INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2005474Indian J. Anaesth. 2005; 49 (6) : 474 - 478

1. Prof and HOD, Department of Cardiac anaesthesia,2. Prof and HOD Neurology,3. Director AIIMS,4. Add. Prof. Neuro-Biochemistry,5. Add. Prof. Biostatistics

Department of Anaesthesia (CTVS), Neurology, BiochemistryCardiac Neuro Center, All India Institute of MedicalSciences, New Delhi-110029Correspond to :Dr. Usha KiranE-mail : dr_ukiran@yahoo.com(Accepted for publication on 01 - 09 - 2005)

THE EFFECT OF AUTOGENIC RELAXATION ONCHRONIC TENSION HEADACHE AND IN

MODULATING CORTISOL RESPONSEDr. Usha Kiran1 Dr. Behari M.2 Dr. Venugopal P.3

Dr. Vivekanandhan S.4 Dr. Pandey R. M.5

SUMMARYHeadache and stress may co-exist as cause or effect. This study was designed to co-relate chronic tension headache with blood cortisollevel and its modulation by autogenic relaxation therapy. Randomized single blind parallel design prospective study carried out in atotal of 380 patients of chronic tension headache, divided into two groups. Group 1 (n=190) patients received 8 lessons and practicaldemonstration of spiritual based meditation, known as Rajyoga meditation for relaxation therapy in addition to routine medical treatment(tab alprazolam 0.25 mg twice a day). Group 2 (n=190) patients received tablet alprazolam 0.25 mg twice a day but no relaxationtherapy in the form of meditation. They were followed up for three months. Effect parameters studied were severity, frequency andduration of headache. Plasma cortisol level was measured before and 8 weeks after the treatment, in all patients.Results- Relaxation group patients (Gr.1) showed a highly significant reduction in headache variables as compared to those who receivedtablet alprazolam alone (Gr.2). Headache relief was 96% as shown by headache index in relaxation group patients as compared to25% in alprazolam group patients (p<0.001). Mean plasma cortisol levels were found to be significantly lower in those suffering withchronic headache for over 5 years. Relaxation therapy with Rajyoga meditation effectively modulated the plasma cortisol to normal range.Conclusions- Spiritual based relaxation therapy (Rajyoga meditation) was effective in chronic tension headache as measured by headacheparameters. The mean plasma cortisol levels were lower in those who were suffering with headache for more than 5 years. Cortisollevels responded to relaxation therapy (Rajyoga meditation)Keywords : Chronic tension type headache; Alprazolam; Spirituality; Relaxation therapy; Plasmacortisol.

IntroductionHeadache is an almost universal experience.

Only few individuals claim never to have suffered fromheadache. Tension type is the most common type ofheadache.1 All variety of drugs e.g. analgesics, anti-depressants, anti-anxiety, muscle relaxant drugs and theircombinations are commonly prescribed to these patients.2Patients with chronic headache try multiple drug therapyand suffer due to their side effects. Treatment is frequentlyunsatisfactory. Whether headache leads to stress or vice-versa is not clear.

Relaxation response is opposite of stress responseand has been effectively used to break the vicious cycle

between pain and stress. Various modalities used forrelaxation are diaphragmatic breathing, deep musclerelaxation, self-hypnosis and autogenic techniques likebiofeedback, yoga and meditation.3 Biofeedback andyoga involve concentration on certain physiologicalfunctions that are normally regulated by autonomic nervoussystem.4 Spirituality and meditation has established its rolein various psychosomatic problems.5 This technique usesthe mind rather than the body but shows an interactionbetween the physiological and psychological processes.Relaxation of body, mind and behavioral change with positiveapproach has been successfully achieved by Rajyogameditation. Rajyoga is a method of autogenic relaxationwith spiritual link, providing training in realization of thetrue self, contemplating on divine ‘Supreme Being’ and adialogue with divine supreme. Rajyoga is one of thetraining courses of Rajyoga Education and Researchfoundation of Brahma Kumaris World Spiritual University(NGO body on consultative status with UNO, UNICEF andWHO). This study was designed to evaluate 1) the role ofautogenic relaxation therapy (Rajyoga meditation) formanagement of chronic tension type headache, (CTH) 2) tofind out if any co-relation exists between cortisol values inCTH patients and the role of relaxation therapy (meditation)in modulating blood cortisol (marker of stress).

CLINICAL INVESTIGATION474

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USHA, BEHARI, VENUGOPAL, VIVEKANANDHAN, PANDEY : AUTOGENIC RELAXATION THERAPY 475

Methods

Selection of patients380 patients over the age of 18 years attending

neurology out patient clinic of cardiac neuro center of AllIndia Institute of Medical Sciences, New Delhi, India, withthe diagnosis of chronic tension headache based on thecriteria of Ad-hoc committee of classification of headachewere included.6 Patients with headache for less than 2 yearswere excluded. Patients with headache due to sinusitis,eyestrain, cervical spondylosis and posttraumatic headacheswere also excluded from the study. All those patients whocould not come for regular training of autogenic relaxation(meditation) were also excluded. Patients with severedepression or anxiety were also excluded.

Design of studyThis was a prospective randomized, single blind

study. Patients were informed about the methodology of theproject and the need for regular follow up was emphasizedto them. After an informed consent they were randomlyallocated to two groups by sealed envelope technique.Patients in group 1 (Relax) were given relaxation therapyin the form of Rajyoga meditation as guided by Rajyogateachers. Eight sittings of 45 mins. each on alternate daysfor two weeks were followed by once a week interviewduring which the method followed by the patients waschecked and any queries relating to the methodologywere answered. At this time patient’s compliance to practiceof meditation was also tested. In addition tab. alprazolam0.25 mg twice a day was also advised. On the otherhand, group 2 (Alpz) patients were given tab. alprazolam0.25 mg twice a day but without relaxation therapy.Group 2 patients were called once a week and complianceabout treatment was noted. All the patients were followedfor minimum of 6 months.

Headache diarySubjects were required to write in their diary the

following parameters i.e. severity of headache on VAS,(scale 0 as no pain and 10 as the maximum possible pain.)frequency of headache per week, duration of each headacheepisode in hours, somatic symptoms like nausea, vomitinggiddiness and amount of analgesic tablets used in case ofintractable headache.

AssessmentNeurologist blinded to the type of treatment received

by the patients, assessed the patients clinically beforeinitiating treatment, at 4 weeks and at 8 weeks of treatment.Effect measures used were headache severity, frequency ofheadache per week and duration of each episode (hour).

Severity was measured on 0-10 visual analogue scale(VAS). Headache index was calculated by multiplyingseverity and frequency of headache per week. Anxiety anddepression were scored as 0 for no, 1 for mild, and 2 formoderate. Any depression, anxiety or somatic symptomsreported by patients were noted on each visit. At the endof the 8 weeks period patients gave the global subjectiveassessment about the effect of therapy.

Autogenic relaxation trainingRelaxation was achieved by giving training in Rajyoga

meditation according to the teachings of Rajyoga Educationand Research Foundation to patients by the experts fromBrahma Kumaris Spiritual University. Meditation trainingwas given with the help of pictures, diagrams and audiocassettes. Meditation was done in a silent dimly lit room.A total of 8 lessons each of 45 minutes were givens ofwhich last 20 minutes were devoted to a guided commentary.They were instructed to perform meditation for 20 minuteseach day at their home either in morning or evening. Allof them were required to note about meditation practice intheir daily diary.

Meditation complianceMeditation compliance was also noted in the diary

and evaluated by questioning about concentration duringmeditation, whether they remembered the time ofmeditation and their liking or disliking about it. Would theylike to accept it as a part of their life style?

Serum cortisolCortisol values in plasma were measured in all the

patients before starting treatment and after 8 weeks oftreatment. To measure cortisol levels, 4 ml of blood wascollected at 8 am and was centrifuged to separate outplasma. Cortisol levels were measured by ELISA technique.

Statistical analysisData was managed on an excel software. All the

entries were manually checked for any possible keyboarderror. Categorical variables were summarized bypercentages. For quantitative variables such as headacheseverity, frequency duration and headache index, (afterassessing the normalcy assumption) summary statistics asmean and standard deviation were calculated for both groupsseparately. The basal values for all the quantitativeparameters between the two groups were compared usingStudent ‘t’ test. Difference between pre treatment and posttreatment values were computed and statistically evaluatedusing Student ‘t’ test. P values detected smaller than 0.05were considered as significant.

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ResultsOn comparing the demographic profile (table - 1) of

the patients in two groups we found that they werecomparable regarding age, sex, social status and maritalstatus to those in alprazolam group. The headache variablesin the two groups were also comparable. There were morefemales than males in both the groups.

