Living with chronic migraine: a qualitative study on female patients' perspectives from a specialised headache clinic in Spain

"It's just part of who I am…" Living with chronic headache: voices from the CHESS trial, a qualitative study

BACKGROUND

Between 2015 and 2019 the Chronic Headache Education and Self-management Study (CHESS) developed and tested a supportive self-management approach that aimed to improve outcomes for people with chronic migraine or chronic tension type headache with/without episodic migraine. However, a paucity of qualitative research which explored the lived experiences of people with chronic headache was evidenced. In response, we undertook to explore the experiences of living with chronic headaches of people who participated in the CHESS study.

METHODS

We adopted qualitative methodologies, inviting participants in the CHESS study to participate in semi-structured interviews. In phase 1 (feasibility study), a thematic analysis was conducted. In phase 2 (main CHESS trial), interviews were informed by topic guides developed from our learning from the phase 1 interviews. Pen portrait methodology and thematic analysis was employed allowing us to explore the data longitudinally.

RESULTS

Phase 1, 15 interviews (10 female) age range 29 to 69 years (median 47 years) revealed the complexities of living with chronic headache. Six overarching themes were identified including the emotional impact and the nature of their headaches. Phase 2, included 66 interviews (26 participants; median age group 50s (range 20s-60s); 20 females. 14 were interviewed at three points in time (baseline, 4 and 12 months) Through an iterative process four overlapping categories of headache impact emerged from the data and were agreed: i) 'I will not let headaches rule my life'; ii) 'Headaches rule my life'; iii) 'Headaches out of control-something needs to change'; and iv) 'Headaches controlled-not ruling my life'. One of these categories was assigned to each pen portrait at each timepoint. The remaining 12 participants were interviewed at two time points during a year; pen portraits were again produced. Analysis revealed that the headache impact categories developed above held true in this sample also providing some validation of the categories.

CONCLUSIONS

These data give an insight into the complexities of living with chronic headache. Chronic headache is unpredictable, permeating all aspects of an individual's life; even when an individual feels that their headache is controlled and not interfering, this situation can rapidly change. It shows us that more work needs to be done both medically and societally to help people living with this often-hidden condition.

TRIAL REGISTRATION

ISRCTN79708100.

Painful Subjects, Desiring Relief: Experiencing and Governing Pain in a Medical Cannabis Program

Cannabis can provide patients benefits for pain and symptom management, improve their functionality, and enhance their well-being. Yet restrictive medical cannabis programs can limit these potential benefits. This article draws on four years of research into Minnesota's medical cannabis program-one of the most restrictive in the United States-including in-depth interviews with patients and a survey of health care professionals. Drawing on the new materialist concepts of Deleuze and Guattari, this article analyzes (a) the benefits patients in Minnesota's medical cannabis program derive from cannabis, (b) how program restrictions mediate access to cannabis and its derived benefits, and (c) some key ways in which medical and criminal justice institutional authorities are reconfigured around medical cannabis. I show how the imperative to authoritatively govern "dangerous drugs" persists in consequential ways as the War on Drugs shifts toward a medicalized, criminalized, and commercial-legalized mixed regime.

Does pain self-efficacy predict, moderate or mediate outcomes in people with chronic headache; an exploratory analysis of the CHESS trial

BACKGROUND

Chronic headache disorders are disabling. The CHESS trial studied the effects of a short non-pharmacological intervention of education with self-management support for people affected by migraine and/or tension type headache for at least 15 days per month for at least three months. There were no statistically significant effects on the Headache Impact Test-6 (HIT-6) at 12-months. However, we observed improvement in pain self-efficacy questionnaire (PSEQ) and short-term HIT-6. We explored the impact of the CHESS intervention on PSEQ, and subsequently, on the HIT-6 and chronic headache quality of life questionnaire (CH-QLQ) at four, eighth and 12 months.

METHODS

We included all 736 participants from the CHESS trial. We used simple linear regression models to explore the change of HIT-6 and CH-QLQ with treatment and PSEQ at baseline (predictor analysis), and the interaction between treatment and baseline PSEQ (moderator analysis). We considered the change of PSEQ from baseline to four months as a mediator in the mediation analysis.

