An Expert Interview
Tori Rodriguez, MA, LPC
Despite this high prevalence, many patients do not disclose to their healthcare providers that they use such interventions, and many clinicians are unfamiliar with these approaches and the mechanisms underlying their effectiveness. A review published in February 2019 in Current Pain and Headache Reports noted that nearly 85% of providers did not feel adequately informed to advise patients on complementary medicine interventions.4
With the aim of increasing providers’ comfort level in discussing such approaches with patients, researchers from Wake Forest Baptist Health in Winston-Salem, North Carolina, examined studies published between 2015 and 2018 in which complementary and integrative medicine interventions used for migraine treatment, either as monotherapy or in combination with other modalities, were examined.4Selected findings by intervention type are highlighted below.
Mind/body therapies. In a 2015 study of 37 patients with chronic migraine or tension-type headache, an 8-week mindfulness-based stress reduction (MBSR) program, when combined with pharmacotherapy vs medication alone, was associated with improved pain intensity and quality of life (assessed with a headache log and short-form 36 questionnaire, respectively).5
In a 2018 study in a similar patient group, MBSR was associated with improvements in disability (P<.0001), mindfulness (P <.001), distress (P <.0001), and the emotional dimension of pain (P <.0001), as evaluated with the Migraine Disability Assessment; the Freiburg Mindfulness Inventory; the Depression, Anxiety, and Stress Scale; and the McGill Short Form Questionnaire, respectively.4
Another study examined the effects of a mindfulness intervention compared with medication after a 5-day outpatient day program for medication overuse in chronic migraine.4 The results indicate similar reductions between groups in headache frequency (by 6-8 days per month), medication use, and Migraine Disability Assessment scores.
Yoga practice has been associated with improvements in migraine, including in one study in which 3 weekly sessions of yoga for 12 weeks led to greater reductions in headache severity, frequency, and impact when combined with medication, compared with mediation alone.6 In another study, patients who practiced yoga daily after completion of an Ayurvedic treatment program experienced greater reductions in headache intensity and quality of life compared with those who took nonsteroidal anti-inflammatory drugs for symptom relief.4
Other recent findings indicate that tai chi practice was associated with fewer migraine days (−3.6 migraine days, P <.001) compared with migraine days in a wait-list control group, and this correlated with a significant decrease in systolic blood pressure (P <.05).4
Supplements. In a 2012 guideline update from the American Headache Society and the American Academy of Neurology, it was determined that the efficacy of butterbur for migraine prevention is supported by level A evidence. “However, concerns over hepatotoxicity with butterbur resulted in these entire guidelines being retired, and new ones are now pending,” the review authors wrote.4 Feverfew, magnesium, and riboflavin were classified as having level B evidence, and coenzyme Q10 was found to have level C evidence for migraine prophylaxis.
A small number of studies suggest that several combinations of these and other compounds, including vitamin B6 and folic acid, may improve the number of migraine days, certain symptoms, and quality of life, although results are mixed.4 In other research, melatonin was found to improve migraine4 in adult and pediatric patients, and results from a randomized controlled trial indicated that ginger extract combined with intravenous ketoprofen decreased headache intensity and pain in patients presenting to the emergency department with migraine compared with in individuals who received ketoprofen plus placebo.7
Manual therapies. This category “encompasses a multitude of interventions to enhance mobilization, reduce pathologic restrictions, and provide neuromodulation via a physical treatment,” according to the review.4 Osteopathic manipulation treatment and high-velocity chiropractic manipulation have been linked with fewer migraine days. Additional studies have produced initial promising results for massage therapy and reflexology in individuals with migraine.
Exercise. A range of studies have shown beneficial effects of regular aerobic exercise on migraine, including a 2018 randomized controlled trial, in which such practices were associated with reductions in migraine frequency, duration, intensity, and disability compared with control treatments.8
Acupuncture. There is accumulating evidence that acupuncture improves migraine outcomes. For example, patients who were treated with acupuncture reported reduced headache intensity, which correlated with increased N-acetylaspartate/creatine in the bilateral thalamus on magnetic resonance spectroscopy.9 “This research showed that the biochemical effect of acupuncture may target brain regions important for pain perception (thalamus) and the effect had clinical significance on pain outcomes,” noted the review authors.4
Researchers are investigating several of these modalities in ongoing studies. “As both patients and providers become more educated on both the research-based evidence and on the most common modalities patients practice, an open dialogue can be created to ensure that patients are informed on the safest and most effective treatment options while concurrently playing an active role” in deciding which of these therapies to use.4
For additional insights regarding this topic, Clinical Pain Advisor interviewed review co-author Rebecca Erwin Wells, MD, MPH, associate professor in the department of neurology at Wake Forest and UCNS Certified Headache Specialist; and Mia Tova Minen, MD, MPH, chief of headache research and assistant professor in the departments of neurology and population health at NYU Langone Medical Center.
