Headache LogoAHS Logo

Evidence-based behavioral interventions for treatment of headache

Elizabeth K. Seng, Ph.D.

Dr. Seng is an Assistant Professor at the Ferkauf Graduate School of Psychology of Yeshiva University and a Research Assistant Professor in the Saul R. Korey Department of Neurology at Albert Einstein College of Medicine. Her research focuses on behavioral interventions for headache disorders.


Behavioral interventions attempt to modify patient behaviors to reduce headache symptoms and improve the patient’s quality of life. Behavioral interventions are ubiquitous in the treatment of primary headache disorders: patients are commonly asked to maintain a daily headache diary, make decisions about when to take acute medications, and manage lifestyle factors associated with headache. Therefore, understanding the current evidence in behavioral interventions for headache disorders is essential for every headache provider.


An evidence-based behavioral intervention is any intervention designed to modify patient behaviors that has demonstrated efficacy to reduce headache symptoms in well-designed randomized clinical trials. To date, the majority of behavioral interventions that have demonstrated this level of efficacy involve treatment components designed to change thought patterns and behaviors related to stress: relaxation training, biofeedback training, and cognitive behavioral therapy for stress management. Evidence-based behavioral interventions for headache demonstrate effect sizes comparable to preventive pharmacotherapy. Further, recent trials suggest that the combination of multi-faceted evidence-based behavioral interventions with preventive medication yields larger treatment effects than either behavioral intervention or preventive medication alone.

Headache toolbox. Behavioral and other nonpharmacologic treatments for headache.
Penzien DB, Taylor FR.
Headache. 2014 May;54(5):955-6.

Behavioral headache treatment: history, review of the empirical literature, and methodological critique.
Rains JC, Penzien DB, McCrory DC, Gray RN.
Headache. 2005 May;45 Suppl 2:S92-109.

Stress management for migraine: recent research and commentary.
Penzien DB.
Headache. 2009 Oct;49(9):1395-8

Recent studies on stress management-related treatments for migraine.
Becker WJ, Sauro KM.
Headache. 2009 Oct;49(9):1387-90.

Headache and behavioral medicine: a 50-year retrospective.
Lake AE 3rd.
Headache. 2008 May;48(5):714-8.


The promise of evidence-based intervention for headache disorders has not yet been translated into standard clinical care of people with headache disorders. Evidence-based behavioral interventions are cost effective treatment options for people with primary headache disorders. Evaluation of dissemination and implementation strategies for evidence-based behavioral headache interventions is essential to improve access to care. Alternative delivery mechanisms may also improve patient access to evidence-based behavioral interventions for headache. Limited contact interventions (which involve only a few sessions with a professional), internet-delivered interventions, and group interventions have all demonstrated promise.

Direct costs of preventive headache treatments: comparison of behavioral and pharmacologic approaches.
Schafer AM, Rains JC, Penzien DB, Groban L, Smitherman TA, Houle TT.
Headache. 2011 Jun;51(6):985-91

Behavioral headache treatment: modest costs, demonstrated long-term effectiveness.
Scopp A.
Headache. 2006 Oct;46(9):1463.

Efficacy and effectiveness approaches in behavioral treatment trials.
Nash JM, McCrory D, Nicholson RA, Andrasik F.
Headache. 2005 May;45(5):507-12

A self-administered behavioral intervention using tailored messages for migraine.
Nicholson R, Nash J, Andrasik F.
Headache. 2005 Oct;45(9):1124-39.

Outpatient Combined Group and Individual Cognitive-Behavioral Treatment for Patients With Migraine and Tension-Type Headache in a Routine Clinical Setting.
Christiansen S, Jürgens TP, Klinger R.
Headache. 2015 Sep;55(8):1072-91.

Pilot Randomized Controlled Trial of Internet-Delivered Cognitive-Behavioral Treatment for Pediatric Headache.
Law EF, Beals-Erickson SE, Noel M, Claar R, Palermo TM.
Headache. 2015 Aug 28

A randomized trial of a web-based intervention to improve migraine self-management and coping.
Bromberg J, Wood ME, Black RA, Surette DA, Zacharoff KL, Chiauzzi EJ.
Headache. 2012 Feb;52(2):244-61.

One-day behavioral intervention in depressed migraine patients: effects on headache.
Dindo L, Recober A, Marchman J, O'Hara MW, Turvey C.
Headache. 2014 Mar;54(3):528-38.


Trials of behavioral interventions contend with different methodological issues than drug trials. The choice of control group is critical, as “active” controls are rarely inert. Double-blinding present unique challenges and may not be feasible in most behavioral trials. Outcome measures may include both headache symptoms and more holistic patient-centered outcomes, such as headache-related quality of life or disability. Trials combining drug and behavior therapies must address potential bias in recruitment and outcome measurement. The American Headache Society Behavioral Clinical Trials Workgroup provided guidelines for trials of behavioral treatments for recurrent headaches, which can assist in evaluation of existing evidence, and provide a framework for future investigations.

Guidelines for trials of behavioral treatments for recurrent headache, first edition: American Headache Society Behavioral Clinical Trials Workgroup.
Penzien DB, Andrasik F, Freidenberg BM, Houle TT, Lake AE 3rd, Lipchik GL, Holroyd KA, Lipton RB, McCrory DC, Nash JM, Nicholson RA, Powers SW, Rains JC, Wittrock DA; American Headache Society Behavioral Clinical Trials Workgroup.
Headache. 2005 May;45 Suppl 2:S110-32.

Behavioral headache research: methodologic considerations and research design alternatives.
Hursey KG, Rains JC, Penzien DB, Nash JM, Nicholson RA.
Headache. 2005 May;45(5):466-78.

