Factors Associated with Patient Adherence to Biofeedback Therapy Referral for Migraine: An Observational Study

doi:10.21203/rs.3.rs-3111986/v1

Download PDF

Research Article

Factors Associated with Patient Adherence to Biofeedback Therapy Referral for Migraine: An Observational Study

https://doi.org/10.21203/rs.3.rs-3111986/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 22 Feb, 2024

Read the published version in Applied Psychophysiology and Biofeedback →

You are reading this latest preprint version

Background

Biofeedback has Grade A evidence for the treatment of migraine, yet few studies have examined the factors associated with patients' decisions to pursue biofeedback treatment recommendations.

Objective

To examine reasons for adherence or non-adherence to referral to biofeedback therapy.

Methods

Patients with migraine who had been referred for biofeedback by a headache specialist/behavioral neurologist were interviewed in person or via Webex. Patients completed a questionnaire addressing demographics and questions related to their headache histories. At one month, patients were asked if they had pursued the recommendation for biofeedback therapy, their reasons for their decision, and their impressions about biofeedback for those who pursued it.

Results

Of the nearly two-thirds (65%; 33/51) of patients who responded at one month, less than half (45%, 15/33) had contacted biofeedback providers, and only 18% (6/33) were able to participate in biofeedback. Common themes emerged in patients who did not pursue biofeedback, including feeling that they did not have time, endorsing financial obstacles, including treatment cost and/or insurance coverage, and finding it too difficult to schedule an appointment due to limited provider availability. When asked about their preference between a physical therapist or psychologist as a biofeedback provider, responses were mixed; many patients indicated no preference so long as they took insurance and/or were experienced, while others indicated a specific preference for a physical therapist or psychologist due to familiarity, or prior experiences with that kind of provider.

Conclusion

Patients with migraine referred for biofeedback therapy face numerous obstacles to pursuing treatment.

Biofeedback

Behavioral Therapy

Neurology

Patient Adherence

Grade A. nonpharmacological therapies for migraine include cognitive behavioral therapy (CBT), relaxation, and biofeedback (Campbell, Penzien, & Wall, 2000). Biofeedback, a therapeutic approach used for over 50 years (Giggins et al., 2013), involves presenting an individual with visual and/or auditory feedback from their autonomic physiologic processes. Individuals then learn how to use that feedback to modulate their conscious physical actions (e.g., controlled breathing) and gain insight into how thoughts and feelings impact their bodies. A meta-analysis of 55 studies (including randomized controlled trials (RCTs) and pre-post trials) revealed a medium effect size for several types of biofeedback-based interventions for migraine (d = 0.58, 95% CI = 0.52, 0.62; migraine frequency and perceived self-efficacy showed the most significant improvements), which was stable over an average of 17 months (Nestoriuc & Martin, 2007). Non-pharmacologic interventions, including biofeedback, are commonly administered in person by a trained provider.

However, despite proven efficacy and availability, few patients engage in nonpharmacological treatments for migraine. In our studies of primary care providers, only 1.4–10% report referring patients with migraine for biofeedback (M. Minen et al., 2016; M. Minen et al., 2016) though referrals for CBT range from 2.53 to 10% and relaxation therapy up to 40% (M. Minen et al., 2016; M. T. Minen et al., 2016).

When a patient is referred for nonpharmacologic migraine intervention, there are additional barriers to engaging with the treatment. In most cases, such treatments are provided by psychologists. Patients report difficulty finding and accessing trained providers and challenges associated with the time and expense required for treatment. There is also a stigma of seeking treatment from a mental health professional, which is enough to discourage many from initiating therapy (Corrigan & Penn, 1999; Kaiser, Mooreville, & Kannan, 2015). Chronic pain, like migraine itself, has long carried an associated stigma, with patients fearing a perception that the disorder is “all in the head” (Young et al., 2013). In one study of > 1,000 people with chronic pain, approximately 30% were concerned that their pain might be felt to be “not real” or “psychological” or expressed doubt that a pain psychologist might be helpful to them (Engel, 1977).

