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A Behavioral Therapy App Helps Reduce Frequency of Migraine Episodes

Article In Brief

An app that teaches users to progressively relax muscle groups helped reduce the number of headaches patients had per month.

What if patients with migraine could learn how to relax when a headache comes on? That question underscored the effort of a team of clinicians and patients, who developed a mobile app for a behavioral therapy program, which reduced weekly episodes of headache.

The research team hopes the findings, published June 4 in Digital Medicine, a journal published by the International Society of Digital Medicine, encourage patients to try non-pharmacological methods—such as cognitive behavioral therapy, biofeedback, and progressive muscle relaxation, among others—to address their headaches.

The app provides audio instruction on how to progressively relax muscle groups during the onset of a headache.

Led by Mia T. Minen, MD, MPH, chief of headache research at NYU Langone Health, the research team reported that patients who used the app at least two times a week had fewer episodes over the course of the study.

A growing body of research demonstrates the long-term benefits of these techniques, Dr. Minen said, but few patients access them. In previous studies, researchers found that only about 50 percent of patients referred for these types of treatments (by a migraine specialist) follow through on them.

Dr. Minen and her colleagues designed the study to determine whether they could motivate more migraine patients to use non-pharmacological treatments. Many primary care providers are not even aware of these effective treatments, she said.

Building an App

The app comprises audio files—one is five minutes, the other, 15 minutes—that instruct patients on how to relax one muscle group at a time.

To see how well the app worked, the researchers recruited 51 migraine patients through the NYU neurology clinic. At baseline, most of them had frequent and severe migraines despite their migraine treatments. More than 60 percent self-reported severe symptoms and 75 percent were taking preventive medications.

“This is a severely affected group,” said Dr. Minen.

The patients were asked to keep a daily log of their headaches. The participants reported a mean amount of time spent on the audio files of 11 minutes and an average number of days engaging with the exercise of 22. The researchers followed patients for 90 days.

Half the patients used the app once a week and a third used it two or more times a week. Those who used it two or more days a week had four fewer headache days during the second month compared with their baseline. Patients who used it once a week had two fewer headache days over the next month of the study.

The researchers also assessed anxiety and depressive symptoms at baseline; at the end of the study they found that those who were anxious were more likely to use the app than those who were depressed.

“We may be able to use the anxiety and depression scales as a tool to see who would benefit from the app,” said Dr. Minen. “The goal is for people to learn the relaxation techniques and then integrate them into their everyday life.”

Now, the researchers are considering ways to integrate the behavioral therapy app into a health care system model.

“It is important to offer these types of interventions for patients with migraine, especially for pregnant women, people with co-morbidities, and the elderly who may be on many other medications,” Dr. Minen said.

Expert Commentary

Headache specialists who were not involved with the study agreed that non-pharmacological approaches could be helpful. “We need innovative ways to deliver non-pharmacological treatments to people without access to doctors who specialize in migraine,” said Elizabeth Loder, MD, MPH, chief of the division of headache in the department of neurology at Brigham and Women's Hospital. “Migraine and other headache disorders are chronic problems and self-management is critical. There is a great need to provide non-pharmacological treatments like relaxation training through an inexpensive app for people who might not have insurance or access to specialists.

“The question is, in real-world practice, how will this compare to treatments available in the headache clinic? Will patients adhere to the technique? Will they derive benefit? All of these questions should be answered with further research,” Dr. Loder said.

Carrie Dougherty, MD, FAHS, assistant professor of neurology at MedStar Georgetown University Hospital, agreed. “Patients are very receptive to non-medication interventions so the idea of using a smart app has a lot of value,” she said.

Dr. Dougherty pointed out, however, that it is difficult to provide patients with coordinated follow-up for behavioral therapies. “There are so many barriers to these treatments including lack of providers, and limited insurance coverage, not to mention the time commitment of more appointments in patients already disabled by migraine,” she said. “Having an app for behavioral therapy with grade A evidence in migraine is a great resource for our patients.”

“One of the main advantages of an app is that it has the potential to substantially increase the accessibility of these behavioral therapies for migraine patients,” said Katherine Hamilton, MD, assistant professor of clinical neurology at Penn Medicine. “Therapies such as cognitive behavioral therapy or progressive muscle relaxation have good evidence in treating migraine; however, these are often not an option for patients due to cost and limited availability. I am excited by the prospect of being able to offer an evidence-based and low-cost behavioral therapy to my patients.

“I anticipate that this will be a good option for clinicians in treating patients whose anxiety, stress, and depression contribute to worsening migraines,” Dr. Hamilton added. “I would imagine that this app could give patients a sense of control and ownership over their migraine care. However, there will certainly be some patients who would still benefit from in-person therapy or some that may not be as technologically savvy, which would be considerations for a clinician in recommending this app.”

Disclosures

Drs. Minen, Loder, Dougherty, and Hamilton had no disclosures.

Link Up for More Information

• Minen MT, Adhikari S, Seng EK, et al. Smartphone-based migraine behavioral therapy: A single arm study with assessment of mental health predictors https://www.nature.com/articles/s41746-019-0116-y. npj Digital Medicine 2019: 46:1–9.