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Cognitive Behavioral Therapy for Migraine Headache: Comparison
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Please note this is a comparison between Version 2 by Lindsay Dong and Version 3 by Lindsay Dong.

Migraine headaches are chronic neurological diseases that reduce the quality of life by causing severe headaches and autonomic nervous system dysfunction, such as facial flushing, nasal stuffiness, and sweating. Their major treatment methods include medication and cognitive behavioral therapy (CBT). CBT has been used for pain treatment and various psychogenic neurological diseases by reducing pain, disability, and emotional disorders caused by symptoms of mental illness and improving the understanding of mental health.

  • migraine
  • migraine headache
  • headache
  • cognitive behavioral therapy

1. Introduction

Migraine is a disease characterized by severe headache accompanied by symptoms, such as nausea, photophobia, phonophobia, and vomiting
[1]
. The prevalence of migraine is estimated to be 15–18%
[2]
, and it is two to three times higher in women than in men
[3][4]
. Migraine is a chronic neurological disorder and autonomic nervous system dysfunction that affects patients’ quality of life
[5][6]
. The preferred treatment for migraine is medication administration. Acute medications include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and triptans
[7]
. Routine use of opioids and barbiturates is not preferred because of their poor safety and tolerability
[8][9][10]
.
Overuse of painkillers can lead to a variety of side effects and medication overuse headache; therefore, attention should be paid to drug abuse during migraine symptoms
[11][12]
. Non-drug therapy is known to have fewer side effects and can be used simultaneously with medications
[12][13]
.
Physicians who treat migraines are increasingly interested in complementary treatments
[14][15]
. Medications, such as antidepressants, hypertension treatments, and flunarizine, were common treatment for migraines. However, acupuncture and biobehavial therapy are also used to prevent migraine headaches for patients with little response to existing drug treatment or pregnant women, or patients with psychological disorders.
[7][16]
. Nutritional supplements, such as riboflavin, pyridoxine, folate, cobalamin, and vitamin D, have recently been widely used as preventive treatments for migraine
[17][18][19]
.
Cognitive behavioral therapy (CBT) is a treatment that uses cognitive factors to improve mental disorders and psychological distress
[20]
. The latest practice guidelines emphasize CBT as a selective psychotherapy for problems ranging from depression, anxiety, and personality disorders to chronic pain, addiction, and relationship pain
[21]
. Previous studies have demonstrated the effectiveness of behavioral therapy for migraine headaches, including CBT, relaxation, and biological feedback, to reduce the frequency of migraine attacks and migraine-related disorders
[22][23][24]
.

2. Cognitive Behavioral Therapy for Migraine Headache

Migraine headache is a chronic neurological disease that varies in its frequency and severity, and [25] is a prevalent condition that can severely affect personal, social, and work life during attacks [26][27]. Although the standard treatment for migraine headaches is currently taking medication, a psychiatric approach with a high level of psychological co-prosperity has also recently drawn attention [28][27]. Individuals with migraine are increasingly approaching complementary and integrative health strategies [14][15]. Because patients have an increased preference for CBT treatment for a variety of reasons, several behavioral treatments for migraine prevention have been used, especially during pregnancy or when pharmacological choices for patients are limited, such as low efficacy or lack of durability in pharmacotherapy, or in combination with pharmacological treatments [16].

CBT refers to cognitive processes related to the development and maintenance of psychopathology, particularly emotional pain and dysfunction, which are primarily conducted during sessions, requiring therapists to coordinate interventions to best help patients
[29]
. CBT therapy enables patients to develop preventive and acute care strategies, such as trigger identification, modification of maladaptive interrelated thoughts, feelings and behaviors surrounding headache, and physiological autoregulation strategies. Behavioral therapies for migraine headaches, including cognitive behavioral therapy, relaxation, and biofeedback, have demonstrated efficacy in reducing migraine attack frequency and migraine-related disorders
[22][23][30][31]
.
Several previous studies have shown that CBT reduces disability and chronic pain in patients
[32][33]
. CBT had a significant effect on reducing headache frequency and MIDAS scores, which is consistent with the results of previous studies. Therefore, although many studies with more samples are needed in the future, it is believed that CBT can be considered for its use as a complementary therapy for migraine treatment (
Table 1
).
Table 1.
Summary of the results and adverse effects.
Study ID Main Result Baseline (BL) Post-Treatment (PT) Follow-Up (F/U) p-Value Adverse Effect Conclusion
Intervention (Mean ± SD)
Control (Mean ± SD)
Powers

[25]

(2013)		           Group MD in change score at PT I:90

C:109		 ○ In I group, headache days and PedMIDAS decreased significantly compared with control group.

