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Quantitative Research
Enhancing migraine self-efficacy and reducing disability
through a self-management program
A. Laurel Short, DNP, MSN, FNP-C (Rehabilitation Nurse Practitioner)1
ABSTRACT
Background: Chronic migraine is a primary headache disorder affecting approximately 3–7 million individuals in the
United States. This condition is associated with significant individual and societal consequences, causing impaired
function and high levels of health care utilization.
Purpose: The aim of this quasi-experimental single cohort study was to determine if an 8-week outpatient selfmanagement program for chronic migraine would decrease migraine disability and enhance self-efficacy.
Methods: This was a prospective, single cohort, pre- and postintervention pilot study. Fifteen adults aged 18–65 years
who met the criteria for diagnosis of chronic migraine were enrolled in the study through convenience sampling.
Participants participated in an evidence-based self-management program with multimodal formats including verbal,
written, video, and online materials. Outcome measures included migraine disability (using Migraine Disability Assessment tool [MIDAS]), headache self-efficacy (using Headache Management Self-Efficacy Scale [HMSE]), acute
medication use, and migraine frequency. Participants also completed a postintervention survey to assess satisfaction.
Results: Findings showed a reduction in MIDAS scores, acute medication use, and frequency of migraine. Outcomes
also included an increase in HMSE scores and a trend of improved health behaviors. Acute medication use decreased
by more than 50%, and frequency of migraine and headache days reduced by close to 40%.
Implications for practice: Despite high rates of disability, patient education and self-management programs for
chronic migraine are not readily available. The findings of this study encourage use of a hybrid clinic and web-based
self-management model to improve migraine disability and self-efficacy.
Keywords: Chronic migraine; self-efficacy; self-management.
Journal of the American Association of Nurse Practitioners 33 (2021) 20–28, © 2019 American Association of Nurse Practitioners
DOI# 10.1097/JXX.0000000000000323
The term migraine comes from the Greek words hemi
and kranion, although the head pain can be unilateral or
bilateral (Green, 2015). Chronic migraine is an underrecognized complication of episodic migraine, defined by 15 or
more headache days per month with 8 of the headache days
meeting International Headache Society (IHS) criteria for
migraine headache (Dodick et al., 2016; Green, 2015). Those
with episodic migraine have less than 15 headache and 8
migraine days per month, respectively. The criteria for a
migraine episode include headache lasting longer than 4
hours, nausea, and/or photophobia and phonophobia and
at least two of four additional symptoms of unilateral location, pulsating quality, moderate-to-severe pain intensity,
and aggravation with physical activity (“Headache
Classification Committee of the IHS The International Classification of Headache Disorders, third edition,” 2018).
Episodic migraine affects approximately 12% of the population in the United States (Merikangas, 2013), with an estimated 3–7 million individuals meeting criteria for chronic
migraine (Buse et al., 2012). The diagnosis of both episodic
and chronic migraine is three times more prevalent in women
than in men (Burch, Loder, Loder, & Smitherman, 2015), and it
is important to recognize that individuals often shift along a
spectrum between episodic and chronic migraine.
Background and significance
Received: 17 May 2019; revised: 6 August 2019; accepted 9 August 2019
Those affected by chronic migraine have impaired daily
function, higher health care utilization, and risk of comorbidities, such as depression and anxiety (Dodick et al., 2016).
Migraine is not merely a pain issue but also a quality of life
issue (Smith, Nicholson, & Banks, 2010). Indeed, migraine is
one of the top 10 causes of disability worldwide (Stovner
et al., 2018). Studies using the Migraine Disability Assessment
tool (MIDAS) show that individuals with chronic migraine
have higher disability scores in multiple areas:
· Volume 33 · Number 1
Journal of the American Association of Nurse Practitioners
1
Kansas City Bone & Joint Clinic, Kansas City, Missouri
Correspondence: Anna Laurel Short, DNP, Kansas City Bone & Joint
Clinic, 10701 Nall Ave #200, Overland Park, KS 66211. Tel: 913-381-5225;
913-381-5225; Fax: 913-901-0186; E-mail: [email protected]
20
January 2021
© 2019 American Association of Nurse Practitioners. Unauthorized reproduction of this article is prohibited.
A. L. Short
schoolwork/paid employment, household work/chores, and
nonwork-related activities such as family and leisure time
(Buse et al., 2016; Dodick et al., 2016).
