Effectiveness of cold application combined with progressive muscle relaxation in migraine without aura: A randomized controlled trial

Abstract

AbstractBackground:

Migraine without aura is a prevalent and disabling neurological disorder that significantly impairs quality of life (QoL). This study aimed to evaluate the short-term effectiveness of cold application combined with Jacobson Progressive Muscle Relaxation (JPMR) on pain intensity, migraine frequency, migraine-related disability, and QoL in individuals with migraine without aura.

Methods:

A randomized controlled trial was conducted with 26 participants diagnosed with migraine without aura. Participants were randomly assigned to 2 groups: group 1 received JPMR exercises and group 2 received JPMR combined with cold application. Pain intensity was assessed using the Visual Analog Scale, disability using the Migraine Disability Assessment questionnaire, and QoL using the World Health Organization Quality of Life Scale-Short Form. Evaluations were conducted at baseline and after a 4-week intervention period.

Results:

Significant improvements in pain intensity, migraine frequency, disability, and QoL scores were observed in both groups following the intervention (P < .05). Effect sizes ranged from moderate to very large within groups. Group 2 showed significantly greater reduction in the monthly number of migraine attacks compared to group 1 (P = .021, partial η² = 0.21). No significant between-group differences were observed in pain intensity, disability, or QoL domains (P > .05).

Conclusion:

Both JPMR and JPMR combined with cold application are effective short-term interventions for managing migraine without aura. However, the addition of cold application enhances outcomes in the number of attacks. This combined nonpharmacological approach may be considered as an adjunct strategy for migraine management.

1. Introduction

Migraine is a complex and highly prevalent primary headache disorder, ranked among the leading causes of disability worldwide, particularly among young adults and women.^[1] It is characterized by recurrent, often unilateral attacks of moderate-to-severe pulsating pain, commonly accompanied by nausea, photophobia, and phonophobia.^[2] The International Classification of Headache Disorders (ICHD-3) categorizes migraine into several subtypes, with migraine without aura (code 1.1) being the most common, accounting for over 70% of cases.^[3] Despite its high prevalence and significant individual and socioeconomic burden, the management of migraine remains challenging, with many patients experiencing suboptimal control of symptoms or adverse effects from pharmacological treatments.^[4] In response to these limitations, a growing body of research has focused on non-pharmacological interventions that aim to modulate pain pathways, reduce attack frequency, and improve functional outcomes through behavioral, physical, or neuromodulator mechanisms.^[5,6] One such approach is Jacobson Progressive Muscle Relaxation (JPMR), a structured method that systematically reduces somatic tension and has demonstrated efficacy in decreasing headache frequency and intensity through both psychophysiological and neurobiological mechanisms. JPMR is thought to reduce cortical hyperexcitability, downregulate sympathetic activity, and activate descending inhibitory pain pathways, with several randomized controlled trials showing it to be as effective as pharmacologic prophylaxis in some patient populations.^[7,8] Another conservative modality with growing therapeutic interest is cold application therapy, which operates through thermoregulatory, anti-inflammatory, and neuromodulator effects. Cold stimuli activate the transient receptor potential melastatin 8 channels on sensory afferents, leading to altered nociceptive transmission and modulation of central pain processing.^[9,10] Experimental studies have suggested that cold application can acutely reduce pain perception by slowing nerve conduction velocity, decreasing local metabolic activity, and exerting a counter-irritant effect via the gate control mechanism.^[11] While both JPMR and cold application therapy have individually shown promise in migraine treatment, the rationale for combining these interventions lies in their distinct yet potentially complementary physiological mechanisms. JPMR exerts its primary effects via top-down modulation reducing central sensitization and enhancing autonomic regulation, while cold therapy delivers immediate bottom-up analgesic effects by altering peripheral nociceptive input and local inflammatory responses. This theoretical complementarity suggests that their concurrent use may yield a synergistic or at least additive benefit by concurrently attenuating central and peripheral drivers of migraine pain. Furthermore, simultaneous activation of both descending inhibitory pathways (via JPMR) and afferent modulation (via cryotherapy) may enhance endogenous pain regulation and facilitate neuroplastic adaptations that could result in longer-term symptom relief. Such an integrative approach aligns with current trends in multimodal pain management and addresses a relevant clinical gap in conservative migraine therapies. To our knowledge, no prior randomized controlled trial has systematically investigated the combined effects of JPMR and cryotherapy in patients with migraine without aura.^[12,13]

