Migraine is a complex and debilitating disorder that affects around one in seven of us.
People with migraine often suffer from insomnia (a lack of sleep) which can, in turn, trigger a migraine. Treating the insomnia can break this cycle and one of the best treatments is cognitive behaviour therapy, which teaches people to change their sleep behaviours and thoughts/worries about sleep loss.
In this project, Dr Crawford evaluated a digital form of cognitive behaviour therapy for insomnia to see whether it is effective in improving sleep in people with migraine, and whether it would be possible to undertake a larger clinical study in this area.
Migraine is one of the most common neurological conditions, affecting around one in seven people. It is a complex and disabling disorder with a variety of symptoms, usually featuring a severe headache. Other symptoms can include disturbed vision, nausea, and increased sensitivity to light and sound.
People with migraine often have problems falling or staying asleep. These are symptoms of insomnia. It is thought that these sleeping problems are due to the way that people try to find relief from their migraines. Often, when a migraine strikes, people try to find a dark, quiet room and try to sleep. However, sleeping in the daytime can disrupt sleep at night and this, in turn, can trigger a migraine the next day. The result is a vicious cycle of migraines and insomnia.
One way to stop the cycle of migraines and insomnia is to treat the insomnia, and one of the best treatments for this is cognitive behaviour therapy.
Cognitive behaviour therapy for insomnia (CBT-I) teaches people to change their sleep behaviour and unhelpful thoughts. CBT-I works well but there are not many trained therapists who can deliver it. Digital CBT-I, provided through an app or website, addresses this problem and has the added benefit that the patient can access it in their own time, in their own home, and does not have to travel to see a therapist.
In a previous small pilot study, the team found that people with migraine liked digital CBT-I, and that it improved both their insomnia and their migraines. This project built on the pilot study to develop a feasibility randomised control trial (RCT) to see whether digital CBT-I could offer better treatment than another option and to refine the study methodology prior to progressing to full-scale clinical trial.
For this feasibility RCT the team recruited 90 participants through the neurology services at NHS Greater Glasgow and Clyde (Glasgow), The Walton Centre NHS Foundation Trust (Liverpool), community recruitment (e.g. social media) and the Scottish Health Research Register. Participants were randomised either to a digital CBT-I group or to digital ‘sleep hygiene education’ control group. Participants in both groups were asked to undertake various matched tasks, including completing baseline questionnaires, engaging with online materials, keeping a 30-day ‘sleep and headache diary’, wearing an ‘actigraphy’ (an electronic measuring device) for seven days to record their sleep and light exposure, and completing follow-up assessments at specific time points. In addition, a subset of participants (and providers) were interviewed to determine potential barriers to participation in this study and uptake of digital CBT-I.
The study was designed to 1) compare insomnia and migraine symptoms at post-treatment and at six months in each group, and 2) measure the feasibility of conducting an RCT for this condition.
The project found that insomnia and migraine symptoms improved post-treatment and at six months in both groups. More specifically, the digital CBT-I group improved more in insomnia symptoms at post-treatment than the control group, but there was no significant group difference at six months. There were also no differences between groups in improvement of migraine symptoms.
The study also found that participants were motivated to take part and had high expectations of changes, but were concerned about the commitment involved, particularly relating to the need to keep the 30-day ‘sleep and headache diary’ and to wear an actigraphy device.
People with chronic migraine can struggle with day-to-day life. They find it hard to work, spend time with family, or exercise. Many people with migraine have trouble sleeping, and this in turn exacerbates their migraines.
This study found that using a digital CBT-I intervention can reduce insomnia in some cases of migraine. The project also provided valuable insight into how best to design a subsequent, larger clinical trial which - if successful - could enable digital CBT-I to be offered as a treatment to patients with migraines, with the potential to significantly improve their quality of life.
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