One-Day Behavioral Intervention for Distressed Veterans with Migraine: Results of a Multimethod Pilot Study

A meta-analytic review of acceptance-based interventions for migraine

OBJECTIVE

To determine the efficacy of acceptance and mindfulness-based interventions on migraine disability, medication use, and attack frequency.

BACKGROUND

Acceptance-based approaches to headache management are those in which individuals learn to mitigate the influence of pain-related experiences on their general functioning without controlling pain itself. Treatment approaches include acceptance and commitment therapy (ACT) and mindfulness-based practices. Both have shown promise in improving broad functioning and disability among individuals with headache. Despite a growing body of research examining acceptance-based interventions for headache broadly and migraine specifically, no meta-analytic review of ACT interventions for headache exists, and two meta-analytic reviews of mindfulness-based practices yielded conflicting results.

METHODS

The present study aimed to systematically and quantitatively review the literature related to the efficacy of acceptance-based interventions among adults with migraine. A multi-database search (PubMed/MEDLINE, Scopus, PsycINFO, and the Cochrane Central Register of Controlled Trials) identified clinical trials among individuals with migraine that compared structured ACT or mindfulness-based interventions to control treatment. Random-effects meta-analyses were performed using RevMan 5.4 meta-analytic software, and standardized mean differences (SMD) with 95% confidence intervals (CIs) quantified effect sizes on outcomes of disability, medication use, and headache frequency. Heterogeneity was quantified via I2 index and explored via subgroup analyses.

RESULTS

Acceptance-based interventions yielded significant improvements in disability (SMD = -0.38, 95% CI = -0.56 to -0.20; I2  = 25%, p = 0.20) but not in medication use (SMD = -0.25, 95% CI: -0.57 to 0.06; I2  = 0%, p = 0.82) or headache frequency (SMD = -0.16, 95% CI = -0.37 to 0.05; I2  = 0%, p = 0.73).

CONCLUSION

Results suggest that acceptance-based interventions are effective in improving disability among adults with migraine and are a viable non-pharmacological treatment option, in addition to well-established behavioral migraine management approaches, for patients seeking functional improvement.

Headache Disorders in VHA Primary Care: Prevalence, Psychiatric Comorbidity, and Health Care Utilization

Military veterans are at increased risk for headache disorders compared to the general population, yet the prevalence and burden associated with headache disorders among veterans is not yet well understood. In this electronic medical record study, we examined the prevalence of headache disorders among veterans seen in a northeastern network of Veterans Health Administration (VHA) primary care during 2017-2018. We also examined rates of psychiatric comorbidity and health care utilization of veterans with headache disorders for the year following the date of the first headache code in the medical record. Of the total population of veterans in the network, 1.3% had a headache disorder and another 3.5% had a possible headache disorder. Migraine and chronic migraine represented the majority of cases. Posttraumatic stress disorder was the most frequent psychiatric comorbidity. Having a headache disorder was associated with higher rates of primary care, neurology, pain clinic, and mental health service use but not higher rates of emergency department or Whole Health (e.g., patient-centered, holistic health services) use. Prevalence findings are comparable to those previously found among veterans, but a substantial proportion of veterans may have been misdiagnosed. Veterans with headache disorders have high rates of psychiatric comorbidity and use several types of health services at higher rates. Findings highlight the need for interdisciplinary care and further education and support for primary care providers. Primary care settings that integrate evidence-based behavioral and Whole Health services may be an optimal way of providing more holistic care for headache disorders.

A qualitative evidence synthesis of patient perspectives on migraine treatment features and outcomes

OBJECTIVES

We aimed to identify migraine treatment features preferred by patients and treatment outcomes most valued by patients.

BACKGROUND

The values and preferences of people living with migraine are critical for both the choice of acute therapy and management approach of migraine.

METHODS

We conducted a qualitative evidence synthesis. Two reviewers independently selected studies, appraised methodological quality, and undertook a framework synthesis. We developed summary of findings tables following the approach of Grading of Recommendations, Assessment, Development and Evaluations Confidence in the Evidence from Reviews of Qualitative Research to assess confidence in the findings.

RESULTS

Of 1691 candidate references, we included 19 studies (21 publications) involving 459 patients. The studies mostly recruited White women from North America (11 studies) and Europe (8 studies). We identified eight themes encompassing features preferred by patients in a migraine treatment process. Themes described a treatment process that included shared decision-making, a tailored approach, trust in health-care professionals, sharing of knowledge and diversity of treatment options, a holistic approach that does not just address the headache, ease of communication especially for complex treatments, a non-undermining approach, and reciprocity with mutual respect between patient and provider. In terms of the treatment itself, seven themes emerged including patients' preferences for nonpharmacologic treatment, high effectiveness, rapidity of action, long-lasting effect, lower cost and more accessibility, self-management/self-delivery option that increases autonomy, and a mixed preference for abortive versus prophylactic treatments. The treatment outcomes that have high value to patients included maintaining or improving function; avoiding side effects, potential for addiction to medications, and pain reoccurrence; and avoiding non-headache symptoms such as nausea, vomiting, and sensitivity to light or sounds.

CONCLUSION

Patient values and preferences were individually constructed, varied widely, and could be at odds with conventional medical perspectives and evidence of treatment effects. Considering the availability of numerous treatments for acute migraine, it is necessary that decision-making incorporates patient values and preferences identified in qualitative research. The findings of this qualitative synthesis can be used to facilitate an individually tailored approach, strengthen the patient-health-care system relationship, and guide choices and decisions in the context of a clinical encounter or a clinical practice guideline.

