Psychological approaches for migraine management

Abstract

Migraine headaches are among the most common medical conditions worldwide and contribute to substantial work loss and psychosocial dysfunction. Best practices in migraine management incorporate a multidisciplinary approach consisting of both pharmacological and non-pharmacological interventions. Among the most important non-pharmacological interventions are psychological treatments that address cognitive, behavioral, and affective factors to reduce migraine-related pain, distress, and disability. The current article provides a narrative overview of current best-practice psychological interventions for migraine, including relaxation therapy, biofeedback, and cognitive behavioral therapy. We also review a second set of interventions for which there is a promising but relatively smaller base of evidence. Finally, we discuss future directions in psychological interventions for migraine, including brief and telehealth-based treatment, considerations of precision medicine, and treatment of patients with histories of adverse life experiences and trauma.

Introduction

Migraine headaches are among the most common and costly medical symptoms in the world; migraine affects more than 1 billion people worldwide.¹ Migraine was identified as the seventh most common cause of years lost to disability across all medical conditions in both 1990 and 2010,² and accounts for more than 50% of years lost to disability for people with a neurological condition.³ Direct costs from migraine-related medical care have been estimated to be $9.2 billion annually over the past 15 years.⁴

Migraine headaches are defined as a neurovascular condition, associated with vascular activity abnormality, altered connectivity between brain regions, circulating neuropeptides, and cervical and cranial nerve dysfunction.⁵ However, there is considerable variability in the intensity, frequency, and functional impact of migraine-related pain between individuals and across time.^{3, 5, 6} As with other chronic pain conditions, it is useful to consider not only the objective pathophysiology but also the coping responses and social environment of the individual to fully understand the factors contributing to disease activity and resulting function.

Modern biopsychosocial conceptualizations of chronic pain recognize the significant contributions of psychological and social factors alongside biological factors to the experience and impact of pain; this model provides a strong conceptual fit for migraine pain and migraine-related disability.⁶ A key benefit of applying a biopsychosocial lens is the ability to identify psychosocial risk factors that can be modified by psychological interventions and complementary biomedical interventions to reduce migraine pain and associated disability.

Psychosocial Risk Factors in Migraine

Several psychosocial risk factors warrant mention as potential targets of psychological interventions in migraine: maladaptive cognitive appraisals, behavioral avoidance, emotional distress, and sleep disturbance. Importantly, as these risk factors develop, they can interact and contribute to even greater migraine severity and disability over time (Figure 1).

Figure 1.

Biopsychosocial model of vulnerability factors in migraine

Cognitive appraisals

Cognitive appraisals are interpretations individuals make about the meaning of their medical condition and the degree to which they can manage their symptoms. The appraisal pattern most often studied in migraine and other chronic pain conditions is pain catastrophizing.⁷ It is a multi-domain construct related to feeling helplessness about pain, magnifying negative aspects of pain, and an inability to disengage from negative thoughts about pain.⁸ Among individuals with migraine, greater catastrophizing is associated with greater long-term disability⁹ and emotional distress⁷. Importantly, catastrophic or fearful appraisals of migraine symptoms can fuel maladaptive behavioral patterns that compound the negative impacts of migraine on function and well-being.^{10, 11}

Behavioral avoidance

Individuals with migraine can engage in progressively greater avoidance of activities associated with headaches. Although effective management may involve some adaptive avoidance (e.g., of particularly potent migraine triggers), consistent and indiscriminate avoidance can increase migraine severity and disability by worsening sensitivity to migraine triggers and undermining meaningful goal pursuits.¹¹ As noted previously, individuals with high levels of catastrophizing and fear associated with migraine report greater avoidance of activity even during interictal periods.⁹ Unfortunately, extreme avoidance of activities commonly associated with a healthy lifestyle (e.g., physical exercise, pleasurable activities) can reinforce existing catastrophic appraisals of migraine, making them even more difficult to change.^{10, 11}

