Use of a structured migraine diary improves patient and physician communication about migraine disability and treatment outcomes

Headache: What to ask, how to examine, and which scales to use. Recommendations of the Spanish Society of Neurology's Headache Study Group

INTRODUCTION

Headache is the most common neurological complaint at the different levels of the healthcare system, and clinical history and physical examination are essential in the diagnosis and treatment of these patients. With the objective of unifying the care given to patients with headache, the Spanish Society of Neurology's Headache Study Group (GECSEN) has decided to establish a series of consensus recommendations to improve and guarantee adequate care in primary care, emergency services, and neurology departments.

METHODS

With the aim of creating a practical document, the recommendations follow the dynamics of a medical consultation: clinical history, physical examination, and scales quantifying headache impact and disability. In addition, we provide recommendations for follow-up and managing patients' expectations of the treatment.

CONCLUSIONS

With this tool, we aim to improve the care given to patients with headache in order to guarantee adequate, homogeneous care across Spain.

Headache Diary Mobile Application for Monitoring and Characterizing Posttraumatic Headaches

OBJECTIVE

This study analyzed the data collected using a headache diary mobile application to characterize posttraumatic headaches (PTHs) in a sample of US veterans. Specifically, we measured patient engagement with the mobile application and compared our findings with previous literature regarding PTHs.

SETTING

A Headache Center of Excellence (HCoE) in a Veterans Health Administration facility.

PARTICIPANTS

Forty-nine veterans currently being treated for ongoing PTH-related complaints with English fluency, reliable access to the internet, and a mobile phone.

DESIGN

Observational study of PTH characteristics using the mobile application over the course of 1 year.

MEASURES

Main outcome measures were collected via a headache diary mobile application developed for patients to track headache-associated symptoms, headache location, triggers, type, intensity, and duration. Patients also completed a baseline Headache Impact Test (HIT-6) survey.

RESULTS

In total, 1569 entries were completed during the first year of application deployment. On average, patients completed 2.5 entries per week and used the application for 70 days. They frequently reported associated PTH symptoms of photophobia (56.7%) and headaches triggered by emotional stress (35.1%). Network analyses revealed patterns of co-occurrence in triggers of headache pain, associated symptoms, and headache pain location. Headache pain severity and impact ratings from the headache diary demonstrated convergent validity with the established HIT-6 measure.

CONCLUSIONS

Headache diary mobile applications are a promising tool for monitoring and characterizing PTHs in veterans. Present results mirror past studies of PTH characteristics. Mobile application headache diaries may be used in both clinical and research settings to monitor headache symptoms and communicate the functional impact of headaches in real time.

"It's Not Just Technology, It's People": Constructing a Conceptual Model of Shared Health Informatics for Tracking in Chronic Illness Management

BACKGROUND

For many people, tracking health indicators is central to managing a chronic illness. However, previous informatics research has largely viewed tracking as a solitary process that lacks the characteristics essential to tracking in support of chronic illness management.

OBJECTIVE

To inform development of effective technologies that aid tracking of health indicators to support chronic illness management, this study aimed to construct a health informatics model that accurately describes the work and social context of that tracking work.

METHODS

As part of a larger project, we conducted semistructured interviews with 40 adults concerning their chronic illness management practices, including tracking and communication. We also assembled transcripts of 30 publicly available videos of 24 adults discussing tracking processes for managing their own chronic illness. We used qualitative methods to analyze interviews and video transcripts through the lens of ongoing personal and health informatics research.

RESULTS

We have described the people and work involved in tracking in support of chronic illness management and contributed a Conceptual Model of Shared Health Informatics (CoMSHI). Specifically, we identified the need for a health informatics model that (1) incorporates the ongoing nature of tracking work and (2) represents the social dimension of tracking for illness management. Our model depicts communication, information, collection, integration, reflection, and action work in the social context of the person with chronic illness, informal carers, health care providers, and community members.

CONCLUSIONS

The resulting CoMSHI yields a more detailed and nuanced viewpoint of tracking in support of chronic illness management and can inform technology design to improve tracking tools to support people in more confident and capable chronic illness management.

Privacy Issues in Smartphone Applications: An Analysis of Headache/Migraine Applications

BACKGROUND

Headache diaries are a mainstay of migraine management. While many commercial smartphone applications (apps) have been developed for people with migraine, little is known about how well these apps protect patient information and whether they are secure to use.

