Mindfulness Training for Migraine Gathers Steam

SAN FRANCISCO—A brief course of mindfulness training for patients with chronic migraine after their withdrawal from overuse of acute migraine medications proved as effective as prophylactic medication over the course of 12 months of follow-up, said Frank Andrasik, PhD, and colleagues at the 60th Annual Scientific Meeting of the American Headache Society.

Frank Andrasik, PhD

“The effects of mindfulness by and large rivaled those of medication alone. Although [it was]not specifically assessed, patients commented that mindfulness did not have side effects and promoted greater involvement and adherence,” said Dr. Andrasik, Professor and Chair of the Department of Psychology and Director of the Center for Behavioral Medicine at the University of Memphis.

He noted that his study, which was published in the Journal of Headache Pain, is best considered exploratory because of its small size and nonrandomized design.

After five days of structured acute medication withdrawal in an outpatient day hospital setting, study participants were treated with either pharmacologic prophylaxis for migraine—most often using botulinum toxin—or a brief course in mindfulness training entailing six once-weekly 45-minute sessions plus home practice for seven to 10 minutes per day. “While this study design does not rise to level one randomized trial evidence, it does reflect real-world clinical practice, where patients often have a big say in choosing their treatment plan,” Dr. Andrasik observed.

At baseline, all 44 patients met diagnostic criteria for chronic migraine with associated acute medication overuse. They averaged 20.5 headache days per month, with 18.4 days of acute migraine medication use. At three, six, and 12 months of follow-up, the 22 patients in the mindfulness group averaged 8.3, 10.4, and 12.4 headache days per month, while the 22 on pharmacologic prophylaxis averaged 8.8, 11, and 8.6 headache days per month. Both groups averaged similar seven- to 10-day reductions in days of acute migraine medication use per month.

Using the widely accepted end point of at least a 50% reduction in headache days per month, 50% of the mindfulness-only group and 52.6% of the prophylactic medication-only group met that standard at 12 months of follow-up. Moreover, at 12 months, 65% of the mindfulness therapy group and 73.7% of the preventive medication group no longer met diagnostic criteria for chronic migraine.

The mindfulness protocol used in the study was based upon the popular mindfulness-based stress reduction program developed by Jon Kabat-Zinn, PhD, and colleagues in the mid 1980s.

Scores on the Migraine Disability Assessment (MIDAS) measure and the Beck Depression Inventory improved significantly and to a similar extent from baseline in both groups. In contrast, scores on the State-Trait Anxiety Inventory did not change significantly in either study arm.

Mindfulness for Migraine Is Still Emerging

Dr. Andrasik and session chair Elizabeth K. Seng, PhD, cautioned that despite solid evidence of efficacy for mindfulness training in the treatment of depression and several chronic pain disorders, mindfulness for treatment of migraine is still in its infancy. Large randomized, controlled clinical trials are ongoing or in the planning stages, and no results are available.

Elizabeth K. Seng, PhD

Dr. Seng, a Research Assistant Professor at Albert Einstein College of Medicine in New York, described mindfulness and acceptance as “third-wave” behavioral treatments for migraine. The first-wave therapies focused on fostering behavioral changes to reduce perceived stress to avoid triggering migraine attacks. Second-wave therapies involved interactions aimed at helping patients reframe maladaptive automatic thoughts to reduce stress stemming from the daily hassles of life.

“The focus in the first- and second-wave therapies is, ‘Change something and your life will be better. Change your behaviors, clean up your act, change your thoughts because your thoughts are not helping you, and thereby reduce stress and reduce migraine.’ These mindfulness therapies are incredibly different from that,” she explained.

Third-wave therapies are not directed toward changing daily stress or automatic thoughts; instead, they seek to change the patient’s relationship to them such that they no longer create barriers to engaging in life activities that the patient finds nourishing and meaningful. It is a matter of creating a willingness to experience pain to achieve worthwhile objectives, Dr. Seng explained.

Measuring Success

It is unclear that a reduction in migraine days—the traditional yardstick for therapeutic efficacy in migraine research—is the right primary outcome measure for third-wave therapies, according to the psychologist. “So far, our evidence would suggest that mindfulness-based therapies do not reduce migraine days as much as other behavioral treatments, but what they are doing is increasing migraine-related quality of life and reducing migraine-related disability to the same or possibly larger extent than our other behavioral treatments,” Dr. Seng said. “Maybe what these third-wave therapies are actually doing is impacting our cognitive and emotional functioning, and even if patients still experience similar levels of headache frequency, their reaction to those headache days no longer leads to suffering. That could be a clinically relevant outcome.”

Dr. Seng plans to formally study mindfulness therapies in a subgroup of migraine patients with high levels of depression. They might respond especially well, she hypothesized, since mindfulness was originally developed as a treatment for severe depression. “Patients who are depressed have a hard time overcoming barriers to engaging in nourishing life activities, and when they have a headache day, it is even worse. That is one of the things that is leading them to have migraine-related disability,” she said.

Dr. Andrasik, whose study was supported by the European Commission and an Italian research foundation, reported having no financial conflicts of interest regarding his presentation. Dr. Seng reported serving as a consultant to GlaxoSmithKline.

—Bruce Jancin

Suggested Reading

Grazzi L, Sansone E, Raggi A, et al. Mindfulness and pharmacological prophylaxis after withdrawal from medication overuse in patients with chronic migraine: an effectiveness trial with a one-year follow-up. J Headache Pain. 2017;18(1):15.

Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8(2):163-190.