Emotional distress

Strong evidence links migraine with emotional distress; several psychiatric conditions including major depressive disorder, panic disorder, social phobia, and bipolar disorder are more common in individuals with migraine compared to those with no history of migraine.¹² Further, emotional distress, including both immediate negative emotional states¹³ and psychosocial stress,¹⁴ are commonly identified causes of migraine. Similarly, depressive and anxious symptom severity shows significant bidirectional relationships with migraine intensity and frequency in cross-sectional and longitudinal research.¹⁵

Sleep disturbance

Insomnia is more common in individuals with migraine than those with no history of migraine¹⁶ and there is a significant bidirectional longitudinal relationship between migraine severity and insomnia symptoms. The role of insomnia in migraine is intertwined with other risk factors; there is a well-established bi-directional link between mood disturbance and insomnia in migraine,¹⁷ and insomnia and emotional distress independently predict migraine severity and disability in longitudinal research.¹⁸ Individuals with migraine and comorbid insomnia may be vulnerable to behavioral patterns that worsen both. Avoidance coping responses to migraine (e.g., lying in bed in a dark room during the day) can precipitate and perpetuate sleep disturbance, with subsequent disruption in sleep physiology and then increasing the propensity for headaches; over time these cycles may interact and transform or perpetuate episodic migraine into patterns of chronic migraine.¹⁹

Social and environmental factors

When considering psychological treatments for migraine, it is important to keep in mind that the pain experience is also influenced by social and environmental factors.²⁰ For example, perceived lack of social support, increased isolation, and lack of time for self-care have been associated with increased migraine severity.²¹ Structural and enacted stigma have also been associated with increased disability in people with migraine.²²

Given the clear contributions of psychosocial factors to migraine, it follows that its severity and impact could be effectively managed from a biopsychosocially-informed multidisciplinary approach that targets these factors for change.¹ A prevailing goal of psychological approaches for migraine is to position individuals with migraine as active managers of their condition. Importantly, psychological interventions tend to show the greatest benefit when used in concert with pharmacological and other medical approaches; best practices therefore emphasize integrative approaches involving biomedical, psychological, and other approaches (e.g., lifestyle management).¹

What follows is a narrative review of evidence-based psychological interventions and the base of current evidence supporting their use, followed by a discussion of future directions in psychological treatments for migraine. The interventions with the largest base of research supporting their efficacy are relaxation strategies, biofeedback, and cognitive-behavioral therapy.²³ A second set of interventions (Acceptance and Commitment Therapy, mindfulness meditation interventions, trigger-focused coping interventions, and hypnosis) have also been studied, but to a more limited extent.

Interventions with the strongest supporting evidence for migraine

Relaxation strategies

Relaxation strategies are a common component of psychological management of migraine. These approaches are intended to elicit a relaxation response through increased parasympathetic nervous system activity²⁴ and/or a reduction in sympathetic nervous system activity.²⁵ These interventions are most effective when used prophylactically (e.g., as routine parts of daily life, in response to migraine-related risk factors such as stress); there is less evidence supporting analgesic benefits during the ictal period.²⁶

This pattern of practice is based on a model that proposes that stress may elicit or potentiate pathophysiological processes that can contribute to migraine onset and greater migraine severity, including premonitory activation of brain regions associated with pain processing, sensitization of central and peripheral nervous system processes, and activation of interactive processes involving the autonomic nervous system and hypothalamic-pituitary-adrenal axis.¹⁴ Consequently, relaxation techniques may dampen some neurophysiological responses and reduce the risk of a migraine attack.

The most common relaxation strategies are diaphragmatic breathing, progressive muscle relaxation (PMR), guided imagery, and autogenic training. Diaphragmatic breathing teaches individuals to expand their lungs into the diaphragm by taking slow, deep, and smooth breaths, often while in a relaxed or supine position.²⁷ Diaphragmatic breathing practices appear to lower pulse rate and reduce sympathetic nervous system responses.²⁸ Diaphragmatic breathing practices do not require equipment, can be taught quickly, and can be readily employed in most situations; even brief practices of a few minutes at a time can be beneficial, though longer breathing practices (20-30 minutes at a time) are typical.²⁹ Notably, diaphragmatic breathing can be employed in conjunction with other relaxation-focused strategies such as guided imagery, hypnosis, and biofeedback.^{25, 30}

