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Pain Medicine 2013; 14: 621–627
Wiley Periodicals, Inc.
HEADACHE & FACIAL PAIN SECTION
Original Research Article
A Virtual Reality System Combined with
Biofeedback for Treating Pediatric Chronic
Headache—A Pilot Study
Shimon Shiri, PhD,*1 Uri Feintuch, PhD,†1
Nilly Weiss, BA,** Alex Pustilnik, BA,* Tal Geffen,
BA,¶ Barrie Kay, MD,‡,§ Zeev Meiner, MD,* and
Itai Berger, MD§
*Department of Physical Medicine and Rehabilitation,
Hadassah Hebrew University Medical Center,
Jerusalem, Israel
† neurology clinic were treated by the proposed
School of Occupational Therapy, Hebrew University,
Jerusalem, Israel
‡
Pediatric Neurology Unit, Hadassah-Hebrew
University Medical Center, Jerusalem, Israel
§
Neuro-Cognitive Center, Pediatric Division,
Hadassah-Hebrew University Medical Center,
Jerusalem, Israel
¶
Department of Psychology, The Hebrew University,
Jerusalem, Israel
**Department of Psychology, Ben-Gurion University of
the Negev, Beer-Sheva, Israel
Reprint requests to: Shimon Shiri, PhD, Department of
Physical and Medical Rehabilitation, Hadassah
University Hospital—Mount Scopus, Jerusalem 91120,
Israel. Tel: 972-2-5610626; Fax: 972-2-5844885;
E-mail: shimonshiri@hadassah.org.il.
1
Equal contributors.
Abstract
Objective. Pediatric headache is highly widespread
and is associated with distress and reduced quality
of life. Pharmacological treatment of chronic head-
ache in children has been only partially effective
and, as in medication-overuse headache, can some-
times be counterproductive. Therefore, there is a
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substantial need to develop other effective methods
of treatment. Here we present the rationale, feasibil-
ity, and preliminary results of a pilot study applying
a novel system, combining virtual reality and bio-
feedback, aimed as an abortive treatment of pediat-
ric chronic headache.
Design. A prospective single-arm open-label, pilot
study. Ten children attending an outpatient pediatric
system. Participants practiced relaxation with
biofeedback and learned to associate successful
relaxation with positive pain-free virtual images of
themselves.
Results. Nine patients completed the 10-session
intervention. Ratings of pain, daily functioning, and
quality of life improved significantly at 1 and at 3
months posttreatment. Most patients reported
applying their newly acquired relaxation and
imagery skills to relieve headache outside the lab.
Conclusion. This novel system, combining bio-
feedback and virtual reality, is feasible for pedi-
atric use. Randomized controlled studies in larger
populations are needed in order to determine
the utility of the system in reducing headache,
improving daily functioning, and elevating quality
of life.
Key Words. Headache; Virtual Reality; Biofeed-
back; Mirror Neurons; Self-Face Recognition
Introduction
Headache is one of the most common chronic distressing
health conditions among children, and considered the
most frequent neurological symptom and commonest
manifestation of pain in childhood [1,2]. Headache, espe-
cially in adolescents, is associated with other physical
and psychiatric comorbidities [1–3]. In population-based
studies, it was mentioned that almost 60% of children are
prone to headache, of variable frequency [4].
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Headache treatment for children and adolescents
includes both pharmacologic and non-pharmacologic
measures [5,6]. However, medication-overuse headache,
resulting from the overuse of analgesics, triptans, or other
acute headache compounds, is highly prevalent and has
in itself severe effects on quality of life [7]. Therefore,
non-pharmacologic interventions are encouraged and fre-
quently used among children including lifestyle adjust-
ments (regular sleep, dietary adjustment, or regular
exercise program), stress management, and other behav-
ioral therapies [8].
Biofeedback (BF) and guided imagery (GI) have been iden-
tified as competent non-pharmacologic paradigms for
headache treatment [9]. BF appears to be effective in
reduction of tension headache and migraine and in reduc-
ing anxiety, depression, and medication overuse [10–12].
GI has been reported as an efficient treatment for head-
ache in the general population [13] and particularly with
children [13,14]. Further, GI has been associated with
increased brain plasticity, which is essential to enhance
therapeutic progress [15,16].
In this study, we present a novel virtual reality (VR) system,
which simultaneously employs both BF and positive
images, similar to images suggested in GI. VR applications
have been applied successfully to treat acute pain by
creating various pain-free virtual environments [17,18].
These applications have traditionally been used to distract
from acute pain during painful medical procedures.
Recent studies suggest that chronic pain, too, is a prom-
ising candidate for VR interventions [19].
We hypothesized that VR can serve as an efficient and
perhaps more potent replacement to GI, as it can provide
therapeutic images even to individuals with difficulty in
following imagery suggestions [18]. Our approach shares
common principles with models promoting the use of
virtual mirrors, as presented in a recent preliminary
study [20].
In this study, we present the rationale, feasibility, and pre-
liminary results of applying an innovative system, com-
bining VR and BF, aimed as an abortive treatment for
pediatric chronic headache. The system has been
designed in light of learning models of chronic pain, in
which the role of operant conditioning in chronic pain is
highlighted [21,22]. In the present context, operating the
system allows patients to associate between their ability to
relax (as indicated by reductions of their galvanic skin
response [GSR]) with headache decline (as illustrated by
virtual images). As in our previous study [23], a self-
face viewing interface was adopted to allow robust
neural activity.
We hypothesized that the learning process of associating
between their ability to relax and viewing themselves in a
headache-free state would enhance the participating chil-
dren’s ability to better cope with their headache and its
consequences [24].
Methods
Participants
The study was designed as a prospective single-
arm open-label, pilot study. The study was conducted
in an outpatient pediatric neurology clinic at a tertiary
care university hospital. Pharmacotherapy continued
during the study period; there were no new preventive
medications started during the study period. The chil-
dren suffered from chronic headache but were otherwise
healthy. Their detailed characteristics are presented
in Table 1.

