Digital Technology and Mobile Health in Behavioral Migraine Therapy: a Narrative Review

Digital clinics for diagnosing and treating migraine

PURPOSE OF REVIEW

Several innovative digital technologies have begun to be applied to diagnosing and treating migraine. We reviewed the potential benefits and opportunities from delivering migraine care through comprehensive digital clinics.

RECENT FINDINGS

There are increasing applications of digitization to migraine diagnosis and management, including e-diaries, and patient self-management, especially after the COVID-19 pandemic. Digital care delivery appears to better engage chronic migraine sufferers who may struggle to present to physical clinics.

SUMMARY

Digital clinics appear to be a promising treatment modality for patients with chronic migraine. They potentially minimize travel time, shorten waiting periods, improve usability, and increase access to neurologists. Additionally, they have the potential to provide care at a much lower cost than traditional physical clinics. However, the current state of evidence mostly draws on case-reports, suggesting a need for future randomized trials comparing digital interventions with standard care pathways.

Development and Evaluation of a Smartphone-Based Chatbot Coach to Facilitate a Balanced Lifestyle in Individuals With Headaches (BalanceUP App): Randomized Controlled Trial

BACKGROUND

Primary headaches, including migraine and tension-type headaches, are widespread and have a social, physical, mental, and economic impact. Among the key components of treatment are behavior interventions such as lifestyle modification. Scalable conversational agents (CAs) have the potential to deliver behavior interventions at a low threshold. To our knowledge, there is no evidence of behavioral interventions delivered by CAs for the treatment of headaches.

OBJECTIVE

This study has 2 aims. The first aim was to develop and test a smartphone-based coaching intervention (BalanceUP) for people experiencing frequent headaches, delivered by a CA and designed to improve mental well-being using various behavior change techniques. The second aim was to evaluate the effectiveness of BalanceUP by comparing the intervention and waitlist control groups and assess the engagement and acceptance of participants using BalanceUP.

METHODS

In an unblinded randomized controlled trial, adults with frequent headaches were recruited on the web and in collaboration with experts and allocated to either a CA intervention (BalanceUP) or a control condition. The effects of the treatment on changes in the primary outcome of the study, that is, mental well-being (as measured by the Patient Health Questionnaire Anxiety and Depression Scale), and secondary outcomes (eg, psychosomatic symptoms, stress, headache-related self-efficacy, intention to change behavior, presenteeism and absenteeism, and pain coping) were analyzed using linear mixed models and Cohen d. Primary and secondary outcomes were self-assessed before and after the intervention, and acceptance was assessed after the intervention. Engagement was measured during the intervention using self-reports and usage data.

RESULTS

A total of 198 participants (mean age 38.7, SD 12.14 y; n=172, 86.9% women) participated in the study (intervention group: n=110; waitlist control group: n=88). After the intervention, the intention-to-treat analysis revealed evidence for improved well-being (treatment: β estimate=-3.28, 95% CI -5.07 to -1.48) with moderate between-group effects (Cohen d=-0.66, 95% CI -0.99 to -0.33) in favor of the intervention group. We also found evidence of reduced somatic symptoms, perceived stress, and absenteeism and presenteeism, as well as improved headache management self-efficacy, application of behavior change techniques, and pain coping skills, with effects ranging from medium to large (Cohen d=0.43-1.05). Overall, 64.8% (118/182) of the participants used coaching as intended by engaging throughout the coaching and completing the outro.

CONCLUSIONS

BalanceUP was well accepted, and the results suggest that coaching delivered by a CA can be effective in reducing the burden of people who experience headaches by improving their well-being.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017422; https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00017422.

Headache providers' perspectives of headache diaries in the era of increasing technology use: a qualitative study

Background

No matter what type of headache is being considered across various populations, one of the mainstays of headache medicine is headache tracking. This self-management tool enables patients and their providers to understand patients' underlying symptoms and the effects of treatments they have tried. This is important to determining whether headaches are related to menses for women's health, to determining the time of headache occurrence, e.g., hypnic headache, and the location and duration of symptoms, e.g., trigeminal autonomic cephalgia. Prior research has investigated what people with headaches perceive about headache diary use and how people with headaches utilize electronic headache diaries. However, headache providers' perspectives on the important factors related to headache diaries are less known. Previously, using the Modified Delphi Process, a panel of four experts opined what they perceived as the most important factors for a headache diary. We sought to better understand headache providers' perspectives about headache diary/app usage from providers working in various institutions nationwide.