RESULTS

Baseline PSEQ neither predicted nor moderated outcomes. The prediction effect on change of HIT-6 from baseline to 12 months was 0.01 (95% CI, -0.03 to 0.04) and the interaction (moderation) effect was -0.07 (95% CI, -0.15 to 0.002). However, the change of PSEQ from baseline to 4-month mediated the HIT-6 (baseline to 8-, and 12-month) and all components of CH-QLQ (baseline to 8-, and 12-month). The CHESS intervention improved the mediated variable, PSEQ, by 2.34 (95% CI, 0.484 to 4.187) units and this corresponds to an increase of 0.21 (95% CI, 0.03 to 0.45) units in HIT-6 at 12-months. The largest mediated effect was observed on the CH-QLQ Emotional Function, an increase of 1.12 (95% CI, 0.22 to 2.20).

CONCLUSIONS

PSEQ was not an effective predictor of outcome. However, change of short-term PSEQ mediated all outcomes, albeit minimally. Future behavioural therapy for chronic headache may need to consider how to achieve larger, and more sustained increases level of self-efficacy than that achieved within the CHESS trial.

TRIAL REGISTRATION

ISRCTN79708100.

Self-management Experience of Nurses Living with Migraine: A Qualitative Study

BACKGROUND

Migraine is a neurobiological condition characterized by a constellation of unpredictable symptoms and is the second cause of disability worldwide. Migraine is prevalent among nurses. However, literature exploring nurses' experience of living with migraine is scarce which has important individual and systems implications for health and wellness and patient safety. Self-management is essential in chronic disease management as the patient engages in various strategies to be able to live with their condition.

PURPOSE

This study explored the experiences of living and working with migraine among female nurses in Ontario, with particular attention to their priorities and strategies for self-management.

METHODS

Interpretive description methodology was employed to guide this study and informed a thematic analysis approach to examine the self-management experiences of nurses living with migraine.

RESULTS

Nurses engaged in various self-management strategies including pharmacological and non-pharmacological strategies and highlighted the role of technology in migraine self-management. Participants described experiences of living with migraine as an invisible condition including feelings of not being understood, stigmatization, and the absence of formal support at the workplace.

CONCLUSION

The implications of these findings support the incorporation of a critical approach to relational engagement that is person-centred including nonjudgemental, strength-based care as a practice approach when caring for persons living with migraines and the need to include experiential learning in educational curriculums as a strategy to reduce stigma against migraines.

The psychosocial impact of migraines on women and alternative therapies for migraine management

Background

Migraines are one of the leading causes of disability globally and in South Africa. There is a paucity of local empirical literature regarding the psychosocial impact of migraines on women. Although there are a variety of treatment approaches, many women prefer alternative and holistic treatment for their migraines.

Aim

The aim of this study was to explore the psychosocial impact of migraines on women and their use of complementary and alternative therapies for migraine pain management.

Setting

The study was conducted in the eThekwini region of KwaZulu-Natal, South Africa.

Methods

The study adopted a qualitative descriptive design. Purposive sampling was used to recruit participants for the study. Data were collected through 12 semi-structured interviews and subsequently analysed using thematic analysis.

Results

Theme 1 related to the psychological and cognitive effects experienced by the participants. Theme 2 focused on the effects migraines had on personal, family and social relationships. Theme 3 discussed the self-management of migraines.

Conclusion

The pertinent psychological effects of migraines were depression, anxiety, feelings of hopelessness and withdrawal, fear-avoidance behaviour, lifestyle changes, and acceptance of migraines. The participants experienced a lack of understanding about their migraine severity from co-workers, family and social networks. The alternative therapies that were sought to alleviate migraine symptoms included chiropractic, massage, meditation, reflexology, yoga, cupping and acupuncture.

Contribution

The awareness of the effectiveness of complementary and alternative therapies for women may be beneficial for healthcare providers seeking a multidisciplinary approach to migraine management.

Living with migraine: A meta-synthesis of qualitative studies

Introduction

Migraine is one of the top ten causes of disability worldwide. However, migraine is still underrated in society, and the quality of care for this disease is scant. Qualitative research allows for giving voice to people and understanding the impact of their disease through their experience of it. This study aims at synthesising the state of the art of qualitative studies focused on how people with migraine experience their life and pathology.

