Migraine education improves quality of life in a primary care setting

Cognition, mental health, and quality of life in patients with chronic and episodic migraine during the interictal period

INTRODUCTION

Migraine is a highly prevalent and disabling condition, not only due to its painful symptoms but also because of its significant impact on mental health and cognitive functioning, leading to a considerable deterioration in quality of life. This study aimed to evaluate the cognitive profile, mental health, and quality of life in patients with chronic and episodic migraine during the interictal period, and to explore their relationship with sociodemographic and clinical variables.

METHOD

This observational, descriptive, cross-sectional analytical study included 60 patients diagnosed with chronic or episodic migraine, who were enrolled in a health program for headache patients between 2010 and 2016. Cognitive function, anxiety and/or depression symptoms, and quality of life during the interictal period were assessed. Descriptive analyses were conducted, and associations were evaluated by configuring primary (type of migraine) and alternative events (cognitive impairment, depression and/or anxiety, and poor quality of life).

RESULTS

The mean age of the participants was 45 years (SD ± 8), with 83.3% being women and 93.3% belonging to middle and low socioeconomic strata. Of the 60 patients, 83.3% (50) were diagnosed with chronic migraine, while the remaining had episodic migraine. The use of one or more cognition-altering medications was observed in 90% of patients with chronic migraine and 60% of those with episodic migraine (p = 0.02). Anxiety was more prevalent in patients with episodic migraine, whereas depression was more common among those with chronic migraine. Female gender, middle socioeconomic status, and longer disease duration were significantly associated with chronic migraine. Among the 57 patients who completed the Mini-Mental State Examination, 38.6% had cognitive impairment, which decreased with longer migraine duration and better social interaction. Memory and selective attention were the most affected cognitive domains in both groups. No significant associations were found for the other variables after adjusting for confounders.

CONCLUSIONS

Chronic migraine significantly impacts mental health, cognition, and quality of life, with depression and cognitive impairments being prevalent. Social interaction and longer disease duration may protect against cognitive decline, highlighting the need for multidisciplinary, personalized interventions addressing neurological and psychosocial challenges.

Treatment patterns and characteristics of headache in patients in Japan: A retrospective cross-sectional and longitudinal analysis of health insurance claims data

BACKGROUND

The present study aimed to investigate prescription patterns for patients aged over 17 years with headaches in the REZULT database.

METHODS

We conducted a cross-sectional study (Study 1) of the proportion of over-prescription of acute medications (≥30 tablets/90 days for triptans, combination non-steroidal anti-inflammatory drugs (NSAIDs) and multiple types; ≥45 tablets/90 days for single NSAIDs) among patients with headache diagnosed in 2020. We longitudinally studied (Study 2) patients for >2 years from initial headache diagnosis (July 2010 to April 2022). The number of prescribed tablets was counted every 90 days.

RESULTS

In Study 1, headache was diagnosed in 200,055 of 3,638,125 (5.5%) patients: 13,651/200,055 (6.8%) received acute medication. Single NSAIDs were prescribed to 12,297/13,651 (90.1%) patients and triptans to 1710/13,651 (12.5%). Over-prescription was found in 2262/13,651 (16.6%) patients and 1200/13,651 (8.8%) patients received prophylactic medication. In Study 2, 408,183/6,840,618 (6.0%) patients were first diagnosed with headaches, which persisted for ≥2 years. Over time, the proportion of patients over-prescribed acute medications increased. Over 2 years, 37,617/408,183 (9.2%) patients were over-prescribed acute medications and 29,313/408,183 (7.2%) patients were prescribed prophylaxis at least once.

CONCLUSIONS

According to real-world data, prophylaxis remains poorly prescribed, and both acute and prophylactic treatment rates for headaches have increased over time.

Consensus recommendations for the treatment of migraine prevention

OBJECTIVE

The objectives are to know the opinion of neurologists and hospital pharmacists on those aspects still under debate regarding the role of anti-CGRP monoclonal antibodies in the preventive treatment of migraine. To identify those controversies that still exist. To propose agreed recommendations for improvement of care. And to promote access of clinicians and patients to these new treatments in the prevention of migraine with biological drugs, in order to improve patient care and follow-up.

METHODOLOGY

Recommendations for the use of biological drugs in the prevention of migraine were identified and evaluated through the Delphi consensus methodology, proposing 88 statements grouped into three themes: a clinical module that deals with the management of biological treatments in migraine; a patient module that discusses patient education and adherence improvement strategies; and a coordination module that includes statements related to strategies to improve joint work between the two groups. The 9-point Likert ordinal scale was used to score these recommendations and, subsequently, the data was statistically analyzed through different metrics.

RESULTS

After both rounds of voting, consensus was reached in agreement on 71 of the 88 statements (80.7%), leaving one statement (1.1%) with consensus in disagreement and 16 remaining as indeterminate (18.2%).

CONCLUSIONS

The high degree of consensus indicates that the opinion of neurologists and hospital pharmacists on the role of anti-CGRP monoclonal antibodies in the treatment of migraine is very similar and allows identifying those controversies that still exist, to improve the care and follow-up of patients with migraine.

New management strategies for primary headache disorders: Insights from P4 medicine

Primary headache disorder is the main cause of headache attacks, leading to significant disability and impaired quality of life. This disorder is increasingly recognized as a heterogeneous condition with a complex network of genetic, environmental, and lifestyle factors. However, the timely diagnosis and effective treatment of these headaches remain challenging. Precision medicine is a potential strategy based on P4 (predictive, preventive, personalized, and participatory) medicine that may bring new insights for headache care. Recent machine learning advances and widely available molecular biology and imaging data have increased the usefulness of this medical strategy. Precision medicine emphasizes classifying headaches according to their risk factors, clinical presentation, and therapy responsiveness to provide individualized headache management. Furthermore, early preventive strategies, mainly utilizing predictive tools, are critical in reducing headache attacks and improving the quality of life of individuals with headaches. The current review comprehensively discusses the potential application value of P4 medicine in headache management.

[Translated article] Consensus recommendations on the preventive treatment of migraine

OBJECTIVE

The objectives are to know the opinion of neurologists and hospital pharmacists on those aspects still under debate regarding the role of anti-Calcitonin Gene-related Peptide monoclonal antibodies in the preventive treatment of migraine. To identify those controversies that still exist. To propose agreed recommendations for improvement of care. And to promote access of clinicians and patients to these new treatments in the prevention of migraine with biological drugs, in order to improve patient care and follow-up.

METHODOLOGY

Recommendations for the use of biological drugs in the prevention of migraine were identified and evaluated through the Delphi consensus methodology, proposing 88 statements grouped into 3 themes: a clinical module that deals with the management of biological treatments in migraine; a patient module that discusses patient education and adherence improvement strategies; and a coordination module that includes statements related to strategies to improve joint work between the two groups. The 9-point Likert ordinal scale was used to score these recommendations and, subsequently, the data was statistically analysed through different metrics.

