Treatments for Migraine

Purpose of Review: The efficacy of some nonpharmacologic therapies appears to approach that of most drugs used for the prevention of migraine and tension-type headaches. These therapies often carry a very low risk of serious side effects and frequently are much less expensive than pharmacologic therapies. Considering this combination of efficacy, minimal side effects, and cost savings, medications should generally not be prescribed alone but rather in combination with nonpharmacologic therapies. Recent Findings: In addition to the established nonpharmacologic therapies, such as biofeedback, relaxation training, butterbur, riboflavin, magnesium, and coenzyme Q10 (CoQ10) supplementation, recent data provide support for the use of aerobic exercise and acupuncture. Discovery of the high incidence of the C677T mutation of the methylenetetrahydrofolate reductase gene, MTHFR, and attendant elevation of homocysteine levels in patients with migraine with aura led to a trial of cyanocobalamin, folate, and pyridoxine in these patients. This trial showed that taking these three supplements resulted in a reduction of homocysteine levels and improvement of migraines. Summary: Therapies proven (to various degrees) to be effective for migraine include aerobic exercise; biofeedback; other forms of relaxation training; cognitive therapies; acupuncture; and supplementationwithmagnesium, CoQ10, riboflavin, butterbur, feverfew, and cyanocobalamin with folate and pyridoxine. Continuum Lifelong Learning Neurol 2012;18(4):796–806. PSYCHOLOGICAL APPROACHES Extensive literature indicates that pain patients with an internal locus of control have lower levels of anxiety, depression, and disability than those who believe that they have no control over their condition because external factors are dominant. This locus of control is modifiable and can be shifted. Patients can learn that they are not entirely at the mercy of genetic factors, weather, or unpredictable behavior of people around them that causes their headaches. They can use self-management techniques including biofeedback, avoid triggers when possible, try alternative and pharmacologic therapies, and become aware of other options such as acupuncture. The knowledge that they have these options, even without trying Address correspondence to Dr Alexander Mauskop, New York Headache Center, 30 East 76th Street, New York, NY 10021, drmauskop@ nyheadache.com. Relationship Disclosure: Dr Mauskop has served as a speaker for Allergan, Inc.; GlaxoSmithKline; and Zogenix, Inc. Unlabeled Use of Products/Investigational Use Disclosure: Dr Mauskop reports no disclosure. * 2012, American Academy of Neurology. 796 www.aan. com/continuum August 2012 Review Article Copyright @ American Academy of Neurology. Unauthorized reproduction of this article is prohibited. all of them, can give them a sense of control over their headaches. Changing the outlook from powerless to empowered will often result in a reduction of headaches. Another psychological factor is known as catastrophizing. Examples of catastrophizing are ‘‘I will never get better,’’ ‘‘My husband will leaveme,’’ and ‘‘I am a total failure. ’’ Independent of anxiety, depression, and physical symptoms, this negative view of life circumstances can lead to impaired functioning and lower quality of life in patients with migraine. Psychological approaches found to be effective in patients with pain are cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT). Table 4-1 and Table 4-2 explain the steps used in CBT and ACT sessions. Biofeedback has been proven to provide long-term benefits in the treatment of bothmigraine and tension-type headaches, although self-administered progressive relaxation training might also be effective. Biofeedback involves learning to control bodily functions that normally are not under our conscious TABLE 4-1 Acceptance Commitment Therapy a 1. The limits of control (shortand long-term costs and benefits), focus on experience (body scan) 2. Values (what you care about, how you want to live your life) 3. Cognitive defusion (observing thoughts without trying to evaluate or change them) 4. Mindfulness (being in the moment) 5. Committed action (road map connecting values, goals, actions, obstacles, and strategies) 6. Review and continued action in support of values 7. Moving forward a Modified from Wetherell JL, et al, Pain. Reproduced with permission of the International Association for the Study of Pain (IASP). www.sciencedirect. com/science/article/pii/ S0304395911003393. TABLE 4-2 Cognitive-Behavioral Therapy a 1. Three-component cognitive-behavioral therapy model (thoughts, feelings, behaviors), pain monitoring 2. Relaxation training (diaphragmatic breathing, progressive muscle relaxation, guided imagery) 3. Pain-fatigue cycle, activity pacing, and pleasant-event scheduling 4. Identifying and challenging negative thoughts (activity, belief, consequences, dispute model) 5. Problem-solving skills training and assertive communication 6. Review and practice 7. Relapse prevention a Modified from Wetherell JL, et al, Pain. Reproduced with permission of the International Association for the Study of Pain (IASP). www.sciencedirect. com/science/article/pii/ S0304395911003393. 797 Continuum Lifelong Learning Neurol 2012;18(4):796–806 www.aan. com/continuum Copyright @ American Academy of Neurology. Unauthorized reproduction of this article is prohibited. control, such as skin temperature and muscle tension. Neurofeedback is a variant of biofeedback and involves learning how to alter one’s own EEG patterns. This ability requires first learning to achieve a state of deep relaxation. The most important factor in achieving success with biofeedback is regular daily practice. The usual course of biofeedback consists of 10 weekly sessions, but some patients may require fewer sessions, particularly children and those who are diligent about their daily practice and are skilled at imagery. Any form of meditation done on a daily basis (I recommend starting with 20 minutes of daily practice) is also likely to provide significant benefits. Patients with disabling headaches should be referred to a psychologist for CBT or ACT. Among other benefits, CBT or ACT can help shift a patient from an external locus of control to an internal locus of control, which improves outcomes. Biofeedback is a simple technique that has been proven to relieve migraine and tension-type headaches, and the benefits have been shown to persist for up to 5 years. Self-taught progressive relaxation is equally effective if the patient is motivated and practices daily.