Methods

MEDLINE via PubMed, EMBASE, CINAHL, PsycINFO, and Cochrane Library were consulted up to November 2021 for qualitative studies. Studies to be eligible had to focus on adults (age > 18 years) with a diagnosis of primary episodic or chronic migraine following the International Classification of Headache. The quality of the study was analysed using the CASP (Critical Appraisal Skills Programme) tool. The synthesis was done through a thematic analysis. CERQual (Confidence in Evidence from Reviews of Qualitative research) approach was used to assess the confidence in retrieved evidence.

Results

Ten studies were included, counting 262 people with migraine. Our synthesis produced four main themes. (1) “Negative impact of migraine symptoms on overall life” as migraine negatively impacts people's whole life. (2) “Impact of migraine on family, work and social relationship” as migraine reduces the possibility to focus at work and interact with people. (3) “Impact of migraine on emotional health” as people with migraine experience psychological distress. (4) “Coping strategies to deal with migraine” such as keep on living one's own life, no matter the symptoms.

Conclusions

Migraine negatively impacts people's whole life, from private to social and work sphere. People with migraine feel stigmatised as others struggle with understanding their condition. Hence, it is necessary to improve awareness among society of this disabling condition, and the quality of care of these people, tackling this disease from a social and health-policy point of view.

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.

Chronic Headache Education and Self-Management Study (CHESS): a process evaluation

BACKGROUND

The Chronic Headache Education and Self-Management Study (CHESS) multicentre randomised trial evaluated the impact a group education and self-management support intervention with a best usual care plus relaxation control for people living with chronic headache disorders (tension type headaches or chronic migraine, with or without medication overuse headache). Here we report the process evaluation exploring potential explanations for the lack of positive effects from the CHESS intervention.

METHODS

The CHESS trial included 736 (380 intervention: 356 control) people across the Midlands and London UK. We used a mixed methods approach. Our extensive process evaluation looked at context, reach, recruitment, dose delivered, dose received, fidelity and experiences of participating in the trial, and included participants and trial staff. We also looked for evidence in our qualitative data to investigate whether the original causal assumptions underpinning the intervention were realised.

RESULTS

The CHESS trial reached out to a large diverse population and recruited a representative sample. Few people with chronic tension type headaches without migraine were identified and recruited. The expected 'dose'of the intervention was delivered to participants and intervention fidelity was high. Attendance ("dose received") fell below expectation, although 261/380 (69%) received at least at least the pre-identified minimum dose. Intervention participants generally enjoyed being in the groups but there was little evidence to support the causal assumptions underpinning the intervention were realised.

CONCLUSIONS

From a process evaluation perspective despite our extensive data collection and analysis, we do not have a clear understanding of why the trial outcome was negative as the intervention was delivered as planned. However, the lack of evidence that the intervention causal assumptions brought about the planned behaviour change may provide some insight. Our data suggests only modest changes in managing headache behaviours and some disparity in how participants engaged with components of the intervention within the timeframe of the study. Moving forwards, we need a better understanding of how those who live with chronic headache can be helped to manage this disabling condition more effectively over time.

TRIAL REGISTRATION

ISRCTN79708100 .

Complex Patient Navigation by Veteran Patients in the Veterans Health Administration (VHA) for Chronic Headache Disease: A Qualitative Study

Patients living with headache diseases often have difficulty accessing evidence-based care. Authors conducted a qualitative research study with 20 patients receiving headache care at seven Headache Centers of Excellence within the Veterans Health Administration to examine their experiences navigating headache care. This study employed thematic qualitative analysis and conducted cross-case comparisons. Several key findings emerged. 1) Most patients saw multiple healthcare providers over numerous years before reaching a headache specialist to manage chronic headaches. 2) Receipt of high-quality and comprehensive headache specialty care was associated with high satisfaction. 3) Patients with headache diseases reported oftentimes they experienced an arduous journey across multiple healthcare systems and between several healthcare providers before receiving evidence-based headache treatment that they found acceptable. Results demonstrate that most patients were satisfied with their current specialty headache care in the Veterans Health Administration. Authors discuss implications for future studies and highlight ways to improve patient satisfaction and timely access to appropriate headache care.

