We have reviewed biofeedback and the specific details of each biofeedback modality elsewhere. Briefly, it is the use of technology to give you measurements of physiological processes that are under the influence of the autonomic nervous system. This technology will usually show you a visual graphic plotting the variable (i.e., peripheral skin temperature, skin conductance, sEMG [surface electromyography], blood volume pulse [BVP], abdominal excursion) being measured and may also employ sound to tally with the variable’s up and down swings. If we can quantify these things on a screen, is it possible that we can influence them? The answer is yes. How can we influence them? A spirit of mindfulness goes a long way here. If you can accept the way things are without judgement – without trying to be what you think you should be – and to attend to these sensations with calm alertness, this will help you correlate what you see on screen with internal cues or ‘sensations’. And then you can experiment with these internal cues and see the effect on the screen. And with enough practice, you will be able to influence the same process without using biofeedback technology.

Multiple studies have found that biofeedback is useful in the management of headaches. A very influential group, the U.S. Headache Consortium in 2000 reviewed all evidence-based behavioural and physical treatments for migraine and recommended biofeedback as a Grade A treatment (“multiple well-designed randomized controlled trials (RCTs) revealing a consistent pattern of positive findings”). Several other reviews (Yucha & Montgomery, 2009; Nestoriuc & Martin, 2007; Andrasik, 2010) found concordant results. In a meta-analysis of 74 studies (Nestoriuc et al., 2008), biofeedback was also found to be effective for the treatment of tension-type headaches.


Moreover, post-concussion patients can have many conditions found in central sensitivity syndrome; many are sensitive to the effects of medication and non-pharmacological options avoid exposure to the same.

The most common phenotypes of post-traumatic headaches are migraines and tension-type headaches.

Blood volume pulse biofeedback gave better results than sEMG and temperature BFB (Nestoriuc & Martin, 2007). Blood volume pulse is intimately related to HRV training. HRV training is used to improve one’s influence over the autonomic nervous system. To further improve one’s influence, sEMG training and temperature training are added. There are ways to increase the challenge level to avoid a plateau in training.

2/3 of patients with TTH have increased EMG activity in the upper trapezius, temporalis, frontalis and posterior neck muscles (Schoenen et al., 1991; Hatch et al., 1992) so it’s  not surprising that one of the main modalities to treat TTH is to train influence over the sEMG. Even still, starting with HRV training is a good idea as it is a more intuitive modality to hone mindfulness in this context. It also helps train a useful relaxation strategy that can be used to relax tense muscles. Low-and-slow diaphragmatic breathing also helps set up the correct breathing mechanics that will offload these same tense muscles. Finally, as mentioned in the biofeedback article, training proper breathing can improve electrochemical potentials in the blood which will promote optimal cell performance. Did you notice that 1/3 of TTH patients don’t have increased EMG activity? This is because increased muscle tension is not the only thing causing TTH. These patients are more sensitive to pain. They may even complain of pain to things that don’t usually cause most people any pain. This is due to changes in the central nervous system with respect to how to sense and handle pain which can in turn cause dysfunction in the autonomic nervous system. (Ashina et al., 2002) Studies (Hubbard & Berkoff, 1993; Gevirtz, 2006) have shown that muscle spindles, sensory organs in the central part of the muscle belly, are involved in trigger points found in chronic pain patients. Different muscles have different concentrations of muscle spindles: muscles at the base of the skull known as occipitalis have between 100-250 spindles/gram of muscle tissue whereas the big muscle latissimus dorsi has 2 spindles/gram of muscle tissue. Muscle spindles are sensitive to stretch and give us information that is used for proprioception, or generally, to coordinate muscles (listen to our podcast Concussion 101, Episode 7: What the heck neck!? for more information about this). It was also found (Hubbard, 1996) that spindles are under the influence of the sympathetic nervous system (see Autonomic Dysfunction for more information). So, things that can trigger our fight-or-flight system (i.e., sympathtic nervous system) can also increase our pain. This is why treating chronic pain can be so challenging, we can’t stop with just training the muscle, we have to train the central nervous system. And to train the brain, we have to train the mind. Generally, relaxation strategies are the best way to influence the nervous system favourably. Home practice significantly contributed to success.
Andrasik, Frank. (2010). Biofeedback in headache: An overview of approaches and evidence. Cleveland Clinic journal of medicine. 77 Suppl 3. S72-6. 10.3949/ccjm.77.s3.13. Ashina, Messoud. (2002). In vivo evidence of altered skeletal muscle blood flow in chronic tension-type headache. Brain. 125. 320-326. 10.1093/brain/awf029. Gevirtz, R. (2006). The muscle spindle trigger point model o chronic pain. Biofeedback, 34(2), 53-56.
  1. Hatch, John & J. Moore, Patricia & Borcherding, Steve & Cyr-Provost, Margaret & Boutros, Nash & Seleshi, Ermias. (1992). Electromyographic and affective responses of episodic tension-type headache patients and headache-free controls during stressful task performance. Journal of behavioral medicine. 15. 89-112. 10.1007/BF00848379.
Hubbard, D., Berkoff, G. (1993). Myofascial trigger points show spontaneous needle EMG activity. Spine, 18, 1803-1807. Hubbard, D. (1996). Chronic and recurrent muscle pain: pathophysiology and treatment, and review of pharmacologic studies. Journal of Musculoskeletal Pain, 4(1/2), 123-143.   Khazan, I. Z. (2013). The clinical handbook of biofeedback: A step-by-step guide for training and practice with mindfulness. Chichester, UK: Wiley-Blackwell. Nestoriuc, Y., & Martin, A. (2007). Efficacy of biofeedback for migraine: A meta-analysis. Pain, 128(1–2), 111–127. doi:10.1016/j.pain.2006.09 .007 Nestoriuc, Yvonne & Martin, Alexandra & Rief, Winfried & Andrasik, Frank. (2008). Biofeedback Treatment for Headache Disorders: A Comprehensive Efficacy Review. Applied psychophysiology and biofeedback. 33. 125-40. 10.1007/s10484-008-9060-3. Schoenen, Jean & Gerard, Pascale & De Pasqua, Victor & Juprelle, Martine. (1991). EMG Activity in Pericranial Muscles During Postural Variation and Mental Activity in Healthy Volunteers and Patients With Chronic Tension Type Headache. Headache. 31. 321-4. 10.1111/j.1526-4610.1991.hed3105321.x. Yucha, C. B., Montgomery, D. (2008). Evidence-based practice in biofeedback and neurofeedback. Evidence-based practice in biofeedback and neurofeedback Association for Applied Psychophysiology and Biofeedback.

Research & writing: Dr. Taher Chugh

Last update: Decemeber 2018