Methods

We conducted 20 semi-structured qualitative interviews of headache providers across the US from various institutions and asked them their perspectives on headache diary use. We transcribed the interviews, which two independent coders then coded. Themes and subthemes were developed using grounded theory qualitative analysis.

Results

Six themes emerged: (1) Providers were generally agnostic regarding the headache tracking method, but nearly all recommend the use of smartphones for tracking; (2) Providers had concerns regarding the accessibility of headache trackers; (3) Providers noted benefits to integrating headache tracking data into the EMR but had mixed opinions on how this integration might be done; (4) Providers had mixed opinions regarding the utility and interpretation of the data, specifically regarding data accuracy and efficiency; (5) Providers generally felt that headache tracking lends itself to more collaborative plan management; (6) Providers recommend behavioral health apps for patients but stated that there are few digital behavioral health interventions for headache specifically.

Conclusion

Interviews of headache providers, recommenders, and users of headache data are vital informants who can provide a robust amount of information about headache diary development, use in different populations, integration, and more.

An Online Psychological Program for Adolescents and Young Adults With Headaches: Iterative Design and Rapid Usability Testing

BACKGROUND

Headache disorders are common, debilitating health problems. Cognitive-behavioral therapy (CBT) is recommended but rarely easily available. With the use of the internet and communication technologies among youth and young adults, these individuals could be self-trained in CBT skills. There is an increasing number of internet-based interventions for headaches, but there has been little research into the usability of these interventions because evaluating usability across the intervention development life cycle is costly. We developed an internet-based CBT program, the Specialized Program for Headache Reduction (SPHERE). While developing it, we aimed to improve SPHERE through rapid usability testing cycles.

OBJECTIVE

This study aims to presents a rapid and affordable usability testing approach that can be performed throughout the intervention development life cycle. This paper also provides evidence of the usability of SPHERE.

METHODS

We used the "think aloud" usability testing method based on Krug's approach to test user interaction within a lab setting. This was followed by a short posttest interview. We planned to test SPHERE with 3-5 participants testing the same part of the program each cycle. Both the design and development team and the research team actively participated in the usability testing process. Observers independently identified the top 3 usability issues, rated their severity, and conducted debriefing sessions to come to consensus on major issues and generate potential solutions.

RESULTS

The testing process allowed major usability issues to be identified and rectified rapidly before piloting SPHERE in a real-world context. A total of 2 cycles of testing were conducted. Of the usability issues encountered in cycles 1 and 2, a total of 68% (17/25) and 32% (12/38), respectively, were rated as major, discussed, and fixed.

CONCLUSIONS

This study shows that rapid usability testing is an essential part of the design process that improves program functionality and can be easy and inexpensive to undertake.

Digital Therapeutics in Migraine Management: A Novel Treatment Option in the COVID-19 Era

Migraine is a chronic and often lifelong disease that directly affects over one billion people globally. Because access to migraine medical services is limited, only a minority of migraine patients are treated adequately. This situation worsened during the COVID-19 pandemic. Digital therapeutics (DTx) is an emerging therapeutic approach that opens up many new possibilities for remote migraine management. For instance, migraine management tools, online migraine diagnosis, guideline-based treatment options, digitally networked patients, and collecting anonymized information about migraine attacks and course parameters for scientific evaluation. Various applications of DTx in migraine management have been studied in recent years, such as the usefulness of digital migraine self-management tools in diagnosing and tracking migraine attacks, and the efficacy and safety of digital cognitive behavioural therapy. However, the development of DTx is still in its infancy and still faces many obstacles. The primary goal of this study is to review the latest research on DTx in migraine management, identify challenges, and outline future trends.

Digital headache self-management interventions for patients with a primary headache disorder: A systematic review of randomized controlled trials

OBJECTIVE

This article systematically reviews the empirical literature examining the efficacy of digital headache management interventions for patients with a primary headache disorder.

BACKGROUND

Digital headache management interventions provide opportunities to improve access to behavioral headache interventions to underserved groups.

METHODS

A systematic search of PubMed, Scopus, and EBSCO (PsycInfo, Education Research Complete, ERIC, Health Source: Nursing/Academic Edition, Psychology and Behavioral Sciences Collection) and reference review was conducted. Included studies had to recruit a sample with a primary headache diagnosis, be a randomized controlled trial including a digital component, assess a headache outcome (i.e., frequency, duration, severity, intensity, disability) or quality of life, and be published in English. Two authors independently extracted data for included studies. The methodological quality of studies was assessed using the revised Cochrane risk-of-bias tool.