RESULTS

After both rounds of voting, consensus was reached in agreement on 71 of the 88 statements (80.7%), leaving 1 statement (1.1%) with consensus in disagreement and 16 remaining as indeterminate (18.2%).

CONCLUSIONS

The high degree of consensus indicates that the opinion of neurologists and hospital pharmacists on the role of anti-Calcitonin Gene-related Peptide monoclonal antibodies in the preventive treatment of migraine is very similar and allows identifying those controversies that still exist, to improve the care and follow-up of patients with migraine.

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.

An investigation of the effects of connective tissue massage in women with migraine: A controlled clinical trial

INTRODUCTION

To investigate the effects of connective tissue massage (CTM) on pain characteristics, accompanying symptoms, medication usage, disability, sleep quality, psychological status, and quality of life in women with migraine.

METHOD

The study was designed as a prospective controlled clinical trial. Women were allocated into the CTM (CTM + education (Ed) program, n = 8) and control groups (only Ed program, n = 8). One session of Ed and 12 sessions of CTM were performed for 4 weeks. They filled out a headache diary, including pain characteristics, accompanying symptoms, and medication usage, for the pre-, during-, and after-treatment periods. Disability, sleep quality, psychological status, quality of life, and disability were evaluated with the Migraine Disability Assessment Scale, the Pittsburgh Sleep Quality Index, the Hospital Anxiety and Depression Scale, and the Headache Impact Test-6, respectively.

RESULTS

The CTM group showed a significant change in pain, accompanying symptoms (except vomiting), medication usage, Headache Impact Test-6, and Disability with Migraine Disability Assessment Scale scores compared to the control group (p < 0.05). Only the CTM group showed a significant change over time in all parameters of the headache diary except vomiting (p < 0.05). Only Headache Impact Test-6 and Migraine Disability Assessment Scale scores improved in the CTM group (p < 0.05).

DISCUSSIONS

CTM was superior for reducing pain characteristics, accompanying symptoms, medication usage, disability, and improving quality of life.

CONCLUSION

CTM may be considered as a non-pharmacological and complementary therapy for migraine.

Migraine abortive treatment in children and adolescents in Israel

Migraine headaches in children may cause attacks that require abortive treatment. This study evaluated the incidence and efficacy of medications used for relieving migraine headache attacks in the pediatric population in Israel. Children 6-18 years of age who were diagnosed in our pediatric neurology clinic as having migraine headaches were enrolled into the study. Children and their parents recorded the children response to abortive treatment during consecutive migraine attacks. Fifty children, with 116 migraine attacks, were included in the study (30 females; mean age 12; range 6-18). Forty-seven (94%) reported on abortive treatment on the first migraine attack, 43 (86%) on a second migraine attack and 26 (52%) on a third migraine attack. During the first recorded migraine attack, 41 children (87.5%) reported taking only one type of medication for each headache episode, mainly ibuprofen or acetaminophen; less than a quarter used dipyrone (metamizol). Overall the improvement rate after two hours was 65.4% ± 27 for ibuprofen, 59.8 ± 35.3 for acetaminophen and 50.9 ± 27.4 for dipyrone without statistical difference. However, in the first recorded headache episode, males had a significantly better response to acetaminophen, compared to ibuprofen (95% ± 28 vs 75 ± 20). In conclusion, Children with migraine in Israel mainly use a single medication for each headache episode. Ibuprofen is the most commonly used abortive treatment; however, acetaminophen was associated with a better response among some of our patients.

Knowledge, Attitudes, and Management of General Practitioners of the Hospital Districts of Ouagadougou about Migraine (Burkina Faso)

Background

Migraine is a common neurological disorder characterized by severe headache attacks that may be debilitating. The objective of this study is to determine the knowledge and attitudes of general practitioners in the hospital districts of the city of Ouagadougou on migraine.

Methods

This cross-sectional study was carried out in hospital districts of Ouagadougou. The data were collected during three months from February 1 to April 30, 2020.

Results

The study included 116 general practitioners. Thirteen percent of them were suffering from migraine. All participants had previous experience with migraine diagnosis before the survey. Eighty percent of general practitioners had a good level of knowledge of ICDH-3 criteria (knowing 6-7 criteria). The most widely recognized IHS criteria were pulsatility quality (93.1%), photophobia or sonophobia (80.2%), and mild-to-moderate intensity (80%). Ninety-five (81.9%) general practitioners rarely ordered brain imaging. The most common acute treatments were nonsteroidal inflammatory drug (39.47%), paracetamol (44.74%), and derivate of ergot (3.95%). The most common preventive treatments were amitriptyline (27.8%), derivate of ergot (18.9%), and NSAID (16.7%). The majority of general practitioners (56.9%) have referred headache patients to a colleague or specialist.

Conclusions

Our study found that diagnostic criteria and acute treatment of migraine were well known by the majority of general practitioners, in contrast of preventive treatment.

Effects of the Dietary Approaches to Stop Hypertension (DASH) diet on clinical, quality of life, and mental health outcomes in women with migraine: A randomised controlled trial

The relationship between the Dietary Approaches to Stop Hypertension (DASH) diet and clinical, quality of life, and mental health outcomes in migraine is unknown. To address this knowledge gap, we conducted a parallel-group, randomised controlled trial to evaluate the effect of the DASH diet on these health outcomes in women with migraine. Of 102 eligible women (20-50 years), 51 randomised to the DASH and 51 to the usual dietary advice (control) groups completed a 12-week intervention. The DASH diet was designed using a 7-day menu cycle to provide 15-20% of total daily energy requirements from proteins, 25-30% from fats, and 55-60% from carbohydrates. Dietary records and serum vitamin C levels were used to assess women's compliance with the DASH diet. The clinical symptoms of migraine (i.e., frequency, duration, severity) and quality of life and mental health (i.e., depression, anxiety, stress) outcomes were assessed in groups pre-and post-intervention. We observed greater decreases in the frequency (-3.00 vs. -1.40, P=0.025) and severity (-1.76 vs. -0.59, P<0.001) of migraine in the DASH vs. control group post-intervention. Similarly, the DASH group exhibited a tendency toward greater decreases in migraine duration (-0.58 vs -0.33 days, P=0.053) and had lower scores of depression (-4.50 vs. -2.73, P=0.019) and stress (-5.84 vs -2.98, P=0.011) vs. controls. However, the quality of life and anxiety outcomes remained comparable in groups post-intervention. Together, evidence supports the benefits of the DASH diet on improving migraine health outcomes in reproductive-aged women. Further research is needed to confirm our findings.

Learning the full impact of migraine through patient voices: A qualitative study

OBJECTIVE

To better characterize the ways that migraine affects multiple domains of life.

BACKGROUND

Further understanding of migraine burden is needed.

METHODS

Adults with migraine randomized to mindfulness-based stress reduction or headache education arms (n = 81) in two separate randomized clinical trials participated in semistructured in-person qualitative interviews conducted after the interventions. Interviews queried participants on migraine impact on life and were audio-recorded, transcribed, and summarized into a framework matrix. A master codebook was created until meaning saturation was reached and magnitude coding established code frequency. Themes and subthemes were identified using a constructivist grounded theory approach.

