Complementary Therapies in Medicine 39 (2018) 62–67

Contents lists available at ScienceDirect

Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

Effectiveness of autogenic training on headache: A systematic review

⁎
Eunju Seoa,1, Eunhee Hongb,1, Jiyeon Choic, Younglee Kimd, Cheryl Brandtd, Sookbin Ime,
a
ShinSung University, Daehak-ro, Deongma-ri, Jeongmi-myeon, Dangjin-si, Chungcheongnam-do, 31801, South Korea
b
Seoul Women’s College of Nursing, 82 Ganhodae-Ro, Seodaemun- Gu, Seoul, 03617, South Korea
c
GimCheon University, Daehagno, Samnak-dong, Gimcheon-si, Gyeongsangbuk-do, 39528, South Korea
d
California State University San Bernardino, 5500 University Parkway, San Bernardino CA, 92407, United States
e
Eulji University, College of Nursing, 77 Gyeryong-ro, 771 beon-gil, Jung-gu, Deajeon, 34824, South Korea

ARTICLE IN FO ABSTRACT

Keywords: Purpose: To investigate the impact of length of autogenic training (AT) use, alone and with the addition of
Autogenic training adjunct treatments, on intensity and duration of primary headache in adults age 19 and older.
Headache Methods: We searched articles published in English and Korean from 1926 to 2016. A search of seven domestic
Systematic review and foreign databases was conducted from September 25, 2016 to December 30, 2016 using the search terms
“autogenic training,” “autogen,” “relaxation,” and “headache.” The search was documented according to
the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search yielded a total
of
262 papers; a multi-step screening and selection process ultimately yielded six articles of randomized controlled
trials (RCTs) for the systematic review. Cochrane’s Risk of Bias Tool was used to evaluate the quality of the
selected papers.
Results: Five of the six studies demonstrated statistically significant reduction in headache by AT-only or bio-
feedback-assisted AT. The reviewed studies varied in characteristics of subjects, length of autogenic training and
practice, use of adjunct therapies, and use of headache measures.
Conclusions: The small number of studies retrieved in this review, with their variations in AT interventions used,
in AT training/practice time, and headache measures used, did not facilitate rigorous evaluation of the effec-
tiveness of specific AT approaches nor of the optimum length of AT practice for reduction of headache. More
research is needed on the effectiveness of AT-only for headache, the most effective duration of autogenic training
and practice, and the type(s) of headache for which it is most effective.

1. Introduction When the cause of headache can be identified and successfully

Headache is the most commonly encountered medical symptoms in
everyday life.
According to the International Classification of Headache Disorders
(ICHD), headache refers to the pain that occurs inside the head without
a specific cause; the disorder is further divided into primary and sec-
ondary headaches.1 Primary headaches include migraine, tension-type
headache (TTH), trigeminal autonomic cephalalgias (TACs), and other
primary headache disorders. Secondary headaches include headache
attributed to a wide range of factors including trauma or injury, cranial
or cervical vascular illness, non-vascular intracranial disease, substance
use, exposure, or withdrawal, and infections.2 Of headaches classified
by the ICHD, TTH is described as very common; the general population
has a reported lifetime prevalence ranging from 30% to 78%.3
treated, the pain is likely to be relieved. However, the cause of primary
headache may not be easily identified; in that case, the person with
headache often seeks symptomatic relief. Pharmacological strategies for
relief and prevention of headache are commonly used. Despite the
usefulness of pharmacotherapy there may be an accompanying increase
in potential for drug dependency and side effects.4 Therefore, non-
pharmacological therapy, such as relaxation therapy, is a useful
strategy for many people with headache.5
According to the literature, interest in psychological methods and
self-control procedures for the treatment of headache is rapidly
growing.6 Interest in autogenic training (AT) in particular is gaining
attention. The term autogenic is a compound word composed of the
Greek words autos, which mean self, and genos, which means to pro-
duce; therefore it indicated self-sustaining.7,8 AT is thus a method of

