Faculty Bibliography

OBJECTIVE:To outline strategies for the treatment of migraine which do not require in-person visits to clinic or the emergency department, and to describe ways that health insurance companies can remove barriers to quality care for migraine. BACKGROUND:COVID-19 is a global pandemic causing widespread infections and death. To control the spread of infection we are called to observe "social distancing" and we have been asked to postpone any procedures which are not essential. Since procedural therapies are a mainstay of headache care, the inability to do procedures could negatively affect our patients with migraine. In this manuscript we review alternative therapies, with particular attention to those which may be contra-indicated in the setting of COVID-19 infection. DESIGN/RESULTS/UNASSIGNED:The manuscript reviews the use of telemedicine visits and acute, bridge, and preventive therapies for migraine. We focus on evidence-based treatment where possible, but also describe "real world" strategies which may be tried. In each section we call out areas where changes to rules from commercial health insurance companies would facilitate better migraine care. CONCLUSIONS:Our common goal as health care providers is to maximize the health and safety of our patients. Successful management of migraine with avoidance of in-person clinic and emergency department visits further benefits the current urgent societal goal of maintaining social distance to contain the COVID-19 pandemic.

BACKGROUND:There are safe and well-tolerated level A evidence-based behavioral therapies for the prevention of migraine. They are biofeedback, cognitive behavioral therapy, and relaxation. However, the behavioral therapies for the prevention of migraine are underutilized. OBJECTIVES/OBJECTIVE:We sought to examine whether people with migraine with 4 or more headache days a month had preferences regarding the type of delivery of the behavioral therapy (in-person, smartphone based, telephone) and whether they would be willing to pay for in-person behavioral therapy. We also sought to determine the predictors of likelihood to pursue the behavioral therapy. METHODS:Using a cross-sectional study design, we developed an online survey using TurkPrime, an online survey platform, to assess how likely TurkPrime participants who screened positive for migraine using the American Migraine Prevalence and Prevention screen were to pursue different delivery methods of the behavioral therapy. We report descriptive statistics and quantitative analyses. RESULTS:There were 401 participants. Median age was 34 [IQR: 29, 41] years. More than two thirds of participants (70.3%, 282/401) were women. Median number of headache days/ month was 5 [IQR: 2.83, 8.5]. Some (12.5%, 50/401) used evidence-based behavioral therapy for migraine. The participants reported that they were "somewhat likely" to pursue in-person or smartphone behavioral therapy and behavioral therapy covered by insurance but were neutral about pursuing the telephone-based behavioral therapy. Participants were "not very likely" to pay out of pocket for the behavioral therapy. Migraine-related disability as measured by the MIDAS grading score was associated with likelihood to pursue the behavioral therapy in-person (P = .004), via telephone (P = .015), and via smart phone (P < .001), and covered by insurance (P = .001). However, migraine-related disability was not associated with likelihood to pursue out of pocket (P = .769) behavioral therapy. Pain intensity was predictive of likelihood of pursuing the behavioral therapy for migraine when covered by insurance. Other factors including education, employment, and headache days were not predictors. CONCLUSION/CONCLUSIONS:People with migraine prefer in-person and smartphone-based behavioral therapy to telephone-based behavioral therapy. Migraine-related disability is associated with likelihood to pursue the behavioral therapy (independent of type of delivery of the behavioral therapy-in-person, telephone based or smartphone based). However, participants were not very likely to pay for the behavioral therapy.

BACKGROUND:Relaxation, biofeedback, and cognitive behavioral therapy are evidence-based behavioral therapies for migraine. Despite such efficacy, research shows that only about half of patients initiate behavioral therapy recommended by their headache specialists. OBJECTIVE:Motivational interviewing (MI) is a widely used method to help patients explore and overcome ambivalence to enact positive life changes. We tested the hypothesis that telephone-based MI would improve initiation, scheduling, and attending behavioral therapy for migraine. METHODS:Single-blind randomized controlled trial comparing telephone-based MI to treatment as usual (TAU). Participants were recruited during their appointments with headache specialists at two sites of a New York City medical center. INCLUSION CRITERIA/METHODS:ages from 16 to 80, migraine diagnosis by United Council of Neurologic Subspecialty fellowship trained and/or certified headache specialist, and referral for behavioral therapy for prevention in the appointment of recruitment. EXCLUSION CRITERIA/METHODS:having done behavioral therapy for migraine in the past year. Participants in the MI group received up to 5 MI calls. TAU participants were called after 3 months for general follow-up data. The prespecified primary outcome was scheduling a behavioral therapy appointment, and secondary outcomes were initiating and attending a behavioral therapy appointment. RESULTS:76 patients were enrolled and randomized (MI = 36, TAU = 40). At baseline, the mean number of headache days was 12.0 ± 9.0. Self-reported anxiety was present for 36/52 (69.2%) and depression for 30/52 (57.7%). Follow-up assessments were completed for 77.6% (59/76, MI = 32, TAU = 27). The mean number of MI calls per participant was 2.69 ± 1.56 [0 to 5]. There was a greater likelihood of those in the MI group to initiating an appointment (22/32, 68.8% vs 11/27, 40.7%, P = .0309). There were no differences in appointment scheduling or attendance. Reasons stated for not initiating behavioral therapy were lack of time, lack of insurance/funding, prioritizing other treatments, and travel plans. CONCLUSIONS:Brief telephone-based MI may improve rates of initiation of behavioral therapy for migraine, but other barriers appear to lessen the impact on scheduling and attending behavioral therapy appointments.

