Behavioral Therapy for Migraine Prevention Continues to Gain Support

Alexandra C. Ross, PhD; Amanda E. Wagstaff, PhD


August 31, 2021

Editorial Collaboration

Medscape &

Behavioral migraine therapies, including cognitive-based therapy and biofeedback, have proven to be among the most effective preventive treatment options available for migraine. And support for newer behavioral interventions, namely mindfulness-based therapies, is also growing. This is perhaps most evidenced by the 2021 American Headache Society Consensus Statement's inclusion of biobehavioral therapy as a preventive treatment for headache.

Behavioral migraine therapies approach patient care from a biopsychosocial model, which views symptoms as emanating from a complex interaction of biological, psychological, and social variables. In addition to reducing the frequency and severity of migraine, behavioral migraine interventions aim to reduce headache-related disability, reliance on poorly tolerated or unwanted pharmacotherapies, and headache-related distress or other psychological symptoms, and to enhance personal control of migraine. A review of several meta-analyses demonstrated that behavioral interventions in patients with migraine reduce migraine by 35%-50% compared with 5%-10% for control condition (placebo) groups and have shown outcomes similar to those of preventive pharmacologic interventions.

Behavioral headache interventions may be used alone or in conjunction with pharmacologic and interventional treatment and, with appropriate developmental considerations, can be tailored to both adult and pediatric populations. Here's a closer look at behavioral therapies for prevention and management of migraine.

Cognitive-Behavioral Therapy in Practice

The effectiveness of behavioral interventions suggests that the experience of the pain of migraine inherently places the body in a state of stress, contributing to an overactive sympathetic nervous system and amplifying existing migraine symptoms. Behavioral therapies with Grade A evidence (eg, multiple well-designed randomized clinical trials) supporting their use in preventive migraine treatment include cognitive-behavioral therapy (CBT), biofeedback, and relaxation therapies.

CBT is a short-term, skills-based psychotherapy built on the interrelationships among thoughts, emotions, behaviors, and physiologic responses (Figure). This approach involves patients learning various cognitive skills (eg, identifying and challenging negative self-talk statements through the generation of realistic and helpful coping thoughts) and behavioral strategies (eg, specific actions including problem-solving skills to adaptively manage daily stressors, modification of triggers, and incorporation of daily practice of relaxation strategies). CBT aims to improve patients' self-efficacy in managing headache as they choose how to respond to stressors and symptoms. 

Modified CBT Cycle for Pain/Headache

Figure. The cognitive-behavioral therapy (CBT) cycle.

A systematic review of CBT for the management of headaches and migraines in adults found that CBT was statistically significantly more effective in improving headache-related outcomes compared with a wait-list control group (three studies), relaxation only (three studies), or antidepressant medication (one study). Among children, results of a meta-analysis also support the clinical role of CBT in the management of pediatric migraine, with clinically significant improvement (≥ 50% headache activity reduction posttreatment and at 3-month follow-up) compared with wait-list control, placebo, or standard medication. Furthermore, the clinical improvement was stable even at 1-year follow-up, as evident in some of the studies.

In biofeedback, patients learn voluntary control over their bodily reactions through feedback-mediated awareness of physiologic processes. The most frequently used biofeedback modalities for migraine treatment are peripheral skin temperature, blood-volume-pulse, and electromyography feedback.

A meta-analysis of 55 studies provided strong evidence for the efficacy of biofeedback for migraine, including significant reductions in migraine symptoms, with a medium effect size that remained stable over an average follow-up interval of more than 1 year. This study found that peripheral skin temperature, blood-volume-pulse, and electromyography feedback alone or in combination are equally efficacious in the treatment of migraine. Similarly, a meta-analysis of randomized, controlled trials among children and adolescents with migraine found that biofeedback significantly reduced migraine frequency, attack duration, and headache intensity compared with a wait-list control group.

Relaxation training skills help patients learn to differentiate between tension and relaxation in the body, decreasing sympathetic arousal in response to pain and stress. Patients are typically taught a variety of relaxation techniques (eg, diaphragmatic breathing, imagery, progressive muscle relaxation) and are encouraged to practice these skills daily. This daily practice functions both as a preventive strategy and to increase the accessibility of this skill to use at the onset of migraine as an abortive measure.

Although it can be difficult to effectively isolate the efficacy of relaxation training (which is also a key component of both biofeedback and CBT), in one meta-analysis, relaxation training demonstrated a medium effect size, similar to that found for more intensive CBT treatments. Pediatric research has indicated improvements in headache frequency and intensity with therapist-assisted relaxation training compared with wait-list control as well as in a series of randomized controlled trials.

Mindfulness-Based Interventions

There is a growing amount of evidence in support of mindfulness-based interventions, as well as acceptance and commitment therapy. Mindfulness-based interventions (eg, mindfulness-based cognitive therapy and mindfulness-based stress reduction) teach the attention-regulation technique, cultivating nonjudgmental awareness of the present moment. This process aims to alter the affective and sensory response to pain and improve quality of life despite symptoms.

One meta-analysis suggests that mindfulness may reduce headache intensity and frequency and improve self-efficacy in treatment of migraine, but the small number of good-quality studies made it challenging to draw a definitive conclusion. Among pediatric populations with migraine, mindfulness research is also limited, but pilot studies indicate that mindfulness interventions may improve stress levels, negative emotions, and quality of life for youth with migraine.

Acceptance and commitment therapy (ACT) is a cognitive-behavioral intervention integrating mindfulness-based strategies. This approach emphasizes psychological flexibility with a focus on acceptance of painful thoughts, feelings, and sensations and minimizing the interference of symptoms with engaging in valued activities.

A recent randomized controlled trial found that patients with primary headache who engaged in ACT had improvements in headache-related disability, quality of life, depression, and functional status. Another randomized pilot study demonstrated that patients who engaged in ACT had greater reductions in headache frequency and medication intake compared with treatment as usual; however, such differences dissipated 6 months after the intervention.

Although research on the impact of ACT on migraine is currently limited, several reviews among both adult and pediatric populations have found benefits of ACT in the treatment of chronic pain more broadly in terms of reducing pain intensity and pain disability, as well as symptoms of anxiety and depression.

Electronic Administration of CBT

Given the limited availability of practitioners trained in evidence-based behavioral migraine therapies, there has been a movement toward the use of behavioral strategies via websites or smartphone applications (known as eHealth and mHealth, respectively).

Electronically administered behavioral training for migraine has some evidence in reducing migraine frequency or migraine related-disability , but findings have varied. Because many electronic interventions involve patients independently engaging with material, several studies found low adherence and high dropout rates, and further research is needed on the effectiveness of these interventions.

In conclusion, behavioral interventions have a strong and growing evidence base in migraine management for both adult and pediatric populations. The practitioner is recommended to consider prescribing behavioral headache management in combination with preventive medication or as a stand-alone treatment to address migraine symptoms as well as the functional impact of migraine.

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