Behavioral Therapy Preferences in People with Migraine

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 (CBT) and relaxation. However, the behavioral therapies for the prevention of migraine are under-utilized.

Objectives:

We sought to examine whether people with migraine with four 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 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 (AMPP) screen were to pursue different delivery methods of 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 telephone-based behavioral therapy. Participants were “not very likely” to pay out of pocket for behavioral therapy. Migraine-related disability as measured by the MIDAS grading score was associated with likelihood to pursue behavioral therapy in person (p=0.004), via telephone (p=0.015), and via smart phone (p<0.001), and covered by insurance (p=0.001. However, migraine-related disability was not associated with likelihood to pursue out of pocket (p=0.769) behavioral therapy. Pain intensity was predictive of likelihood of pursuing 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 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 While these therapies have long lasting benefits, ² there are challenges to getting patients to utilize these recommended treatments. ³ 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. ⁴ Time was cited as the most common barrier to initiating behavioral therapy. ⁴ A randomized controlled study found that motivational interviewing increased the rates of initiation (inquiring about behavioral therapy) but not the rates of scheduling (making an appointment) or attending (presenting to) the behavioral therapy appointment for migraine. ⁵ Time, cost and difficulty accessing the treatment were cited as some of the barriers to scheduling/attending these appointments. New mechanisms for delivering behavioral therapy for migraine have been evaluated recently. ^6-9 Most recently, there has been the development of smartphone based behavioral therapy for migraine. ¹⁰ 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.

Methods

Study Design and Population

This analysis is a preplanned secondary analysis of previously collected data. ¹¹ This was a cross-sectional study assessing migraine participants’ intention to pursue behavioral treatment based on a) the type of delivery of behavioral therapy for migraine and b) its cost. Thus, given the open design of an online platform, by definition we used convenience sampling. Study participants were recruited online via TurkPrime, a research platform that integrates with MTurk and is designed to improve the quality of the crowdsourcing data collection process ¹². TurkPrime addresses limitations found in MTurk, including; excluding participants based on previous participation, setting up longitudinal studies, and controlling the rate at which data is collected, improving data quality ¹². TurkPrime facilitates the recruitment of a wide variety of participants and prevents multiple participations by tracking IP addresses ¹². The survey ran from September 22, 2018 to October 31, 2018.

A pre-qualifier panel set-up by TurkPrime identified potentially eligible Turk Prime participants with migraine. The pre-qualifier panel identified 1,481 potentially eligible participants who were provided with a study description including the monetary compensation and the time required to complete the study. Those interested then completed an eligibility screener and 401 participants were eligible to participate in the study. Eligibility criteria were 1) age 18 to 89 years old, 2) proficiency in English, 3) migraine listed as a medical condition, 4) endorsing (modified) International Classification of Headache Disorders (ICHD) – 3 criteria for migraine using the (validated) American Migraine Study (AMS)/American Migraine Prevalence and Prevention (AMPP) migraine (diagnostic) screener, ¹³ and 5) reporting 4 or more headache days per month.

Measures

Participants who met eligibility criteria then completed the following measures: headache history (age at first headache, number of headache days, history of medication usage, and more), and migraine disability (Migraine Disability Assessment Scale also known as the MIDAS), ¹⁴ a self-administered 7-item survey (with scores ranging from 0 to 90 for the first 6 items and 0 to 10 for the last item) designed to assess the extent to which migraine was associated with occupational and social disability in the past 3 months. Participants were given a description of behavioral therapy for migraine, see Table 3 and Table 4, and attitudes toward cognitive behavioral therapy, relaxation therapy, and biofeedback were assessed together. We asked likert scale (1= Not at all likely, 2= Not very likely, 3= Neutral, 4=Somewhat likely, 5=Strongly likely) questions to assess likelihood to pursue various types of behavioral therapy for migraine. No statistical power calculation was conducted prior to the study to determine the sample size.