Table 1 Demographic characteristics

Symptoms Treatment
Duration Duration
Participant Diagnosis Age (Years) Gender (Years) Medications (Months)

1 CTH 16.5 F 5.5 AC; NS 60

2 CTH 12 M 1 AC 11
3 CTH 12 F 2 AC; NS 12
4 CTH 10 M 3 AC 30
5 CM 17 M 5 AC; NS; T 36
6 CM 17.5 F 0.5 AC; NS; AM* 6
7 CM 13.5 M 1 AC 12
8 CM 13 M 3 AC; NS 24
9 CM 10.5 M 0.25 — —
10 CM 12 M 3 AC 18

* Dose and duration of treatment using amitriptyline was 10 mg for 1 month.

F = female; M = male; CTH = chronic tension headache; CM = chronic migraine; AC = acetaminophen/paracetamol;
NS = nonsteroidal anti-inflammatory drug; T = triptans; AM = amitriptyline.

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Headache diagnosis was established by a certified pedi-
atric neurologist based on the International Classification
of Headache Disorders criteria [25]. After an interview
with the child and parents with specific attention being
paid to headache and treatment, a neurological exami-
nation, and further evaluation, including ophthalmic
examination by a certified ophthalmologist and brain
imaging where clinically indicated were performed and
found to be normal. Six of the children fulfilled the criteria
for migraine headache and four children fulfilled the cri-
teria for tension-type headache. Nine out of 10 children
were treated (previous to their inclusion in the study) by
at least one medication. Data are specified in
Table 1.
Exclusion criteria were intellectual disability, other chronic
condition, and primary psychiatric diagnosis (e.g.,
depression, anxiety, autistic spectrum disorders, and psy-
chosis). Children diagnosed with learning disabilities
and/or attention/deficit-hyperactivity disorders were not
excluded from the study, yet all participants study in
regular school classes. Ethical approval was obtained
from the Internal Review Board (Helsinki Committee) of
Hadassah-Hebrew University Medical Center. All children
agreed to participate in the study and all parents signed an
informed consent form.
Intervention
The system consists of a desktop computer and the
ProComp Infiniti system by Thought Technology (Montreal,
Quebec, Canada). The latter gathers physiological data
using two electrodes tracking the patient’s GSR, which
was used as a BF device because of its sensitivity for
headache [26]. This signal is processed online by our
system, which provides a visual feedback based on the
patient’s emotional state. The visual presentation is based
on a set of images acquired during the introductory
meeting. During this session, patients had their picture
taken with different facial expressions such as “happy,”
“neutral,” “agony” etc. Each of these pictures was then
Figure 1 Patient’s set of self-images.
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A Virtual Reality Biofeedback System
integrated with a graphical representation of the pain,
which the patient found appropriate. Thus, as can
be seen in Figure 1, each patient’s set of self images
represented a full spectrum of emotional states, from agony
to happiness.
During each session, patients were instructed to gaze at
the screen and try to relax, as it displays a virtual rep-
resentation of the patients and their pain. Success-
ful relaxation, as indicated by GSR reductions, led
to gradual fading of headache representations, while
changing color and size. The algorithm was designed so
patients were led by their virtual self from a painful state
to a relaxed pain-free state. At the beginning of each
session, the first 10 seconds were used to gather GSR
data and create a baseline. Then four thresholds were
set to distinguish between the five emotional ranges,
each associated with a representative facial picture. The
distance between the thresholds was set by the thera-
pist and adjusted according to the patient’s progress. In
order to achieve a smooth transition between the five
