Department of Rehabilitation Medicine, NYU Langone Health, New York, NY, USA.
Department of Physical Medicine & Rehabilitation, MetroHealth System, Cleveland, OH, USA.
J Gen Intern Med. 2021 Oct;36(10):3103-3112. doi: 10.1007/s11606-020-06539-x. Epub 2021 Feb 1.
Migraine affects over 40 million Americans and is the world's second most disabling condition. As the majority of medical care for migraine occurs in primary care settings, not in neurology nor headache subspecialty practices, healthcare system interventions should focus on primary care. Though there is grade A evidence for behavioral treatment (e.g., biofeedback, cognitive behavioral therapy (CBT), and relaxation techniques) for migraine, these treatments are underutilized. Behavioral treatments may be a valuable alternative to opioids, which remain widely used for migraine, despite the US opioid epidemic and guidelines that recommend against them. Identifying and removing barriers to the use of headache behavioral therapy could help reduce the disability as well as the personal and social costs of migraine. These techniques will have their greatest impact if offered in primary care settings to the lower socioeconomic status groups at greatest risk for migraine. We review the societal and cultural challenges that impose barriers to optimal use of non-pharmacological treatment services. These barriers include insufficient knowledge of migraine/headache behavioral treatments and insufficient availability of clinicians trained in non-pharmacological treatment delivery; limited access in underserved communities; financial burden; and stigma associated with both headache and mental health diagnoses and treatment. For each barrier, we discuss potential approaches to minimizing its effect and thus enhancing non-pharmacological treatment utilization.Case ExampleA 25-year-old graduate student with a prior history of headaches in college is attending school in the evenings while working a full-time job. Now, his headaches have significant nausea and photophobia. They are twice weekly and are disabling enough that he is unable to complete homework assignments. He does not understand why the headaches occur on Saturdays when he pushes through all week to get through his examinations that take place on Friday evenings. He tried two different migraine preventive medications, but neither led to the 50% reduction in headache days his doctor had hoped for. His doctor had suggested cognitive behavioral therapy (CBT) before initiating the medications, but he had been too busy to attend the appointments, and the challenges in finding an in-network provider proved difficult. Now with the worsening headaches, he opted for the CBT and by the fifth week had already noted improvements in his headache frequency and intensity.
偏头痛影响了超过 4000 万美国人，是世界上第二大致残疾病。由于偏头痛的大部分医疗护理发生在初级保健环境中，而不是在神经病学或头痛亚专科诊所，因此医疗保健系统的干预措施应侧重于初级保健。尽管有针对偏头痛的行为治疗（例如生物反馈、认知行为疗法（CBT）和放松技术）的 A 级证据，但这些治疗方法的利用率仍然很低。尽管美国阿片类药物泛滥和指南建议反对使用阿片类药物，但行为治疗可能是治疗偏头痛的一种有价值的替代方法。确定并消除使用头痛行为疗法的障碍，可以帮助减少偏头痛的残疾以及个人和社会成本。如果将这些技术提供给最容易患偏头痛的低社会经济地位群体，那么在初级保健环境中，这些技术将产生最大的影响。我们回顾了对非药物治疗服务的最佳利用构成障碍的社会和文化挑战。这些障碍包括对偏头痛/头痛行为治疗的了解不足以及缺乏接受过非药物治疗方法培训的临床医生；服务不足的社区中获取机会有限；经济负担；以及与头痛和心理健康诊断和治疗相关的耻辱感。对于每一个障碍，我们都讨论了潜在的方法来最小化其影响，从而提高非药物治疗的利用率。
一位 25 岁的研究生，他在大学时就有头痛病史，现在正在晚上上学，同时全职工作。现在，他的头痛伴有明显的恶心和畏光。他每周发作两次，头痛严重到无法完成家庭作业。他不明白为什么他在星期六头痛，因为他在整个星期都在努力完成星期五晚上的考试。他尝试了两种不同的偏头痛预防药物，但都没有达到他的医生希望的减少 50%头痛天数的效果。他的医生在开始药物治疗之前曾建议他进行认知行为疗法（CBT），但他一直忙于参加预约，而且在找到网络内提供者方面遇到了困难。现在头痛加重了，他选择了 CBT，到第五周，他已经注意到头痛频率和强度有所改善。
