Pharmacological versus non-pharmacological prophylaxis of recurrent migraine headache: a meta-analytic review of clinical trials

Abstract

In order to generate information about the relative effectiveness of the most widely used pharmacological and non-pharmacological interventions for the prophylaxis of recurrent migraine (i.e., propranolol HCl and combined relaxation/thermal biofeedback training), meta-analysis was used to integrate results from 25 clinical trials evaluating the effectiveness of propranolol and 35 clinical trials evaluating the effectiveness of relaxation/biofeedback training (2445 patients, collectively). Meta-analysis revealed substantial, but very similar improvements have been obtained with propranolol and with relaxation/biofeedback training. When daily recordings have been used to assess treatment outcome, both propranolol and relaxation/biofeedback have yielded a 43% reduction in migraine headache activity in the average patient. When improvements have been assessed using other outcome measures (e.g., physician/therapist ratings), improvements observed with each treatment have been about 20% greater. In both cases, improvements observed with propranolol and relaxation/biofeedback have been significantly larger than improvement observed with placebo medication (14% reduction) or in untreated patients (no reduction). Meta-analysis thus revealed substantial empirical support for the effectiveness of both propranolol and relaxation/biofeedback training, but revealed no support for the contention that the two treatments differ in effectiveness. These results suggest that greater attention should be paid to determining the relative costs and benefits of widely used pharmacological and non-pharmacological treatments.

Mind-Body Medicine: State of the Science, Implications for Practice

“…49 Both approaches yielded similar results-43% reduction in headache activity in the average patient compared with 14% reduction with placebo medication and no reduction in unmedicated subjects. A more recent narrative review concluded that a combination of relaxation training and thermal biofeedback is the preferred behavioral treatment for recurrent migraine disorder.…”

“…In those reviews in which nonrandomized trials were included, in no instance were significant differences observed when the outcomes in randomized (ie, higher quality) trials were compared with those in nonrandomized trials. In six reviews, 38,48,49,55,58,61 it was not possible to determine whether trials referred to as controlled were randomized or not.…”

The Pharmacotherapy of Chronic Pain: A Review

“…None of these agents have been demonstrated to exhibit high efficacy and there is no evidence on which to base the choice of one over the other (11); however, prophylactic agents are useful and it is worth pursuing serial trials of the agents listed. In addition, the value of nonpharmacological approaches should be emphasized, because a meta-analytic review found substantial support for the effectiveness of both biofeedback approaches and pharmacological approaches, with no preference for one over the other (234). Thus, it appears that a combined approach is the way to go in migraine prophylaxis.…”

Melatonin therapy for headache disorders

“…Migraine prophylaxis is divided into a nonpharmacologic and a medication-based approach. Education, trigger avoidance, lifestyle reformulation, and getting adequate sleep are the main nonpharmacologic strategies [Holroyd and Penzien, 1990]. Several medications are used in migraine prevention, including antidepressants, badrenergic blockers, anticonvulsants/neuromodulators, and calcium channel antagonists [Bigal and Lipton, 2006].…”