Acceptance and commitment therapy for high frequency episodic migraine without aura: Findings from a randomized pilot investigation.

OBJECTIVE: We compared the incremental effects of adding acceptance and commitment therapy (ACT) to pharmacological treatment as usual (TAU) in a sample of patients with high frequency episodic migraine without aura (HFEM), assessing impact on a spectrum of measures across multiple domains. BACKGROUND: Patients with HFEM are at risk of developing chronic migraine and medication overuse headache. ACT has been shown to be effective for the treatment of various chronic pain conditions, but little attention has been given to its therapeutic value in the management of recurring headaches. METHODS: In this single-blind (masking for outcome assessor), open-label, randomized clinical trial, 35 patients with HFEM, with a monthly headache frequency ranging from 9 to 14 days, were recruited at the headache center of C. Besta Neurological Institute and randomized to either TAU (patient education and pharmacological prophylaxis; n = 17) or TAU + ACT (n = 18). Patients assigned to the combined treatment arm additionally received six 90-min weekly group sessions of ACT therapy and two supplementary "booster" sessions. All patients were on a stable course of prophylactic medication in the 3 months prior to initiating either treatment. Monthly headache frequency served as the primary outcome measure, with all other data collected being considered as secondary measures (medication intake, disability, headache impact, anxiety and depression, catastrophizing, allodynia, cognitive inflexibility, pain acceptance, mindful attention and awareness). RESULTS: A total of 35 patients were enrolled: 17 randomized to TAU, of whom three dropped out, and 18 to TAU + ACT (no dropouts in this group). Headache frequency and medication intake decreased in both groups over 12 months, with patients in the TAU + ACT group showing statistically significant reduction earlier, that is, by month 3. Headache frequency was reduced by 3.3 days (95% CI: 1.4 to 5.2) among those randomized to ACT + TAU, whereas it increased by 0.7 days (95% CI: -2.7 to 1.3) among those randomized to TAU only (p = 0.007, partial η2  = 0.21), the difference being 4 days (95% CI: 1.2 to 6.8). Medication intake was reduced by 4.1 intakes (95% CI: 2.0 to 6.3) among those randomized to ACT + TAU and by 0.4 intakes (95% CI: -1.8 to 2.5) among those randomized to TAU only (p = 0.016; partial η2  = 0.17), the difference being 3.8 intakes (95% CI: 0.7 to 6.8). At 6 and 12 months, the variations were not different between the two groups for headache frequency and medication intake. The opposite was found for measures of headache impact and pain acceptance, where the differences over time favored patients allocated to TAU. Both groups improved with regard to measures of disability, anxiety and depression, catastrophizing, and cognitive inflexibility, whereas measures of allodynia and pain acceptance were stable over time. CONCLUSIONS: Our preliminary findings indicate that supplementing TAU with ACT can enhance the main clinical outcomes, namely headache frequency and medication intake of patients with HFEM.

The Buteyko breathing technique in children with asthma: a randomized controlled pilot study.

BACKGROUND: Evidence supports the Buteyko breathing technique (BBT) as reducing medication and improving control and quality of life in adults with asthma, but having minimal impact on spirometry. For children with asthma, evidence addressing the utility of BBT is sparse. We evaluated the effectiveness of BBT in managing various aspects of asthma in children. METHODS: Thirty-two children with partly controlled asthma (age 6-15 years, 66% male) were randomized to either Treatment as Usual (TAU) or TAU combined with Buteyko training (Buteyko group, BG). Children in the BG received an intensive five-day training followed by three months of home practice. Primary outcome was bronchodilator reduction. Secondary outcomes were changes in physiological parameters FEV1_AR (at rest), FEV1_ER (after ergometry), FEV1_BR (after bronchospasmolysis), corticosteroid use, FeNO, SpO2, breath-hold test and questionnaire data [Asthma Control Questionnaire and Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ)]. All measures were collected at Baseline and a three-month follow-up. RESULTS: For the primary outcome, no significant between-group difference was found. Regarding the secondary outcomes, children receiving treatment augmented with BBT revealed significantly greater improvement at the follow-up than those receiving TAU for FEV1_AR (p = .04, d=-0.50), FEV1_ER (p = .02, d=-0.52), and the emotional function subscale of the PACQLQ (p < .01, d = 1.03). No between-group differences were found for the remaining secondary measures of outcome. CONCLUSIONS: Our preliminary findings suggest that the addition of BBT to treatment as usual for children with asthma enhances outcomes with respect to spirometry and parental emotional function but does not lead to reductions in medication, at least over the short term.