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Dr Minen: Please note that the preferred term is now “complementary and integrative health” so that the modalities can still be paired with more “traditional” medicine. This is why the National Center for Complementary and Alternative Medicine was renamed the National Center for Complementary and Integrative Health.
The approaches with the most evidence are biofeedback and progressive muscle relaxation therapy — these are level A evidence-based migraine preventive treatments. Cognitive behavioral therapy is also level A evidence-based behavioral therapy. There is evidence for acupuncture, although it is not level A evidence. Mindfulness modalities include MBSR and mindfulness-based cognitive therapy. Research is conducted to explore how these treatments might be helpful in migraine.
Daily intake of vitamin B2 400 mg, magnesium 400 mg, and coenzyme Q10 is supported by the oldest and best evidence for its efficacy in migraine. I use the two former ones. Melatonin 3 mg has been shown to have a side effect profile similar to that of placebo and had efficacy rates similar to placebo in one study.
Clinical Pain Advisor: What are the overall treatment implications of these findings for clinicians, and how would you advise those who want to learn more about these strategies to incorporate them into their practice?
Dr Minen: Learn ways in which patients can integrate and access the evidence-based treatments. Find providers who are knowledgeable with these modalities. There are audio files with progressive muscle relaxation, for example. We recently developed a research app based on progressive muscle relaxation.10
Dr Wells: Although integrative treatment options are often considered safe and “all-natural,” it is important for patients and providers to recognize that risks do exist with these treatments. For example, butterbur preparations need to be free of pyrrolizidine alkaloids to ensure safety, given the associated risk for liver toxicity, and high-velocity cervical maneuvers in chiropractic manipulation have a risk for vertebral or carotid artery dissection.
It is also important for providers to ask their patients about use of integrative treatment options, and for patients to discuss their use with their providers. Many of these treatments may be integrated into conventional treatment approaches as complementary vs alternative to traditional pharmacologic approaches.
Clinical Pain Advisor: What are remaining needs in this area in terms of research?
Dr Minen: We are still trying to learn more about these modalities, about the optimal duration and frequency of these behavioral techniques. We need to find ways to make the evidence-based treatments accessible to patients because we know that they are safe and effective with long-term enduring benefits.
Dr Wells: Much of the research in this area has methodologic challenges that limit interpretation, so more studies and funding for integrative treatment options for migraine are critical to better understand the benefits, mechanisms of actions, risks, and which patients are most likely to respond to which modalities.
1. National Center for Complementary and Integrative Health. Americans Spend $30 Billion a Year Out-of-Pocket on Complementary Health Approaches. June 22, 2016. Accessed on March 18, 2019.
2. Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the United States: updated statistics from government health surveillance studies. Headache.2015;55(1):21-34.
3. Wells RE, Bertisch SM, Buettner C, Phillips RS, McCarthy EP. Complementary and alternative medicine use among adults with migraines/severe headaches. Headache. 2011;51(7):1087-1097.
4. Wells RE, Beuthin J, Granetzke L. Complementary and integrative medicine for episodic migraine: an update of evidence from the last 3 years. Curr Pain Headache Rep. 2019;23(2):10.
5. Bakhshani NM, Amirani A, Amirifard H, Shahrakipoor M. The effectiveness of mindfulness-based stress reduction on perceived pain intensity and quality of life in patients with chronic headache. Glob J Health Sci. 2016;8(4):142-151.
6. Boroujeni MZ, Marandi SM, Esfarjani F, Sattar M, Shaygannejad V, Javanmard SH. Yoga intervention on blood NO in female migraineurs. Adv Biomed Res. 2015;4:259.
7. Bhering Martins L, dos Santos Rodrigues AM, Fernandes Rodrigues D, dos Santos LC, Lúcio Teixeira A, Matos Ferreira AV. Double-blind placebo-controlled randomized clinical trial of ginger (Zingiber officinale Rosc.) addition in migraine acute treatment. Cephalalgia. 2019;39(1):68-76.
8. Krøll LS, Sjödahl Hammarlund C, Gard G, Jensen RH, Bendtsen L. Has aerobic exercise effect on pain perception in persons with migraine and coexisting tension-type headache and neck pain? A randomized, controlled, clinical trial. Eur J Pain. 2018;22(8):1399-1408.
9. Gu T, Lin L, Jiang Y, et al. Acupuncture therapy in treating migraine: results of a magnetic resonance spectroscopy imaging study. J Pain Res. 2018;11:889-900.
10. Minen MT, Jalloh A, Ortega E, Powers SW, Sevick MA, Lipton RB. User design and experience preferences in a novel smartphone application for migraine management: a think aloud study of the RELAXaHEAD application. Pain Med. 2019;20(2):369-377.
This article originally appeared on Clinical Pain Advisor