RESULTS

Thirteen studies with unique interventions met inclusion criteria. More than half of the studies were pilots; however, nearly 70% (9/13) demonstrated significant between-group or within-group improvements on one or more headache-related outcomes. All interventions included some form of relaxation training and the majority were delivered via interactive website. While fewer than half the studies report participant race and/or ethnicity, of those that do, 83% (5/6) reported a predominately White/Caucasian sample.

CONCLUSIONS

Efficacy testing of digital headache interventions is in its infancy with the majority of these studies relying on pilot studies with small samples comprised of homogenous patient populations. Interactive websites were the most common digital medium to deliver digital headache management interventions and have demonstrated promising results. Further testing using large-scale randomized controlled trials and exploration of other digital tools is warranted. Future studies with more diverse samples are needed to inform health equity of digital headache interventions.

A Comprehensive Literature Search of Digital Health Technology Use in Neurological Conditions: Review of Digital Tools to Promote Self-management and Support

BACKGROUND

The use of digital health technology to promote and deliver postdiagnostic care in neurological conditions is becoming increasingly common. However, the range of digital tools available across different neurological conditions and how they facilitate self-management are unclear.

OBJECTIVE

This review aims to identify digital tools that promote self-management in neurological conditions and to investigate their underlying functionality and salient clinical outcomes.

METHODS

We conducted a search of 6 databases (ie, CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, and the Cochrane Review) using free text and equivalent database-controlled vocabulary terms.

RESULTS

We identified 27 published articles reporting 17 self-management digital tools. Multiple sclerosis (MS) had the highest number of digital tools followed by epilepsy, stroke, and headache and migraine with a similar number, and then pain. The majority were aimed at patients with a minority for carers. There were 5 broad categories of functionality promoting self-management: (1) knowledge and understanding; (2) behavior modification; (3) self-management support; (4) facilitating communication; and (5) recording condition characteristics. Salient clinical outcomes included improvements in self-management, self-efficacy, coping, depression, and fatigue.

CONCLUSIONS

There now exist numerous digital tools to support user self-management, yet relatively few are described in the literature. More research is needed to investigate their use, effectiveness, and sustainability, as well as how this interacts with increasing disability, and their integration within formal neurological care environments.

Diagnostic accuracy of an artificial intelligence online engine in migraine: A multi‐center study

Objective

This study assesses the concordance in migraine diagnosis between an online, self‐administered, Computer‐based, Diagnostic Engine (CDE) and semi‐structured interview (SSI) by a headache specialist, both using International Classification of Headache Disorders, 3rd edition (ICHD‐3) criteria.

Background

Delay in accurate diagnosis is a major barrier to headache care. Accurate computer‐based algorithms may help reduce the need for SSI‐based encounters to arrive at correct ICHD‐3 diagnosis.

Methods

Between March 2018 and August 2019, adult participants were recruited from three academic headache centers and the community via advertising to our cross‐sectional study. Participants completed two evaluations: phone interview conducted by headache specialists using the SSI and a web‐based expert questionnaire and analytics, CDE. Participants were randomly assigned to either the SSI followed by the web‐based questionnaire or the web‐based questionnaire followed by the SSI. Participants completed protocols a few minutes apart. The concordance in migraine/probable migraine (M/PM) diagnosis between SSI and CDE was measured using Cohen’s kappa statistics. The diagnostic accuracy of CDE was assessed using the SSI as reference standard.

Results

Of the 276 participants consented, 212 completed both SSI and CDE (study completion rate = 77%; median age = 32 years [interquartile range: 28–40], female:male ratio = 3:1). Concordance in M/PM diagnosis between SSI and CDE was: κ = 0.83 (95% confidence interval [CI]: 0.75–0.91). CDE diagnostic accuracy: sensitivity = 90.1% (118/131), 95% CI: 83.6%–94.6%; specificity = 95.8% (68/71), 95% CI: 88.1%–99.1%. Positive and negative predictive values = 97.0% (95% CI: 91.3%–99.0%) and 86.6% (95% CI: 79.3%–91.5%), respectively, using identified migraine prevalence of 60%. Assuming a general migraine population prevalence of 10%, positive and negative predictive values were 70.3% (95% CI: 43.9%–87.8%) and 98.9% (95% CI: 98.1%–99.3%), respectively.

Conclusion

The SSI and CDE have excellent concordance in diagnosing M/PM. Positive CDE helps rule in M/PM, through high specificity and positive likelihood ratio. A negative CDE helps rule out M/PM through high sensitivity and low negative likelihood ratio. CDE that mimics SSI logic is a valid tool for migraine diagnosis.