The American College of Emergency Physicians (ACEP) published guidelines in July 2019 on the diagnosis and management of acute nontraumatic headaches in the emergency department, focusing predominantly on the diagnosis of subarachnoid hemorrhage and the role of imaging and lumbar puncture in diagnosis. The ACEP Clinical Policies document is intended to aide Emergency Physicians in their approach to patients presenting with acute headache and to improve the accuracy of diagnosis, while promoting safe patient care practices. The Clinical Policies document also highlights the need for future research into best practices to distinguish primary from secondary headaches and the efficacy and safety of current treatment options for acute headaches. The following commentary on these guidelines is intended to support and expand on these guidelines from the Headache specialists' perspective, written on behalf of the Refractory, Inpatient, Emergency Care section of the American Headache Society (AHS). The commentary have been reviewed and approved by Board of Directors of the AHS.

OBJECTIVE:There has been a rise in urgent care centers throughout the country over the past 10 years, leading to an increase in patients accessing medical care in these locations. These centers advertise an alternative to the Emergency Department (ED) for the evaluation and treatment of urgent medical conditions. The goal of this analysis was to examine the use of urgent care visits for migraine within 2 urgent care centers within a large academic medical system in New York City. We examined the trends in management and treatment of migraine in these urgent care settings, as well as prescriptions and instructions given to this patient population upon discharge. We paid particular attention to whether the medications administered and prescribed on discharge were those recommended by American Headache Society migraine management guidelines. METHODS:We conducted a retrospective chart review of patients with migraine diagnoses at 2 different urgent care locations within 1 large urban medical center. We determined baseline patient demographics, previous migraine characteristics, frequencies of reasons for urgent care visits as well as various medications administered, medications prescribed on discharge, and characteristics of patient outcomes post-discharge. RESULTS:Of the 78 patients who visited urgent care with a migraine diagnosis, 20 (25.6%) had a known primary care provider within the urgent care centers' healthcare system. More than three-fourths of all patients (78.2%) had a self-reported history of either recurrent headache or migraine prior to the urgent care visit. Of those with a documented frequency of prior headaches, 94.1% (32/34) had episodic migraine and 79.4% (27/34) experienced at most 1-2 headache days per month. Of those presenting to the urgent care during an episode of migraine, 12.3% (9/73) were given intravenous metoclopramide and none were given subcutaneous sumatriptan or intravenous prochlorperazine. Of those with reported nausea or vomiting with their migraine, 46.2% (18/39) received an anti-emetic at the visit and 33.3% (13/39) were given an anti-emetic prescription. Only 11.1% (6/54) of patients who did not have a record of previous triptan use were given a triptan prescription at the urgent care visit. CONCLUSIONS:The majority of patients in our study who sought medical treatment for migraine in these 2 urgent care centers were not established patients within the urgent care centers' healthcare system. While 93.6% (73/78) of patients were experiencing current pain upon presentation to the urgent care centers, only 12.3% (9/73) received administration of the medications with the highest level of evidence by the American Headache Society (Level B) for acute migraine treatment in an ED. In addition, the majority of patients with a migraine history presenting to the urgent care setting were not given triptans or anti-emetic prescriptions upon discharge from their urgent care visit. Having these migraine-specific prescriptions may improve self-treatment at home should a migraine attack recur.

