Cognitive-Behavioral Therapy, Meditation, and Biofeedback

Many people feel that they do not have time to engage in cognitive techniques. They don’t seem to understand that the busier they are the more they would benefit from meditation and relaxation training. Zen Buddhists say that you should meditate 20 minutes a day, unless you are too busy, in which case you should meditate for an hour.

Cognitive and behavioral techniques provide a change from external to internal locus of control where patients no longer feel helpless in the face of their illness and stress, but instead gain a measure of some control over their condition. The most widely used behavioral treatments for headache include relaxation therapy, biofeedback therapy, and cognitive-behavioral/stress-management therapies. These approaches can be used in combination with pharmacologic and other non-pharmacologic therapies. Relaxation and biofeedback training enable patients to recognize, and learn to control, headache-related physiologic responses.

These are the goals of cognitive-behavioral therapy:

– Attempt to foster an internal locus of control and modify distress-related thoughts

– Rehearse adaptive cognitive and behavioral responses to the development of a migraine

– Accurately interpret body signals

– Develop “action plans”

– Reduce anxiety and depression

– Recognize triggers

An excellent website for self-administered cognitive-behavioral therapy, which is free or costs $50-$60 per course, is They have modules for anxiety, health-related anxiety, depression, PTSD, chronic pain, insomnia, and other.

While self-taught relaxation techniques may be equally effective, biofeedback offers the advantage of having a “personal coach” teaching, motivating and supervising the process. As few as three biofeedback sessions can be effective, although a typical course involves about 10 sessions. The sessions consist of learning relaxation and breathing techniques which allow you to learn to control physiological functions which are normally not under conscious control. Feedback from a temperature or electromyography probe is typically displayed on a computer monitor. Neurofeedback is another version of biofeedback where patients monitor and alter their brain wave patterns. Patients are often impressed by their newfound ability to control the line on a computer screen purely by thoughts.

With regular practice you do not need to rely on visual feedback and become able to control tension in their body without effort. Biofeedback has been shown to be effective for both migraine and tension-type headaches. In one biofeedback study with five-year follow-up, 80-90% of migraine and tension-type headache patients reported continued benefit following a single course of biofeedback.

Meditation is an excellent substitute for biofeedback, but just like biofeedback requires regular practice and patience. You can learn how to meditate using apps, such as 10% Happier, Headspace, or Calm, free podcasts at, books, such as Mindfulness in Plain English by Gunaratana, or in-person classes. Patients often tell me “meditation is not for me”, “I just could not do it”, “my mind is always racing and I can’t stop it”, “I tried and failed”, but all you have to do is just keep doing it. When you start meditating it does seem like a waste of time, but if you persist and sit for 10-20 minutes every day, after a few weeks you will notice a change. At first, you may be able to stop thinking for 5 seconds, then for longer and longer periods of time. Very few people can go for more than 5-10 minutes without a single thought, but this is perfectly sufficient to reap significant benefits.