In this study, we sought to understand patient perspectives for adhering or not adhering to the recommendation to pursue biofeedback. We also learned how this safe and effective migraine treatment could improve engagement rates.

Between 1/21/2020 and 11/1/2022, 119 patients presented to pre-designated providers for care at an urban headache center and were referred for biofeedback. Notably, due to healthcare disruptions from COVID-19 in New York City during 2020 and 2021, recruitment methods changed from in-person (from 1/21/2020 to 3/9/2020) to virtual visits (from 10/26/2020 to 11/1/2022). This study, and all modifications to accommodate COVID-19 disruptions, were approved by NYU Langone Health’s Institutional Review Board (see Fig. 1). Of note, patients in the study could be new or returning Headache Center patients.

Pre-Covid-19 Pandemic

Between January and March 2020, members of the Headache Research Team approached in-person potentially eligible patients waiting for their headache center appointments. Inclusion criteria comprised being greater than or equal to 16 years of age, speaking English, having a diagnosis of migraine, and being referred to biofeedback therapy. Informed consent was completed for interested, qualifying patients. Patients completed a paper questionnaire consisting of baseline questions and measures. Completed questionnaire responses were transferred from paper questionnaires into REDCap (Harris et al., 2009) by a research team member. A second research team member reviewed the original questionnaires and REDCap records to screen for typos or manual errors.

Of note, the study was paused during the height of the COVID-19 pandemic in New York City and then transitioned to entirely virtual.

During the Covid-19 Pandemic

Between October 2020 and November 2022, patients presenting for virtual (telehealth) headache center appointments to pre-designated providers were screened by the study team coordinator after completing their appointments via their EMR. Eligibility criteria remained the same. Patients referred to biofeedback during their appointments were called by the study coordinator and invited to participate. Interested patients completed the informed e-consent process virtually over the phone with the study coordinator using REDCap. Once the informed e-consent was completed, patients completed baseline questionnaires using the same REDCap link. The study coordinator remained on the phone with the patient to answer any questions that arose while completing the questionnaires. All virtually recruited patients were moved to the follow-up arm as they had all been referred to biofeedback.

Measures

Across all patients, the baseline questionnaires included demographic questions, including name, date of birth, age, gender, race, ethnicity, height, weight, years of formal education, highest degree achieved, health insurance coverage, drug prescription coverage, and annual income (Table 1). The baseline questionnaire also included questions specific to the patient's headache experience, prior history of behavioral therapy treatment for headache, headache medications used, and any medical or psychiatric comorbidities (See Appendix 1 for complete baseline questionnaire).

Table 1

Patient Demographics
Variable	Characteristics	Frequency (N = 51)	Percent
Gender	Male Female	3 48	6% 94%
Ethnic Group	Hispanic/Latino Non-Hispanic/Latino Refused	2 46 3	4% 90% 6%
Racial Group	African American American Indian or Alaskan Native Asian or Pacific Islander White/Caucasian Other/More than one race Refused	2 0 4 37 2 6	4% 0% 8% 73% 4% 12%
Age (in years)	18–30 31–40 41–50 51+	15 11 13 12	29% 22% 25% 24%
Formal Education (highest degree earned)	High School Associates Bachelors Advanced Degree Refused	2 1 19 28 1	4% 2% 37% 55% 2%
Health Insurance Coverage	Yes No Refused	48 1 2	94% 2% 4%
Prescription Coverage	Yes No Refused	48 1 2	94% 2% 4%
Annual Income	Under $25,000-$50,000 $50,000-$100,000 $100,000-$200,000 Over $200,000 Refused Unknown	8 18 11 10 4 1	16% 35% 22% 20% 8% 2%
Headache-Specific Demographics
Headache Days per Month	0 1–3 4–9 10 or more	1 4 23 23	2% 8% 45% 45%
Age of Headache Onset	< 10 10–17 18–30 > 30 Unknown	12 26 7 3 3	24% 51% 14% 6% 6%
Age of Migraine Diagnosis	< 10 10–17 18–30 31–40 > 40 Unknown	2 14 21 10 2 2	4% 27% 41% 20% 4% 4%
Number of Patients who Reported being Prescribed Triptans		35	69%
Number of Patients who Reported being Prescribed Opioids for Migraine		4	8%
Number of Migraine Preventative Medications Used	None 1–5 6–10 10+	1 20 15 15	2% 39% 29% 29%