The current planned secondary analysis of a randomized clinical trial aimed to evaluate whether the efficacy of Mindfulness-Based Cognitive Therapy for Migraine (MBCTM) to reduce headache-related disability differs among people with episodic migraine (EM) and chronic migraine (CM). After a 30-day monitoring period, participants were stratified by EM (6-14 days/month) and CM (15-30 days/month) and randomized to receive MBCT-M (8 weekly individual sessions) or 8 weeks of wait list/treatment as usual (WL/TAU). Surveys were completed at Months 0, 1, 2, and 4; daily diary was also completed during the 30-day post-treatment evaluation period. Primary outcomes were the Headache Disability Inventory (HDI; Range 0-100) and the Migraine Disability Assessment (MIDAS >= 21 indicating Severe Disability); secondary outcomes (headache days/30 days, average headache attack pain intensity) were derived from daily headache diary. Intent-to-treat mixed models for repeated measures tested formal moderation (time*treatment*CM) in the full sample. Planned subgroup analyses evaluated treatment*time effects EM and CM separately. Sixty participants were randomized to receive MBCT-M (n = 31) or WL/TAU (n = 29). Participants (M age = 40.1, SD = 11.7) were predominantly White (n = 49/60; 81.7%), Non-Hispanic (N = 50/60; 83.3%) women (n = 55/60; 91.7%). At baseline, 29 participants (48.3%) met criteria for EM and 31 (51.7%) met criteria for CM. At baseline, people with CM reporter higher HDI [M(SD) = 57.6 (16.7) vs. 45.5 (19.4), p = .015] and greater headache days/30 days [M(SD) = 20.5 (3.0) vs 11.2 (4.2), p < .001]; no other variable differed by CM status (ps > .30). For the MIDAS, CM status moderated the effect of MBCTM on the MIDAS; MBCT-M reduced the proportion of people reporting severe disability in EM only, p = .013. For the HDI, subgroup analysis revealed that MBCT-M (vs WL/TAU) significantly reduced HDI for EM (p = .011) but not for CM (p = .268). Subgroup analysis found no significant effect of MBCT-M on headache days/30 days or average headache attack pain intensity in either EM or CM. MBCT-M is a promising treatment for reducing disability. Surprisingly, MBCT-M produced larger changes on both primary outcomes in the EM, rather than CM, subgroup

OBJECTIVE:To estimate the prevalence of having at least one or two or more chronic health conditions among US adults with self-reported migraine or severe headaches. DESIGN/METHODS:Cross-sectional study. METHODS:Using data collected from the 2013-2015 National Health Interview Survey, we examined adults with and without migraine or severe headache and associations with chronic obstructive pulmonary disease, cancer, heart disease, stroke, diabetes, and hypertension. We calculated point estimates, variances, and 95% confidence intervals and conducted bivariate and multivariable logistic regression modeling to examine the relationships between migraine or severe headache and each of the chronic health conditions, as well as multinomial modeling, to examine the relationship between migraine or severe headache and having one or more chronic health conditions. RESULTS:A total of 104,926 people were in the study. Adults aged 18 to 44 years (18.2%), women (20.1%), and those with some college education (17.6%) had the greatest proportion with migraine or severe headache (P < 0.0001). Using multinomial modeling with the number of chronic health conditions as the dependent variable, adults reporting migraine had an increased odds of reporting a single chronic health condition (adjusted odds ratio [aOR] = 1.7, 95% confidence interval [CI] = 1.6-1.8) and more than double the odds of reporting two or more chronic health conditions (aOR = 2.5, 95% CI = 2.3-2.8) compared with adults who did not have migraine or severe headache. CONCLUSIONS:Our study confirms observed relationships between migraine or severe headache and chronic health conditions and supports the need for further research to uncover the shared biological pathways.

OBJECTIVES/OBJECTIVE:We conducted focus groups in people who had participated in mobile health (mHealth) studies of behavioral interventions for migraine to better understand: (a) Participant experience in the recruitment/enrollment process; (b) participant experience during the studies themselves; (c) ideas for improving participant experience for future studies. METHODS:We conducted four focus groups in people who had agreed to participate in one of three studies involving mHealth and behavioral therapy for migraine. Inclusion criteria were being age 18-80, owning a smartphone, and having four or more headache days per month. All participants met the International Classification of Headache Disorders third edition beta version criteria for migraine. Exclusion criteria were not speaking English and having had behavioral therapy for migraine in the past year. Focus groups were audio recorded, fully transcribed and coded using general thematic analysis. RESULTS:(ii) Enrollment should be simple and study requirements should be carefully explained prior to enrollment. When asked about their experiences during the studies (b), the following themes emerged: (i) It is difficult to participate in study follow-up and compliance phone calls; (ii) participants prefer to choose from among various options for contact with the study team; (iii) there are barriers that limit app use related to migraine itself, as well as other barriers; (iv) completing diaries on a daily basis is challenging; (v) technical difficulties and uncertainties about app features limit use; (vi) being part of a research study promoted daily behavioral therapy use; (vii) progressive muscle relaxation (PMR) is enjoyable, and has a positive impact on life; (viii) behavioral therapy was a preferred treatment to reduce migraine pain. Ideas for improving study design or patient experience (c) included: (i) Increased opportunity to interact with other people with migraine would be beneficial; (ii) navigating the app and data entry should be easier; (iii) more varied methods for viewing the data and measures of adherence are needed; (iv) more information on and more varied behavioral treatment modalities would be preferred. CONCLUSION/CONCLUSIONS:Though people with migraine are motivated to participate in mHealth and behavioral treatment studies, better communication up front about interventions as well as greater flexibility in interventions and follow-up methods are desired.