RESULTS

Despite most participants being treated with acute and/or prophylactic medications, 90% (73/81) reported migraine had a negative impact on overall life, with 68% (55/81) endorsing specific domains of life impacted and 52% (42/81) describing impact on emotional health. Six main themes of migraine impact emerged: (1) global negative impact on overall life; (2) impact on emotional health; (3) impact on cognitive function; (4) impact on specific domains of life (work/career, family, social); (5) fear and avoidance (pain catastrophizing and anticipatory anxiety); and (6) internalized and externalized stigma. Participants reported how migraine (a) controls life, (b) makes life difficult, and (c) causes disability during attacks, with participants (d) experiencing a lack of control and/or (e) attempting to push through despite migraine. Emotional health was affected through (a) isolation, (b) anxiety, (c) frustration/anger, (d) guilt, (e) mood changes/irritability, and (f) depression/hopelessness. Cognitive function was affected through concentration and communication difficulties.

CONCLUSIONS

Migraine has a global negative impact on overall life, cognitive and emotional health, work, family, and social life. Migraine contributes to isolation, frustration, guilt, fear, avoidance behavior, and stigma. A greater understanding of the deep burden of this chronic neurological disease is needed to effectively target and treat what is most important to those living with migraine.

Effects of combining manual therapy, neck muscle exercises, and therapeutic pain neuroscience education in patients with migraine: a study protocol for a randomized clinical trial

BACKGROUND

Non-pharmacological approaches for the management of migraine exhibit low to moderate effectiveness due to a lack of high-quality randomized clinical trials. In fact, previous studies applied isolated techniques, which were not representative of common clinical practice. A multimodal approach for migraine may benefit these patients more than isolated approaches. This randomized clinical trial aims to determine the effectiveness of a multimodal protocol combining manual therapy, exercise, and therapeutic pain neuroscience education versus the application of manual therapy or pain neuroscience education alone in patients with migraine.

METHODS

This clinical trial will include 75 individuals of both sexes, aged between 18 and 55 years, with migraine. Participants will be randomized into three groups: the therapeutic pain neuroscience education (TPNE; n = 25) group, the manual therapy (MT; n = 25) group, and the multimodal (MM; n = 25) group. The TPNE group will receive one orientation session on migraine and pain self-management, and recommendations for daily active stretching and walking, with subsequent therapist monitoring. The MT group will receive manual therapies targeting musculoskeletal disorders of the cervical spine. The MM group will receive manual therapies targeting musculoskeletal disorders of the cervical spine, active neck exercises, and therapeutic pain neuroscience education. The treatment period will last 12 weeks. The primary outcome will be the headache impact, measured using the Headache Impact Test (HIT-6). Secondary outcomes will include migraine frequency and intensity, cervical mobility and strength parameters, neck pain-related disability, kinesiophobia, cutaneous allodynia, pain-related catastrophizing, quality of life, and self-perception of change. All outcomes will be evaluated at the fourth, eighth, and twelfth weeks of the treatment period. Primary and secondary clinical outcomes, such as headache impact, frequency, and intensity, will also be evaluated at the 1-, 2-, and 4-month follow-ups.

DISCUSSION

The results of this randomized clinical trial may provide high-quality clinical evidence of the effects of non-pharmacological treatment options for the management of migraine.

TRIAL REGISTRATION

This study was registered under the access code RBR-7s22c75 in the Registro Brasileiro de Ensaios Clínicos (ReBEC) in December 2020.

Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study

BACKGROUND

Though a large amount of research on the management of headache has been conducted, the clinical effectiveness of these treatments remains unclear.

OBJECTIVES

To reach consensus among international musculoskeletal experts on what the most appropriate management is in patients that suffer from headache.

DESIGN

Expert group and Delphi-study.

METHODS

A total of 11 experts participated in the expert panel groups, where the role of physiotherapy in the management of headache was discussed. Afterwards, 14 of the initial 25 participants in the field of headache completed the whole Delphi study, which was conducted over 4 rounds. The first round aimed to identify clinical indicators and treatments that are useful in patients with headache. These questions were then categorized and ranked during the second, third, and fourth rounds. Consensual agreement was set at ≥ 80%.

RESULTS

After the final round, 9 interventions were rated as useful by the participants. In the final extra round, 14 clinical indicators were retrieved as important to decide whether or not to start one of the consensual treatments. The top 3 management strategies were (1) upper cervical spine mobilisations in cervivogenic headache, (2) active mobilisation exercises of the cervical spine in cervivogenic headache, and (3) lifestyle advice in tension-type headache and migraine.

CONCLUSION

International experts agreed that most scientifically established effective treatments are useful in cervicogenic headache. Consensual agreement on treatments for migraine and tension-type headache were only reached for specific treatments. Their recommendations provide a framework for further research and the clinical management of headache.

Migraine diagnosis and treatment: A knowledge and needs assessment of women's healthcare providers

BACKGROUND

Studies suggest that migraine is often underdiagnosed and inadequately treated in the primary care setting, despite many patients relying on their primary care provider (PCP) to manage their migraine. Many women consider their women's healthcare provider to be their PCP, yet very little is known about migraine knowledge and practice patterns in the women's healthcare setting.

OBJECTIVE

The objective of this study was to assess women's healthcare providers' knowledge and needs regarding migraine diagnosis and treatment.

METHODS

The comprehensive survey assessing migraine knowledge originally developed for PCPs was used in this study, with the addition of a section regarding the use of hormonal medications in patients impacted by migraine. Surveys were distributed online, and primarily descriptive analyses were performed.

RESULTS

The online survey was completed by 115 women's healthcare providers (response rate 28.6%; 115/402), who estimated that they serve as PCPs for approximately one-third of their patients. Results suggest that women's healthcare providers generally recognize the prevalence of migraine, but experience some knowledge gaps regarding migraine management. Despite 82.6% (95/115) of survey respondents feeling very comfortable or somewhat comfortable with diagnosing migraine, only 57.9% (66/114) reported routinely asking patients about headaches during annual visits. Very few were familiar with the American Academy of Neurology guidelines on preventative treatment (6.3%; 7/111) and the Choosing Wisely Campaign recommendations on migraine treatment (17.3%; 19/110), and many prescribed medications known to contribute to medication overuse headache. In addition, only 24.3% (28/115) would order imaging for a new type of headache, 35.7% (41/115) for worsening headache, and 47.8% (55/115) for headache with neurologic symptoms; respondents cited greater tendency with sending patients to an emergency department for the same symptoms. Respondents had limited knowledge of evidence-based, non-pharmacological treatments for migraine (i.e., biofeedback or cognitive behavioral therapy), with nearly none placing referrals for these services. Most providers were comfortable prescribing hormonal contraception (mainly progesterone only) to women with migraine without aura (80.9%; 89/110) and with aura (72.5%; 79/109), and followed American College of Obstetricians and Gynecologists (ACOG) guidelines to limit combination hormonal contraception for patients with aura. When queried, 6.3% or less (5/79) of providers would prescribe estrogen-containing contraception for women with migraine with aura. Only 37.3% (41/110) of respondents reported having headache/migraine education. Providers indicated interest in education pertaining to migraine prevention and treatment (96.3%; 105/109), migraine-associated disability (74.3%; 81/109), and diagnostic testing (59.6%; 65/109).

