What non‑pharmacologic strategies can I use to prevent and manage my migraines?

Non-Pharmacologic Management of Migraines

Aerobic exercise (40 minutes, 3 times weekly) and cognitive-behavioral therapy combined with biofeedback should be your primary non-pharmacologic interventions, as they have efficacy equivalent to topiramate for migraine prevention and provide additive benefit when combined with medications. 1, 2

First-Line Non-Pharmacologic Interventions

Aerobic Exercise

• Prescribe supervised moderate-intensity aerobic exercise (walking, cycling, or swimming) at 60-70% maximum heart rate for 40 minutes, 3 times weekly 1, 2
• This regimen has demonstrated efficacy equivalent to topiramate or relaxation therapy for migraine prevention 1, 2
• Implement a mandatory 10-15 minute warm-up period to prevent exercise-induced headaches 2
• Start at low intensity with gradual progression if patients experience exercise-triggered headaches 2

Behavioral Therapies

• Offer cognitive-behavioral therapy (CBT) and biofeedback to all patients, as these provide additive benefit to pharmacotherapy 1
• These interventions are particularly effective in patients with psychiatric comorbidities (depression, anxiety) 1, 3
• Relaxation training (progressive muscle relaxation, guided visualization) combined with thermal biofeedback has strong evidence for migraine prevention 4, 5, 6
• Electromyographic biofeedback is also effective as a standalone or combined intervention 5, 6

Neuromodulatory Devices

• Consider non-invasive neuromodulatory devices as adjuncts to other treatments or as stand-alone therapy when medications are contraindicated 4
• These devices have supporting evidence but should be considered after behavioral therapies 4

Acupuncture

• Acupuncture can be offered as a first-line preventive intervention based on positive randomized trial findings 6
• However, one study showed it is not superior to sham acupuncture, so set realistic expectations 4
• Use as an adjunct to acute and preventive medications or when medication is contraindicated 4

Lifestyle Modifications and Trigger Management

Essential Patient Education

• Advise patients and families on lifestyle factors, migraine triggers, and avoidance of acute medication overuse 4
• Implement mandatory headache diary tracking to record frequency, severity, duration, triggers, and all medication use 1, 7
• Patients often underestimate milder headaches, so specifically ask about frequency 7

Modifiable Risk Factors to Address

• Systematically identify and manage obesity, sleep apnea, psychiatric comorbidities, stress, and excessive caffeine use 7
• Treat depression and anxiety aggressively, as their management directly improves migraine outcomes 1
• Evaluate and treat sleep apnea if present 7

Interventions with Limited or No Evidence

Not Recommended

• Physical therapy, spinal manipulation, and dietary approaches have little to no supporting evidence 4
• Cervical manipulation, occlusal adjustment, and hyperbaric oxygen have shown mixed results 4
• Transcutaneous electrical nerve stimulation (TENS) has inconsistent evidence 4

Insufficient Evidence

• Melatonin, magnesium, and riboflavin have limited evidence and restricted clinical use 4
• Hypnosis has shown mixed results in reported studies 4

Integration with Pharmacologic Care

When to Combine Approaches

• Behavioral therapy should be combined with preventive drug therapy to achieve additional clinical improvement 4, 3
• The highest level of care is achieved when behavioral therapies are integrated with physical and pharmacological interventions 3
• Non-pharmacologic therapies can be used as stand-alone treatment when medication is contraindicated 4

Monitoring Response

• Reassess at 3-month intervals using Headache Impact Test-6 (HIT-6) and Migraine-Specific Quality-of-Life Questionnaire (MSQ) to objectively measure response 1, 2, 7
• Continue headache diary review at every follow-up visit 1, 7

Common Pitfalls to Avoid

• Do not abandon behavioral treatments prematurely—efficacy requires several weeks to months of consistent practice 3, 8
• Avoid recommending unproven dietary approaches or physical therapy as first-line interventions, as evidence does not support their use 4
• Do not overlook psychiatric comorbidities, as addressing them directly improves migraine outcomes 1
• Ensure patients understand that behavioral interventions require active participation and practice to be effective 3, 8