The term migraine comes from the Greek words hemi and kranion, although the head pain can be unilateral or bilateral (Green, 2015). Chronic migraine is an underrecognized complication of episodic migraine, defined by 15 or more headache days per month with 8 of the headache days meeting International Headache Society (IHS) criteria for migraine headache (Dodick et al., 2016; Green, 2015). Those with episodic migraine have less than 15 headache and 8 migraine days per month, respectively. The criteria for a migraine episode include headache lasting longer than 4 hours, nausea, and/or photophobia and phonophobia and at least two of four additional symptoms of unilateral location, pulsating quality, moderate-to-severe pain intensity, and aggravation with physical activity (“Headache Classification Committee of the IHS The International Classification of Headache Disorders, third edition,” 2018).
Episodic migraine affects approximately 12% of the population in the United States (Merikangas, 2013), with an estimated 3–7 million individuals meeting criteria for chronic migraine (Buse et al., 2012). The diagnosis of both episodic and chronic migraine is three times more prevalent in women than in men (Burch, Loder, Loder, & Smitherman, 2015), and it is important to recognize that individuals often shift along a spectrum between episodic and chronic migraine.
Background and significance
Those affected by chronic migraine have impaired daily function, higher health care utilization, and risk of comorbidities, such as depression and anxiety (Dodick et al., 2016). Migraine is not merely a pain issue but also a quality of life issue (Smith, Nicholson, & Banks, 2010). Indeed, migraine is one of the top 10 causes of disability worldwide (Stovner et al., 2018). Studies using the Migraine Disability Assessment tool (MIDAS) show that individuals with chronic migraine have higher disability scores in multiple areas: schoolwork/paid employment, household work/chores, and nonwork-related activities such as family and leisure time (Buse et al., 2016; Dodick et al., 2016).
Societal impact from the condition of migraine is substantial. Average direct health care costs for an individual with chronic migraine is $3,155 over 12 months, compared with $1,560 for those with episodic migraine (Silberstein et al., 2018). Both direct costs related to medical resources and indirect costs associated with impact on productivity are significantly higher for those with chronic migraine versus episodic migraine (Messali et al., 2016). In 2016, the total direct and indirect annual cost of migraine in the United States was estimated at $36 billion (Bonafede et al., 2018). Results of the American Migraine Prevalence and Prevention Study, a national epidemiologic survey, showed that individuals with chronic migraine had 85.7 hours per year of absenteeism and 256 hours per year of reduced productivity (Munakata et al., 2009). Another marker of health care cost related to migraine is utilization of emergency department (ED) resources, and headache is among the top five reasons for ED visits (National Center for Health Statistics, 2014).
Most comprehensive migraine care is currently provided by neurologists or headache specialists. Nationally, it is anticipated that from 2013 to 2025, the supply of neurologists will increase by 11%, although demand is estimated to grow by 16% (Health Resources and Services Administration, 2017). When patients do not have access to a comprehensive migraine program, treatment is often suboptimal and leads to increased use of medications and emergency services (Blumenfeld & Tischio, 2003). The projected growth of nurse practitioners (NPs) from 2016 to 2026 is 31% (Bureau of Labor Statistics, 2019), and NPs are in prime position to improve access to chronic migraine care in both primary care and specialty areas. Given their focus on chronic disease management, shared decision-making, and patient education, NPs are well suited to work with these patients.
Collaborating with patients to enhance their decision-making skills for disease management is an essential component of evidence-based practice (Melnyk & Fineout-Overholt, 2015). The use of self-management skills includes empowering patients to manage a chronic condition through problem solving, provision of resources, and shared decision-making (McGowan, 2012), which all are imperative for adequate chronic migraine management. Less than 5% of those with chronic migraine currently receive all three steps needed for optimal care: access to care, correct diagnosis and education, and a treatment plan with acute and preventive modalities (Dodick et al., 2016). In addition, the American Migraine Communication Study showed minimal time during an average 12-min appointment was spent on migraine education (Lipton et al., 2008), demonstrating a need to improve self-management techniques. Succeeding with a self-management approach enables individuals to feel in control of their health (Bandura, 2001). Applying self-management to chronic migraine treatment has potential to reduce migraine severity and frequency, subsequently enhancing patient function and quality of life.