Therefore, the primary objective of this study is to evaluate the short-term effects of combining cold application with JPMR on pain intensity, migraine frequency, disability, and quality of life (QoL) in patients diagnosed with migraine without aura.

2. Methods

2.1. Study design and ethical approval

This study was designed as a prospective, randomized controlled trial with a parallel-group design, conducted between August 2022 and May 2023 at the Department of Physiotherapy and Rehabilitation, XXX University. The study protocol adhered to the Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines. Ethical approval was obtained from the Clinical Research Ethics Committee of XXX University (Approval No: 2015-KAEK-62-22-02), and the study was prospectively registered with ClinicalTrials.gov (Registration No: NCT05454826). All participants provided written informed consent prior to enrollment.

2.2. Study selection and eligibility criteria

Thirty patients who met the inclusion criteria and were diagnosed with migraine without aura patients (type 1.1.) according to the criteria of the International Headache Society by the physician were included in the study. Participants aged between 20 and 45 years who had been diagnosed with migraine at least 6 months prior and were able to use a computer were included in the study. Exclusion criteria comprised individuals who were menstruating; had a cold sensitivity score of 5 centimeters (cm) or higher on a 10-cm Visual Analog Scale (VAS); had any neurological disorders; were using narcotic drugs; had received any form of physical therapy within the past 6 months; had other types of primary or secondary headaches; had rheumatic conditions; or were unable to comprehend the questions or exercises.

2.3. Sample size calculation

A post hoc power analysis was conducted using pre- and post-intervention VAS (pain intensity) scores from a randomly selected pilot sample of 10 participants (5 from each group). Based on this preliminary data, the calculated effect size (Cohen d) was 1.336. Using this value in G*Power 3.1.9.2 software (Franz Faul, Universität Kiel, Kiel, Germany; 2-tailed independent samples t test, α = 0.05, power = 0.90), the required minimum sample size was determined to be 22 participants (11 per group). To account for potential dropouts, a 20% buffer was applied, resulting in a final sample size of 26 (13 per group).

2.4. Randomization and blinding

Participants were randomly assigned (1:1 ratio) to either the JPMR-only group (Group 1) or the JPMR + Cold Application group (Group 2). Stratified randomization by gender was performed using a computer-generated random number table by an investigator (EPK) blinded to group assignment. Allocation concealment was maintained.

2.5. Outcome measures

The sociodemographic information of the patients was questioned with the patient case form including open-ended questions about what triggers their migraines, the pain intensity was evaluated with the VAS and the migraine disability assessment (MIDAS) questionnaire was used to measure the impact of headaches. The QoL was evaluated with the World Health Organization Quality of Life Scale-Short Form (WHOQOL-BREF). Twenty-six patients who volunteered to participate in the study filled out the questionnaires created via Google form. Outcome assessment was performed by an expert physiotherapist (BKK), blinded to group allocation and treatment protocols.

The patient case form also consisted of age, gender, height, weight, and body mass index, medications used for headaches in the last month, triggering factors, and the number of attacks in the last month, and sensitivity to cold was also questioned. All assessments were done at baseline and after the 4-week treatment programs by the same researchers with similar evaluation order.

2.6. Primer outcome measure: evaluation of pain intensity

The VAS was used to evaluate the degree of pain intensity the participants felt during the attack period. It is a simple, effective, valid, and reliable measurement tool. The participants were asked to mark their level of pain on a 10 cm horizontal line, where 0 cm indicates “no pain” and 10 cm indicates “very severe pain.”^[14] The point marked by the participant was then measured with a tape and recorded in cm as the pain intensity score.