CONCLUSION

Women's healthcare providers appear to have several knowledge gaps regarding the management of migraine in their patients. These providers would likely benefit from access to a headache-specific educational curriculum to improve provider performance and patient outcomes.

Impact of migraine on workplace productivity and monetary loss: a study of employees in banking sector in Malaysia

BACKGROUND/OBJECTIVE

Productivity and monetary loss due to migraine in the workplace may be substantial. This study aimed to determine the impact of migraine on productivity and monetary lost among employees in the banking sectors, in a multiethnic middle income country.

METHODS

A cross-sectional online survey was conducted among employees in two multinational banks in Malaysia between April and July 2019. Screening for migraine was conducted using the self-administered ID-Migraine™ questionnaire. Migraine-related disability (MIDAS) and headache frequency were recorded. Impact of migraine on work productivity and activities were evaluated using the Work Productivity and Activity Impairment (WPAI) questionnaire.

RESULTS

Of the 1268 employees who submitted complete responses, 47.2% (n = 598) were screened positive for migraine. Strikingly, the mean percent productivity loss at work (presenteeism) was almost 20-fold higher than the mean percent work time missed due to migraine (absenteeism) (39.1% versus 1.9%). The mean percent productivity loss in regular activity (activity impairment) and overall work productivity loss (work impairment) was 38.4% and 39.9%, respectively. It was also found that the costs related to presenteeism (MYR 5392.6) (US$1296) was 3.5-fold higher than absenteeism (MYR1,548.3) (US$370). Highest monetary loss related to presenteeism was reported in migraineurs with frequency of headache of above 3 days (MYR 25,691.2) (US$6176), whereas highest monetary loss related to absenteeism was reported in migraineurs with MIDAS grade IV (MYR 12,369.1) (US$2973). Only 30% of migraineurs of MIDAS grade IV reported taking prescribed medication. Notably, a vast majority (96%) of migraineurs who had three or lower episodes of migraine per month did not seek treatment.

CONCLUSION

The significant impact of migraine on work productivity and regular activity, appears to lead to substantial monetary loss attributed to not only absenteeism, but more importantly to presenteeism. This study also highlights the unmet needs in migraine management among employees in the banking sector.

Neck-specific strengthening exercise compared with sham ultrasound when added to home-stretching exercise in patients with migraine: study protocol of a two-armed, parallel-groups randomized controlled trial

BACKGROUND

Migraine is a highly disabling condition and pharmacological treatment is the gold standard. However, several patients have also positive responses to the application of different manual techniques and therapeutic exercises in terms of reducing the intensity and frequency of migraine attacks. Nevertheless, the effects of a neck-specific exercise program have not yet been evaluated in these patients.

OBJECTIVE

To determine the effectiveness of a neck-specific exercise program in reducing the intensity and frequency of migraine attacks as compared to a sham ultrasound group.

METHODS

A two-armed, parallel-groups randomized controlled trial with 3 months of follow-up will be conducted. 42 individuals, both genders, aged between 18 and 55 years old with a medical diagnosis of migraine will be included. The intervention group will perform a protocol consisting of exercises for strengthening the muscles of the cervical spine. Participants within the sham ultrasound group will receive detuned ultrasound therapy in the upper trapezius muscle. Both groups will receive a weekly session for 8 weeks. The efficacy of each intervention will be measured by the frequency and intensity of migraine at a 3-months follow-up.

TRIAL REGISTRATION

This study was registered under access code RBT-8gfv5j in the Registro Brasileiro de Ensaios Clínicos (ReBEC) in November 28, 2016.

CONCLUSION

This study will aim to determine the efficacy of a neck-specific exercise program in reducing the frequency and intensity of migraine attacks. If the results show that a neck-specific exercise program is effective in reducing the frequency and intensity of migraine attacks, therapists will have a low cost and easily applicable tool to treat migraine.

One-Day Acceptance and Commitment Therapy Compared to Support for Depressed Migraine Patients: a Randomized Clinical Trial

In patients with migraine, depression is associated with poorer medical prognosis, decreased quality of life, and increased risk of suicidality and disability; yet, behavioral interventions have rarely been investigated. The current study compared the efficacy of two 1-day (5- to 6-h) interventions for co-occurring migraine and depression: (1) acceptance and commitment therapy plus migraine education (ACT-ED), and (2) support plus migraine education (S-ED). One hundred and thirty-six patients with comorbid depression and migraine were randomized to a treatment. One hundred and three (76%) completed the ACT-ED (N = 56) or S-ED (N = 47) workshop. Primary outcomes were depression diagnosis and symptoms. Secondary outcomes were anxiety symptoms, headache-related disability and general functioning, and quality of life. Assessments were completed at baseline and 3 and 6 months following the workshop. At the 6-month follow-up, on categorical outcomes, a significantly greater number of people in the ACT-ED condition no longer met criteria for a major depressive episode and exhibited a > 50% drop in symptoms on the Hamilton Rating Scale of Depression. Similarly, though, weaker results were found when examining depressive symptoms dimensionally. On secondary outcomes, people in the ACT-ED condition exhibited significantly greater improvements in anxiety, headache-related disability, and quality of social relationships, compared to S-ED, No differences between groups were observed in general functioning. A 1-day (5- to 6-h) ACT workshop can deliver substantial and lasting benefits to depressed migraineurs, over and above those provided by group support and education. This approach is an attractive alternative to weekly psychotherapy. Clinicaltrials.gov # NCT02108678.

Enhancing migraine self-efficacy and reducing disability through a self-management program

BACKGROUND

Chronic migraine is a primary headache disorder affecting approximately 3-7 million individuals in the United States. This condition is associated with significant individual and societal consequences, causing impaired function and high levels of health care utilization.

PURPOSE

The aim of this quasi-experimental single cohort study was to determine if an 8-week outpatient self-management program for chronic migraine would decrease migraine disability and enhance self-efficacy.

METHODS

This was a prospective, single cohort, pre- and postintervention pilot study. Fifteen adults aged 18-65 years who met the criteria for diagnosis of chronic migraine were enrolled in the study through convenience sampling. Participants participated in an evidence-based self-management program with multimodal formats including verbal, written, video, and online materials. Outcome measures included migraine disability (using Migraine Disability Assessment tool [MIDAS]), headache self-efficacy (using Headache Management Self-Efficacy Scale [HMSE]), acute medication use, and migraine frequency. Participants also completed a postintervention survey to assess satisfaction.

RESULTS

Findings showed a reduction in MIDAS scores, acute medication use, and frequency of migraine. Outcomes also included an increase in HMSE scores and a trend of improved health behaviors. Acute medication use decreased by more than 50%, and frequency of migraine and headache days reduced by close to 40%.

