Psychiatric treatmentMany patients with migraine have some degree of depression but this may be secondary to their headaches rather than a primary cause. In these cases, the opinion of a psychiatrist is of great value since their training facilitates assessment of which patient will respond best to a particular method of therapy. Some experts favour a more complex interpretation of headaches based on psychoanalytic theory but this approach has not often proved helpful.
BiofeedbackBiofeedback is the term used for the methods by which conscious control can be gained of functions that are usually automatic. This is achieved by ‘feeding back’ to the patient information about the automatic function so that its control can be modified. Possibly the commonest use of biofeedback is in the control of blood pressure, where patients are told to concentrate in various ways and the results of their efforts are relayed to them; most people can learn a technique which will reduce their blood pressure, an effect which can be maintained. Epileptic patients often say ‘I almost had an attack but I felt it coming and fought it off-an interpretation of events verified using EEG monitoring; patients can be taught to suppress epileptic activity when the EEG information is fed back to them but the mechanism of this suppression is unknown.There have been many attempts to treat migraine in the same way. Three types of information can be relayed to the migraine sufferer, the first of which is the degree of distension of the temporal artery. During an attack of migraine, the temporal artery becomes dilated and it is possible for sufferers to learn to reduce the diameter of the temporal artery, and so abort attacks.Muscle contraction can also be brought under feedback control. When a patient develops a migraine associated with neck muscle tension, contraction of the neck can be recorded using a machine – the electromyograph (EMG). Therapy consists of feeding back to the patient information on the amount of muscle activity in the neck, so encouraging him to relax. Results have been fairly encouraging but there is a great placebo effect; the relief of tension can work by affecting the stress provoking the migraine attack, and other forms of relaxation not using biofeedback can also relieve the tension in the muscles of the neck.Thirdly, there is an increase in temperature over the head during a migraine attack with an increase in blood flow; this is most marked during an attack of cluster headache. The response of blood vessels of the limbs to increased blood flow is abnormal in migraine sufferers, and increasing the blood flow through the skin of the hand is associated with a decreased flow of blood to the skin of the forehead. People can alter the blood flow through their hands following appropriate concentration using biofeedback and, interestingly enough, it is the dominant hand which shows the best response. Using biofeedback, the patient can be trained to warm his hand when an attack is coming on. This technique is not effective in all sufferers, however, because the responses of the blood vessels vary. (Similar responses to the same stimuli occur in anger: some people go white due to constriction of their blood vessels whilst others go red, due to dilation of their blood vessels.)Hand-warming is worth trying as the biofeedback apparatus required is fairly simple, and consists of a surface thermometer attached to the hand with a means of relaying the information to the patient; these devices are becoming available commercially and are not too expensive. The patient sits in a relaxed position and attempts various thoughts in order to obtain vessel constriction until a satisfactory lessening in blood flow is obtained, as evidenced by a small decrease in temperature. It is the skin temperature that is important so there is no point in clenching the hand. With practice, when the technique has been mastered, changes in temperature of one to two degrees can be achieved.Anecdotal reports bear out the usefulness of the method: one patient, who suffered from severe cluster headaches, spontaneously said ‘I know it sounds funny, but I think that if I concentrate I can make my hand feel warmer and then the pain in my head seems to get better.’