Table 2

Type of Provider Seen for Evaluation and/or Treatment of Headache
Provider Type	Frequency (N = 51)	Percent
Eye Doctor (Ophthalmologist)	21	41%
Dentist	14	27%
Emergency Department/Urgent Care	9	18%
Primary Care Physician (Pediatrician/Internist/Family Medicine Physician)	40	78%
Ear Nose and Throat (ENT)	9	18%
Chiropractor	15	29%
Acupuncturist	19	37%
Psychologist	13	25%
Physical Therapist	18	35%
Psychiatrist	7	14%

Measures included in both the baseline questionnaire and the follow-up questionnaire were the following self-reported questionnaires, the Migraine Disability Assessment (MIDAS) (Stewart et al., 2000), the Migraine Specific Quality of Life Questionnaire (MSQv2) (Speck et al., 2021), the Patient Health Questionnaire depression scale (PHQ-8) (Kroenke et al., 2009), the Generalized Anxiety Disorder scale (GAD-7),(Spitzer et al., 2006), and the Insomnia Severity Index (ISI) (Bastien, Vallieres, & Morin, 2001).

At their 1-month (+/- 10 days) follow-up, patients were asked whether they followed up with the referral for biofeedback and their experiences with biofeedback therapy. Patients were also asked to respond to questions regarding their satisfaction with treatment from their biofeedback healthcare provider (see the Appendix for the complete list of questions).

We report the results of baseline and follow-up data collection, with the follow-ups being completed virtually, as initially intended, by the study coordinator via phone or REDCap email. Data were captured via REDCap questionnaire either as completed by patients or manually entered by the study coordinator if patients preferred to dictate responses over the phone. For patients recruited in person and whose study period was disrupted by COVID-19, a brief, additional survey was added to differentiate between traditional and COVID-19-specific barriers to accessing behavioral therapy treatment.

Of the 119 patients who presented for care between January 2020 and November 2022, 51 were fully enrolled in the study; 25% (13/51) were enrolled in person by a member of the Headache Research Team before the COVID-19 pandemic, and most 75% (38/51) were enrolled virtually after the onset of the COVID-19 pandemic (See Fig. 1).

Baseline

Most patients (94%, 48/51) identified as female (Table 1). Most patients (90%, 45/51) were non-Hispanic and White/Caucasian (73%, 37/51). The average age was 41 ± 14.1 (18–84) years; a majority (75%, 33/51) had an annual income greater than $50,000/year. Nearly all patients (93%, 41/51) had health insurance and prescription coverage.

The average age of headache onset was 14 ± 8.4 (6–40) years, and an intermediate diagnosis of migraine at age 24 ± 10.7 (7–52). Patients had an average of 12 ± 8.4 (0–30) headache days each month with an average pain intensity rating of 6 ± 1.9 on a 10-point pain scale. Patients had a median MIDAS score of 19 (IQR 47.5-9) (scores from 11–20 indicated moderate disability and greater than 21 indicated severe disability). Patients had an average PHQ-8 score of 7 ± 5.3 (0–22) (indicative of the average patient having mild depression), an average GAD-7 score of 6 ± 5.1 (0–21) (indicative of the average patient having mild anxiety), and an average ISI score of 8 ± 5.0 (0–19) (indicative of sub-threshold insomnia).

All but one patient (98%, 50/51) had tried migraine-preventative medication. Most (67%, 34/51) patients had been referred for behavioral therapy for their headaches before the onset of the appointment in which they were screened into the study. Still, less than half (44%, 15/34) pursued the recommendation. Of the patients who had tried behavioral therapy specifically for headache, most (60%, 9/15) had tried CBT, one-third (33%, 5/15) had tried progressive muscle relaxation (PMR), and less than half (46%, 7/15) had tried biofeedback for headache.

