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5 Articles in Volume 0, Issue #1
Chronic Tension Headache
Corticosteroid Use in Pain Management
Fibromyalgia Syndrome & Surface Electromyography
Intraarticular Mechanisms for Pain Control
Pharmaceuticals in the Pipeline - Anti-rheumatic Drugs

Chronic Tension Headache

The use of sEMG biofeedback for the treatment of chronic tension headache.

Headache is the most common pain complaint1 and the most frequent medical problem seen in medical clinics.2 Most experts3 believe that the majority of headaches are muscle tension-type. Community-based epidemiological studies have found that 14 percent of men and 29 percent of women have had headaches either every few days or headaches which significantly bothered them.4

Tension headache is generally described as a bilateral dull ache, pressure or cap-like pain that is usually located in the forehead, neck and shoulder regions. The headache typically occurs from two to seven days a week and can last from one hour to all day; a small proportion of tension headache sufferers have continuous headache. Migraine head-ache, on the other hand, is described as a unilateral pain, generally ac-companied with nausea and vomiting, with the pain characterized as throbbing or pulsating. Clinicians who deal with headache patients should use a standardized set of inclusion and exclusion criteria for diagnosis such as specified by the Ad Hoc Committee on the Classification of Headache5 or the newer Ad Hoc Committee of the International Headache Society.6

Treatment of Chronic Tension Headache

Behavioral treatments for chronic tension headache have been found to be as effective as pharmacological interventions.7 Although nearly all of the headache literature treats biofeedback and relaxation therapy as separate interventions, most clinicians combine both procedures when treating their tension head-ache patients.

A study by Holroyd and his colleagues8 detected no significant difference between subjects who trained to increase or decrease their muscle tension levels; high success feedback groups showed substantially greater improvements in headache activity (53 percent) than low success groups (26 percent). This study demonstrated the importance that cognitive mediating factors such as perceived success and self efficacy play in biofeedback training, and the enhanced awareness of ones level of muscle tension during non-biofeedback periods. Thus, the emphasis on biofeedback training with tension headache should focus on skill acquisition and the clinician-patient relationship.

Initial Session Strategies

We say something like this: "Its traditionally been assumed that the type of headache you have – tension headache – is caused by very high levels of muscle tension in your forehead, neck and shoulder areas. These muscles have been tense for a long time. Through biofeedback training, you will learn to both be aware of and decrease your muscle tension levels at any time. When you do this, its hoped that you will get a decrease in your headaches."

We next give the patient a number of possible strategies to choose from. We emphasize that learning the biofeedback response is purely an idiosyncratic process and that what works for others may not work for them. We customarily describe six possible biofeedback strategies outlined in Table 1.

  • Relaxing imagery, in which the patient imagines a pleasant scene.
  • Relaxing (autogenic) phrases repeated over and over again. We have found that the most effective phrases with biofeedback training are those the patient thinks up on their own.
  • Deep breathing procedure, during which the patient with eyes closed concentrates on relaxed, slow and moderately deep diaphragmatic breathing and repeats a relaxing word such as “relax” or “peaceful” while exhaling.
  • Becoming aware of sensations of tightness and tension in the forehead, by focusing on what it is like when those muscles relax, loosen up and unwind.
  • Nothingness. Some patients report that if they can make their minds blank and think of nothing – actually stop thinking – that they can relax and lower their muscle tension.
  • Mental games. Some patients find that focusing in on a color (“warm” colors such as blue, green or brown seem to work best) or actually play a game in their mind, such as tic-tac-toe, bowling, cards or basketball, are effective in lowering their muscle tension levels.


In the first session, we usually tell the patient to pick only one strategy and stick with it the entire session. We keep the initial session short – a three to five minute adaptation period (Just sit quietly with your eyes closed) and a maximum of 12 minutes of biofeedback. (In latter sessions, we increase the biofeedback portion to a maximum of 25 minutes). We emphasize that learning to relax muscles at will can be a difficult response to learn and that it may take some time before they can lower their forehead muscle tension reliably; we tell them not to get discouraged if they cannot control their sEMG levels immediately. We instruct the patients to let the response occur rather than make it occur, to be passive rather than try to force their forehead muscles to relax. We let them choose which type of visual and auditory feedback they like. At the end of the biofeedback session when the sensors are removed and the sessions data is saved, we inquire as to which strategy was employed and the patients perception as to how effective it was. We also get a self-report of relaxation, muscle tension and pain levels on a one to 10 scale prior to and following the session. If using a computer, we review the actual minute by minute printout of the data with the patient. Throughout this review we attempt to impart to the patient the most positive feeling of success gained, based on the realities of the sessions data. The number of sessions may run from 10 to as many as 24.

