Many patients with migraine do not ask providers about complementary, integrative medicine
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In a recent social media survey, 90% of patients with migraine said they use complementary and integrative medicines like meditation, yoga and vitamins, but only about 20% discuss these treatment strategies with a health care provider.
“It is important for providers to be conversant with complementary and integrative medicine (CIM) treatments and the available evidence-based data,” Deena E. Kuruvilla, MD, a neurologist at Yale New Haven Health, and colleagues wrote in BMC Complementary Medicine and Therapies.
The researchers developed a confidential cross-sectional survey to identify common CIMs that patients with migraine use and ascertain which CIMs patients consider to be “most effective.” The survey was posted on Move Against Migraine’s Facebook page. It was completed by 372 individuals who were clinically diagnosed with migraine.
Overall, 90% of survey responders said they use CIM. Among them, 86.6% said they use CIM in combination with mainstream migraine treatments. Most survey responders who reported using CIM were women (94.3%), white (88.4%) and aged 35 to 44 years (24%), 45 to 54 years (23.3%) or 55 to 64 years (24.5%).
The researchers wrote that among all the survey respondents who reported using CIM, 56.4% used two or more. The most common CIMs were vitamins (18.8%), followed by meditation, relaxation, breathing exercises and/or guided imagery (5.6%), yoga (2.6%), cognitive behavioral therapy (2.6%), mindfulness training (1.19%), craniosacral therapy (0.59%) and biofeedback (0.59%). Another 13.4% respondents selected “other.”
In addition, among the entire cohort using CIM:
- 5.9% reported it was “very effective” (led to a 50% to 100% reduction in headache days);
- 22.6% said it was “moderately effective” (resulted in a 10% to 50% reduction in headache days);
- 34.1% said it was “slightly effective” (led to a 1% to 10% reduction in headache days);
- 18.6% said it was “not effective at all” (no change in the number of headache days); and
- 18.6% did not answer.
About half of the survey respondents also reported using CBD oil or “other cannabis derivative” to prevent migraine. Among this subgroup:
- 2.4% said it was “extremely effective;”
- 8.5% said it was “very effective” (resulted in a 50% to 100% reduction in headache days);
- 21.9% said it was “moderately effective” (led to a 10% to 50% reduction in headache days);
- 26.2% said it was “slightly effective” (resulted in a 1% to 10% reduction in headache days); and
- 39% said it was “not effective at all” (no change in the number of reduction days).
The researchers reported that 20.2% of survey participants sought guidance from a health care provider (MD, DO, NP or PA) regarding CIM, while 7.1% relied exclusively on the internet for CIM information, 3.5% sought guidance from another patient with migraine, 1.1% sought guidance from a naturopathic provider and 57.6% used two or more of these sources.
Kuruvilla and colleagues said the CARE mnemonic can be used to discuss CIM treatments with patients.
“It can be helpful to ask about their history with conventional treatments while also avoiding judgement,” they wrote. “When reviewing integrative treatment options, it is imperative to counsel patients on their limitations so that they have appropriate expectations. Finally, in order to adequately educate patients on CIM, it is helpful to explore where the patient’s interest in CIM stems from.”
Perspective
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As the survivor of an accident where my car was hit by an 18‐wheeler and burst into flames — an accident that still causes me nerve pain in my right arm 4 years later — I am very empathetic toward people who have any kind of constant chronic pain or acute pain that comes and goes and/or is very hard to control.
Personally, I begin treating patients’ migraines with Western‐style treatments such as migraine relief medications, and for those who suffer frequent headaches, beta‐blockers and calcitonin gene‐related peptide medications. When a patient tells me they do not want to use these types of medications, then I might suggest some of the treatments mentioned in the Kuruvilla study.
There is certainly a place for some of the CIM treatments Kuruvilla and colleagues studied in health care settings. I have used acupuncture myself and I have recommended it to my patients. Sometimes massage helps, and I would certainly recommend it in patients who have muscle tension headaches as well as migraines. In states where medical marijuana and CBD are legal, and the doctor has recommended it, those therapies might be worth trying. Some patients have reported that chiropractic treatment has given them relief. Personally, I do not recommend a chiropractor, but do not discourage that treatment if the patient feels confident in their chiropractor’s abilities to treat migraine.
Physicians can also keep in mind that migraine treatments do not have to be all Western‐style medicine, or all the ones Kuruvilla and colleagues studied. If you have a patient getting some relief from Western medicine treatment, and they want more relief, maybe they add one of the CIM treatments discussed in the paper. Patients should do what they need to do to feel good and be able to function.
Perspective
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I enthusiastically agree with the findings of the Kuruvilla study. The Jefferson Headache Center absolutely believes that CIM is a critical, and often overlooked, component to comprehensive care for migraine and other headache disorders. There is a growing body of research which supports the introduction of lifestyle changes through CIM modalities as an important complement to traditional medicine.
The Kuruvilla study highlights a long-standing gap in the current migraine care model. A majority of patients with migraine are seeking CIM modalities as part of their comprehensive migraine care. But often this is outside the awareness of their headache provider. This is because both patients and providers face challenges in accessing CIM, as well as safe, effective and trustworthy sources. Providers are left with a lack of evidenced-based referral options, putting the burden is on patients to find CIM solutions on their own, which often drains the patient’s time, energy and finances. Patients who would otherwise benefit from CIM with added time, oversight, and/or support can conclude that these modalities are ineffective for their migraine based on a sub-therapeutic experience.
Last fall, the Jefferson Headache Center introduced Ctrl M Health, a unique and innovative collaboration to provide safe, reliable and accurate information, resources and tools to help patients engage in evidenced-based CIM approaches at home. Ctrl M Health is a lifestyle change app focused on helping those living with migraine accelerate the process of identifying the nonmedication approaches, which will help break the cycle of headache and migraine. Our goal is to help providers better understand the importance of lifestyle change, while advancing the goals of their patients by providing them with education, support and tailored guidance to incorporate lifestyle changes proven to benefit migraine. The American Academy of Neurology guideline on migraine encourages providers to introduce one modifiable risk factor related to lifestyle change at each patient appointment. But physicians need support in this mission. Ctrl M Health can help them do that. Physicians can learn more about Ctrl M Heath from www.ctrlmhealth.com or download the app in the App Store.
It is critical that physicians understand that CIM is an evidence-based, safe strategy for anyone living with any level of disruptive headache. It can and should be introduced in complement to traditional medical care to help treat the whole patient.
Professor of neurology, Thomas Jefferson University
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