BlueCross and BlueShield of Montana Medical Policy/Codes
Biofeedback as a Treatment of Headache
Chapter: Medicine: Treatments
Current Effective Date: July 18, 2013
Original Effective Date: October 01, 1990
Publish Date: July 18, 2013
Revised Dates: July 19, 2012; April 26, 2013
Description

Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not normally considered to be under voluntary control. Biofeedback is frequently used in conjunction with other therapies (e.g., relaxation, behavioral management, medication) to reduce the severity and/or frequency of headaches.

Biofeedback involves the feedback of a variety of types of information not normally available to the patient, followed by a concerted effort on the part of the patient to use this feedback to help alter the physiological process in some specific way. Biofeedback training is done either in individual or group sessions, alone, or in combination with other behavioral therapies designed to teach relaxation. A typical program consists of 10 to 20 training sessions of 30 to 60 minutes each. Training sessions are performed in a quiet, non-arousing environment. Subjects are instructed to use mental techniques to affect the physiologic variable monitored, and feedback is provided for successful alteration of the physiologic parameter. This feedback may be signals such as lights or tone, verbal praise, or other auditory or visual stimuli.

The various forms of biofeedback differ mainly in the nature of the disease or disorder under treatment, the biologic variable that the individual attempts to control, and the information that is fed back to the individual. Biofeedback techniques include peripheral skin temperature feedback, blood-volume-pulse feedback (vasoconstriction and dilation), vasoconstriction training (temporalis artery), and electromyographic (EMG) biofeedback; these may be used alone or in conjunction with other therapies (e.g., relaxation, behavioral management, medication). In general, EMG biofeedback is used to treat tension headaches. With this procedure, electrodes are attached to the temporal muscles, and the patient attempts to reduce muscle tension. Feedback on achievement of a decrease in muscle tension is provided to the individual, reinforcing those activities (behaviors or thoughts) that are effective. Thermal biofeedback, in which patients learn to increase the temperature of their fingertips through the use of imagery and relaxation, is a commonly employed technique for migraine headaches. In this technique a temperature sensor is placed on the finger, and the subject is taught to increase peripheral vasodilation by providing feedback on skin temperature, an effect that is mediated through sympathetic activity. The combination of thermal biofeedback and relaxation training has also been used to improve migraine symptoms. The pulse amplitude recorded from the superficial temporal artery has also been used to provide feedback. Temporal pulse amplitude biofeedback has been used to treat both chronic tension type headaches and migraine headaches.

Regulatory Status

A variety of biofeedback devices are cleared for marketing through the U. S. Food and Drug Administration (FDA) 510(k) process. These devices are designated by the FDA as class II with special controls and are exempt from the premarket notification requirements. The FDA defines a biofeedback device as “an instrument that provides a visual or auditory signal corresponding to the status of one or more of a patient's physiological parameters (e.g., brain alpha wave activity, muscle activity, skin temperature, etc.) so that the patient can control voluntarily these physiological parameters.”

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Medically Necessary

BCBSMT may consider biofeedback medically necessary as part of the overall treatment plan for migraine and tension-type headache.  Initial coverage for these indications is limited to 20 training sessions.  Requests for additional sessions are subject to medical necessity review.

Not Medically Necessary

BCBSMT considers home use of biofeedback for treatment of headache not medically necessary.

Investigational

BCBSMT considers biofeedback for the treatment of all other types of headache, including cluster headache, experimental, investigational and unproven.

Rationale

A 2007 book chapter on integrative medicine states that biofeedback as part of a stress management program can provide significant benefit for patients with migraine and tension-type headache without side effects. (1) Meta-analysis of 25 controlled studies suggested that biofeedback is comparable to preventive pharmacotherapy. Another meta-analysis of 5 studies revealed a 37% improvement in headache symptoms associated with thermal biofeedback. There are no established criteria for predicting benefit, and the training requires a significant time commitment (e.g., 10 to 15 one-hour-long sessions plus home practice). Pharmacotherapy combined with biofeedback has not been studied for synergy. This is an important point because vascular reactivity (a major target in biofeedback training) may be modified by medications used for prevention (e.g., beta blockers), potentially limiting the effects of training.

In 2007 and 2008, Nestoriuc and colleagues published systematic reviews of biofeedback for migraine and tension-type headaches. (2, 3) The meta-analysis for treatment of migraine included 55 studies (randomized, pre-post, and uncontrolled) and 39 controlled trials, reporting a medium effect size of 0.58 (pooled outcome of all available headache variables) for treatment of migraine. (2) Effect sizes were computed using Hedges g, which refers to the mean difference between the experimental and control groups divided by the pooled standard deviation. For treatment of tension-type headaches, 53 studies met criteria for analysis; these included controlled studies with standardized treatment outcomes, follow-up of at least 3 months, and at least 4 patients per treatment group. (3) Meta-analysis showed a medium-to-large effect size of 0.73 that appeared to be stable over 15 months of follow-up. Biofeedback was reported to be more effective than headache monitoring, placebo, and relaxation therapies. Biofeedback in combination with relaxation was more effective than biofeedback alone, and biofeedback alone was more effective than relaxation alone, suggesting different elements for the two therapies. Although these meta-analyses are limited by the inclusion of studies of poor methodologic quality, the authors did not find evidence of an influence of study quality or publication bias in their findings.

