Resolving a chronic headache with posture feedback and breathing

This blog describes the process by which a 32 year old woman student’s chronic headaches  that she had since age eighteen was resolved in a single coaching session. The student suffered two or three headache per week a week which initially began when she was eighteen after using digital devices and encouraged her to slouch as she looked down.  Although she describes herself as healthy, she reported having high level of anxiety and occasional depression. She self-medicated with 2 to 10 Excedrin tablets a week. It is possible that the chronic headaches could partially be triggered by caffeine withdrawal which get resolved by taking more Excedrins (Greben et al., 1980) since Excedrin contains 65 mg of caffeine as well as 250 mg of Acetaminophen which can be harmful to liver function (Bauer et al., 2021). 

The behavioral coaching intervention

During the first day in class, the student approached the instructor and she shared that she had a severe headache.  During their conversation, the instructor noticed that she was breathing in her chest without abdominal movement, her shoulders were held tight, her posture slightly slouched and her hands were cold. As she was unaware of her body responses, the instructor offered to guide her through some practices that may be useful to reduce her headache. The same strategies could also be useful for the other students in the class; since, headaches, anxiety, zoom fatigue, neck and shoulder tension, abdominal discomfort, and vision problems are common and have increased as people spent more time in front of screens (Charles et al., 2021;  Ahmed et al., 2021;  Bauer, 2021; Kuehn, 2021; Peper et al., 2021 ).

These symptoms may occur because of bad posture, neck and shoulder tension, shallow chest breathing, stress and social isolation (Elizagaray-Garcia et al., 2020; Schulman, 2002).  When people become aware of their dysfunctional somatic patterns and change their posture, breathing pattern, internal language and implement stress management techniques, they often report a reduction in symptoms such as irritable bowel syndrome, acid reflux, neck and shoulder tension, or anxiety (Peper et al, 2017a; Peper et al, 2016a). Sometimes, a single coaching session can be sufficient to improve health.

Working hypothesis: The headaches were most likely tension headaches and not migraines and may be the result of chronic neck and shoulder tension which was maintained during chest breathing and the slouched head forward body posture.  If she could change her posture, relax her neck and shoulders, and breathe diaphragmatically so that the lower abdomen widen during inhalation, most likely her shoulder and neck tension would decrease.  Therefore, by changing posture from a slouched to upright position combined with slower diaphragmatic breathing, the muscle tension would be reduced and the headaches would decrease.

Breathing and posture changes

She was encouraged to sit upright so that the abdomen had space to expand (Peper et al., 2020).  In addition, she needed to loosen the clothing around her waist to provide room for her abdomen to expand during inhalation instead of her chest lifting (MacHose & Peper, 1991). Allowing abdominal expansion can be challenging  for many paticipants since they are self-conscious about their body image, as well holding their stomach in as  an unconscious learned response to avoid pain after having had abdominal surgery, or as an automatic protective response to threat (Peper et al., 2015).  The upright position also allowed her to sit tall and erect in which the back of head reaches upward towards the ceiling while relaxing and feeling gravity pulling her shoulders downward and at the same time relaxing her hips and legs.

With guided verbal and tactile coaching, she learned to master slower diaphragmatic breathing in which she gently and slowly exhaled by making a sound of pssssssst (exhaling through pursed lips) which tends to activate the transverse and oblique abdominal muscles and slightly tighten the pelvic floor muscles so that her lower abdomen would slightly constrict at the end of the exhalation (Peper et al., 2016). Then, by allowing the lower abdomen and pelvic floor relax so that the abdomen could expand in 360 degrees, inhalation occurred.

While practicing the slower breathing in this relaxed upright position, she was instructed to sense/imagine feeling a flow of down and through her arms and out her hands as she exhaled (as if the air could flow through straws down her arms). After a few minutes, she felt her headache decrease and noticed that her hands had warmed.  After this short coaching intervention, she went back to her seat in class  and continued to practice the relaxed effortless breathing while sitting upright and allowing her shoulders to melt downward.

The use of muscle feedback to demonstrate residual covert muscle tension

During class session, she volunteered to have her trapezius muscle monitored with electromyography (EMG).  The EMG indicated that her muscles were slightly tense even though she reported feeling relaxed.  With a few minutes of EMG biofeedback exploration, she discovered that she could relax her shoulder muscles by feeling them being heavy and melting.

