Eight patients with tension headache received 10 sessions of ILF neurofeedback and 10 sessions of sham neurofeedback in random order. The intervention was in addition to a baseline psychotherapeutic intervention. Results of the study titled "Infra-Low Frequency Neurofeedback in Tension-Type Headache: A Cross-Over Sham-Controlled Study" from Arina et al. showed that compared to sham treatment, the frequency of headaches after treatment with ILF neurofeedback, was significantly lower.

Neurofeedback and headache

Although neurofeedback is increasingly used for chronic pain, its effectiveness for headaches has been little studied. Yet headaches are among the most common conditions; 38% of the adult population actively suffers from tension headaches (Jensen and Stovner, 2008). In treatment, non-drug treatments, including biofeedback and neuromodulation, are promising alternatives to medication (Nestoriuc et al., 2008; Bendtsen et al., 2010; Ailani et al., 2021).

Neurofeedback uses brain signals and aims to therapeutically modulate a dysfunctional brain state, such as an imbalance in electroencephalographic (EEG) activity or altered intrinsic connectivity patterns (Ros et al., 2013; Marzbani et al., 2016; Nicholson et al., 2016; Dobrushina et al., 2020). In the present study, infra-low frequency (ILF) neurofeedback was applied, which targets the slow brain fluctuations. In practice, neurofeedback is already widely used in the treatment of headache (Othmer, 2017). However, a sham-controlled study in patients with tension headache has not yet been conducted.

Study and methods

The aim of the present study was therefore to evaluate the effects of low-frequency EEG neurofeedback in patients with tension headache using a sham-controlled cross-over study. 8 patients, aged between 18 and 45 years, diagnosed with tension headache, received 10 sessions of neurofeedback treatment and 10 sessions of sham neurofeedback treatment in two intervention phases. The order (neurofeedback first or sham neurofeedback first) was randomized. In addition, the mechanisms of tension headache, including the benign nature of the headache and the risk of medication overdose, and progressive muscle relaxation training were explained to all participating subjects. Patients received an audio recording of the relaxation technique and were asked to use it three times per week. During the study period, participating subjects were required to keep a headache diary that included information on the duration and intensity of headaches and medication use. 
Neurofeedback sessions were conducted according to the Othmer protocol. Furthermore, the NeuroAmp as well as the Cygnet software of the BEE Medic company were used.

Results and implications

Results of the study showed a significant effect of neurofeedback and no effect of sham sessions. Treatment with neurofeedback reduced the frequency of tension headaches. Sham sessions, on the other hand, resulted in a placebo effect in one participant and a nocebo effect in two others. Furthermore, it was found that beliefs about neurofeedback and behavior during the sessions did not influence the effectiveness of neurofeedback.

In conclusion, the results of the study support the use of low-frequency neurofeedback in the integrative treatment of patients with tension headaches.

Read the entire study here.

References

Ailani, J., Burch, R. C., and Robbins, M. S. (2021). The American Headache Society Consensus Statement: update on integrating new migraine treatments into clinical practice. Headache J. Head Face Pain 61, 1021–1039. doi: 10.1111/head.14153

Bendtsen, L., Evers, S., Linde, M., Mitsikostas, D. D., Sandrini, G., and Schoenen, J. (2010). EFNS guideline on the treatment of tension-type headache - Report of an EFNS task force. Eur. J. Neurol. 17, 1318–1325. doi: 10.1111/j.1468-1331.2010.03070.x

Dobrushina, O. R., Vlasova, R. M., Rumshiskaya, A. D., Litvinova, L. D., Mershina, E. A., Sinitsyn, V. E., et al. (2020). Modulation of intrinsic brain connectivity by implicit electroencephalographic neurofeedback. Front. Hum. Neurosci. 14:192. doi: 10.3389/fnhum.2020.00192

Jensen, R., and Stovner, L. J. (2008). Epidemiology and comorbidity of headache. Lancet Neurol. 7, 354–361. doi: 10.1016/S1474-4422(08)70062-0

Marzbani, H., Marateb, H. R., and Mansourian, M. (2016). Neurofeedback: a comprehensive review on system design, methodology and clinical applications. Basic Clin. Neurosci. 7, 143–158. doi: 10.15412/J.BCN.03070208

Nestoriuc, Y., Rief, W., and Martin, A. (2008). Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J. Consult. Clin. Psychol. 76, 379–396. doi: 10.1037/0022-006X.76.3.379
 

What is ASD?

Autism Spectrum Disorder (ASD) is a profound developmental disorder that begins in (early) childhood. Diagnostic criteria include deficits in social communication and interaction, limited repetitive behavioral patterns such as inflexible holding on to routines and hyper-/ or hypoactivity to sensory stimuli. Functions of speech, visual spatial skills and movement coordination are often affected by developmental limitations or delays. The term spectrum disorder indicates that different forms of autistic disorders can be distinguished, especially early childhood autism, atypical autism and Asperger syndrome. 