○ Headache days were ≥50% Reduction in 66% of I and 36% of C at PT (odds ratio, 3.5 [95%CI, 1.7 to 7.2]; p < 0.001).

○ PedMIDAS <20 points were in 75% of I, and 56% of C at PT (odds ratio, 2.4 [95%CI, 1.1 to 5.1]; p = 0.02).
HA frequency

(day/month)		 I 21.3 ± 5.2 9.8 ± 9.8 Not mentioned p = 0.002
C 21.3 ± 5.2 14.5 ± 9.8
PedMIDAS I 68.2 ± 31.7 15.5 ± 17.4 Not mentioned 14.1 (95% CI 3.3, 24.9) p = 0.01
C 68.2 ± 31.7 29.6 ± 42.2
Seng

[24]

(2019)		         4 M   ○ No AE in control group

○ 2 AE in intervention group

(1) Vivid recollection of traumatic event while practicing mindfulness

(2) Severe increase in Headache frequency and pain intensity		 ○ HDI change: the group*month interaction was significant, p = 0.004

○ MIDAS: Group*month (N.S. accounting for divided alpha) p = 0.027

○ MIDI: −0.6/10(I), +0.3/10(C) p = 0.007

○ Headache days, headache intensity: Group*month interaction and group*time interaction (N.S.)
HDI 1 I 52.5 ± 21.2   38.2 ± 16.6 p < 0.004
C 50.2 ± 16.2   50.4 ± 14.3
MIDAS 2 Group*month interaction

BL vs. 4 M		 B = 1.6, 95%CI = −0.7,3.9 F(3,213) = 3.12, p = 0.027
MIDAS-A 3 B = 6.3, 95%CI = −2.0,14.5, F(3,94.6) = 1.21, p = 0.312
MIDAS-B 4 B = 0.3, 95%CI = −0.4,1.1, F(3,102.9) = 0.65, p = 0.589
HA days/month I 16.5 ± 6.0   14.8 ± 4.8 p = 0.773    
C 15.5 ± 5.9   14.2 ± 4.8
Average Attack Intensity /month 5 I 1.7 ± 0.3   1.6 ± 0.3 p = 0.888
C 1.8 ± 0.3   1.7 ± 0.3
Average MIDI/month 6 I 2.8 ± 1.6   1.7 ± 2.7 p = 0.007
C 3.4 ± 2.0   4.4 ± 1.3
Grazzi

[26]

(2019)		         3 M   N ○ Headache days and medication intake days declined in I group, not in C group
HA days/month I 10 ± 2.0   6.5 ± 3.5 N
C 9.27 ± 3.43   11.5 ± 4.71
Using medication days/month I 9.4 ± 2.75   5.75 ± 3.3 N
C 9.9 ± 3.6   10.5 ± 5.8
Mansourishad

[27]

(2017)		       3 M   N ○ Covariance analysis showed I group is effective compared with C group in reducing headache frequency (p= 0.001< 0.05), duration (p = 0.001 < 0.05), and severity (p= 0.001 < 0.05) in women with migraine.
HA Frequency (days/month) I 10.63 ± 6.16 4.27 ± 3.01 4.73 ± 2.01 p = 0.001
C 10.81 ± 4.56 10.27 ± 3.21 10.45 ± 6.07
HA Intensity I 6.20 ± 2.30 4.12 ± 1.90 4.32 ± 1.13 p = 0.001
C 6.41 ± 3.40 6.40 ± 2.83 6.50 ± 2.75
HA Duration (h/month) I 10.63 ± 3.05 5.90 ± 4.29 5.08 ± 2.76 p = 0.001
C 11.73 ± 5.49 12.45 ± 6.22 11.36 ± 4.85
            PT F/U    
Smitherman

[34]

(2016)		 HA Frequency

(days/month)		 I 22.7 16.6 11.6 p = 0.883 p = 0.028 N ○ Headache frequency reduction from baseline of I group was not statistically significant com-pared with C group at PT, FU p = 0.883

○ I and C group showed clinically meaningful re-ductions in MIDAS, HIT-6, headache severity at PT, FU with no group differences when controlling for baseline scores