Forehead placement of sEMG electrodes.

Shoulder and neck placement of EMG electrodes.

Coaching and Clinician Attitude

The first, and most important thing for a clinician to determine about coaching, is whether a patient wants and could benefit from coaching. This is truly idiosyncratic. There are three general situations during sEMG biofeedback that you have to be prepared for:

Situation 1– The patient has decreased forehead muscle tension levels.

Possible responses are: "That's fantastic! Keep up the good work. I want you to remember what you are doing now so you can tell me at the end of the session. Real good! Try to get it even lower."

Situation 2– The patient has not been able to decrease forehead muscle tension levels.

Possible responses are: "That's OK. It’s as important to find out what makes it go up as it is to find out what makes it go down. I want you to remember what you're doing now so you can tell me at the end of the session. That's OK. You can only go up so far before you have to start going down. You seem to be going up; you might want to switch to a different strategy."

Situation 3– The patient seems frustrated or appears to be trying too hard.

Possible responses are: "That's to be expected. Remember, I told you that this is a very difficult response to get. If it was easy, you wouldn't need me or the machines. Let's take a break. Sometimes all you need is a few minutes to clear your mind and then you come back like gangbusters."

You may want to think of yourself as a scientist who dispassionately tests theories and tosses them in or out depending on whether or not they work. As a rule, we would suggest that coaching be done in a limited basis, as this will help to generalize the response to the real world, for in everyday situations patients do not have a clinician accompanying them. It is imperative for the clinician to convey as enthusiastically as possible to the patient that he or she is doing well in the biofeedback session.


Home practice has traditionally been considered an essential aspect of all psychophysiological interventions for chronic tension headache.7,9 Home practice can be conducted in many ways. The simplest form of homework is to instruct the patient to practice the office strategy that seemed to work the best at home and in other real world locations such as the job, supermarket, etc. (we usually instruct them to do so at least four times a day). The use of a home practice sEMG unit is also quite helpful. For example, computer operators might monitor muscle activity while typing, using the delayed threshold function which provides a tonal warning only when the threshold level has been exceeded for more than four seconds. In this way, maintained muscle tension is minimized, while appropriate low levels of muscle activity is reinforced.


Generalization involves preparing the patient to carry the learning that may have occurred during the biofeedback session into the real world. The most common method, by far, is a self-control condition which is interspersed between a baseline and a feedback condition. The self-control condition involves asking the patient to control the desired psychophysiological re-sponse (e.g., "Please try to lower your forehead muscle tension") without any feedback. If the patient can control the response, the clinician may assume that there has been between-session learning (i.e., generalization). Another method of testing for generalization is to present a pre- and post-treatment stressor to the patient and, if there is less arousal during and after a stressor in the post treatment, the clinician may infer that generalization has oc-curred. A third way of preparing the patient to generalize the biofeedback response is to try to make the office biofeedback training as close to real world situations as possible, such as switching to an uncomfortable chair or standing during the session.

Biofeedback for Tension Headache in the Elderly

Based upon the research10-12 and our clinical experience we would suggest the following when working with the elderly tension headache patient. First, to be certain that the patient understands the clinician's instructions, we would suggest requesting each patient to verbally repeat each session’s instructions. Second, clinicians should talk at a somewhat slower rate than usual to ensure that rationale and instructions are comprehended. Third, the clinician should make every attempt to simplify the instructions and, especially, to avoid the use of sophisticated language or jargon. Fourth, a brief summary of previously imparted information should be given at subsequent sessions to aid patients in retaining details. Fifth, turn up the biofeedback auditory feedback volume to ensure the patient can hear it, or use an earphone. We would also suggest moving the visual feedback monitor closer to ensure that the patient does not have to strain to see it. Finally, be patient with the elderly headache sufferer. Spend some extra time listening; do not communicate a desire to hurry the session. Schedule appointments for 10 minutes longer than usual.


A biofeedback behavioral program to assist headache patients to decrease both the severity and frequency of headaches has been described. The program includes in-clinic training as well as the inclusion of sEMG portable home trainers to provide reinforcement of behavioral and muscle control strategies in the real world.

Last updated on: November 16, 2012
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