Study Design and Protocol of a Randomized Controlled Trial of the Efficacy of a Smartphone-Based Therapy of Migraine (SMARTGEM)

Background

Digitalization and electronic health (eHealth) offer new treatment approaches for patients with migraine. Current smartphone applications (apps) for migraine patients include a wide spectrum of functions ranging from digital headache diaries to app-based headache treatment by, among others, analysis of the possible triggers, behavioral therapy approaches and prophylactic non-drug treatment methods with relaxation therapy or endurance sport. Additional possibilities arise through the use of modern, location-independent communication methods, such as online consultations. However, there is currently insufficient evidence regarding the benefits and/or risks of these electronic tools for patients. To date, only few randomized controlled trials have assessed eHealth applications.

Methods

SMARTGEM is a randomized controlled trial assessing whether the provision of a new digital integrated form of care consisting of the migraine app M-sense in combination with a communication platform (with online consultations and medically moderated patient forum) leads to a reduction in headache frequency in migraine patients, improving quality of life, reducing medical costs and work absenteeism (DRKS-ID: DRKS00016328).

Discussion

SMARTGEM constitutes a new integrated approach for migraine treatment, which aims to offer an effective, location-independent, time-saving and cost-saving treatment. The design of the study is an example of how to gather high quality evidence in eHealth. Results are expected to provide insightful information on the efficacy of the use of electronic health technology in improving the quality of life in patients suffering from migraine and reducing resource consumption.

Telemedicine application to headache: a critical review

BACKGROUND

Migraine affects more than a billion people all over the world and requires critical employment of healthcare resources. Telemedicine could be a reasonable tool to manage people suffering from headaches, and it received a big push from the COVID-19 pandemic.

OBJECTIVE

This review aims to propose a practical approach for the virtual management of these patients.

METHODS

To do this, we conducted a literature search, including 32 articles relevant to the topic treated in this review.

RESULTS

The most challenging step in telemedicine applied to practical neurology remains the clinical assessment, but through a careful headache history and a recently proposed entirely virtual neurological assessment, this hitch can be easily overcome. Electronic diary compilations and virtual administration of disability-measuring scales, conversely, are the key features of effective long-term follow-up although we do not have apps that met the criteria of scientific reliability. Furthermore, tele-rehabilitation seems to be effective and has demonstrated to be a solution to alternatively treat chronic patients at home, and can be considered part of the remote management of headache patients. Moreover, virtual management of headaches finds an application in specific communities of patients, as pediatric patients and for rural communities of low- and middle-income countries suffer from health disparities, with inadequate resources and knowledge gaps.

CONCLUSION

Telemedicine could be promising for patients with no regular or convenient access to headache specialists and seems to be a priority in managing migraine patients to avoid non-urgent hospitalizations.

Digital diary App use for migraine in primary care: Prospective cohort study

BACKGROUND

Headache diaries are recommended for migraine management in primary care.

OBJECTIVE

Determine the acceptability and use of a digital headache diary App for migraine METHODS: Evaluative prospective primary care cohort study in North of England. Part 1 was a postal survey; if responders were interested, in Part 2 participants trialled the digital N1-Headache App headache diary for 90 days, followed by survey feedback on the App's usability.

RESULTS

A total of 637 out of 2189 invited patients (29%) completed the initial survey, and 32% of respondents had previously used a headache diary; 437 out of 637 patients (69%) were interested in using the App. Regression analysis showed that interested patients were those with more severe migraines that limit physical/intellectual activities, and who indicate to not know enough about their migraine. Actual registration numbers and compliance with the App was very modest; 53 out of 173 participants (23%), who ultimately activated their personal N1-Headache App account, were able to generate a personalised trigger and protector map & report. Furthermore, at the end of the 90 day App trial period there was a non-significant trend towards improvements in participants' health confidence levels.

CONCLUSION

Migraine patients - particularly those with more severe and frequent migraines - show an interest in using a digital headache diary App, Ultimately, consistent daily use is very modest. The challenge is to improve App usage and compliance rates to allow interpretation of more patients' migraine trigger and/or protector patterns, and wider use amongst patients.

Tele-healthcare in migraine medicine: from diagnosis to monitoring treatment outcomes

INTRODUCTION

: Primary headaches represent a huge cost in terms of decreased productivity and migraine occupies the first position among disabilities in working population. Migraine has a high incidence, disproportionate to the available primary care centres. In most cases, migraine can be managed through the simple and accurate collection of clinical history, which makes it an ideal candidate for tele-healthcare.