Headache profile: Patients of group 1 (Relax)showed highly significant reduction in severity of pain.(p<0.001). Frequency of headache and duration of eachepisode was also significantly reduced from pretreatmentlevel. However patients of group 2 (Alpz) also showed anoverall reduction in all headache variables but these werenot statistically significant. Mean headache relief asmeasured by headache index was 95% for group 1 (Relax)patients as compared to 25% for group (alpz). Completerelief was seen in 150 out of 190 patients at 6 monthsfollow up in the group (relax) as compared to 35 patientsout of 190 in the group (alpz). (table - 2)

Associated anxiety, depression and somaticsymptoms: Depression and anxiety were scoressignificantly dropped by 70% and 61% respectively in thegroup (relax) as compared to 31% and 22% in the group(alpz) (table - 2). Complaints like irritability, giddiness andnausea were also reduced. Ninety percent of patients werefree of all somatic problems at 6 months follow up in thegroup (relax) patients whereas 55% were free from somaticcomplaints in the group (alpz). Patients who learned andpracticed Rajyoga meditation were very cheerful. They feltconfident in easily handling their stress and day-to-dayproblems. Their attitude became positive.

Table - 1 : Demographic profile of patients of chronictension type headache.

Total Group Group p value(Relax) (Alpz)

Number 380 190 190

Age (years)Mean ± SD 31.92±1.71 30.67±8.93 33.17±11.98 nsRange 18-80 19-56 18-80

M: F 136:244 70:120 66:124

Headache duration(yr)Mean±SD 4.17±0.55 5.1 ±1.87 4.32±1.89 nsRange 2-10 2-10 2-10

Marital statusMarried 252 121 131 nsSingle 128 69 59 ns

ns - not significant

Table 2. Headache relief in patients of chronic tensiontype headache.

Variables Group 1 (Relax) Group 2 (Alpz)

Pre Rx Post Rx Relief Signif. Pre Rx Post Rx Relief Signf.

Severity 5 . 9 ± 1 . 1 ± 83% p < 5 . 8 ± 4 . 7± 18% ns(VAS) 0.99 1.29 0.001 1.5 2.21

Frequency 5 . 5 ± 1 . 1 ± 80% p < 5 .85± 5 .42± 20% ns(episode/wk) 4.84 1.29 0.001 1.39 1.90

Duration 12.26 1.17 ± 81% p < 13.97± 12.97± 9% nsEpisode ± 7 . 0 1.3 0.001 8.22 8.98(Hours)

Headache 31.97± 1 . 6 ± 95% p < 33.97± 26.15± 25% nsIndex 8.4 1.39 0.001 12.4 15.49

Depression 1 .01 ± 0 . 3 ± 70% p < 1 .60± 1 .11± 31% p < . 0 5Score 1.01 0.49 0.001 1.11 0.78

Anxiety 1 .89 ± 0 .83± 61% p < . 0 5 1 .55± 1 .22± 22% nsScore 0.49 0.5 0.52 0.42

ns - not significant

Table - 3 : Mean plasma cortisol changes in patientsof chronic tension headache in mg/dl.

Group (Relax) Group (Alpz)

0 week 8 week 0 week 8 week

Plasma Cortisol 5.68±3.92 7.31±4.13 5.93 ±3.68 6.87 ±2.63.

Headache Duration 5.22±2.09 7.27±3. 35 5,61±2.89 6.32±2.88(More than 5 yr)

(Less than 5 yr) 7.13±2.01 7.39±3.87 7.11±1.98 7.28±3.11

Plasma cortisol : The mean plasma cortisol levelwas found to be lower than normal in both the groupsbefore initiating treatment. However these values wereoptimized after meditation (table - 3). Patients sufferingwith headache for 5 year or more showed significantlylower initial values of cortisol as compared to those sufferingwith headache for less than 5 year. This difference wasstatistically significant (p<0.05). In both the groups wenoted a tendency towards optimizing the cortisol values butthis was statistically significant in group (relax) patients(5.22±2.09 to 7.27±3.35 mgdl-1 as compared to group (alpz)patients (5.61±2.89 to 6.32±2.88 mgdl-1).

DiscussionIn view of the presumably multi-factorial

pathogenesis, a multi-dimensional therapeutic approach isrequired for patients of tension headache. Stress had longbeen viewed as a major contributor towards chronic tensiontype headache. Benzodiazepines are the most commonlyused agents for its management although many argue thatits mode of action is sedation rather than relaxation of

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USHA, BEHARI, VENUGOPAL, VIVEKANANDHAN, PANDEY : AUTOGENIC RELAXATION THERAPY 477

contracted muscle. The risk of habituation and dependenceare the major drawbacks with these drugs. Relieving stressby non-pharmacological means has been tried with variablesuccess.7-8 Direct relaxation of frontalis muscle for 2 hoursdid not provide significant relief.9 Acupuncture has beentried with some success.10