Of those who had been referred previously for behavioral therapy for headache but did not pursue the recommendation, most (65%, 11/17) felt that they did not have time, and nearly all (88%, 15/17) endorsed financial obstacles such as treatment cost and/or insurance coverage, and 47% (8/17) found it too difficult to schedule an appointment due to limited provider availability. Only 30% (5/17) of patients did not think the treatment would work, and just 6% (1/17) did not know enough about it.

Follow-Up

Approximately two-thirds of (65% 33/51) of patients completed their follow-up questionnaire. Of those who completed their follow-up, patients had a median MIDAS score of 28 ± 28.1 (0-102) (scores greater than 21 indicate severe disability). Otherwise, depression, anxiety, and insomnia scores were similar to all those who fully enrolled in the study; patients had an average PHQ-8 score of 6 ± 5.8 (0–22), an average GAD-7 score of 6 ± 6.4 (0–21), and an average ISI score of 8 ± 5.5 (0–19).

Less than half (45%,15/33) of patients had contacted biofeedback providers, yet only 18% (6/33) of patients could pursue biofeedback therapy after being referred. Those who tried biofeedback averaged trying 4 + 3.0 (2–10) preventative migraine medications, while those who did not average 8 ± 4.9 (1–19).

Qualitative Results

Patients addressed four text-response questions upon completing their follow-up questionnaire (see Table 3 for qualitative themes and subthemes).

Table 3

Qualitative Data Themes and Subthemes
Question	Overarching Theme	Themes	Patient Quotes
What went through your mind when your physician made a referral for biofeedback?	Interest in pursuing biofeedback	Interested in trying alternative/non-pharmacological treatments.	“I was pleased that there was a potential non-medicinal option.” “I'm not opposed to it - I've thought of doing that for a while and did know a provider. I'm on board for trying alternative things like that.”
	Hesitation in pursuing biofeedback	Effectiveness of biofeedback General lack of knowledge on what biofeedback is Prior experience with biofeedback	“I was unaware of the form of treatment for headaches and questioned if this was a valid form of prevention for headaches.” “Recognition of hearing that before but no real knowledge of biofeedback or how it works.” “I had already done about 10 sessions of biofeedback about six years ago for migraines, and didn't see improvement, so I was hesitant to try it again.”
	Disinterest in pursuing biofeedback	Time constraints	“I don't know how I'm going to make this happen without help locating a provider and setting up an appointment.”
Do you have a preference for seeing a physical therapist or a behavioral therapist for treatment of migraine?	No preference	Provider that accepts insurance Provider that is qualified/experienced	“Was looking for someone who'd take my insurance.” “Whichever is most experienced.” “I think my physician would recommend only qualified providers.”
	Preference for Physical Therapist	Familiarity Previous experience with biofeedback	“I would probably prefer a physical therapist; I understand their approach and what they do a little bit more.” “My neurologist previously referred me to a behavioral therapist. I saw him for 5 or 6 sessions, but I ultimately saw no benefit or decrease in headaches at all, so I stopped going.”
	Preference for Behavioral Therapist	Previous experience with physical therapy	“I have already tried physical therapy so I would prefer to try behavioral therapy.”
What do you think is the most important reason you did not make an appointment for biofeedback?	Insurance coverage and expense		“Unable to find a recommended provider that works with my insurance.” “I want to see how the supplements work first because therapy is really expensive.”
	Effectiveness of the treatment	Opted for medication-based treatment. Did not think it would help	“Fortunately, my migraine headaches have been infrequent and minimal. I have gotten relief from one tablet of Rizatriptan. I have only had two slight migraines in the last 6 weeks.” “Later on, saw my neurologist/psychiatrist recommended that I opt for medication rather than biofeedback.” “I have already seen a behavioral therapist and don't understand how they can help with my migraines.”
	Lack of response from a provider		“They haven't called me back.”
	Time constraints	Too much work to find a provider	“I have so many projects and things to do. It takes time and research to find insured covered people to work with me and carve out time for it as well.” “Lack of time to research provided options and lack of motivation.”
	Have additional acute medical conditions		“Currently pregnant and overwhelmed by doctor's appointments.” “Severe exacerbation of colitis so competing priorities.”
(For those that attended appointments, N = 6) What are your impressions thus far?	Positive impression	Enjoy educational aspects	“Fantastic! This has been REALLY helpful. I've experienced a dramatic decrease in headaches in the last several weeks since starting biofeedback. The tension in my shoulders and neck feels significantly better already.” “I liked the approach and am hopeful going forward. The explanations of what and why biofeedback helps makes sense. The progressive muscle relaxation video is particularly good.” “I've liked learning techniques to help my mind/body relax.”

