Behavioral interventions for migraine prevention: A systematic review and meta-analysis

Abstract

Objectives/background: This study was undertaken to synthesize evidence on the benefits and harms of behavioral interventions for migraine prevention in children and adults. The efficacy and safety of behavioral interventions for migraine prevention have not been tested in recent systematic reviews.

Methods: An expert panel including clinical psychologists, neurologists, primary care physicians, researchers, funders, individuals with migraine, and their caregivers informed the scope and methods. We searched MEDLINE, Embase, PsycINFO, PubMed, the Cochrane Database of Systematic Reviews, clinicaltrials.gov, and gray literature for English-language randomized trials (January 1, 1975 to August 24, 2023) of behavioral interventions for preventing migraine attacks. Primary outcomes were migraine/headache frequency, migraine disability, and migraine-related quality of life. One reviewer extracted data and rated the risk of bias, and a second verified data for completeness and accuracy. Data were synthesized with meta-analysis when deemed appropriate, and we rated the strength of evidence (SOE) using established methods.

Results: For adults, we included 50 trials (77 publications, N = 6024 adults). Most interventions were multicomponent (e.g., cognitive behavioral therapy [CBT], biofeedback, relaxation training, mindfulness-based therapies, and/or education). Most trials were at high risk of bias, primarily due to possible measurement bias and incomplete data. 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 therapies may reduce 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 (16 publications, N = 1444 children), 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: Results suggest that for adults, CBT, relaxation training, and mindfulness-based therapies may each reduce the frequency of migraine/headache attacks, and education alone may reduce disability. For children/adolescents, CBT + biofeedback + relaxation training may reduce migraine attack frequency and disability more than education alone. Evidence consisted primarily of underpowered trials of multicomponent interventions compared with various types of control groups. Limitations include semantic inconsistencies in the literature since 1975, differential usage of treatment components, expectation effects for subjectively reported outcomes, incomplete data, and unclear dosing effects. Future research should enroll children and adolescents, standardize intervention components when possible to improve reproducibility, consider smart study designs and personalized therapies based on individual characteristics, use comparison groups that control for expectation, which is a known challenge in behavioral trials, enroll and retain larger samples, study emerging digital and telehealth modes of care delivery, improve the completeness of data collection, and establish or update clinical trial conduct and reporting guidelines that are appropriate for the conduct of studies of behavioral therapies.

Keywords: cognitive–behavioral therapy; headache; migraine; mindfulness; relaxation.

FIGURE 1

Trial flow diagram. This figure shows the counts and various stages of our article screening process. Searches identified 1791 potentially relevant references, of which 106 were duplicates. An additional 61 potentially relevant references were identified from the reference lists of relevant systematic reviews. We excluded 1526 citations at the abstract level and ordered the remaining 220 for full‐text consideration. Of these, we excluded 127 studies, with the most common reasons for exclusion being “Does not meet population criteria,” “Does not evaluate a comparison of interest,” and “Does not evaluate a key outcome of interest.” As a result, we included 63 studies in 93 publications.

FIGURE 2

Meta‐analyses of cognitive behavioral therapy in adults. (A) Migraine or headache frequency. (B) Migraine disability. (C) Migraine‐specific quality of life. B, biofeedback; CBT, cognitive behavioral therapy; Chr, only patients with chronic migraine; CI, confidence interval; E, education; Epi, only patients with episodic migraine; HA, headaches (unreported timeframe); HA d/w, headache days per week; HA d/28 d, headache days per 28‐day period; HA/w, headaches per week; HDI, Headache Disability Inventory; HIT‐6, HIT‐6, Headache Impact Test‐6; MBSR, mindfulness‐based stress reduction; Mi d/w, migraine days per week; Mi d/30 d, migraine days per 30‐day period; Mi/w, migraine attacks per week; MIDAS, Migraine Disability Assessment; Mix, both episodic and chronic patients; MSQoL, Migraine‐Specific Quality of Life; NA, not applicable; NR, not reported; O, other (neither behavioral nor pharmacologic); P, pharmacologic; PDI, Pain Disability Inventory; R, relaxation training; SMD, standardized mean difference; T, tailored treatment; TAU, treatment as usual.