Verhagen and colleagues published a systematic review of behavioral treatments for chronic tension-type headache in adults in 2009. (4) Eleven studies, including two studies with low risk of bias, compared biofeedback with waiting-list conditions. Results were found to be inconsistent due to low power, leading the authors to conclude that larger and more methodologically robust studies should be performed.

In one study, Martin et al. compared cognitive behavioral therapy (CBT) versus temporal pulse amplitude (TPA) biofeedback (8 weekly sessions plus homework) or waiting-list control among patients who volunteered for a study of psychological treatments. (5) Thirty patients with migraine and 21 with tension-type headaches were randomized to 1 of the 3 treatments; 51 completed the protocol (20% dropout) with no significant difference in loss to follow-up among the groups. Patient logs showed an average reduction in headaches of 68% for the CBT group, 56% for biofeedback, and 20% for the control condition. Clinically significant improvement, defined as at least 50% reduction in either headache rating or medication use, was observed in 78% of the CBT group, 63% of the biofeedback group, and 23% of the control group. The cognitive mediators (self-efficacy and locus of control) that had been hypothesized to underlie efficacy of both biofeedback and CBT were not found to be associated with improvement for either treatment. Statistical analysis was limited by the small group sizes.

Some studies indicate that the physiologic parameter "fed back" to the patient may not be related to the pathophysiology of headache. For example, Andrasik and Holroyd examined the correlation between success in controlling scalp muscle tension and the reduction in headache symptoms. (6) Thirty patients with tension headaches were taught to decrease, keep stable, or increase frontal muscle tension but were all led to believe that they were decreasing muscle tone. Despite changes in muscle tone in the intended direction, the degree of headache relief was the same in all groups. In another similar study, patients who were told that they were successful at decreasing muscle tension, regardless of the actual results, achieved greater reduction in symptoms. (7) Similar results were reported in patients with migraine undergoing thermal biofeedback. (8)

Children

A meta-analysis by Trautmann et al. in 2006 assessed psychological treatments of recurrent tension headache or migraine in children. (9) Three studies were included that compared relaxation combined with biofeedback versus relaxation training alone. In general, small standardized effect sizes (0, 0.5, and 0.25) were reported from the three studies for the addition of biofeedback on headache symptoms (frequency, intensity, and duration of headache). Small standardized effect sizes were also reported for clinically significant changes (i.e., greater than 50% reduction) in headache symptoms (0.20, 0.34, and 0). A 2006 systematic review of nonpharmacologic treatments for migraine concluded that the literature at that time did not show clear effectiveness of biofeedback for migraine in children. (10)

A 2009 Cochrane review evaluated psychological therapies for the management of chronic and recurrent pain in children and adolescents. (11, 12) Twenty-one randomized controlled trials (RCTs) met inclusion criteria for the analysis on headache, including three trials with biofeedback and relaxation training and three trials with biofeedback and cognitive training. Clinically significant pain reduction was found with biofeedback (odds ratio of 23.34), but there was no significant effect on disability or emotional functioning. The authors concluded that psychological treatments (including biofeedback as part of a treatment regimen) are effective in pain control for children with headache, and the benefits appear to be maintained.

In 2010, Gerber et al. reported an RCT of a multi-modal behavioral training program (n=19) compared to the “benchmark” of biofeedback (n=15) in pediatric patients 7 to 16 years of age with recurrent migraine and/or tension-type headache. (13) Patients with chronic daily headache (> 15 days per month) were excluded from the study. The multi-model behavioral educational group program included eight 90-minute sessions of training (diagnostic, educational, and behavioral) for the children and four 120-minute sessions for their parents. Children in the biofeedback group underwent electromyographic (EMG) and thermal biofeedback once per week for 20 sessions (total of 900 minutes of training). During treatment, 5 patients withdrew due to difficulty with adherence (4 from the biofeedback group). At 6 months, children’s diaries indicated a 47% decrease in the intensity of headaches after biofeedback but no significant difference in the frequency or duration of headaches. Diary results are limited by the low (40%) completion rate. Questionnaire results from parents and children indicated a decrease in headache duration, frequency, and intensity. Diaries of daily living activities and a pediatric quality-of-life questionnaire indicated that after treatment, the children were less disturbed by their headaches in the domains of school, homework, and leisure time. There were no significant differences between the treatments, although power analysis indicated that 50 patients per group would be needed to detect differences.

