The approaches with the most evidence are biofeedback and progressive muscle relaxation therapy — these are level A evidence-based migraine preventive treatments. Cognitive behavioral therapy is also level A evidence-based behavioral therapy. There is evidence for acupuncture, although it is not level A evidence. Mindfulness modalities include MBSR and mindfulness-based cognitive therapy. Research is conducted to explore how these treatments might be helpful in migraine.

Daily intake of vitamin B2 400 mg, magnesium 400 mg, and coenzyme Q10 is supported by the oldest and best evidence for its efficacy in migraine. I use the two former ones. Melatonin 3 mg has been shown to have a side effect profile similar to that of placebo and had efficacy rates similar to placebo in one study.

Clinical Pain Advisor: What are the overall treatment implications of these findings for clinicians, and how would you advise those who want to learn more about these strategies to incorporate them into their practice?

Dr Minen: Learn ways in which patients can integrate and access the evidence-based treatments. Find providers who are knowledgeable with these modalities. There are audio files with progressive muscle relaxation, for example. We recently developed a research app based on progressive muscle relaxation.10

Dr Wells: Although integrative treatment options are often considered safe and “all-natural,” it is important for patients and providers to recognize that risks do exist with these treatments. For example, butterbur preparations need to be free of pyrrolizidine alkaloids to ensure safety, given the associated risk for liver toxicity, and high-velocity cervical maneuvers in chiropractic manipulation have a risk for vertebral or carotid artery dissection.  

It is also important for providers to ask their patients about use of integrative treatment options, and for patients to discuss their use with their providers. Many of these treatments may be integrated into conventional treatment approaches as complementary vs alternative to traditional pharmacologic approaches.   

Clinical Pain Advisor: What are remaining needs in this area in terms of research?

Dr Minen: We are still trying to learn more about these modalities, about the optimal duration and frequency of these behavioral techniques. We need to find ways to make the evidence-based treatments accessible to patients because we know that they are safe and effective with long-term enduring benefits.

Dr Wells: Much of the research in this area has methodologic challenges that limit interpretation, so more studies and funding for integrative treatment options for migraine are critical to better understand the benefits, mechanisms of actions, risks, and which patients are most likely to respond to which modalities.

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10. Minen MT, Jalloh A, Ortega E, Powers SW, Sevick MA, Lipton RB. User design and experience preferences in a novel smartphone application for migraine management: a think aloud study of the RELAXaHEAD application. Pain Med. 2019;20(2):369-377.