○ No significant group difference in Headache frequency, HIT-6, MIDAS score, headache severity, ESS, PHQ-9, GAD-7, CEQ

○ Significant group difference in TST, sleep efficiency, PSQI
C 19.6 12.5 14.7
MIDAS I 59.9 ± 39.0 44.2 ± 43.1 31.9 ± 33.2 N
C 54.5 ± 41.0 41.0 ± 46.2 34.7 ± 34.5
HIT-6 I 66.9 ± 3.8 62.6 ± 5.3 59.9 ± 5.5 N
C 64.8 ± 3.9 61.4 ± 8.0 59.6 ± 7.2
HA Severity I 5.2 ± 0.9 5.1 ± 1.4 4.5 ± 1.5 N
C 5.4 ± 1.6 5.2 ± 2.1 5.1 ± 1.9
PSQI 7 I 11.3 ± 4.4 7.6 ± 2.6 7.0 ± 3.1 p = 0.009
C 11.6 ± 2.5 10.9 ± 3.8 11.5 ± 3.9
ESS 8 I 11.0 ± 3.4 9.0 ± 3.2 8.9 ± 3.55 N
C 9.9 ± 4.892 9.2 ± 4.7 8.8 ± 4.6
TST (h) 9 I 7.4 ± 1.5 7.3 ± 1.4 8.3 ± 2.6 p = 0.049
C 6.7 ± 1.5 6.9 ± 1.2 6.8 ± 0.5
Sleep Efficiency I 81.2 ± 7.7 79.1 ± 8.9 84.9 ± 4.5 p = 0.001
C 81.2 ± 8.3 82.4 ± 6.4 80.9 ± 4.9
PHQ-9 10 I 12.1 ± 5.8 6.9 ± 4.8 6.3 ± 4.6 p = 0.054
C 10.5 ± 4.5 8.4 ± 4.7 8.6 ± 4.7
GAD-7 11 I 10.6 ± 6.4 6.6 ± 5.2 6.3 ± 4.8 p = 0.430
C 9.8 ± 5.3 7.0 ± 4.6 6.9 ± 4.9
Cousins

[35]

(2015)		         4 M   N ○ At 4 months after treatment, no significant change between I and C group statistically in.

- Diary headache days

- Medication days/ month

- MIDAS, HIT-6, HADS-A,

- HADS-D, IPQ
HA days/month I 12.03 ± 8.70   9 ± 7.27 N
C 11.54 ± 6.64   9.68 ± 6.28
Using rescue medication

days/month		 I 6.69 ± 5.30   5.86 ± 5.12 N
C 7.08 ± 5.87   6.2 ± 4.86
MIDAS I 51.03 ± 43.68   33.86 ± 34.93 N
C 65.78 ± 46.79   53.85 ± 78.49
HIT-6 12 I 66.5 ± 5.88   59.17 ± 8.19 N
C 65.97 ± 4.41   60.85 ± 8.4
HADS-A 13 I 7.78 ± 4.01   5.76 ± 4.45 N
C 9.32 ± 3.55   7.96 ± 4.37
HADS-D I 5.83 ± 4.61   4.24 ± 4.6 N
C 5.68 ± 3.09   4.52 ± 3.51
Brief IPQ 14 I 52.81 ± 9.69   44.17 ± 15.89 N
C 51.41 ± 9.77   45.26 ± 10.17
Wells

[12]

(2014)		           PT FU N ○ The severity and du-ration of all head-aches decreased in the I group, but not statistically significant

○ Significant decrease in I group compared with C group on HIT-6 at PT (p = 0.043), FU(p = 0.022) and MIDAS at PT (p = 0.017)

○ Self-efficacy and mindfulness also in-creased at PT (p = 0.035)

○ MBSR is safe and feasible for adults with migraine.
Migraine Frequency

/month		 I 4.2 ± 2.9 2.6 ± 3.8   p = 0.38 p = 0.63
C 2.9 ± 5.2 2.7 ± 6.9  
HA Frequency

days/month		 I 9.9 * 9.0 * 9.0 * p = 0.14 p = 0.22
C 12.3 * 10.0 * 7.7 *
HA severity (0–10) I 4.4 * 3.2 * 3.3 * p = 0.053 p = 0.66
C 4.8 * 5.2 * 4.8 *
HA duration I 5.1 * 2.9 * 3.6 * p = 0.043 p = 0.19
C 6.4 * 6.1 * 6.1 *
HIT-6 I 63.0 ± 8.0 57.6 ± 6.7 58.3 ± 6.0 p = 0.043 p = 0.022
C 64.7 ± 5.0 64.1 ± 3.8 64.1 ± 3.9
MIDAS I 12.5 ± 9.8 5.9 ± 5.3 5.8 ± 3.8 p = 0.017 p = 0.072
C 11.0 ± 6.7 17.0 ± 11.9 12.0 ± 8.1
HA Management

