IS A FEASABILITY STUDY PUBLISHED IN THE CANADIAN FAMILY PHYSICIANS MAGAZINE
Techniques and Attitudinal Changes in Adolescents with Migraines: A Feasibility
3.2% to 9% of school-age children suffer from migraine headaches. Many
physicians are concerned that pharmacological treatment of migraines can
have undesirable side-effects, as well as lead to drug dependence in adolescents.
A number of review articles have shown that biofeedback, behaviour modification
and relaxation exercises can significantly help migraine sufferers. This
article describes a feasibility study undertaken at a West Toronto high
school to see if non-pharmacological treatment of migraines was effective.
(Can Fam Physician 937; 33:417-421.)
migraine headaches, children, biofeedback
Borins, a certificant of the College, is an instructor in the Department
of Family and Community Medicine at the University of Toronto. He is also
an active staff member of the Department of Family & Community Medicine
at St. Joseph’s Health Centre, Toronto. Crystal Hawk is a health-care educator
and psychotherapist in private practice in Toronto.
Migraine is much more common than most people realize. Researchers Bille
and Sparks have found that from 3.2% to 9% of children suffer migraine.
Family physicians do not usually see a large patient population of child
migraine. Bille and others noted that children seldom consult a doctor
because usually one of the parents has had migraine for many years, and
in these families well-known symptoms are taken relatively lightly. Parents
also become resigned, believing that little can be done about migraine
attacks except to give medication and so do not bother to take the child
to their physician.
has always been viewed as a model for a psychosomatic disorder because
the mind and the emotions have a profound effect on the nature of the physical
disease, and vice versa. Techniques which alter physiology could well be
adapted to other so-called "psychosomatic diseases" such as peptic ulcers,
Raynaud’s disease, temporomandibular joint dysfunction and asthma.
pain of migraine may be caused by dilated, hyperpermeable, extracranial
and intracrainial arteries. The dysfunction of vascular behaviour in the
head could be related to intense sympathetic activation followed by over-compensation
and the subsequent vasodilation. This accounts for the brief phase of vasoconstriction
thought to be associated with the pre-headache aura and the subsequent
painful vasodilation. Theoretically, biofeedback and relaxation interferes
with this initial sympathetic activation and teaches the autonomic system
to be less reactive.
review articles have suggested that biofeedback relaxation-treatment procedures
and behaviour-modification techniques can significantly help both adults
and children suffering from headaches.
feasibility study was undertaken in a high school setting to see if a program
on biofeedback, relaxation and medical information could be introduced.
were made in a West Toronto high school of 1,300 children that a pilot
project teaching students how to prevent migraine headaches would be undertaken,
and volunteers were requested. Of the 17 students with headaches identified,
three students with migraines agreed to participate. Two were girls (aged
14 and 16), and one was a boy (aged 15).
investigators have used the diagnostic criteria of Vahlquist, which requires
paroxysmal headaches separated by pain-free intervals and at least two
of the following: nausea, aura, unilateral pain and positive family history.
For the identification of migraine, we decided to rely on the standards
in the community: that is to say we accepted as confirmation the diagnosis
of the patient’s doctor. Our questionnaire, too, helped to confirm the
pre-program questionnaire was circulated to each student and the parents,
detailing the frequency, duration and severity of the student’s migraines.
The amount of medication taken and the number of hours missed from school
and other activities were documented. Family history and precipitating
factors were elicited.
volunteers then collected data on their migraine headaches. They were seen
after school for two hours twice a week for three weeks and once
each week for the next two weeks. They were educated about all aspects
of migraine headaches. They were taught thermo-biofeedback, using a hand-held
thermometer; an active progressive relaxation technique; and an abdominal
breathing exercise; they were instructed to practice these exercises daily.
Parents, teachers and a school nurse were also involved in supportive and
dynamics play an important part in the experience of children with migraine.
Therefore, as a part of the study, meetings with parents were held at the
beginning and end of the program. At these meetings details of the study
were discussed and their support and answers to questions were elicited.
Because interactions among family members may affect a child’s headache
patterns, a whole family might be affected as changes took place in the
children. The parents were taught that support and new kinds of attention
should be provided when the children were headache free.
our purposes were to duplicate this program in other schools, and to have
the project continue after the researchers left, two sessions were spent
with the teachers and school nurse to familiarize them with the program.
These staff members also provided another support system for the student
subjects. Teachers or the school nurse could provide follow-up for students
at a later time to reinforce techniques and discover problem areas.
three students reported a reduction in the number and severity of their
headaches, as well as in the amount of medication taken and time lost from
activities. Since the sample size was so small, there was no control group,
and since no diaries were kept to substantiate the numbers reported, no
claims of therapeutic efficacy can be made. For these reasons, only anecdotal
information will be given.
a 14-year-old female grade nine student, had her first headache at age
13. She had been having about three headaches a month, each lasting from
four to eight hours. She had been taking either two Aspirin or one Tylenol
for pain, but never more than three tablets per day. However, the medication
was often ineffective and seemed to make her drowsy, She diligently practiced
the program, and during its six weeks duration she was migraine free. Five
months after the program she was doing the finger-warming exercise nightly
at bedtime and had experienced only two headaches. When she felt the start
of a headache, she was able to interfere quickly with the cycle and with
the pattern as well. In both instances the headaches were started by food
triggers, and she did not allow them to proceed to the pre-treatment level.