Progressive muscle relaxation (PMR) emphasizes purposeful relaxation of specific muscle groups.³¹ PMR typically requires upwards of 20 minutes per day focused on gentle tensing and relaxing of one muscle group at a time and moving through large muscle groups in the body.³² In more advanced practice patients may be able to elicit relaxation of muscle groups through awareness of tension without needing to tense of the muscle group.³² There is evidence that PMR alters autonomic nervous system responses that underlie or exacerbate migraine, including activation for neural circuits related to modulation of attention and emotion³³ and central information processing.³⁴

Guided imagery techniques involve purposeful direction of attention away from distressing experiences like pain and towards typically pleasurable or positive images.³⁵ Guided imagery is often conducted in combination with diaphragmatic breathing or autogenic training when treating migraine³⁶ and demonstrates promising efficacy in reducing pain, although there are methodological problems with the research in this area.³⁷ The therapeutic benefit of guided imagery appears to be due in part to distraction from the distressing aspects of pain.³⁸

Autogenic training is intended to reduce states of high sympathetic arousal by teaching patients to observe and (if possible) shift towards feelings of relaxation through self-suggestion (e.g., eliciting feelings of warmth/heaviness in the hands, arms, or abdomen, regulation of breathing, internal organs, and heartbeat).³⁹ This approach shares some features with hypnosis,³⁹ such as the utilization of suggestions (and later self-suggestions) towards feelings of calm and beliefs in control over interoceptive signals. Autogenic training yields measurable changes in physiological stress indices such as increased heart rate variability and reduced heart rate, muscle tension, and blood pressure.³⁹ Autogenic training has demonstrated efficacy in reducing migraine intensity and frequency^{39, 40} as well as broader effects on improving mood and quality of life.⁴¹

Biofeedback

Biofeedback employs measurements of physiological processes that are usually outside of conscious awareness, which are then fed back to patients in real time (e.g., through a visual display or auditory feedback) with the goal of teaching them to recognize and modulate indices of stress. Biofeedback utilizes multiple modalities including respiratory rate, skin conductance response, electromyographic muscle group activity measurement, extremity temperature modulation, blood volume pulse, heart rate variability, and electroencephalography-assessed neuronal activity.⁴² Although biofeedback in migraine is intended to improve control over physiological stress responses,⁴³ a significant degree of benefit from biofeedback may be attributable to changes in cognitive factors such as perceived self-efficacy for managing headaches.⁴⁴ Meta-analytic studies conclude moderate impact of biofeedback on migraine frequency, intensity, duration, and impact, with comparable levels of effect across biofeedback modalities.⁴⁵

Cognitive-behavioral therapy

Cognitive-behavioral therapy is considered the “gold standard” for treatment of chronic pain conditions⁴⁶ and there is a large evidence base supporting the efficacy of CBT for reducing migraine pain and disability.⁴⁷ CBT is also useful for patients with comorbid migraine and mood disorders, as CBT also demonstrates efficacy for improving most mood disorders.²⁵ Similarly, CBT-based interventions for insomnia improve both migraine severity and sleep quality.⁴⁸

The CBT approach for migraine emphasizes developing a “coping skills toolbox”⁴⁹ that addresses migraine triggers and unhelpful cognitive or behavioral responses to headaches through cognitive and behavioral strategies to reduce the frequency and impact of migraine headaches.⁵⁰ CBT sessions often include training in relaxation strategies like those described above, more regular engagement in healthy behaviors like drinking water and tolerable levels of exercise, graded activity approaches focused on teaching patients to build in periods of rest and gradually build up tolerable levels of valued activity throughout the day despite pain, behavioral activation approaches (e.g., scheduling of pleasurable events to improve motivation and mood), and use of cognitive and behavioral strategies for improving sleep and decreasing avoidance behaviors.⁵⁰ With CBT, patients also learn to recognize automatic thoughts associated with migraine symptoms and related stressors (e.g., missing valued activities due to a headache), to understand the impact of these thoughts on pain, mood, and behavior, and to develop strategies for reappraising or replacing maladaptive thoughts with more adaptive ones. Some CBT programs also include training in assertive communication to address interpersonal issues that may contribute to stress or interfere with self-care (e.g., communicating about the need to exercise or practice relaxation).²⁵

