Are Psychological Interventions Efficacious for Adults With Migraine?

A Systematic Review and Meta-Analysis

Joanne Dudeney PhD; Louise Sharpe PhD; Sarah McDonald PhD; Rachel E. Menzies PhD; Brian McGuire PhD


Headache. 2022;62(4):405-419. 

In This Article

Abstract and Introduction


Objective: To determine the efficacy of psychological interventions in studies of adults with migraine, in reducing pain, and functional and psychosocial difficulties.

Background: A recently published Cochrane Review showed no strong evidence for psychological intervention for adults with migraine. However, this review was limited by stringent inclusion criteria, potentially resulting in low power. The current review examines the stability of these findings.

Methods: CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases were systematically searched from inception to July 31, 2021. Reviewers independently conducted the search and extraction process. Risk of bias was conducted, and we provide GRADE ratings of our confidence in the evidence. We included 39 randomized controlled trials in the meta-analyses (n = 3155); 31 included data on migraine only and eight combined data from adults with migraine or tension-type headache (TTH).

Results: In contrast to the Cochrane Review, for studies including adults with migraine only, we found psychological interventions had a small to medium beneficial effect on improving migraine frequency, pain intensity, and disability post-treatment, compared to controls (Cohen's d range 0.23 to 0.33), and disability at follow-up (d = 0.44). We found no evidence of a beneficial effect on quality-of-life post-treatment, or mood at post-treatment or follow-up. Our sensitivity analyses on studies with mixed headache populations (migraine and combined migraine/TTH) found a similar magnitude of effects for most outcomes (d range 0.25 to 0.36), except for mood, which produced a small to medium beneficial effect (d = 0.32).

Conclusion: We found evidence that adults with migraine may benefit from psychological intervention, and psychological treatment may equally benefit adults with a range of headache conditions. However, as with previous reviews, quality of the evidence was low, findings should be cautiously interpreted, and this field would benefit from future high-quality trials.


Migraine is a leading cause of pain in adults, with prevalence rates of approximately 15%.[1,2] The individual and societal burden is extreme, with approximately 28% reporting substantial headache-related disability,[1,2] along with increased psychiatric difficulties, reduced health-related quality of life, greater work absenteeism, and increased emergency department and long-term health-care use.[1,3–6]

Prophylactic and acute medications are a first-line treatment.[7] However, data on the use of preventative medication shows less than 25% adherence rates after 12 months.[8] Factors identified for low adherence include medication cost, contraindication (e.g., pregnancy, diabetes, heart conditions),[9] adverse effects,[10,11] intolerability of frequency and dose,[12] perceived delay in therapeutic benefits,[13,14] or decreased efficacy over time.[15]

Accordingly, there has been interest in reducing or preventing migraine by non-pharmacological methods such as psychological intervention. These interventions aim to reduce the psychological processes (e.g., cognitions, behaviors, attention) that can maintain migraine pain and associated disability and distress. However, periodic evidence-based reviews on psychological approaches have reported contrasting findings. Reviews in favor of psychological intervention for adults with migraine are limited by qualitative methodology,[16,17] precluding the calculation of treatment efficacy, or included inadequate study designs (e.g., uncontrolled, non-randomized studies, small sample sizes) which potentially leads to an overestimation of the observed effects.[18–20] In contrast, a recent Cochrane Review published by members of our research group on randomized controlled trials (RCTs) showed no strong evidence for psychological intervention.[21] There are some possible reasons for the contradictory findings. First, Cochrane Reviews are stringent in how data are reported in the eligible studies, only including outcome data reported as means and standard deviations. This leads to a small number of studies being eligible for meta-analysis, potentially reducing power. Second, the Cochrane Review included studies with migraine only, excluding those in which participants with migraine and other headache conditions (e.g., tension-type headache [TTH]) were combined in analyses. This decision mitigated heterogeneity, however, as there is currently no evidence to indicate whether migraine and other headache conditions respond equivalently or not to psychological interventions, and several studies include combined populations; removing these combined studies again likely reduced the power of the overall effects.

Our aim for the current review was to extend and update the Cochrane Review, broadening the range of studies investigating psychological treatments for adults with migraine, while maintaining the scientific rigor of the review and meta-analytical approach. Through this, we aimed to determine the overall efficacy of psychological interventions for adults with migraine in reducing migraine frequency, pain, and functional and psychosocial difficulties.