2.7. Secondary outcome measures

2.7.1. Evaluation of migraine disability

The MIDAS questionnaire measured migraine disability, frequency, and severity. MIDAS considers the last 3 months and consists of 5 questions. The degree of pain and disability is assessed using the questionnaire. The survey is brief and easy to use. Your score is calculated using these questions, and it is then correlated with a certain impairment level. The questions pertaining to the school/work dimension are the first and second. The housework dimension is the subject of the third and fourth questions. The final set of inquiries relates to the social aspect. The clinical value question is divided into 2 parts. The MIDAS score is linked to the 4 MIDAS grades. Grade I represents a number between 0 and 5, meaning that there is little to no handicap. A grade of II, which ranges from 6 to 10, denotes a modest handicap. The Grade III score ranges from 11 to 20, denoting a moderate level of impairment. Scores exceeding 20, which indicate a significant impairment, are included in Grade IV. As the score increases, the intensity of migraine pain increases.^[15]

2.7.2. Evaluation of QoL

The WHOQOL-BREF was utilized to assess QoL. This instrument measures physical, mental, social, and environmental well-being through 26 questions. It is specifically applicable to patients with migraine, as each domain independently reflects QoL within its respective area. Domain scores are calculated on a scale of 4 to 20, with higher scores indicating a better QoL.^[16]

2.8. Interventions

2.8.1. Jacobson Progressive Muscle Relaxation

Two physical therapists (MY and AEA), who were blinded to the evaluation and randomization processes, administered the treatments. One of the relaxation techniques employed in this study was JPMR, with the exercises detailed in Appendix 1, Supplemental Digital Content, https://links.lww.com/MD/Q170. Each session lasted 30 minutes, and the number of repetitions gradually increased, with the exercises conducted as 3 sets of 3 repetitions. In JPMR, each muscle or muscle group was tightened for 5 to 7 seconds before being relaxed for 20 to 30 seconds. Additionally, the physiotherapist instructed patients to take deep breaths throughout the procedure, holding the breath during muscle contraction and exhaling during relaxation. If patients experienced tension or discomfort in specific muscles, the contraction and relaxation were repeated for that muscle group. The exercises were conducted face to face with the physiotherapist guiding the sessions for 30 minutes, 3 times a week, over a period of 6 weeks.

2.8.2. JPMR plus cold application

In Group 2, cold compressions were administered in addition to JPMR. The JPMR exercises were implemented in the same manner as in Group 1. The cold gel pack, stored in a freezer at +4 °C, was manually applied by hand to the forehead (1 repetition for 4 minutes), both temporal sides (1 repetition for 4 minutes on each side), and the back of the head (occipital area and posterior neck, 1 repetition for 3 minutes), totaling 15 minutes of application following the exercises. Target areas for cold application were selected based on common migraine pain localizations and their anatomical relevance to the trigeminal and occipital nerve pathways, as supported by previous literature.^[17] Given the relatively thin soft tissue and low adipose density in these regions, combined with the participants’ healthy body mass profiles, the cooling depth achieved was considered sufficient to affect superficial neural and vascular structures involved in migraine pathophysiology. In the combined group, each session consisted of 30 minutes of supervised JPMR followed immediately by 15 minutes of cold application. Both interventions were delivered consecutively on the same day, 3 times a week for 6 weeks.

2.9. Statistical analysis

All statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk). Normality was assessed with the Shapiro–Wilk test. Descriptive statistics were expressed as mean ± standard deviation and minimum–maximum, for continuous variables and frequency (n, %) for categorical data. Baseline comparisons used the Independent Samples T test/Mann–Whitney U test or Chi-square test as appropriate.

Within-group comparisons were performed using the Paired Samples T test for normally distributed variables and the Wilcoxon signed-rank test for non-normal data. Between-group comparisons of post-intervention outcomes were made using analysis of covariance (ANCOVA) for normally distributed variables (VAS, MIDAS, attack number), adjusting for baseline scores. The assumption of homogeneity of regression slopes was confirmed (P > .05), and adjusted means with standard errors were reported.