Emerging therapies

Mindfulness-based therapies

The most common therapeutic application of mindfulness is mindfulness-based stress reduction (MBSR), which has demonstrated efficacy across multiple chronic pain conditions.⁵¹ More recent adaptations have examined mindfulness-based cognitive therapy, which integrates principles of mindfulness and CBT.⁵² Mindfulness meditation typically emphasizes regular (i.e., daily) meditation practice.⁵¹ Mindfulness approaches teach patients to attend to interoceptive and external events (e.g., breathing, eating, thoughts, emotions, pain, interpersonal communication) in a calm and non-judgmental fashion, allowing the patient to free themselves from automatic patterns of cognitive, behavioral, and emotional reactions that may worsen distress or disability.⁵³ The base of evidence for mindfulness interventions for migraine is smaller and more heterogeneous in terms of study quality than that for the interventions described above. However, recent reviews have concluded that they are more reliably effective in reducing migraine-related distress and disability, but show equivocal effects on migraine frequency or intensity.⁵³

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) integrates CBT with mindfulness principles.²⁶ Like mindfulness, ACT teaches patients to adopt a non-judgmental (accepting) view of their internal experience, including pain, thoughts, and emotions.⁵⁴ Subsequent sessions are spent teaching patients to orient their behavioral efforts towards valued goals derived from their personal values (committed action) rather than ineffective efforts to diminish pain symptoms.⁵⁵ Unlike CBT, ACT emphasizes promotion of flexible psychological processes rather than changing the content of thoughts or reduction of symptoms or stress; patients are encouraged to pursue personally meaningful goals even in the presence of pain, distress, or negative thoughts.⁵⁶ The base of research for ACT in migraine is small. The evidence that exists suggests that ACT may improve function and reduce distress, but have equivocal effects on migraine pain.⁵⁷

Learning to Cope with Triggers

As noted previously, a central contention in behavioral migraine management addresses how patients manage migraine triggers. Martin and colleagues have developed a hybrid behavioral intervention (Learning to Cope with Triggers; LCT) that emphasizes recognition of migraine triggers and learning to make mindful and deliberate decisions about avoidance versus “living alongside” triggers as a means of bolstering function and reducing the risk of sensitization to triggers.⁵⁸ A few randomized clinical trials have indicated preliminary evidence of reductions in migraine frequency and intensity and associated disability with LCT treatment^{58, 59} and LCT principles have been integrated with CBT,⁵⁹ suggesting that this approach may be a useful complement to other evidence-based interventions. However, there is considerable debate on the topic of desensitization approaches in migraine, as it may be impossible or counterproductive to increase exposure to or otherwise change the frequency of major triggers.⁶⁰ At this stage, it appears sufficient to state that there is potential benefit in psychological approaches that promote flexible responding to migraine triggers that is worthy of additional study.

Hypnosis

Clinical hypnosis approaches have demonstrated efficacy across a variety of chronic pain conditions.⁶¹ A clinical hypnosis session typically involves two steps: an induction that encourages the patient to experience a state of focused attention followed by a clinical suggestion or series of suggestions (e.g., greater comfort, changing location of uncomfortable sensations, increased feelings of calm or control, or increased frequency of adaptive pain-related thoughts).⁶² For many patients hypnosis training can be transitioned into a self-guided hypnosis practice to be used outside of therapy.⁶³ In the area of migraine management, there is a relatively small base of research suggesting that hypnosis can reduce migraine frequency and intensity.⁶⁴ However, the efficacy of hypnosis as a monotherapy is unclear as it is often used in concert with CBT or relaxation techniques.⁶⁴

