Exploring Current and Developing Migraine Behavioral Treatments: Expert Q&A

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Evidence-based behavioral treatments may be at least as effective for migraine prophylaxis as medication.
Evidence-based behavioral treatments may be at least as effective for migraine prophylaxis as medication.

Migraine affects an estimated 12% to 15% of women, 6% to 8% of men, and 9% of children and adolescents.1 Although pharmacotherapy remains the standard strategy for migraine management, there are many patients for whom nonpharmacological approaches are indicated, such as those with low response to or tolerance for medication, women who are pregnant, and those who prefer nondrug approaches because of potential adverse effects.

For these and other patients, evidence-based behavioral treatments may be at least as effective for migraine prophylaxis as medication, according to a substantial body of research. Findings from adult studies, for example, suggest that cognitive behavioral therapy (CBT) can reduce physical symptoms of migraine, and a 2016 meta-analysis of 14 studies showed significant, enduring clinical improvement with CBT vs waitlist, placebo, or medication in pediatric patients.2,3 With CBT, the odds ratio of achieving a 50% greater reduction in headache activity posttreatment was 9.11 (95% CI, 5.01-16.58, P <.001); 3 months later, it was 9.18 (95% CI, 5.69-14.81; P <.001).

Behavioral interventions delivered via computer or smartphone have also shown promise, although further research is needed regarding duration of treatment and privacy issues.4,5 It is expected that the availability of treatments offered in this format will continue to grow along with further technological advances.

To explore the top behavioral options for migraine and additional clinical implications, Neurology Advisor spoke with Mia T. Minen, MD, MPH, assistant professor of neurology and director of Headache Services at New York University Langone Medical Center in New York City, and Scott W. Powers, PhD, professor of pediatrics at the University of Cincinnati College of Medicine, director of clinical and translational research at the Cincinnati Children's Research Foundation, and codirector of the Headache Center at Cincinnati Children's Hospital in Ohio.

Neurology Advisor: What are the most effective behavioral treatment strategies for migraine, and what else is known about these approaches?

Dr Minen: The top evidence-based behavioral treatments for migraine prevention include CBT, biofeedback, and relaxation therapy. They are effectively free of adverse effects and have enduring benefits. Some of these have been known to be effective for migraine for a long time: progressive muscle relaxation is a standardized, evidence-based behavioral treatment that has been in use for migraine since the 1980s. Progressive muscle relaxation has also been successfully used as a simple behavioral technique patients can do independently. 

There are also other behavioral treatments available, including acupuncture, exercise, yoga, and hypnosis. There was a pilot study examining mindfulness-based stress reduction. These behavioral therapies may also be used for migraine preventive treatment. In addition, there is an ongoing mindfulness-based cognitive behavioral therapy study currently taking place.

Behavioral treatments may be less costly than pharmacologic interventions. They can work alone in migraine prevention. There are also studies that show that when paired with pharmacologic treatment, there is not just an additive benefit but also a synergistic one, meaning the combination of behavioral treatment and pharmacologic treatment is most effective.1 This is true in both adult medicine and

pediatrics. We know that adherence to behavioral therapy is key, but studies examining adherence rates to specific behavioral treatment recommendations are underrepresented in the medical literature.

Dr Powers: Numerous studies have investigated behavioral treatments for migraine in adults and youth. Overall, CBT treatment packages have been the most studied. These often include relaxation training with biofeedback and cognitive reappraisal training. The approach involves understanding how the perception of pain can be modified by learning various techniques, practicing skills, and using problem-solving techniques to apply these skills in each patient's life.

Relaxation training has been found to be a fundamental aspect of behavioral approaches. In some studies, it appears that use of biofeedback enhances the outcome of relaxation training for individuals with migraine, but this is not definitive. However, the appeal of this technology to children and adolescents is notable, and we predominantly include biofeedback-assisted relaxation training in our treatment approach.

Neurology Advisor: What are the main takeaways for clinicians? 

