Faculty Bibliography

BACKGROUND:Emergency department (ED) visits for migraine are burdensome to patients and to the larger healthcare system and society. Thus, it is important to determine strategies used to prevent ED visits and the common communication patterns between headache specialists and the ED team. OBJECTIVE:We sought to understand: (1) Whether headache specialists use headache management protocols. (2) The strategies they use to try and reduce the number of ED visits for headache. (3) Whether protocols are used in the EDs with which they are affiliated. (4) The level of satisfaction with the coordination of care between headache physicians and the ED. METHODS:We surveyed via SurveyMonkey members of the American Headache Society Emergency Department/Refractory/Inpatient (EDRI) Section to understand their practice regarding patients who call their office to be seen urgently, and to understand their communication with their local EDs. RESULTS:There were 96 eligible AHS members, 50 of whom responded to questionnaires either by email or in person (52%). Of these, 59% of respondents reported giving rescue treatment to their patients to manage acute attacks. Fifty-four percent reported using standard protocols for outpatients not responding to usual acute treatments. In the event of a request for urgent care, 12% of specialists reported bringing patients into the office most or all of the time, and 20% reported sending patients to the ED some or most of the time for headache management. Thirty-six percent reported prescribing a new medicine and 30% reported providing telephone counseling some/most/all of the time. Sixty percent reported that their ED has a protocol for migraine management. Overall, 38% were usually or very satisfied with the headache care in the ED. CONCLUSIONS:A substantial number of headache specialists are dissatisfied with the care their patients receive in the ED. More standardized protocols for ED visits by patients with known headache disorders, and clear guidelines for communication between ED providers and treating physicians, along with better methods for follow-up following discharge from the ED, might appear to improve this issue.

Background: Little is known about how well headache smartphone applications (apps) protect patient information and whether they are secure to use. 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, abstracted from the apps the types of data the apps requested from users, and examined the existence and content of privacy policies. In particular, we analyzed the app function, data storage, and statements in the app';s privacy policy, app store entry, or other documentation to determine whether an app collected various types of personal information from the user such as (a) whether the app requests user input regarding the user';s identity, (b) headache condition (e.g. medications, triggers, dates and times of headaches), or (c) data that might be collected based on a user';s actions rather than their data entries. 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. 55% (6/11) stated that some user data was used to serve targeted advertisements. Sixty four percent (7/11) of the policies (including those for apps without remote headache diary functionality) stated why they shared data with third parties and 18% (2/11) did not clearly explain the purpose of data sharing. 11/15 (73%) of the relaxa-tion apps had privacy policies. Conclusion: Of concern, there were several areas where information may not be transparent to migraine users or to the physicians recommending use of the apps. These include: 1. Whether apps have privacy policies and whether the apps'; policies provide "plain English" explanations about how user';s data is stored and how it is used. 2. Whether any user data (including the very fact that a user downloaded a headache app) could be used for advertising or marketing purposes. In conclusion, 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

Background: Level A evidence supports behavioral treatments for migraine. However, such treatments are underutilized due to the lack of 1) time, 2) insurance payment, and 3) patients'; therapeutic education on the behavioral options. Health message framing is a promising way to help guide patients with treatment decisions. Methods: Eight message frames about behavioral treatment for migraine were developed: six specific messages and two nonspecific messages, with half being gain-framed and the other half loss-framed. Message frames were assessed via a survey distributed on Turk Prime to people with migraine. Results: Fifty-six people completed the survey, with seven participants per message frame. Specific gain of frame was the most understood (90% of participants understood) and motivated participants to pursue behavioral therapy (57% willing to try in person behavioral therapy and 76% willing to try smartphone based behavioral treatment options). In this most motivated group, 14% reported that they would pay out of pocket for behavioral treatment. The least understood and least likely to motivate participants were the specific loss of frame messages; 52% were willing to try in person behavioral therapy and 38% were willing to try smartphone behavioral treatment options. 5% would pay out of pocket Conclusion: In this pilot study, the most easily understood and successful message frame was specific gain frame message. Larger studies may help determine best message framing for discussing behavioral treatments for migraine patients

Background: There are limited data on the adherence of migraine patients to recommendations for evidence-based behavioral treatments. Among patients seen by a headache specialist, we sought to determine rates of adherence to recommended behavioral treatments and barriers to adherence. We also sought to determine whether psychosocial factors such as migraine related disability, locus of control and self-efficacy were associated with adherence to migraine behavioral treatment recommendations. Methods: We conducted a prospective study of consecutive patients presenting to four headache specialists who were diagnosed with migraine at our Headache Center from 2016-2017 to examine whether they adhered to the recommendation to receive behavioral treatment. The primary outcome was whether patients had scheduled at least one visit for behavioral treatment. Descriptive statistics were reported. Patients who made an appointment for behavioral treatment were compared to those who did not across multiple categories including demographics, migraine characteristics, and personal beliefs with ANOVA and chi-square tests. Qualitative analyses were also done for open ended survey questions. Results: Of the 234 eligible patients, 69 (29.5%) were referred for behavioral treatment. Fifty-three (76.8%) patients referred for behavioral treatment were successfully reached by phone. Mean duration from time of referral to follow-up was 76 days (median 76, SD5 45). Just over half of patients (56.6%, N530) adhered to the recommendation for behavioral treatment. Patients who had previously seen a psychologist for their migraines were more likely to adhere to the behavioral treatment recommendation than patients who had not. Time constraints were the most common barrier cited for not scheduling a behavioral treatment appointment. Conclusion: Less than one third of eligible patients were referred for behavioral treatment and only about half adhered to the recommendation to schedule an appointment for behavioral treatment. More research should assess factors which might play a role in adherence to migraine behavioral treatment recommendations