Societal impact from the condition of migraine is substantial. Average direct health care costs for an individual
with chronic migraine is $3,155 over 12 months, compared
with $1,560 for those with episodic migraine (Silberstein
et al., 2018). Both direct costs related to medical resources
and indirect costs associated with impact on productivity are
significantly higher for those with chronic migraine versus
episodic migraine (Messali et al., 2016). In 2016, the total
direct and indirect annual cost of migraine in the United
States was estimated at $36 billion (Bonafede et al., 2018).
Results of the American Migraine Prevalence and Prevention
Study, a national epidemiologic survey, showed that individuals with chronic migraine had 85.7 hours per year of
absenteeism and 256 hours per year of reduced productivity
(Munakata et al., 2009). Another marker of health care cost
related to migraine is utilization of emergency department
(ED) resources, and headache is among the top five reasons
for ED visits (National Center for Health Statistics, 2014).
Most comprehensive migraine care is currently provided
by neurologists or headache specialists. Nationally, it is anticipated that from 2013 to 2025, the supply of neurologists
will increase by 11%, although demand is estimated to grow
by 16% (Health Resources and Services Administration, 2017).
When patients do not have access to a comprehensive migraine program, treatment is often suboptimal and leads to
increased use of medications and emergency services (Blumenfeld & Tischio, 2003). The projected growth of nurse
practitioners (NPs) from 2016 to 2026 is 31% (Bureau of Labor
Statistics, 2019), and NPs are in prime position to improve
access to chronic migraine care in both primary care and
specialty areas. Given their focus on chronic disease management, shared decision-making, and patient education,
NPs are well suited to work with these patients.
Collaborating with patients to enhance their decisionmaking skills for disease management is an essential
component of evidence-based practice (Melnyk &
Fineout-Overholt, 2015). The use of self-management
skills includes empowering patients to manage a chronic
condition through problem solving, provision of resources, and shared decision-making (McGowan, 2012), which
all are imperative for adequate chronic migraine management. Less than 5% of those with chronic migraine
currently receive all three steps needed for optimal care:
access to care, correct diagnosis and education, and a
treatment plan with acute and preventive modalities
(Dodick et al., 2016). In addition, the American Migraine
Communication Study showed minimal time during an
average 12-min appointment was spent on migraine education (Lipton et al., 2008), demonstrating a need to
improve self-management techniques. Succeeding with a
self-management approach enables individuals to feel in
control of their health (Bandura, 2001). Applying selfJournal of the American Association of Nurse Practitioners
management to chronic migraine treatment has potential
to reduce migraine severity and frequency, subsequently
enhancing patient function and quality of life.
Literature review
Behavioral modalities encompassing patient education,
self-care, cognitive behavioral therapies, and biobehavioral
training such as biofeedback and relaxation are supported
by the literature (Buse & Andrasik, 2009; Kindelan-Calvo
et al., 2014). Evidence-based guidelines and meta-analyses
support behavioral interventions for the management of
migraine, though there is a broad variety of types of behavioral therapies (Kindelan-Calvo et al., 2014; Nestoriuc &
Martin, 2007). Outcome measures most commonly focused
on for migraine studies include headache frequency, the
MIDAS, self-efficacy, locus of control, quality of life, and depression (Kindelan-Calvo et al., 2014). Prior research has
demonstrated the importance of focusing on self-efficacy for
adherence to both pharmacologic and nonpharmacological
headache treatment (Matsuzawa et al., 2019).
There is a need to emphasize integrated care models and
self-management strategies for chronic disease, given these
conditions create approximately 70% of health care costs
and result in compromised quality of life (Marks, Allegrante,
& Lorig, 2005). Specific to chronic migraine, despite high
rates of disability patient education and self-management
programs for chronic migraine are not readily available.
Multiple studies have assessed self-management for
chronic disease such as asthma, diabetes, and arthritis
(Bandura, 2004a; Franek, 2013). However, there is significantly
less published literature on self-management and selfefficacy in relation to chronic migraine. There is also a gap in
the evidence for combined clinic-based and online selfmanagement tools that are realistic for a busy practice setting. A recent narrative review identified multiple barriers to
adherence for behavioral headache modalities, and it is
proposed that individual patient factors are considered
when planning treatment (Matsuzawa et al., 2019). This recommendation fits well with the concept of self-management,
which uses customized patient preferences and goals.
