Biobehavioral treatments are a great addition to the toolkit that primary care providers already have. Not only can they help with managing the pain condition, they can help with all sorts of associated symptoms like depression and anxiety, frustration and lack of self-efficacy, as well as with adherence and motivation. The options for non-pharmacologic migraine management with the strongest evidence include cognitive behavioral therapy, which includes stress management training, biofeedback and relaxation training. All three of these can be taught to patients who live with migraine to help both prevent attacks and to reduce the duration, severity and intensity of attacks when they occur. They can be combined with medication or done independently, and are great treatment options especially for women who are considering pregnancy or who may be pregnant or lactating, since they do not carry side effects that some medications do. They’re also cost effective and they’re good for patients who may want to avoid medication. However, the research shows that their best efficacy is when they’re combined with the most appropriate optimized pharmacologic treatment. In three different meta-analyses comparing biofeedback, cognitive behavioral therapy and relaxation training with a preventive pharmacologic agent, the outcome of using just one or the other was somewhat similar. They’re on a similar efficacy range. However, in three different studies that combined the pharmacologic and the non-pharmacologic treatment, the outcomes were far superior with more than 70% of people showing good response to the combined pharmacologic and non-pharmacologic treatment.
Some of these treatments, particularly dealing with relaxation, can be taught and learned by the patient on their own. I have guided visual imagery, diaphragmatic breathing and progressive muscle relaxation exercise available free on my personal website, which is www.dawnbuse.com, and there are also free apps available through the iTune store and the Google playstore. Biofeedback is something that’s taught and engaged with a psychologist, possibly an occupational therapist or physical therapist, and to find a practitioner, there are links on the Association for the Advancement of Physiologic and Biofeedback Therapies (AAPB) website. For cognitive behavioral therapy, you’ll want to look for a psychologist with training in the technique and it’s good if they have a background in either chronic pain or migraine because there are some specific things we do when we’re working with CBT for chronic pain. To find a practitioner, you can look on the society for behavioral medicine website, the Association for the Advancement of Behavioral and Cognitive Therapies (AABCT) website or the American Psychological Association (APA) website.
It’s very important when making a referral that the primary clinician clarify they’re not abandoning the patient; that they believe the patient has a biologic/neurologic condition, which they are going to continue to treat, but they’re really just bringing on a team member into the care team. When a patient hears “psychology/psychologist”, it’s really easy to think “Oh no, my doctor thinks I’m crazy. My healthcare professional thinks this is all in my head and this isn’t real.” So start by saying, “I’m adding a member to our team. You have a real biologic/neurologic condition. We’re just going to add some more tools to our armamentarium to best treat you.”