Behavioral Therapy Preferences in People With Migraine

Mia T. Minen, MD, MPH; Adama Jalloh, BS; Olivia Begasse de Dhaem, MD; Elizabeth K. Seng, PhD

Disclosures

Headache. 2020;60(6):1093-1102. 

In This Article

Abstract and Introduction

Abstract

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: 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: 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.

Introduction

There are safe and well-tolerated level A evidence-based behavioral migraine preventive treatments such as biofeedback, cognitive behavioral therapy (CBT), and relaxation.[1,2] While these therapies have long lasting benefits,[3] there are challenges to getting patients to utilize these recommended treatments.[4] One recent study found that only about half of patients referred by a headache specialist for behavioral therapy for migraine prevention initiated scheduling an appointment for the behavioral therapy.[5] Time was cited as the most common barrier to initiating the behavioral therapy.[5] A randomized controlled study found that motivational interviewing increased the rates of inquiring about the behavioral therapy but not the rates of scheduling or attending therapy appointments.[6] Apprehension about the time commitment, cost, and difficulty accessing the treatment were cited as some of the barriers to scheduling/attending these appointments. Essentially, behavioral therapy requires a great deal of time and "buy in" from participants. New mechanisms for delivering the behavioral therapy for migraine have been evaluated recently.[7–10] Most recently, there has been the development of smartphone-based behavioral therapy for migraine.[11] However, to our knowledge, there have not been studies on the preferences of people with migraine for the type of delivery of behavioral therapy they would pursue (in-person, telephone based, smartphone based) or whether they would pursue it if covered by insurance or whether they had to pay for it out of pocket. Thus, we sought to examine preference for the type of delivery of the behavioral therapy (in-person, smartphone based, telephone) and insurance/cost factors (behavioral therapy covered by insurance or having to pay out of pocket), and whether there were certain demographics or headache characteristics that might be associated with such preferences.

We hypothesized that those who were younger would be more interested in the smartphone-based behavioral therapy while those who were older would be more interested in the in-person behavioral therapy, and that people would be more likely to pursue the behavioral therapy (all types) if it was covered by insurance. We also hypothesized that people with higher levels of migraine disability, headache days, and intensity would be more likely to pursue the behavioral therapy.

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