Adherence to Behavioral Therapy for Migraine: Knowledge to Date, Mechanisms for Assessing Adherence, and Methods for Improving Adherence
Purpose of Review
In other disease states, adherence to behavioral therapies has gained attention, with a greater amount of studies discussing, defining, and optimizing adherence. For example, a meta-analysis formally discussed adherence in 25 studies of CBT for 11 different disorders, with only 6 of the 25 omitting addressing or defining adherence. Many studies have discussed the use of text messages, graph-based adherence rates, and email/telephone reminders to improve adherence. This paper examined the available literature regarding adherence to behavioral therapy for migraine as well as adherence to similar therapies in other disease states. The goal of this research is to apply lessons learned from adherence to behavioral therapy for other diseases in better understanding how we can improve adherence to behavioral therapy for migraine.
Treatment for migraine typically includes both pharmacologic and non-pharmacologic therapies, including progressive muscle relaxation (PMR), cognitive behavioral therapy (CBT), and biofeedback. Behavioral therapies have been shown to significantly reduce headache frequency and intensity, but high attrition rates and suboptimal adherence can undermine their efficacy. Traditionally, adherence to behavioral therapy has been defined by self-report, including paper headache diaries and assignments. In person attendance has also been employed as a method of defining and monitoring adherence. With the advent of personal electronics, measurements of adherence have shifted to include electronic-based methods such as computer-based programs and mobile-based therapies. Furthermore, some studies have taken advantage of electronic methods such as email reminders, push notifications, and other mobile-based reminders to optimize adherence. The JITA-I, a novel method of engaging individual patient adherence, has also been suggested as a possible method to improve adherence by tailoring engagement with a mobile health app-based on patient input. These novel methods may be utilized in behavioral therapy for migraine for further optimizing adherence.
Few intervention studies to date have addressed the optimal ways to impact adherence to migraine behavioral therapy. Further research is required regarding adherence with behavioral therapies, specifically via mobile health interventions to better understand how to define and improve adherence via this novel forum. Once we are able to understand optimal methods of tracking adherence, we will be better equipped to understand the role of adherence in shaping outcomes for behavioral therapy in migraine.
KeywordsAdherence Behavioral therapy Migraine Prevention
Compliance with Ethical Standards
Conflict of Interest
Mia Minen has funding from the National Center for Complementary and Integrative Health (NCCIH) K23 AT009706-01 and the American Academy of Neurology (AAN)-American Brain Foundation (ABF) Practice Research Training Fellowship. Alexandra Gewirtz declares no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Campbell J, Penzien D, Wall E. Evidence-based guidelines for migraine headache: behavioral and physical treatments. 2000.Google Scholar
- 2.Matchar DB, Harpole L, Samsa GP, et al. The headache management trial: a randomized study of coordinated care. Headache. 2008;48(9):1294–310.Google Scholar
- 3.Holroyd KA, Cottrell CK, O’Donnell FJ, et al. Effect of preventive (beta blocker) treatment, behavioural migraine management, or their combination on outcomes of optimised acute treatment in frequent migraine: randomised controlled trial. BMJ. 2010;341:c4871. https://doi.org/10.1136/bmj.c4871.PubMedCentralGoogle Scholar
- 5.Penzien DB, Rains JC, Andrasik F. Behavioral management of recurrent headache: three decades of experience and empiricism. Appl Psychophysiol Biofeedback. 2002;27(2):163–81.Google Scholar
- 6.Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754–62.Google Scholar
- 7.Schafer AM, Rains JC, Penzien DB, Groban L, Smitherman TA, Houle TT. Direct costs of preventive headache treatments: comparison of behavioral and pharmacologic approaches. Headache. 2011;51(6):1526.Google Scholar
- 8.Horwitz R. Adherence to treatment and health outcomes. Arch Intern Med. 1993;153(16):1863.Google Scholar
- 10.Claxton A, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001;23:1296.Google Scholar
- 12.•• Ramsey RR, Ryan JL, Hershey AD, Powers SW, Aylward BS, Hommel KA. Treatment adherence in patients with headache: A systematic review. Headache. 2014;54(5):795–816. https://doi.org/10.1111/head.12353. This was a study of adherence for children undergoing progressive muscle relaxation for migraine. Adherence in this study was defined by the number of correct “relaxation passwords of the day” as recorded on the individual child’s relaxation log. The study also found a significant relationship between adherence and number of headache free days.
