Behavioral therapy for migraine prevention

Behavioral therapies for migraines, including cognitive therapy and biofeedback, have proven to be one of the most effective preventative treatments for migraines. And support for newer behavioral interventions, namely mindfulness-based therapies, is also growing. This is perhaps best evidenced by the inclusion of bio-behavior therapy as a preventative treatment for headaches in the American Headache Society’s 2021 consensus statement.

Behavioral therapies for migraines approach patient care according to a bio-psychosocial model that views symptoms as the result of a complex interaction of biological, psychological, and social variables. In addition to reducing the frequency and severity of migraines, behavioral migraine interventions aim to reduce headache-related disabilities, dependence on poorly tolerated or undesirable pharmacotherapies and headache-related stress or other psychological symptoms, and to improve personal control of migraines. A review of several meta-analyzes showed that behavioral interventions in migraineurs reduced migraines by 35–50% compared to 5–10% in control groups (placebo) and showed similar results as preventive pharmacological interventions.

Behavioral headache interventions can be used alone or in conjunction with pharmacological and interventional treatment and can be tailored to both adults and children with appropriate developmental considerations. Here’s a closer look at behavioral therapies to prevent and treat migraines.

Cognitive behavior therapy in practice

The effectiveness of behavioral interventions suggests that the experience of migraine pain naturally puts the body in a state of stress that contributes to an overactive sympathetic nervous system and exacerbates existing migraine symptoms. Behavioral therapies with Level A evidence (e.g., several well-designed randomized clinical trials) that support their use in preventive migraine management include cognitive behavioral therapy (CBT), biofeedback, and relaxation therapies.

CBT is a short-term, skills-based psychotherapy that builds on the interactions between thoughts, emotions, behaviors, and physiological responses (Figure). This approach includes learning various cognitive skills (e.g. recognizing and questioning negative self-talk statements by generating realistic and helpful coping thoughts) and behavioral strategies (e.g. triggers and integration into the daily practice of relaxation strategies). CBT aims to improve patients’ self-efficacy in managing headaches in deciding how to respond to stressors and symptoms.

Modified CBT cycle for pain / headache

Illustration. The Cognitive Behavioral Therapy (CBT) cycle.

A systematic review of CBT for the treatment of headaches and migraines in adults found that CBT was statistically significantly more effective at improving headache-related outcomes when compared to a waiting list control group (three studies), relaxation only (three studies), or antidepressants (one Study). In children, the results of a meta-analysis also support the clinical role of CBT in the treatment of pediatric migraines, with a clinically significant improvement (≥ 50% reduction in headache activity after treatment and at 3-month follow-up) compared to waiting list control, Placebo or standard medication. In addition, clinical improvement was stable even after 1 year of follow-up, as can be seen from some studies.

With biofeedback, patients learn to voluntarily control their body reactions through feedback-mediated perception of physiological processes. The most common biofeedback modalities used to treat migraines are peripheral skin temperature, blood volume pulse, and electromyography feedback.

A meta-analysis of 55 studies provided strong evidence for the effectiveness of biofeedback in migraine, including a significant reduction in migraine symptoms with a mean effect size that remained stable over a mean follow-up interval of more than 1 year. This study found that peripheral skin temperature, blood volume pulse, and electromyographic feedback alone or in combination are equally effective in treating migraines. Similarly, a meta-analysis of randomized controlled trials in children and adolescents with migraines found that biofeedback significantly reduced migraine frequency, seizure duration, and headache intensity compared to a waiting list control group.

Relaxation training skills help patients differentiate between tension and relaxation in the body, thereby reducing sympathetic arousal in response to pain and stress. Patients are typically taught various relaxation techniques (e.g., diaphragmatic breathing, images, progressive muscle relaxation) and are encouraged to practice these skills on a daily basis. This daily practice serves both as a preventive strategy and to increase the accessibility of this skill to use as an abortive measure at the onset of migraines.

Although it can be difficult to effectively isolate the effectiveness of relaxation training (which is also a key component of biofeedback and CBT), in a meta-analysis, relaxation training showed a medium effect size, similar to more intense CBT treatments. Pediatric research has shown improvements in the frequency and intensity of headaches with therapist-assisted relaxation training compared to waiting list controls and in a number of randomized controlled trials.

Mindfulness-Based Interventions

There is growing evidence for mindfulness-based interventions and acceptance and commitment therapy. Mindfulness-based interventions (e.g. mindfulness-based cognitive therapy and mindfulness-based stress reduction) teach the technique of attention regulation and cultivate a value-free awareness of the present moment. This process aims to change the affective and sensory response to pain and improve the quality of life despite symptoms.

A meta-analysis suggests that mindfulness can reduce the intensity and frequency of headaches and improve self-efficacy in treating migraines, but the small number of high-quality studies made it difficult to draw a definitive conclusion. Mindfulness research is also limited among pediatric populations with migraines, but pilot studies show that mindfulness interventions can improve stress levels, negative emotions, and quality of life in adolescents with migraines.

Acceptance and Commitment Therapy (ACT) is a cognitive-behavioral intervention that integrates mindfulness-based strategies. This approach emphasizes psychological flexibility with an emphasis on accepting painful thoughts, feelings, and sensations and minimizing the disruption of symptoms when engaging in valuable activities.

A recent randomized controlled trial found that patients with primary headache who received ACT showed improvements in headache-related disability, quality of life, depression, and functional status. Another randomized pilot study showed that patients receiving ACT had a greater reduction in headache incidence and medication use compared to usual treatment; however, these differences disappeared 6 months after the intervention.

Although research on the effects of ACT on migraines is currently limited, several reviews in both adults and children have found the benefits of ACT in treating chronic pain in general in terms of reducing pain intensity and pain relief, as well as symptoms of anxiety noted and depression.

Electronic management of CBT

Given the limited availability of physicians trained in evidence-based behavioral migraine therapy, there is a movement towards the use of behavioral strategies through websites or smartphone applications (known as eHealth and mHealth, respectively).

Electronic behavioral training for migraines has some evidence of migraine reduction or migraine-related disability, but the results have varied. Because many electronic interventions involve patients handling material on their own, several studies have found low adherence and high dropout rates, and further research is needed on the effectiveness of these interventions.

In summary, behavioral interventions have a strong and growing evidence base in migraine management in both adults and children. The doctor is advised to consider behavioral headache treatment in combination with preventive medications or as a stand-alone treatment to manage migraine symptoms as well as the functional effects of migraines.

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