Published studies have shown that biofeedback, cognitive behavioral therapy, and relaxation are safe and well-tolerated nonpharmacologic strategies for migraine prevention and may provide long-term benefits. “We know that these treatments can be effective as monotherapy and can also be used together with migraine medications,” says Mia T. Minen, MD, MPH. “However, studies indicate that many of these treatments are largely underutilized.”
Finding time to attend appointments and costs associated with nonpharmacologic therapies have been identified as barriers to using behavior therapy in migraine in previous research. A recent study by Dr. Minen and colleagues found that only about half of patients with migraine who were referred for behavioral therapy inquired about making an appointment. “In this analysis, we identified time and money as the main barriers to using behavioral therapy,” Dr. Minen says.
In a different randomized controlled study, Dr. Minen and colleagues assessed whether telephoned based motivational interviewing (MI) sessions increased the initiation, scheduling, and/or attending of behavioral therapy appointments for migraine prevention. “The MI calls increased rates of initiation but did not increase rates of scheduling or attending appointments,” says Dr. Minen. “This was likely the result of other systematic barriers.”
For a new analysis published in Headache, Dr. Minen and colleagues assessed preferences for delivery of behavioral therapy with in-person treatment or via smartphone or telephone and reviewed the impact of insurance and other cost factors. The study surveyed whether people with migraine had preferences regarding the type of delivery of behavioral therapy and whether they would be willing to pay for in-person behavioral therapy. The authors also assessed if there were any predictors of likelihood to pursue behavioral therapy.
“Given the low usage of these effective interventions, our survey was conducted to better understand the behavioral therapy preferences in people with migraine,” says Dr. Minen. In total, the study included 401 participants who screened positive for migraine using the American Migraine Prevalence and Prevention screen. The median age of the study group was 34 years, and more than two-thirds of the cohort was women. Participants reported having a median of 5 headache days per month.
According to the study, only 12.5% of patients with migraine used evidence-based behavioral therapy, but when asked if interested in this treatment, many participants reported being “somewhat likely” to try it. Study patients reported being “somewhat likely” to pursue in-person or smartphone behavioral therapy and behavioral therapy covered by insurance. Respondents were neutral about pursuing telephone-based behavioral therapy. Of note, participants were “not very likely” to pay out of pocket for the behavioral therapy (Table).
“Our data showed that there is no one-size-fits-all situation for patient preferences in migraine,” Dr. Minen says. “Some people may prefer in-person sessions while others may prefer smartphone delivered therapy. People are willing to engage in behavioral therapy if it is covered by insurance. However, they are less likely to engage in this treatment if it is not covered by insurance.” Pain intensity was predictive of likelihood of pursuing behavioral therapy for migraine when covered by insurance. Other factors were not deemed predictors, including education, employment, and headache days.
According to Dr. Minen, efforts are needed to advocate for behavioral therapy coverage. “Clinicians should take time to find behavioral therapy resources in their area that may be covered,” she says. “It is helpful to explain to patients that their treatment does not need to be billed under mental health codes. Instead, it can be billed under behavioral health codes, which may help patients who do not have mental health coverage.”
In the future, Dr. Minen says more comparison studies are needed to assess different treatment delivery modalities. “We should determine the minimum dose required to achieve benefit,” she says. “In addition, we need point-of-value analyses and more cost effectiveness research for behavioral therapy for migraine. Most importantly, it would be beneficial to investigate ways to create scalable, accessible forms of evidence-based behavioral therapy for patients.”
Minen MT, Jalloh A, Begasse de Dhaem O, Seng EK. Behavioral therapy preferences in people with migraine. Headache. 2020 Mar 23 [Epub ahead of print]. Available at: https://headachejournal.onlinelibrary.wiley.com/doi/epdf/10.1111/head.13790.
Minen MT, Azarchi S, Sobolev R, et al. Factors related to migraine patients’ decisions to initiate behavioral migraine treatment following a headache specialist’s recommendation: a prospective observational study. Pain Med. 2018;19:2274-2282.
Gewirtz A, Minen M. Adherence to behavioral therapy for migraine: knowledge to date, mechanisms for assessing adherence, and methods for improving adherence. Curr Pain Headache Rep. 2019;23(1):3.
Jalloh A, Begasse de Dhaem O, Seng E, Minen MT. Message framing and the willingness to pursue behavioral therapy: a study of people with migraine. J Neuropsychiatry Clin Neurosci. 2020;32(2):196-200.