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100 CHAPTER 5 CHRONIC TTH ANALYSIS BY EMG AND GSR BIOFEEDBACK

decrease in the number of red bars and an increase in the number of green bars indicated a decrease in
stress or tension (increase in skin resistance). The EMG was similar to auditory feedback, i.e., in the
form of clicks that became a continuous noise with an increase in stress and to no sound with relaxation.
The training was given at 2% sensitivity with actual GSR. Throughout the training sessions, no changes
in sensitivity were made.
Skin preparation was done prior to attachment of electrodes by cleaning the skin using a spirit-
soaked cotton pad. After skin preparation, surface EMG electrodes (Ag-AgCl, triode electrodes) were
applied 2.5cm above the center of each eyebrow [19] and the GSR electrodes were applied on the mid-
dle phalanx of the index and ring finger [20]. Both EMG and GSR BF electrodes were placed on all the
subjects including the control group irrespective to which group they belonged or what training they
received. The subjects were unaware of whether they were receiving EMG BF or GSR BF. The inves-
tigator was aware of the group that the subject belonged to and instructed the subject accordingly.
Both EMG and GSR BF auditory groups received only respective auditory feedback. The subjects
were instructed to reduce the tone and frequency of the sound, which would help them achieve relax-
ation. During the session, the monitor on which the visual display was present was moved away from
the field of vision of the subject.
Similarly, both EMG and GSR BF visual groups were instructed to reduce the number of glowing
bars. In the case of GSR, they were instructed to decrease the number of red bars and increase the num-
ber of green bars to indicate relaxation. During the treatment session, the volume of the auditory tone
was muted.
Both EMG and GSR audio-visual groups were instructed to lower the tone and frequency of sound
and also decrease the number of bars simultaneously.
Subjects in the control group were not asked to manipulate either the visual or auditory display.
They were only informed that their stress levels were being recorded through the machines.
The subjects were instructed to practice relaxation at home, both during the course of therapy and at
the end of 15 sessions, in a way similar to the relaxation during the biofeedback therapy sessions. How-
ever, compliance of the subjects in the home program was not monitored. All subjects were allowed to
take the medications prescribed by their treating physicians, especially if they were preventive/prophy-
lactic medications. They were requested to avoid taking any analgesic/abortive/palliative medication
unless the headache was unbearable.

5.6.7 OUTCOME PARAMETERS
5.6.7.1 Primary variables
As per the recommendations of the American Headache Society Behavioral Clinical Trials Workgroup,
2005 [21] of the primary variables selected for our study were: medium size of frequency, duration, and
intensity of headache per week.
The HIS has issued guidelines for the headache for controlled way of drug treatment of tension type
chronic headache.
As per [22], the recommendation for headache frequency reporting favors metaanalyses and other
comparisons across studies and its various interventions are consistent with the HIS guidelines for
controlled trials of drug treatments [23,24].