Table 3:

Likelihood of pursuing behavioral treatment for migraine based on MIDAS grading score

Total N = 401	Total Median, [IQR]	Grade I (little or no disability) Median, [IQR]	Grade II (mild disability) Median, [IQR]	Grade III (moderate disability) Median, [IQR]	Grade IV (severe disability) Median, [IQR]	Kruskal-Wallis (Asymp. Sig.)
In person	4 [3,4]	4 [3,4]	4 [2,4]	4 [3,4]	4 [3,4]	p=0.004
Telephone-based	3 [2,4]	2 [1.5,4]	2.5 [2,4]	3 [2,4]	4 [2,4]	p=0.015
Smartphone application	4 [3,5]	3 [2,4]	3 [2,4]	4 [3,4]	4 [3,5]	p= 0.0004
Out of pocket	2 [1,3]	2 [1.5,3.5]	2 [1,3]	2 [1,3]	2 [1,3]	p=769
Covered by insurance	4 [3,5]	4 [2.5,4]	4 [2.25,4]	4 [3,5]	4 [4,5]	p=0.001

Table 4.

Linear regression analysis

Mode of behavioral therapy delivery N=401	Number of patients for each category	Likelihood to pursue in person behavioral therapy (1-5 Likert scale)	Likelihood to pursue telephone based (1-5 Likert scale)	Likelihood to pursue smart phone based (1-5 Likert scale)	Likelihood to pursue BT if Covered by insurance (1-5 Likert scale)	Likelihood to pursue BT if have to pay out of pocket (1-5 Likert scale)
Age	N/A	B=0.04 p=0.461	B=0.07 p=0.150	B=0.03 p=0.503	B=0.03 p=0.484	B=−0.04 P=0.425
Women/ Not Women	282/119	B=0.05 p=0.462	B=−0.005 p=0.944	B=−0.05 p=0.483	B=0.004 p=0.953	B=−0.03 P=0.691
Employment Full time/not	252/149	B=0.11 p=0.125	B=0.07 p=0.478	B=0.09 p=0.332	B=0.133 p=0.153	B=−0.03 P=0.783
Ethnicity (White/Black/ Hispanic/Asian	302/50/26/23	B=0.019 p=0.818	B=−0.058 p=0.474	B=0.004 p=0.963	B=−0.09 p=0.240	B=−139 P=0.090
Education High school/some college and vocational/ Bachelor and associate/masters and Doctorate)	55/112/185/ 49	B=−0.126 p=0.279	B=0.05 p=0.695	B=−0.57 p=0.620	B=−0.05 p=0.671	B=−0.15 P=0.202
HA pain intensity Mild/Moderate/Severe	9/110/282	B= 0.04 P=0.499	B=−0.0002 P=0.996	B=0.02 P=0.688	B=0.104 P=0.042	B= 0.22 P=0.677
Headache frequency Episodic/Chronic	356/45	B= 0.05 P=0.342	B=−0.05 P=0.336	B=−0.08 P=0.138	B=0.042 P=0.400	B=−0.08 P=0.114
Prior behavioral therapy for migraine prevention Yes/No	50/351	B= 0.018 P=0.803	B=0.05 P=0.471	B=0.12 P=0.100	B=0.013 P=0.861	B=0.09 P=0.242
MIDAS Grade I/Grade II/Grade III/Grade IV	13/31/78/279	B= 0.15 P=0.004	B=0.16 P=0.002	B=0.195 P=<0.001	B=0.152 P=0.004	B=0.04 P=0.415

Note:

Episodic <15 headache days per month, chronic=15 or more HA days per month

mild=1-3, mid=4-6, severe= 7-10

0 to 5: MIDAS grade I, little or no disability. 6 to 10: MIDAS grade II, mild disability. 11 to 20: MIDAS grade III, moderate disability. 21 or higher: MIDAS grade IV, severe disability

Statistical Analyses

The distribution of the data was assessed for normality with Kolmogorov-Smirnov test. Ordinal variables were presented as median, interquartile range, and analyzed with t-tests for factor and covariate groups. Data not meeting parametric assumptions was presented as median, interquartile range, and analyzed with Kruskal-Wallis. Ordinal regressions were performed to determine associations for whom might be most likely to pursue behavioral therapy. We evaluated a pre-specified set of covariates for the ordinal regressions, and removed non-significant covariates until only significant covariates remained. Self-reported likelihood to pursue behavioral therapy for migraine prevention (1 = not at all likely, 5 = strongly likely) was the outcome. Predictors in the model were demographic data, headache characteristics, and method and cost of behavioral treatment for migraine. Statistical significance was defined as p < 0.05. Tests were two-tailed. The statistical analyses were performed with IBM SPSS Statistics V25.0.0.

The study was approved by the New York University Langone Health Institutional Review Board (IRB). As this was an online survey, written consent was not required. Participants were provided with an introductory screen indicating that consent was voluntary, and consent was implied by completion of the survey. Subjects were paid $0.75 for each completed survey.

Results

Demographic Variables

There were 401 participants with no missing data. The median age was 34 [IQR: 29, 41] years old. More than two thirds (282/401 participants, 70.3%) were women. Caucasian was the predominant race (302/401 participants, 75.3%). More than half (234/401 participants, 58.4%) held at least a bachelor’s degree. In terms of employment, 252/401 participants (62.8%) worked full time. (Table 1)

Table 1:

Demographics and Headache characteristics

Participant Demographics
Age: median [IQR]	34 [29, 41]
Women	282 (70.3%)
Ethnicity
White	302 (75.3%)
Black	50 (12.5%)
Hispanic	26 (6.5%)
Asian	23 (5.7%)
Education
High school	55 (13.7%)
some college and vocational	112 (27.9%)
Bachelor and associate/masters	185 (46.1%)
Doctorate	49 (12.2%)
Full time employment	252 (62.8%)
Headache Characteristics and Treatment History
Number of headache days per month: median [IQR]	5 [2.83, 8.50]
Number of participants with at least 2 moderate to severe headache per week	181 (45.1%)
Number of participants with at least 15 headache days per month	45 (11.2%)
Headache intensity: median [IQR]	7 [6,8]
MIDAS score: median [IQR]	28 [18, 47]
# of participants with preventive medications	117 (29.2%)
# of participants with prior evidence-based behavioral treatments for migraine prevention	50 (12.5%)

Headache characteristics

The median number of headache days per month was 5 [IQR: 2.83, 8.5]. Nearly half (181/401 participants or 45.1% of participants) reported at least two headaches of moderate to severe intensity per week. Forty-five participants (11.2 %) reported having more headache days than not, meeting chronic migraine criteria. The median headache intensity was 7 [IQR: 5, 9). The median MIDAS score was 28 [IQR: 18, 47]. A remarkably high number of participants suffered from severe migraine-related disability (279 or 69%). Nearly a third (29.2% or 117) of participants reported taking at least one migraine preventive medication. One in eight (50 or 12.5%) participants had previously tried at least one evidence-based cognitive behavioral treatment for migraine prevention.

Likelihood to pursue behavioral therapy

The participants reported an average of 4 on a 1-5 scale (that they were “somewhat likely”) to pursue in person or smartphone behavioral therapy and behavioral therapy covered by insurance. (Table 2) Participants reported an average of 3 on a 1-5 scale (neutral) about pursuing phone-based behavioral therapy. (Table 2) Participants reported an average of 2 on a 1-5 scale ( “not very likely”) to pay out of pocket for behavioral therapy. (Table 2) Responses based on the MIDAS scores can be found in Table 3.

Table 2:

Likelihood of pursuing behavioral treatment for migraine

Total N = 401	Median, [IQR]
In person	4 [3,4]
Telephone-based	3 [2,4]
Smartphone application	4 [3,5]
Out of pocket	2 [1,3]
Covered by insurance	4 [3,5]

Using ordinal regression, migraine-related disability as measured by MIDAS was associated with likelihood to pursue behavioral therapy in person, via telephone, via smart phone, and if covered by insurance. (Tables 4) However, migraine-related disability was not associated with likelihood to pursue out of pocket behavioral therapy. (Table 4) Age, gender, race, employment, education, migraine chronicity, and prior attempts of behavioral therapy do not seem to impact likelihood to pursue any type of behavioral therapy when using ordinal regression. (Table 4) However, pain intensity was predictive of likelihood of pursuing behavioral therapy for migraine when covered by insurance while headache frequency was predictive when behavioral therapy was delivered via telephone.

Discussion

Similar to epidemiologic studies of the general U.S. population ¹⁵, the majority of participants in this study who qualify for migraine preventive therapy (e.g. have 4 or more headache days a month) are not receiving it. When queried regarding interest in behavioral therapy for migraine, participants reported on average that they were somewhat likely to try it. In particular, those with higher levels of migraine disability (but not higher headache days/month) reported greater interest in trying behavioral migraine treatment. Regarding treatment modality, participants reported greater interest in trying in-person and smartphone based behavioral therapy compared to telephone based behavioral therapy. However, across all modalities participants reported unwillingness to pay out of pocket for the cost of the behavioral therapy.