IMPLICATIONS FOR PRACTICE

Despite high rates of disability, patient education and self-management programs for chronic migraine are not readily available. The findings of this study encourage use of a hybrid clinic and web-based self-management model to improve migraine disability and self-efficacy.

Extensor/flexor ratio of neck muscle strength and electromyographic activity of individuals with migraine: a cross-sectional study

PURPOSE

Neck pain is considered a common characteristic of migraine attacks. The relationship between neck pain and migraine can be explained by central sensitization of the trigeminocervical complex, where superior cervical afferents and the trigeminal nerve converge. However, few studies have evaluated motor control of cervical muscles in individuals with migraine. Thus, the purpose of the present study was to determine the extensor/flexor ratio of neck muscle strength and electromyographic activity during a test of maximal voluntary isometric contraction and craniocervical flexion in individuals with migraine and individuals without history of migraine or other headaches.

METHODS

Fifty-two women with the disease and 52 women with neither a history of migraine nor neck pain, between 18 and 55 years old, were included in the study. The electromyographic activities of the sternocleidomastoid, anterior scalene, splenius capitis, and upper trapezius muscles were evaluated during a test of maximal voluntary isometric contraction and craniocervical flexion.

RESULTS

The migraine group presented lower flexor muscle strength and a higher extensor/flexor muscle strength ratio than the control group. In addition, the migraine group showed a reduced electromyographic extensor/flexor muscle ratio during maximal voluntary isometric contraction in flexion. The results demonstrated worse performance in the craniocervical flexion test of the migraine group and a lower electromyographic ratio of extensor/flexor neck muscles in the last stage of the test.

CONCLUSION

Altogether, the migraine group presented an imbalance in cervical muscles verified not only during force production, but also during muscle activity. These slides can be retrieved under Electronic Supplementary Material.

Making a new-patient headache education session more patient-centered: what participants want to know

Purpose: To describe the new-patient Education Session provided by the Calgary Headache Assessment and Management Program, analyze patient evaluations, and generate potential patient-centered improvements based on themes in patient feedback.Materials and Methods: Between 2008 and 2012, 1873 new patients attended the Education Session, and 913 evaluations were completed. Session objectives ratings were analyzed. Open-ended questions regarding most- and least-helpful components and suggestions for improvement were examined using thematic analysis.Results: Eighty-seven percent of respondents indicated they would recommend the session to others with headache. Median objectives ratings ranged from 9.0-10.0 out of 10 and were stable over time. Most-helpful themes included medication, types of headache, our program's multi-faceted management approach, medication overuse, triggers, and not feeling alone. Most respondents left the least-useful and suggestions sections blank or commented "nothing" or "not applicable". Least-useful themes included migraine overemphasis, insufficient or excessive medication content, participant over-disclosure, and lack of practical trigger management strategies.Conclusion: Most attendees found the Education Session useful. Those who did not provided valuable input that will allow us to modify the content. Our findings may benefit other headache programs seeking to implement or improve patient education programing. Implications for RehabilitationHeadache is a common and debilitating condition.Education is an important part of headache treatment, and has been associated with decreases in headache frequency, intensity, and disability, as well as increases in self-efficacy.A new-patient Education Session is a practical and inexpensive way to provide evidence-based medical and behavioral headache information.Quantitative and qualitative analysis of patient evaluations can help gauge relevance and direct content changes.

Benefits of an on-line migraine education video for patients with co-occurring migraine and depression

OBJECTIVE

To evaluate effects of an online, hour-long migraine education and management education program on health outcomes in people with migraine experiencing significant depressive symptoms.

METHODS

Eligible individuals in the community with comorbid migraine and depressive symptoms (n = 95) participated in the 12-week study. Participants completed self-report questionnaires examining general functioning, headache-specific disability, migraine frequency, pain, and depressive symptoms, before, and at 2, 6, and 12 weeks following the migraine education and management program. Primary analyses evaluated change over time in each outcome, using individual linear growth curve models.

RESULTS

After watching the migraine education and management video, there were significant effects of time (across all time points) for average pain level in the past 30 days (b = -0.20, p < .001), most intense pain level in the past 30 days (b = -0.33, p < .001) depression (Patient Health Questionnaire-8; b = -0.28, p = .002), and headache-specific disability (Headache Disability Inventory; b = -1.32, p < .001), such that each of these outcomes improved linearly over time.

CONCLUSIONS

A brief, online educational video is practical and effective and can lead to enhanced migraine knowledge and self-management skills and lessen the burden of migraine and concurrent depressive symptoms.

Effect of Educating the Primary Care Physician About Headache to Help Reduce "Trivial" Referrals and Improve the Number and Quality of "Substantial" Referrals that Truly Need Subspecialty Headache Medicine Care

OPINION STATEMENT

Technology is likely to play an increasingly important role in the delivery of healthcare as the disparity between provider availability/expertise and patient numbers/needs increases. This article is intended to lend insight into the ways in which technology can facilitate the evaluation of patients with headache disorders and improve the ongoing monitoring of disease progression and response to therapy, following proper diagnosis. While it is not possible to prognosticate the impact of technologies not yet available, the article addresses potential novel usage of currently existing technology to standardize intake, expedite evaluations, ensure adequate history and documentation, and monitoring of patient care.

Management of Chronic Daily Headache and Psychiatric Co-Morbidities by Lifestyle Modification: Participatory Action Research Combining New Communication Media

Background

Lifestyle modification has a significant role in chronic daily headache (CDH) management. Participatory action research (PAR) can play an important role in managing chronic medical conditions. However, it has been scarcely used in CDH management.

Objectives

This study aimed to empower patients with CDH to modify their lifestyle in order to reduce both their headache and related psychiatric co-morbidities in a multidisciplinary headache clinic at Baqiyatallah hospital, Tehran, IR Iran.

Methods

In the PAR plan, 37 patients (27 females) diagnosed with CDH were selected using purposeful sampling. Along with face-to-face group sessions, all available communication means such as phone calls, emails, short message system (SMS), and social media (Telegram) were used to facilitate the process. Questionnaires of health promotion lifestyle profile (HPLPІІ), visual analog scale (VAS), and depression-anxiety-stress scale (DASS21) were used to collect data. The data were analyzed using SPSS software.

Results

Mean age of the patients was 38.33 (± 9.7) years. Both “general pain” and “the worst imaginable pain” reduced (mean of reduction: 2.56 ± 2.7 and 2.3 ± 2.9, respectively, P < 0.001). > 50% of pain reduction occurred in “the worst imaginable pain" category (-1.45 ± 2.02, P < 0.001) and mean VAS score reduced to 5.20 (± 2.3) compared to the start of the study (7.50 ± 1.9, P < 0.001). Mean DASS-21 score also reduced significantly for depression (P < 0.016), anxiety (P < 0.026), and stress (P < 0.008). HPLPІІ score significantly improved (118.17 ± 14.8 vs. 160.83 ± 16.4, P < 0.001) and the highest increase was seen in the subscale of "stress management" (17.73 ± 2.8 vs. 25.53 ± 3.9, P < 0.001).