Real-world experience of OnabotulinumtoxinA treatment in female patients with chronic migraine: a qualitative study using in-depth interviews

BACKGROUND

Chronic migraine (CM) causes great disability and affects an individual's quality of life. OnabotulinumtoxinA (OBT-A, Botox®) was the first prophylactic treatment specifically indicated for CM. The aim of this study was to describe the experiences of women with CM treated with OBT-A.

MATERIALS AND METHODS

The study design is a qualitative descriptive study. A purposeful sampling of 30 women (mean age, 42.7; standard deviation, 10.6) who had received at least two administrations of OBT-A for CM (PREEMPT protocol) was performed. Data collection included in-depth interviews and researchers' field notes. A thematic analysis was carried out according to qualitative research guidelines.

RESULTS

Five themes were identified: (a) A long way to go before Botox®, (b) First time hearing about the treatment and its expectations, (c) The administration of Botox®, (d) Treatment effects, and (e) Follow-up. Patients described a long history of treatment failures prior to the start of OBT-A treatment. Information about this migraine treatment came from the neurologist; following the information, patients had high expectations, including unrealistic expectations regarding the onset and duration of effect. They acknowledged fear of the injections and some discomfort due to the procedure. With treatment, participants reported better migraine control and an improvement in their quality of life. Follow-up had some barriers, such as delayed appointments for subsequent doses, but also strengths, such as effectiveness and few side effects.

CONCLUSIONS

Qualitative research offers insight into how patients with CM experience treatment with OBT-A. Our results highlight some relevant aspects that should be considered when providing OBT-A treatment.

Measuring interictal burden among people affected by migraine: a descriptive survey study

BACKGROUND

Previous research has extensively documented the impact of migraine episodes ('ictal') on patients' health-related quality of life. Few studies have looked at the impact of migraine on migraine-free days ('interictal'). This study was designed to describe interictal burden of migraine in a mixed group of people affected by migraine and to explore patient characteristics associated with interictal burden.

METHODS

People with migraine in the United States (US) and Germany were recruited for a cross-sectional online survey, including a subgroup treated with calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb). The survey included the Migraine Interictal Burden Scale (MIBS-4), Headache Impact Test (HIT-6), and items measuring patient demographics, clinical and treatment background. Data were analyzed using descriptive statistics and linear regression.

RESULTS

Five hundred six people with migraine completed the survey (US: n = 257; Germany: n = 249), of whom 195 had taken a CGRP mAb for three or more months. Participants had a mean of 8.5 (SD = 6.4) Monthly Migraine Days (MMD) and 10.4 (SD = 7.1) Monthly Headache Days (MHD). The mean MIBS-4 score was 6.3 (SD = 3.4), with 67% reporting severe interictal burden (MIBS-4: ≥5). The mean HIT-6 score was 65.3 (SD = 6.0), with 86% reporting severe migraine impact (HIT-6: ≥60). MIBS-4 was correlated with the HIT-6 (r = 0.37), MMD and MHD (both r = 0.27). The HIT-6, MMD, MHD, CGRP mAb treatment, and depression all had an independent positive association with the MIBS-4.

CONCLUSION

Two-thirds of the study sample reported substantial interictal burden. Whilst interictal burden was associated with migraine frequency and impact of migraine attacks, study results also show it represented a distinct aspect of the overall disease burden. Study findings further indicate unique associations between interictal burden and depression. A unique positive association between interictal burden and CGRP mAb treatment suggests a remaining unmet need among people affected by migraine treated with CGRP mAb.

Greater occipital nerve block for chronic migraine patients: A meta-analysis

INTRODUCTION

Greater occipital nerve block (GONB) is a minimally invasive procedure frequently used in patients with chronic migraine (CM); however, the quality of the evidence supporting its use is still unknown. Therefore, we aimed to conduct a systematic review, meta-analysis and quality assessment of GONB local anaesthetics combined or not with corticosteroids to prevent CM.

