Dr Stephen SilbersteinStephen D. Silberstein, MD
As scientists, we're natural skeptics. So it’s not surprising to see that the adoption of complementary or wellness-based approaches in migraine care has been slower than some might hope. 

Despite reservations, quality clinical evidence shows that these approaches, including exercise, cognitive behavioral therapy, and breathing/meditation, can all be effective in patients with migraine and help reduce not only migraine frequency and severity but also the overall burden that the condition places on patients.1 

As with any other disease, there are things said in the media and unfounded claims made about purported migraine treatments that aren’t evidence-based. It’s our job as clinicians to clearly inform our patients and help them make educated decisions about their care. 

With the newest class of migraine therapies, we are clearly witnessing an unprecedented time in treatment. We are able to reduce migraine frequency and severity in patients with both chronic and episodic disease and even in patients with debilitating disorders like cluster headache. But we have to look at the big picture: Reducing just the number of monthly migraine days doesn’t necessarily mean that our patients are suddenly well; producing clinically meaningful change is very important and encompasses not only the number of migraines that a person experiences but also symptom management and how the disease affects their day-to-day life. In the end, if patients’ quality of life is still significantly affected by their disorder, we haven’t completely done our job. And that’s where complementary medicine has a place in your practice. 

Complementary therapies are especially relevant for patients who experience adverse effects from pharmaceutical treatments, have contraindications to those treatments, or have an inadequate response, as well as for patients who are planning for pregnancy, are pregnant, or are breast-feeding. An emphasis on lifestyle and behavioral changes can also benefit patients with medication overuse and those with high levels of stress. In many cases, clinicians can use wellness-based approaches in conjunction with pharmaceutical therapies to improve overall treatment benefit.2 
Several complementary therapies, though not conclusively supported by clinical evidence, are widely used with a good degree of success. These include acupuncture, chiropractic care, hypnosis, and physical therapy. 

"IN MANY CASES, CLINICIANS CAN USE WELLNESS-BASED APPROACHES IN CONJUNCTION WITH PHARMACEUTICAL THERAPIES TO IMPROVE OVERALL TREATMENT BENEFIT." 
— STEPHEN D. SILBERSTEIN, MD

Significant evidence also supports the use of behavioral therapies for headache and migraine; these include relaxation training, biofeedback, and cognitive-behavioral therapy.1 These therapies help teach the patient how to modify physiological responses related to headache or migraine, including how to reduce muscle tension and nervous system arousal and stress related to triggers. 

Clinicians also cannot forget the impact of other good lifestyle habits, including exercise, good sleep hygiene, hydration, and vitamin support, notably with B2 and magnesium. Indeed, results of a 2011 study by Varkey et al3 showed that exercise 3 times per week, regular relaxation exercises, and topiramate use were all equally effective in reducing the frequency of migraines. Exercise can help reduce stress and improve sleep—2 central migraine triggers. 

Providing patients with support, resources, and access to wellness-based care can help them play a direct role in their disease management beyond taking their prescribed pharmaceutical therapy. In the end, taking better care of themselves both physically and mentally will help improve not only their migraine management but also their lives. 

Stephen D. Silberstein, MD, is a professor of neurology and the director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia, Pennsylvania. He is also Editor in Chief of NeurologyLive.
REFERENCES 
1. Puledda F, Shields K. Non-pharmacological approaches for migraine. Neurotherapeutics. 2018;15(2):336-345. doi: 10.1007/s13311-018-0623-6. 
2. Penzien DB, Taylor FR. Headache toolbox. Behavioral and other nonpharmacologic treatments for headache. Headache. 2014;54(5):955-956. doi: 10.1111/head.12369. 
3. Varkey E, Cider A, Carlsson J, Linde M. Exercise as migraine prophylaxis: a randomized study using relaxation and topiramate as controls. Cephalalgia. 2011;31(14):1428-1438. doi: 10.1177/0333102411419681.