Patients were first asked, “What went through your mind when your physician made a referral for biofeedback?” The following themes emerged: 1) Interest in trying non-pharmacological treatments; 2) General lack of knowledge on what biofeedback is; 3) Hesitation about the effectiveness of biofeedback; 4) Hesitation due to prior experience with biofeedback; 5) Time constraints.

To gauge the kinds of providers patients might prefer, they then answered, “Do you have a preference for seeing a physical therapist or a behavioral therapist for treatment of migraine?” and the following themes emerged: 1) Any provider that accepts insurance; 2) Any provider that is qualified and/or experienced; 3) Physical therapist because of familiarity; 4) Preference for a physical therapist due to prior experience with physical therapy; 5) Preference for a behavioral therapist due to prior experience with behavioral therapy.

Patients then answered, “What do you think is the most important reason you did not make an appointment for biofeedback?” Themes included: 1) Insurance coverage and expense; 2) Pursuing medication-based treatment; 3) Did not think it would help; 4) Lack of response from biofeedback provider; 5) Too much work to find a provider; 6) Time constraints.

For patients who had made appointments with a biofeedback provider, “How many appointments have you attended? What are your impressions thus far?” Themes about appointment impressions included: 1) Significantly positive results; 2) Enjoyed educational aspects. All six patients who had attended appointments endorsed positive impressions.

In patients with four or more headache days each month, migraine treatment characteristically involves a combination of acute and preventive medications. Still, RCTs have found that the ideal treatment for migraine typically comprises a blend of pharmacologic and non-pharmacologic treatment (Holroyd et al., 2010; Powers et al., 2013). Nevertheless, patients with migraine rarely engage in Grade A evidence-based behavioral therapies (M. T. Minen et al., 2016; M. T. Minen et al., 2018; M. T. Minen et al., 2020) and thus, in this study, we sought to determine if they might be more willing to engage in biofeedback specifically. Our prior studies found that reasons for the gap between treatment efficacy and treatment utilization include few trained providers, difficulty with insurance coverage (being billed under mental health benefits), and patient-perceived barriers. Further, our study may reinforce that stigma, and access may be barriers to behavioral therapy because, interestingly, more patients reported trying acupuncture for headache treatment at baseline, followed by physical and behavioral therapy.

Within the neurology setting, patients with more significant migraine-related disability are likely to pursue behavioral therapy (M. T. Minen, Jalloh, Begasse de Dhaem, & Seng, 2020) though the preference not to have to pay for behavioral therapy was identified (M. Minen et al. et al., 2020). In this study, we found that patients who had used, on average, eight migraine preventive medications still had not pursued biofeedback compared to those who used four migraine preventive medications on average. A theme emerged that patients need clarification regarding what biofeedback is and what it entails.

We sought to understand better whether patients with migraine might prefer a therapist with a background in psychology or a related field, e.g., a psychologist or a therapist with a background in physical therapy (PT). We found that our patients had mixed responses; some preferred one over the other for various reasons, e.g., they were more familiar with one field than another or had already tried a provider in a field. They wanted to try a provider in a different field with different perspectives based upon the additional training, or they might want the most experienced provider.

Strengths

This is the first study to examine whether people with migraine pursue biofeedback and their reasons for doing so. This is also one of the first studies to explore patient perspectives on the types of providers from whom they would want to see to learn the biofeedback technique.

