Cognitive Behavioral Treatment is a set of non-pharmacological techniques for help to:

  • prevent migraines and other headaches
  • decrease the emotional impact of headache
  • decrease disability from headaches
  • improve pain coping

These skills are intended for chronic benign headaches:

  • Migraines
  • Tension-Type Headache
  • Medication Rebound Headache
  • Chronic Daily Headache

After an initial assessment, we will work with you to identify the best treatments for your headaches. Treatment is designed to be time- and cost-effective and may include any of the following:

  • Thermal Biofeedback
  • Relaxation Training
  • Cognitive Stress Management Skills
  • Trigger Identification and Management
  • Pain Coping Skills
  • Children & Headaches
  • Getting Treatment

Thermal Biofeedback & Migraines

What is Thermal Biofeedback?

In thermal biofeedback, a person works with a therapist and a sensitive instrument, to learn to mentally raise hand temperature. The cardiovascular mechanisms that regulate skin temperature in the hands and feet are closely linked with the activity of the sympathetic division of the autonomic nervous system. Upon activation of this system, the smooth muscles surrounding the blood vessels under the skin surface contract resulting in decreased blood flow to the capillaries and capillary beds (body tissue) near the skin surface. This process is termed “vasoconstriction”. As blood flow through the peripheral capillaries and tissues near the skin surface decreases, the temperature of the skin decreases (stress).

Conversely, an increase in skin temperature is the products of vasodilation, or relaxation of the smooth muscles surrounding the peripheral blood vessels. Vasodilation is usually accompanied by a relaxation of sympathetic activity.

The learning is surprisingly rapid, usually within the first 3 sessions. Children with migraines seem to benefit from biofeedback as well (Hermann, Kim, & Blanchard, 1995).

Colin Schafer, located in our Norwood and Quincy OP offices, specializes in thermal biofeedback for migraines.

Effectiveness of Thermal Biofeedback in Headache Prevention

By 1990, there had been 60 studies, involving over 2440 patients, of the effectiveness of thermal biofeedback in preventing migraines. The effectiveness is approximately equal to that of propranolol: Roughly 45% of participants have at least a 50% decrease in migraine frequency. Moreover, there is preliminary evidence that the combined effects of propranolol and thermal biofeedback are greater than the individual effects, with between 75% and 93% of patients obtaining at least a 50% reduction in migraine frequency (Holroyd, et al., 1995; Mathew, 1981). The combined treatments may help break the pain cycle, allowing success with lower doses of propranolol (Holroyd, et al., 1995).

Relaxation Training & Headaches

In this approach, an individual learns to mentally bring about a state of deep relaxation, essentially at will, using imagery, focused attention, increased awareness of the sensations of tension and relaxation (i.e., progressive muscle relaxation). Patients learn that blood vessel constriction followed by dilation were associated with migraine pain and that the goal of relaxation training is to stop this process.

Stress Management Skills & Headaches


In this approach, individuals learn to maximize the effectiveness of their skills for dealing with stresses. Younger children (i.e., under 13) are taught to identify maladaptive ways of thinking, stop those thoughts and replace them with more accurate positive self instructs. This increases self-confidence, and maximizes the probability that the stressor will be resolved.


By 1994, there had been 15 studies on cognitive therapy for tension-type headache. It appears to lead to an approximately 53% reduction in total headache activity (Bogaards & ter Kuile, 1994; McCrory, Penzien, Rains & Hasselblad, 1996). In a direct comparison, it was more effective than EMG biofeedback and relaxation for people who were also attempting to deal with high levels of daily stresses (Tobin, et al., 1988).

Trigger Identification and Headache Management


In retrospective studies, the most important migraine triggers have been stress, hormones (premenstrual and mid-cycle migraines), exercise, and disrupted sleep and eating times (Rains & Penzien, 1996; Robbins, 1994). In addition, a number of substances found in foods have been suspected of causing migraines, leading to recommendations that specific trigger foods be avoided, such as alcoholic beverages and particularly red wine, caffeine, aged cheeses, citrus fruits, chocolate, MSG and hydrolyzed vegetable protein (Constantine & Scott, 1994). Patients are taught to recognize stressful situations (e.g., tests) so that they can employ relaxation and cognitive techniques (i.e., thought stopping & positive self instruction). Behavioral skills are useful for adopting a more regular lifestyle and for managing stresses, as well as for identifying and eliminating any dietary triggers.


For dietary triggers, the outcome literature consists mostly of case studies and small-scale clinical trials (e.g., Radnitz, Blanchard, & Bylina, 1990). Within the limits of this design, the results have been encouraging. It seems likely that dietary triggers are a significant factor for only a small minority of people with migraines (e.g., Hanington & Harper, 1968; Nicolodi & Sicuteri, 1999). However, for people who fall in this category, dietary management may be an important component of treatment. For lifestyle triggers, there does not yet seem to be a relevant outcome literature, but of course there are strong rational reasons for believing that their modification will help prevent migraines.

Headache Pain Coping Skills


Pain is a significant stress that can interfere with a person’s well-being, school, job, and family activities. Sometimes fear of having a severe headache is disruptive by itself. In the worst case this leads to a vicious cycle, in which thinking about headaches, stress from them, and sometimes overuse of symptomatic medications leads to still more headaches. Chronic pain treatment consists of a set of cognitive and behavioral skills for regaining confidence in one’s ability to cope with the headaches, and for minimizing the impact of headaches.