Background: There are no clear guidelines on how to treat post-traumatic headache (PTH) or post-concussive symptoms (PCS). However, behavioral interventions such as cognitive behavioral therapy, biofeedback and relaxation are Level-A evidence-based treatments for headache prevention. To understand how to develop and study further mind body interventions (MBIs) and behavioral therapies for PTH and PCS, we developed the following question using the PICO framework: Are behavioral therapies and MBIs effective for treating PTH and PCS? Methods: We conducted a systematic search of three databases (Medline, PsycINFO and EMBASE) for behavioral interventions and MBIs with the subject headings and keywords for PTH, concussion, and traumatic brain injury (TBI). Inclusion criteria were (1) ran-domized controlled trial (RCT) (2) the majority of the intervention had to be behavioral or mind-body therapy focused (3) the majority of the participants (>50%) had to have had a mild TBI (not a moderate or severe TBI) (4) published in a peer reviewed publication. The search identified 917 individual studies. Two independent reviewers screened citations and full text articles independently. Nineteen articles were pulled for full article review. Seven articles met the final inclusion criteria. The systematic review was registered in Prospero (CRD42017070072). Results: In total from all studies, there were 1,120 adult participants ranging from 18-80. Sixty-nine percent were male. Of the 7 studies, 3/7 were focused on military staff (retired and active). Time post injury for inclusion into the studies varied from 48 hours post-injury to more than two years post injury. Two studies recruited from patients who had visited their emergency depart-ments. There was vast heterogeneity across studies making it difficult to fully assess efficacy. The heterogeneity ranged from differences in patient populations, the timing of when the interventions were initiated (2 weeks-2 years post injury), the types of intervention e.g. in-person CBT, group CBT, telephone counseling, the amount of contact with study staff, and the methods for assessing outcomes e.g. Rivermead and Post Concussive Score. Conclusion: Many of the interventions offered vastly different methods of delivery of intervention and doses of intervention. Many of the negative studies were done after an extended duration post injury (>one-year post TBI). In addition, participants were lumped together regardless of their pre-concussion comorbidities, their mechanism of injury, their symptoms, and the duration from injury to the start of the intervention. Thus, there are various considerations for the design of the intervention for future behavioral/MBI studies for PTH and concussion

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.

Objective/UNASSIGNED:To evaluate the frequency with which migraine patients initiated behavioral migraine treatment following a headache specialist recommendation and the predictors for initiating behavioral migraine treatment. Methods/UNASSIGNED:We conducted a prospective cohort study of consecutive patients diagnosed with migraine to examine whether the patients initiated behavioral migraine treatment following a provider recommendation. The primary outcome was scheduling the initial visit for behavioral migraine treatment. Patients who initiated behavioral migraine treatment were compared with those who did not (demographics, migraine characteristics, and locus of control) with analysis of variance and chi-square tests. Results/UNASSIGNED:Of the 234 eligible patients, 69 (29.5%) were referred for behavioral treatment. Fifty-three (76.8%) patients referred for behavioral treatment were reached by phone. The mean duration from time of referral to follow-up was 76  (median 76, SD = 45) days. Thirty (56.6%) patients initiated behavioral migraine treatment. There was no difference in initiation of behavioral migraine treatment with regard to sex, age, age of diagnosis, years suffered with headaches, health care utilization visits, Migraine Disability Assessment Screen, and locus of control (P > 0.05). Patients who had previously seen a psychologist for migraine were more likely to initiate behavioral migraine treatment than patients who had not. Time constraints were the most common barrier cited for not initiating behavioral migraine treatment. Conclusions/UNASSIGNED:Less than one-third of eligible patients were referred for behavioral treatment, and only about half initiated behavioral migraine treatment. Future research should further assess patients' decisions regarding behavioral treatment initiation and methods for behavioral treatment delivery to overcome barriers to initiating behavioral migraine treatment.

OBJECTIVE:Using a science, technology, engineering, arts, and mathematics (STEAM) curriculum, we developed, piloted, and tested the Headache and Arts Program. This program seeks to increase knowledge and awareness of migraine and concussion among high school students through a visual arts-based curriculum. METHODS:values were calculated using SPSS V.24 and Microsoft Excel. RESULTS:Forty-eight students participated in the research program. Students created artwork that integrated STEAM knowledge learned through the program and applied creative methods to teach others about migraine and concussion. At baseline, students' total scores averaged 67.6% correct. Total scores for the longitudinal preassessment, immediate postassessment, and delayed 3-month postassessment averaged 69.4%, 72.8%, and 80.0% correct, respectively. CONCLUSION/CONCLUSIONS:The use of a visual arts-based curriculum may be effective for migraine and concussion education among high school students.