In the present study it was found that autogenicrelaxation technique in the form of meditation for patientsof chronic tension type headache, produced a significantreduction in headache variables. No study has reportedheadache relief of 95% as of our study. Larsen et al noted16% relief with self-help relaxation and 19.4% relief ofheadache on combining relaxation with pharmacologicaltreatment.11 Cott et al reported significant relief of headacheactivity (p<0.05) on combining relaxation training withtemperature biofeedback.12 In addition, amelioration ofpsychological and somatic complaints in those who practicedmeditation confirms the previous studies that relaxationtherapy provides definite help to patients of chronic tensionheadache.13 The highly effective result in our case may beexplained by the fact that patients learnt a spiritual basedmeditation called Rajyoga. Need for spirituality is beingexplored in medical practice during last decade. Rajyoga isrelaxation therapy purely based on spirituality, realizationof self and divine supreme (Rajyoga meditation). Our patientsdeveloped self-confidence, positive thinking by awakeningthe spiritual component of human being. All lessons weregiven in the hospital with practical demonstration. Thecompliance was too good. Secondly we combined thisrelaxation therapy with pharmacological therapy.

Considering the involvement of stress, as one of thepredominant associated factor with chronic tension headache,we evaluated plasma cortisol levels in all patients beforeand after both types of treatment. Very often stress andhigh cortisol level is considered synonymous. This studyrevealed a very surprising fact that longer the history ofsuffering with headache, lower was the cortisol levels.Another surprising finding was that regular practice ofRajyoga meditation for 8 weeks, to achieve continuousrelaxation, optimized blood cortisol levels. When clinicallyco related, these patients were noticed to be completelyrelieved of headache and its associated psychologicalsymptoms. Cortisol is not widely studied in tension headachepatients, though cluster headache patients showed a rise inplasma cortisol at the time of episode.14 A lower value ofcortisol was observed by Yehudo in patient with posttraumatic stress disorder and suggested that stress shouldno longer be defined as glucocorticoid excess because stressover a long period of time is associated with low cortisolin human.15 This was postulated to be due to hippocampus

atrophy resulting from chronic stress.16,17 Cortisol responseto various drug and non-drug treatments of tension headachehas not been studied in detail so far. Venable et al exploredco-relation of anger, anxiety, depression and daily lifestressors with tension type headache but their study was notsupported by any biochemical/ hormonal change18. Thefindings in the present study that the patients with lowcortisol values showed a positive response to Rajyogameditation reveals the fact that a spiritually orientedapproach resulting in perceptual, attitudinal, and behavioralchange must have acted at central level. Further studiesare needed for evaluating the role of centrally actingneuro-endocrines and neuro-chemicals.

Hence relaxation therapy by spiritual based Rajyogameditation was found to be highly effective for patients ofchronic tension type headache. Associated somatic symptomswere also relieved. In addition they developed a higherself-esteem, positive thinking and improved work efficiency.The results of this combined clinical and biochemical studyindicates some co relation of plasma cortisol with durationof chronic type of headache, as most of the patients sufferingover 5 years had significantly lower blood cortisol level.Modulation of cortisol levels in blood by relaxation techniquegives a clue towards the effective role of spirituality-basedmeditation, positive attitude for treatment of chronic tensionheadache. This would prove to be very cost effective.

AcknowledgementWe are grateful to Rajyoga Education and Research

Foundation of Brahma Kumaris who provided techniquesand material like audio cassettes, Pictures, books and audiovisual material and tutors for meditation training (Rajyoga)

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3. Van-hook K. Non-pharmacological treatment of headache.Why? Clin neurosc. 1998; 5: 43-49.

4. Rokicki LA, Holroyd KA, Fronce CR et al. Change mechanismassociated with combined relaxation EMG biofeedback trainingfor chronic tension headache. App Psychophysiol-Biofeedback1997; 22: 21-41.

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7 De-Bruijin-Norman AT, van-de-wiel n, Groenman NM, SorbiMJ, Klip K. Effect of mass media behavioral treatment forchronic headache. A pilot study. Headache 1997; 37: 418-20.

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10. Wylie KR, Jackson, Crawford PM. Does psychological testinghelp to predict the response of acupuncture or massage/relaxation therapy in patients presenting to general neurologyclinic with headache. J Trad Clin med. 1997: 17: 130-39

11. Larsen B, Melin 1, Dobert A. Recurrent tension headache inadolescents treated with self-help relaxation training and amuscle relaxant drug. Headache 1990; 30: 665-71.

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17 Bremner JD, Randall R, Scott TM et al. MRI basedmeasurement of hippocampus volume in patients with combatrelated post traumatic stress disorder. Am J Psychiatry. 1995;152: 978-81.

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