Edward Lichten, M.D.,PC
555 S. Old Woodward Avenue Suite 700
Birmingham, MI 48009 

Email: drlichten



Lecturer #1: Seymour Diamond, M.D.,
Director, Diamond Headache Clinic, Chicago, Illinois
Director, Inpatient Headache Unit, Columbus Hospital
Adjunct Professor of Pharmacology and Molecular Biology, The Chicago Medical School
Phone contact@ 1-800-HEADACH
Novi Headache Symposium 1994



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The treatment of pain concerns every practitioner. This article is one of series alerting the physician to recent trends and theories in the management of a common problem.

If I were to choose between pain and nothing, I would chose pain. William Faulkner.


Each year 550 million workdays are lost in the United States because of pain, which is probably the principal compliant presented by patients and the major determinant in their to consult a physician. A recent survey by Louis Harris and Associates deline ated this loss according to type of pain.[1]

  • 155 million workdays lost annually- Headache
  • 107 million workdays lost annually- Joint pain
  • 98 million workdays lost annually- Stomach pain
  • 89 million workdays lost annually- Back pain
  • 58 million workdays lost annually- Muscular pain
  • 22 million workdays lost annually- Menstrual pain
  • 13 million workdays lost annually- Dental pain

Reaction to chronic pain varies greatly. I have observed patients who function well despite tremendous pain and others who are devastated or completely disabled by it. Although a plethora of methods is available for direct treatment, including analgesi cs, narcotics, tricyclic antidepressants, biofeedback, transcutaneous stimulation, surgery, and acupuncture, a reliable regime for relief of chronic pain remains elusive.

Management of patients refractory to traditional methods of pain relief is difficult. A recent study described 90 patients who were trained for 10 weeks in a mindfulness-meditation program that integrated stress reduction and relaxation approaches. On an intensive daily basis, patients practice meditation and were encouraged to employ this technique in coping with stress and pain. Various pain indexes were used to make pre- and post-innervation assessments; patient gender and type of pain were not con sidered as variables in the final results.

The following were significantly reduced as a result of training; pain outcome, mean number of symptoms during the preceding month, and incidence of mood disturbances and psychological symptomatology. The incidence of anxiety and depression decreased th e most. Of 39 patients who used drugs to control pain before starting the program of meditation, relaxation, and stress reduction, 17 reported decreased intake of medication. At the end of the treatment period, 11 of 17 patients indicated that they rare ly used medication. Interestingly, with the exception of present moment pain, improvements observed during the meditation period were maintained for up to 15 months after training was completed.

Many patients stressed the importance of continuing to practice meditation techniques. Patients who were most responsive fell into two groups of equal size. In the first group, pain was greatly reduced or eliminated. In the second group. patients repo rted that although the pain continued, their fear, self-pity, and willingness to permit pain or fear of pain to restrict their activities were decreased.

The authors compared the results in these patients to those in 21 patients who had conventional therapy and were not trained in any form of self-regulation. The comparison group reported little relief of pain or its effects.

Headache is the most common cause of lost workdays in the United States. Most generalists find that muscle contraction is the cause of headache in 90% of patients, vascular conditions (including migraine and cluster headaches) in 8%, and an organic basi s in 2%. In many of these patients, behavioral approaches offer a powerful alternative to the use of medication.

For the past 15 years, biofeedback has been employed at the Diamond Headache Clinic in Chicago, to treat headache on both an outpatient and inpatient basis. Most patients are referred by their physicians because of recurring pain or because they are hab ituated to analgesics, barbiturates, tranquilizers, or ergot alkaloids. In two retrospective studies, we reported the excellent response to biofeedback, meditation, and progressive relaxation techniques by patients refractory to traditional therapy. Thes e techniques also may augment other treatment including use of analgesics and antidepressants.

Studies of the long-term efficacy of biofeedback-behavioral programs are scarce. A recent survey conducted by the Ochsner Clinic, New Orleans, assessed results of a specific biofeedback-behavioral program for muscle contraction headaches 20 months after completion. The study examined the relationship of a personality variable (expectation of control) to alleviation of headache through self-regulation. The concept of an internal locus of control reflects the extent to which individuals perceive reinforci ng or punishing events to be related to their own actions. It was hypothesized that patients with an internal locus of control would be more likely to use self-control methods over bodily functions and rate biofeedback-behavioral programs higher than woul d persons with external orientation, who assume that reinforcing events result from chance, the acts of other, more powerful individuals, or fate.

Of 114 persons contacted, 74 (65%) completed the questionnaire. Of these 74 patients 82% achieved and maintained a significant decrease in the overall headache severity and duration for the 20 month period. Personnel who benefited from biofeedback were usually under 40 years of age, as we had also noted in our previous studies. The results of the Ochsner study was encouraging because the Pain Locus of Control Scale appears to be extremely effective in predicting which patients will be successful with biofeedback behavioral programs or other self regulation techniques.


Diamond Headache Questionnaire

1.  Which statement best describes the frequency of your headaches?
_____more than one a day    _____one a week ____one/ month
_____fewer than 1/2-3 mon   _____one a day  ____one per month
2.  Place a check by the statement that best describes the
    pain level of your typical headache.
_____no headache    _____headache, but can be ignored
_____headache, cannot be ignored, but does not interfere daily
_____headache, cannot be ignored, interferes with concentration
_____headache, cannot be ignored, interferes everything except basics 
_____headache, cannot be ignored, bed rest required
3.  Which symptoms accompany your usual headache?
_____loss of appetite   _____dizziness  _____vision problem
_____Mood change        _____vomiting   _____nausea
4.  Do any relatives have server or recurring headaches?
_____Mother _____Father _____Brother/sis _____Grandparent
5.  Check the appropriate box  

QuestionAlwaysVery OftenUncertainSeldomNever
Headache begin on the side of the head? _ __ _ _
Is the pain greater on one side? _ __ _ _
Do noise/ lights make headache worse? _ __ _ _
Does your headache throb? _ __ _ _
Change from one side to the other? _ __ _ _
Get very depressed during headache? _ __ _ _
Arms/legs get cold during headache? _ __ _ _
Eyes moisten, itch, burn ...headache? _ __ _ _
Have stomach pains during headache? _ __ _ _
Lose your appetite during...headache? _ __ _ _
Is the pain on both sides of head? _ __ _ _
Does the pain feel like a tight band? _ __ _ _
Pain increase with head movement? _ __ _ _
Do you wake with headaches? _ __ _ _
Does your headache awaken you at night? _ __ _ _
Does your headache get better lying down? _ __ _ _
Headaches begin in AM, worse in PM? _ __ _ _
. Headache associated with weather change? _ __ _ _
Headaches caused by tension/stress? _ __ _ _
Interferese with regular activities? _ __ _ _


  1. Harris L. Nurprin pain report. Press release. October 22, 1985.
  2. Hahat-Zian J, Lipworth L, Nufney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behavioral Medicine 1965:5:163-190.
  3. Diamond S, Medina JL, Diamond-Falls JL, The value of biofeedback in the treatment of chronic headache: a five-year retrospective study. Headache 1979;19:90.
  4. Diamond S, Matthews D. The value of biofeedback in the treatment of chronic headache: a four-year retrospective study. Headache 1984;24:5-18.
  5. Hudzinski LG, Levinson FL. Biofeedbck behavioral treatment of headache with locus of control pain analysis: a 20 month retrospective analysis. Headache 1985;5:390-6.

More Articles by Seymour Diamond:

  1. New Advances in Migraine Diagnosis and Treatment
  2. Biofeedback- Treatment for Migraine

Revised: January 1, 2011