Cognitive Behavioral Therapy for Migraine: Q&A

Elizabeth Seng, PhD, FAHS, discusses the significance of CBT and how it can be included as part of a patient’s migraine treatment  

Change can be hard. It can be even harder for patients who are also managing migraine. So when doctors add cognitive behavioral therapy (CBT) to a patient’s migraine treatment plan, they need to have a firm understanding of CBT and how it can be used within this context.

Elizabeth Seng, PhD, FAHS, is an associate professor currently focused on developing and evaluating various behavioral strategies to improve migraine and pain management. Her work also revolves around describing and evaluating methods to improve in-the-moment decision-making regarding adherence to medication and lifestyle recommendations. She also works on identifying modifiable factors associated with higher disease-related disability in these clinical populations. 

Dr. Seng is also the lead investigator and author of the manuscript, “Does Mindfulness-Based Cognitive Therapy for Migraine Reduce Migraine-Related Disability? Results from a Phase 2b Pilot Randomized Clinical Trial,” which was published in Headache®. The study was recognized as the recipient of the Early Career Lecture Award at the American Headache Society’s 61st Annual Scientific Meeting. She recently spoke with the American Headache Society about CBT and its place in migraine treatment.

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Tell us about the significance of your research as it relates to CBT, disability and headache frequency.
Other psychologists and I have produced plenty of evidence showing that relaxation, biofeedback and certain CBT strategies seem to be effective at reducing headache-related disability and headache days in people with migraine and tension-type headaches. CBT for migraine is a little bit different than other forms of CBT. It rests, however, on the foundation of the same therapist skills: helping people change thought patterns that are maladaptive, and changing behaviors that may actually be increasing the likelihood that migraine will happen.

What have you learned about how mindfulness-based CBT interventions help migraine?
We saw large changes in headache-related disability over the course of eight weeks of mindfulness-based cognitive therapy for migraine. This is interesting because we normally thought about headache-related disability as something that happens because people have attacks. If you reduce the attacks, you’ll reduce the disability. But what we’re finding with mindfulness-based interventions is that they can reduce the impact of headache on people’s lives. This is tue even while those people still experience headache days. The impact of headache on their life, however, can be reduced with certain treatments.

What are the possible implications for providers?
The first-line treatment for every person who walks through your door should include broad behavior change techniques. That can include CBT for migraine or various stress reduction techniques. But if patients have experienced some kind of frequency reduction and their migraine is still impacting their daily lives, that might be a good time to pivot to a mindfulness-based intervention. These treatments really do seem to help people improve their quality of life while they’re managing chronic illness like migraine.

Is CBT sufficient to treat migraine on its own without medication?
A trial by Ken Holroyd, PhD, which was published in BMJ in 2010, showed that a preventive medication had a similar effect on headache days for people with severe migraine, compared with a minimal-contact behavioral migraine management protocol alone. However, we saw the biggest reductions in headache days and disability when we combined preventive medication and behavioral migraine management. But it depends on patient preference. The patient may prefer not to go on medication. They may be pregnant or have issues with side effects. But for patients who are willing, if you’re thinking about prevention, I would recommend the two-pronged approach

How can providers make it simpler for patients to access CBT for migraine?
It’s sometimes difficult to make a referral to a mental health care provider for a medical condition. If you would like to incorporate behavioral treatment referrals into your practice more, I would recommend trying to bring a behavioral treatment provider into your practice. It’s always going to be easier to refer to somebody sitting down the hall who you know specializes in migraine; who your patient thinks of as part of the headache practice, not part of the mental health practice. That’s always going to reduce the stigma of the referral. 

I would also recommend thinking about how you can make sure that your referral is as destigmatizing as possible. You want to make sure that it’s clear to both the patient and to the referring provider that what you’re referring someone for is headache—not depression or anxiety. This will help make the patient better understand the reason for the referral and, hopefully, they will have better adherence to the treatment.

Elizabeth Seng, PhD, FAHS, is a member of the American Headache Society. AHS is a professional society for doctors and other health care workers specializing in studying and treating headache and migraine. The Society’s objectives are to promote the exchange of information and ideas concerning the causes and treatments of headache and related painful disorders, and to share and advance the work of its members. Learn more about the American Headache Society’s work and find out how you can become a member today.

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