اثر کوتاه مدت آموزش رفتاری آنلاین در خودمدیریتی میگرن : مطالعه کنترل شده تصادفی

Behavioral training (BT) is recommended as a supplementary preventive treatment for migraine. Online interventions have been successful in promoting health behavior change, the evidence for online BT in migraine is limited, however. This randomized controlled trial aimed to determine the post-treatment effectiveness of online BT (n = 195) compared to a waitlist control group (WLC; n = 173) on migraine attack frequency (primary outcome), headache self-efficacy and locus of control (secondary outcomes). BT aims to counteract attacks in the prodromal stage through early detection of prodromal features and self-management via physical relaxation and cognitive behavioral regulation, and was offered with minimal e-mail support in eight online lessons. Results showed that 120 (62%) participants completed BT. A decrease of 20–25% in migraine attack frequency was found in both conditions without a between-group difference (ES = 0.02, p = .71). BT participants improved more than WLC participants on migraine related self-efficacy (ES = 0.86, p < .001), developed more internal (ES = 0.57, p < .001), and less external control (ES = 0.78, p < .001). To conclude, results at post-training did not corroborate that improvements in migraine attack frequency were due to online BT, the waitlist control group improved accordingly. However, positive effects of BT on self-efficacy and locus of control were established. We have to await the long term effects to see if improvements in psychological variables translate to a reduction in migraine headache.

Migraine is a common neurological disorder with a year prevalence of approximately 18% in women and 6% in men in the general population (Breslau and Rasmussen, 2001 and Lipton et al., 2007). Migraine attacks are characterized by severe headache accompanied by nausea or vomiting, and sensitivity to light and sound (Goadsby, Lipton, & Ferrari, 2002), and its occurrence may be triggered by weather conditions, perceived stress, and hormonal changes related to the menstrual cycle (Lipton et al., 2007). Migraine attacks can be highly debilitating and many patients report daily life problems such as disrupted family life, restricted social activities, and reduced work performance (Bigal & Lipton, 2009). The societal costs of migraine are high and largely attributable to health care use, work absenteeism, and loss of work productivity (Stewart, Lipton, Dowson & Sawyer, 2001). Optimal management of migraine is important considering the high burden for both patients and society. Pharmacological treatment for the abortion or prevention of migraine attacks is well-established (Silberstein, 2000 and Sprenger and Goadsby, 2009) and neurological guidelines endorse behavioral training (BT) as an evidence-based supplementary preventive treatment (Silberstein, 2000). BT includes strategies for the identification of headache triggers and the acquisition of self-regulation skills. At the physiological level, self-regulation is provided by relaxation training that may be supported by biofeedback of involuntary physiological processes. Self-regulation at the psychological level is delivered through cognitive-behavioral intervention (Rains, Penzien, McCrory, & Gray, 2005). BT can reduce attack occurrence by 35–55% when delivered individually and face-to-face by health care professionals in the clinic (Andrasik, 2007 and Rains et al., 2005). An increased focus on treatment accessibility, cost-effectiveness, and patient empowerment in people with chronic illness instigated the development of self-management programs that are applied in the home setting with minimal guidance (Haddock et al., 1997 and Mérelle et al., 2008). These programs generally include the same components as clinic-based BT and show comparable treatment effects (Haddock et al., 1997 and Rowan and Andrasik, 1996). The internet offers great opportunities for the delivery of self-management programs and promises wider availability and higher efficiency (Cuijpers, Van Straten, & Andersson, 2008). The evidence for online BT in migraine is limited, however. Six studies investigated its effect in primary headache (Andersson et al., 2003, Bromberg et al., 2012, Devineni and Blanchard, 2005, Nicholson et al., 2005, Ström et al., 2000 and Trautmann and Kröner-Herwig, 2010), five were randomized controlled (Andersson et al., 2003, Bromberg et al., 2012, Devineni and Blanchard, 2005, Ström et al., 2000 and Trautmann and Kröner-Herwig, 2010), one concerned adolescents (Trautmann & Kröner-Herwig, 2010). The results were promising, particularly concerning psychological benefits (Andersson et al., 2003, Bromberg et al., 2012, Devineni and Blanchard, 2005, Nicholson et al., 2005 and Trautmann and Kröner-Herwig, 2010). Regarding headache frequency, two studies reported a significant decrease compared to a control group (Devineni and Blanchard, 2005 and Ström et al., 2000), two showed no effect compared to an active control (Andersson et al., 2003 and Trautmann and Kröner-Herwig, 2010), two did not have a control group or did not report on the issue (Bromberg et al., 2012 and Nicholson et al., 2005). Since sample sizes were limited, more evidence is required from larger controlled trials. The purpose of the present randomized controlled trial was to establish the post-treatment effectiveness of online BT delivered with minimal guidance for adults with episodic migraine compared to a waitlist control group (WLC). Our first aim was to examine whether the training could reduce attack frequency (primary outcome). The second goal was to determine if BT could strengthen self-efficacy and locus of control, two aspects that are considered imperative for behavior change to occur and represent patient empowerment (secondary outcomes) (Bandura, 2004 and Samoocha et al., 2010). Additional training gains were examined for attack peak intensity, number of day parts with severe headache, number of days with headache, and for migraine-specific disability and quality of life. Methods

Fig. 1 shows the flow of participants through the study. Of the 877 patients assessed for eligibility, 280 (32%) were excluded because they did not meet the inclusion criteria and 229 (26%) declined participation. The remaining 368 participants were randomized to either BT (N = 195) or WLC (N = 173). 2 Of the people randomized to BT, 120 (62%) completed all eight modules. The 120 participants that completed BT were in training for an average of 100.3 days (SD = 40.5) and completed migraine diaries on 88% of days of being in training. In a random sample of 60 participants we explored compliance with the relaxation exercises. The results showed that participants reported having conducted at least one relaxation exercise on 45.5% days of being in training. Table 1 presents the demographic characteristics and migraine related variables of the BT-, the WLC- and the total group. Participants were aged 44 years on average (SD = 12) and were mainly female (85%). The majority was married and had accomplished a bachelor or master's degree. Migraine duration varied widely and ranged from 1 to 59 years (mean = 22; SD = 13). Most participants used triptans (81%) and/or analgesics (72%) to relieve their migraine; a minority (27%) used prophylactics for attack prevention. There were no statistically significant between-group differences at baseline regarding demographic characteristics or migraine related variables (all p's > .05).