⁎
Corresponding author.
E-mail addresses: carnival315@naver.com (E. Seo), ehhong@snjc.ac.kr (E. Hong), cjy.1218@hanmail.net (J. Choi), younglee.kim@csusb.edu (Y. Kim),
cheryl.brandt@csusb.edu (C. Brandt), imsb@eulji.ac.kr (S. Im).
1
First authors.

https://doi.org/10.1016/j.ctim.2018.05.005
Received 2 October 2017; Received in revised form 11 May 2018; Accepted 14 May 2018
Available online 22 May 2018
0965-2299/ © 2018 Elsevier Ltd. All rights reserved.
E. Seo et al.
learning to relax oneself by using the power of one's own mind.8
AT was first reported by the German psychiatrist Johannes Heinrich
Schultz in 1926,7 and represents a relaxation method now widely re-
searched and utilized in Europe. It is an established therapeutic method
that uses set stages of suggestion to transition a high sympathetic
arousal response to a low parasympathetic arousal response by relaxing
the muscles of the body, and performing self-training, starting from the
control of the body muscles and extending to the control of the circu-
latory system, the heart, respiration, and the abdomen.8 Individuals
learning AT are taught a sixstep sequenceof AT (i.e., hands feel heavy;
hands feel warm; breathing is comfortable; belly feels warm; forehead
feels cool; and heart is beating calmly or and regularly). The patient’s
physiological responses to relaxation, including decreased muscle ten-
sion, lowered heart rate, blood pressure, and brain activity, and in-
creased skin surface temperature, can be directly observed in the form
of light or sound via a biofeedback instrument4 and can be manipulated
to relieve headache. Physical effects of AT increase resistance to anxiety
and stress due to cardiovascular disease, migraine, sleep disorders,
hypertension, and psychological influences, suggesting extensive use
for the technique.9 Because AT induces self-hypnosis, it reduces sym-
pathetic activity and increases the ability to defend against disease.10
Relaxation therapies such as AT can even help to stabilize psychosis by
reducing the activation of the sympathetic nervous system by altering
the perception of stress.11
AT has been found to be effective for headache.11–19 Frequency of
use of analgesics and headache pills was found to decrease after starting
AT; the occurrence of mixed headaches and tension headaches de-
creased after 1 month of AT use while occurrence of migraine was re-
duced after 3 months.18,19
Variations exist in research reports of the effectiveness of AT, in-
cluding length of the study period and use of adjuvant
therapy.8,13–15,17,20 A previous systematic review of the impact of AT on
tension headache in adults was performed. However, the risk of bias
was high in that review because it included both controlled clinical
trials (CCTs) as well as RCTs.21Thus, a systematic review of published
RCTs only was conducted to investigate the impact of length of AT use
and addition of adjunct treatments on intensity and duration of primary
headache.
2. Methods
2.1. The review question
The components of the review question (following the Populations,
Intervention, Comparison, Outcome or PICO outline) were as follows:
• Population: The population of interest was adults age 19 years and
older who experienced headache.
• aIntervention: The intervention of interest was AT as instructed using
six-step training sequence (i.e., hands feel heavy; hands feel warm;
breathing is comfortable; belly feels warm; forehead feels cool; and
heart is beating calmly or and regularly). Training prompts may
have been supplied by a coach/instructor or using devices such as an
audio player.
• Comparative intervention (Comparison): Comparison interventions
of interest included relaxation, medication, hypnotherapy, or no
intervention.
• Outcome(s) of the intervention (Outcome): The studies that mea-
sured headaches as the consequence variable using various methods
were selected to determine the effect of AT on adults. Outcomes of
interest included self-reported headache scale scores and scores on
headache indexes.
2.2. Data sources
The data search was performed during the interval from September
63
Complementary Therapies in Medicine 39 (2018) 62–67
Table 1
Searching strategy.
No Searching term
1 Autogenic training
2 Autogen*
3 #1 or #2
4 Relaxation
5 #3 and #4
6 Headache
7 #5 and #6
25 to December 30, 2016. We searched the data from January1926 to
December 2016. English- and Korean-language research papers pub-
lished between January 2916 and December 2017 were sought.
Databases searched were PubMed, CINAHL, and Cochrane Library.
Additionally, Korean databases such as RISS (Research Information
Sharing Service), KISS (Korean Studies Information Service System),
DBpia (DataBase Periodical Information Academic), and NDSL
(National Digital Science Library) were searched. The search formula
used MeSH terms, test words linked with AND/OR, and a wildcard
search appropriately applied. The main keywords used for the search
were “autogenic training”, “autogen”, “relaxation”, and
“headache.” Finally, the search was limited to reports of
randomized controlled trials (RCT) (Table 1).
2.3. Study selection
A three-phase process of screening, title followed by abstract and
then full text, was used to select suitable papers. Selection criteria were
as follows: (1) RCTs investigating effects of AT on adult subjects age 19
and older with headache; (2) selection of the journal article if a journal
article and a thesis for an academic degree reported the same study.
Exclusion criteria were as follows: (1) studies not published in Korean
or English; (2) studies that did not employ an appropriate experimental
design, such as case studies. Reviewers independently screened re-
trieved papers for inclusion in the systematic review. Discrepancies in
screening decisions were discussed with the goal of reaching an
agreement at all three levels. If an agreement was not reached, the
screening decision was reviewed by another independent reviewer.
The PRISMA (Preferred Reporting Items for Systematic Reviews and
Meta-Analyses) schema was used to describe the step-by-step literature
search and selection process in detail.
2.4. Data extraction
Criteria for data extraction from studies were adapted from the
Cochrane Collaboration Handbook for Systematic Reviews. As depicted
in the column headings in Table 2, the criteria relate to the first author
(years), study design, number of subjects, headache type, intervention
group, control group, follow up, main outcome measures and main
results.
2.5. Risk of bias in individual studies
Cochrane’s Risk of Bias Tool was used to evaluate the quality of the
papers selected for inclusion. The Risk of Bias Tool is used to evaluate
the risks of the following potential biases in each RCT: random se-
quence generation, allocation concealment, blinding of participants and
personnel, blinding of outcome data, incomplete outcome data, selec-
tive reporting, and other biases (Fig. 3). The presence of these biases,
rated as “low,” “unclear,” or “high” risk according to the Tool,
threaten study validity. The Tool was used to generate a composite risk
graphic (Fig. 2).
 E. Seo et al.
Table 2
Summary of randomized controlled trials examining Autogenic training.