Theory
Social cognitive theory has previously been applied to
self-management interventions for other chronic conditions. A study assessing a web-based program for heart
failure emphasized the importance of using Bandura’s
self-efficacy theory for technology-focused self-care
interventions (Bashi, Windsor, & Douglas, 2016). Another
study on the use of an in-depth self-management
framework for diabetes demonstrated improved selfefficacy and support for behavioral changes (Lamprinos
et al., 2016). Concepts from these frameworks, with technology facilitating goal setting, action plans, and data
collection should be applied to other chronic conditions,
including chronic migraine.
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Quantitative Research
The primary assumption of social cognitive theory is
that behavior is influenced by personal, behavioral, and
environmental factors (Bandura, 2001; Glanz, Burke, &
Rimer, 2018). In addition, each of these domains can influence the other factors, which is referred to as the triad of
reciprocal determinism (Glanz et al., 2018). Individuals have
cognitive and emotional control over behavior, and behavior is more than reactions to internal or external cues
(McEwen & Wills, 2014; Thompson, 2014). Those with
chronic migraine experience disruption in multiple areas
of life, and it is common for individuals to feel self-blame
for the associated disability (Cady & Durham, 2015). It is
imperative to address behavioral methods for coping with
chronic diseases (Marks et al., 2005), because individuals
will not consider improvement possible if they do not
believe they have control (Bandura, 2004b). By framing
self-management education with concepts of social cognitive theory, those with chronic migraine can be
empowered rather than overwhelmed and discouraged.
Objective
This study was a quasi-experimental, single cohort design
with pretest and posttest evaluation. The aim of this pilot
project was to determine if an outpatient selfmanagement program for chronic migraine over eight
weeks would (a) decrease migraine disability and (b)
improve self-efficacy. Secondary outcome goals included
decreased migraine days, headache days, acute medication use, and ED visits.
Methods
The project was approved by the University of MissouriKansas City Institutional Review Board. Adults with chronic
migraine were recruited through convenience sampling
at a Midwestern outpatient rehabilitation (physiatry) clinic.
Minors were not included due to the project focusing on
adults with the condition of chronic migraine. Chronic
migraine may differ in minors, and the study tools were
designed for adults.
Participants were eligible for the study if they had at
least a 3-month history of chronic migraine with or
without aura consistent with a diagnosis according to the
International Classification of Headache disorders, third
edition (“Headache Classification Committee of the IHS
The International Classification of Headache Disorders,
third edition,” 2018). Exclusion criteria for the project included difficulty distinguishing migraine from tension
type or other headaches; headache characteristics that
did not meet criteria for chronic migraine; and inability to
attend required appointments.
Blending technology with clinic education
The aim of the self-management intervention was to
implement a toolkit of specific patient education and
lifestyle behavior recommendations for individuals with
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Self-management toolkit for chronic migraine
chronic migraine. The intervention included a hybrid of
web-based, verbal, and written content based on current
migraine treatment guidelines. The intervention was
designed to be practical for outpatient clinic use during a
45-minute initial appointment, a follow-up phone call,
and a 30-minute follow-up visit. The collaboration with a
videographer/web designer yielded a unique concept
and design for self-management education.
Traditional patient education is delivered in the health
care setting. This may be provided one-on-one or in a
group structure. This project used a hybrid approach of
in-person and web-based self-management. Having the
participants view brief videos in the clinic introduced the
concepts and goals of the chronic migraine intervention.
It also allowed the NP clinician to individualize education
based on what questions arose from this introduction.
Following the clinic visit, the participants were able to
customize focus on lifestyle behaviors and selfmanagement tools, which were most pertinent for them.
Customizing education for health behaviors has been
shown to be more effective compared with a standardized approach (Legler et al., 2018). This approach
encourages empowerment, engaging patients as active
partners in the treatment process.
Assessments and intervention
At the initial visit, participants completed demographic
information, baseline questionnaires, and a health behavior survey. The self-management program was
implemented both at the clinic visit and through
resources participants accessed via the Internet outside
of the clinical setting. At the initial 45-minute clinic visit,
participants received patient education via a series of
short videos about chronic migraine followed by additional verbal information, customized based on participant feedback and questions. Video content was
approximately 10 minute total and based on current
best practices. The videos were produced by the investigator in collaboration with a local advertising and
marketing agency. The content encompassed definitions and statistics about chronic migraine, use of a
migraine diary, and the importance of specific lifestyle
behaviors (sleep hygiene, hydration, relaxation techniques, and timing of acute medication).