Dr Minen: Physician and patient awareness of these effective behavioral therapies is limited and needs to be expanded. Difficulty accessing CBT and biofeedback for migraine is an issue for many patients with migraine. There are few providers who are trained in the techniques and feel comfortable applying them. Moreover, insurance companies may cover these treatments, but patients and physicians need to know how to inquire about insurance coverage. These treatments can be billed under "Health and Behavior" codes, not mental health codes -- this is key.

Dr Powers: Behavioral treatments are effective for many patients. Once they learn the skills, they are theirs, and they can use them over time, unlike a medication that is no longer in their system once it is discontinued. New pilot data indicate that neural changes at the brain level occur after CBT in youth with migraine. Our challenge is making this evidence-based treatment more broadly available and having third-party payers reimburse for it. Progress is being made, but advocacy from patients and families would accelerate access and affordability. 

In adults, data show that behavioral treatments combined with prevention medications produce better results than medication alone or CBT alone.1 In youth, efficacy of prevention medications is quite uncertain, but a placebo effect of pill-taking is present in adults and kids. One study of chronic migraine in youth did show that CBT plus amitriptyline was superior to medication and education alone.6

Neurology Advisor: What should be the focus of future research in this area? 

Dr Minen: There are many potential areas for future research:

  • Examining adherence to these behavioral therapies.
  • Examining new modalities to deliver these proven behavioral treatments to migraine patients in a scalable, cost-effective manner; this can be done via telebehavioral health studies and smartphone-based studies. (I am currently conducting a study using smartphone-based behavioral therapy.)
  • Understanding how to tailor the therapy to patients with migraine, as we don't know which modalities are best for which patients.

Dr Powers: Our team is investigating how and why youth with migraine get better with CBT. Our work included functional brain imaging (fMRI) and quantitative sensory testing using a conditioned pain modulation paradigm to see how the brain may change and how pain is communicated to and from the brain and the peripheral nervous system before and after 8 weeks of CBT for youth with migraine.

Our pilot data show steady state changes in brain functioning, and that inefficient modulation pretreatment is predictive of being likely to lead to reduced headache days and disability in youth who participate in CBT. Our next step is to see whether these neural changes are specific to CBT by investigating a placebo pill and a preventive medication along with CBT, using this study design.

We are also working to adapt face-to-face CBT into a self-management approach that uses mobile health technology and can be initiated by an allied health provider in clinical practice. We are testing a web-based portal that can be used on a phone, tablet, or computer to understand feasibility and patient preferences. We will then test for efficacy in a pragmatic clinical trial. 

We expect benefit, but maybe not as robust as face-to-face. However, this low-contact approach would provide for scaling and use in primary care and neurology practice. If a patient is not a responder, they could move on to face-to-face treatment, or we may find predictors that would help guide referral to mobile health first or go directly to face-to-face.

References

  1. Kropp P, Meyer B, Meyer W, Dresler T. An update on behavioral treatments in migraine – current knowledge and future options. Expert Rev Neurother. 2017;17(11):1059-1068.
  2. Harris P, Loveman E, Clegg A, et al. Systematic review of cognitive behavioural therapy for the management of headaches and migraines in adults. Br J Pain. 2015;9(4):213-224.
  3. Ng QX, Venkatanarayanan N, Kumar L. A systematic review and metaanalysis of the efficacy of cognitive behavioral therapy for the management of pediatric migraine. Headache. 2017;57(3):349-362.
  4. Minen MT, Torous J, Raynowska J, et al. Electronic behavioral interventions for headache: a systematic review. J Headache Pain. 2016;17:51.
  5. Sorbi MJ, Balk Y, Kleiboer AM, et al. Follow-up over 20 months confirms gains of online behavioural training in frequent episodic migraine. Cephalalgia. 2017;37(3):236-250.
  6. Kroner JW, Hershey AD, Kashikar-Zuck SM, et al. Cognitive behavioral therapy plus amitriptyline for children and adolescents with chronic migraine reduces headache days to </=4 per month. Headache. 2016;56(4):711-716. 
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