Conclusions

The empowering PAR plan combined with new communication tools helped the CDH patients better handle their lifestyle, reduce their headache, and lower their symptoms. Further studies with better use of currently available communication tools and social media are recommended for action research to be more applicable.

The effectiveness of Orem's self-care program on headache-related disability in migraine patients

Background: Providing a self-care program appropriate for patient needs in a supportive educative nursing system format could reduce migraine-induced disability. This study was designed to determine the effectiveness of Orem's self-care program on headache related disability in migraine patients. Methods: In this randomized clinical trial, episodic migraine patients with or without aura who signed the informed consent were randomly assigned to two groups (44 patients each). The data collection tools included a demographic questionnaire, the Migraine Disability Assessment (MIDAS) questionnaire, an Orem cognition form, and a self-care checklist. The programs were held as four 30 to 45 minutes training sessions for experimental group. The MIDAS were filled out before and three months after program in two groups. Data were analyzed with SPSS statistical software, version 16 and using chi-square, Mann-Whitney and Wilcoxon tests. Results: There was no statistically significant difference between the two groups in terms of demographic variables (P > 0.05). The mean total MIDAS score in the experimental group, before and after the intervention was 28.1 ± 17.5 and 6.03 ± 4.52, respectively (P = 0.001); and for the control group, it was 37.6 ± 16.4 and 55.6 ± 14.5, respectively (P < 0.001). Also, there was a statistically significant difference in disability indices between the two groups after the intervention (P < 0.001). Conclusion: Self-care program was suitable for needs assessment and provided basis for acquiring positive results in order to decrease disability and saved patient treatment costs.

A migraine management training program for primary care providers: An overview of a survey and pilot study findings, lessons learned, and considerations for further research

BACKGROUND

There are five to nine million primary care office visits a year for migraine in the United States. However, migraine care is often suboptimal in the primary care setting. A prior study indicated that primary care physicians (PCPs) wanted direct contact with headache specialists to improve the migraine care they provide.

OBJECTIVE

We sought to further examine PCPs' knowledge of migraine management and assess the feasibility of a multimodal migraine education program for PCPs.

METHODS

We conducted a survey assessing PCPs' knowledge about migraine. We then held three live educational sessions and developed an email consultative service for PCPs to submit questions they had about migraine. We report both quantitative and qualitative findings.

RESULTS

Twenty-one PCPs completed the survey. They were generally familiar with the epidemiology of migraine (mean prevalence of migraine reported was 12.6% ± 10.1), the psychiatric comorbidities (mean prevalence of comorbid depression was 24.5% ± 16.7, mean prevalence of comorbid anxiety was 24.6% ± 18.3), and evidence-based behavioral treatments. Fifty-six percent cited cognitive behavioral therapy, 78% cited biofeedback, and 61% cited relaxation therapy as evidence based treatments. Though most were aware of the prevalence of psychiatric comorbidities, they did not routinely assess for them (43% did not routinely assess for anxiety, 29% did not routinely assess for depression). PCPs reported frequently referring patients for non-level A evidence based treatments: special diets (60%), acupuncture (50%), physical therapy (30%), and psychoanalysis (20%). Relaxation therapy was a therapy recommended by 40% of the PCPs. Only 10% reported referring for cognitive behavioral therapy or biofeedback. Nineteen percent made minimal or no use of migraine preventive medications. Seventy-two percent were unaware of or only slightly aware of the American Academy of Neurology guidelines for migraine. There was variable attendance at the educational sessions (N=22 at 1st session, 6 at 2nd session, 15 at 3rd session). Very few PCPs used the email consultative service (N=4).

CONCLUSIONS

Though PCPs are familiar with many aspects of migraine care, there is a need and opportunity for improvement. The three live sessions were poorly attended and the email consultative service was rarely used. We provide an in depth discussion of targeted areas for educational intervention, of the challenges in developing a migraine educational program for PCPs, and areas for future study.

Behavioral treatments for migraine management: useful at each step of migraine care

Migraine is a disabling and prevalent disorder. Migraine is most effectively treated with a stepped care approach, where patients initially receive a broad level of care (primary care) and proceed to receive increasingly specialized care throughout the course of treatment. Behavioral treatments for migraine modify behaviors of people with migraine with the intention to prevent migraine episodes and secondary consequence of migraine. Behavioral treatments can be incorporated into each level of the stepped care approach for migraine treatment. In this article, we provide a rationale for including behavioral treatment strategies in the treatment of migraine. We then describe and review the evidence for behavioral treatment strategies for migraine, including patient education, relaxation strategies, biofeedback, and cognitive behavioral treatment strategies. Finally, we describe how behavioral treatments can be integrated into a stepped care approach for migraine care.

Nurses improve migraine management in primary care

Introduction

Migraine is a common disorder with a high burden. Adequate treatment results in improvement of quality of life. Migraine patients are mainly treated by general practitioners (GPs), but there is still room for improvement. This study investigated whether primary care nurses could improve the treatment of migraine patients compared to usual care as provided by the GPs.

Participants and methods

We conducted a non-randomized controlled prospective trial in 235 patients diagnosed with migraine with or without aura according to ICHD-II criteria, aged between 18 and 65 years. Patients with migraine treated only by their GP were compared to management by a nurse supervised by a GP.

Results

In the intervention group, fewer migraine patients were referred to a neurologist ( p < 0.001). The reduction in monthly migraine days compared to baseline was more apparent in the intervention group at six ( p = 0.09) and nine months ( p = 0.006). There was no significant change in dichotomized HIT score ( p = 0.076). Change in satisfaction of patients did not differ significantly ( p = 0.070).

Conclusions

The care administered by a headache nurse in the primary care setting supervised by a GP resulted in fewer referrals to the neurologist and more migraine-free days per month, but no change in HIT score. There was no difference in satisfaction scores between both groups.

Outpatient Combined Group and Individual Cognitive-Behavioral Treatment for Patients With Migraine and Tension-Type Headache in a Routine Clinical Setting

OBJECTIVE

To test the long-term clinical effectiveness (follow-up at 3, 6 and 12 months) of an outpatient combined group and individual cognitive-behavioral treatment (CBT) for headache patients following standard medical care. A decrease in headache intensity, frequency, headache-specific impairment, depression, and change of pain-related cognitions was expected.

BACKGROUND

The efficacy of CBT for primary headaches has been confirmed in research, yet the translation into clinical practice has remained untested thus far.

DESIGN

In this single-group outcome study, 87 headache patients diagnosed with migraine and/or tension-type headache received (1) headache-specific medication for 10 weeks and (2) a subsequent CBT treatment made up of 13 individual and 12 group sessions consisting of psychoeducation, progressive muscle relaxation, coping strategies for pain and stress, and goal setting skills. Booster group sessions after 3 and 6 months were implemented to stimulate individual goal attainment, and follow-up measures were recorded up to 12 months.