Effectiveness of mindfulness by smartphone, for patients with chronic migraine and medication overuse during the Covid-19 emergency.

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Behavioral Interventions for Migraine.

Biobehavioral interventions for migraine incorporate both physiologic and psychological factors. This article details treatments for migraine management and prevention, ranging from traditional to newly emerging interventions. Similarly, this article reviews key person-related factors that may affect migraine prevalence and management. Aspects related to patient-physician relationships and communication are also reviewed. Research involving childhood and adolescent migraine is reviewed, and special considerations regarding this population are summarized. Clinical trials and other studies have provided evidence that these behavioral interventions, when combined with pharmacotherapy, show a marked improvement in primary treatment outcomes, such as a decrease in headache frequency and duration.

A prospective pilot study of the effect on catecholamines of mindfulness training vs pharmacological prophylaxis in patients with chronic migraine and medication overuse headache.

AIM: To address whether, in patients with chronic migraine and medication overuse headache, mindfulness-based treatment is associated with changes in plasma levels of catecholamines and elusive amines that are similar to those observed in patients undergoing pharmacological prophylaxis. METHODS: In this non-randomized, clinic-based effectiveness study, patients aged 18-65, with a history of chronic migraine ≥ 10 years and overuse of triptans or non-steroidal anti-inflammatory drugs ≥ 5 years, were enrolled. Upon completion of a structured withdrawal program, patients received either pharmacological prophylaxis or six weekly sessions of mindfulness-based treatment and were followed for 12 months. Daily headache diaries were used to record headache frequency and medication intake; catecholamines (noradrenaline, epinephrine and dopamine) and levels of elusive amines were assayed from poor platelet plasma. RESULTS: Complete follow-up data were available for 15 patients in the pharmacological prophylaxis-group (14 females, average age 44.1) and 14 in the mindfulness treatment-group (all females, average age 46.4), and all variables were comparable between groups at baseline. At 12 months, significant improvement ( p < .001) was found in the pharmacological prophylaxis group for headache frequency and medication intake (by 51% and 48.7%, respectively), noradrenaline, epinephrine and dopamine (by 98.7%, 120.8% and 501.9%, respectively); patients in the mindfulness treatment-group performed similarly. For elusive amines, no longitudinal changes were found. CONCLUSIONS: The similar improvement trends observed in the two groups of patients further support the utility of mindfulness-based treatment in migraine care, and reinforce the hypothesis that alteration and normalization of tyrosine metabolism are implicated in migraine chronification and in remission of chronic migraine.

Self-Myofascial Vibro-Shearing: a Randomized Controlled Trial of Biomechanical and Related Changes in Male Breakdancers.

BACKGROUND: This randomized controlled trial explored the practicality and effectiveness of a novel tool-assisted self-help device, one that combines vibrational oscillation, leverage, and the shearing effect from the edges, for promoting meaningful changes in key biochemical tissue indices and related parameters. METHODS: One hundred and thirteen male breakdancers were randomized to an intervention or control group. Individuals assigned to the intervention group performed the self-help treatment on the quadriceps and the iliotibial band of their right thighs for 8 min, while individuals assigned to the control condition merely sat quietly during this period. Various primary outcome measures (e.g., elasticity, stiffness, range of motion, pain pressure threshold sensitization, and blood flow) were assessed before and after the intervention for each participant, with position and posture being standardized throughout. Subjective sensations and a measure selected to assess for potential experimental demand effects, serving as secondary measures, were also administered pre- to post-treatment. RESULTS: Stiffness was significantly reduced for both structures (p < 0.001), elasticity and flexibility of the quadriceps were increased significantly (p < 0.001 for each), sensitization was significantly lessened (p < 0.001), and local temperatures increased to a significant degree as well (p < 0.001) when comparing change scores following application of the self-help tool on the treated thighs to those on the untreated thighs. Participants using the self-help tool reported their treated leg as being more relaxed, light, and stable. CONCLUSIONS: The vibro-shearing manipulation with a muscle-fascia tool resulted in significant improvements in various objective mechanical tissue properties, range of motion, and pain desensitization in healthy, well-conditioned dancers. These promising effects for a new tool-assisted self-treatment indicate further basic investigations are warranted, as are pilot investigations with patient populations.

Behavioral therapy: emotion and pain, a common anatomical background.