Indicating a prevalence for ASD is not trivial, as there is no uniform approach or criteria, and numbers are not available for all regions worldwide. It may be possible to estimate a prevalence of approximately 1.5% for ASD in industrialized countries (see literature 1). The clinical appearance of ASD changes considerably over the life span from infancy to adulthood, both in core symptoms and compensation strategies. 

Neurofeedback as an option in a multimodal therapy approach
 

Neurofeedback can be used as a block of therapy for those affected by the autism spectrum. Recent research into the neurophysiology of autism spectrum disorders has shown that autistic individuals have different connectivity networks and specific regions of hyper- and hypo-connectivity than healthy subjects in comparison with a control group (see literature 2). Other theories, such as those on altered mirror neuron activity, or hypotheses on the Theory of Mind and the Polyvagal Theory, also emphasize neurological differences for patients with ASD. 

The effect of Neurofeedback is alteration of dysregulated brain activity. It is known from studies that patterns of resting EEG and evoked potentials in patients with ASD differ from those of healthy populations. The effect of neurofeedback on the brain has been confirmed in a recently published study. The functional connectivity (communication between neurons) in the brains of subjects was examined by fMRI before and after a 30-minute neurofeedback session. After the neurofeedback session, an increased connectivity of neurons in the brain was found (see literature 3). From these results it can be deduced, among other things, that neurofeedback not only has a positive effect on the symptoms of illnesses but can also cause effects in the brain and thus possibly change connectivity patterns in the long term, such as those that occur in chronic pain. These results support the hypothesis of neurofeedback as a method of improving the self-regulating capacity of the brain.   

State of Research: Neurofeedback in Autism Spectrum Disorders 

Due to the functional neuroanatomical abnormalities in patients with ASD, neurofeedback can be an effective treatment method for reducing the symptoms of dysregulation (see literature 4). This hypothesis is strengthened in a controlled study, in which ASD patients had a reduction of cerebral hyper-connectivity after 20 sessions of Neurofeedback as well as a significant reduction of the symptoms by the treatment (see literature 5). It is also shown that neurofeedback in combination with other treatment methods is a possibility to improve the patients' performance (see literature 6). A follow-up study shows that 12 months after the Neurofeedback treatment, the obtained improvements are still present (see literature 7), which indicates that Neurofeedback not only helps with the current symptoms, but it also helps the brain to improve the executive functions. 

Previous work (literature 8) and a recent review of the existing literature concludes that neurofeedback is a promising treatment for autism and cites the evaluation of numerous studies and case reports (see literature 9). However, it is also noted that further studies, particularly controlled and randomized studies, should be conducted to evaluate further details of treatment conditions.

Literature
1.    Fombonne, E. Editorial: The rising prevalence of autism. J. Child Psychol. Psychiatry Allied Discip. 59, 717–720 (2018).
2.    Holiga, Š. et al. Patients with autism spectrum disorders display reproducible functional connectivity alterations. Sci. Transl. Med. 11, (2019).
3.    Dobrushina, O. R. et al. Modulation of Intrinsic Brain Connectivity by Implicit Electroencephalographic Neurofeedback. Front. Hum. Neurosci. 14, 1–13 (2020).
4.    Thompson, L., Thompson, M. & Reid, A. Functional neuroanatomy and the rationale for using EEG biofeedback for clients with Asperger’s syndrome. Appl. Psychophysiol. Biofeedback 35, 39–61 (2010).
5.    Coben, R. & Padolsky, I. Assessment-Guided Neurofeedback for Autistic Spectrum Disorder. J. Neurother. 11, 37–41 (2008).
6.    Knezevic, B., Thompson, L. & Thompson, M. Pilot Project to Ascertain the Utility of Tower of London Test to Assess Outcomes of Neurofeedback in Clients with Asperger’s Syndrome. J. Neurother. Investig. Neuromodulation 14, 3–19 (2010).
7.    Kouijzer, M. E. J., de Moor, J. M. H., Gerrits, B. J. L., Buitelaar, J. K. & van Schie, H. T. Long-term effects of neurofeedback treatment in autism. Res. Autism Spectr. Disord. 3, 496–501 (2009).
8.    Coben, R., Linden, M. & Myers, T. E. Neurofeedback for autistic spectrum disorder: A review of the literature. Appl. Psychophysiol. Biofeedback 35, 83–105 (2010).
9.    Van Hoogdalem, L. E., Feijs, H. M. E., Bramer, W. M., Ismail, S. Y. & Van Dongen, J. D. M. The Effectiveness of Neurofeedback Therapy as an Alternative Treatment for Autism Spectrum Disorders in Children: A Systematic Review. J. Psychophysiol. (2020). doi:10.1027/0269-8803/a000265