AREAS COVERED

: In this narrative review we retrace the most important scientific evidence regarding use of tele-healthcare in headache medicine. Over the last few years, it has proved to be a valid and useful tool for the management of migraine. Furthermore, current pandemic has imposed a drastic change in the way of thinking and setting up medicine, forcing clinicians and patients to a huge expansion of telemedicine.

EXPERT OPINION

: We should permanently insert the culture of telemedicine in the headache care not only in academies and scientific societies, but extend it to specialized hospitals for the treatment of headaches. Only by broadening the old book-based strategy, we will be able to open the door to the multidimensional culture of headache medicine. Experts of excellence centres should set an example and pave the way for the rest of the clinicians.

Psychological Interventions for Pediatric Headache Disorders: A 2021 Update on Research Progress and Needs

PURPOSE OF REVIEW

This review summarizes key findings from recent investigations of psychological interventions for pediatric headache disorders and discusses important avenues for future research.

RECENT FINDINGS

Cognitive Behavioral Therapy (CBT) is effective in reducing headache days among youth with chronic headache. There is mixed evidence for the benefit of CBT on reducing disability associated with migraine, suggesting that there is room to optimize CBT by leveraging complementary or alternative psychological interventions, such as Acceptance and Commitment Therapy (ACT) and mindfulness-based approaches. Tailoring CBT may be especially important for youth with more impairing or complex clinical presentations, such as those with continuous headache. Using eHealth and novel study designs to expand access to and dissemination of psychological interventions is promising. Although CBT is the gold standard psychological treatment for youth with migraine, we are only beginning to understand how and why it is effective. Other promising psychological treatments are available, and studies are beginning to examine how CBT can be optimized to fit the unique needs of each patient. Improving access and equitability of care for youth with migraine will require tailoring psychological treatments for patients with varying headache presentations and youth from a variety of cultural, racial, ethnic, and linguistic backgrounds.

The use of virtual complementary and integrative therapies by neurology outpatients: An exploratory analysis of two cross-sectional studies assessing the use of technology as treatment in an academic neurology department in New York City

Background

Prior to the COVID-19 pandemic, about half of patients from populations that sought care in neurology tried complementary and integrative therapies (CITs). With the increased utilization of telehealth services, we sought to determine whether patients also increased their use of virtual CITs.

Methods

We examined datasets from two separate cross-sectional surveys that included cohorts of patients with neurological disorders. One was a dataset from a study that examined patient and provider experiences with teleneurology visits; the other was a study that assessed patients with a history of COVID-19 infection who presented for neurologic evaluation. We assessed and reported the use of virtual (and non-virtual) CITs using descriptive statistics, and determined whether there were clinical characteristics that predicted the use of CITs using logistic regression analyses.

Findings

Patients who postponed medical treatment for non-COVID-19-related problems during the pandemic were more likely to seek CITs. Virtual exercise, virtual psychotherapy, and relaxation/meditation smartphone applications were the most frequent types of virtual CITs chosen by patients. In both studies, age was a key demographic factor associated with mobile/virtual CIT usage.

Interpretations

Our investigation demonstrates that virtual CIT-related technologies were utilized in the treatment of neurologic conditions during the pandemic, particularly by those patients who deferred non-COVID-related care.

A Biofeedback App for Migraine: Development and Usability Study

Background

Biofeedback is effective in treating migraines. It is believed to have a beneficial effect on autonomous nervous system activity and render individuals resilient to stressors that may trigger a migraine. However, widespread use of biofeedback is hampered by the need for a trained therapist and specialized equipment. Emerging digital health technology, including smartphones and wearables (mHealth), enables new ways of administering biofeedback. Currently, mHealth interventions for migraine appear feasible, but development processes and usability testing remain insufficient.

Objective

The objective of this study was to evaluate and improve the feasibility and usability of an mHealth biofeedback treatment app for adults with migraine.

Methods

In a prospective development and usability study, 18 adults with migraine completed a 4-week testing period of self-administered therapist-independent biofeedback treatment consisting of a smartphone app connected to wearable sensors (Cerebri, Nordic Brain Tech AS). The app included biofeedback training, instructions for self-delivery, and a headache diary. Two wearable sensors were used to measure surface electromyographic voltage at the trapezius muscle and peripheral skin temperature and heart rate at the right second fingertip. Participants were instructed to complete a daily headache diary entry and biofeedback session of 10 minutes duration. The testing period was preceded by a preusability expectation interview and succeeded by a postusability experience interview. In addition, an evaluation questionnaire was completed at weeks 2 and 4. Adherence was calculated as the proportion of 10-minute sessions completed within the first 28 days of treatment. Usability and feasibility were analyzed and summarized quantitatively and qualitatively.