Behavioral modalities encompassing patient education, self-care, cognitive behavioral therapies, and biobehavioral training such as biofeedback and relaxation are supported by the literature (Buse & Andrasik, 2009; Kindelan-Calvo et al., 2014). Evidence-based guidelines and meta-analyses support behavioral interventions for the management of migraine, though there is a broad variety of types of behavioral therapies (Kindelan-Calvo et al., 2014; Nestoriuc & Martin, 2007). Outcome measures most commonly focused on for migraine studies include headache frequency, the MIDAS, self-efficacy, locus of control, quality of life, and depression (Kindelan-Calvo et al., 2014). Prior research has demonstrated the importance of focusing on self-efficacy for adherence to both pharmacologic and nonpharmacological headache treatment (Matsuzawa et al., 2019).
There is a need to emphasize integrated care models and self-management strategies for chronic disease, given these conditions create approximately 70% of health care costs and result in compromised quality of life (Marks, Allegrante, & Lorig, 2005). Specific to chronic migraine, despite high rates of disability patient education and self-management programs for chronic migraine are not readily available.
Multiple studies have assessed self-management for chronic disease such as asthma, diabetes, and arthritis (Bandura, 2004a; Franek, 2013). However, there is significantly less published literature on self-management and self-efficacy in relation to chronic migraine. There is also a gap in the evidence for combined clinic-based and online self-management tools that are realistic for a busy practice setting. A recent narrative review identified multiple barriers to adherence for behavioral headache modalities, and it is proposed that individual patient factors are considered when planning treatment (Matsuzawa et al., 2019). This recommendation fits well with the concept of self-management, which uses customized patient preferences and goals.
Social cognitive theory has previously been applied to self-management interventions for other chronic conditions. A study assessing a web-based program for heart failure emphasized the importance of using Bandura's self-efficacy theory for technology-focused self-care interventions (Bashi, Windsor, & Douglas, 2016). Another study on the use of an in-depth self-management framework for diabetes demonstrated improved self-efficacy and support for behavioral changes (Lamprinos et al., 2016). Concepts from these frameworks, with technology facilitating goal setting, action plans, and data collection should be applied to other chronic conditions, including chronic migraine.
The primary assumption of social cognitive theory is that behavior is influenced by personal, behavioral, and environmental factors (Bandura, 2001; Glanz, Burke, & Rimer, 2018). In addition, each of these domains can influence the other factors, which is referred to as the triad of reciprocal determinism (Glanz et al., 2018). Individuals have cognitive and emotional control over behavior, and behavior is more than reactions to internal or external cues (McEwen & Wills, 2014; Thompson, 2014). Those with chronic migraine experience disruption in multiple areas of life, and it is common for individuals to feel self-blame for the associated disability (Cady & Durham, 2015). It is imperative to address behavioral methods for coping with chronic diseases (Marks et al., 2005), because individuals will not consider improvement possible if they do not believe they have control (Bandura, 2004b). By framing self-management education with concepts of social cognitive theory, those with chronic migraine can be empowered rather than overwhelmed and discouraged.
This study was a quasi-experimental, single cohort design with pretest and posttest evaluation. The aim of this pilot project was to determine if an outpatient self-management program for chronic migraine over eight weeks would (a) decrease migraine disability and (b) improve self-efficacy. Secondary outcome goals included decreased migraine days, headache days, acute medication use, and ED visits.
The project was approved by the University of Missouri-Kansas City Institutional Review Board. Adults with chronic migraine were recruited through convenience sampling at a Midwestern outpatient rehabilitation (physiatry) clinic. Minors were not included due to the project focusing on adults with the condition of chronic migraine. Chronic migraine may differ in minors, and the study tools were designed for adults.
Participants were eligible for the study if they had at least a 3-month history of chronic migraine with or without aura consistent with a diagnosis according to the International Classification of Headache disorders, third edition (“Headache Classification Committee of the IHS The International Classification of Headache Disorders, third edition,” 2018). Exclusion criteria for the project included difficulty distinguishing migraine from tension type or other headaches; headache characteristics that did not meet criteria for chronic migraine; and inability to attend required appointments.
Blending technology with clinic education
The aim of the self-management intervention was to implement a toolkit of specific patient education and lifestyle behavior recommendations for individuals with chronic migraine. The intervention included a hybrid of web-based, verbal, and written content based on current migraine treatment guidelines. The intervention was designed to be practical for outpatient clinic use during a 45-minute initial appointment, a follow-up phone call, and a 30-minute follow-up visit. The collaboration with a videographer/web designer yielded a unique concept and design for self-management education.
Traditional patient education is delivered in the health care setting. This may be provided one-on-one or in a group structure. This project used a hybrid approach of in-person and web-based self-management. Having the participants view brief videos in the clinic introduced the concepts and goals of the chronic migraine intervention. It also allowed the NP clinician to individualize education based on what questions arose from this introduction. Following the clinic visit, the participants were able to customize focus on lifestyle behaviors and self-management tools, which were most pertinent for them. Customizing education for health behaviors has been shown to be more effective compared with a standardized approach (Legler et al., 2018). This approach encourages empowerment, engaging patients as active partners in the treatment process.
Assessments and intervention
At the initial visit, participants completed demographic information, baseline questionnaires, and a health behavior survey. The self-management program was implemented both at the clinic visit and through resources participants accessed via the Internet outside of the clinical setting. At the initial 45-minute clinic visit, participants received patient education via a series of short videos about chronic migraine followed by additional verbal information, customized based on participant feedback and questions. Video content was approximately 10 minute total and based on current best practices. The videos were produced by the investigator in collaboration with a local advertising and marketing agency. The content encompassed definitions and statistics about chronic migraine, use of a migraine diary, and the importance of specific lifestyle behaviors (sleep hygiene, hydration, relaxation techniques, and timing of acute medication).
The self-management toolkit for use outside of the clinic was available to participants through a website, yourmigrainetoolkit.com (Short, 2018). The site includes patient education videos, tips for keeping a headache diary, and resources such as articles, podcasts, and website links. Participants tracked headache frequency, severity, and lifestyle behaviors in a written headache log for the eight-week time frame (Figure 1). A traffic light scale was blended into the headache chart to simplify pain rating and assist participants in timing of acute medication (Marissa Lagman-Bartolome & Lay, 2018). Participants were provided a summary page with the website address, a headache chart, and colored stickers to use with the chart (Figure 2).
The curriculum for the intervention included migraine education and self-care skills. Content was incorporated from published literature and online resources through the American Headache Society and National Migraine Foundation, as well as from previously published studies led by NPs (Blumenfeld & Tischio, 2003; Lagman-Bartolome, Lawler, & Lay, 2018). Participants received a weekly migraine health behavior reminder via text message. Health tips covered topics of sleep, hydration, relaxation techniques, and early migraine treatment. The inclusion of text messaging is a simple method for health behavior promotion as part of chronic disease management (Legler et al., 2018). The web site with videos and collateral resources could be accessed from a computer, tablet, or smartphone. A 4-week follow-up phone call or clinic visit was completed to provide encouragement to participants and assess for questions about the program. The outcome measures were then repeated at the 8-week, 30-minute follow-up visit. All clinic visits and phone calls were completed by the NP investigator.
Sample of weekly text reminders
- “Hi, thank you for practicing healthy habits for migraine management. Have you been drinking water today?” or “Have you practiced your deep breathing today? It's important to practice your relaxation each day.”
- “Have you made time to practice relaxation and deep breathing today? Keeping calm during a migraine can make pain less severe.”
- “Remember that practicing breathing techniques every day can help with sleep, mood, and pain.”
- “Great work practicing healthy lifestyle as part of migraine care! Are you tracking your migraine symptoms daily?”
- “How much sleep did you get last night? It is important to follow a good sleep schedule. Migraine brains crave consistency.”
- “How often have you used rescue migraine medication this week? Please keep track of when you take medication to help track your migraine triggers and frequency.”
- “How much water have you had today? Staying well-hydrated is a simple way to help prevent migraine attacks. Review your hydration tips!”
- “Remember to avoid screen time for one hour before bed to promote good sleep!”
Outcome measures and measurement instruments
Primary outcome measures included improved migraine disability and headache self-efficacy. Secondary outcomes included migraine days, headache days, ED visits, and acute medication use. Through measuring the use of health care resources and disability, this study tracked effects on both the personal and economic burden of chronic migraine.
Four outcome measures were used for this project, and two of these are established tools that have been previously used in migraine studies. The MIDAS has been used widely in research and evaluates the level of disability an individual is experiencing related to migraine (Stewart, Lipton, Dowson, & Sawyer, 2001). Reliability data for the MIDAS include Cronbach α of 0.76, test–retest Pearson correlation of 0.54–0.068, and test–retest Spearman correlation coefficient of 0.8. The Headache Management Self-Efficacy Scale (HMSE) assesses patients' confidence to prevent and manage headache-related pain and disability (French et al., 2000). Reliability data for the HMSE demonstrates Cronbach α of 0.90 for internal consistency. Headache and migraine days, ED visits, and acute medication use were tracked with a written headache chart, which is commonly used in migraine studies.
A total of 15 participants enrolled and completed the chronic migraine self-management intervention (Table 1). The convenience sample included 14 female and 1 male subjects, with ages ranging from 19 to 55 years (mean, 40.9 years).
Descriptive statistics and the Wilcoxon signed-rank test were selected for this study, due to the small sample size and one-group pretest–posttest design. Descriptive statistics were used for the above outcomes and demographic participant data.
Baseline data showed MIDAS scores that ranged from 28–180 (mean 86.1); HMSE scores of 72–143 (mean 98.6); migraine days per month or 3–30 (mean 11.8); and monthly headache days from 2 to 31 (mean 21.8). Participants reported acute medication use of 3–15 times per week (mean 6.1). One subject reported one ED visit within the past month. Participants also completed a survey of health behaviors, including sleep amount and quality, hydration, use of relaxation techniques and a headache diary, and morning protein intake (Table 2).
At the 4-week phone or clinic visit, 12 of 15 (80%) participants reported improvement in migraine severity, frequency, or both. Multiple participants commented on the benefit of tracking headache days, triggers, and lifestyle behaviors. Postintervention data showed MIDAS scores of 0–310 (mean, 60.73); HMSE scores of 76–156 (mean, 117.7); migraine days per month of 0–30 (mean, 7.3); and headache days per month of 1–30 (mean, 12.7). Weekly acute medication use ranged from 0 to 7 days per week (mean, 2.9 days). One additional ED visit was reported at postintervention.
The statistical analysis of data was significant for the change in MIDAS (p = .035), HMSE (p = .013), headache days per month (p = .002), migraine days per month (p = .024), and acute medication use (p = .005) (Table 3). The validity of these findings is weak due to a small sample size, rather the value of the data is the change from pre-to-post descriptive measures.
This pilot study supports a multimodal self-management intervention for adults with chronic migraine. There were multiple successes for the single-group pretest–posttest study. All 15 participants completed the intervention, showing excellent retention. The findings support a trend of reduced migraine disability and improved self-efficacy with the use of self-management strategies and a headache diary. The results of this project are congruent with evidence in the literature. Leroux et al. (2017) also demonstrated changes in headache disability and self-efficacy with a nurse-led intervention. Consistent with prior online-based studies, this project supported a reduction in migraine frequency (Hedborg & Muhr, 2011; Kleiboer, Sorbi, van Silfhout, Kooistra, & Passchier, 2014; Trautmann & Kröner-Herwig, 2010) and improved coping strategies (Bromberg et al., 2012). In this project, the frequency of migraine and headache days lowered by close to 40%.