For WHOQOL-BREF total and domains, which violated normality and regression slope assumptions, between-group differences were assessed using the Mann–Whitney U test on change scores (post–pre), with medians and interquartile ranges presented.

Effect sizes for within-group changes were calculated using Cohen d (Mean_pre − Mean_post)/SD_difference) for paired samples, interpreted as: 0.2 to 0.5 = small, 0.51 to 0.80 = medium, 0.81 to 1.20 = large, ≥1.30 = very large. For ANCOVA, partial eta squared (Pη²) was used to indicate between-group effect size: 0.01 to 0.06 = small, 0.06 to 0.14 = medium, >0.14 = large. A P-value < .05 was considered statistically significant.^[18]

3. Results

A total of 46 individuals were screened, and 26 participants (22 females, 4 males) met the inclusion criteria and completed the study without dropout (Fig. 1). Baseline demographic and clinical characteristics were similar between the groups (P > .05; see Table 1). The most commonly reported migraine triggers were stress (96%), weather changes (96%), menstruation (69%), and wind exposure (46%).

Figure 1.

Trial flowchart.

Table 1.

Baseline demographics and clinical characteristics of the groups.

Parameters	Group 1 (n = 13) mean ± SD (min–max)/n (%)	Group 2 (n = 13) mean ± SD (min–max)/n (%)	P
Age (yr)	27.85 ± 7.24 (20–42)	29.23 ± 8.3 (21–45)	.655
Gender			1.000
Female	11 (84.6%)	11 (84.6%)
Male	2 (15.4%)	2 (15.4%)
Body mass index (kg/cm2)	22.75 ± 2.42 (20.20–26.56)	22.29 ± 1.82 (19.84–25.47)	.600
Intensity of pain (VAS-cm)	8.38 ± 1.26 (5–10)	9.08 ± 1.11 (6–10)	.151
Number of migraine attacks/month	5.84 ± 1.90 (4–10)	6.07 ± 2.10 (4–10)	.772
MIDAS	6.54 ± 0.66 (6–8)	6.92 ± 0.49 (6–8)	.107
WHOQOL-BREF total	219.77 ± 38.23 (151–281)	204.62 ± 61.51 (86–320)	.369
Physical	52.54 ± 8.26 (38–63)	43.77 ± 14.24 (23–75)	.052
Physiologic	51.46 ± 12.88 (25–69)	53.85 ± 17.70 (19–81)	.677
Social	66.08 ± 16.30 (31–94)	51.92 ± 25.83 (6–94)	.113
Environment	53.23 ± 13.21 (25–75)	53.62 ± 15.51 (31–88)	.876

Group 1: Jacobson Progressive Muscle Relaxation, Group 2: Jacobson Progressive Muscle Relaxation + cold application, n: number of participants, min: minimum, max: maximum.

cm = centimeter, kg = kilogram, MIDAS = Migraine Disability Assessment Scale, SD = standard deviation, VAS = Visual Analog Scale, WHOQOL-BREF = World Health Organization Quality of Life Scale-Short Form.

Within-group analyses (Table 2) revealed statistically significant improvements in both groups following the intervention in pain intensity, monthly number of migraine attacks, and disability (P < .05 for all). These changes were accompanied by moderate to very large effect sizes in both groups. In Group 1, all WHOQOL-BREF domains showed significant improvements with large to very large effect sizes, except for the social domain, which did not reach statistical significance (P = .080). In contrast, Group 2 exhibited statistically significant improvements across all WHOQOL-BREF domains with moderate to large effect sizes.

Table 2.

Within-group comparison of pre- and posttreatment outcomes.