Implementing home practice with a posture app

As part of the class homework, she was assigned a self-study for two weeks with the posture feedback app, Dario Desktop.  The app uses the computer/laptop camera to monitor posture and provides visual feedback in a small window on the computer screen and/or an auditory signal each time she slouches as shown in Figure 1.

Figure 1. Posture feedback to signal to participant that the person is slouching.

To observe the effect of the posture breathing training, she monitored her symptoms for three days without feedback and then installed the posture feedback application on her laptop to provide feedback whenever she slouched. The posture feedback reminded her to practice better posture during the day while working on her computer and also do a few stretches or shift to standing when using the computer for an extended period of time. Each time the feedback signal indicated she slouched, she would sit up and change her posture, breathe lower and slower and relax her shoulders.

She also monitored what factors triggered the slouching. In additionally, she added daily reminders to her phone to remind her of her posture and to stretch and stand after each hour of studying.  After two weeks she recorded her symptoms for three days for the post assessment without posture feedback.

Results

The chronic headache condition which had been present for fourteen years disappeared and she has not used any medication since the first day of class. She reported after two weeks that her shoulder and back discomfort/pain, depression, anxiety and lack of motivation decreased as shown in Figure 2.  At the fourteen week follow up, she continues to have no headaches and has not used any medication.  

Figure 2.  Changes in symptoms after implementing posture feedback for two weeks.

She used the desktop posture app every time she opened her laptop at home as often as 3-5 times per day (roughly 2-6 hours).In addition, when she felt beginning of discomfort or thought she should take medication, she would adjust her posture and breathe. While using the app, she identified numerous factors that were associated with slouching as shown in Figure 3.

Figure 3. Behaviors associated with slouching.

Discussion

The decrease in depression, anxiety and increase in motivation may be the direct result of posture change; since, a slouched position tends to  increase hopeless, helpless and powerless thoughts while  the upright position tends to increase subjective felt energy and easier access to empowering and positive thoughts (Peper et al., 2017b; Veenstra et al., 2017; Wilson & Peper, 2004; Tsai et al., 2016).  Most likely, a major factor that contributed to the elimination of her headaches was that she implemented changes in her behavior. One major factor was using posture feedback tool at home to remind her to sit tall and relax her shoulders while practicing slower diaphragmatic breathing. As she noted, “Although it was distracting to be reminded all the time about my posture, it did decrease my neck pain. With the pain reduction, I was able to sit at the computer longer and felt more motivated.”

The combination of slower lower abdominal breathing with the upright posture reversed her protective/defensive body position (tightening the muscle in the lower abdomen and pelvic floor and pressing the knees together while curling the shoulder forward for protection).  The upright posture creates a position of empowerment and trust by which the lower abdomen could expand which supported health and regeneration.  In addition, the upright posture allowed easier access to positive thoughts and reduced recall of hopeless, powerless, defeated memories.  It is also possible that caffeine withdrawal was a co-factor in evoking headaches (Küçer, 2010). By eliminating the medication containing caffeine, she also eliminated the triggering of the caffeine withdrawal headaches.

This case example suggests that health care providers first rule out any pathology and then teach behavioral self-healing strategies that the clients can implement instead of immediately prescribing medications. These interventions could include slower and lower diaphragmatic breathing, upright posture feedback, muscle biofeedback training, hear rate variability training, stress management, cognitive behavior therapy and facilitating health promoting lifestyles modifications such as regular sleep, exercise and healthier diet. When students implement these behavioral changes as part of a five week self-healing program, many report significant decreases in symptoms such as headaches, anxiety, neck and shoulder pain, and gastrointestinal distress (Peper et al., 2016a).

Watch April Covell describe her experience with the self-healing approach to eliminate her chronic headaches.

See the following blogs for additional instructions how to breathe diaphragmatically.