RESULTS

A significant decrease was found for all primary and secondary outcome criteria, ie, average headache intensity (prae M: 6.0, standard deviation [SD]: 1.5 vs follow-up [FU] 1 year M: 5.1, SD: 1.9), headache frequency (prae M: 16.0, SD: 9.5 vs FU 1 year M: 13.4, SD: 9.9), and catastrophizing (prae M: 3.4, SD: 1.0 vs FU 1 year M: 2.6, SD: 1.1). Coping strategies were increased (prae M: 3.4, SD: .9 vs FU 1 year M: 4.0, SD: 1.0).

CONCLUSION

CBT treatment is a useful component within a routine clinical setting and can improve standard medical care thereby helping patients in managing their headache pain.

Migraine diagnosis and treatment: A knowledge and needs assessment among primary care providers

Background

Studies reveal that migraine is often under-recognized, misdiagnosed and inadequately treated in the primary care setting.

Objective

The objective of this article is to assess primary care providers’ (PCP) knowledge and needs regarding migraine diagnosis and management.

Methods

We held semi-structured group interviews and distributed a brief questionnaire to PCPs in our hospital network. Building on the information from the interviews, we developed a comprehensive survey assessing PCPs’ knowledge about migraine. Descriptive analyses were performed.

Results

The initial interviews and brief questionnaires revealed that PCPs are aware of the prevalence of migraine but are uncertain about the details of management. Eighty-three of 120 physicians completed the comprehensive survey. Only 47% would order imaging for a new type of headache, 31% for worsening headache, and 35% for a headache unresponsive to treatment. Only 28% were familiar with the American Academy of Neurology guidelines on preventive treatment and 40% were familiar with the Choosing Wisely Campaign recommendations on migraine treatment. Just 34% were aware that opioids can cause medication-overuse headache. Non-pharmacologic treatment was not usually recommended. PCPs favored educational opportunities involving direct contact with headache physicians (56%).

Conclusions

PCPs are not universally aware of the specific recommendations for managing migraine patients. Future work should focus on innovative ways to provide decision support and education for PCPs caring for migraineurs.

Quality of life and migraine disability among female migraine patients in a tertiary hospital in Malaysia

BACKGROUND

Disability caused by migraine may be one of the main causes of burden contributing to poor quality of life (QOL) among migraine patients. Thus, this study aimed to measure QOL among migraine sufferers in comparison with healthy controls.

METHODS

Female diagnosed migraine patients (n= 100) and healthy controls (n=100) completed the Malay version of the World Health Organization QOL Brief (WHOQOL-BREF) questionnaire. Only migraine patients completed the Malay version of the Migraine Disability Assessment questionnaire.

RESULTS

Females with migraines had significantly lower total WHOQOL-BREF scores (84.3) than did healthy controls (91.9, P<0.001). Similarly, physical health (23.4 versus 27.7, P<0.001) and psychological health scores (21.7 versus 23.2, P< 0.001) were significantly lower than those for healthy controls. Seventy-three percent of patients experienced severe disability, with significantly higher number of days with headaches (13.8 days/3 months, P< 0.001) and pain scores (7.4, P< 0.013). Furthermore, migraine patients with lower total QOL scores had 1.2 times higher odds of having disability than patients with higher total QOL scores.

CONCLUSIONS

The present study showed that migraine sufferers experienced significantly lower QOL than the control group from a similar population. Disability was severe and frequent and was associated with lower QOL among the migraine patients.

Functioning of women with migraine headaches

BACKGROUND

Migraines are one of the most commonly occurring ailments affecting the nervous system. The aim of this research paper was to evaluate the effect migraines have on the everyday functioning of women.

METHOD

The study involved women with diagnosed migraine headaches (IHS-2004) undergoing treatment at a neurological clinic. In order to evaluate the influence of headaches on the everyday functioning of women, a MSQ v.2 questionnaire was used, whereas pain severity was assessed on a linear VAS scale.

RESULTS

Among the clinical factors, the most influential was the frequency of headaches. Headache duration was particularly significant for women below the age of 40. Pain severity cited at 8-10 pts on the VAS significantly disrupted and limited everyday functioning. On the emotional function subscale, the most influential factors were age, education, and the frequency of headaches.

CONCLUSIONS

On account of headache frequency emerging as the most significant influencing factor, it is of the utmost importance to inform patients of the value of taking prophylactic measures. Central to this is the identification of factors that trigger the onset of migraines. This approach would greatly aid the individual in choosing the appropriate treatment, either pharmacological or others.

Migraine education brochures and patient-perceived satisfaction

INTRODUCTION

Brochures are commonly used as educational tools in daily neurological practice. They are provided to increase the general population's knowledge of a specific disease and also to combat sources of erroneous information. Surveys are the most commonly used method of ascertaining user satisfaction with services received.

OBJECTIVES

This study will assess patient-perceived satisfaction and provide feedback to measure the comprehensibility and overall utility of an educational brochure on migraine.

MATERIAL AND METHODS

Open prospective multicentre study of a group of patients diagnosed with migraine in neurology clinics in Alicante province. During the initial visit, each patient received a migraine brochure prepared by the Valencian Society of Neurology's study group for headaches (CEFALIC). During a follow-up visit, they were then asked to fill out a personal survey on the overall quality of the information in the brochure.

RESULTS

We included a total of 257 patients diagnosed with migraine (83% episodic migraine; 17% chronic migraine); mean age was 37.6 years. Two hundred seven patients confirmed having read the brochure (80.5%); 50 patients (19.5%) either forgot to read it or had no interest in doing so. The brochure seemed interesting and easy to understand according to 90% of the patients. Seventy-six per cent of the respondents stated that reading the brochure increased their overall knowledge of migraine, while 50% of the patients found the brochure useful for improving migraine control.

CONCLUSIONS

Patients found the migraine educational brochure to be comprehensible, a means of increasing overall knowledge of the disease, and useful for increasing control over migraines. Evaluations of the educational brochures that we provide to our patients with migraine should be studied to discover the causes of dissatisfaction, determine the level of quality of service, and investigate potential areas for improvement.

Evaluation and treatment of migraine in the emergency department: a review

Head pain is the fifth most common reason for emergency department (ED) visits. It is second only to focal weakness as the most common reason for neurological consultation in the ED. This manuscript reviews how patients with migraine, the most common primary headache disorder for which patients seek medical treatment, are managed in the ED. We discuss existing guidelines for head imaging in patients with migraine, recommended pharmacologic treatments, and current treatment trends. We also review studies evaluating the discharge care of migraine patients in the ED. With the goal of standardizing, streamlining, and optimizing ED-based migraine care, we offer ideas for future research to improve the evaluation, treatment, and discharge care of patients who present to an ED with acute migraine.