Emotion and pain are closely intertwined in the brain, as the human experience of pain includes both affective and nociceptive components. Although each of these components relies on a different system in the brain, the two systems converge on the anterior cingulate and insular cortices, which interact with the prefrontal cortex and other frontal structures to influence behavior. Both emotional and physical pain elicit activity in these common areas, and conditions that affect one system (e.g., drugs, neural plasticity) may affect the function of the other-ultimately altering the experience of pain. Changes in these areas and their connections may even contribute to the chronification of pain. This relationship should not be overlooked in the treatment of painful conditions, including headache. Nonpharmacological therapies, such as cognitive behavioral therapy, yoga, biofeedback, and meditation, that are often used for enhancing emotional regulation, are increasingly being turned to for augmenting management of migraine and pain. Because of the overlap between emotion and pain, these therapies are likely acting through similar mechanisms, and emotional cues can be sensitive indicators of treatment-related changes in patients.

Mindfulness and pharmacological prophylaxis have comparable effect on biomarkers of inflammation and clinical indexes in chronic migraine with medication overuse: results at 12 months after withdrawal.

Chronic migraine (CM) is a disabling condition arising from a complex mixture of interconnected biological, psychological and social factors, and is often associated with medication overuse (MO). Mindfulness is emerging as a helpful treatment for pain, and one study showed that the longitudinal 12 months' course of CM-MO patients that attended mindfulness-based treatment alone was similar to that of patients receiving medical prophylaxis alone; in this study, we describe the course of biomarkers of inflammation. Our results provide initial evidence of sustained similar effects on reduced concentration of biomarkers of inflammation, although not sizeable enough to reach statistical significance. Whether more intensive treatment and/or larger samples would lead to greater changes is unknown, but these encouraging preliminary findings suggest further research is warranted.

Mindfulness and pharmacological prophylaxis after withdrawal from medication overuse in patients with Chronic Migraine: an effectiveness trial with a one-year follow-up.

BACKGROUND: Chronic Migraine (CM) is a disabling condition, worsened when associated with Medication Overuse (MO). Mindfulness is an emerging technique, effective in different pain conditions, but it has yet to be explored for CM-MO. We report the results of a study assessing a one-year course of patients' status, with the hypothesis that the effectiveness of a mindfulness-based approach would be similar to that of conventional prophylactic treatments. METHODS: Patients with CM-MO (code 1.3 and 8.2 of the International Classification of Headache Disorders-3Beta) completed a withdrawal program in a day hospital setting. After withdrawal, patients were either treated with Prophylactic Medications (Med-Group), or participated in a Mindfulness-based Training (MT-Group). MT consisted of 6 weekly sessions of guided mindfulness, with patients invited to practice 7-10 min per day. Headache diaries, the headache impact test (HIT-6), the migraine disability assessment (MIDAS), state and trait anxiety (STAI Y1-Y2), and the Beck Depression Inventory (BDI) were administered before withdrawal and at each follow-up (3, 6, 12 after withdrawal) to patients from both groups. Outcome variables were analyzed in separate two-way mixed ANOVAs (Group: Mindfulness vs. Pharmacology x Time: Baseline, 3-, 6-, vs. 12-month follow-up). RESULTS: A total of 44 patients participated in the study, with the average age being 44.5, average headache frequency/month was 20.5, and average monthly medication intake was 18.4 pills. Data revealed a similar improvement over time in both groups for Headache Frequency (approximately 6-8 days reduction), use of Medication (approximately 7 intakes reduction), MIDAS, HIT-6 (but only for the MED-Group), and BDI; no changes on state and trait anxiety were found. Both groups revealed significant and equivalent improvement with respect to what has become a classical endpoint in this area of research, i.e. 50% or more reduction of headaches compared to baseline, and the majority of patients in each condition no longer satisfied current criteria for CM. CONCLUSIONS: Taken as a whole, our results suggest that the longitudinal course of patients in the MT-Group, that were not prescribed medical prophylaxis, was substantially similar to that of patients who were administered medical prophylaxis.

Mindfulness and headache: A "new" old treatment, with new findings.

Background Mindfulness refers to a host of procedures that have been practiced for centuries, but only recently have begun to be applied to varied pain conditions, with the most recent being headache. Methods We reviewed research that incorporated components of mindfulness for treating pain, with a more in depth focus on headache disorders. We also examined literature that has closely studied potential physiological processes in the brain that might mediate the effects of mindfulness. We report as well preliminary findings of our ongoing trial comparing mindfulness alone to pharmacological treatment alone for treating chronic migraine accompanied by medication overuse. Results Although research remains in its infancy, the initial findings support the utility of varied mindfulness approaches for enhancing usual care for headache management. Our preliminary findings suggest mindfulness by itself may produce effects comparable to that of medication alone for patients with chronic migraine and medication overuse. Conclusions Much work remains to more fully document the role and long term value of mindfulness for specific headache types. Areas in need of further investigation are discussed.