METHODS

We searched Medline, Scopus and Web of Science up to October 2020. We included randomized control trials (RCT) and observational studies assessing GONB without language restrictions. Two researchers selected the studies, extracted the data and evaluated the risk of bias independently. The primary outcomes measured to assess efficacy were the change from baseline in the intensity and frequency of headache in the intervention group compared to placebo at a onetime point. We performed a meta-analysis with random effect models, and we evaluated random errors with trial sequential analysis (TSA). We assessed the risk of bias (ROB) with the ROB2 tool and the certainty of the evidence with GRADE.

RESULTS

We identified 2864 studies in the databases and included three RCTs for quantitative synthesis. Most ROB assessments were 'high risk' or 'some concerns'. GONB reduced the intensity of headaches at the end of the first month (MD: -1.35, 95% CI: -2.12 to -0.59) and the second month (MD: -2.10, CI 95%: -2.94 to -1.26) as well as the frequency of headaches (first month: MD: -4.45 days, 95% CI: -6.56 to -2.34 days; second month: MD: -5.49, 95% CI -8.94 to -2.03 days). Corticosteroids did not show a significant decrease in the frequency of headaches during the first month of treatment (MD: -1.1 days, 95% CI: -4.1 to 1.8, p = .45). Included trials reported similar adverse events between groups. The exploratory TSA showed inconclusive results. Overall, the quality of the evidence was very low because of the substantial risk of bias and imprecision.

CONCLUSION

The limited evidence available shows that GONB with local anaesthetics could reduce headache frequency and intensity compared to placebo, while adding corticosteroids did not show additional benefits. GONB was safe with a similar number of minor adverse events. However, our confidence in these estimates is very low since the evidence is based on a few trials, with a small sample size and a significant risk of bias. In addition, the exploratory TSA was inconclusive, so we need larger and specific trials.

Real-World experience of interictal burden and treatment in migraine: a qualitative interview study

Background

The debilitating nature of migraine attacks is widely established; however, less is known about how the interictal burden (i.e., how patients are affected in-between migraine episodes) of migraine impacts on patients’ health-related quality of life (HRQL). Acute and preventive treatments may lift the burden of the disease, but they often have unwanted side effects and limited effectiveness. The objective of this study was to understand the interictal burden of migraines, from the patient perspective, and to explore patient experience with migraine treatments.

Methods

Participants (n=35) with a self-reported diagnosis of migraine were recruited in the US, UK and Canada, including a subgroup of patients who had taken calcitonin gene-related peptide monoclonal antibody (CGRP mAb) treatment for at least three months. Participants completed a background questionnaire, followed by a semi-structured interview via telephone or video call. The interviews explored patients’ migraine symptoms, perception of interictal burden and treatment experience. The interview transcripts were analysed using thematic analysis.

Results

The most reported migraine symptom was migraine pain, followed by aura, sensory sensitivity and nausea. Most participants reported interictal impact on HRQL, lifestyle changes they made to avoid triggers or in anticipation of an attack, impacts on work, career, daily activities and relationships. Emotional impacts were reported by all participants, including anger, depression, anxiety and hopelessness. Many participants who took preventive treatments reported improvements in HRQL and functioning but still experienced breakthrough attacks. Among patients who took CGRP mAbs, participants noted varying consistency of treatment effectiveness between treatment administrations.

Conclusion

This study detailed the additional HRQL impact of migraine in-between migraine attacks and described the unmet need for effective treatment options to prevent and mitigate migraine attacks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-022-01429-5.

A Qualitative Study to Explore Patient Perspectives of Prophylactic Treatment with OnabotulinumtoxinA for Chronic Migraine

INTRODUCTION

OnabotulinumtoxinA (OBT-A) is one of the most studied prophylactic treatments for chronic migraine. Large clinical trials, and now real-world studies, continue to provide evidence to support the use of OBT-A as an effective treatment to manage chronic migraine. The objective of this study was to explore patient experience and perception of prophylactic treatment with OBT-A for chronic migraine.

METHODS

Data were collected using semi-structured interviews using open-ended questions to uncover rich descriptive data on patient experiences. Interviews were transcribed and analysed using NVivo data analysis software to code and identify themes across the dataset. Three patient groups were included in the analysis: (1) patients who were receiving continued OBT-A treatment; (2) patients who discontinued OBT-A treatment; (3) patients who were recommended for OBT-A treatment but did not proceed.