Self Efficacy		 I 117.2 ± 18.7 122.6 ± 25.0 124.5 ± 22.6 p = 0.035 p = 0.060
C 118.4 ± 31.1 110.7 ± 29.2 111.9 ± 35.7
Five Factor

Mindfulness		 I 142.9 ± 14.7 149.1 ± 18.7 153.8 ± 19.7 p = 0.035 p = 0.045
C 143.7 ± 20.3 136.8 ± 18.3 138.0 ± 19.6
MSQoL 15 I 47.0 * 31.5 * 38.1 * p = 0.12 p = 0.035
C 46.4 * 45.2 * 45.2 *
PHQ-9 16 I 3.6 ± 3.0 2.0 ± 1.8 2.7 ± 2.2 p = 0.77 p = 0.59
C 6.4 ± 6.5 4.2 ± 1.8 3.9 ± 1.9
STAI 17 I 68.7 ± 16.3 61.6 ± 15.0 60.5 ± 16.8 p = 0.13 p = 0.10
C 67.0 ± 15.8 70.2 ± 14.9 69.1 ± 10.3
Perceived Stress Scale-10 I 15.8 ± 6.4 13.3 ± 5.1 12.1 ± 5.1 p = 0.87 p = 0.27
C 14 ± 8.1 12.1 ± 8.0 13.6 ± 7.0
Rapoff

[29]

(2014)		         3 M BL PT N ○ In I group, pain severity decreased at PT compared with C group (p = 0.03)

○ At 3 M FU, significant change in PedMIDAS score in I group compared with C group (p = 0.04)

No other group differences at PT or 3M FU
HA frequency

(% of days)		 I 41.09 ± 22.67 31.28 ± 28.14 21.43 ± 23.47 p = 0.48 p = 0.46 p = 0.36
C 40.67 ± 28.79 32.14 ± 22.23 18.18 ± 17.60
HA duration

(hr/episode)		 I 5.47 ± 4.20 4.47 ± 4.26 1.53 ± 0.91 p = 0.19 p = 0.24 p = 0.07
C 4.15 ± 3.88 5.56 ± 4.01 4.25 ± 5.19
HA severity (VAS) I 5.06 ± 1.84 5.06 ± 1.50 4.46 ± 1.88 p = 0.07 p = 0.03 p = 0.20
C 6.00 ± 1.52 6.25 ± 1.92 3.68 ± 2.04
PedMIDAS total 18 I 13.26 ± 9.69 7.82 ± 10.59 0.91 ± 1.45 p = 0.25 p = 0.14 p = 0.05
C 15.53 ± 10.08 12.29 ± 12.94 3.50 ± 4.86
PedsQL total 19 I 82.10 ± 12.18 83.70 ± 12.07 84.88 ± 18.22 p = 0.25 p = 0.26 p = 0.46
C 79.35 ± 11.55 80.69 ± 14.36 85.67 ± 14.32
Fritsche

[30]

(2010)		         3 M 12–30 M   N ○ Significant change in time effect observed in I, C group in headache days, migraine days, Intake at headache days, Intake at migraine days (p < 0.001)

○ Improvement in psychological variables (p < 0.001)

- Remained stable in both groups at short- and long-term F/U

○ MCT (C) and biblio-therapy (I) are useful to prevent

“medication overuse headache” and transition to chronic head-ache
HA days I 11.40 ± 5.92 9.17 ± 5.45 8.55 ± 5.51 8.68 ± 5.29 Time effect p < 0.001
C 10.51 ± 4.98 8.47 ± 5.54 8.11 ± 4.82 8.33 ± 5.15
Migraine days I 7.23 ± 3.70 5.60 ± 3.79 6.15 ± 3.97 6.15 ± 4.02 Time effect p < 0.001
C 7.27 ± 3.82 5.78 ± 4.01 5.45 ± 3.16 5.84 ± 3.76
HA disability I 4.46 ± 1.80 4.49 ± 2.01 4.61 ± 1.97 4.39 ± 2.16 Time effect N.S
C 4.16 ± 1.56 4.13 ± 1.97 4.25 ± 1.88 4.40 ± 1.73
Intake at HA days I 7.17 ± 2.48 5.92 ± 3.10 5.93 ± 3.23 6.18 ± 3.65 Time effect p < 0.001
C 7.58 ± 3.11 6.35 ± 3.66 6.47 ± 3.20 6.00 ± 2.82
Intake

