How effective are educational, behavioural, and cognitive interventions for adults with chronic migraine?

Problem

Around 3% of general practitioner consultations are for headaches. In epidemiological studies, 2-4% of adults have chronic headaches, primarily chronic migraine - a severely disabling condition, affecting people’s careers, psychological wellbeing, and general health. The vast majority of those affected are managed exclusively in primary care. The annual medical cost for chronic migraine is 4.8 times higher than for episodic migraine. Medications are used prophylactically and to relieve symptoms, however, they are not always effective. Non-pharmacological interventions may complement existing therapies, enabling individuals to recognise and manage triggers, and use medication safely. We evaluated the effects of educational, behavioural, and cognitive interventions, on headache frequency, disability, pain intensity, quality of life, psychological wellbeing, and medication consumption.

Approach

We did a systematic review, searching Cochrane, Embase, Medline, PsychINFO, Scopus, and Web of Science for randomised controlled trials assessing the effectiveness of educational, behavioural, and cognitive interventions for chronic migraine in adult populations when compared against usual care. We assessed trials using the Cochrane Handbook for Systematic Reviews and extracted data on relevant outcomes at baseline and follow-up.

Findings

Five trials (N=240) met our inclusion criteria; one educational, two psycho-educational and two behavioural interventions, none were done in primary care. Participants were predominantly female (83.3-100%), aged 30-43 years. For headache frequency reduction, evidence was found in one behavioural intervention trial at six weeks (p=.01); headache-related disability was significantly lower after an educational intervention at six months (p<.05), and a psycho-educational intervention at four months (95% CI: -1.27, -0.08); severity of symptoms was reduced following one behavioural intervention at six weeks (p=.001); one psycho-educational intervention reported borderline significance for improving the quality of life at seven weeks (p=.049); for medication consumption, one educational and one behavioural intervention showed reductions at follow-up.

Consequences

We found some weak evidence for the effectiveness of educational, behavioural, and psycho-educational interventions in reducing headache frequency, headache-related disability, and pain intensity. Additionally, headache-related disability could be reduced even when headache frequency remained the same when using a psycho-educational intervention, highlighting that the two variables are not co-dependent. Self-help interventions could be valuable tools aimed at targeting the ability to function with pain, but more robust primary-care based studies are needed. The International Classification of Headache Disorders criteria for chronic migraines is strict, requiring individuals to have 15 headaches a month, with eight migraines for longer than three months. Therefore, very few studies could be included in our analysis. For many people, headache frequency can fluctuate below 15 a month, so we suggest that a broader definition may be more practical for treating patients and recruiting them for research. Chronic migraine is a disabling condition, and more high quality, primary care research is needed to improve headache-related outcomes for individuals with chronic migraine.