The self-management toolkit for use outside of the
clinic was available to participants through a website,
yourmigrainetoolkit.com (Short, 2018). The site includes
patient education videos, tips for keeping a headache
diary, and resources such as articles, podcasts, and
website links. Participants tracked headache frequency,
severity, and lifestyle behaviors in a written headache log
for the eight-week time frame (Figure 1). A traffic light
scale was blended into the headache chart to simplify
pain rating and assist participants in timing of acute
medication (Marissa Lagman-Bartolome & Lay, 2018).
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A. L. Short
Figure 1. Sample of headache diary with traffic light descriptions.
Participants were provided a summary page with the
website address, a headache chart, and colored stickers
to use with the chart (Figure 2).
The curriculum for the intervention included migraine
education and self-care skills. Content was incorporated
from published literature and online resources through the
American Headache Society and National Migraine Foundation, as well as from previously published studies led by
NPs (Blumenfeld & Tischio, 2003; Lagman-Bartolome, Lawler,
& Lay, 2018). Participants received a weekly migraine health
behavior reminder via text message. Health tips covered
topics of sleep, hydration, relaxation techniques, and early
migraine treatment. The inclusion of text messaging is a
simple method for health behavior promotion as part of
chronic disease management (Legler et al., 2018). The web
site with videos and collateral resources could be accessed
from a computer, tablet, or smartphone. A 4-week follow-up
phone call or clinic visit was completed to provide encouragement to participants and assess for questions about the
program. The outcome measures were then repeated at the
Journal of the American Association of Nurse Practitioners
8-week, 30-minute follow-up visit. All clinic visits and phone
calls were completed by the NP investigator.
Sample of weekly text reminders
c
c
c
c
c
“Hi, thank you for practicing healthy habits for migraine management. Have you been drinking water
today?” or “Have you practiced your deep breathing
today? It’s important to practice your relaxation
each day.”
“Have you made time to practice relaxation and
deep breathing today? Keeping calm during a migraine can make pain less severe.”
“Remember that practicing breathing techniques
every day can help with sleep, mood, and pain.”
“Great work practicing healthy lifestyle as part of
migraine care! Are you tracking your migraine
symptoms daily?”
“How much sleep did you get last night? It is important to follow a good sleep schedule. Migraine
brains crave consistency.”
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Self-management toolkit for chronic migraine
Quantitative Research
Figure 2. Migraine toolkit summary. Source: www.yourmigrainetoolkit.com.
c
24
“How often have you used rescue migraine medication this week? Please keep track of when you
take medication to help track your migraine triggers
and frequency.”
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c
“How much water have you had today? Staying well-hydrated is a simple way to help prevent migraine attacks. Review your hydration
tips!”
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A. L. Short
c
“Remember to avoid screen time for one hour before bed to promote good sleep!”
Table 1. Demographic data (N = 15)
Demographics
Outcome measures and
measurement instruments
Primary outcome measures included improved migraine
disability and headache self-efficacy. Secondary outcomes included migraine days, headache days, ED visits,
and acute medication use. Through measuring the use of
health care resources and disability, this study tracked
effects on both the personal and economic burden of
chronic migraine.
Four outcome measures were used for this project,
and two of these are established tools that have been
previously used in migraine studies. The MIDAS has been
used widely in research and evaluates the level of disability an individual is experiencing related to migraine
(Stewart, Lipton, Dowson, & Sawyer, 2001). Reliability data
for the MIDAS include Cronbach a of 0.76, test–retest
Pearson correlation of 0.54–0.068, and test–retest
Spearman correlation coefficient of 0.8. The Headache
Management Self-Efficacy Scale (HMSE) assesses
patients’ confidence to prevent and manage headacherelated pain and disability (French et al., 2000). Reliability
data for the HMSE demonstrates Cronbach a of 0.90 for
internal consistency. Headache and migraine days, ED
visits, and acute medication use were tracked with a
written headache chart, which is commonly used in migraine studies.
Results
A total of 15 participants enrolled and completed the
chronic migraine self-management intervention (Table 1).