Myofascial triggerpoint release (MTR) for treating chronic shoulder pain: A novel approach.

BACKGROUND: This study comprehensively evaluated a myofascial triggerpoint release (MTR) technique for shoulder pain. METHODS: Twenty-three (from an initial sample of 25) patients experiencing shoulder pain received MTR, in four 10-min sessions over a period of 2 weeks, applied exclusively on the more painful shoulder, with assessments being recorded both before and after treatment (and for pain at 1 and 13 months). Measures of stiffness and elasticity were collected to monitor the process of therapy, while subjective measures of pain and objective measures of pressure pain thresholds tracked primary outcomes. Secondary outcomes focused on suffering, stress, and quality of life. RESULTS: A statistically significant decrease in stiffness and increase in elasticity was observed post intervention for the treated side only, while pressure pain thresholds improved on the untreated side as well. Reports of pain significantly decreased after treatment, with gains being maintained at 1 and 13 months following treatment. Levels of suffering, stress, and quality of life revealed statistically significant improvement as well. CONCLUSIONS: MTR resulted in clinically significant improvements in the primary measures of pain, objective mechanical tissue properties, and secondary measures in patients with chronic shoulder pain.

Biofeedback and behavioral treatments: filling some gaps.

Biofeedback and related behavioral approaches have been employed for decades in the management of recurrent headache conditions, with ample evidence to support their clinical utility. Initially, these treatments were employed entirely in the office and required an extended number of face-to-face sessions. Researchers have entered a new era wherein they are focusing on ways to make these treatments less intensive on the part of therapists, less expensive on the part of patients, more widely available and accessible, and retain their level of effectiveness. Initial efforts have focused on PLOT, group, internet, and mass media delivery approaches. This article discusses further approaches being explored to continue to extend behavioral treatment options for patients, focusing on alternative approaches for managing headaches, discussing the value of exercise, addressing depression and sleep problems more directly, and incorporating techniques of motivational interviewing. The importance, role, and value of patient education are stressed throughout.

Nonpharmacologic treatments for migraine and tension-type headache: how to choose and when to use.

OPINION STATEMENT: There are a variety of nonpharmacologic treatments for headache. Educating patients about headache and its management, identifying and managing triggers (via diaries), modifying lifestyles, and understanding the importance of adopting and adhering to interventions (either pharmacologic or nonpharmacologic) are relevant to all persons with headache. In addition, specific nonpharmacologic treatments can be used either alone or in conjunction with ongoing pharmacologic intervention. Strong candidates for nonpharmacologic treatment include individuals with significant headache-related disability, comorbid mood or anxiety disorders, difficulty managing stress or other triggers, medication overuse, and patients who prefer a specific treatment. Behavioral treatments (relaxation, biofeedback, and cognitive-behavioral therapy) possess the most evidence for successful headache management. They have a long history of randomized trials showing efficacy and are considered first-line preventive options. Among complementary and alternative treatments, recent positive findings from randomized trials using acupuncture provide evidence of its potential as a first-line intervention. Other complementary and alternative techniques do not have a consistent base of research to recommend them for headache prevention, but they may be used if the patient prefers this approach or when other first-line interventions (nonpharmacologic or pharmacologic) have not provided adequate results. Among "natural" treatments, both butterbur extract and vitamin B2 have shown efficacy in more than one randomized trial and are thus potentially useful first-line preventive interventions.

Biofeedback in headache: an overview of approaches and evidence.

Biofeedback-related approaches to headache therapy fall into two broad categories: general biofeedback techniques (often augmented by relaxation-based strategies) and methods linked more directly to the pathophysiology underlying headache. The use of general biofeedback-assisted relaxation techniques for headache has been evaluated extensively by expert panels and meta-analyses. Taken together, these reviews indicate that (1) various forms of biofeedback are effective for migraine and tension-type headache; (2) outcomes with biofeedback rival outcomes with medication therapy; (3) combining biofeedback with medication can enhance outcomes; and (4) despite efficacy in many patients, biofeedback fails to bring significant relief to a sizeable number of headache patients. Biofeedback methods that more directly target headache pathophysiology have focused chiefly on migraine. These headache-specific approaches include blood volume pulse biofeedback, which has considerable supportive evidence, and electroencephalographic feedback.