Limitations

This was a small study, and the Covid-19 pandemic may limit our results; fewer patients may have wanted to engage in in-person therapy and may have yet to realize that, in some instances, biofeedback was being delivered at times via telehealth. Some patients may also have felt that the pandemic would improve shortly and that they could defer the in-person therapy until they thought it was safe to partake in it. Other limitations were that our patient population was not heterogeneous. Most patients identified as non-Hispanic white females (92%, 47/51), and over half (55%, 28/51) had obtained an advanced degree. Most (76%, 39/51) of patients endorsed making over $50,000 in annual income, and almost all (94%, 48/51) patients had health and prescription insurance coverage.

Future Directions

Patient preference for the type of provider to teach biofeedback is an important area for future research. In addition, determining effective ways to overcome access barriers (both the difficulty in finding providers and the challenges related to cost/lack of or limited insurance coverage) is vital to increasing the number of patients learning biofeedback. While there are some forms of biofeedback (e.g., HeartMath, in which patients can practice the technique at home without trained providers) (M. T. Minen et al., 2021), the cost may still be a barrier. The cumulative result of all these factors is that only some patients engage in biofeedback. Future work needs to explore new innovative strategies to increase the uptake of biofeedback, a Grade A evidence-based migraine behavioral therapy, such as optimizing patient education in the clinical setting so that patients are more comfortable and/or familiar with how biofeedback therapy works and the routes of possible administration (e.g., at home or a clinical setting).

The authors have no competing interests relevant to this article's content.

Acknowledgments:

We would like to thank Sarah Corner for her help with recruitment for this research study and for providing information on initial recruitment methods.