The convenience sample included 14 female and 1 male
subjects, with ages ranging from 19 to 55 years (mean, 40.9
years).
Descriptive statistics and the Wilcoxon signed-rank
test were selected for this study, due to the small sample
size and one-group pretest–posttest design. Descriptive
statistics were used for the above outcomes and demographic participant data.
Baseline data showed MIDAS scores that ranged from
28–180 (mean 86.1); HMSE scores of 72–143 (mean 98.6);
migraine days per month or 3–30 (mean 11.8); and
monthly headache days from 2 to 31 (mean 21.8). Participants reported acute medication use of 3–15 times per
week (mean 6.1). One subject reported one ED visit within
the past month. Participants also completed a survey of
health behaviors, including sleep amount and quality,
hydration, use of relaxation techniques and a headache
diary, and morning protein intake (Table 2).
At the 4-week phone or clinic visit, 12 of 15 (80%) participants reported improvement in migraine severity,
frequency, or both. Multiple participants commented on
the benefit of tracking headache days, triggers, and
Journal of the American Association of Nurse Practitioners
Gender
Male
1
Female
14
Age, year
N
15
Mean
40.9
Range
19–55
Ethnicity
Caucasian
15
Education level
High school
15
College
10
Post graduate
4
Own a smartphone
Yes
14
No
1
Prefer to use online/app technology?
Yes
11
No
4
lifestyle behaviors. Postintervention data showed MIDAS
scores of 0–310 (mean, 60.73); HMSE scores of 76–156
(mean, 117.7); migraine days per month of 0–30 (mean, 7.3);
and headache days per month of 1–30 (mean, 12.7).
Weekly acute medication use ranged from 0 to 7 days per
week (mean, 2.9 days). One additional ED visit was
reported at postintervention.
The statistical analysis of data was significant for the
change in MIDAS (p = .035), HMSE (p = .013), headache days
per month (p = .002), migraine days per month (p = .024),
and acute medication use (p = .005) (Table 3). The validity
of these findings is weak due to a small sample size,
rather the value of the data is the change from pre-topost descriptive measures.
Discussion
This pilot study supports a multimodal self-management
intervention for adults with chronic migraine. There were
multiple successes for the single-group pretest–posttest
study. All 15 participants completed the intervention,
showing excellent retention. The findings support a trend
of reduced migraine disability and improved self-efficacy
with the use of self-management strategies and a headache diary. The results of this project are congruent with
January 2021
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© 2019 American Association of Nurse Practitioners. Unauthorized reproduction of this article is prohibited.
Self-management toolkit for chronic migraine
Quantitative Research
Table 2. Health behavior data of study
participants (N = 15)
Preintervention
Postintervention
Never
0
0
Sometimes
5
4
Frequently
5
5
Always
5
6
4 cups
12
11
Never
1
0
Sometimes
4
2
Frequently
8
8
Always
2
5
Morning protein intake
Daily water intake
Follow sleep routine
Average hours of sleep per night
Range
5–8.5
5.5–9
Mean
6.6
7
Yes
12
14
No
3
1
Yes
3
13
No
12
2
Use of relaxation techniques
Use of headache diary
or app
evidence in the literature. Leroux et al. (2017) also demonstrated changes in headache disability and self-efficacy
with a nurse-led intervention. Consistent with prior onlinebased studies, this project supported a reduction in migraine frequency (Hedborg & Muhr, 2011; Kleiboer, Sorbi,
van Silfhout, Kooistra, & Passchier, 2014; Trautmann &
Kröner-Herwig, 2010) and improved coping strategies
(Bromberg et al., 2012). In this project, the frequency of
migraine and headache days lowered by close to 40%.
In addition to assessing disability and self-efficacy,
acute medication use was tracked due to the association
between medication overuse and chronic migraine. As
previous therapeutic education studies have shown reduced acute medication intake (Fritsche et al., 2010;
Lagman-Bartolome et al., 2018), this project also
demonstrated a significant drop in acute medication use.
Participants reduced acute medication use by more than
50%. There were also modest improvements in health
26
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behaviors of morning protein intake, use of a sleep routine, and practice of relaxation techniques. At the initial
visit, only three participants reported using a headache
diary or app. Therefore, this intervention allowed for
participant exposure to the strategy of migraine tracking.