Effects of weight-related literal and metaphorical suggestions about the forearms during hypnosis.

During hypnosis, the authors tested repeated weight-related, literal and metaphorical suggestions about the heaviness of the subjects' arms. The purpose was to determine if linguistically varied hypnotic suggestions produced significantly different motor reactions--involuntary pressure forces of the forearms--as assessed by a linguistic biomechanical system. Classic, literal (L) suggestions such as "your right arm is heavy" were used, as well as metaphorical (M) suggestions, such as "your right arm is made of lead." A specific effect on the progressive increase of pressure forces only in the temporal sequence L-M for each forearm (literal suggestions followed by metaphorical suggestions) was found. This effect, termed crescendo image metaphor effect, conceptualized within context-limited simulation theory, explains the findings.

Non-pharmacological approaches in migraine prophylaxis: behavioral medicine.

Although behavioral approaches cannot be seen as offering a panacea for all emotional ills, the assumption upon which they are based make their integration with physiological concepts a natural and comfortable union. The application of behavioral treatments for psychosomatic disturbances has been developed in the last 30 years favouring the organization of clinical protocols of treatment more standardized and scientifically proved in particular in headache field where the behavioral approach is actually an important therapeutical support for traditional pharmacological approaches. The different therapeutical approaches, initial outcomes are discussed.

An innovative approach for migraine prevention in young age: a preliminary study.

Headache is one of the commonest conditions to affect children and adolescents in industrialized countries. Effective pharmacological treatments without side effects are still lacking. Ginkgolide B, an herbal constituent extract from ginkgo biloba tree leaves, is a natural antiplatelet activating factor (PAF). PAF is a potent proinflammatory and nociceptive agent released during the inflammation process. Therefore, Ginkgolide B can be considered a promising non-pharmacological tool for treatment of migraine with and without aura. We propose to determine the efficacy of Ginkgolide B as preventive treatment in a group of young patients suffering from migraine without aura. A small sample of 24 young patients suffering from migraine without aura entered the open-label prospective trial. Migraine without aura was diagnosed according to International Headache Society criteria. The treatment was well tolerated and the compliance was good. These preliminary data show that Ginkgolide B seems to be effective as preventive treatment in reducing migraine attack frequency and in attenuating the use of symptomatic medication in our small series of children with primary headache.

MIPAS-Family-evaluation of a new multi-modal behavioral training program for pediatric headaches: clinical effects and the impact on quality of life.

Several meta-analyses have demonstrated that the combination of electrical muscle activity and Temperature Biofeedback could be regarded as gold standard in chronic pediatric headaches. However, these techniques seem to be uneconomical and furthermore they are not directed to improve the social competence as well as resolve possible impairments in daily activities of the child. Therefore, multi-modal behavioral techniques have been proposed, but no studies comparing these with the gold standard were conducted. The present study compared the impact of a new multi-modal behavioral education and training program--MIPAS-Family--with a combined Biofeedback treatment, evaluating clinical efficacy as well as the effect on the quality of life (QoL) of children with chronic headaches. Thirty-four children and adolescents with recurrent headache, ranging from 7 to 16 years, were randomly assigned to the MIPAS-Family (N = 19) or the Biofeedback (N = 15) condition. All patients were diagnosed by the criteria of the International Headache Society. The children and their parents completed headache diaries, diaries of daily living activities and a QoL questionnaire (KINDL). Both groups showed significant improvements concerning the headache intensity and headache duration. We found no significant differences in the main headache parameters between both treatments. After the treatments, the children were less disturbed by their headaches in the domains school, homework, and leisure time. In conclusion, MIPAS-Family is as effective as Biofeedback but it is more cost-effective and addresses the whole family and the daily activities.

Behavioral medicine for migraine and medication overuse headache.

Primary headaches, including migraine and medication overuse headache (MOH), can be conceptualized as biobehavioral disorders based on the interaction of biological, psychological, and environmental factors. This article reviews empirically supported and efficacious behavioral approaches to the treatment and management of headaches in general, with an emphasis on migraine and MOH from a biopsychosocial perspective. Evidence-based behavioral medicine treatments for migraine and MOH are reviewed, including patient education, cognitive behavioral therapy, and biobehavioral training (biofeedback, relaxation training, and stress management). Information regarding psychological comorbidities and risk factors for progression of migraine and the development of MOH is also reviewed. Strategies are provided for enhancing adherence and motivation, as well as facilitating medical communication.