- 13.Engel JM. Children’s compliance with progressive relaxation procedures for improving headache control. OTJR (Thorofare N J). 1993;13:219.Google Scholar
- 14.Wisniewski JJ, Genshaft JL, Mulick JA, Coury DL, Hammer D. Relaxation therapy and compliance in the treatment of adolescent headache. Headache. 1988;28:612.Google Scholar
- 15.Guibert MB, Firestone P, McGrath P, Goodman JT, Cunningham JS. Compliance factors in the behavioural treatment of headache in children and adolescents. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement. 1990;22(1):37.Google Scholar
- 16.•• Minen MT, Azarchi S, Sobolev R, Shallcross A, Hapern A, Berk T, et al. Factors related to migraine patients' decisions to initiate behavioral migraine treatment following a headache specialist’s recommendations: a prospective observational study. In: Pain medicine; June 2018. This was a multi center randomized controlled trial for adults with symptoms of depression (with scores of ≥ 10 on a standardized questionnaire for depression) who were randomised to receive a commercially produced computerized Cognitive Behavioral Therapy (CBT) program or a free to use cCBT program in addition to standard of care. Participants adhered to self report of symptoms. The study found that a commercially available cCBT or free to use CBT was not superior to general practitioner standard of care.Google Scholar
- 17.Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, et al. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015;351:5627.Google Scholar
- 18.Tassorelli C, Sances G, Allena M, Ghiotto N, Bendtsen L, Olesen J, et al. The usefulness and applicability of a basic headache diary before first consultation: results of a pilot study conducted in two centres. Cephalagia. 2008;28(10):1023.Google Scholar
- 19.Lipchik GL, Holroyd KA, Nash JM. Cognitive-behavioral management of recurrent headache disorders: a minimal-therapist-contact approach. In: Psychological approaches to pain management. 2nd ed. New York: Guilford Pubs; 2002. p. 356.Google Scholar
- 20.•• Kroon Van Diest AM, Ramsey R, Kashikar-Zuck S, et al. Treatment adherence in child and adolescent chronic migraine patients: results from the cognitive behavioral therapy and amitriptyline trial. Clin J Pain. 2017;33:892. This paper reviewed the pathophysiology, diagnosis, and management of migraine in children and adolescents. As part of the management section, the paper discusses relaxation techniques that are commonly employed in the armamentarium against pediatric and adolescent headache. The paper also discusses strategies commonly employed in the effort to improve patient adherence to relaxation techniques. Visual reminders to cue compliance, such as charts for self monitoring, are suggested as a possible tool.Google Scholar
- 25.Andersson G, Lundström P, Ström L. Internet-based treatment of headache: does telephone contact add anything? Headache. 2003;43:353.Google Scholar
- 26.Devineni TBE. A randomized controlled trial of an internet-based treatment for chronic headache. Behav Res Ther. 2005;43:277.Google Scholar
- 27.Ström L, Pettersson R, Andersson G. A controlled trial of self-help treatment of recurrent headache conducted via the internet. J Consult Clin Psychol. 2000;68:722.Google Scholar
- 29.Dear BF, Titov N, Perry KN, Johnston L, Wootton BM, Terides MD, et al. The pain course: a randomised controlled trial of a clinician-guided internet-delivered cognitive behaviour therapy program for managing chronic pain and emotional well-being. Pain. 2013;154(6):942.Google Scholar
- 31.Sorbi MJ, van der Vaart R. User acceptance of an internet training aid for migraine self-management. J Telemed Telecare. 2010;16(1):30.Google Scholar