Disability and quality of life in headache: where we are now and where we are heading

Headache disorders determine relevant personal and societal burden, and thus the use of patient-reported outcome measures (PROMs) investigating the level of disability and health-related quality of life (HRQoL) have been increasingly used in headache research. The aim of this review was to address the status of research on disability and HRQoL, by addressing results from recently published clinical trials as well as in longitudinal observational studies on headache patients. PubMed has been searched for papers in which measures of HRQoL and/or disability were used as primary or secondary outcome on adult subjects with primary headache, and published in 2010-2012. Among the 70 records retrieved, 12 papers were selected for narrative synthesis. They included data on 2,621 patients with episodic migraine with and without aura, chronic daily headache, and/or chronic migraine with and without medication overuse. The selected trials investigated the efficacy of different pharmacological prophylaxis, of some surgical approaches, of education programmes and osteopathic manipulative treatment; two studies reported longitudinal observations of patients currently under treatment. Overall, the results of our review showed that headache frequency as well as HRQoL and disability were positively impacted by treatment interventions; positive outcomes were less evident in two studies, and similar results were found in the two observational studies. Our findings confirmed that the most commonly used PROMs, including disease-specific tools to assess disability and HRQoL and SF-36, are sensitive to the beneficial effects occurring over time in functioning and quality of life domains in headache patients. They also suggest that the personal and societal costs of headache disorders are likely to be reduced when headache patients receive appropriate treatments and when continuity of care is offered. In terms of future directions, we note that the systematic use of appropriate PROMs should be encouraged both in the clinical practice and in the research field, as they offer a valid option to assess the global effect of treatments on patient-perceived sense of well-being and quality of performance.

Refractory migraine - a review

Refractory migraine has long been a challenge to all headache specialists. This subgroup of migraine patients experience disability and impaired quality of life, despite optimal treatment. This article reviews the proposed definitions and epidemiology of refractory migraine, as well as the pathophysiology that may contribute to the genesis of this disorder. Aspects of treatment, including pharmacological, complementary/adjunct, and invasive approaches, are reviewed. Comorbid factors, medication overuse, potential pitfalls to treatment, and areas for future investigation are highlighted.

Psychological evaluation of a primary headache patient

A patient's experience with headache is influenced, not only by the frequency and pain of the attacks, but also by the patient's perception of the controllability of the attacks, their willingness to engage in activities despite attacks and their attitude towards the medications used to treat the headaches. Clinicians are often aware of the need to evaluate their patients for the existence of comorbid psychiatric disorders but may be less aware of the importance of these nonpathological beliefs/attitudes that are present to some degree in every headache sufferer. This article gives an overview (by no means exhaustive) of several important psychological constructs, with an emphasis on how these constructs can be assessed in headache patients using freely available paper-pencil questionnaires.

A randomized trial of a web-based intervention to improve migraine self-management and coping

OBJECTIVE

To test the clinical efficacy of a web-based intervention designed to increase patient self-efficacy to perform headache self-management activities and symptom management strategies, and reduce migraine-related psychological distress.

BACKGROUND

In spite of their demonstrated efficacy, behavioral interventions are used infrequently as an adjunct in medical treatment of migraine. Little clinical attention is paid to the behavioral factors that can help manage migraine more effectively and improve the quality of care and quality of life. Access to evidenced-based, tailored, behavioral treatment is limited for many people with migraine.

DESIGN

The study is a parallel group design with 2 conditions: (1) an experimental group exposed to the web intervention; and (2) a no-treatment control group that was not exposed to the intervention. Assessments for both groups were conducted at baseline (T1), 1-month (T2), 3-months (T3), and 6-months (T4).

RESULTS

Compared with controls, participants in the experimental group reported significantly: increased headache self-efficacy, increased use of relaxation, increased use of social support, decreased pain catastrophizing, decreased depression, and decreased stress. The hypothesis that the intervention would reduce pain could not be tested.

CONCLUSIONS

Demonstrated increases in self-efficacy to perform headache self-management, increased use of positive symptom management strategies, and reported decreased migraine-related depression and stress suggest that the intervention may be a useful behavioral adjunct to a comprehensive medical approach to managing migraine.

A proactive approach to migraine in primary care: a pragmatic randomized controlled trial

BACKGROUND

Migraine is a common, disabling headache disorder that leads to lost quality of life and productivity. We investigated whether a proactive approach to patients with migraine, including an educational intervention for general practitioners, led to a decrease in headache and associated costs.

METHODS

We conducted a pragmatic randomized controlled trial. Participants were randomized to one of two groups: practices receiving the intervention and control practices. Participants were prescribed two or more doses of triptan per month. General practitioners in the intervention group received training on treating migraine and invited participating patients for a consultation and evaluation of the therapy they were receiving. Physicians in the control group continued with usual care. Our primary outcome was patients' scores on the Headache Impact Test (HIT-6) at six months. We considered a reduction in score of 2.3 points to be clinically relevant. We used the Kessler Psychological Distress Scale (K10) questionnaire to determine if such distress was a possible effect modifier. We also examined the interventions' cost-effectiveness.

RESULTS

We enrolled 490 patients in the trial (233 to the intervention group and 257 to the control group). Of the 233 patients in the intervention group, 192 (82.4%) attended the consultation to evaluate the treatment of their migraines. Of these patients, 43 (22.3%) started prophylaxis. The difference in change in score on the HIT-6 between the intervention and control groups was 0.81 (p = 0.07, calculated from modelling using generalized estimating equations). For patients with low levels of psychological distress (baseline score on the K10 ≤ 20) this change was -1.51 (p = 0.008), compared with a change of 0.16 (p = 0.494) for patients with greater psychological distress. For patients who were not using prophylaxis at baseline and had two or more migraines per month, the mean HIT-6 score improved by 1.37 points compared with controls (p = 0.04). We did not find the intervention to be cost-effective.

INTERPRETATION

An educational intervention for general practitioners and a proactive approach to patients with migraine did not result in a clinically relevant improvement of symptoms. Psychological distress was an important confounder of success. (Current Controlled Trials registration no. ISRCTN72421511.).

Antimigraine medication use and associated health care costs in employed patients

Migraine is under diagnosed and suboptimally treated in the majority of patients, and also associated with decreased productivity in employees. The objective of this retrospective study is to assess the antimigraine medication use and associated resource utilization in employed patients. Patients with primary diagnosis of migraine or receiving antimigraine prescription drugs were identified from an employer-sponsored health insurance plan in 2010. Medical utilization and health care costs were determined for the year of 2010. Generalized linear regression was applied to evaluate the association between health care costs and the use of antimigraine medications by controlling covariates. Of 465 patients meeting the study criteria, nearly 30% that had migraine diagnosis were prescribed antimigraine medications, and 20% that had migraine diagnosis were not prescribed antimigraine medications. The remaining 50% were prescribed antimigraine medications but did not have migraine diagnosis. Patients with antimigraine medication prescriptions showed lower frequency of emergency department visits than those without antimigraine medication prescriptions. Regression models indicated an increase in migraine-related health care costs by 86% but decreases in all-cause medical costs and total health care costs by 42 and 26%, respectively, in the antimigraine medication use group after adjusting for covariates. Employed patients experienced inadequate pharmacotherapy for migraine treatment. After controlling for covariates, antimigraine prescription drug use was associated with lower total medical utilization and health care costs. Further studies should investigate patient self-reported care and needs to manage headache and develop effective intervention to improve patient quality of life and productivity.