Earlier work includes a study by Kroner-Herwig et al. in fifty pediatric patients with either tension headaches or combined tension-migraine headaches. (14) Four treatment groups were created, based on combinations of the presence or absence of parental involvement in treatment and whether patients received either relaxation training or biofeedback. A waiting-list control group was also included. Several analytic approaches were used, one of which found biofeedback to have better effects on pain than relaxation. Another study by Bussone et al. compared biofeedback-assisted relaxation training in adolescents with a control group, finding better pain improvement in the former group. (15) Scharff et al. enrolled 36 children and adolescents and randomized them to hand-warming biofeedback, to hand-cooling biofeedback, or to a waiting list. (16) Patients treated with hand-warming biofeedback achieved greater degrees of clinical improvement than either of the other two groups. Hand-cooling biofeedback could be considered a placebo. Sartory et al. randomly assigned 43 children to either relaxation training plus stress management, biofeedback plus stress management, or drug therapy with a beta-adrenergic blocking agent. (17) Both the relaxation and biofeedback groups had better therapeutic outcomes than the drug therapy group.

Practice Guidelines and Position Statements

The National Institute of Neurologic Disorders and Stroke (2008) states that when headaches occur three or more times a month, preventive treatment is usually recommended.(18) “Drug therapy, biofeedback training, stress reduction, and elimination of certain foods from the diet are the most common methods of preventing and controlling migraine and other vascular headaches. Drug therapy for migraine is often combined with biofeedback and relaxation training.”

The American Academy of Family Physicians’ (AAFP) 2000 guidelines on preventive therapy for migraines, based on evidence review by the U.S. Headache Consortium, recommend relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback, and cognitive-behavioral therapy as treatment options for prevention of migraine (Grade A recommendation). (19, 20) Relaxation techniques and biofeedback may be combined with preventative drug therapy to achieve additional clinical improvement (Grade B recommendation). According to the guidelines, nonpharmacologic therapy may be well-suited for patients who have exhibited a poor tolerance or poor response to drug therapy, who have a medical contraindication to drug therapy, and who have a history of long-term, frequent or excessive use of analgesics or other acute medications. Nonpharmacologic intervention may also be useful in patients with significant stress or in patients who are pregnant, are planning to become pregnant, or are nursing.

The American Academy of Neurology’s (AAN) recommendations for the evaluation and treatment of migraine headaches states that behavioral and physical interventions are used for preventing migraine episodes rather than for alleviating symptoms once an attack has begun. (21) Although these modalities may be effective as monotherapy, they are more commonly used in conjunction with pharmacologic management. Relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy may be considered treatment options for prevention of migraine. Specific recommendations regarding which of these to use for specific patients cannot be made.

In 2010, the European Federation of Neurological Societies (EFNS) gave an A-level recommendation for use of EMG biofeedback for the treatment of tension-type headache, based on the meta-analysis by Nestoriuc et al. (3, 22) The guidelines state that the aim of EMG biofeedback is to help the patient to recognize and control muscle tension by providing continuous feedback about muscle activity. Sessions typically include an adaptation phase, baseline phase, training phase, during which feedback is provided, and a self-control phase, during which the patient practices controlling muscle tension without the aid of feedback.

Summary

Biofeedback is a technique intended to teach patients self-regulation of certain physiologic processes not normally considered to be under voluntary control and is frequently used in conjunction with other therapies (e.g., relaxation, behavioral management, medication) to reduce the severity and/or frequency of headaches. Based on physician specialty society recommendations and the evidence available at this time, biofeedback may be considered medically necessary to treat migraine and tension-type headaches when included in a comprehensive treatment program. Evidence is insufficient to evaluate the effect of biofeedback on cluster headaches. Biofeedback, along with other psychological and behavioral techniques, such as relaxation training, may be particularly useful for children, pregnant women, and other adults who are not able to take medications.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

94.39, 307.81, 339.00-339.89, 346.00-346.93, 784.0

ICD-10 Codes

G43.001, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111,G43.119, G43.401,G43.409, G43.411, G43.419, G43.501, G43.509, G43.511, G43.519, G43.601, G43.609, G43.611, G43.619, G43.701, G43.709, G43.711, G43.719, G43.801, G43.809, G43.811, G43.819, G43.821, G43.829, G43.831, G43.839, G43.901, G43.909, G43.911, G43.919, G43.A0, G43.A1, G43.B0, G43.B1, G43.C0, G43.C1, G43.D0, G43.D1, G44.001, G44.009, G44.011, G44.019, G44.021, G44.029, G44.031, G44.039, G44.041, G44.049, G44.051, G44.059, G44.091, G44.099, G44.1, G44.201, G44.209, G44.211, G44.219, G44.221, G44.229, G44.301, G44.309, G44.311, G44.319, G44.321, G44.329, G44.40, G44.41, G44.51, G44.52, G44.53, G44.59, G44.81, G44.82, G44.83, G44.84, G44.85, G44.89, R51, GZC9ZZZ