First author (Years) Design, No. of subjects(age) Intervention group Control group F/U Outcome Main results
headache type (Regime) (Regime) (Dropout) measures

Blanchard (1978) RCT (A)Temperature biofeedback assisted AT(n = 10) (B)PR(n = 10) (1)1 month(2) HI (1) A↓, B↓, C↓
30 patients :total 12 sessions for 6 weeks(50 min session twice per (C)waiting = list(n = 10) (2)4 months(7) (C < A < B)
week) + home practice
F = 25, M = 5 Avs.B NS
(21–77 years) Avs.C p < .05*
Migraine(n = 30) Bvs.C p < .05*

Janssen (1986) RCT (A)AT(n = 20) (B) PR(n = 21) (1)3 months HS -Tension headache
41 patients :over 12 sessions 12 weeks(1hr) + home practice(twice a day) A↓, B↓,p = .088(A < B)
F = 26, M = 15 -Migraine
(mean 33.4 years) A↓, B↓,p = .066(B < A)
-Tension headache(n = 10) -Combined tension migraine headache
-Migraine(n = 12) A↓, B↓,p = .081(B < A)
-Combined tension migraine
headache(n = 19)

Kang (2008) RCT (A) biofeedback assisted autogenic training(n = 18) (B) waiting list(n = 17) none HI (1) A↓, B↓, p = .001*
35 patients AT: 8 sessions for 4 weeks(45–50 min session twice a week) + (B < A)
home practice
F = 22, M = 13 using audio tape(15 min)
(mean 31.08 years)
64

Tension headache(n = 35)