Discussion

Although the literature base examining psychological interventions for migraine is large, one key issue concerns research quality; recent reviews have concluded that the majority of clinical trials involving psychological interventions for migraine yield only low-quality evidence due to methodological flaws, inconsistent reporting of important methodological details, variability in sampling, or variability in the use of control or comparator conditions.^{65, 66} Although a reasonable consensus exists that psychological interventions yield some degree of benefit for migraine pain, disability, and distress,^{23, 65} there is nevertheless a strong need for high-quality clinical trials testing all of the aforementioned interventions to determine the scope and magnitude of their effectiveness with more confidence. At present, although CBT, relaxation therapy, and biofeedback show the strongest empirical base of support, many of the published studies yield only very low-quality evidence. As noted previously, psychological interventions are most efficacious in the context of multidisciplinary management plan. However, we wish to highlight that more rigorous clinical trials would be invaluable both for examining psychological interventions as monotherapies and in concert with medical and other non-pharmacological interventions. We discuss other future directions for research below.

Improving patient access

Improving patient access is another key consideration for future research. This includes the need to evaluate the feasibility and efficacy of brief and telehealth-based interventions for migraine. Specialty-trained mental health providers often deliver psychological interventions for migraine (e.g., health or rehabilitation psychologists); however, access to specialty-trained mental health is limited and quite rare outside tertiary care settings.⁶⁷ Further, interventions such as CBT, MBSR, or relaxation therapy typically require weekly sessions over a span of 8-12 weeks. Thus, even among patients who are able to find these services through a specialty clinic, significant time, cost, and associated patient burden pose a major barrier to patient access.⁶⁷ Thus, brief and scalable interventions are needed to improve access to psychological treatment for migraine. Brief psychological interventions show preliminary evidence of feasibility in pilot studies with individuals with headache, but larger and more rigorous studies are needed to determine their efficacy.^{55, 68}

Telehealth interventions

Another key aspect to improving patient access to psychological interventions for migraine is telehealth. Behavioral interventions demonstrate comparable effects to in-person treatment when delivered via telehealth modalities (e.g., telephone, Internet), suggesting that these services can be valuable options for individuals not regularly seen in specialty clinics.⁶⁹ However, response to telehealth or mHealth (mobile health) interventions may vary between contemporaneous and asynchronous delivery systems; the availability of a live therapeutic provider may improve patient ratings of treatment acceptability⁷⁰ and patient engagement⁷¹ and reduce rates of treatment attrition compared to strictly self-guided Internet-based interventions.⁷² Consequently, additional research is needed to determine whether specific interventions may be better suited for minimal-contact interventions and which may require more active, contemporaneous engagement with a provider. We speculate that, particularly for patients uninitiated with or ambivalent about psychologically-based management strategies, initial contact with a live therapist may be indicated to build competence and self-efficacy regarding use of migraine management strategies.

Life stress/trauma-informed approaches

Major life stressors are a significant risk factor for the presence of a migraine disorder,⁷³ transition from episodic to chronic migraine,¹⁴ and for overlapping non-headache pain conditions, which exacerbate patterns of migraine-related distress and disability.⁷⁴ Similarly, individuals with a history of trauma and ongoing symptoms of post-traumatic stress disorder show greater severity and burden of migraine symptoms compared to those without a history of trauma.⁷⁵

Although the mechanisms connecting trauma/life stress and migraine are likely multifactorial,⁷³ one potential mechanism concerns patterns of emotional avoidance or suppression that can arise when individuals face highly threatening or invalidating environments. Notably, patterns of emotional avoidance or suppression appear to be more common in individuals with migraine, particularly among those with a history of trauma or adverse life experiences^{76, 77} and these avoidance/suppression patterns demonstrate a direct relationship with severity of migraine symptoms.⁷⁸ Novel psychotherapies (e.g., Emotional Awareness and Expression Therapy) that teach patients to recognize, express or otherwise act upon their own emotions in new and more productive ways show at least comparable benefit to CBT and in some cases superior efficacy in reducing pain intensity in conditions that may have a nociplastic pain component like fibromyalgia.⁷⁹ Although there is preliminary efficacy for emotional expression-focused approaches in headache,⁸⁰ large-scale randomized trials in migraine have not yet been conducted and remain as a viable future direction for research, particularly for patients with migraine and identifiable histories of major life stress or trauma.