OBJECTIVE

We sought to assess whether there are privacy issues surrounding apps so that physicians and patients could better understand what medical information patients are providing to the app companies, and the potential privacy implications of how the app companies (and other third parties) might use that information.

METHODS

We conducted a systematic search of the most popular "headache" and "migraine" apps and developed a database of the types of data the apps requested for input by the user and whether the apps had clear privacy policies. We also examined the content of the privacy policies.

RESULTS

Twenty-nine apps were examined (14 diary apps, 15 relaxation apps). Of the diary applications, 79% (11/14) had visible privacy policies. Of the diary apps with privacy policies, all (11/11) stated whether or not the app collects and stores information remotely. A total of 55% (6/11) stated that some user data were used to serve targeted advertisements. A total of 11/15 (73%) of the relaxation apps had privacy policies.

CONCLUSIONS

Headache apps shared information with third parties, posing privacy risks partly because there are few legal protections against the sale or disclosure of data from medical apps to third parties.

Effects of different endurance exercise modalities on migraine days and cerebrovascular health in episodic migraineurs: A randomized controlled trial

Aerobic exercise training is a promising complementary treatment option in migraine and can reduce migraine days and improve retinal microvascular function. Our aim was to elucidate whether different aerobic exercise programs at high vs moderate intensities distinctly affect migraine days as primary outcome and retinal vessel parameters as a secondary. In this randomized controlled trial, migraine days were recorded by a validated migraine diary in 45 migraineurs of which 36 (female: 28; age: 36 (SD:10)/BMI: 23.1 (5.3) completed the training period (dropout: 20%). Participants were assigned (Strata: age, gender, fitness and migraine symptomatology) to either high intensity interval training (HIT), moderate continuous training (MCT), or a control group (CON). Intervention groups trained twice a week over a 12-week intervention period. Static retinal vessel analysis, central retinal arteriolar (CRAE) and venular (CRVE) diameters, as well as the arteriolar-to-venular diameter ratio (AVR) were obtained for cerebrovascular health assessment. Incremental treadmill testing yielded maximal and submaximal fitness parameters. Overall, moderate migraine day reductions were observed (ηP2 = .12): HIT revealed 89% likely beneficial effects (SMD = 1.05) compared to MCT (SMD = 0.50) and CON (SMD = 0.59). Very large intervention effects on AVR improvement (ηP2 = 0.27), slightly favoring HIT (SMD=-0.43) over CON (SMD=0), were observed. HIT seems more effective for migraine day reduction and improvement of cerebrovascular health compared to MCT. Intermittent exercise programs of higher intensities may need to be considered as an additional treatment option in migraine patients.

Superior Effects of High-Intensity Interval Training vs. Moderate Continuous Training on Arterial Stiffness in Episodic Migraine: A Randomized Controlled Trial

Background: Migraine is associated with increased cardiovascular risk and vascular dysfunction. Since aerobic exercise can reduce cardiovascular risk, the present randomized controlled trail aimed at investigating the effects of high-intensity interval training (HIT) vs. moderate continuous exercise training (MCT) on arterial stiffness in migraine patients.

Methods: Forty-eight episodic migraineurs were initially enrolled in the study. 37 patients [female: 30; age: 37 (SD: 10); BMI: 23.1 (5.2); Migraine days per month: 3.7 (2.5)] completed the intervention. Central blood pressure, pulse wave reflection, and aortic pulse wave velocity (PWV) were obtained by an oscillometric monitor. Incremental treadmill exercise testing yielded maximal and submaximal fitness parameters. Participants were randomly assigned to either HIT, MCT, or a control group (CON). The intervention groups trained twice a week over a 12-week intervention period.

