The reality of living with migraine can be hard to accept, especially for people who have frequent episodic or chronic migraine. One thing that may help when drugs and other treatments don’t help enough is psychotherapy or behavioral health approaches. Behavioral therapies can help many people manage migraine pain, in part by managing the ways they respond to pain. Mindfulness-based stress reduction for migraine (MBSR-M), cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), biofeedback, and relaxation training are all methods used to “retrain” the brain to manage stress differently. Evidence suggests that for some people, these treatment modalities reduce the number of migraine attacks, reduce pain severity, shorten the length of migraine attacks, and lower overall migraine burden. People can use these methods as their sole form of treatment, but mental health modalities for migraine are usually used as part of a comprehensive treatment plan that includes preventive and acute medications and lifestyle modifications as needed.
Neuroplasticity Allows Your Brain to Change
Some experts believe that some of the benefits of behavioral therapies for chronic diseases such as migraine are possible because of neuroplasticity. “Neuroplasticity is the idea that the brain can change in response to what is practiced and what is experienced,” says Rebecca Wells, MD, MPH, an associate professor of neurology at Wake Forest Baptist School of Medicine in Winston-Salem, North Carolina, the director of the comprehensive headache program and an associate director of clinical research at the university’s center for integrative medicine. “The brain can form and reorganize its pathways in response to the things that we do every day that help us grow and learn,” says Dr. Wells. Just as a muscle grows stronger from use, a person can use modalities such as mindfulness to change the function and structure of his or her brain, says Wells.
Mindfulness Enables Greater Self-Knowledge
We all have the capacity to be mindful, says Wells. “We are born with the innate ability to be mindful in our daily lives. As we grow and develop and have the capacity to think about the future and the past, it can become more challenging to be in the present moment. Mindfulness is the practice of paying attention in the present moment in a nonjudgmental way,” she says. According to Wells, mindfulness meditation is one of many ways we can learn to become more mindful. “One example that is available to everyone is focusing on a sensation such as the breath,” she says. “When practicing mindfulness meditation, thoughts or feelings will come into your mind. Notice them, give them compassion, and then return your attention to the sensory experience of the breath,” says Wells. By bringing our attention to the breath over and over again while still noticing the thoughts and feelings that arise and treating them with compassion, we’re teaching ourselves to differentiate our experience from our thoughts and our feelings, she explains. “When we have things happen in our lives, we have a tendency to react. Mindfulness gives us the opportunity to take an event that happens and be mindful in how we recognize and respond to that event,” says Wells. Many health systems offer in-person or online courses for meditation or relaxation training, both of which can enhance mindfulness. RELATED: How Meditation Can Improve Your Mental Health
Mindfulness-Based Stress Reduction Shows Promise for Migraine Relief
Up to 80 percent of patients say stress is a trigger for their headaches, making it the number one reported trigger, says Wells. “Our hypothesis is that mindfulness may change an individual’s ability to respond to stress. We’re trying to understand if practicing mindfulness can decrease the likelihood that you’re going to experience an event as stressful, or when a stressful event does happen, you’re able to better respond to it,” she says. A small pilot study, conducted by Wells and some colleagues and published in Headache, used an eight-week mindfulness-based intervention in which participants with episodic migraine were taught how to practice mindful meditation in a group setting. The researchers found that compared with individuals who had not learned the practice, people who completed the intervention had shorter headaches and reported that their headaches had less of an impact on their lives. Mindfulness may help people with chronic migraine, too. A small study that included people with chronic migraine and medication-overuse headache gave participants a choice — upon completion of a structured withdrawal program — between mindfulness training and preventive medication. The research, published in 2019 in Cephalalgia, found that both groups had dramatic decreases in headache frequency and use of medications, as well as levels of stress hormones. A limitation of the study was that it wasn’t randomized, meaning that participants were allowed to choose which intervention they wanted to try, and this may have affected the results.
Acceptance and Commitment Therapy Can Change Your Pain Response
Acceptance and commitment therapy (ACT) is a mindfulness-based therapy that emphasizes cognitive diffusion, which is defined as the creation of space between ourselves and our thoughts and feelings, according to Carolyn A. Bernstein, MD, an assistant professor of neurology at Harvard University and a neurologist at Brigham and Women’s Hospital in Boston. The therapy focuses on helping people accept the fact that they have an ongoing chronic condition and is most often used on individuals with pain conditions, including people with migraine, says Dr. Bernstein. “In acceptance and commitment therapy you learn to control your responses to pain,” she says. ACT is done in a group setting, and there are homework assignments, says Bernstein. “Mindfulness is part of the process, and people learn to pay attention to their own responses to different triggers around their migraine attacks. Acceptance and commitment therapy is about figuring out what you can accept, what you can let go of, and what you can manage,” she says. Bernstein is involved in research that is focused on exploring whether this therapy can actually change the way the brain functions in response to pain. In a study that was postponed because of the pandemic, Bernstein and colleagues planned to use functional MRI imaging, which measures dynamic brain activity, to find out if there were changes in the brain in pain-modulating areas. They were also going to measure the presence of cortisol levels before and after people learned ACT to look for changes in some of the markers that modulate stress. These types of behavioral therapies aren’t necessarily used in place of medications, but they can be part of a migraine treatment plan, says Bernstein. “The idea of ACT is not that you can make your migraines go away, but that by accepting them and reframing the experience, you’ll feel better and be able to be more present in your life,” she says.