at migraine days		 I 5.27 ± 2.25 4.30 ± 2.76 4.83 ± 3.00 5.03 ± 3.52 Time effect p < 0.001
C 6.25 ± 2.98 5.04 ± 3.11 4.75 ± 2.82 5.02 ± 2.78
Calhoun

[31]

(2007)		 HA frequency

/28 days		 I 24.2 ** 17.4 **   p = 0.001 N ○ In I group, statistically significant reduction compared to C group observed headache frequency (p = 0.001) and Headache intensity(p= 0.01) at PT

○ No one in C group re-verted to episodic migraine, and 48.5% in I group reverted to epi-sodic migraine
C 23.2 ** 23.9 **  
HA Intensity I 46.7 ** 28.3 **   p = 0.01
C 50.2 ** 44.1 **  
Reverted to episodic migraine         p = 0.029
       
Scharff

[36]

(2002)		           PT F/U N ○ Clinical improvement in all variables (head-ache index change, highest intensity, days with headache) over time and compared with C group.

○ In HWB and HCB group

○ At PT, there is no significant temperature change

○ At 3 M F/U, temperature changes in both HWB and HCB group were significant com-pared to BL

○ At 6 M F/U, HWB group showed clinical improvement compared to HCB group
HA Index change (1) Effect of time

(Pillai’s trace = 0.267,

F[3, 29] = 3.53, p < 0.03)

(2) Trend for treatment group

(Pillai’s trace = 0.36,

F[6, 60] = 2.21, p < 0.05)		 (1) Effect for time

(Pillai’s trace =0.81,

F[9, 12] = 5.62, p < 0.01)

(2) Trend for treatment group

(Pillai’s trace = 0.32,

F[3, 18] = 2.80, p < 0.07)		 p < 0.005 p < 0.001
Highest intensity

rating for 2-week		 p < 0.01 N
HA days p < 0.02 p < 0.01
Temperature change (1) Effect of time

(Philai’s trace = 0.44,

F[12, 69] = 4.44, p < 0.001)

(2) No significant difference

in treatment		   6 M N
72.2% of HWB 20,

33.3% of HCB 		21 were significant compared to BL

(χ² 		[1] = 3.76, p < 0.05). 100% of HWB

62.5% of HCB

showed clinical improvement

(χ² 		[1] = 4.50, p < 0.05).
1
HDI: Headache Disability Inventory;
2
MIDAS: Migraine Disability Asessment;
3
MIDAS A: Self-reported headache days over a 90 day period, divided by 3;
4
MIDAS B: Self-reported average headache attack intensity over a 90 day period (1–10);
5
Average Attack Intensity/30 Days (by 1–3 scale);
6
MIDI = Migraine Disability Index (by 0–10 scale);
7
PSQI: Pittsburgh Sleep Quality Index;
8
ESS: Epworth Sleepiness Scale;
9
TST: Total Sleep Time;
10
PHQ-9: Patient Health Questionnaire 9-item Depression Module;
11
GAD-7: Generalized Anxiety Disorder 7-item Scale;
12
HIT-6: Headache Impact Test;
13
HADS: Hospital Anxiety and Depression Scale;
14
Brief-IPQ: Brief Illness Perceptions Questionnaire;
15
MSQoL: Migraine-Specific Quality of Life;
16
PHQ-9: Patient Health Questionnaire-depression module;
17
STAI: State Trait Anxiety Inventory;
18
PedMIDAS: The Pediatric Migraine Disability Assessment;
19
PedsQL: Pediatric Quality of Life Inventory (4th ed.);
20
HWB: handwarming biofeedback;
21
HCW: handcooling biofeedback; I, intervention; C, control; N.S., not statistically significant; BL, baseline; PT, post-treatment F/U, follow-up; M, months; Yrs, years; HA, headache; CBT, cognitive behavioral therapy; MCT, minimal contact therapy; Frequency of migraine, days per month during treatment; T, time effect.

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