Results

A total of 391 biofeedback sessions were completed with a median of 25 (IQR 17-28) per participant. The mean adherence rate was 0.76 (SD 0.26). The evaluation questionnaire revealed that functionality and design had the highest scores, whereas engagement and biofeedback were lower. Qualitative preexpectation analysis revealed that participants expected to become better familiar with physical signals and gain more understanding of their migraine attacks and noted that the app should be simple and understandable. Postusability analysis indicated that participants had an overall positive user experience with some suggestions for improvement regarding the design of the wearables and app content. The intervention was safe and tolerable. One case of prespecified adverse events was recorded in which a patient developed a skin rash from the sticky surface electromyography electrodes.

Conclusions

The app underwent a rigorous development process that indicated an overall positive user experience, good usability, and high adherence rate. This study highlights the value of usability testing in the development of mHealth apps.

Determining the Evolution of Headache Among Regular Users of a Daily Electronic Diary via a Smartphone App: Observational Study

Background

Smartphone-based apps represent a major development in health care management. Specifically in headache care, the use of electronic headache diaries via apps has become increasingly popular. In contrast to the soaring volume of available data, scientific use of these data resources is sparse.

Objective

In this analysis, we aimed to assess changes in headache and migraine frequency, headache and migraine intensity, and use of acute medication among people who showed daily use of the headache diary as implemented in the freely available basic version of the German commercial app, M-sense.

Methods

The basic version of M-sense comprises an electronic headache diary, documentation of lifestyle factors with a possible impact on headaches, and evaluation of headache patterns. This analysis included all M-sense users who had entered data into the app on a daily basis for at least 7 months.

Results

We analyzed data from 1545 users. Mean MHD decreased from 9.42 (SD 5.81) at baseline to 6.39 (SD 5.09) after 6 months (P<.001; 95% CI 2.80-3.25). MMD, AMD, and migraine intensity were also significantly reduced. Similar results were found in 985 users with episodic migraine and in 126 users with chronic migraine.

Conclusions

Among regular users of an electronic headache diary, headache and migraine frequency, in addition to other headache characteristics, improved over time. The use of an electronic headache diary may support standard headache care.

Telemedicine Applications for the Evaluation of Patients with Non-Acute Headache: A Narrative Review

The COVID-19 pandemic has spurred a hasty transition to virtual care but also an abundance of new literature highlighting telehealth’s capabilities and limitations for various healthcare applications. In this review, we aim to narrate the current state of the literature on telehealth applied to migraine care. First, telemedicine in the context of non-acute headache management has been shown to produce non-inferior patient outcomes when compared to traditional face-to-face appointments. The assignment of patients to telehealth appointments should be made after referring more urgent cases to dedicated in-person clinics. During the virtual appointment, physicians can ask their patients about the “3 F’s” in order to perform a thorough assessment of their headaches: frequency of headache days, frequency of acute medication usage and functional impairment. Clinical assessment scores that have been studied and deemed feasible for telemedicine, safe and efficient include the HIT-6, VAS and MIDAS scores. Although MIDAS was found to be redundant and inadequate to use on a daily basis, we suggest that it can be useful in periodic remote follow-up appointments. Additionally, several mobile health apps have been studied including Migraine Buddy, Migraine Coach and Migraine Monitor. All of these are appropriate for use in telemedicine when combined with an adequate trial period with Migraine Buddy being rated the highest, as it captures the most detailed clinical picture. High satisfaction rates have been reported for virtual headache management which were shown to be equal to in-person consults. These are based on patients’ perceived increase in convenience due to avoided travel time, less disruption of their daily routine and feeling more comfortable in the environment of their choice. Despite this, limitations such as technological knowledge, access to videoconferencing modalities and having a more impersonal consultation with the physician may hinder some patients from adopting this service.

Perception of Purposeful and Recreational Smartphone Use in Physiotherapy: Randomized Controlled Trial

Background

Many people constantly use their smartphones in all kinds of situations. Often smartphones are used in a meaningful and targeted way, but frequently they are used as a pastime without any purpose. This also applies to patients and therapists in treatment situations.

Objective

The aim of this study was to investigate how purposeful smartphone use compared with recreational smartphone use (by a physiotherapist or by a patient) influenced the perception of a physiotherapeutic treatment situation. We examined the impact of smartphone use during a physiotherapy session on the perception of the physiotherapist, evaluation of attentiveness, and evaluation of smartphone use in physiotherapy in general.

