Cognitive Behavioral Therapy (CBT) for dizziness and migraine

Timothy C. Hain, MD• Page last modified: July 31, 2022

See also: Psychological causes of dizzinessMigraine headache

CBT has been suggested as an effective treatment for several disorders related to dizziness and hearing, especially tinnitus and undiagnosed chronic dizziness. There is also a small literature about pediatric migraine. These are generally disorders that have no drug treatment, and the emphasis is more on adjusting to the symptoms rather than eliminating them. CBT is usually considered "the gold standard for the psychotherapeutic treatment of many or even most mental disoders (Leichsenring and Steinert, 2017).

Psychotherapy is a reasonable treatment approach to disorders that are defined mainly by symptoms such as dizziness, tinnitus, and headache disorders, because in essence, these disorders are defined by the persons inner state rather than external measurements. In other words, we often have no method of separating out mental causation from physical causation. Furthermore, many of our present treatments for dizziness, tinnitus and headaches involve psychoactive medications. This doesn't prove that they are psychogenic, but it does point out there is overlap. Talk therapy has no "side effects", and might be a good alternative to using drugs.

Following is a discussion of the most popular type of psychotherapy in medical settings, CBT. CBT papers use specific jargon that practitioners use in special ways, such as "cognitive distortions", "cognitive restructuring". Most fields use regular words in unique ways. Psychology seems to have quite a few of these. We will explain the ones relevant to CBT as we go.

Basic Assumptions and Focus of CBT

The basic premise of CBT is that our thoughts about ourselves, our world and our future are maintained by our core beliefs. The core beliefs, along with automatic thoughts and schema, affect the way we feel and how we behave. These premises are pretty reasonable, but that doesn't prove that CBT is effective. In CBT, the words "automatic thoughts", and "schema" are part of their special jargon. To provide an example, someone who is unsteady because they have ear damage, might think "I might fall", when they cross the parking lot. In CBT speak, the "I might fall", would be classified as an automatic thought. In other contexts, one might instead categorize this thought as a reasonable consideration concerning risk assessment. The term "schema", in CBT jargon, is basically a series of thoughts that generally include some inferences -- using the same example, a person with ear damage might say to themselves, "If I cross the street, I might fall". If I go shopping, I have to cross the street. If I go shopping, I might fall. In CBT, the implicit assumption is that the "autonomic thoughts", are at least partially incorrect, or that the schema is wrong. If one took the previous example, and extended it by saying, "If I do anything, I might have to cross the street", thus "If I do anything I might fall", this would be an example of an exaggerated inference and incorrect schema.

For the example of tinnitus, the external event, that is, the loud or/and annoying sound in the ear, is present, but how the patients manage the situation is determined largely by their perception of the situation. A common “core belief” among some tinnitus patients is that “life is ruined because of tinnitus”. This schema can be viewed both as an inference as well as a belief that might create distress and anxiety. CBT theory then states that the distress/anxiety gives rise to behavior and/or somatic (body) symptoms that reinforce the dysfunctional core belief. Here the term "dysfunctional", is a little tricky as it doesn't say that the belief is wrong, but it suggests that the belief is harmful.

In order to help patients with tinnitus, CBT uses both behavioral and cognitive tasks to modify the patients’ "cognitive distortions" (i.e. wrong thinking), that is, their dysfunctional responses such as fear and hyper-vigilance to the thought of an impending or increased volume of a sound and anticipation of the lack of control over their behavior once the sound starts to ring in their ears. Through intervention including psychoeducation (teaching) about the nature of tinnitus, the therapists help to generate an understanding of the connection between thoughts, feeling and behavior concerning tinnitus. The goal is to replace negative thought patterns by raising cognitive accessibility of alternative belief formulations. Rewording this last jargon term, the goal is to convince the patient to think about their symptoms in a more positive way.

The process of cognitive restructuring involves the patients to challenge the negative thinking patterns. CBT uses the jargon "cognitive restructuring" instead of "convincing the patient that their thinking is harmful". The cognitive distortions that cognitive restructuring might be aimed at might include a tendency to allocate attention to anticipating negative consequences and catastrophizing. For example, the therapist and the patient may examine the fearful thought of “life is ruined when the sound is there” as a hypothesis. They work together searching for discrepant (i..e contradicting) evidence to disconfirm these pathogenic (harmful) thoughts.

The core dogma of CBT states that the patient learns to replace faulty thoughts with more functional one, and ultimately the patient establishes new and more functional behavior.

Criticism of CBT in the literature

There are an immense number of papers concerning CBT and its utility in medical settings. Hofmann et al (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012) summarized the efficacy of CBT (in general) based on 269 studies. The problems included substance use disorder, schizophrenia, depression and dysthymia, bipolar disorder, anxiety, somatoform, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, and general stress.

CBT is somewhat of a "Swiss army knife" treatment, and may be oversubscribed by therapists (Leichsenring and Steinert, 2017). CBT supposedly is effective in conditions for which one would think that restoration of normal thinking is impossible. Nobody would expect reasonably psychotherapy to return the dead to life, restore vision to the blind, or hearing to the deaf. Similarly, from the perspective of a neurologist, it is difficult to see how any "talk" therapy can be effective for disorders involving neural wiring, such as schizophrenia. Nevertheless many papers suggesting that CBT can treat psychosis due to schizophrenia do exist (Burns et al, 2014).

Meta-analyses comment that many studies of CBT have a "high risk of bias" (Nowak et al, 2016). Another way of putting it, according to a recent paper, is "researcher allegiance, the researchers belief in the superiority of a treatment". This has been an "uncontrolled factor in comparisons of treatment efficacy" (Leichsenring and Steinert, 2017). In other contexts, we would say that CBT studies seem often to be judged "biased" by meta-analytic papers. Or if this were the media, we would say that many claims about CBT are "fake news".

