Discussing Behavioral Treatment with Migraine Patients

How to frame and explain a behavioral treatment recommendation

A large body of literature supports the efficacy of behavioral intervention for migraine. Behavioral migraine treatment goals include reducing migraine frequency and severity, improving the patient’s functioning and engagement in life, and limiting reliance on medication.

It’s important for providers to frame a recommendation for behavioral treatments appropriately. This is so patients understand behavioral treatments as a tool for managing migraine, not a sign that their provider views migraine as a psychological problem.

Framing a behavioral treatment recommendation

Behavioral treatment typically involves a referral to a therapist or psychologist. So patients may interpret this recommended treatment as an indication their provider views the headache as “psychological” or “in their head.”

That’s why it’s crucial to first normalize behavioral strategies as an essential and evidence-based component of migraine treatment. The provider might consider framing the behavioral intervention as a prescription to emphasize its vital treatment role.

Behavioral treatment is one of many tools patients can use to treat migraine, and studies show behavioral treatment is most effective in conjunction with other treatments. “I often recommend a combination of using traditional medications from migraine and then adding things like biofeedback or cognitive behavioral therapy or relaxation or all three depending upon the patient,” says Dr. Anna Pace, assistant professor of neurology at Mount Sinai in New York City.

Download our guide to behavioral treatment for migraine here.

Explaining how behavioral treatment works

The experience of chronic pain secondary to migraine places the body in a state of stress. This contributes to an overactive sympathetic nervous system and can make an existing migraine problem worse. Behavioral migraine treatment disrupts this problematic pattern and enhances patient self-efficacy in migraine management.

Dr. Pace says patients she sees often have anxiety about impending migraine attacks, especially for patients who have less frequent attacks. “They really do benefit from cognitive behavioral therapy and biofeedback where they can actually modify their stress response to the attack and essentially try to mitigate any of the other associated symptoms that they’re feeling.”

While behavioral therapy can be especially beneficial for patients with depression and anxiety, it can work for all patients. “The great thing about these behavioral therapies is that the studies have shown that they do benefit patients with migraine, even if they don’t also suffer from anxiety or depression,” says Dr. Pace.

That’s because stress is a common trigger for migraine attacks. “These behavioral therapies can really help to work on that stress response, reduce cortisol levels, help reduce muscle tension, which can also help reduce migraine, even if they don’t have anxiety or depression that occur along with their migraines,” she says.

Helping patients who’ve had a negative experience with therapists

Not every therapist-patient relationship is a good fit. It is also possible that the therapist did not use a behavioral approach. You can recommend the patient try again with another therapist. You can also suggest the patient ask therapists some screening questions on the phone in advance of an appointment. Here are some example questions your patient can ask:

  1. Do you practice cognitive behavioral therapy?
  2. Are you comfortable helping me work on lifestyle management of migraine symptoms?
  3. Are you comfortable teaching relaxation techniques?

Primary care practitioners are essential to identifying and treating headache disorders. The American Headache Society’s First Contact – Headache in Primary Care program provides educational resources to empower healthcare professionals and improve headache and migraine care. Learn more about the program here.

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