 References

Ahmed, S., Akter, R., Pokhrel, N. et al. (2021). Prevalence of text neck syndrome and SMS thumb among smartphone users in college-going students: a cross-sectional survey study. J Public Health (Berl.) 29, 411–416. https://doi.org/10.1007/s10389-019-01139-4

Bauer, A.Z., Swan, S.H., Kriebel, D. et al. (2021). Paracetamol use during pregnancy — a call for precautionary action. Nat Rev Endocrinol . https://doi.org/10.1038/s41574-021-00553-7

Charles, N. E., Strong, S. J., Burns, L. C., Bullerjahn, M. R., & Serafine, K. M. (2021). Increased mood disorder symptoms, perceived stress, and alcohol use among college students during the COVID-19 pandemic. Psychiatry research, 296, 113706. https://doi.org/10.1016/j.psychres.2021.113706

Elizagaray-Garcia, I., Beltran-Alacreu, H., Angulo-Díaz, S., Garrigós-Pedrón, M., Gil-Martínez, A. (2020).  Chronic Primary Headache Subjects Have Greater Forward Head Posture than Asymptomatic and Episodic Primary Headache Sufferers: Systematic Review and Meta-analysis. Pain Med, 21(10):2465-2480. https://doi.org/10.1093/pm/pnaa235

Greden, J.F., Victor, B.S., Fontaine, P., & Lubetsky, M. (1980). Caffeine-Withdrawal Headache: A Clinical Profile. Psychosomatics, 21(5), 411-413, 417-418. https://doi.org/10.1016/S0033-3182(80)73670-8

Küçer, N. (2010). The relationship between daily caffeine consumption and withdrawal symptoms: a questionnaire-based study. Turk J Med Sci,  40(1), 105-108.  https://doi.org/10.3906/sag-0809-26

Kuehn, B.M. (2021). Increase in Myopia Reported Among Children During COVID-19 Lockdown. JAMA, 326(11),999.  https://doi.org/10.1001/jama.2021.14475

MacHose, M. & Peper, E. (1991). The effect of clothing on inhalation volume. Biofeedback and Self-Regulation 16, 261–265 (1991). https://doi.org/10.1007/BF01000020

Peper, E., Booiman, A., Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49. https://doi.org/10.5298/1081-5937-44.1.03

Peper, E., Gilbert, C.D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173-179.  https://doi.org/10.5298/1081-5937-43.4.06

Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017b). How posture affects memory recall and mood.  Biofeedback. 45 (2), 36-41. https://doi.org/10.5298/1081-5937-45.2.01

Peper, E., Mason, L., Harvey, R., Wolski, L, & Torres, J. (2020). Can acid reflux be reduced by breathing? Townsend Letters-The Examiner of Alternative Medicine, 445/446, 44-47. https://www.townsendletter.com/article/445-6-acid-reflux-reduced-by-breathing/

Peper, E., Mason, L., Huey, C. (2017a).  Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. (45-4). https://doi.org/10.5298/1081-5937-45.4.04

Peper, E., Miceli, B., & Harvey, R. (2016a). Educational Model for Self-healing: Eliminating a Chronic Migraine with Electromyography, Autogenic Training, Posture, and Mindfulness. Biofeedback, 44(3), 130–137. https://doi.org/10.5298/1081-5937-44.3.03

Peper, E., Wilson, V., Martin, M., Rosegard, E., & Harvey, R. (2021). Avoid Zoom fatigue, be present and learn. NeuroRegulation, 8(1), 47–56. https://doi.org/10.15540/nr.8.1.47

Schulman, E.A. (2002). Breath-holding, head pressure, and hot water: an effective treatment for migraine headache. Headache, 42(10), 1048-50. https://doi.org/10.1046/j.1526-4610.2002.02237.x

Tsai, H. Y., Peper, E., & Lin, I. M.* (2016). EEG patterns under positive/negative body postures and emotion recall tasks. NeuroRegulation, 3(1), 23-27. https://doi.org/10.15540/nr.3.1.23

Veenstra, L., Schneider, I.K., & Koole, S.L. (2017). Embodied mood regulation: the impact of body posture on mood recovery, negative thoughts, and mood-congruent recall. Cogntion and Emotion, 31(7), 1361-1376. https://doi.org/10.1080/02699931.2016.1225003

Wilson, V.E. and Peper, E. (2004). The effects of upright and slumped postures on the generation of positive and negative thoughts. Applied Psychophysiology and Biofeedback, 29(3), 189–195. https://doi.org/10.1023/b:apbi.0000039057.32963.34