The American Headache Society Position Statement on Integrating New Migraine Treatments Into Clinical Practice

American Headache Society



In This Article

Neuromodulation and Biobehavioral Therapies


Several noninvasive devices have been developed for the treatment of patients with migraine. These treatments modulate pain mechanisms involved in headache by stimulating the nervous system centrally or peripherally with an electric current or a magnetic field.[78] Based on results demonstrating efficacy and safety in clinical trials, the United States Food and Drug Administration has cleared:[79,80]

  • Single-pulse transcranial magnetic stimulation for the acute and preventive treatment of migraine

  • Electrical trigeminal nerve stimulation for the acute and preventive treatment of migraine

  • Noninvasive vagus nerve stimulation for the acute treatment of migraine

Patients who prefer nondrug therapies and those who have failed to respond to, have contraindications to, or poor tolerability with pharmacotherapy may be candidates for neuromodulation.

Biobehavioral Therapies

As with all chronic medical conditions, education and lifestyle modification is important in the management of migraine. Minimizing exposure and managing unavoidable trigger factors, appropriate and individualized nutrition advice, exercise, and adequate hydration should be implemented and personalized for each patient.

There is a large and growing body of published evidence examining the use of behavioral therapies for migraine (and other forms of headache) including meta-analytic studies and evidence-based reviews. Biobehavioral therapy, including cognitive behavioral therapy (CBT) and biofeedback, and relaxation therapies have been shown to be effective in the acute and preventive treatment of migraine and have Grade A evidence for their use preventively.[81–85] The US Headache Consortium advised that nonpharmacologic treatments might be particularly well suited for patients who:[22]

  • Prefer nonpharmacologic interventions

  • Have inadequate response, poor tolerance, or medical contraindications to specific pharmacologic treatments

  • Are pregnant, lactating, or planning to become pregnant

  • Have a history of acute medication overuse as defined in the section on Indications for Preventive Treatment

  • Exhibit significant stress or deficient stress-coping skills

They identified the following goals for behavioral interventions as preventive treatment for headache:

  • Reduced frequency and severity of headache

  • Reduced headache-related disability

  • Reduced reliance on poorly tolerated or unwanted pharmacotherapies

  • Enhanced personal control of migraine

  • Reduced headache-related distress and psychological symptoms

Biobehavioral therapies may be used alone or in conjunction with pharmacologic and interventional treatments. Evidence suggests that combining biobehavioral interventions with pharmacotherapy provides greater benefits than either modality alone.[82,83,86]