Refractory Migraine: Non-Drug Rehabilitation Options After Botox and CGRP Treatments

What the Research Shows

Exercise

In a 2022 network meta-analysis of 21 clinical trials with 1,195 people with migraine, strength training reduced monthly migraine days by about 3.5, high-intensity aerobic exercise by about 3.1 and moderate aerobic exercise by about 2.2, compared with control groups.^[5] An earlier meta-analysis found a smaller average benefit from aerobic exercise, about 0.6 fewer migraine days a month, with moderate-quality evidence.^[6] In one randomized trial, 40 minutes of exercise three times a week reduced attacks about as much as the preventive drug topiramate.^[7] The key is dosing exercise carefully so it doesn’t trigger attacks.

Behavioral and Mind-Body Approaches

The American Headache Society lists behavioral treatments such as relaxation training and biofeedback among appropriate migraine treatments.^[14] In a randomized trial, mindfulness-based stress reduction didn’t reduce migraine days more than headache education did, but it improved disability, quality of life and depression for up to 36 weeks.^[8]

Nerve-Stimulation Devices

Several external devices are FDA-cleared for migraine. In sham-controlled trials, 38% of people using forehead (supraorbital) stimulation cut their monthly migraine days by at least half, versus 12% with sham,^[10] and upper-arm remote electrical neuromodulation gave pain relief at 2 hours for 67% of people, versus 39% with sham.^[11] Results aren’t uniform: in a large trial of vagus nerve stimulation for prevention, the device didn’t beat sham overall.^[12]

Other Options With Lower Certainty

• Supplements: magnesium, riboflavin (vitamin B2) and feverfew are rated probably effective for preventing episodic migraine, and coenzyme Q10 possibly effective. The guideline dates from 2012 and the studies are small.^[13]
• Manual therapy: chiropractic guidelines support spinal manipulation and multimodal care for migraine, at a moderate level of evidence at most.^[15]
• Acupuncture: a Cochrane review found that headache frequency was at least halved in 41% of people receiving acupuncture, versus 17% without it, with a small effect over sham acupuncture.^[9] We don’t offer acupuncture, but it’s a reasonable option to discuss with your doctor.

Almost all of this research was done in people with episodic or chronic migraine generally, not specifically in people who have failed Botox and CGRP treatments.

What Care Looks Like at Harcourt Brain Center

We organize migraine care around Dr. Harcourt’s 4-Factor Migraine Framework, which looks at hormonal, nutritional, musculoskeletal and neurological factors together. Your first visit includes a detailed history, a functional neurological exam, and an exam of your neck, posture and eye movements. Depending on your findings, a plan may include:

• A carefully dosed exercise program, including strength and aerobic training
• Manual therapy and cervical spine proprioceptive retraining for neck-related symptoms
• Vestibular rehabilitation if you also have dizziness or motion sensitivity
• Nutritional guidance, including evidence-based supplements, reviewed with your doctor for interactions
• Daily routines for sleep, meals and stress that reduce your overall migraine load

We track progress with the MIDAS disability questionnaire and your monthly headache days, and re-test at planned checkpoints. With your permission, we send findings and progress reports to your neurologist or headache specialist. If you live far from York, ask about our Remote Migraine Program. Learn more on our Migraine page and our Clinical Rationale & Evidence page. Clinicians can find referral details on our For Clinicians page.