FIGURE 3

Meta‐analyses of biofeedback in adults. (A) Migraine or headache frequency. (B) Migraine disability. B, biofeedback; CBT, cognitive behavioral therapy; Chr, only patients with chronic migraine; CI, confidence interval; E, education; Epi, only patients with episodic migraine; HA d/w, headache days per week; MBSR, mindfulness‐based stress reduction; Mi d/w, migraine days per week; Mi/w, migraine attacks per week; MIDAS, Migraine Disability Assessment; NA, not applicable; R, relaxation training; SMD, standardized mean difference; TAU, treatment as usual.

FIGURE 4

Meta‐analyses of relaxation training in adults. (A) Migraine or headache frequency. (B) Migraine disability. (C) Migraine‐specific quality of lifeB, biofeedback; CBT, cognitive behavioral therapy; Chr, only patients with chronic migraine; CI, confidence interval; E, education; Epi, only patients with episodic migraine; HA, headaches (unreported timeframe); HA d/28 d, headache days per 28‐day period; HA d/w, headache days per week; MBSR, mindfulness‐based stress reduction; Mi d/30 d, migraine days per 30 day period; Mi d/w, migraine days per week; Mi/4 w, migraine attacks per 4‐week period; Mi/w, migraine attacks per week; MIDAS, Migraine Disability Assessment; Mix, both episodic and chronic patients; MSQoL, Migraine‐Specific Quality of Life; NR, not reported; O, other (neither behavioral nor pharmacologic); P, pharmacologic; R, relaxation training; SMD, standardized mean difference; T, tailored treatment; TAU, treatment as usual.

FIGURE 5

Meta‐analyses of mindfulness‐based therapy in adults. (A) Migraine or headache frequency. (B) Migraine disability. B, biofeedback; CBT, cognitive behavioral therapy; CI, confidence interval; E, education; Epi, only patients with episodic migraine; HA d/w, headache days per week; HA/d, headaches per day; HA/w, headaches per week; HDI, Headache Disability Inventory; MBSR, mindfulness‐based stress reduction; Mi/w, migraine attacks per week; Mix, both episodic and chronic patients; NA, not applicable; NR, not reported; PDI, Pain Disability Inventory; R, relaxation training; SMD, standardized mean difference; TAU, treatment as usual.

FIGURE 6

Meta‐analyses of cognitive behavioral therapy in children/adolescents. (A) Migraine or headache frequency. (B) Migraine disability. B, biofeedback; CBT, cognitive behavioral therapy; CI, confidence interval; E, education; Epi, only patients with episodic migraine; HA d/w, headache days per week; HA/2 w, headaches per 2‐week period; HA/w, headaches per week; Mi/w, migraine attacks per week; Mix, both episodic and chronic patients; PedMIDAS, Pediatric Migraine Disability Assessment; R, relaxation training; SMD, standardized mean difference; TAU, treatment as usual.

FIGURE 7

Meta‐analyses of biofeedback in children/adolescents. (A) Migraine or headache frequency. (B) Migraine disability. B, biofeedback; CBT, cognitive behavioral therapy; CI, confidence interval; E, education; Epi, only patients with episodic migraine; HA/2 w, headaches per 2‐week period; Mi/w, migraine attacks per week; NA, not applicable; R, relaxation training; SMD, standardized mean difference.

FIGURE 8

Meta‐analyses of relaxation training in children/adolescents. (A) Migraine or headache frequency. (B) Migraine disability. B, biofeedback; CBT, cognitive behavioral therapy; CI, confidence interval; E, education; Epi, only patients with episodic migraine; HA d/w, headache days per week; HA/2 w, headaches per 2‐week period; HA/w, headaches per week; Mi/w, migraine attacks per week; Mix, both episodic and chronic patients; PedMIDAS, Pediatric Migraine Disability Assessment; R, relaxation training; SMD, standardized mean difference; TAU, treatment as usual.