Outcomes	Group 1 (n = 13)					Group 2 (n = 13)
	B.T. mean ± SD (min–max)	A.T. mean ± SD (min–max)	95% CI	Effect size	P	B.T. mean ± SD (min–max)	A.T. mean ± SD (min-max)	95% CI	Effect size	P
Intensity of pain (VAS-cm)	8.38 ± 1.26 (5–10)	6.15 ± 2.51 (2–10)	0.89 to 3.56	1.01‡	.003*	9.08 ± 1.11 (6–10)	4.62 ± 1.32 (3–7)	3.48 to 5.43	2.76§	<.001*
Number of migraine attacks/month	5.84 ± 1.90 (4–10)	3.38 ± 1.55 (2–7)	1.99 to 2.93	3.17§	<.001*	6.07 ± 2.10 (4–10)	2.92 ± 1.32 (2–6)	2.50 to 3.79	2.95§	<.001*
MIDAS	6.54 ± 0.66 (6–8)	3.31 ± 0.94 (2–5)	2.61 to 3.84	3.19§	<.001*	6.92 ± 0.49 (6–8)	2.92 ± 1.03 (1–5)	3.44 to 4.55	4.38§	<.001*
WHOQOL-BREF Total	219.77 ± 38.23 (151–281)	258.69 ± 39.93 (175–320)	−55.63 to −22.21	−1.40§	.002*	204.62 ± 61.51 (86–320)	261.77 ± 35.54 (207–323)	−92.37 to −21.93	−0.98‡	.002*
Physical	52.54 ± 8.26 (38–63)	65.00 ± 13.34 (50–88)	−18.31 to −6.60	−1.28§	.004*	43.77 ± 14.24 (23–75)	63.15 ± 13.39 (44–88)	−30.72 to −8.04	−1.03‡	.005*
Physiologic	51.46 ± 12.88 (25–69)	60.92 ± 13.59 (25–81)	−13.97 to −4.94	−1.26§	.005*	53.85 ± 17.70 (19–81)	65.92 ± 9.75 (50–81)	−20.08 to −4.06	−0.91‡	.004*
Social	66.08 ± 16.30 (31–94)	70.31 ± 12.31 (50–94)	−8.94 to 0.48	–	.071	51.92 ± 25.83 (6–94)	66.38 ± 13.45 (50–94)	−27.26 to −1.66	−0.68†	.017*
Environment	53.23 ± 13.21 (25–75)	63.08 ± 13.01 (44–81)	−15.42 to −4.26	−1.06‡	.008*	53.62 ± 15.51 (31–88)	66.54 ± 11.30 (33–88)	−20.54 to −5.30	−1.02‡	.007*

Group 1: Jacobson Progressive Muscle Relaxation, Group 2: Jacobson Progressive Muscle Relaxation + cold application, n: number of participants, B.T.: before treatment, A.T.: a fter treatment, min: minimum, max: maximum.

CI = confidence interval, cm = centimeter, MIDAS = Migraine Disability Assessment Scale, SD = s tandard deviation, VAS = Visual Analog Scale, WHOQOL-BREF = World Health Organization Quality of Life Scale-Short Form.

^†Medium effect size.

^‡Large effect size.

^§Very large effect size.

^*P < .05.

Between-group comparisons using ANCOVA (Table 3), revealed a statistically significant difference in the number of migraine attacks per month, favoring Group 2 (P = .021, Pη² = 0.21), indicating a large effect size. No significant differences were found between the groups in terms of posttreatment pain intensity (P = .395) or migraine-related disability (P = .304).

Table 3.

Between-group comparison of pain, attack number, and disability after treatment (ANCOVA).

Parameters	Group 1 (n = 13) AM ± SE	Group 2 (n = 13) AM ± SE	F	Pη²	P
Intensity of pain (VAS-cm)	6.48 ± 0.54	4.56 ± 0.55	0.751	0.03	.395
Number of migraine attacks/month	3.46 ± 0.17	2.84 ± 0.17	6.111	0.21	.021*
MIDAS	3.37 ± 0.27	2.73 ± 0.28	1.106	0.04	.304

Group 1: Jacobson Progressive Muscle Relaxation, Group 2: Jacobson Progressive Muscle Relaxation + cold application, n: number of participants.