Precision medicine

As in other chronic pain conditions,⁴⁶ there is a pressing need to move beyond determining if psychological interventions for migraine improve outcomes, to for whom and how the interventions work. The current literature suggests that as many as 50% who receive a psychological intervention for migraine do not achieve a clinically significant (i.e., 50% or greater) degree of pain relief.⁶⁵ This may be due to a mismatch between a specific treatment and a specific individual; for example, CBT may not benefit those who do not have problematic levels of maladaptive thinking (e.g., pain catastrophizing) or behavior (e.g., inactivity) prior to entering treatment.⁸¹ A better understanding of the patient characteristics associated with response to specific interventions (i.e., treatment effect moderators) may improve migraine care by matching patients to the treatment that they are most likely to benefit from and to tailor specific interventions to the moderating patient characteristics. Research examining moderators is underway in several pain populations, including low back pain⁸² and multiple sclerosis⁸³; despite longstanding calls for moderation research²⁸ this area of research in migraine has remained very limited.

Practical and clinical considerations

There is an unfortunate shortfall of mental health providers with specialized training in management of chronic pain and headache conditions. Indeed, many medical systems do not have consistent access to headache- or chronic pain-trained mental health providers, which can complicate efforts to promote multidisciplinary migraine management. We would like to acknowledge ongoing efforts to expand pain management approaches as a more common aspect of mental health training curricula.^{84, 85}

However, it is likely that this scarcity of appropriately trained mental health providers will continue for the foreseeable future; consequently, there may be alternative pathways that providers may pursue to access the psychological treatments detailed above.

For medical providers who do not have co-located mental health services within their department or institution, a few options may be considered. Mental health providers who offer psychological services for pain or migraine management (e.g., CBT, MBSR) may be identified through the Therapist Search function of the Psychology Today website, which allows for filtering by insurance type, therapy and condition type, among other factors. Some state-level psychological associations also offer similar listings but may include only doctoral-level psychological providers. Additionally, there are public lists of providers trained in MBSR (https://www.mindfulleader.org/mbsr-certified-teacher-directory), ACT (https://contextualscience.org), and biofeedback (https://www.bcia.org/consumers-find-a-practitioner). Therapists trained in Empowered Relief, an empirically supported brief cognitive-behavioral intervention for chronic pain, can be found at their training website through Stanford University (https://empoweredrelief.stanford.edu/find-provider). Further, Internet-based intervention classes may be available both locally and nationally; for example, Internet-based MBSR courses are offered through the University of Massachusetts Medical School (https://www.ummhealth.org/). However, it should be noted that these services are not uniformly available across insurance payors or across geographic regions.

In cases where patients are not able to find pain-trained mental health professionals, it may be possible to engage patients in the use of self-management techniques through referral to websites, phone apps, or books that outline how to use empirically supported therapeutic approaches. The University of Michigan’s Pain Guide (https://painguide.com) is an evidence-based education and self-management resource that includes information about pain, self-management tools, and tracking tools, as well as a section on migraine.⁸⁶ The UCLA Mindful Awareness Research Center offers free recordings of guided mindfulness meditations through their website and corresponding phone app (https://www.uclahealth.org/programs/marc/free-guided-meditations/guided-meditations). For patients with co-occurring insomnia or PTSD, there are free self-guided programs based in cognitive-behavioral therapy for insomnia and post-traumatic stress disorder through the Veterans Affairs website (CBT-I Coach and PTSD Coach, respectively; https://www.ptsd.va.gov). Proprietary phone apps also review principles of relaxation therapy (e.g., Calm, Breathe2Relax) and mindfulness meditation (e.g., Headspace, Insight Timer). However, it is likely that the degree of efficacy from these applications will vary across patients; as noted previously, interventions that rely on asynchronous delivery of psychological treatment for migraine are vulnerable to reduced patient engagement and adherence compared to engagement with a live therapist.^70-72

Similarly, there may be books that describe CBT, MM and ACT principles in actionable ways; though the research on bibliotherapy is quite limited in the area of chronic pain or migraine management, there is preliminary evidence of efficacy when these materials are rigorously developed.^{87, 88}