phases, we implemented an approach of overlapping
ranges. This was done in order to avoid unstable
jumps between two pictures when the GSR signal fluc-
tuates around the threshold value. Thus, once crossing
the threshold and moving from one range to the adja-
cent one and changing the picture presented on the
screen, the GSR level was actually set to be in the
center of the new range, thus requiring a substantial
increase or decrease of the signal in order to cross the
next threshold.
Protocol
The patients attended an introductory meeting where the
treatment and its rationale were explained. They, as well as
their guardian, signed a consent form and had their picture
taken in various emotional states (either mimicked at the
lab or photographed by the parent in the natural setting at
home), to which they attached graphical images repre-
senting their pain at each state.
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 Shiri et al.

In the following 10 sessions, patients were connected to Headache

the GSR electrodes and instructed simply to watch their
image on the screen and try to relax. These sessions
lasted up to 30 minutes depending on the patient’s per-
formance. In the latter stages of the intervention, patients
were instructed to try and implement their new relaxation
skill whenever experiencing a headache.
Outcome Measures
The patient’s pain was measured using visual analog scale
(VAS) to report the average pain level over the past week,
as well as the level of functional limitation imposed by the
pain attacks. Quality of life was assessed using the Pedi-
atric Quality of Life Inventory (PedsQL™) developed by Dr.
James W. Varni et al. [27]. This questionnaire contains 23
Likert scale questions, evaluating various aspects (e.g.,
physical, social, and emotional) of the patient’s quality of
life. The patients were also asked to rate their satisfaction
following operating the system and were asked to report
freely about their experience during the treatment.
Data were collected prior to the intervention, immediately
following its completion, 1 month later, and at 3 months
follow-up.
Statistical Analysis
Due to the small sample size and the low measurement
scale, we have chosen to analyze the data using nonpara-
metric tests. The Pretest-Posttest measures were ana-
lyzed using the Wilcoxon signed rank test for paired
sample. Analysis of the four time-points data (pretest,
posttest, 1 month, 3 months) was conducted using the
Freidman test.
Patients were asked to grade on a VAS (0–10):
1. To what extent does your headache limit your
daily function?
2. On average, how severe was your headache during the
previous week?
As can be seen in Table 2, the values have declined from
the pretest to the posttest to the final follow-up. Wilcoxon
paired sample test has produced a significant improve-
ment before and after the intervention for Question 1
(P < 0.05) and approached significance for Question 2
(P = 0.068). When conducting the Friedman nonparamet-
ric test for related samples, this improvement seems to
persist over a longer period of time, beyond the duration of
the intervention for both VAS ratings (P < 0.01 and
P < 0.05, respectively).
Quality of Life
When examining the data of the PedsQL, collected at the
different time points, one can observe an improvement in
the quality of life, measured before and after the interven-
tion. This change, from 48.67 to 39.78, was found to be
significant by the Wilcoxon test (P < 0.01). Here, too, the
improvement was stable beyond the treatment period and
remained throughout the follow-up period, as indicated by
the Freidman test (P < 0.01). It should be noted that in all
outcome measures, no difference were found between
the migraine and tension-type headache patients. Given
the small sample size, the ability to detect differences
between these two small samples is limited.
User Satisfaction and Feedback

