JEFFREY A. CARMEN, PH.D. MANLIUS, NY

1. JEFFREY A. CARMEN, PH.D.MANLIUS, NY ISNR Progress in Biofeedback in Application to Migraine August, 28, 2008 7:30pm

2. DVD HANDOUT • Lots of useful information. • Most important part is International Headache Society diagnostic system. • Distributed with permission.

3. pIR HEG • Efficacy. Very high. Similar to peripheral vascular training but much faster – fewer sessions – more rapid reductions • 10 to 15 minutes in one session to “turn off” a migraine. This requires a re-evaluation of theoretical mechanisms of migraine. • 6 sessions for a 90% prophylaxis rate for symptom reduction to where the migraine sufferer has a difficult time telling if the headache was a migraine or not. I have now accumulated over 200 “relatively clean” migraine cases. The original observation of 6 sessions for a cutoff still holds.

4. pIR HEG (continued) • As the number of sessions increases, migraines progressively “soften”. The migraine “events” probably never stop, but they become difficult to detect. • This is “management” not “cure”. There is no specific treatment stopping point. Sessions are spread out farther and farther based on symptom stability and patient comfort levels. • It is expected that migraines will return under extreme stress such as college (drinking, variable sleep, exam stress, etc.). Refresher sessions bring control back quickly.

5. NEGATIVE ASPECTS TO MIGRAINES • They usually hurt a lot. • They disrupt daily life activities. • They increase the risk for both occlusive and hemorrhagic stroke, and may be a risk factor for cardiovascular disease.

6. POSITIVE ASPECTS TO MIGRAINES • This is my own speculation: 50,000 years ago, migraines may have worked as an efficient detection system for rapid reduction in barometric pressure (storm detection).

7. DIAGNOSIS OF MIGRAINE • INTERNATIONAL HEADACHE SOCIETY DIAGNOSTIC CRITERIA (HANDOUT) • I.H.S. CRITERIA IS FOR RESEARCH • MIGHT BE A LITTLE TOO STRONG FOR CLINICAL WORK

8. MORE GENERAL DIAGNOSTIC CRITERIA FOR CLINICAL WORK • A headache that hits at the end of a hard day or hard week is probably migraine. (Tension-Type headaches tend to rise with stress and decrease as stress decreases.) • A headache that hits just before a big storm moves in is probably migraine. • A headache that hits just before the menstrual period begins is likely to be a migraine. • With a migraine, pain is optional.

9. WHAT IS KNOWN WITH SOME CERTAINTY • Migraines and Tension-Type headaches are probably different in terms of pathophysiology. • Migraines represent a cluster of slightly different entities with different genes involved. • Cortical Spreading Depression appears to be validated. • Attacks originate from a mechanism that involves the trigeminal nerve, the brainstem, and to some extent the vascular system. • They can be managed, but the essential condition or predisposition does not go away. Think “management” not “cure”.

10. MORE • Migraines are a brain event, similar to a seizure. • Migraines have two major stages: • 1. Silent with or without definable aura. The aura is usually visual but may be auditory, cognitive, emotional. • 2. Headache.Note: not all migraines have the second stage. Some people only have the first stage. • Migraines without aura may (probably) still have a first stage, but it may be difficult to identify.

11. INTERESTING COGNITIVE ASPECTS • 1ST stage may last a long time, hours to days, possibly weeks. • Symptom may be “floating” learning disabilities. • This may be the case for a person who has a bad day or two in school, then gets a bad headache, then is fine.

12. EFFICACY MEASURES FOR MIGRAINE INTERVENTION • FREQUENCY - unreliable • INTENSITY – subject to “drift” • DURATION – somewhat reliable but most people sleep migraines off so don’t know when they quit • These are potentially useful but also problematic

13. PAIN LEVEL CUTOFF • For my work I use the criteria of the point at which the person has difficulty telling if the headache they just had was a migraine or not. • Nice practical working measure.

14. BIOFEEDBACK INTERVENTIONS • HISTORIC: Gold Standard – peripheral thermal training – temperature sensor on finger – effective training for increase but also works by training for a decrease of finger temperature. • Based on vascular theory of migraine, which turned out to be an incorrect theory. • Valid treatment based on invalid theory.

15. HISTORIC PERIPHERAL THERMAL TECHNOLOGY • Physical analog meter. Needed log response to increase resolution. Good to .1 degree with electronic enhancements beyond. Very effective

17. BIOFEEDBACK INTERVENTIONS • MORE RECENT • EEG (electron based Electroencephalography feedback) – feeding back brain wave data. • HEG (photon based Hemoencephalography feedback) – feeding back brain blood flow data. • These methods are at least as effective as peripheral thermal training, but tend to produce stable effects much more quickly. It is possible that the effect is also stronger due to improved frontal inhibition.