RESULTS

For patients who received at least one OBT-A treatment, four main themes emerged, which described patients' expectations, experiences, and feelings towards their treatment decisions. Two main themes emerged that were common to patients, who had discontinued their treatment and those, who were recommended for OBT-A treatment but did not proceed, which were identified as potential barriers to initiate or continue prophylactic treatment with OBT-A.

CONCLUSION

Understanding patients' perspective is an important part of clinical practice and may impact on decision-making. Qualitative data can provide a more holistic view of patient care and treatment insights that may not be evaluated during a clinical trial. This study revealed potential barriers to treatment that can inform future policy and practice.

Pictures and a thousand words: the experiences of significant others whose loved ones have a severe brain injury who are being discharged home

Purpose:

To investigate the experiences of significant others when their loved one with a severe acquired brain injury (ABI) is being discharged from an ABI-specific rehabilitation unit.

Participants:

Significant others of loved ones with an ABI participated in interviews close to their loved ones being discharged from inpatient ABI rehabilitation.

Methods:

Semi-structured interviews were conducted, and thematic analysis applied. Additionally, the drawing method was also used which involved participants drawing what it was like for them as their loved one was going home. Image analysis was then combined with the interview data.

Results:

Eight significant others participated in interviews on discharge and completed a drawing describing their experience. Five themes were identified (Change, Mixed feelings, Support of family and friends, Journey and Staff interactions).

Conclusion:

The experience of having a loved one with a severe ABI in rehabilitation is an emotional event. Compassionate communication, consistency of information and thorough discharge planning practices were cornerstones to enhancing the experience of significant others, empowering them to undertake their new role.

Understanding the diagnoses and medical care experience of patients with new daily persistent headache: a qualitative study in Spain

OBJECTIVE

To explore the experiences of patients suffering from new daily persistent headache (NDPH) regarding the diagnostic process, treatment and medical care.

DESIGN

A qualitative phenomenological study was conducted.

SETTING

A specialised headache unit at two university hospitals in Spain between February 2017 and December 2018.

PARTICIPANTS

Patients diagnosed with NDPH according to the International Classification of Headache disorders (third beta edition).

METHODS

Purposeful sampling was performed. Data were collected using unstructured and semistructured interviews, researchers' field notes and patients' drawings. An inductive thematic analysis was used to identify significant emerging themes from interviews, field notes and descriptions of patients' drawings. Also, Guillemin's proposal was used to analyse the contents of drawings.

RESULTS

Nineteen patients with a mean age of 45.3 were recruited. Four main themes emerged: (1) Seeking a diagnosis, patients visit many doctors without receiving a clear answer and their diagnosis is delayed; (2) Self-medication-minimising pill intake, medication is ineffective, and therefore, some patients discontinue treatment, or are flexible with how they take medication; (3) Trying other non-pharmacological options, many patients turn to other therapies and complementary and/or alternative therapies as a second option, however these are ineffective and (4) Medical care, with two subthemes, referrals and lacking continuity of care, and building the doctor-patient relationship. Patients describe how the referral breaks the continuity of care, and how they identify the traits of a doctor who is approachable and which behaviours the doctor should avoid when caring for patients.

CONCLUSIONS

An in-depth knowledge of the beliefs and expectations of patients with NDPH will allow the professional to establish a relationship of trust, which will improve the patients' knowledge of which therapies are the most appropriate, and to establish expectations based on the relationship with the doctor, and not only on patients' beliefs.

Coping and Motivation for Change-An Interview Study of the Experience From Participation in an Educational Program for Patients With Medication-Overuse Headache

Patient educational programs (PEP) are recommended as part of the treatment for medication-overuse headache (MOH), however, knowledge of patients' experiences when participating is sparse. This study explored how patients experienced participating in a PEP focusing on empowering coping strategies and motivation for behavioral changes. Eight individual semistructured interviews were conducted among patients suffering from MOH who had attended a PEP intervention in a randomized controlled trial. The PEP involved techniques from Motivational Interviewing as its communicative approach. Data collection, analysis, and interpretation were performed within a phenomenological-hermeneutic framework. Results showed that patients found the educational program relevant regarding coping with headache. Participants shifted from focusing on medication to include other ways to manage headache. Experiences regarding ambivalent feelings for behavioral change and feelings of stigmatization were key issues. Participation in this PEP helped the participants cope with headache in new ways relevant to their everyday lives and challenges. The individualized approach enabled by Motivational Interviewing was experienced as useful by the participants, as it actively involved them in the treatment.

