therapist with experience in it. Waiting lists can be long. In the meantime there is a lot you can do yourself — you can start with notes and relaxation exercises.

They do not resolve everything migraine opens up. CBT focuses on symptoms and skills. If migraine has become something the family does not talk about, or a source of resentment between partners, or if it revives old experiences that your needs do not matter, that is work that reaches further.

Where I can help

As I wrote at the beginning, I do not provide biofeedback or CBT. As a marriage and family therapist in training under supervision, I work with another part of the story: how migraine lives in relationships and in the family. How to talk to a partner who does not understand why you are cancelling again. How not to feel like a burden. What to do with the fear of the next attack, which over time can become bigger than the attacks themselves. How attitudes to illness and rest are passed down in a family. This work does not replace a doctor or specialised psychological approaches — but it can complement them.

If you recognise yourself in this and would like us to talk about it, you are welcome to write to me. I also work with English-speaking clients, in person in Ljubljana. If you are looking specifically for biofeedback or CBT, the best place to start is a conversation with the doctor who is treating you.

What to remember

• Migraine is a neurological disease. Being referred to a psychologist does not mean you are making it up, but that your doctor knows the research.
• Biofeedback, especially thermal and EMG, has good evidence for migraine prevention; the effect comes with practice.
• CBT for migraine combines self-monitoring, relaxation, working with thoughts, rhythm and a plan for attacks.
• In research, the best results often come from a combination of psychological and medical treatment.
• Thoughts about pain are not guilt — they are part of a cycle you can influence.