Results: After adjustment for between-group baseline differences, a moderate meaningful overall reduction of the augmentation index at 75 min⁻¹ heart rate (AIx@75) was observed [partial eta squared (ηp2) = 0.16; p = 0.06]. With 91% likely beneficial effects, HIT was more effective in reducing AIx@75 than MCT [HIT: pre 22.0 (9.7), post 14.9 (13.0), standardized mean difference (SMD) = 0.62; MCT: pre 16.6 (8.5), post 21.3 (10.4), SMD −0.49]. HIT induced a relevant reduction in central systolic blood pressure [cSBP: pre 118 (23) mmHg, post 110 (16) mmHg, SMD = 0.42] with a 59% possibly beneficial effect compared to CON, while MCT showed larger effects in lowering central diastolic blood pressure [pre 78 (7) mmHg, post 74 (7) mmHg, SMD = 0.61], presenting 60% possibly beneficial effects compared to CON. Central aortic PWV showed no changes in any of the three groups. Migraine days were reduced more successfully by HIT than MCT (HIT: SMD = 1.05; MCT: SMD = 0.43).

Conclusion: HIT but not MCT reduces AIx@75 as a measure of pulse wave reflection and indirect marker of systemic arterial stiffness. Both exercise modalities beneficially affect central blood pressure. HIT proved to be an effective complementary treatment option to reduce vascular dysfunction and blood pressure in migraineurs.

Information Quality Challenges of Patient-Generated Data in Clinical Practice

A characteristic trend of digital health has been the dramatic increase in patient-generated data being presented to clinicians, which follows from the increased ubiquity of self-tracking practices by individuals, driven, in turn, by the proliferation of self-tracking tools and technologies. Such tools not only make self-tracking easier but also potentially more reliable by automating data collection, curation, and storage. While self-tracking practices themselves have been studied extensively in human-computer interaction literature, little work has yet looked at whether these patient-generated data might be able to support clinical processes, such as providing evidence for diagnoses, treatment monitoring, or postprocedure recovery, and how we can define information quality with respect to self-tracked data. In this article, we present the results of a literature review of empirical studies of self-tracking tools, in which we identify how clinicians perceive quality of information from such tools. In the studies, clinicians perceive several characteristics of information quality relating to accuracy and reliability, completeness, context, patient motivation, and representation. We discuss the issues these present in admitting self-tracked data as evidence for clinical decisions.

Tracking and journaling the cancer journey

Clinicians sometimes suggest to patients that they keep track of illness-related issues. Self-monitoring is a helpful term to describe these at-home activities that yield essential information for self-management. The purpose of this article is to create greater awareness of the opportunities (and potential shortcomings) of patient self-monitoring for oncology nursing practice.

Supporting chronic disease care quality

Chronic medical conditions take a huge toll on lives of a growing number of people and are a major contributor to the rising costs in healthcare. As patients are increasingly willing to take an active part in managing their conditions, chronic disease self-management programs and information systems that support them are recognized for their potential to improve the quality of healthcare delivery. These programs often rely on recording longitudinal patient data and analyzing it. Therefore, maintaining appropriate data quality is important for self-management programs to be efficient and safe. We designed and implemented a prototype of a health self-management service for chronically ill people. It is a distributed application that supports patients with diabetes at tracking their blood glucose levels. The main design goals were usability, extensibility, security, and interoperability. The system integrates with the Microsoft HealthVault and Google Health personal health record platforms. It utilizes industry-strength storage and security mechanisms, is scalable, and as a result, can be used to gather, securely store, and analyze patient data over long periods of time. In this article we examine how software information technology can support chronic disease self-management and its impact on the quality of patient data. Furthermore, we describe the requirements that drove the system's development, its architecture, and design decisions.

A basic diagnostic headache diary (BDHD) is well accepted and useful in the diagnosis of headache. a multicentre European and Latin American study

AIMS

We tested the usability and usefulness of the basic diagnostic headache diary (BDHD) for the diagnosis of migraine, tension-type headache and medication-overuse headache in European and Latin American countries.

METHODS

Patients were subdivided into two groups according to a 1:1 randomization list. Those in group 1 were sent the BDHD before their first visit to the headache centre and asked to complete it for at least 1 month. Those in group 2 made their first visit to the headache centre without receiving the BDHD.

RESULTS

A total of 626 patients from nine countries and 16 centres completed the study. The BDHD entries were complete in 97.5% of cases. BDHD information and clinical interview were, when taken together, considered complete for diagnosis in 97.7% of cases in group 1 whereas the information obtained by clinical interview alone in group 2 was considered complete in only 86.8% of cases (p < 0.001). The median number of diagnoses per patient in group 1 was significantly higher than in group 2 (p = 0.04). The BDHD was very well accepted by both patients and doctors.

