Although both mindfulness and headache education reduce migraine frequency, only mindfulness significantly improves disability, depression, quality of life, and pain catastrophizing/magnifying pain-related thoughts, new research shows.
Results of a randomized study also suggest mindfulness may result in a shift in pain perception.
Migraine is severely debilitating and is “not all in your head,” said study investigator Rebecca Erwin Wells, MD, MPH, associate professor of neurology at Wake Forest School of Medicine, Winston-Salem, North Carolina.
“Recognizing and treating the full impact that migraine has on a person’s life is critical, and mindfulness may be an additional tool that may help treat the total burden of migraine,” Wells told Medscape Medical News.
The findings, which expanded on those published last year in JAMA Internal Medicine, were presented here at the virtual annual meeting of the American Neurological Association.
“Dramatic” Need for Non-Opioid Solutions
Dr Rebecca Erwin Wells
Previous studies show migraine is the second leading cause of disability worldwide. About one third of patients with migraine use opioids and many experience drug side effects or inefficacy. “There is a dramatic need for non-opioid treatment options for migraine, especially those that target factors such as stress, since stress is the number one reported trigger for migraine,” said Wells.
The current study included 89 mostly female adult patients (mean age, 44 years) who had four to 20 migraine days per month. Participants were randomly assigned to receive Mindfulness Based Stress Reduction (MBSR) or headache education.
MBSR is a standardized protocol of eight weekly 2-hour in-person classes. Sessions involve different forms of mindfulness meditation including “body scans” that focus on different body parts, meditation, and mindful movements akin to Hatha yoga, said Wells.
Participants receiving this intervention were encouraged to practice at home using taped sessions. In this study, they practiced at home an average of 33 minutes per day 4 days per week.
The headache education intervention, which involved instruction on pathophysiology, headache triggers, and treatment approaches, was developed to “match the time and attention” of the mindfulness intervention. However, there was no homework, Wells said.
The study was blinded in that participants were told they would learn about managing their headaches without medication, but did not know which was the intervention and which was the comparator intervention.
After baseline screening, follow-up occurred at 12, 24, and 36 weeks. Each study visit included questionnaires, and patients could continue all medication during the study.
At 12 weeks, both groups had a reduction in migraine days per month that was not significantly different from each other.
In the MBSR group, the reduction in days was -1.6 (95% CI, -0.7 to -2.5) and in the headache education group it was -2.0 (95% CI, -1.1 to -2.9). The group difference was -0.5 (P = .5).
However, compared to headache education, mindfulness had significantly greater improvements in a “multitude” of secondary outcomes important to patients, said Wells.
“Moderate to large clinically meaningful effect sizes were seen in pain catastrophizing, disability, self-efficacy, depression, and quality of life,” she said. Self-efficacy is the feeling of having control over experiences, which in this case was migraine.
Mindfulness also had an effect on anxiety, but it didn’t quite reach statistically significance.
“I typically think of mindfulness as helping people who have anxiety, so I was surprised by that finding,” said Wells, However, a larger sample size might have made a difference, she added.
The treatment effects continued to 36 weeks.
Pain–Response Test
Researchers also carried out an experimental pain–response test. They applied probes with different temperatures to an arm or leg and asked participants to rate pain on a visual analog scale.
The findings here were “pretty dramatic,” said Wells. The MBSR group had a 30% reduction in pain unpleasantness and a 36% reduction in pain intensity, while in the headache education group pain unpleasantness rose by 11% and intensity rose by 13% (P = .004 for intensity and .005 for unpleasantness) at 36 weeks.
“This suggests that mindfulness really shifted the way participants perceived pain,” Wells noted.
Another analysis by the researchers showed that depression as well as pain catastrophizing are key factors explaining the effect of mindfulness.
“The mindfulness seems to be at least partially mediated by improvements seen in depression and pain catastrophizing,” said Wells.
Their research has also delved into the extent to which migraine affects day-to-day life. To do this, the investigators interviewed 81 trial participants after their intervention.
Although most participants were being treated with acute and/or prophylactic medications, 90% still reported migraine had a negative impact on their overall life. Cognition, emotional health, work, family life, and social life were all affected.
Most Likely to Benefit?
During the ANA virtual headache poster session, co-moderator Steven Galetta, MD, a neurologist at NYU Langone in New York City, asked about patient access to such “very helpful” nonpharmacologic therapies.
Having online mindfulness interventions available “would level the playing field” for patients who find it difficult to access in-office headache care, Galetta noted.
“The number of online mindfulness offerings tripled during the pandemic,” as all instructors converted to virtual classes, Wells answered. “So now there are a lot of online options available.”
Asked by another session attendee if certain patients do better with mindfulness, Wells said her research group is currently assessing predictors of response.
“We would like to know who are the patients most likely to benefit from this intervention,” she said.
Study funding sources included the NIH National Center for Complementary & Integrative Health and the American Pain Society. Wells has disclosed no relevant financial relationships.
ANA 2021: 146th Annual Meeting of the American Neurological Association: Abstract 387. Presented October 17, 2021.
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