Burden of migraine and unmet needs from the patients' perspective: a survey across 11 specialized headache clinics in Korea

BACKGROUND

Migraine is a neurological, primary headache disorder affecting more than 1 billion people worldwide, with a multi-faceted burden that can significantly impact the everyday life of a patient, both during and between attacks. However, studies on patient awareness, burden, and clinical management of migraine in Korea are limited and outdated. The aim of this study was to comprehensively investigate the current difficulties and unmet needs that Korean patients with migraine encounter from their perspective.

METHODS

A total of 207 patients with episodic or chronic migraine aged between 15 and 76 years, completed a survey designed to cover the following topics: diagnosis, understanding of the disease, treatment experience, disability, and quality of life. Patients were recruited by their neurologists from 11 specialized headache clinics in Korea and completed the survey between 22 July and 19 August 2019. Validated scales such as the Migraine Disability Assessment (MIDAS) questionnaire and Migraine-Specific Quality of Life Questionnaire version 2.1 (MSQv2.1) were used to assess levels of disability and quality of life, respectively, in patients.

RESULTS

On average, it took 10.1 years from onset of symptoms to diagnosis and a mean of 3.9 hospitals were visited for treatment prior to the patient's current hospital. There was a lack of understanding among respondents about migraine, with 55.6% believing that unilateral headache is a unique feature of migraine compared with other headache disorders. On average, high levels of disability and poor quality of life were reported by patients, as assessed by MIDAS and MSQv2.1, respectively, but only 23.7% had regularly taken preventive medication in the past. Overall satisfaction with previous doctor-patient relationships was reported by 29.5% of respondents, and satisfaction with preventive and acute medications by only 40.8% and 27.1% of the respondents, respectively.

CONCLUSION

Korean patients with migraine experience significant disability and reduced quality of life as a result of the disease and have clear unmet needs in terms of diagnosis, understanding of the disease, and disease management including treatment.

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

Objective

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

Background

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

Method

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

Results

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

Conclusion

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

Clinical Reasoning Behind Non-Pharmacological Interventions for the Management of Headaches: A Narrative Literature Review

Headache is the clinical syndrome most commonly observed by neurologists in daily practice. Pharmacological and non-pharmacological treatments are commonly used for the management of headaches; however, the clinical reasoning behind these interventions is not properly applied. We conducted a narrative literature review using as data sources for academic PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PEDro, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, and SCOPUS. This narrative literature review mainly considered systematic reviews, meta-analyses, randomised clinical trials, and expert opinions published after the year 2000 discussing clinical reasoning for application of non-pharmacological interventions in individuals with tension-type, migraine, and cervicogenic headaches. After the data extraction, we organized the literature thematically as follows: (1) mapping of theoretical aspects of non-pharmacological interventions; (2) summarizing most updated literature about effectiveness of non-pharmacological interventions grouped by targeted tissue and headache; (3) identifying research gaps in the existing literature and proposing hypotheses for better understanding of current clinical reasoning. We found that there are many non-pharmacological treatment strategies used for headaches, including beyond the tissue-based impairment treatments (bottom-up) and strategies targeting the central nervous system (top down). Bottom-up strategies include joint-biased, soft-tissue biased, or needling interventions, whereas top-down strategies include exercise and cognitive interventions. Evidence shows that the effectiveness of these interventions depends on the application of proper clinical reasoning, since not all strategies are effective for all headaches. For instance, evidence of non-pharmacological interventions is more controversial for migraines than for tension-type or cervicogenic headaches, since migraine pathogenesis involves activation of sub-cortical structures and the trigemino- vascular system, whereas pathogenesis of tension-type or cervicogenic headaches is most associated to musculoskeletal impairments of the cervical spine. We conclude that current literature suggests that not all non-pharmacological interventions are effective for all headaches, and that multimodal, not isolated, approaches seem to be more effective for patients with headaches. Most published studies have reported small clinical effects in the short term. This narrative literature review provides some hypotheses for discrepancies in the available literature and future research. Clinical reasoning should be applied to better understand the effects of non-pharmacological interventions.