Cognitive Behavioral Therapy Identifies Unhelpful Thought Patterns
Cognitive behavioral therapy (CBT) works by identifying behaviors that a person is engaging in or avoiding, as well as thoughts they’re having that are unhelpful, inaccurate, or maladaptive, says Neda Gould, PhD, an associate professor of psychiatry and behavioral sciences at Johns Hopkins Medicine in Baltimore. “We examine the thoughts that could be maintaining or exacerbating the condition and then work to change both the thoughts and the behaviors in a systematic way to improve it,” says Dr. Gould. For example, if a person gets into a spiral of negative thoughts, it can produce anxiety and stress, which can in turn trigger a migraine, according to the American Migraine Foundation. In CBT, the goal would be to identify those thought patterns and focus on ways to shift them into something less destructive and more positive. A study published in 2019 in Headache looked at mindfulness-based cognitive therapy, which pulls in features of cognitive behavioral therapy and mindfulness. Migraine was evaluated by the MIDAS questionnaire (Migraine Disability Assessment) which measures the degree to which migraine impacts life, and includes questions about how much work or school a person misses and if and how migraine affects their productivity. Investigators found that eight weeks of a mindfulness-based CBT intervention decreased migraine disability compared with a “usual treatment” group, suggesting that the therapy may help by reducing the impact of headache on people’s lives.
Biofeedback Can Help You Change Your Reactions to Stress
Another way to manage the stress that can contribute to migraine is through biofeedback. Biofeedback tools measure things like brain waves, breathing, heart rate, muscle contraction, sweat gland activity, and body temperature, according to the Mayo Clinic. By recognizing how the body responds to stress and strain, a person can make adjustments in order to minimize some of the negative consequences, thereby helping prevent or reduce a headache, according to the American Migraine Foundation. There is a large body of research that suggests biofeedback can help stabilize the nervous system between attacks and lower the number of migraine attacks, according to the National Headache Foundation. If you’d like to try biofeedback to help with migraine, speak to your headache doctor about where to find biofeedback providers in your area.
Progressive Muscle Relaxation May Reduce Migraine Frequency
The idea of training yourself to relax may sound a little odd, but learning to achieve a calm mental state is another way to manage day-to-day stress. Relaxation can slow down the nervous system and regulate the heart rate, blood pressure, and blood vessel expansion and contraction. A small study published in the Journal of Headache Pain in April 2016 found that people with migraine who completed a six-week training in progressive muscle relaxation showed a significant reduction in migraine frequency. Progressive muscle relaxation involves tensing then relaxing each muscle group in the body sequentially. The practice enables a person to sense more clearly what a tensed muscle feels like versus a relaxed muscle, and it also tends to leave a person feeling more relaxed. You can practice progressive muscle relaxation on your own by following an audio recording such as the one offered by HelpGuide. Some hospitals and clinics also offer in-person training in progressive muscle relaxation.
Access to Psychotherapy Can Be Limited by Cost
While various forms of psychotherapy appear helpful in living with migraine, access to therapy is often limited by cost. If you have health insurance, your insurance provider can tell you which mental health practitioners and how many therapy sessions per year are covered by your plan. Many therapists don’t accept insurance because of low reimbursement rates, but some charge on a sliding scale, meaning the fee per session is based on your income. To find therapy you can afford, look for community service agencies or mental health clinics in your area that offer lost-cost visits or sliding-scale payments. You can also ask your headache doctor or primary care physician what mental health resources they’re aware of. Online psychotherapy, through a platform such as Teladoc, may be another lower-cost option, but be sure you understand the pricing at the outset so you’re not surprised when you see the bill. There are also apps that can help people with chronic pain, including migraine, according to Natalia Murinova, MD, a neurologist and headache specialist at UW Medicine in Seattle. Curable is an online pain psychology program that can be accessed through your phone or computer, says Dr. Murinova. “This program makes this type of therapy accessible for less than $5 a month,” she says.
