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Migraines respond to great expectations

Meds and placebos both fight pain better when patients anticipate getting active drug

In a new study, migraine patients experienced the greatest decline in pain when placebo pills (blue) and Maxalt pills (brown) were labeled as “Maxalt” (M) or “Maxalt or placebo” (U). Pills labeled “placebo” (P) were the weakest painkillers in each treatment condition. Between 30 minutes and 2.5 hours after an attack started, migraine pain increased among patients who got no treatment at all (black). 

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When it comes to pain, what migraine-headache sufferers think about their pills’ identities matters nearly as much as whether or not those pills contain active medication, a new study suggests.

Migraine meds labeled as placebos dull headache pain less effectively than the same pills identified either as the real deal or as possibly a genuine drug, say neuroscientist Rami Burstein of Harvard Medical School and his colleagues. Placebo pills given to migraine patients worked the same way, easing headache pain better when labeled as definitely or possibly containing active medication, the researchers report in the Jan. 8 Science Translational Medicine.

Placebo pills mislabeled as the migraine drug Maxalt provided close to as much pain relief as Maxalt mislabeled as a placebo. Overall, though, Maxalt eased migraine pain better than placebos did.

“These findings suggest that the physiological effects of the drug and the psychological effects of a placebo contributed almost equally to the therapeutic efficacy of the migraine treatment,” Burstein says.

He suspects that physicians who equivocate about Maxalt’s pain-fighting power with statements such as “let’s give the drug a try and see if it works” end up lowering patients’ expectations. As a result, patients don’t experience as much pain relief as they potentially could from taking Maxalt.

Burstein’s group also found that patients who took accurately labeled placebos reported more pain relief from migraine attacks than those receiving no treatment. The ritual of pill taking by itself may help treat migraines, the scientists suggest.

The study is one of only a few to demonstrate that a patient knowingly getting a placebo can experience “an actual effect superior to not receiving a treatment,” says physician Damien Finniss of the University of Sydney.

Burstein’s group recruited 66 patients who experienced recurring migraine headaches. Patients recorded pain scores 30 minutes and 2.5 hours after an untreated migraine attack. In six ensuing attacks, each participant did the same but took Maxalt at the 30-minute mark of three episodes and a placebo at the same point in three other headache bouts. Each treatment was alternately labeled as “placebo,” “Maxalt or placebo” and “Maxalt.”

A 2001 study led by neuroscientist Fabrizio Benedetti of the University of Turin Medical School in Italy similarly observed that a saline solution described to patients recovering from surgery as a powerful painkiller produced more pain relief than an accurately portrayed saline solution did for other surgical patients. A third postsurgical group receiving a saline drip depicted as a possible painkiller reported levels of pain relief in between those of the other groups.

Each migraine patient in the new study took a drug and a placebo labeled in three different ways, an improvement in research design over his own group’s surgery investigation, Benedetti says.

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