Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Psychological Interventions to Manage Migraines

Psychological interventions do not affect migraine frequency in adults, according to a recent Cochrane Database review. The objective of the review was to evaluate the efficacy and adverse events of psychological therapies for the prevention of migraine in adults. Researchers included randomized controlled trials (RCTs) of a psychological therapy for people with chronic to episodic migraine, with or without aura. They found:

  • From 21 RCTs, including 2,482 participants with migraine, meta-analytic data was extracted from 14 of these studies.
  • Those who received psychological interventions were twice as likely to be classified as responders in the short term, but this was based on very low quality evidence.
  • There was no evidence to an effect of psychological interventions on migraine frequency in the short-term or long-term.
  • There was insufficient evidence to draw conclusions regarding adverse events.


Sharpe L, et al. Psychological therapies for the prevention of migraine in adults. [Published online ahead of print July 2, 2019]. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD012295.pub2.


This 2019 Cochrane meta-analysis makes discouraging reading on evidence for psychological interventions in migraine management. Every evaluable RCT of psychological therapies, mostly behavioral or cognitive-behavioral treatments (CBT), had very poor quality. All “had at least one domain at high risk of bias, and 20 had 2-5 domains at high risk. Randomization procedures and allocation concealment were at high or unclear risk of bias… Few studies reported …outcomes of interest; most only reported outcomes post-treatment.” Reviewed trials were of brief duration; only 4 reported any follow-up data at all, from 4-11 months. The group reported no reasonable evidence for or against these migraine treatments. The last evaluation of cognitive/behavioral treatments by AHS/AAN was in 2000 (Silberstein et al. Neurology. 2000;55(6):754-62), and most were rated Grade A or B evidence, analysis which now seems woefully out-of-date. Rather than tossing out therapies widely felt to be beneficial, better prospective studies with adequate statistical analysis plans are indicated. —Stewart J. Tepper, MD, FAHS, Professor of Neurology, Geisel School of Medicine at Dartmouth, Director, Dartmouth Headache Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH