Adherence to Behavioral Therapy for Migraine: Knowledge to Date, Mechanisms for Assessing Adherence, and Methods for Improving Adherence

DOI: https://doi.org/10.1007/s11916-019-0739-3

Abstract-Summary In other disease states, adherence to behavioral therapies has gained attention, with a greater amount of studies discussing, defining, and optimizing adherence.

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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.

Adherence to behavioral therapy has been defined by self-report, including paper

headache diaries and assignments.

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.

These novel methods may be utilized in behavioral therapy for migraine for fur-

ther 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, spe- cifically 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.

Introduction The definition of adherence to behavioral therapy for migraine, specifically, varies widely among studies evaluating its use.

While behavioral therapies have consistently been shown to improve outcomes of migraine patients, their efficacy may be limited by adherence and high attri- tion rates.

The majority of studies evaluating behavioral therapies in migraine do not include discussions of adherence and potential methods of improving the extent to which patients comply with treatment.

In a systematic review of 23 studies on adherence and outcomes for electroni- cally based migraine behavioral treatment, only two studies included absolute rates of adherence and they mention that the rates were suboptimal [596].

Other studies evaluating behavioral treatment in the pediatric population esti-

mated adherence rates of 44% [597] and 52% [598].

Many studies evaluating the use of behavioral therapies for migraine, in addition,

do not address methods of improving adherence.

Behavioral Therapy Adherence in Headache Research Initial electronic headache behavioral studies used CD roms, Internet delivered via the computer, and mobile web-based headache behavioral therapies.

Most of these studies have focused on the electronic diary as an intervention, and have not fully assessed adherence to the dose and duration of the behavioral ther- apy itself.

Some studies have utilized electronic methods such as emails and electronically

based reminders to improve adherence [599, 600].

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The ongoing Women’s Health and Migraine (WHAM) trial evaluates the efficacy of behavioral weight loss intervention in improving migraine symptoms and fre- quency utilizing smartphone-based headache diaries.

One app that was recently developed, RELAXaHEAD, has progressive muscle relaxation (PMR) and an electronic headache diary and may be used to assess the dose and frequency of the behavioral therapy [601].

Electronic apps have enabled investigators to potentially better assess adherence to daily assignments completed as part of the behavioral treatment program for headache [602].

Behavioral Adherence in Other Disease States In a large study of 3876 patients undergoing Internet-based CBT for depression, adherence with CBT was significantly associated with less depressive symptoms and greater treatment response [603].

A meta-analysis of Internet-based CBT for insomnia included two studies that

used text messages to reinforce weekly adherence logs to treatment [604].

Other app-based novel methods have been employed successfully in the effort to

improve adherence in other fields.

A recent review of smartphone apps employed for mental health suggested that web-based treatments that have built-in email or telephone reminders easily increase adherence and may even reduce patient dropout [605].

The just-in-time intervention (JITAI) has been identified in other fields as a pos- sible method of further engaging patient adherence and optimizing benefit from smartphone-based behavioral interventions [606].

The JITAI is a novel method of individualizing patient engagement with a health-

based app and may improve adherence.

Future Directions/Conclusion App-based behavioral therapies allow for tracking adherence; researchers can obtain real-time information about how often the app is used and whether the patient is practicing the behavioral therapy technique.

Internet-based reminders, whether in the push notification, text, or email-based format, will increase adherence and possibly decrease patient dropout for behav- ioral therapies.

The JITAI could track engagement with the behavioral therapy via an app and send individualized prompts only if patients stop the behavioral therapy earlier than the allotted treatment time.

It stands to reason that adherence with behavioral therapy for migraine could potentially improve with a tailored approach similar to that already used for other diseases.

Further research is required regarding adherence with behavioral therapies, spe- cifically via mobile health interventions to better understand how to define and improve adherence via this novel forum.

Acknowledgement A machine generated summary based on the work of Gewirtz, Alexandra; Minen, Mia. 2019 in Current Pain and Headache Reports.

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Efficacy and Feasibility of Behavioral Treatments for Migraine, Headache, and Pain in the Acute Care Setting