In a population in need of migraine preventive therapy (about one in ten participants (11.2%) met criteria for chronic migraine and nearly half (45.1%) had at least two moderate to severe headaches per week), only about a quarter (29.2%) of participants had taken preventive medications and only an eighth (12.5%) had tried evidence based behavioral treatments for migraine. The participants were willing to pursue in-person or smart-phone based behavioral therapy for migraine. Participants were less likely to pursue telephone-based and unlikely to pay out of pocket for behavioral therapy for migraine. These preferences align with objective outcomes of behavioral therapy for other disease states. For depression, face-to-face cognitive behavioral therapy was found to be more beneficial long-term than telephone-based cognitive behavioral therapy ¹⁶. Although internet-based behavioral therapy seemed acceptable to patients, there is still limited data on its effectiveness ⁷. Future research should focus on the effectiveness of these internet based behavioral therapies in comparison to face to face behavioral therapy. Furthermore, research should assess these modern methods in regards to protecting patient privacy and adhering to the public policies designed to protect patient information.

There was an association between migraine pain severity and willingness to pursue behavioral therapy if it was covered by insurance. Participants’ reported likeliness to engage in behavioral therapy decreased when they were asked if they would pay out of pocket for these treatments. Future work might inform key stakeholders (those with migraine who would need to pay for treatments and the decision makers who decide which migraine treatments to cover) about migraine chronification and the ability of migraine behavioral treatments to try to prevent migraine chronification, which has a worsened prognosis ¹⁷. Direct individual and societal costs of behavioral therapy for migraine should be weighed against the direct and indirect costs of migraine including healthcare utilization and loss of productivity. ¹⁸ While out-of-pocket migraine prescription costs differ between patients with low frequency of headaches versus patients with a high frequency of headaches, the driver of the large difference in direct costs of migraine between low and high frequency migraine patients is health-care provider visits. ¹⁸ However, in the long term (after one year of preventive headache treatment), clinic-based behavioral therapy was found to be the least costly headache prevention method, even less costly than pharmacological prevention. ¹⁹

Migraine-related disability is associated with willingness to pursue any type of behavioral therapy for migraine prevention. Interestingly, headache frequency was not associated with likelihood to pursue behavioral therapy for migraine. Although migraine-related disability is associated with headache frequency ^18,20,21, there is a trend to evaluate patients for both headache frequency and functional outcomes. In this study, disability was associated with likelihood to pursue behavioral therapy, but not frequency. MIDAS score was related to healthcare utilization and lost productivity, hence the importance of preventive treatment to reduce the MIDAS score and improve quality of life. ²²

Limitations

There were limitations in this study. Participants were selected from an online survey platform, TurkPrime, (not a clinic) but they were still clearly in need of prevention based on the migraine severity scores and headache frequency. We do not know the geographic location of the participants-only that they were based in the United States. As this studied had a majority of white, educated women, we do not know whether our results are generalizable to those with a lower educational background. Future work might also examine non-whites and those with a lower educational attainment. Future work should also separate out race and ethnicity; our study only asked about race. Our sample had few people with chronic migraine. Future work might also examine utilization of behavioral treatments in a sample composed exclusively of people with chronic migraine. In addition, we do not know how our results compare to those who present to various medical settings with a diagnosis of migraine. Also, we do not know whether a clinician ever explained and/or encouraged the participants to pursue behavioral therapy for migraine. We also did not address potential stigma around behavioral therapy and participants’ education about behavioral therapy, i.e. their understanding of the evidence and logistic of behavioral therapy for migraine prevention. We did not examine whether other potential diagnosed comorbidities predicted participants’ responses. This study only addressed participants’ willingness to pursue behavioral therapy. There were no data on whether they initiated and/or continued behavioral therapy. There were no qualitative data to delve deeper in the factors that might influence participants’ willingness to pursue behavioral therapy for migraine.

Conclusion

Despite the high burden of migraine, preventive treatment is underutilized, especially evidence-based behavioral therapy for migraine. Based on this study, people with migraine report a preference for in-person and smartphone-based behavioral therapy to telephone-based behavioral therapy. Migraine-related disability is associated with pursuing most of these delivery routes of migraine behavioral therapy. However, if participants would have to pay out of pocket for behavioral therapy, they would be not very likely to do it. Thus, it is essential that insurance companies and other payers (possibly peoples’ jobs given the significant amount of indirect costs attributed to migraine) pay for behavioral therapy for migraine.