• Adults: Interventions including cognitive behavioral therapy (CBT), relaxation training, or mindfulness-based treatment (alone or combined with other components) may lower migraine/headache attack frequency, and education alone may also improve migraine-related disability (strength of evidence [SOE]: All low).
• Evidence regarding adverse effects among individuals of any age, effectiveness for children and adolescents, and biopsychosocial factors is inconclusive.
• Adults: Mindfulness-based stress reduction (MBSR) may offer greater benefit for disability than education; CBT + relaxation training might result in higher migraine attack frequency but also higher quality of life (QOL) than propranolol; relaxation training may outperform CBT + relaxation + education in QOL; MBSR + education may reduce attack frequency compared with stress management training + education; and biofeedback may reduce attack frequency compared with CBT + relaxation training (SOE: All low).
• Children/adolescents: a combination of CBT, biofeedback, and relaxation training may lead to lower migraine attack frequency and disability compared with education alone (SOE: low).
• Evidence is insufficient to address the effects of individual behavioral components.
• In adults with chronic migraine, behavioral sleep modification may reduce headache frequency at 6 weeks (SOE: low); no studies were included for children.

Objectives. Behavioral interventions for migraine prevention can offer an important alternative or complement to medications. An updated systematic review is needed to support evidence-based guidance for clinicians and identify evidence gaps for future research.

Data Sources. MEDLINE, Embase, PsycINFO, PubMed, the Cochrane Database of Systematic Reviews, clinicaltrials.gov, and grey literature sources for randomized trials published from January 1, 1975, to August 24, 2023.

Review Methods. A multidisciplinary expert panel including adult and pediatric clinical psychologists, adult and pediatric neurologists, primary care physicians, researchers, funders, children and adults with migraine and their caregivers provided input on scope and methods. We included randomized trials enrolling at least 80% participants with migraine (or outcomes for migraine participants reported separately) and reporting a primary outcome at 4 weeks or more after the start of treatment. Primary outcomes were migraine/headache attack frequency, migraine disability, and migraine-related quality of life. We did not require a formal diagnosis of migraine (i.e., International Classification of Headache Disorders criteria). The review team tabulated information from included trials, rated risk of bias, conducted pairwise meta-analyses, and rated the strength of evidence (SOE). The SOE is a formal rating of the reviewer’s confidence in the estimated effects.

Results. For adults, we included 50 trials published since 1978. Most preventive interventions were multicomponent, using one or more of five primary components (cognitive behavioral therapy [CBT], biofeedback, relaxation training, mindfulness-based therapies, and/or education). Most trials were at high risk of bias, primarily due to measurement bias and incomplete data. Given the small amount of evidence on any given intervention/comparator/outcome combination, data were often insufficient to permit conclusions. For adults, we found that any of three components (CBT, relaxation training, mindfulness-based therapies) may reduce migraine/headache attack frequency (SOE: low). Education alone that targets behavior may improve migraine-related disability (SOE: low). For three other interventions (biofeedback, acceptance and commitment therapy, and hypnotherapy), evidence was insufficient to permit conclusions. We also found that mindfulness-based therapy may improve migraine disability more than education, and relaxation + education may improve migraine-related quality of life more than propranolol (SOE: low). For children/adolescents, we included 13 trials published since 1984 (average age 14.5), but the evidence was only sufficient to conclude that CBT + biofeedback + relaxation training may reduce migraine attack frequency and disability more than education alone (SOE: low).

Conclusion. Several behavioral interventions appear to reduce migraine/headache attack frequency in adults. Evidence consisted primarily of underpowered trials of multicomponent interventions compared with various types of control groups. Future research should enroll children and adolescents, standardize intervention components to improve reproducibility, use comparison groups that control for expectation confounds, enroll larger samples, consider digital and telehealth modes of care delivery, and improve the completeness of data collection.

This evidence review was funded by the Patient-Centered Outcomes Research Institute under Contract No. 75Q80120D00002 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, through a Memorandum of Understanding Amendment, number 20-603M-23.

Treadwell JR, Tsou AY, Rouse B, Ivlev I, Fricke J, Buse D, Powers S, Minen M, Szperka C, Mull NK. Behavioral Interventions for Migraine Prevention. Comparative Effectiveness Review No. 270. (Prepared by the ECRI-Penn Evidence-based Practice Center under Contract No. 75Q80120D00002.) AHRQ Publication No. 24-EHC015. PCORI Publication No. 2024-SR-01. Rockville, MD: Agency for Healthcare Research and Quality; September 2024. DOI: https://doi.org/10.23970/AHRQEPCCER270. Posted final reports are located on the Effective Health Care Program search page.