Preventing Migraine – Behavioral Treatment and Medication: 1 + 1 > 2

  • Whether we're discussing migraine and other headache disorders or life in general, aren’t some things in life are better when paired together? Peanut butter and jelly; Lewis and Clark; “Brangelina”; R2D2 and C3PO; Thelma and Louise; Hall and Oates (okay, maybe not that one). Alone, each of these is good, but when combined, they become a memorable pair. It’s like the adage “the whole is greater than the sum of its parts.” Unfortunately, when it comes to medical care for all kinds of diseases, including migraine and other headache disorders, this principle is often forgotten. More often than not, treatments are segmented, especially when it comes to combining more than one treatment approach (“modality”). I find that the question I most often hear from other health care providers (and at times from patients) is, “who would benefit from behavioral treatment?” More often than not, behavioral treatment for migraine and other headache disorders has been an “In Case of Emergency, Break Glass” approach. It's saved for only when meds don’t work or the patient becomes “too much to handle” for the doctor.

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    There are two things that bother me most about this approach:

    1. The idea that behavioral treatments are only appropriate and/or useful for a certain kind of patient; and
    2. Not knowing the scientific literature from this century showing that combining behavioral treatment and medication for preventing migraine is more effective than either alone.

    In 2001, Dr. Ken Holroyd and colleagues published the seminal article1  on this topic in the Journal of the American Medical Association. In this study, the main outcome for “success” was whether patients had a 50% decrease in headache frequency following treatment. Dr. Holroyd and team reported success among 64% of patients who got both medication and behavioral treatment (“stress management training”) compared to 38% who got medication only, 35% who got behavioral only, and 29% who got placebo.


    In 2010, Holroyd and colleagues published a similar study2 showing success among 77% of patients who got both medication and behavioral treatment compared to 40% who got medication only, 36% who got behavioral only, and 34% who got placebo. More recently, Dr. Scott Powers and colleagues published an article3 in the Journal of the American Medical Association about the benefits of combining medication and behavioral treatment among young persons (ages 10-17) with chronic migraine. In this study, Dr. Powers and colleagues reported success among 66% of patients who got both medication and behavioral treatment compared to 36% who got medication only. See this figure I put together that summarizes these findings. Now, in another interesting finding emanating from this study, Dr. Powers and team reported at the American Headache Society meeting this year (2014) that 53% of patients who got both medication and behavioral treatment had no more than five days with headache a month compared to 23% of those who got only medication. This is interesting in that not only did these patients see benefit overall when combining medication and behavioral treatment but more than half of the patients who got the combination of behavioral and medication treatment were experiencing basically no more than one headache / migraine day on average per week. This brings us back to the question, "Who would benefit from behavioral treatment?" The studies show us that we should not be asking why would you ever include behavioral treatment with medication, but instead, why wouldn't you? Of course there are times and situations where it may not be feasible or practical to get behavioral treatment.


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    It can be hard to find someone who understands the nuances of providing behavioral treatment for migraine (but check out the Association for Behavioral and Cognitive Therapies' Find a CBT Therapist widget to see if someone is in your area), or medication may work on its own. However, these studies show us that behavioral treatment isn't something to consider only when nothing else has worked. Adding behavioral treatment to medication has benefits that far exceed either alone. Or, one might say behavioral treatment may be the jelly to medication's peanut butter.





    1 Holroyd, Kenneth A., PhD; O'Donnell, Francis J., DO; Stensland, Michael, MS; Lipchik, Gay I., PhD; Cordingley, Gary E., MD, PhD; Carlson, Bruce W., PhD. "Management of Chronic Tension-Type Headache With Tricyclic Antidepressant Medication, Stress Management Therapy, and Their Combination." JAMA, May 2, 2001—Vol 285, No. 17.


    2 Holroyd, Kenneth A.; Cottrell, Constance K.; O'Donnell, Francis J.; Cordingley, Gary E.; Drew, Jana B.; Carlson, Bruce W.; Himawan, Lina. "Effect of preventive (β blocker) treatment, behavioural migraine management, or their combination on outcomes of optimised acute treatment in frequent migraine: randomised controlled trial." BMJ 2010;341:c4871


    3 Powers, Scott W., PhD; Kashikar-Zuck, Susmita, PhD; Allen, Janelle R., MS; LeCates, Susan L., MSN; Slater, Shalonda K., PhD; Zafar, Marium, PsyD; Kabbouche, Marielle A., MD; O'Brien, Hope L., MD; Shenk, Chad E., PhD; Rausch, Joseph R., PhD; Hershey, Andrew D., MD, PhD. "Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents." JAMA. 2013;310(24):2622-2630


    My best to you,



    Dr. Nicholson


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    © Robert A. Nicholson, PhD, 2014, •  Last updated December 3, 2014.


Published On: December 02, 2014