Efficacy and safety of non-pharmacologic interventions for management of pediatric migraine: a systematic review of randomized controlled trials

Pediatric migraine affects approximately 7.7% to 9.1% of children and adolescents worldwide, significantly impacting their quality of life by hindering academic performance, social activities, and daily physical tasks. These effects are comparable to chronic conditions like rheumatoid arthritis or cancer. This study aimed to systematically review the effectiveness and safety of non- pharmacologic interventions for pediatric migraine. Articles were identified through systematic searches in PubMed, Cochrane, and Elsevier databases, supplemented by manual searches from inception to October 19, 2024. Data were extracted using structured forms and analysed qualitatively, with study-level results extracted and summarized narratively. Risk of bias were assessed using the Cochrane Risk of Bias Tool 2 (RoB2). Eligible studies were randomized controlled trials (RCTs) evaluating non-pharmacologic interventions as stand- alone treatments, with comparator groups receiving pharmacologic therapy alone, non-pharmacologic therapy alone or placebo/usual care with outcomes related to migraine frequency, severity, duration, or safety. Exclusion criteria included studies on non-migraine headache types, mixed populations without subgroup analysis, insufficient data, or non-RCT designs. Eighteen RCTs involving 816 pediatric participants were included. Relaxation therapy reduced migraine frequency from 2.59 to 0.89 episodes per week while biofeedback decreased episodes from 2.7 to 1.0 weekly. Acupuncture demonstrated significant benefit, reducing frequency from 9.3 to 1.4 episodes per month. Butterbur root extract achieved 36.1% reduction. Coenzyme Q10 showed promising results, whereas riboflavin did not outperform placebo. These values represent individual study finding, no meta-analysis was performed. Overall, relaxation therapy, biofeedback, and selected dietary supplements appear effective and well- tolerated, offering safer, evidence-based alternatives to pharmacologic treatments and supporting individualized strategies to improve quality of life in young patient.