Effectiveness of pain neuroscience education in migraine management: a systematic review

Abstract

Abstract Background Migraine is a leading cause of disability worldwide. Although pharmacological therapies are available, many patients remain symptomatic or discontinue treatment. Pain neuroscience education (PNE), which reframes pain as a multifactorial experience, has been proposed as a low-cost, scalable intervention. Its role in migraine care remains uncertain. Methods This systematic review was conducted according to PRISMA 2020 and registered in PROSPERO (CRD420251082539). Eligible studies were randomised controlled trials including adults with migraine, where PNE was delivered alone or in combination with physiotherapy, or usual primary care, compared with usual care or non-neuroscience education. The primary outcome was headache-related disability (MIDAS, HIT-6); secondary outcomes were headache frequency and intensity. Risk of bias (ROB) was assessed using the Joanna Briggs Institute (JBI) checklist and certainty of evidence with GRADEpro gdt. Narrative synthesis was performed due to heterogeneity. Results Five RCTs (n=416) were included. Short-term MIDAS results were inconsistent (very low certainty), whereas long-term outcomes favoured PNE, with high-certainty evidence that PNE more than doubled the likelihood of achieving ≥50% disability reduction at 12 months. HIT-6 improved across all groups, with between-group differences below the minimal clinically important difference (moderate certainty). Headache frequency showed mixed results: very low certainty short-term, low certainty long-term, but high-certainty benefit when analysed dichotomously. Headache intensity improved within groups, with moderate-certainty evidence supporting superior outcomes for PNE at several follow-ups. Conclusions PNE may reduce disability, headache frequency, and intensity in migraine, particularly when used in multimodal programmes. Evidence for standalone PNE is promising but limited to single trials. Standardised PNE content/dose, attention-matched comparators, and consistent outcome reporting (with MCIDs) are priorities for future trials.