Single-Session Acceptance and Commitment Therapy (ACT) Interventions for Patients with Chronic Health Conditions: A Systematic Review and Meta-Analysis

RATIONALE

Chronic health conditions (CHCs) are costly and difficult to manage. Patients often struggle with behavioral adherence to complex treatment regimens and experience psychiatric distress. Acceptance and Commitment Therapy (ACT) is a transdiagnostic behavioral approach that aims to improve functioning and quality of life (QoL), which are important treatment outcomes for this population. Preliminary efficacy of multi-session ACT in patients with CHCs has been demonstrated, and single-session ACT interventions have since been developed to increase feasibility, acceptability, and accessibility. The purpose of this systematic review and meta-analysis was to describe the literature on single-session ACT intervention studies in CHC populations with regards to (1) study design and methodology, (2) patient characteristics and conditions targeted, and (3) efficacy for outcomes across various domains, using narrative and quantitative methods.

METHODS

PsycINFO, PubMed, and Web of Science were systematically searched in August 2020. Studies of single-session ACT interventions in adult patients with CHCs that reported quantitative outcomes in any of the following domains were included: (a) functioning and related domains (e.g., disability, QoL, well-being); (b) mental health; (c) physical health; (d) ACT processes. Both controlled and uncontrolled studies were included. Study quality was assessed using the Psychotherapy Outcome Study Methodology Rating Scale (POMRF). Between-group random effects meta-analysis was conducted on general functioning outcomes.

RESULTS

Fourteen manuscripts reporting outcomes from 13 studies (N = 793) met inclusion criteria. Ten studies were identified by their authors as pilot or feasibility trials. Eight studies used comparison or control groups. Twelve studies delivered the ACT content in workshop format. Studies recruited for a variety of conditions. Narrative review found that between- and within-group effect sizes showed generally positive results favoring single-session ACT overall (69%), especially for measures of functioning and related domains (88%), mental health (67%), and ACT processes (73%). Meta-analysis found that ACT did not significantly outperform comparison groups on measures of general functioning (Hedges' g: -0.51, 95% confidence interval: [-1.19, 0.16]; I 2 = 86%; K = 5) despite a medium-sized pooled effect.

DISCUSSION

Use of single-session ACT interventions in CHC populations is an emergent field. There is preliminary evidence for the acceptability, feasibility, and efficacy of these interventions, which provides support for further testing in fully-powered RCTs. Additional RCTs will enable larger meta-analyses and stronger conclusions about efficacy. Recommendations for future trials are provided.

One-day Acceptance and Commitment Therapy workshop for preventing persistent post-surgical pain and dysfunction in at-risk veterans: A randomized controlled trial protocol

OBJECTIVE

Persistent post-surgical pain is common among patients undergoing surgery, is detrimental to patients' quality of life, and can precipitate long-term opioid use. The purpose of this randomized controlled trial is to assess the effects of a behavioral intervention offered prior to surgery for patients at risk for poor post-surgical outcomes, including persistent pain and impaired functioning.

METHODS

Described herein is an ongoing randomized, patient- and assessor-blind, attention-controlled multisite clinical trial. Four hundred and thirty Veterans indicated for total knee arthroplasty (TKA) with distress and/or pain will be recruited for this study. Participants will be randomly assigned to a one-day (~5 h) Acceptance and Commitment Therapy workshop or one-day education and attention control workshop. Approximately two weeks following their TKA surgery, patients receive an individualized booster session via phone. Following their TKA, patients complete assessments at 1 week, 6 weeks, 3 months, and 6 months.

RESULTS

The primary outcomes are pain intensity and knee-specific functioning; secondary outcomes are symptoms of distress and coping skills. Mediation analyses will examine whether changes in symptoms of distress and coping skills have an impact on pain and functioning at 6 months in Veterans receiving ACT. This study is conducted mostly with older Veterans; therefore, results may not generalize to women and younger adults who are underrepresented in this veteran population.

CONCLUSIONS

The results of this study will provide the first evidence from a large-scale, patient- and assessor-blind controlled trial on the effectiveness of a brief behavioral intervention for the prevention of persistent post-surgical pain and dysfunction.

Episodic Migraine Comorbidities: Avoiding Pitfalls and Taking Therapeutic Opportunities

Migraine is a common neurologic disorder. This article will discuss a few factors that influence migraine (mostly episodic) and its treatment, such as sleep, obstructive sleep apnea (OSA), obesity, and affective disorders, as well as autoimmune diseases. Practitioners must be aware of these coexisting conditions (comorbidities) as they affect treatment. It is noted in literature that both the quantity (too much or too few hours) and the quality (OSA related) of sleep may worsen migraine frequency. An associated risk factor for OSA, obesity also increases migraine frequency in episodic migraine cases. A bidirectional relationship with migraine along with depression and anxiety is debated in the literature. Retrospective cohort studies are undecided and lack statistical significance, but prospective studies do show promising results on treatment of anxiety and depression as a means of improving migraine control. Finally, we address the topic of autoimmune diseases and migraine. While few studies exist at this time, there are cohort study groups looking into the association between rheumatoid arthritis, hypothyroidism, and antiphospholipid antibody. There is also evidence for the link between migraine and vascular diseases, including coronary and cerebral diseases. We suggest that these comorbid conditions be taken into account and individualized for each patient along with their pharmaceutical regimen. Physicians should seek a multifactorial treatment plan including diet, exercise, and healthy living to reduce migraine frequency.