CONCLUSIONS

It is concluded that the BDHD is a useful tool in the diagnostic assessment of the most frequent and disabling forms of primary headache and in headache management.

Development of a comprehensive medical recorder on a cellphone

Paper medical diaries have effectively been used in chronic diseases for self-management without information and communication technology for many cases. To facilitate self-control in chronic diseases, and observe one's own condition objectively and continuously, we developed a cellphone-based medical recorder (MedData) for patients with chronic diseases. The MedData is based on the Java2 Micro Edition and DoJa-3.5 (NTT DoCoMo, Inc.), and it runs like a scheduler with a calendar, diary, and data entry canvas. The MedData stores laboratory data, such as blood pressure, BUN (blood urea nitrogen), creatinine, Hb A1c (glycosylated hemoglobin), and other pertinent comments, into a cellphone memory. Detailed graphic displays of the data are automatically visualized. The MedData can customize recording events, items, prescriptions, and graphics all on the cellphone. These can then be transferred via an infrared port between a cellphone and a PC.

Headache diaries and calendars

Headache is one of the most common types of pain and, in the absence of biological markers, headache diagnosis depends only on information obtained from clinical interviews and physical and neurological examinations. Headache diaries make it possible to record prospectively the characteristics of every attack and the use of headache calendars is indicated for evaluating the time pattern of headache, identifying aggravating factors, and evaluating the efficacy of preventive treatment. This may reduce the recall bias and increase accuracy in the description. The use of diagnostic headache diaries does have some limitations because the patient's general acceptance is still limited and some subjects are not able to fill in a diary. In this chapter, we consider diaries and calendars specially designed for migraine and, in particular, aim to: (1) determine what instruments are available in clinical practice for diagnosis and follow-up of treatments; and (2) describe the tools that have been developed for research and their main applications in the headache field. In addition, we include information on diaries available online and proposals for future areas of research.

In-office discussions of migraine: results from the American Migraine Communication Study

BACKGROUND

Research indicates that successful migraine assessment and treatment depends on information obtained during patient and healthcare professional (HCP) discussions. However, no studies outline how migraine is actually discussed during clinical encounters.

OBJECTIVE

Record naturally occurring HCP-migraineur interactions, analyzing frequency and impairment assessment, and preventive treatment discussions.

DESIGN

HCPs seeing high volumes of migraineurs were recruited for a communication study. Patients likely to discuss migraine were recruited immediately before their normally scheduled appointment and, once consented, were audio- and video-recorded without a researcher present. Separate post-visit interviews were conducted with patients and HCPs. All interactions were transcribed.

PARTICIPANTS

Sixty patients (83% female; mean age 41.7) were analyzed. Patients were diagnosed with migraine 14 years and experienced 5 per month, on average.

APPROACH

Transcripts were analyzed using sociolinguistic techniques such as number and type of questions asked and post-visit alignment on migraine frequency and impairment. American Migraine Prevalence and Prevention Study guidelines were utilized.

RESULTS

Ninety-one percent of HCP-initiated, migraine-specific questions were closed-ended/short answer; assessments focused on frequency and did not focus on attention on impairment. Open-ended questions in patient post-visit interviews yielded robust impairment-related information. Post-visit, 55% of HCP-patient pairs were misaligned regarding frequency; 51% on impairment. Of the 20 (33%) patients who were preventive medication candidates, 80% did not receive it and 50% of their visits lacked discussion of prevention.

CONCLUSIONS

Sociolinguistic analysis revealed that HCPs often used narrowly focused, closed-ended questions and were often unaware of how migraine affected patients' lives as a result. It is recommended that HCPs assess impairment using open-ended questions in combination with the ask-tell-ask technique.