The patients were asked to rate on a Likert scale (1–5)

Results
whether the treatment was helpful and whether they
would recommend it to a friend suffering from a similar
Participants
condition. They were also asked to freely report whether
and how the treatment had influenced their daily life and
Mean age of participants was 13.4 ⫾ 2.7 years and the
whether they used the relaxation technique they were
mean duration of reported headache 29.1 ⫾ 21.8
taught, and if so, to describe an example. As indicated in
months. Average headache frequency reported as 17
Table 2 the user feedback tended to be positive.
days per month, average duration per headache attack
reported as 19 hours (before taking medications),
When reviewing the patient data, it is evident that there are
the frequency of acetaminophen, nonsteroidal anti-
two subpopulations. Seven of the patients demonstrated
inflammatory drug, or triptan usage reported as 16
a high level of satisfaction, rating their experience as 4 or
days per month. Taking headache-abortive medications
5, whereas two patients did not feel the treatment helped
at this frequency decreased the headache duration
them, rating it as 1 or 2. Yet, it is of interest to note, upon
to an average of 6 hours, but did not change heada-
examining the PedsQL scores, that even these two
che frequency.
patients have shown at least 20% improvement from their
pretest score to their posttest and follow-up scores. This
Adherence effect was similar to that of the other patients.

All the patients, except for one, completed all the inter-
vention sessions and cooperated during the whole
process without difficulties. One patient, a 12-year-old
male, withdrew after six sessions, as he felt that the
progress was not satisfactory.
Finally, most patients reported incidents where they expe-
rienced a headache and harnessed their new relaxation
skills to relieve it. Being a free report, we cannot know the
exact approach employed by the patients. Some reports
state laconically that “I tried to relax and I succeeded; the

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 A Virtual Reality Biofeedback System

headache stopped,” or “Many times when I wake up with

Four Measurements
P Value across All
a headache, I concentrate and it decreases.” On the other
hand, many of the reports refer explicitly to components of
the intervention: “I imagined I was seeing the pictures of
myself in the treatment, and the headache reduced, and
then after a few minutes it went away,” or “I sat in front of

0.001

0.004

0.003
a mirror and drove away the headache.”

—
—
Discussion

38.94 (10.58)*
Posttreatment

1.63 (1.92)*

2.06 (2.08)*

4.1 (0.7)*
4.9 (0.2)*
In this work, we present the rationale, feasibility, and
3 Months

results of a pilot study operating a novel system, combin-

ing VR and BF to relieve chronic headache and its nega-
tive consequences among children. Following this
intervention, patients reported significant declines in head-
ache severity, improvements in daily functioning, and in
38.78 (10.17)*
Posttreatment

1.29 (1.98)*

2.23 (2.98)*

quality of life. These reports were consistent immediately,

3.8 (1.3)*
3.9 (1.6)*

1 month, and 3 months post intervention both in migraine

1 Month

and tension-type headache.

The system has been found to be feasible, and the par-

ticipants reported no negative side effects. Moreover, the
(Post-Pre)

ratings indicated that the children were mostly satisfied

P Value

with their experience operating the system and found this

0.069

0.015

0.006

treatment method as helpful and valuable to the degree

—
—

that most of them would recommend it to others with a

similar condition.
39.78 (10.24)*
2.22 (2.99)*

3.11 (2.63)*

4.1 (1.3)*
4.1 (1.6)*

Operating the system served as an additional treatment as

most participants were treated prior to their inclusion in
Posttest

the study by medications for an average of 29 months

without significant improvement. One could deduce that
the decline in their headache, the improvement in func-
tioning, and the elevations in QOL may have been the
48.67 (10.83)*
5.00 (3.08)*

4.28 (2.92)*

result of this intervention. Yet, the design of the study does

not allow us to draw conclusions as to the effectiveness of
the system, and further randomized controlled studies are
Pretest

necessary to establish this as a treatment for chronic

—
—

pediatric headache.