18. EEG • Covered by the other presenters in this symposium: • Siegfried Othmer, Ph.D. • Deb Stokes, Ph.D.

19. HEG (PIR format) • Developed by me about 10 years ago, to apply infrared detection to peripheral and central vascular function. Measures the thermal waste product of brain metabolism. • Originally applied to migraines to train a reduction in excessive cerebral blood flow. (Based on the old vascular theory of migraine.) Did not work! • Applied to forehead train an increase did work. • The probable reason it works has to do with chopping off the head of a chicken!

21. The function of a chicken’s brain becomes evident when it is slaughtered the old fashioned way, by chopping the head off with an axe on a chopping block. The chicken jumps up, runs around, flaps its wings, makes noises, and jumps in the air. Then it drops motionless. The reason is that much of the function of the chicken brain is to inhibit automatic actions. Chickens are not noted for their intelligence. Most of their behavior is automatic based on genetic programming. • Humans are somewhat similar. The human brain, while massively more intelligent than a chicken’s brain has some similar inhibiting functions. In this case, the frontal lobes of the human brain relate to the rest of the human brain in a manner similar to the way the whole chicken brain relates to the rest of the chicken’s body. • Damage to the front of the human brain, or chronic disuse, results in a reduction of inhibition. Under conditions of stress, the inhibiting functions of the human brain are supposed to temporarily turn off to allow emergency “fight or flight” responses. Under conditions of chronic stress the frontal inhibiting functions remain inactive. This normal inhibition is useful and in fact necessary for the maintenance of brain stability. Reduced frontal inhibition allows the already irritable migraine brain to erupt into a full blown migraine headache.

22. pIR HEG HEADSET

23. TECHNICAL NOTES • The headset is the core of the pIR HEG system. It picks up infrared radiation from the forehead in a uniform 1.5 by 1.9 inch rectangular field of view. This infrared output increases when the person concentrates intensely with simultaneously relaxed emotions. Exercising this mechanism has the effect of maintaining increased brain stability. This also has the effect of making the migraine mechanism “sloppy”, producing headaches that are less intense or with no pain at all. The person still retains the genetic predisposition for migraines, and in fact will still have migraines but they are much less troublesome. Sometimes they are evidenced only by painless “events” that require careful self observation to detect.

24. SCREEN SHOT

25. TECHNICAL NOTES • The software regulates the interaction between the hardware and the computer. It produces a situation in which the person’s mental state must flip back and forth between a passive mental state and an active mental state. This helps encourage a flexibility of brain responses, based on situational demands. It also encourages a dominance of the frontal inhibition systems.

26. PIR HEG CHARACTERISTICS 1. Infrared (unlike a contact sensor, there is no alteration of the thermal characteristics of the source). • 2. Fast response time (< 80ms) • 3. Field of view. Flat field of view, 1.5 inches high by 1.9 inches wide. Picks up large area of brain activity.

27. AN UNUSUAL CASE DIAGNOSED AS “STATUS MIGRAINE” FOR SIX MONTHS

28. The preceding infrared image is unusual in that typically the headaches don’t throw off that much surface heat. Yellow color indicates excessive thermal activity and in this case correlates with the area of extreme pain. • Frontal pIR HEG training quieted it down to the level seen in the next image. • Pain levels approximated the intensity of the image. • There was minimal response until session #6.

29. POST SESSION IMAGE

30. DETAILS • On a 0 to 10 pain scale, his first image was rated at “10”. The post session image reflects a pain level of “3 to 4” on the same scale. • Pain scales are notoriously unreliable, although they do reflect perception of discomfort. Regardless, dropping from “10” to “3 to 4” represents a significant change. • This particular manifestation of his headache activity eventually quieted down to a pain level of zero and his headaches stopped being chronic. However he persisted in producing periodic migraine headaches for several months by which time they were reduced to a non troublesome status.

31. CAVEAT • People don’t lose the ability to generate migraines. This young man stayed reasonably well controlled until he went off to college. College life is not consistent with easy migraine management. They did return, although as intermittent rather than status migraine. They were also relatively easy to pull back under control.

32. Left temporal migraine • Intense, throbbing pain

33. Pain gone • 25 minutes, pirheg at Fpz

34. What do all these methods have in common? • There are three biofeedback methods that stand out over other methods as having a repeatable positive effect on migraine management. These are: • Peripheral thermal training • Passive Infrared training on the forehead • EEG feedback • The likely commonality among these three methods is that they all help quiet excessive brain irritability. PIR HEG and EEG biofeedback appear to have the additional effect of improving frontal inhibition. Ultimately as the strength of inhibitory mechanisms increases, it becomes more difficult for the migraine mechanism to generate a “high quality migraine”. It gets “clumsy”.

35. MIGRAINE TREATMENT REALITY • Migraines probably do not get fixed or go away. • If questioned carefully, most people will still have “events” the under the same conditions they used to have “migraines”.

36. THIS IS THE END • Thanks very much for coming.