In addition to assessing disability and self-efficacy, acute medication use was tracked due to the association between medication overuse and chronic migraine. As previous therapeutic education studies have shown reduced acute medication intake (Fritsche et al., 2010; Lagman-Bartolome et al., 2018), this project also demonstrated a significant drop in acute medication use. Participants reduced acute medication use by more than 50%. There were also modest improvements in health behaviors of morning protein intake, use of a sleep routine, and practice of relaxation techniques. At the initial visit, only three participants reported using a headache diary or app. Therefore, this intervention allowed for participant exposure to the strategy of migraine tracking.
The satisfaction survey responses showed positive reaction to the benefits and ease of use for the multimodal intervention. All participants reported that they plan to continue practicing the recommended health behaviors as part of their migraine management. They were asked to rate from 0 to 10 the likelihood of continuing with the self-management tools. Overall, 11 participants chose 10/10, three responded 7–9/10, and one answered 3/10. Multiple participants also reported value in sharing the website with a significant other or family members. Most participants, 13 of 15, were enthusiastic about receiving text message reminders and found this motivating.
It was anticipated that participants would use the self-management website and videos in multiple, self-directed sessions outside of the clinic. Based on survey reports, participants spent less time using the website than expected. This was likely due to perceived schedule constraints or difficulty setting aside time to explore the website tools. Additional time in the clinic setting is recommended for participants to take exploring the website. This has potential to better engage individuals with the resources, so they are motivated to increased time on the site outside of the office. Participants could also be encouraged to dedicate a specific amount of time per week to using tools and resources on the website (e.g., at least 15 minutes per week). Written goal setting could be added to the headache diary to better focus participants on which behaviors they aim to practice.
Participants reported high satisfaction with the use of the simple headache chart, which was anticipated. Although the chart was initially designed to allow data collection, many found this to be a very beneficial component of the intervention due to improved insight of migraine symptom patterns and health behaviors. The intervention functioned well in an outpatient clinic, and it has potential to be efficacious in additional outpatient practices. Internet access is needed to use the website and videos, which is available in most office settings. This program is appropriate for application in primary care, neurology, and other specialty clinics that treat the diagnosis of migraine.
Study limitations included lack of a control group, small sample size, and participant self-selection with potential enhanced motivation for practicing self-management. The sample was a homogeneous group, which limits the ability to generalize findings. Participants were not limited from use of existing or new medications.
This pilot study assessed a creative video and web-based intervention for adults with chronic migraine. Therapeutic education strategies should be emphasized when treating migraine, so that patients understand how to be truly active participants in their care (Lagman-Bartolome et al., 2018). Tools that can easily blend with traditional clinic visits are needed to streamline migraine treatment. The intervention for this project represents a self-management toolkit that is practical for the outpatient environment. Use of a hybrid model that incorporates in-person and web-based strategies allows for individualized education and reinforcement of recommended health behaviors.
There is a bevy of opportunities for future work with this intervention. Potential collaborative research with additional NPs would expand sample size, diversity, and the number of study sites. This project was anticipated to reduce direct and indirect costs associated with chronic migraine. It can be inferred that the outcomes of this pilot project support cost savings. Acute medication use decreased, which represents savings to direct health care costs. Migraine disability scores decreased and self-efficacy increased, demonstrating improved productivity and presenteeism.
Chronic migraine is a headache disorder that causes significant consequences for individual quality of life and broader society. This project of a self-management model supports significantly improved self-efficacy and reduced migraine disability. Applying a multimodal self-management strategy facilitates partnership and shared decision making with individuals who have the condition of chronic migraine.
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