The system has been designed in congruence with learn-

23–115
Scale*

0–10

0–10

ing models of chronic pain, stressing the significance of

1–5
1–5

operant conditioning in promoting and exacerbating

chronic pain behaviors [21,22] Traditionally, operant
models of chronic pain have highlighted the role of positive
To what extent does your headache limit your

On average, how severe was your headache

To what extent would you recommend it to a

social reinforcements in pain behaviors such as facial pain

friend suffering from a similar problem?

expressions and complaints of pain and of negative rein-

Do you feel the treatment helped you?

forcements such as avoiding undesired or fear-provoking

activities [21]. In the present context, the behavior that has
Outcome measures

been enhanced is the patients’ ability to reach relaxation

as indicated by the system. A positive reinforcement for
during the previous week?

this behavior is the gradual presentation of a patient’s

image as pain free and happy [24]. A negative reinforce-
ment that increases the probability of successful relaxation
* Standard deviation.

is the gradual minimization of the headache representation

attached to the patient’s own face image presented on a
daily function

computer screen [24]. These reinforcements had been

presented immediately after reductions in GSR, as high
Table 2

PedsQL

immediacy increases the effectiveness of learning [28,29].

Other possible reinforcements of reducing GSR are the
relaxation and calmness and sense of control over bodily

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 Shiri et al.
reactions that may be achieved when control over GSR is
learned [26]. The reduction in headache intensity and
frequency that may be achieved following this training may
serve as an additional negative reinforcement.
It is possible that mirror neurons [30,31] that are active
either when a person performs an action or upon viewing
another performing the same action may have been acti-
vated when patients operated the system. With regard to
pain, it has been suggested that pain can be produced
when it is observed in another or even when it is imagined
[32] We speculate that this mechanism may as well work
vice versa, that viewing pain decline in another or in
oneself, as virtually illustrated by the current system, may
relieve pain in the observer. Obviously, this hypothesis
needs to be examined in the future, using brain imaging
techniques. Additionally, viewing oneself smiling, as hap-
pened when patients reached relaxation, has the potential
of creating positive emotions, hence enhance the effec-
tiveness of coping with headache [33].
This system is distinct from other VR systems in the sense
that it implements a representation of a third-person
image of the patient, unlike most other VR systems which
provide a first-person (egocentric) perspective. Further,
this image is not a graphical avatar, but is a realistic
photograph-based image of the user. This paradigm was
implemented in light of recent neuropsychological find-
ings, suggesting that self-face recognition is faster and
more accurate than recognition of strange faces or even
highly familiar faces and is characterized by unique bilat-
eral activity [34]. We have therefore hypothesized that
implementing such a self-face viewing paradigm may be
particularly effective in drawing patient’s attention and in
generating sound neural processing of the virtual sce-
nery, especially neural networks within the mirror neuron
system [35].
The interpretation and generalization of the results is
limited by several methodological issues: a relatively
small number of participants, a lack of a controlled, ran-
domized design, a gross age range seen within the
sample, an underrepresentation of female participants,
variability among subjects’ symptom duration, and a
mixture of tension-type and migraine headache patients
do not allow “clear-cut” conclusions to be drawn with
regard to the system effectiveness in coping with pedi-
atric chronic headache.
However, this pilot study provides an initial indication with
regard to the benefits of combining BF and VR for pedi-
atric use. Following the explorative findings of our study, it
seems reasonable to promote randomized controlled
studies in order to establish the effectiveness of this
system in coping with chronic headache and its conse-
quences among children and adolescents.
Acknowledgments
We would like to thank Zieva D. Konvisser, PhD, and Marc
Konvisser, PhD, for their brave support in this study.
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