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Am Fam Physician. 2021;104(6):online

Clinical Question

Are nonpharmacologic treatments effective in decreasing migraine frequency in children and adolescents?

Bottom Line

Active nonpharmacologic treatments such as biofeedback, relaxation techniques, and general or specific psychological support (e.g., cognitive behavior therapy) may be a good place to start when trying to decrease migraine frequency in children and adolescents. The research is positive, although there is not much out there. (Level of Evidence = 1a−)


The researchers conducted this meta-analysis following PRISMA criteria, searching four databases, including the Cochrane CENTRAL and a previous systematic review. The articles were selected by five coauthors, and two authors evaluated studies for risk of bias. They identified 12 randomized controlled studies of 576 children and adolescents exposed to at least one nonpharmacologic treatment for the prevention of migraine with or without aura. Most studies were small, of short duration, and had a moderate risk of bias. Combined with network meta-analysis, these limitations are a cause for concern about the direct comparisons of the interventions. Compared with no treatment (being on a waiting list), biofeedback, relaxation, self-administered psychological treatment (e.g., written or audio strategies for coping and relaxation), psychological placebo (e.g., one-hour sessions not specifically aimed at migraine treatment), and psychological treatments (e.g., cognitive behavior therapy) decreased the number of migraine days, frequency of attacks, or headache index. These differences were still present after at least three months. The typical difference (effect size) was small for long-term psychological placebos and medium for self-administered treatments. There was no evidence of publication bias, which might have been difficult to find given the small numbers of studies. Heterogeneity was reported but not discussed in detail.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Outpatient (any)

Reference: Koechlin H, Kossowsky J, Lam TL, et al. Nonpharmacological interventions for pediatric migraine: a network meta-analysis. Pediatrics. 2021;147(4):e20194107.

Editor's Note: Dr. Shaughnessy is an assistant medical editor for AFP.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

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