Effects of pregnancy on slow cortical potentials in migraine patients and healthy controls

Increased negative amplitudes and lack of habituation of contingent negative variation (CNV) in migraine are well established and are supposed to reflect an altered cortical excitability level. Migraine attacks occur less during pregnancy but often relapse after delivery. We investigated the effect of pregnancy on slow cortical potentials and reaction time in migraine patients and healthy controls. Four groups were examined: 14 pregnant migraine patients, 12 non-pregnant migraine patients, 15 pregnant healthy women and 16 non-pregnant healthy women aged 19-38 years. Two recordings were performed in the pregnant subjects: in the 36th week of gestation and 4 weeks after delivery. The non-pregnant subjects were recorded at the same time interval of 8 weeks. Pregnant migraine patients showed significantly fewer migraine days during the third trimester of pregnancy and returned to nearly the former level 4 weeks post delivery. Non-pregnant migraine patients demonstrated a significant reduction of migraine days at the second measurement. There was no effect of pregnancy on CNV amplitudes, but there was an effect of pregnancy on the habituation coefficient and reaction time of migraine patients. Faster habituation from a higher preactivation level was found. As an explanation for the changed habituation level we favour the model of correlation between preactivation level and habituation level, the so-called law of initial value. We found a correlation between preactivation level and habituation. Our study confirms a specific effect of pregnancy on slow cortical potentials in migraine patients.

What is the impact of physician communication and patient understanding in the management of headache?

Migraine is a common and debilitating condition. Despite the burden of disease and increasing availability of effective treatment, migraine management is unsatisfactory. Evidence in other chronic conditions indicates that effective physician communication results in better patient understanding and health outcomes.The current literature review was intended to evaluate evidence regarding the relationship of effective physician-provider communication to health outcomes and patient satisfaction among patients with migraine. The authors searched MEDLINE((R)) (1966-June 2007) and the Cochrane Database of Systematic Reviews for relevant publications. The search strategy combined the concepts of "headache disorders" and "physician-patient relations". 912 abstracts were identified, and 80 (9%) of them were included for data abstraction.There were no studies that met our eligibility criteria. Therefore we revised the eligibility criteria to allow for the inclusion of non-migraine primary headache disorders or the role of non-physician health care providers. Twelve published papers met the revised criteria. The findings from the limited evidence available suggests, but does not prove, that improvements in physician-patient communication could result in a significant decrease in the burden of suffering and health care resource utilization associated with migraine. More research is needed to assess the explicit role of physician-patient communication in the management of migraine.

To track or not to track: user reactions to concepts in longitudinal health monitoring

BACKGROUND

Advances in ubiquitous computing, smart homes, and sensor technologies enable novel, longitudinal health monitoring applications in the home. Many home monitoring technologies have been proposed to detect health crises, support aging-in-place, and improve medical care. Health professionals and potential end users in the lay public, however, sometimes question whether home health monitoring is justified given the cost and potential invasion of privacy.

OBJECTIVE

The aim of the study was to elicit specific feedback from health professionals and laypeople about how they might use longitudinal health monitoring data for proactive health and well-being.

METHODS

Interviews were conducted with 8 health professionals and 26 laypeople. Participants were asked to evaluate mock data visualization displays that could be generated by novel home monitoring systems. The mock displays were used to elicit reactions to longitudinal monitoring in the home setting as well as what behaviors, events, and physiological indicators people were interested in tracking.

RESULTS

Based on the qualitative data provided by the interviews, lists of benefits of and concerns about health tracking from the perspectives of the practitioners and laypeople were compiled. Variables of particular interest to the interviewees, as well as their specific ideas for applications of collected data, were documented.

CONCLUSIONS

Based upon these interviews, we recommend that ubiquitous "monitoring" systems may be more readily adopted if they are developed as tools for personalized, longitudinal self-investigation that help end users learn about the conditions and variables that impact their social, cognitive, and physical health.

Diaries and calendars for migraine. A review

Headache is one of the most common types of pain and, in the absence of biological markers, headache diagnosis depends only on information obtained from clinical interviews and physical and neurological examinations. Headache diaries make it possible to record prospectively the characteristics of every attack and the use of headache calendars is indicated for evaluating the time pattern of headache, identifying aggravating factors and evaluating the efficacy of preventive treatment. This may reduce the recall bias and increase accuracy in the description. The use of diagnostic headache diaries does have some limitations because the patient's general acceptance is still limited and some subjects are not able to fill in a diary. In this review, we considered diaries and calendars especially designed for migraine and, in particular, we aimed at: (i) determining what instruments are available in clinical practice for diagnosis and follow-up of treatments; and (ii) describing the tools that have been developed for research and their main applications in the headache field. In addition to the literature review, we added two paragraphs concerning the authors' experience of the use of diaries and calendars in headache centres and their proposals for future areas of research.