Digital Cognitive Behavioral Therapy for Insomnia in Women With Chronic Migraines

OBJECTIVE/BACKGROUND

Insomnia commonly co-occurs with chronic migraines (CM). Non-pharmacological treatments for insomnia in CM patients remain understudied. This is a proof-of-concept study, which aims to evaluate the feasibility, acceptability, and preliminary efficacy of a digital cognitive behavioral therapy for insomnia (dCBT-I) for individuals with CM and insomnia (CM-I) in the United States.

METHODS

We recruited 42 females with CM-I symptoms from a U.S.-based observational cohort and from the general population via advertisements. Within a multiple baseline design, participants were randomized to receive dCBT-I after 2, 4, or 6 weeks of completing baseline sleep diaries. DCBT-I was scrutinized against benchmarks for completion rates (≥90% to complete dCBT-I), acceptability (≥80% to find dCBT-I acceptable), and posttreatment changes in insomnia symptoms (≥50% indicating a clinically relevant improvement in their insomnia symptoms). As a secondary measure, we also reported percentage of individuals reverting to episodic migraines.

RESULTS

Out of 42 randomized, 35 (83.3%) completed dCBT-I within the 12 weeks provided. Of these completers, 33 (94.3%) reported being satisfied (n = 16) or very satisfied (n = 17) with treatment. Additionally, 65.7% of completers responded to treatment as per universally accepted criteria for insomnia. Lastly, 34% of completers reverted from CM to episodic migraine.

CONCLUSION

This study provides evidence for the feasibility and acceptability of dCBT-I in patients with CM-I complaints. Effects of improving insomnia and migraines were suggested. These results indicate that a randomized controlled trial is needed to determine the efficacy of dCBT-I in CM patients.

Effects of onabotulinumtoxinA treatment in chronic migraine patients with and without daily headache at baseline: results from the COMPEL Study

BACKGROUND

OnabotulinumtoxinA is effective in preventing chronic migraine (CM); however, the benefit of onabotulinumtoxinA in patients with CM with daily headache is unknown because these patients are typically excluded from clinical trials. This subanalysis of the COMPEL Study assessed the efficacy and safety of onabotulinumtoxinA in people with CM with and without daily headache.

METHODS

In total, 715 patients received onabotulinumtoxinA 155 U with or without concomitant oral preventive treatment. Patients who had complete daily diary records for the 28 days of the baseline period were stratified based on daily headache status. The primary outcome variable was reduction in headache-day frequency per 28-day period at 108 weeks (after 9 treatment cycles) relative to baseline. Exploratory outcomes included moderate to severe headache days, migraine disability (using the Migraine Disability Assessment [MIDAS] questionnaire), and health-related quality of life (Migraine-Specific Quality-of-Life Questionnaire v2 [MSQ]). Adverse events and their relatedness were recorded.

RESULTS

Overall, 641 patients had complete daily diary records at baseline. In patients with daily headache (n = 138) versus without (n = 503), treatment with onabotulinumtoxinA was associated with a significant mean (SD) reduction in 28-day headache-day frequency relative to baseline at week 108 (- 10.5 [9.2] vs - 12.2 [6.7], respectively; both P < 0.001) with no significant between-group difference (P = 0.132). The mean (SD) reduction in moderate to severe headache days at week 108 was significant in patients with and without daily headache (- 11.5 [9.4] and - 9.9 [6.4]; P < 0.001) with no significant between-group difference (P = 0.153). Mean (SD) MIDAS scores significantly improved from baseline at week 108 (- 43.3 [73.4] and - 43.6 [46.7]; both P < 0.001), with no significant between-group difference (P = 0.962). Similarly, mean (SD) MSQ subscale scores significantly improved from baseline at week 108 for patients with and without daily headache. OnabotulinumtoxinA was well tolerated in patients with and without daily headache.

CONCLUSION

Results indicate that onabotulinumtoxinA is associated with reductions from baseline in headache-day frequency and improvements in disability and quality of life for up to 108 weeks in people with CM with daily headache; however, a longer duration of treatment was required to fully realize the treatment effect on headache. No new safety concerns were identified.