The satisfaction survey responses showed positive
reaction to the benefits and ease of use for the multimodal intervention. All participants reported that they
plan to continue practicing the recommended health
behaviors as part of their migraine management. They
were asked to rate from 0 to 10 the likelihood of continuing with the self-management tools. Overall, 11
participants chose 10/10, three responded 7–9/10, and
one answered 3/10. Multiple participants also reported
value in sharing the website with a significant other or
family members. Most participants, 13 of 15, were enthusiastic about receiving text message reminders and
found this motivating.
It was anticipated that participants would use the selfmanagement website and videos in multiple, selfdirected sessions outside of the clinic. Based on survey
reports, participants spent less time using the website
than expected. This was likely due to perceived schedule
constraints or difficulty setting aside time to explore the
website tools. Additional time in the clinic setting is recommended for participants to take exploring the website.
This has potential to better engage individuals with the
resources, so they are motivated to increased time on the
site outside of the office. Participants could also be encouraged to dedicate a specific amount of time per week
to using tools and resources on the website (e.g., at least
15 minutes per week). Written goal setting could be added
to the headache diary to better focus participants on
which behaviors they aim to practice.
Participants reported high satisfaction with the use
of the simple headache chart, which was anticipated.
Although the chart was initially designed to allow data
collection, many found this to be a very beneficial
component of the intervention due to improved insight
of migraine symptom patterns and health behaviors.
The intervention functioned well in an outpatient clinic,
and it has potential to be efficacious in additional outpatient practices. Internet access is needed to use the
website and videos, which is available in most office
settings. This program is appropriate for application in
primary care, neurology, and other specialty clinics that
treat the diagnosis of migraine.
Limitations
Study limitations included lack of a control group, small
sample size, and participant self-selection with potential
enhanced motivation for practicing self-management.
The sample was a homogeneous group, which limits the
ability to generalize findings. Participants were not limited from use of existing or new medications.
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A. L. Short
Table 3. Migraine disability, headache self-efficacy, symptom frequency, and medication use
Measure
Na
Preintervention Range (Mean)
Postintervention Range (Mean)
p-Valueb
MIDAS
15
28–180 (86.1)
0–310 (60.7)
.035
HMSE
15
72–143 (98.6)
76–156 (117.7)
.013
Headache days per month
15
2–31 (21.8)
1–30 (12.7)
.002
Migraine days per month
15
3–30 (11.8)
0–30 (7.3)
.024
ED visits
15
1
1
1
15
3–15 (6.06)
0–7 (2.9)
.005
c
Acute med use
Note: ED = emergency department; HMSE = Headache Management Self-Efficacy Scale; MIDAS = Migraine Disability Assessment tool.
a
Number of patients with pre- and postintervention data.
b
Descriptive statistics and the Wilcoxon signed-rank test were used for this one-group pretest–posttest design with small sample size. Both the MIDAS and HMSE tools
yield a total score based on questionnaire items. The Wilcoxon matched-pair test was also applied to migraine days, headache days, acute medication use, and ED
visits. Validity is limited due to small sample size.
c
Number of days per week of acute medication use.
Conclusions
References
This pilot study assessed a creative video and web-based
intervention for adults with chronic migraine. Therapeutic education strategies should be emphasized when
treating migraine, so that patients understand how to be
truly active participants in their care (Lagman-Bartolome
et al., 2018). Tools that can easily blend with traditional
clinic visits are needed to streamline migraine treatment.
The intervention for this project represents a selfmanagement toolkit that is practical for the outpatient
environment. Use of a hybrid model that incorporates inperson and web-based strategies allows for
individualized education and reinforcement of recommended health behaviors.
There is a bevy of opportunities for future work with this
intervention. Potential collaborative research with additional
NPs would expand sample size, diversity, and the number of
study sites. This project was anticipated to reduce direct and
indirect costs associated with chronic migraine. It can be
inferred that the outcomes of this pilot project support cost
savings. Acute medication use decreased, which represents
savings to direct health care costs. Migraine disability scores
decreased and self-efficacy increased, demonstrating improved productivity and presenteeism.
Chronic migraine is a headache disorder that causes
significant consequences for individual quality of life and
broader society. This project of a self-management model
supports significantly improved self-efficacy and reduced
migraine disability. Applying a multimodal self-management
strategy facilitates partnership and shared decision making
with individuals who have the condition of chronic migraine.
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