Behavioral research and the double-blind placebo-controlled methodology: challenges in applying the biomedical standard to behavioral headache research.
Rains JC, Penzien DB.
Headache. 2005 May;45(5):479-86. Review.

Outcome measurement in behavioral headache research: headache parameters and psychosocial outcomes.
Andrasik F, Lipchik GL, McCrory DC, Wittrock DA.
Headache. 2005 May;45(5):429-37.

Methodological issues in clinical trials of drug and behavior therapies.
Holroyd KA, Powers SW, Andrasik F.
Headache. 2005 May;45(5):487-92. Review.


Development of behavioral interventions for headache disorders is guided by validated psychological theories. However, evidence-based behavioral interventions may influence headache outcomes through a variety of mechanisms. Many of the most pressing clinical questions related to behavioral interventions for headache involve treatment mechanisms: In a multi-faceted treatment, which components are essential? How can I maximize the treatment effect? Which type of behavioral treatment should I use with this patient? Existing research suggests that changes in thought patterns related to headache are likely key mechanisms of both biofeedback and cognitive behavioral therapies. Trials specifically designed to answer questions regarding mechanisms of behavioral headache interventions are warranted.

Moderators and mediators of behavioral treatment for headache.
Nicholson RA, Hursey KG, Nash JM.
Headache. 2005 May;45(5):513-9.

Behavioral migraine management modifies behavioral and cognitive coping in people with migraine.
Seng EK, Holroyd KA.
Headache. 2014 Oct;54(9):1470-83.

Cognitive changes of migraineurs receiving biofeedback training.
Mizener D, Thomas M, Billings R.
Headache. 1988 Jun;28(5):339-43.

Biofeedback therapy for pediatric headache: factors associated with response.
Blume HK, Brockman LN, Breuner CC.
Headache. 2012 Oct;52(9):1377-86

Does relaxation treatment have differential effects on migraine and tension-type headache in adolescents?
Fichtel A, Larsson B.
Headache. 2001 Mar;41(3):290-6.


As our understanding of the interplay between behavioral risk factors and headache symptoms improves, behavioral interventions will increasingly target specific maladaptive behavior patterns. Select examples are described below.

Poor sleep is a risk factor for migraine onset. Behavioral interventions targeting insomnia have demonstrated efficacy for insomnia symptoms, and demonstrate promise for treating migraine.

Behavioral sleep modification may revert transformed migraine to episodic migraine.
Calhoun AH, Ford S.
Headache. 2007 Sep;47(8):1178-83.

Chronic headache and potentially modifiable risk factors: screening and behavioral management of sleep disorders.
Rains JC.
Headache. 2008 Jan;48(1):32-9.

Sleep and headache disorders: clinical recommendations for headache management.
Rains JC, Poceta JS.
Headache. 2006

Mediation Adherence
Medication overuse headache is the result of a maladaptive behavioral pattern of medication overuse. Behavioral interventions to improve medication adherence have been efficacious for other conditions; more research is needed to develop interventions to improve medication adherence in the context of primary headache disorders.

Treatment adherence in patients with headache: a systematic review.
Ramsey RR, Ryan JL, Hershey AD, Powers SW, Aylward BS, Hommel KA.
Headache. 2014 May;54(5):795-816

Adherence to acute migraine medication: what does it mean, why does it matter?
Katić BJ, Krause SJ, Tepper SJ, Hu HX, Bigal ME.
Headache. 2010 Jan;50(1):117-29.

The headache management trial: a randomized study of coordinated care.
Matchar DB, Harpole L, Samsa GP, Jurgelski A, Lipton RB, Silberstein SD, Young W, Kori S, Blumenfeld A.
Headache. 2008 Oct;48(9):1294-310.

Behavioral facilitation of medical treatment for headache--part II: Theoretical models and behavioral strategies for improving adherence.
Rains JC, Penzien DB, Lipchik GL.
Headache. 2006 Oct;46(9):1395-403

Depression and Anxiety
Migraine comorbidities include depression and anxiety disorders; behavioral treatments that combine strategies to address both conditions may be fruitful.

Headache chronification: screening and behavioral management of comorbid depressive and anxiety disorders.
Smitherman TA, Maizels M, Penzien DB.
Headache. 2008 Jan;48(1):45-50.

Traditional and alternative treatments for depression: implications for migraine management.
Peck KR, Smitherman TA, Baskin SM.
Headache. 2015 Feb;55(2):351-5.

Obesity is a risk factor for increased disease severity and disability among people with migraine. Incorporating exercise and calorie restriction in the treatment of obese people with migraine shows promise.

Obesity and headache: Part II--potential mechanism and treatment considerations.
Chai NC, Bond DS, Moghekar A, Scher AI, Peterlin BL.
Headache. 2014 Mar;54(3):459-71.

A systematic review of behavioral headache interventions with an aerobic exercise component.
Baillie LE, Gabriele JM, Penzien DB.
Headache. 2014 Jan;54(1):40-53

Screening and behavioral management: obesity and weight management.
Nicholson R, Bigal M.
Headache. 2008 Jan;48(1):51-7.

“Third-wave” cognitive behavioral therapies include mindfulness training, a cognitive strategy involving non-judgmental awareness. Preliminary studies examining behavioral interventions for headache disorders which include a mindfulness component have produced promising results.

Meditation for migraines: a pilot randomized controlled trial.
Wells RE, Burch R, Paulsen RH, Wayne PM, Houle TT, Loder E.
Headache. 2014 Oct;54(9):1484-95

Behavioral and mind/body interventions in headache: unanswered questions and future research directions.
Wells RE, Smitherman TA, Seng EK, Houle TT, Loder EW.
Headache. 2014 Jun;54(6):1107-13.

Search the Site