 
Procedural Codes: 90875, 90876, 90901, E0746
References
  1. Mann JD, Coeytaux RR. Migraine and tension-type headache. In: Rakel D, ed. Integrative Medicine, 2nd edition. Philadelphia: Saunders Elsevier; 2007.
  2. Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain 2007; 128(1-2):111-27.
  3. Nestoriuc Y, Rief W, Martin A. Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J Consult Clin Psychol 2008; 76(3):379-96.
  4. Verhagen AP, Damen L, Berger MY et al. Behavioral treatments of chronic tension-type headache in adults: are they beneficial? CNS Neurosci Ther 2009; 15(2):183-205.
  5. Martin PR, Forsyth MR, Reece J. Cognitive-behavioral therapy versus temporal pulse amplitude biofeedback training for recurrent headache. Behav Ther 2007; 38(4):350-63.
  6. Andrasik F, Holroyd KA. Specific and nonspecific effects in the biofeedback treatment of tension headache: 3-year follow-up. J Consult Clin Psychol 1983; 51(4):634-6.
  7. Holroyd KA, Andrasik F, Noble J. A comparison of EMG biofeedback and a credible pseudotherapy in treating tension headache. J Behav Med 1980; 3(1):29-39.
  8. Gauthier J, Doyon J, Lacroix R et al. Blood volume pulse biofeedback in the treatment of migraine headache: a controlled evaluation. Biofeedback Self Regul 1983; 8(3):427-42.
  9. Trautmann E, Lackschewitz H, Kroner-Herwig B. Psychological treatment of recurrent headache in children and adolescents--a meta-analysis. Cephalalgia 2006; 26(12):1411-26.
  10. Damen L, Bruijn J, Koes BW et al. Prophylactic treatment of migraine in children. Part 1. A systematic review of non-pharmacological trials. Cephalalgia 2006; 26(4):373-83.
  11. Eccleston C, Palermo TM, Williams AC et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev 2009; (2):CD003968.
  12. Palermo TM, Eccleston C, Lewandowski AS et al. Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: an updated meta-analytic review. Pain 2010; 148(3):387-97.
  13. Gerber WD, Petermann F, Gerber-von Muller G et al. MIPAS-Family-evaluation of a new multi-modal behavioral training program for pediatric headaches: clinical effects and the impact on quality of life. J Headache Pain 2010; 11(3):215-25.
  14. Kroner-Herwig B, Mohn U, Pothmann R. Comparison of biofeedback and relaxation in the treatment of pediatric headache and the influence of parent involvement on outcome. Appl Psychophysiol Biofeedback 1998; 23(3):143-57.
  15. Bussone G, Grazzi L, D'Amico D et al. Biofeedback-assisted relaxation training for young adolescents with tension-type headache: a controlled study. Cephalalgia 1998; 18(7):463-7.
  16. Scharff L, Marcus DA, Masek BJ. A controlled study of minimal-contact thermal biofeedback treatment in children with migraine. J Pediatr Psychol 2002; 27(2):109-19.
  17. Sartory G, Muller B, Metsch J et al. A comparison of psychological and pharmacological treatment of pediatric migraine. Behav Res Ther 1998; 36(12):1155-70.
  18. National Institute of Neurologic Disorders and Stroke. NINDS Headache information page. Available online at: http://www.ninds.nih.gov . Last accessed June 2012.
  19. Morey SS. Practice guidelines of the American Academy of Family Physicians. Guidelines on migraine: part 4. General principles of preventive therapy. Am Fam Physician 2000; 62(10):2359-60, 63 Available at: <http://www.aafp.org>. Last accessed June 2012.
  20. Campbell JK, Penzien DB, Wall EM et al. Evidenced-based guidelines for migraine headache: behavioral and physical treatments. 2000. Available online at: http://www.aan.com . Last accessed June 2012.
  21. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55(6):754-62.
  22. Bendtsen L, Evers S, Linde M et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol 2010; 17(11):1318-25.
  23. Biofeedback as a Treatment of Headache. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (April 2012) Medicine 2.01.29.
History
July 2012 Policy updated with literature review through February 2012; references 13, 18, and 23 added; references reordered; policy statements include medical necessary and not medically necessary criteria; information about number and length of treatment sessions added to policy guidelines
April 2013 Policy formatting and language revised.  Policy statement unchanged.
BCBSMT Home
®Registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. ®LIVE SMART. LIVE HEALTHY. is a registered mark of BCBSMT, an independent licensee of the Blue Cross and Blue Shield Association, serving the residents and businesses of Montana.
CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Biofeedback as a Treatment of Headache