Pain Reprocessing Therapy for migraine: A case series

Pain Reprocessing Therapy (PRT) is a behavioral intervention that aims to remediate learned threat associations underlying chronic pain. It has shown efficacy in treating chronic low back pain and was explicitly developed to address a broader range of centrally mediated pain conditions. The focus of PRT on learned threat associations dovetails with emerging neurobiological models of migraine, which highlight learned threat associations-nonharmful internal (e.g., hunger, fatigue) or external (e.g., weather changes) cues that are persistently misinterpreted as danger signals-as a modifiable contributor to migraine pathophysiology. Despite its conceptual relevance, PRT has not yet been studied for migraine, a leading cause of disability with an ongoing need for more effective treatments, especially for patients who are refractory to evidence-based treatments. Addressing this gap, we present the first case series on PRT for migraine. We describe three individuals with chronic migraine who engaged in PRT delivered by a physician. All three patients had inadequate response to standard-of-care preventive and acute migraine treatments and presented with complex clinical histories, including non-headache pain comorbidities. PRT sessions (initial visit 60 min; follow-ups 30 min) focused on two key components: (1) education about neuroplastic pain and its relevance to migraine, and (2) guided instruction and daily practice of somatic tracking. Across all three cases, patients experienced large reductions in headache frequency and clinically meaningful improvements in pain intensity and functional outcomes. Case 1 improved from 18 to 25 headache days/month to 3, discontinued cannabis use, and canceled planned interventional treatments. Case 2 improved from 30 headache days/month to 5 and reported greater effectiveness and decreased use of acute medication. Case 3 improved from 30 migraine days/month to 3-4, remained off preventive medication, and reported improvement in migraine and comorbid pelvic and abdominal pain. In all cases, the most substantial gains appeared to follow a shift in pain attribution toward a learned threat association model and daily engagement in somatic tracking, consistent with prior literature on PRT in low back pain. This case series is the first to document the use of PRT for migraine and suggests its potential relevance as a mechanistically informed behavioral intervention for migraine. There is now a need to systematically evaluate PRT for migraine in controlled studies.