Kang (2009) RCT (A) biofeedback assisted autogenic training(n = 17) (B) monitoring(n = 15) none HI (1) A 58.9%, B 20.0% improvement, χ2 = 4.979,
p = .029*
53 patients (mean 30.79 years) AT: 8 sessions for 4 weeks(45–50 min session twice a week) + (using biofeedback) (B < A)
home practice
Migraine(n = 53) (C) normal control
(n = 21)
↓ ↓ *
Pickering (2012) RCT (A) AT(n = 19) (B) waiting list(n = 17) (1)2 months (0) HS (1) A , B , p = .0115
36 patients 8 sessions for 8 weeks(1 h session once a week) + using CD at (B < A)
home
(mean 39 years) using headache diary
ICHD-I(n = 36)

Complementary Therapies in Medicine 39 (2018) 62–67

Zitman (1992) RCT (A) AT(n = 28) (B) FI(n = 27) (1)6 months (13) HI A↓, B↓, C↓p < .001*
79 patients AT: 6 standard exercise, 4 sessions for 8 weeks(2 1/2 h session) (C) FI-H(n = 24) (A,C < B)
+ using cassette at home
F = 43, M = 36
(mean 34.7 years)
Tension headache(n = 79)

HI: Headache index; HS: Headache Score; FI: Future-oriented imagery; F: Female; M: Male; ICHD-I: International Classification of Headache Disorders-I; FI-H: Future oriented hypnotic imagery; AT: Autogenic training;
PR: Progressive relaxation; NS: Not significant
↓
decreased compared with baseline.
* statistically significant.
E. Seo et al.
Fig. 1. Flow Diagram.
3. Results
A total of 262 research papers were initially retrieved using the
above-described search method. Screening of the initial pool resulted in
the exclusion of 139 articles including duplicates and articles that, on
closer inspection, clearly did not meet selection criteria. Three in-
vestigators reviewed the remaining 123 articles in the primary selec-
tion, focusing on the titles and abstracts with the review questions and
selection and exclusion criteria in mind. This process yielded 89 articles
for the secondary selection process; 34 articles were excluded that were
not related to the review question, were not published in Korean or
English, or which did not have an RCT research design. The complete
body text of each of the remaining 89 articles was then reviewed using
the same criteria as for the primary selection. An additional 83 articles
were excluded for reasons of irrelevance or not meeting selection cri-
teria (Fig. 1). Ultimately, six research studies met selection criteria and
were included in the systematic review.12–17 Evaluation of the six pa-
pers using the Cochrane Risk of Bias Tool yielded ratings of “low” risk
for incomplete outcome data, selective reporting and other biases.
However, 67% (4 of 6 papers) yielded ratings of “uncertain” risk for
Fig. 2. Risk of bias graph: Review authors’ judgment about each risk of bias item presented as percentages across all included studies.
65
Complementary Therapies in Medicine 39 (2018) 62–67
random sequence generation and allocation concealment, both types of
selection bias. Additionally, 83% (5 of 6 papers) yielded ratings of
“high” risk for performance bias related to the blinding of participants
and personnel and for detection bias related to blinding of outcome
assessment. While the latter two high risk ratings are recognized as a
potential limitation of those studies, due to study characteristics sub-
jects were required to be trained in the use of the intervention being
investigated so it was not possible to blind participants and personnel.
A summary of the results of this systematic review can be found in
Table 2. All six studies12–17 were randomized, controlled clinical trials.
Each study examined the effects of AT on adult headaches. Headache
was categorized as tension headache,13,14,17 migraine,12,13,15 combined
or chronic headache.13,16
Five of the six RCTs reviewed reported statistically significant re-
duction in headache12,14–17. Two of those studies used AT only as the
intervention; the other three studies used biofeedback-assisted AT. The
subjects in the AT-only or biofeedback-assisted AT intervention group
reported a greater reduction in headache over baseline than comparison
group subjects in just three of the five studies.14–16 In the other two
studies, patients in one or more comparison groups reported a similar or
E. Seo et al.
Fig. 3. Risk of bias summary: Review authors’ judgments about each risk of bias
item for each included study.
even greater reduction in headache over baseline compared to patients
in the AT group.12,17 The length of the training/intervention period in
the two studies using AT only was eight weeks;16,17 the length of the
training/intervention period in the three studies using biofeedback-as-
sisted AT ranged from four to six weeks.12–15
The method of AT used across all reviewed studies was not uniform.
The practice/follow-up period ranged from 4 weeks to 12 weeks. Three
of the studies included use of a CD or cassette tape to provide AT re-
inforcement and practice at home. The AT comparison group in each
study was different; waiting list, progressive relaxation, and future-or-
