OBJECTIVES: Behavioral interventions for migraine prevention can offer an important alternative or complement to medications. An updated systematic review is needed to support evidence-based guidance for clinicians and identify evidence gaps for future research.
DATA SOURCES: MEDLINE, Embase, PsycINFO, PubMed, the Cochrane Database of Systematic Reviews, clinicaltrials.gov, and grey literature sources for randomized trials published from January 1, 1975, to August 24, 2023.
REVIEW METHODS: A multidisciplinary expert panel including adult and pediatric clinical psychologists, adult and pediatric neurologists, primary care physicians, researchers, funders, children and adults with migraine and their caregivers provided input on scope and methods. We included randomized trials enrolling at least 80% participants with migraine (or outcomes for migraine participants reported separately) and reporting a primary outcome at 4 weeks or more after the start of treatment. Primary outcomes were migraine/headache attack frequency, migraine disability, and migraine-related quality of life. We did not require a formal diagnosis of migraine (i.e., International Classification of Headache Disorders criteria). The review team tabulated information from included trials, rated risk of bias, conducted pairwise meta-analyses, and rated the strength of evidence (SOE). The SOE is a formal rating of the reviewer’s confidence in the estimated effects.
RESULTS: For adults, we included 50 trials published since 1978. Most preventive interventions were multicomponent, using one or more of five primary components (cognitive behavioral therapy [CBT], biofeedback, relaxation training, mindfulness-based therapies, and/or education). Most trials were at high risk of bias, primarily due to measurement bias and incomplete data. Given the small amount of evidence on any given intervention/comparator/outcome combination, data were often insufficient to permit conclusions. For adults, we found that any of three components (CBT, relaxation training, mindfulness-based therapies) may reduce migraine/headache attack frequency (SOE: low). Education alone that targets behavior may improve migraine-related disability (SOE: low). For three other interventions (biofeedback, acceptance and commitment therapy, and hypnotherapy), evidence was insufficient to permit conclusions. We also found that mindfulness-based therapy may improve migraine disability more than education, and relaxation + education may improve migraine-related quality of life more than propranolol (SOE: low). For children/adolescents, we included 13 trials published since 1984 (average age 14.5), but the evidence was only sufficient to conclude that CBT + biofeedback + relaxation training may reduce migraine attack frequency and disability more than education alone (SOE: low).
CONCLUSION: Several behavioral interventions appear to reduce migraine/headache attack frequency in adults. Evidence consisted primarily of underpowered trials of multicomponent interventions compared with various types of control groups. Future research should enroll children and adolescents, standardize intervention components to improve reproducibility, use comparison groups that control for expectation confounds, enroll larger samples, consider digital and telehealth modes of care delivery, and improve the completeness of data collection.
| Discipline Area | Score |
|---|---|
| Psychologist |  |
| Physician |  |
Physician rater
Knowing there is low-quality evidence that behavioral interventions that may modestly improve some migraine outcomes but are unlikely to be available is of uncertain utility.
Physician rater
This is a well-done study that is useful in dispelling myths about the “proven” benefits of commonly touted interventions (often expensive and not covered by third-party payors). It is similarly useful in further delineating the types of research and needed element inclusion that would be most beneficial. These are valuable benefits given the paucity of other robust resources within this clinical area.
Physician rater
From a primary care perspective, these findings are helpful for the minority of patients who are motivated to spend the time needed for these interventions and have the financial ability to pay for them, as insurance often does not cover them.
Psychologist rater
As a clinical psychologist with a specialty in pain management, I would have expected the results of this review. The benefit of this review to me is that it provides evidence when I am asked to give an opinion or advice to my orthopaedic colleagues.
, McMaster University