- 32.Jahns RG. Jahns R-G. 500m people will be us- ing healthcare mobile applications in 2015 . Updated 2010. Accessed 06/12, 2018.Google Scholar
- 34.Minen MT, Jalloh A, Ortega E, Powers SW, Sevick MA, Lipton RB. User design and experience preferences in a novel smartphone application for migraine management: a think aloud study of the RELAXaHEAD application. Pain Med. 2018.Google Scholar
- 35.Ramsey R, Holbein C, Powers S, Hershey A, Kabbouche MA, et al. A pilot investigation of a mobile phone application and progressive reminder system to improve adherence to daily prevention treatment in adolescents and young adults with migraine. Cephalalgia. 2018.Google Scholar
- 36.Stawarz K, Preist C, Tallon D, Wiles N, Coyle D. User experience of cognitive behavioral therapy apps for depression: An analysis of app functionality and user reviews. J Med Internet Res. 2018;20(6).Google Scholar
- 38.• Lindhiem O, Bennett CB, Rosen D, Silk J. Mobile technology boosts the effectiveness of psychotherapy and behavioral interventions: a meta-analysis. Behav Modif. 2015;39(6):785. This was a comprehensive systemic review and meta-analysis of internet delivered CBT (iCBT) for children and adolescents. The review included twenty five studies of iCBT for 11 different disorders. Treatment adherence and therapist time varied largely amongst sutudies. Twenty-four studies (N = 1882) were eventually included in the. There was a moderate between-group effect size of the iCBT group when compared with the waitlist, g = 0.62, 95% CI [0.41, 0.84], suggesting that iCBT for multiple different disorders can be successfully used.Google Scholar
- 39.Vigerland S, Lenhard F, Bonnert M, Lalouni M, Hedman E, et al. Internet-delivered cognitive behavior therapy for children and adolescents: a systematic review and meta-analysis. Clin Psychol Rev. 2016;50:1.Google Scholar
- 42.Kim HS, Yoo YS, Shim HS. Effects of an internet-based intervention on plasma glucose levels in patients with type 2 diabetes. J Nurs Care Qual. 2005;20(4):335.Google Scholar
- 46.Push notification. https://searchmobilecomputing.techtarget.com/definition/push-notification. Updated 2016. Accessed 06/01, 2018.
- 48.Jones K, Lekhak N, Kaewluang N. Using mobile phones and short message service to deliver self-management interventions for chronic conditions: a meta-review. Worldviews Evid-Based Nurs. 2014;11(2):81.Google Scholar
- 49.•• Nahum-Shani I, Smith SN, Spring BJ, Collins LM, Witkiewitz K, Tewari A, et al. Just-in-time adaptive interventions (JITAIs) in mobile health: key components and design principles for ongoing health behavior support. Ann Behavioral Med. 2018;52(6):446. This was a randomized clinical trial involving 5 residential programs for patients meeting the criteria for DSM-IV alcohol dependence (n = 349). Patients were randomized to usual treatment (n = 179) or usual treatment plus a smartphone (n = 170) with the Addiction-Comprehensive Health Enhancement Support System (A-CHESS) application, designed to improve care for alcohol dependence. Patients in the A-CHESS group had significantly fewer risky drinking days than did the control patients (mean difference, 1.37; 95% CI, 0.46-2.27; P = .003).Google Scholar
- 52.Dayer L, Heldenbrand S, Anderson P, Gubbins PO, Martin BC. Smartphone medication adherence apps: potential benefits to patients and providers. J Am Pharm Assoc. 2013;53(2):172.Google Scholar
- 53.Boulos MNK, Brewer AC, Karimkhani C, Buller DB, Dellavalle RP. Mobile medical and health apps: State of the art, concerns, regulatory control and certification. Online Journal of Public Health Informatics. 2014;5(3229).Google Scholar
- 54.Dantzig S, Geleijnse G, Halteren AT. Toward a persuasive mobile application to reduce sedentary behavior. Pers Ubiquit Comput. 2013;17(6):1237–46.Google Scholar