Methods

Members of various music and sports clubs were invited to participate in an online randomized controlled trial. Participants were randomly assigned to one of four conditions. They watched a video in which a physiotherapeutic treatment was shown and in which a smartphone was used or not used in the following four different ways: (1) therapeutically purposeful use, (2) recreational use by the physiotherapist (looking at the phone from time to time with no therapeutic purpose), (3) recreational use by the patient, and (4) no smartphone use (control condition). After watching the video, the participants indicated their perception of the physiotherapist’s professional competence, social competence, and empathetic behavior. They also rated the physiotherapist’s and patient’s attentiveness and evaluated the usage of smartphones generally in physiotherapy.

Results

The analysis included 118 participants (63 women and 55 men). When the physiotherapist used the smartphone in a purposeful way, the physiotherapist was perceived as more professionally competent (P=.007), socially competent (P=.03), and empathetic (P=.04) than if the physiotherapist used it with no therapeutic purpose. These effects occurred because recreational smartphone use by the physiotherapist was evaluated more negatively than the behavior in the control condition (professional competence: P=.001; social competence: P=.03; empathy: P=.04). Moreover, when the physiotherapist used the smartphone in a recreational way, the physiotherapist was perceived as being less attentive (P<.001). Likewise, when the patient used the smartphone in a recreational way, the patient was perceived as being less attentive (P<.001). Finally, smartphone use in physiotherapy was rated as more positive in general when the smartphone was used in a purposeful way compared with the conditions in which the physiotherapist or patient looked at the smartphone with no therapeutic purpose (P<.001). This positive evaluation occurred because purposeful use led to a more positive rating than no smartphone use (P<.001, R=0.42).

Conclusions

Smartphones are only appropriate for therapists and patients if they are used directly for a therapeutic purpose. Otherwise, it is better not to use smartphones during treatment.

Trial Registration

AsPredicted (aspredicted.org) #24740; https://aspredicted.org/blind.php?x=vv532i

Telerehabilitation for Headache Management

Headache is one of the most disabling conditions in the world. Despite plentiful evidence supporting rehabilitation strategies, headache is significantly underassessed and undertreated. Obstacles to headache care include lack of available expertise in headache management, few available resources for effective assessment and treatment, and cost and disability that preclude treatment seeking in patients with headache. Telerehabilitation can allow providers to access expert consultation and gives patients easier access to assessment and treatment. This article covers existing telerehabilitation options for headache management and explores the strength of evidence supporting these approaches. Risks of telerehabilitation and recommendations for future development are discussed.

Self‐administered biofeedback treatment app for pediatric migraine: A randomized pilot study

Objective

To investigate the effect size, safety, and tolerability of a therapist‐independent biofeedback treatment app among adolescent with migraine.

Materials and Methods

This was a prospective, 3:1 ratio randomized, sham‐controlled, double‐blind, pilot study with 16 adolescents diagnosed with migraine randomized to eight weeks of biofeedback treatment (n = 12) or sham biofeedback (n = 4), carried out at two university hospitals in Norway. The prespecified and primary objective of the study was to observe changes in outcomes within the active treatment group. The sham control group was included in a minor ratio primarily to evaluate its feasibility. The primary outcome was change in headache frequency. A modified intention to treat analysis was performed, including participants completing at least seven biofeedback sessions in weeks 1–4 (n = 12 vs. n = 4) and weeks 5–8 (n = 7 vs. n = 2).

Results

Adherence was poor with 40% (136/336) of planned biofeedback sessions completed during weeks 5–8. Within the biofeedback group, a not statistically significant reduction in headache frequency was observed at weeks 1–4 (2.92 days/month, 95% CI −1.00 to 6.84, p = .145) and weeks 5–8 (1.85 days/month, 95% CI −2.01 to 5.72, p = .395). The biofeedback group experienced a median of one fewer headache days/month versus sham that did not reach significance (95% CI −4.0 to 9.0, p = .760).

Conclusions

We observed a small reduction in headache frequency in the active treatment group. Findings were likely undermined by low adherence and underpowered analyses but indicate that a therapist‐independent biofeedback treatment app has the potential to be an effective, tolerable, and inexpensive treatment option.

Towards eHealth to support the health journey of headache patients: a scoping review

Objective

The aim of this study is to (1) review the digital health tools that have been used in headache studies, and (2) discuss the effectivity and reliability of these tools.

Background

Many headache patients travel a long and troublesome journey from first symptoms until a meaningful care plan. eHealth, mHealth, and digital therapeutic modalities have been advocated as the way forward to improve patient care.