It is also interesting to note that psychological studies seem to have a general problem with replication -- in other words, it is more common than not, when psychological studies are done over, to get different results. According to an article published in Science in 2015, "Replication effects were half the magnitude of original effects, representing a substantial decline. Ninety-seven percent of original studies had statistically significant results. Thirty-six percent of replications had statistically significant results; 47% of original effect sizes were in the 95% confidence interval of the replication effect size; 39% of effects were subjectively rated to have replicated the original result; and if no bias in original results is assumed, combining original and replication results left 68% with statistically significant effects." This is a troubling analysis -- it appears that in the pschological field, about 2/3 studies reporting significant results, turn out to be not significant. Again, sounds like "fake news".

It has also been our observation that psychotherapy businesses seem to often claim to be offering CBT, but actually seem to be pursuing "feel good" type supportive therapy. In the retail world, this might be called a "bait and switch" type operation. In the medical world, it would be rare to have a surgeon who is a heart surgeon, actually perform bowel surgery, because these are very concrete activities. In the therapy world, it is sometimes a little harder to figure out what is going on. If you dial up "CBT R US", you might end up with your patient getting some other type of psychotherapy than CBT. This is undesirable from several perspectives. First it is unethical. Second, while we are criticizing CBT here, still it is structured and seems to have a rather well defined process and outcome. We like this. It seems to us that tighter monitoring of psychotherapy in general, in a similar way to which physical therapy is monitored, would be a very good idea. In other words, for insurance to pay for CBT or whatever therapy, it should be actually CBT, as verified by an outside observer.

Well to close this section, we suggest the clinician recommending CBT to their patients be sensible. CBT is just another type of talk psychotherapy -- it is currently trendy but CBT can't pull of feats of magic. The likelihood of CBT working is highly correlated with the skills of the the practitioner of CBT. When you refer a patient for CBT, you should do your best to identify someone who will do what you ask, and who has a proven track record of success.

Use of CBT in Tinnitus

This is reviewed separately in this page: cbt in tinnitus

Use of CBT to treat Dizziness

As of 2017, there were only 4 papers in Pubmed having the words "cognitive behavioral therapy", and the keyword "dizziness". There were about 130 papers containing the keywords CBT and dizziness, but almost none of them are relevant. Two papers discussed its use in "phobic postural vertigo", a dizziness pattern attributed to psychological sources. More about PPV, also known as "CSD" (chronic subjective dizziness), and recently renamed to be "PPPD" (persistent postural perceptive dizziness) is found here. Note how the last acronym sounds enough like "BPPV" that it might be confused.

Holmberg et al (2007) reported that "Cognitive behavioral therapy has a limited long-term effect on phobic postural vertigo. This condition is more difficult to treat than panic disorder with agoraphobia. Vestibular rehabilitation exercises and pharmacological treatment might be the necessary components of treatment."

Johansson et al (2001) reported that "Cognitive behavioral therapy combined with vestibular rehabilitation decreases dizziness in older people. ". This was a very small study, which combined exercise, and did not separate out the CBT from the exercise component.

Wan et al (2018) reported "These results demonstrated that the addition of CBT could make low-dose beta-histine produce similar results to high-dose betahistine in treating residual dizziness. " (we added the link -- betahistine is a prescription medication mainly used for Meniere's disease)

Waterson et al (2021) reported that "The use of cognitive behavioral therapy (CBT) as a treatment for PPPD resulted in impressive reductions in anxiety and measures of dizziness over follow up periods of up to 6 months. "

We think that there is considerable room for more research on CBT in dizziness conditions. We would especially like to see studies of CBT in chronic vertigo conditions. We think it is important to separate out effects of CBT on filling out surveys (i.e. the DHI questionnaire or others), and CBT on real world activities -- i.e. how many steps per day did the person with CBT make before and after the treatment. Doing this would control for the investigator bias, that appears to be the huge problem with CBT research as well as other psychology research.

CBT for Migraine -- probably not effective.

As of 2022, there are 31 papers in Pubmed having the words "cognitive behavioral therapy", and the keyword "migraine". Bae et al (2021), in a meta-analysis,reported "CBT for migraine effectively reduced headache frequency and MIDAS score in meta-analysis and headache intensity subgroup analysis, with few adverse events. Additional RCTs with CBT for migraine headaches are needed for a more accurate analysis."

In a randomized controlled trial, Klan et al (2022) reported, using the acronyms miCBT for migraine specific CBT, and RLX for relaxation training, "The miCBT has no better treatment effects compared to RLX in migraine-prophylaxis. Both treatments effectively increase patients' self-efficacy."

Many papers concern pediatric migraine, a condition for which medications are generally avoided. Kroner et al (2017), suggested that CBT and amitriptyline was a good combination. In a meta-analysis, Ng (2017) concluded that "There is good evidence that CBT is beneficial to children suffering from migraine, and may also augment the efficacy of standard medications such as amitriptyline." Powers et al (2013) reported that CBT reduced scores on a survey of migraine symptoms.

Altogether, we don't find it very surprising that talk therapy, whether CBT or other forms of therapy, can alter scores on subjective surveys of migraine intensity. Tests can be taught. More importantly, we would want to see how CBT altered the time spent in school. Something "real", not a survey.

We would also be interested in comparing CBT to the effect of "placebo" therapy -- perhaps talking to the children about some innocuous but fun topic combined with some "education" about words on the pediatric migraine survey. Given the criticism of CBT outlined above, it is obviously important to control for investigator bias. The placebo would help. As noted above, CBT seems no different than relaxation in adults in the trial of Klan et al (2022).