Bastien, C. H., Vallieres, A., & Morin, C. M. (2001). Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Medicine, 2(4), 297-307. doi:S1389945700000654 [pii]
Campbell, K., Penzien, D., & Wall, E. (2000). Evidenced-based guidelines for migraine headache: Behavioral and physical treatments. American Academy of Neurology,
Corrigan, P. W., & Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric stigma. Am Psychol, 54(9), 765-776.
Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136. doi:10.1126/science.847460
Giggins, O. M., Persson, U. M., & Caulfield, B. (2013). Biofeedback in rehabilitation. Journal of Neuroengineering and Rehabilitation, p. 10, 60-0003-10-60. doi:10.1186/1743-0003-10-60 [doi]
Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. doi:10.1016/j.jbi.2008.08.010 [doi]
Holroyd, K. A., Cottrell, C. K., O'Donnell, F. J., Cordingley, G. E., Drew, J. B., Carlson, B. W., & Himawan, L. (2010). Effect of preventive (beta blocker) treatment, behavioral migraine management, or their combination on optimized acute treatment outcomes in frequent migraines: Randomised controlled trial. BMJ (Clinical Research Ed.), p. 341, c4871. doi:10.1136/bmj.c4871 [doi]
Kaiser, R. S., Mooreville, M., & Kannan, K. (2015). Psychological interventions for managing chronic pain: A review of current evidence. Curr Pain Headache Rep., 19(43) doi:10.1007/s11916-015-0517-9.
Kroenke, K., Strine, T. W., Spitzer, R. L., Williams, J. B. W., Berry, J. T., & Mokdad, A. H. (2009). The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disorders, 114(1), 163. doi:https://doi.org/10.1016/j.jad.2008.06.026
Minen, M., Shome, A., Halpern, A., Tishler, L., Brennan, K. C., Loder, E., . . . Silbersweig, D. (2016). A migraine management training program for primary care providers: An overview of a survey and pilot study findings, lessons learned, and considerations for further research. Headache, 56(4), 725-740. doi:10.1111/head.12803 [doi]
Minen, M. T., Azarchi, S., Sobolev, R., Shallcross, A., Halpern, A., Berk, T., . . . Seng, E. (2018). Factors related to migraine patients' decisions to initiate behavioral migraine treatment following a headache specialist's recommendation: A prospective observational study. Pain Medicine (Malden, Mass.), doi:10.1093/pm/pny028 [doi]
Minen, M. T., Corner, S., Berk, T., Levitan, V., Friedman, S., Adhikari, S., & Seng, E. B. (2021). Heartrate variability biofeedback for migraine using a smartphone application and sensor: A randomized controlled trial. General Hospital Psychiatry, 69, 41-49. doi:S0163-8343(20)30177-8 [pii]
Minen, M. T., Jalloh, A., Begasse de Dhaem, O., & Seng, E. K. (2020). Behavioral therapy preferences in people with migraine. Headache, doi:10.1111/head.13790 [doi]
Minen, M. T., Loder, E., Tishler, L., & Silbersweig, D. (2016). Migraine diagnosis and treatment: A knowledge and needs assessment among primary care providers. Cephalalgia: An International Journal of Headache, 36(4), 358-370. doi:10.1177/0333102415593086 [doi]
Minen, M. T., Sahyoun, G., Gopal, A., Levitan, V., Pirraglia, E., Simon, N. M., & Halpern, A. (2020). A pilot randomized controlled trial to assess the impact of motivational interviewing on initiating behavioral therapy for migraine. Headache, 60(2), 441-456. doi:10.1111/head.13738 [doi]
Nestoriuc, Y., & Martin, A. (2007). Efficacy of biofeedback for migraine: A meta-analysis. Pain, 128(1-2), 111-127. doi:S0304-3959(06)00465-9 [pii]
Powers, S. W., Kashikar-Zuck, S. M., Allen, J. R., LeCates, S. L., Slater, S. K., Zafar, M., . . . Hershey, A. D. (2013). Cognitive behavioral therapy plus amitriptyline for chronic migraine in children and adolescents: A randomized clinical trial. Jama, 310(24), 2622-2630. doi:10.1001/jama.2013.282533 [doi]
Speck, R. M., Yu, R., Ford, J. H., Ayer, D. W., Bhandari, R., & Wyrwich, K. W. (2021). Psychometric validation and meaningful within-patient change of the migraine-specific quality of life questionnaire version 2.1 electronic patient-reported outcome in patients with episodic and chronic migraine. Headache, 61(3), 511-526. doi:10.1111/head.14031 [doi]
Spitzer, R. L., Kroenke, K., & Williams, J. B. W. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med., 166(10), 1092. doi:10.1001/archinte.166.10.1092
Stewart, W. F., Lipton, R. B., Kolodner, K. B., Sawyer, J., Lee, C., & Liberman, J. N. (2000). Validity of the migraine disability assessment (MIDAS) score in comparison to a diary-based measure in a population sample of migraine sufferers. Pain, 88(1), 41–52. doi:10.1016/s0304-3959(00)00305-5
Young, W. B., Park, J. E., Tian, I. X., & Kempner, J. (2013). The stigma of migraine. PloS One, 8(1), e54074. doi:10.1371/journal.pone.0054074

The Appendix is not available with this version

No competing interests reported.

Download PDF

Journal Publication

published 22 Feb, 2024

Read the published version in Applied Psychophysiology and Biofeedback →

Editorial decision: Major revision
29 Sep, 2023
Reviews received at journal
01 Aug, 2023
Reviewers agreed at journal
03 Jul, 2023
Reviewers invited by journal
03 Jul, 2023
Editor assigned by journal
30 Jun, 2023
Submission checks completed at journal
30 Jun, 2023
First submitted to journal
26 Jun, 2023

You are reading this latest preprint version

Factors Associated with Patient Adherence to Biofeedback Therapy Referral for Migraine: An Observational Study

Status:

Journal Publication

Version 1

Abstract

Background

Objective

Methods

Results

Conclusion

Figures

Introduction

Methods

Pre-Covid-19 Pandemic

During the Covid-19 Pandemic

Measures

Results

Baseline

Follow-Up

Qualitative Results

Discussion

Strengths

Limitations

Future Directions

Declarations

References

Appendix

Additional Declarations

Status:

Journal Publication

Version 1