iented imagery were all used. A measure of headache served as the
major outcome variable of the studies. However, the headache 15,17
mea-
sures varied across studies; different pain scales were used,
15,17
and
headache indices were calculated using different factors. Informa-
tion on the minimally clinically important difference (MCID) in head-
ache measures was not reported.
4. Discussion
The effect of AT on adult headache was investigated through a
systematic review of six published reports of RCTs. The review was
limited to RCTs in order to minimize bias.22The types of headache in
the reviewed studies were various. Additional research with larger
numbers of subjects is necessary to study the effect of AT on headache
by headache type.
The AT intervention methods varied in the studies included in this
review. The German psychiatrist Schulz recommended using AT alone.
However, some researchers have combined use of AT and other stra-
tegies for headache reduction. The addition of adjunct strategies has
been shown to effectively reduce headache without interfering with the
effectiveness of AT.7 Certainly biofeedback-assisted AT was effective in
reducing headache in the three studies in this review that employed
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Complementary Therapies in Medicine 39 (2018) 62–67
that adjunct to AT. However, because biofeedback training alone has
also been reported to be effective in migraine,12 when the two strategies
are combined it is difficult to determine the contribution of AT alone to
reduction in headache.
The developer of AT, Dr. Schultz, used an eight-week training
period.7 Additionally, it is asserted that six sessions of AT must be run
19
for at least eight weeks to be effective. At least six sessions were
conducted in all studies included in this review, but the practice/
follow-up period ranged from four to twelve weeks. The studies re-
porting use of AT-only adhered to Dr. Schultz’s eight-week practice, but
the studies that used biofeedback-assisted AT used training periods
ranging from four to six weeks. In order for AT to be effective, it is
necessary to induce a relaxation response on a regular basis.23 Past
studies 24reported that 12 sessions for 6 weeks were most effective at 3–4
weeks, with others reporting that it was most effective at 2 weeks.25
Additional studies are needed to compare results by number of sessions
and length of practice time. It is difficult to determine the contribution
of a shorter training period for AT to reduction in headache because
biofeedback was used as an adjunct to AT in the studies that trained
subjects for four to six weeks.
An important strength of this review is that it focuses on AT as a
useful non-pharmacological intervention for adults with headaches.
There are significant limitations to the review, however. Although a
comprehensive search was carried out, few studies were retrieved that
investigated AT alone. Also, thereview was restricted to articles pub-
lished in English and Korean, so the possibility of incorporating findings
of studies reported in other languages was eliminated.
In some of the studies interventions were used in combination,
making it difficult to verify the effect of AT alone. Additionally, the
long-term efficacy of AT could not be rigorously evaluated because the
reviewed studies incorporated relatively short term follow-up. Small
group sample sizes in all reviewed studies yield low statistical power
and the potential for overestimation of effect size. Additionally, the
“high” risk ratings for performance and detection bias for five of the six
studies signify threats to their internal validity. Finally, variation in
headache measures used across studies, as well as the dearth of in-
formation about minimal clinically significant differences in those
measures, limits the interpretability of findings.
5. Conclusion
Five of the six reviewed RCTs investigating AT-only or biofeedback-
assisted AT reported statistically significant reductions in headache
However, the findings of the six reviewed studies must be viewed
cautiously because of significant limitations. As described above, those
limitations include a small number of retrieved studies, high risk of
systematic bias due to lack of blinding of participants and personnel,
small group sample sizes, variations in AT interventions used as well as
in length of AT training/intervention, and differences in headache
measures used. Rigorous evaluation of the effectiveness of specific AT
approaches and of the optimum length of AT practice for reduction of
headache is still needed, as is more research on the effectiveness of AT
with different types of headache. This review contributes meaningfully
to proposing the direction of research on use of AT for headache.
Funding
This work is not supported by any grantor. The authors have de-
clared that they have no conflict of interest.
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