Faculty Bibliography

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.

Progressive muscle relaxation (PMR) is an under-utilized Level A evidence-based treatment for migraine prevention. We studied the feasibility and acceptability of smartphone application (app)-based PMR for migraine in a neurology setting, explored whether app-based PMR might reduce headache (HA) days, and examined potential predictors of app and/or PMR use. In this single-arm pilot study, adults with ICHD3 migraine, 4+ HA days/month, a smartphone, and no prior behavioral migraine therapy in the past year were asked to complete a daily HA diary and do PMR for 20 min/day for 90 days. Outcomes were: adherence to PMR (no. and duration of audio plays) and frequency of diary use. Predictors in the models were baseline demographics, HA-specific variables, baseline PROMIS (patient-reported outcomes measurement information system) depression and anxiety scores, presence of overlapping pain conditions studied and app satisfaction scores at time of enrollment. Fifty-one patients enrolled (94% female). Mean age was 39 ± 13 years. The majority (63%) had severe migraine disability at baseline (MIDAS). PMR was played 22 ± 21 days on average. Mean/session duration was 11 ± 7 min. About half (47%) of uses were 1+ time/week and 35% of uses were 2+ times/week. There was a decline in use/week. On average, high users (PMR 2+ days/week in the first month) had 4 fewer days of reported HAs in month 2 vs. month 1, whereas low PMR users (PMR < 2 days/week in the first month) had only 2 fewer HA days in month 2. PROMIS depression score was negatively associated with the log odds of using the diary at least once (vs. no activity) in a week (OR = 0.70, 95% CI = [0.55, 0.85]) and of doing the PMR at least once in a week (OR = 0.77, 95% CI = [0.68, 0.91]). PROMIS anxiety was positively associated with using the diary at least once every week (OR = 1.33, 95% CI = [1.09, 1.73]) and with doing the PMR at least once every week (OR = 1.14 [95% CI = [1.02, 1.31]). In conclusion, about half of participants used smartphone-based PMR intervention based upon a brief, initial introduction to the app. App use was associated with reduction in HA days. Higher depression scores were negatively associated with diary and PMR use, whereas higher anxiety scores were positively associated.

OBJECTIVE:The current Phase 2b study aimed to evaluate the efficacy of mindfulness-based cognitive therapy for migraine (MBCT-M) to reduce migraine-related disability in people with migraine. BACKGROUND:Mindfulness-based interventions represent a promising avenue to investigate effects in people with migraine. MBCT teaches mindfulness meditation and cognitive-behavioral skills and directly applies these skills to address disease-related cognitions. METHODS:Participants with migraine (6-30 headache days/month) were recruited from neurology office referrals and local and online advertisements in the broader New York City area. During the 30-day baseline period, all participants completed a daily headache diary. Participants who met inclusion and exclusion criteria were randomized in a parallel design, stratified by chronic migraine status, to receive either 8 weekly individual MBCT-M sessions or 8 weeks of waitlist/treatment as usual (WL/TAU). All participants completed surveys including primary outcome evaluations at Months 0, 1, 2, and 4. All participants completed a headache diary during the 30-day posttreatment evaluation period. Primary outcomes were the change from Month 0 to Month 4 in the headache disability inventory (HDI) and the Migraine Disability Assessment (MIDAS) (total score ≥ 21 indicating severe disability); secondary outcomes (headache days/30 days, average headache attack pain intensity, and attack-level migraine-related disability [Migraine Disability Index (MIDI)]) were derived from the daily headache diary. RESULTS: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%) and Non-Hispanic (N = 50/60; 83.3%) women (n = 55/60; 91.7%) with a graduate degree (n = 35/60; 55.0%) who were working full-time (n = 38/60; 63.3%). At baseline, the average HDI score (51.4, SD = 19.0) indicated a moderate level of disability and the majority of participants (50/60, 83.3%) fell in the "Severe Disability" range in the MIDAS. Participants recorded an average of 16.0 (SD = 5.9) headache days/30 days, with an average headache attack pain intensity of 1.7 on a 4-point scale (SD = 0.3), indicating moderate intensity. Average levels of daily disability reported on the MIDI were 3.1/10 (SD = 1.8). For the HDI, mean scores decreased more from Month 0 to Month 4 in the MBCT-M group (-14.3) than the waitlist/treatment as an usual group (-0.2; P < .001). For the MIDAS, the group*month interaction was not significant when accounting for the divided alpha, P = .027; across all participants in both groups, the estimated proportion of participants falling in the "Severe Disability" category fell significantly from 88.3% at Month 0 to 66.7% at Month 4, P < .001. For diary-reported headache days/30 days an average headache attack pain intensity, neither the group*month interaction (Ps = .773 and .888, respectively) nor the time effect (Ps = .059 and .428, respectively) was significant. Mean MIDI scores decreased in the MBCT-M group (-0.6/10), whereas they increased in the waitlist/treatment as an usual group (+0.3/10), P = .007. CONCLUSIONS:MBCT-M demonstrated efficacy to reduce headache-related disability and attack-level migraine-related disability. MBCT-M is a promising emerging treatment for addressing migraine-related disability.

BACKGROUND:Migraine is a chronic disabling neurologic condition that can be treated with a combination of both pharmacologic and complementary and integrative health options. EVIDENCE ACQUISITION/METHODS:With the growing interest in the US population in the use of nonpharmacologic treatments, we reviewed the evidence for supplements and behavioral interventions used for migraine prevention. RESULTS:Supplements reviewed included vitamins, minerals, and certain herbal preparations. Behavioral interventions reviewed included cognitive behavioral therapy, biofeedback, relaxation, the third-wave therapies, acupuncture, hypnosis, and aerobic exercise. CONCLUSIONS:This article should provide an appreciation for the wide range of nonpharmacologic therapies that might be offered to patients in place of or in addition to migraine-preventive medications.