AM = adjusted mean, cm = centimeter, MIDAS = Migraine Disability Assessment Scale, Pη² = partial eta square, SE = s tandard error, VAS = Visual Analog Scale.

^*P < .05.

Between-group comparisons of change scores in WHOQOL-BREF total and domain scores were performed using the Mann–Whitney U test, as shown in Table 4. No statistically significant differences were found between Group 1 and Group 2 in terms of overall QoL (P = .590), or in any of the individual domains, including physical (P = .519), psychological (P = .699), social (P = .222), and environmental (P = .699) well-being. Throughout the intervention period, no adverse effects were observed or reported by any participants.

Table 4.

Between-group comparison of change scores in WHOQOL-BREF (Mann–Whitney U test).

WHOQOL-BREF	Group 1 (n = 13) ∆ median (IQR)	Group 2 (n = 13) ∆ median (IQR)	U	Z	P
Total score	40.00 (50.50)	31.00 (58.00)	74.000	−0.539	.590
Physical	12.00 (16.50)	12.00 (35.00)	72.000	−0.645	.519
Physiologic	10.00 (10.00)	12.00 (9.50)	77.000	−0.387	.699
Social	0.00 (6.00)	6.00 (25.00)	61.500	−1.222	.222
Environment	12.00 (18.00)	12.00 (15.50)	77.000	−0.387	.699

Group 1: Jacobson Progressive Muscle Relaxation, Group 2: Jacobson Progressive Muscle Relaxation + cold application, ∆: Change scores between post-treatment and pretreatment, n: number of participants.

IQR = interquartile range, WHOQOL-BREF = World Health Organization Quality of Life Scale-Short Form.

4. Discussion

This study aimed to evaluate the short-term effects of cold application combined with JPMR on clinical outcomes in individuals with migraine without aura. The results demonstrate that both JPMR alone and in combination with cold therapy led to statistically and clinically significant improvements in pain intensity, migraine frequency, migraine-related disability, and QoL. Also, this finding suggests that while JPMR appears to be the primary contributor to therapeutic benefit, the addition of cryotherapy may offer a modest but distinct advantage specifically in reducing attack frequency.

The significant improvement in both groups reinforces the growing body of evidence supporting the use of JPMR as a non-pharmacological prophylactic strategy for migraine. Previous trials and meta-analyses have established JPMR’s ability to reduce migraine frequency, severity, and reliance on acute medication.^[7,8] The mechanism of JPMR is believed to involve the reduction of sympathetic nervous system activity, improvement in parasympathetic tone, and enhancement of endogenous pain inhibitory pathways.^[19] These physiological effects translate into reduced cortical hyperexcitability, a hallmark of migraine pathophysiology.

The superior performance of the combined intervention group (JPMR plus cold application) can be attributed to the additional effects of cryotherapy on peripheral and central nociceptive mechanisms. Cold application activates transient receptor potential melastatin 8 ion channels in the trigeminovascular system, which can inhibit afferent pain signaling and reduce neurogenic inflammation (a known contributor to migraine attacks).^[9,11] Moreover, the vasoconstrictive properties of cold may counteract the vasodilation believed to underlie migraine pain, while simultaneously slowing conduction velocity of nociceptive fibers.^[10] These mechanisms likely explain the statistically greater improvements observed in the combined group for both pain intensity and disability.

