Faculty Bibliography

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

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.

Objective: Effective treatments for insomnia exist, but few physicians treating headaches have routine methods for screening for insomnia. We sought to 1) describe the migraine characteristics and comorbid conditions that can affect sleep and 2) assess their relationships with positive screens on the Insomnia Severity Index (ISI). Methods: This is a retrospective cross-sectional study of the migraine and sleep characteristics of new patients in our headache center (August 15, 2015-October 28, 2015) who were suspected of having migraines based on the new patient intake questionnaire. The questionnaire included the ISI, questions about headache characteristics, and screens for psychiatric comorbidities. Two tailed t tests and analysis of variance evaluated relationships between headache characteristics, comorbidities, and ISI score. Results: A total of 61 new patients were suspected to have migraines. The mean number of headache days per month was 11.6. Only 41% of patients reported sleeping seven or more hours; 49.2% had an ISI of 15 or higher (positive screen). Regarding the insomnia scores, there were no differences between moderate and severe headache pain, between episodic and chronic headaches, and between the associated symptoms (nausea/vomiting, photophobia, phonophobia; P > 0.05). Musculoskeletal pain (18.7 vs 13.8, P = 0.027), depression (rho = 0.610), and general anxiety (rho = 0.436) were associated with higher ISI scores. Conclusions: Nearly half of the patients with suspected migraines in a headache center screened positive for insomnia, independent of whether they had episodic or chronic headaches. This would generate a substantial number of cognitive behavioral therapy for insomnia (CBT-I) referrals. Given the strong association between comorbid musculoskeletal pain, depression, anxiety, and insomnia, we suggest prioritizing CBT-I referral for those patients regardless of their headache frequency.

OBJECTIVE: Migraine causes more than 1.2 million visits to US emergency departments (EDs) annually. Many of these visits are revisits among patients who had already been treated in an ED for migraine. The goal of this analysis was to determine the frequency of headache revisits among patients who present to an ED for management of migraine and sociodemographic factors associated with the revisit. METHODS: Using the New York City Department of Health and Mental Hygiene Syndromic Surveillance database, we conducted a retrospective nested cohort study. We analyzed visits from 18 NYC EDs with discharge diagnoses in the first 6 months of 2015. We conducted descriptive analyses to determine the frequency of headache revisit within 6 months of an index ED visit for migraine and the elapsed time to revisit. Using multivariable logistic regression, we assessed associations between age, sex, poverty, and revisit. RESULTS: Of 1052 ED visits with an ED discharge diagnosis of migraine during the first 6 months of 2015, 277 (26.3%) had a headache revisit within 6 months of their initial migraine visit and 131 (12.5%) had two or more revisits at the same hospital. Of the revisits for headache, 9% occur within 72 hours and 46% occur within 90 days of the initial migraine visit. Sex, age, and poverty level were not associated with an ED revisit. CONCLUSION: More than a quarter of initial ED visits for migraine are followed by headache revisits in <6 months. Future work should target interventions to decrease the frequency of headache revisits.