Particularly for patients with high levels of migraine-related symptom burden, significant psychiatric comorbidities, or ambivalence about engagement with mental health treatments, it may be necessary to reinforce the importance of patient engagement with the material presented in self-help books regularly during medical visits and to refer them for psychiatric or psychological care, even if the provider does not have expertise in pain management. In cases where patients may have an ongoing relationship with a mental health provider, it may also be feasible to encourage the patients to bring self-guided materials like those listed above and review them in future treatment sessions. Even in cases where mental health providers are not specifically trained in psychological approaches for chronic pain or migraine management, they may have had training in CBT, MBSR, or ACT for other conditions such as depression or anxiety and would be able to reinforce and support the use of psychological approaches like relaxation, cognitive reappraisal, meditation, and behavioral or social activation. They should also be able to assess and treat common co-occurring conditions, including mood disorders and insomnia.

From the standpoint of communicating with patients about the role of psychological interventions, we encourage all health care providers to present a biopsychosocial conceptualization of migraine headaches (i.e., brain-based neurophysiological processes that are reciprocally related to thoughts, emotions and behaviors as well as factors in the broader social environment) and to impress upon their patients the importance of multidisciplinary approaches and self-management of migraine headaches. Explaining to patients that psychological techniques are intended to complement, rather than replace, biomedical management may assuage concerns about their headache condition being viewed as illegitimate, the possibility of having needed medical treatments withdrawn, or their symptoms being viewed as occurring “all in the head.” In cases where patients or providers may be unsure about how to choose an appropriate psychological treatment, these decisions may be informed either by which treatments are immediately available (e.g., through the current medical system, covered treatment services under insurance programs) or by patient preference. It may be useful to encourage patients to begin psychological treatment with an approach they feel might be most useful as a first step to fostering a more diverse set of coping responses to migraine.

Summary

Psychological interventions are a central aspect of best-practice migraine management and can address major psychosocial contributors to the severity and impact of migraine. Despite some important limitations in methodological approaches and study design, the extant base of research supports the conclusion that psychological interventions can improve migraine symptoms and disability, both independently and in concert with medical and lifestyle interventions. However, several essential areas remain for future study, including improving the methodological quality of clinical trials, improving patient access, and incorporating of treatments for historically overlooked migraine-relevant factors such as trauma and emotional avoidance.

Synopsis:

Migraine headaches are among the most prevalent and disabling pain conditions worldwide. Best-practice migraine management is multidisciplinary and includes psychological approaches to address cognitive, behavioral, and affective factors that worsen pain, distress, and disability. The psychological interventions with the strongest research support are relaxation strategies, cognitive-behavioral therapy, and biofeedback, though the quality of clinical trials for all psychological interventions needs continued improvement. The efficacy of psychological interventions may be improved by validating technology-based delivery systems, developing interventions for trauma and life stress, and precision medicine approaches matching treatments to patients based on specific clinical characteristics.

Key points:

• Psychological therapies are a central aspect of best-practice migraine management.

• The best-supported interventions are relaxation strategies, cognitive-behavioral therapy, and biofeedback, with less robust evidence for mindfulness meditation, hypnosis, Acceptance and Commitment Therapy, and trigger management interventions.

• Areas of continued need in psychological intervention research for migraine include higher-quality clinical trials, brief and telehealth-based treatment delivery, incorporation of trauma and life stress approaches, and identification of treatment outcome moderators.

Clinics Care Points.

• Psychological therapies are a central component of best-practice approaches for migraine management and are best utilized in conjunction with biomedical and other non-pharmacological interventions.

• CBT, relaxation strategies, and biofeedback have the strongest base of evidence for their effectiveness.

• Other interventions (mindfulness interventions, ACT, hypnosis, LCT) have shown preliminary efficacy but require more thorough evaluation through large-scale clinical trials.

• Greater consideration to patient-specific factors (e.g., experiences of major life stress or trauma, treatment-relevant factors like self-efficacy or motivation) and improving patient access through brief and telehealth interventions can potentially improve the quality and reach of psychological interventions.

• There is a strong need for additional rigorous clinical trials for all psychological approaches for migraine, as the quality of evidence from existing studies is low due to the methodological limitations of those studies.