Method

Online databases PubMed, Cinahl, and PsycINFO were searched using a predefined search query. A data extraction form was used to gather relevant data elements from the selected papers.

Results

A total of 39 studies were selected. The studies included 94,127 participants. The majority of studies focused on diaries (N = 27 out of 39). Digital (cognitive) behavioral therapy were also quite common (N = 7 out of 39). Other digital health tool categories were tele-consultations, telemonitoring and patient portals.

Conclusion

Many digital health tools for headache patients regarding diaries and behavioral/therapeutical treatment are described in scientific research with limited information on effectivity and reliability. Scientific knowledge with regard to other categories such as tele-consultations, patient portals, telemonitoring including medication adherence, online information resources, wearable, symptom checkers, digital peer support is still scarce or missing.

Assessment of Work Productivity and Activity Impairment (WPAI) questionnaire for migraine with the help of a smartphone app

BACKGROUND

Migraine is a major cause of disability, which affects many areas of life, including productivity at work. Measuring absenteeism and presenteeism resulting from migraine with the use of appropriate tools is essential for better understanding the impact of this disease.

OBJECTIVE

The aim of the present study was to assess the work impact of migraine using the Brazilian Portuguese version of Work Productivity and Activity Impairment (WPAI) questionnaire.

METHODS

This survey was carried out with the aid of a smartphone app (Dr Cefaleia for Doctors) containing the questionnaires: ID-Migraine, Headache Impact Test (HIT-6), and WPAI. The data were collected during a headache awareness event. Correlations were assessed between migraine impact (HIT-6) with WPAI parameters: a) work time missed (absenteeism), b) impairment at work (presenteeism), c) overall work productivity loss (absenteeism+presenteeism), and d) activity impairment outside work.

RESULTS

Overall, 305 subjects with headache were interviewed and 167 were classified as having migraine. No significant differences in migraine impact according to sex (p=0.8) and modality of work were registered (p=0.8). Females had significantly higher absenteeism score (p<0.001), but presenteeism score was not significantly different between genders (p=0.3). WPAI absenteeism and presenteeism scores significantly correlated with migraine impact (HIT-6).

CONCLUSIONS

The results suggest WPAI Brazilian Portuguese version was efficient in assessing migraine related work impact. The use of an app with validated questionnaires facilitates the conduction of migraine impact research in different populations, allowing a better understanding of the burden of this disease.

Smartphone use and primary headache: A cross-sectional hospital-based study

Objective

To determine the association of smartphone use with occurrence of new-onset headache and/or increased severity of headaches in patients with primary headache.

Methods

In a cross-sectional study between June 2017 and December 2018, patients with primary headache were divided into 2 groups: smartphone users (SUs) and non-smartphone users (NSUs). A questionnaire was administered for headache characteristics and treatment taken. The primary objective was to determine the association of smartphone use with new-onset headache or increase severity. The secondary objective was to determine any differences in the requirement of acute medication and prophylaxis.

Results

Four hundred patients were included in the study, of which 194 were NSUs and 206 were SUs. The NSUs were older with lower education and socioeconomic status. The headache characteristics were similar in both the groups, except for higher occurrence of aura (NSUs: 15 [7.7%] vs SUs: 36 [17.5%]; p = 0.003) in the SU group. There was, however, higher proportion of patients taking analgesics (NSUs: 157 [80.9%] vs SUs: 197 [95.6%]; p < 0.001), with less relief in headache with medication in the SU group. This was driven by increased pill count (low SUs: 5.0 [3.0; 10.0] vs high SUs: 10.0 [5.0; 15.0]; p = 0.007) and poor response to medication in the high SU group.

Conclusions

The use of smartphone was associated with increase in requirement of acute medication and less relief with acute medication. Longitudinal studies may be required to confirm these findings.

The global burden of neurological disorders: translating evidence into policy

Neurological disorders are the leading cause of disability and the second leading cause of death worldwide. In the past 30 years, the absolute numbers of deaths and people with disabilities owing to neurological diseases have risen substantially, particularly in low-income and middle-income countries, and further increases are expected globally as a result of population growth and ageing. This rise in absolute numbers of people affected suggests that advances in prevention and management of major neurological disorders are not sufficiently effective to counter global demographic changes. Urgent measures to reduce this burden are therefore needed. Because resources for health care and research are already overstretched, priorities need to be set to guide policy makers, governments, and funding organisations to develop and implement action plans for prevention, health care, and research to tackle the growing challenge of neurological disorders.