Fifteen months after the program began, KN had been migraine free for the
past five months.
was a 16-year-old female grade ten student whose migraines had begun when
she was eight years old. She was having one headache every two weeks, lasting
from 12 hours to five days. She had missed 22 days of school during the
previous six months, mostly as a result of these headaches. To control
the pain, she had been using 222s, Aspirin or Bufferin, taking two tablets
three or four times daily. These medications were causing drowsiness and
dyspepsia. Until the program began, she had been also seeing a chiropractor
weekly, with no improvement or change in the pattern of her pain.
the program and for four months afterward TG was migraine free. She practiced
the finger-warming exercise daily, and she twice aborted an attack when
she noticed a "tightness in her head", by doing the finder-warming exercise
and head massage.
15 months follow-up she had had no absences from school because of migraines.
She still experienced the occasional migraine once every two to three months,
but they were less intense and lasted only a few hours.
was a 15-and-a-half-year-old male grade ten student who experienced only
about one headache per month. He was taking three Cafergot or one to two
Tylenol tablets two to three times daily, as needed, but said that the
medication offered little relief. Because his migraine pattern was monthly,
it was difficult for him to be motivated to practice a daily self-help
program which provided immediate results. He had two migraines within
four months from the start of the program. One he described as his usual
"headcracker", but the second he was able to abort by practicing some relaxation
15 months follow-up he had had no headache for five months and had been
successful in using the finger-warming exercise to "calm down" his last
all three students benefited from this project. However, the small sample
size, the lack of control group and the absence of diaries to substantiate
the results that were reported make it impossible to draw any definite
conclusions. A number of difficulties were encountered in this pilot project
that would need attention in a larger study.
3.2% to 9% of school children have migraines and 30% to 50% of adults with
migraine had such headaches before the age of 20, why where there only
three students who agreed to participate out of a school population of
made to high school students do not often attract their attention. Some
thought that in coming forward and identifying themselves they might be
ostracized by their peers or considered "sick" or "different". Others said
they had busy school schedules and could not sacrifice the time needed
care would be needed to contact each student individually and confidentially.
Written communication, returned to a confidential depot, might allay students’
fears of being singled out. Highly respected recruiters who are influential
with students could be identified and used to encourage students to take
part in such a survey.
none of the three students did their physicians report migraines on their
school physical forms. Surprisingly, some parents had difficulty
contacting their doctors to get their confirmation of a diagnosis of migraine.
Others were reluctant to phone their doctors, and at least two doctors
considered that the project would involve them in too much paperwork and
advised their patients not to take part. The doctor of one of the participants
refused to co-operate, and the child’s mother had to phone the doctor back
a second time to get him to agree to sign the paper confirming the migraine
many physicians resented their patients being involved in treatment of
a medical condition at school. Sometimes doctors can feel threatened that
someone else is "stealing" their patients. An alternative approach to treatment
might be seen as a "put down" to their approach. Doctors are continually
being bombarded with forms to sign and have a tendency to want to decrease
letter written by a physician to deflect these concerns might help to obtain
physicians’ co-operation. A follow-up phone call by the physician researcher
might ensure that communication to family physicians would be optimal.
Since it was the intention of this project to apply the techniques tested
in a family physician’s office, it would be helpful to have patients’ doctors
involved in a positive way.
have often observed among migraine sufferers a lack of willingness to take
part in self-help programs. Perhaps there is some secondary gain inducing
people to hold onto their migraine pattern. Perhaps some have sought treatment
so often that they mistrust all approaches which claim success. Perhaps
there are some qualities of a psychosomatic personality which preclude
these people from gaining mastery over their autonomic nervous system.
Efficacy of the Intervention
remissions are common with migraine, and Brensky found that irrespective
of the form of treatment, about one-half of all patients had more than
a 50% reduction headache frequency in the six months following their initial
visit to a neurologist. The reason may be that any positive energy introduced
into a stable pathological condition upsets the balance and has some placebo
effect. Perhaps referral to a neurologist may co-exist with an acute exacerbation
of the disease which might have resolved spontaneously if a neurologist
had not been consulted.
of the strong placebo effect, children in a future study would need to
be allocated at random to different intervention groups. Data could be
collected from children in all groups by means of diaries.
control group, for example, might use diaries to collect data about the
frequency and severity of their headaches, the amount of medication used,
and the hours missed from activities.
second group might keep diaries and also take part in a program involving
medical information and support of peers and parents. A third group
might be exposed to the whole package of interventions including thermal
biofeedback, relaxation and abdominal breathing. Comparisons might be made
across all three groups and the findings compared to previous baseline
authors agree that children are excellent subjects for biofeedback, autogenic
training and relaxation exercises. However, we found that the most difficult
task in working with adolescents is to attract these young people to participate
in their own self-help program. Teenagers do not like to be singled out
as "different". They are involved in busy school schedules, lack the time
to participate, and may not receive support and encouragement from their
families and peers.
authors wish to thank Dr. Earl Dunn, Rita Shaughnessey and Maggie Likavec
for their valuable assistance and the Department of Family and Community
Medicine of the University of Toronto for funding the project.
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