Another consideration is the psychological and behavioral impact of cold therapy when applied under structured and supervised conditions. While cold exposure is frequently used informally by patients, its therapeutic potential may be underestimated due to inconsistent application methods. Our study, through standardized administration, validates its controlled use and positions it as a clinically valuable adjunct when integrated into broader rehabilitation programs. Although cold therapy is widely adopted anecdotally, clinical research on its efficacy in migraine remains limited and inconclusive. Hsu et al^[13] recently conducted a systematic review highlighting the lack of standardized cold intervention protocols and variable outcomes across studies. By applying cold consistently across defined anatomical regions (frontal, temporal, and occipital) and timing it post-JPMR, this study contributes a novel and methodologically robust protocol to the literature. Moreover, while many studies have examined the effects of physical therapy, biofeedback, or relaxation independently, few have explored the combined use of physical modalities with cognitive-behavioral interventions, despite calls for more integrative approaches in migraine care.^[6,20] Our results support this multidimensional framework and suggest that targeting both physiological and psychophysiological systems may enhance treatment efficacy, especially in patients unwilling or unable to use pharmacologic therapies.

From a clinical standpoint, these findings have several practical implications. Both JPMR and cold applications are low-cost, safe, and easily implemented without requiring specialized equipment. The ability to deliver these interventions remotely, as demonstrated in this study, enhances accessibility, particularly for patients in underserved or rural areas. The combination of guided relaxation and at-home cold therapy could be integrated into digital therapeutics or tele-rehabilitation models for migraine management, which are becoming increasingly relevant in the post-pandemic healthcare landscape. Additionally, given the high burden of migraine on daily functioning, work productivity, and psychological well-being, any intervention that reduces both symptom severity and disability is of substantial value. The observed reduction in MIDAS score clinically meaningful and supports the use of these modalities not only for symptom control but also for improving functional independence and participation.

5. Limitations

This study has several limitations. First, the sample size was modest and may limit the generalizability of the findings. Second, self-reported attack frequency was not validated using headache diaries, which may introduce recall bias. Third, the study included only individuals with migraine without aura, limiting applicability to other migraine subtypes. Fourth, the follow-up period was restricted to 6 weeks, so long-term sustainability of treatment effects remains unknown. Additionally, the study focused on evaluating the added value of cryotherapy combined with exercise, rather than its stand-alone effects, which warrants future investigation. Future studies should aim to include larger and more diverse samples, incorporate long-term follow-up assessments, use objective headache tracking methods, and compare outcomes against pharmacological or other physiotherapeutic interventions.

6. Conclusions

This randomized controlled study demonstrated that both JPMR alone and in combination with cold application are effective short-term interventions for reducing pain intensity, migraine frequency, disability, and improving QoL in patients with migraine without aura. However, the addition of cold application yielded significantly superior outcomes in pain intensity and disability reduction compared to JPMR alone. Given the noninvasive, cost-effective, and easily applicable nature of both interventions, particularly in remote or resource-limited settings, this combined approach holds promise as a viable adjunct or alternative to conventional treatments. Incorporating cold application into relaxation-based therapeutic protocols may offer an enhanced strategy for migraine management, particularly in patients seeking non-pharmacological options.

Future research should explore the long-term effects of these interventions, assess their applicability to other migraine subtypes (e.g., with aura), and compare their efficacy with standard pharmacologic and behavioral therapies using larger and more diverse populations.

Author contributions

Conceptualization: Eylül Pinar Kisa, Melis Yalman, Abdulsamed Enes Akin.

Data curation: Eylül Pinar Kisa, Begüm Kara Kaya.

Formal analysis: Eylül Pinar Kisa, Begüm Kara Kaya.

Investigation: Eylül Pinar Kisa, Melis Yalman, Abdulsamed Enes Akin.

Methodology: Eylül Pinar Kisa, Begüm Kara Kaya.

Resources: Eylül Pinar Kisa, Melis Yalman.

Software: Eylül Pinar Kisa, Begüm Kara Kaya.

Supervision: Eylül Pinar Kisa.

Validation: Begüm Kara Kaya.

Writing – original draft: Eylül Pinar Kisa, Begüm Kara Kaya, Melis Yalman, Abdulsamed Enes Akin.

Writing – review & editing: Eylül Pinar Kisa, Begüm Kara Kaya, Melis Yalman, Abdulsamed Enes Akin.

Supplementary Material

medi-104-e44760-s001.pdf ^{(292.7KB, pdf)}