By 1999, there had been approximately 30 controlled trials of cognitive-behavioral treatment for various chronic pain conditions (Morley, Eccleston, & Williams, 1999). These show that behavioral treatment is superior to standard alternative treatments in reducing pain and increasing cognitive coping. Behavioral treatment is alternative to waiting list controls on a number of dimensions, including pain level, mood, activity, and functioning. This refers to pain conditions in general. However, we have no reason to believe that chronic daily headaches would be less susceptible than other conditions to behavioral treatment.

Children & Headaches

Pediatric migraine is a common problem, affecting 3%-10% of the school age population. The quality of life of children with headaches is comparable to that of children with such serious conditions as cancer and rheumatic diseases, according to a study by researchers at Cincinnati Children’s Hospital Medical Center. In fact, the study shows that children with headaches appear to be more affected in emotional functioning and school performance than children with other serious, chronic medical conditions, according to lead author Scott W Powers, PhD, co-director of the Cincinnati Children’s Headache Center.

In the study, published in the July 2004 issue of Pediatrics, the researchers surveyed 572 children and adolescents. The researchers discovered that quality of life is negatively affected in all areas of functioning when compared to healthy children, including school functioning, emotional functioning and physical health. Children with migraines reported more impairment in school functioning and emotional functioning than children with other chronic illnesses.

A meta-analysis (Hermann et al., 1995) of 17 behavioral studies and 24 drug studies of pediatric migraine found that thermal biofeedback, as well has progressive muscle relaxation had larger effect sized than any other treatments examined. In 1999 a review of evidence concluded that sufficient evidence exists to conclude that relaxation/self-hypnosis is a well-established and efficacious treatment for recurrent headache in children (Holden, Deichmann & Levy, 1999). A study conducted at Boston Children’s Hospital and the University of Pittsburgh (Scharff, Marcus & Masek, 2002) confirmed findings of earlier pediatric migraine studies supporting the effectiveness of thermal biofeedback treatment in children with migraine. This study also provided support for the specific effect of stress management treatment.

Selected References

Bogaards, M. C., & ter Kuile, M. M. (1994). Treatment of recurrent tension headache: A meta-analytic review. Clinical Journal of Pain, 10, 174-190.

Constantine, L. M., & Scott, S. (1994). Migraine: The complete guide. NY: DTP Press. (An American Council for Headache Education book.)

Hanington, E., & Harper, A. M. (1968). The role of tyramine in the aetiology of migraine and related studies on the cerebral and extracerebral circulations. Headache, 8, 84-97.

Hermann, C., Kim, M., & Blanchard, E. B. (1995). Behavioral and prophylactic pharmacological intervention studies of pediatric migraine: An exploratory meta-analysis. Pain, 60, 239-256.

Holden, E.W., Deichmann, M.M, & Levy, JD (1999). Empirically supported treatments in pediatric psychology: recurrent pediatric headache. Journal of Pediatric Psychiatry, Vol 24, 91-109.

Holroyd, K. A., & Penzien, D. B. (1990). Pharmacological versus non-pharmacological prophylaxis of recurrent migraine headache: A meta-analytic review of clinical trials. Pain, 42, 1-13.

Holroyd, K. A., France, J. L., Cordingley, G. E., Rokicki, L. A., Kvaal, S. A., Lipchik, G. L., & McCool, H. R. (1995). Enhancing the effectiveness of relaxation-thermal biofeedback training with propranolol hydrochloride. Journal of Consulting and Clinical Psychology, 63, 327-330.

Mathew, N. T. (1981). Prophylaxis of migraine and mixed headache: A randomized controlled study. Headache, 21, 105-109.

McCrory, D. C., Penzien, D. B., Rains, J. C., & Hasselblad, V. (1996). Efficacy of behavioral treatments for migraine and tension-type headache: Meta-analysis of controlled trials. Headache, 36, 272.

Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80, 1-13.

Nicolodi, M., & Sicuteri, F. (1999). Wine and migraine: Compatibility or incompatibility? Drugs in Experimental and Clinical Research, 25, 147-153.

Radnitz, C. L., Blanchard, E. B., & Bylina, J. (1990). A preliminary report of dietary therapy as a treatment for refractory migraine headache. Headache Quarterly, 1, 239-243.

Rains , J. C., & Penzien, D. B. (1996). Precipitants of episodic migraine: Behavioral, environmental, hormonal, and dietary factors. Headache, 36, 274-275.

Rains, J.C., Penzien, D.B., McCrory, D.C., Gray, R.N. (2005). Behavioral headache treatment: History, review of empirical literature, and methodological critique. Headache: The Journal of Head and Face Pain, 45, s92-s109.

Robbins, L. (1994). Precipitating factors in migraine: A retrospective review of 494 patients. Headache, 34, 214-216.

Scharff, L, Marcus, D.A., & Masek, B.J. (2002). A controlled study of minimal contact thermal biofeedback treatment in children with migraine. Journal of Pediatric Psychology, Vol. 27, No. 2, 109-119.

Tobin, D. L., Holroyd, K. A., Baker, A., Reynolds, R. V. C., & Holm, J. E. (1988). Development and clinical trial of a minimal contact, cognitive-behavioral treatment for tension headache. Cognitive Therapy and Research

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