An Integrative Approach to Migraine Treatment: An Interview with Rebecca Erwin Wells

“It’s important for any provider who is caring for patients to understand this. We were trained in medical school to listen to our patients, and what’s fascinating is that I’ve discovered – and it’s taken all of my training and all of the time I’ve spent caring for patients – that there is therapeutic value in allowing someone to share their story and letting their story be heard. For patients with migraine, where the world tells them migraine isn’t that big of a deal and to just push through, being able to share the impact migraine has on your life is important. It’s not only extraordinarily validating, but it can help you determine the best course of care.” – Rebecca Erwin Wells, on the importance of the patient voice.

Rebecca Erwin Wells, MD, MPH, is a professor of neurology at the Wake Forest University School of Medicine, Winston-Salem, North Carolina, US, and the founder and director of the Comprehensive Headache Program at Atrium Health Wake Forest Baptist. Her research focuses on integrative medicine approaches to treat migraine. She was just awarded a five-year, $3.2 million grant from the National Center for Complementary and Integrative Health, part of the National Institutes of Health (NIH), to study non-pharmacological interventions for migraine.

In this Migraine Science Collaborative interview, she speaks with freelance writer Kayt Sukel about her career path to the headache field, what integrative treatments for migraine have to offer, the importance of listening to the patient voice, and more. What follows is an edited transcript of their conversation.

What first interested you in studying and treating migraine?

After I finished my neurology residency, I decided to do an integrative medicine research fellowship. I was interested in integrative treatment options and mind-body approaches. I recognized that, to understand if they are really effective for our patients, I needed to be able to test them within the context of clinical trial research.

So I went to Boston and did a three-year research fellowship at Harvard, and got a master’s degree in public health. I learned that a lot of modalities that are often considered integrative often don’t get the time or attention in clinical trials. There’s often not industry support or funding to test them. I wanted to be able to test integrative options very rigorously because I recognize that evidence-based medicine is critical to justifying a course of patient care and knowing whether or not it will be helpful.

While I was doing that research fellowship, I was also caring for patients at Beth Israel Deaconess Medical Center in the Department of Neurology. As a general neurologist straight out of residency, I was seeing a lot of patients with headache. I realized straightaway that I needed more training. I started going to headache conferences. It was amazing because I would learn something new and could directly apply it to a patient and see them get better. I was very drawn to how practical it was. Going to those conferences was also powerful because most providers who care for patients with headache are very kind, compassionate people, and I really connected with them.

Rebecca Erwin Wells

With the stigma attached to patients seeking care for headache disorders, I quickly realized this is a patient population that really needed care, and really appreciated being cared for. I finished that first research fellowship in integrative medicine and then followed it with a headache medicine fellowship. I ended up doing four years’ worth of fellowships, and it’s been a joy to care for patients with headache, to improve the quality of their lives, and really connect with them.

What is behind the reasoning that integrative approaches would be beneficial for headache patients?

First of all, many patients are interested in them and are already doing it whether we’re recommending it or not. That was one of the first things I learned when I started doing research in this field: [In 2011, we found that] nearly 50% of adults with migraine were using integrative medicine. That’s even more than those without migraine. And then 50% of adults who are using it don’t talk to their providers about it.

Then you need to ask why patients are doing it. I think there are a variety of reasons. Number one, medications can be very effective, but they don’t work for everyone. There are also medication side effects, medication costs, and challenges with insurance coverage. And then there’s medication overuse headache, where people who use medications too much end up with another headache disorder. So as powerful and helpful as medications can be for so many patients, they aren’t the only thing that can help headaches.

The other thing to consider is that there are a lot of factors that can affect whether a person with migraine will have an individual attack. A lot of these factors are associated with overall well-being and brain health. Many patients report stress as a trigger for headache, and diet, sleep, and other factors can also play a role. These are also things that can be targeted with integrative medicine approaches, and it can be very powerful to use integrative medicine to augment pharmacological approaches. It doesn’t have to be an either/or; I’m a big believer in a “let’s do both,” or “let’s do everything we can possibly do” to get people better.

Your work has also highlighted the importance of the patient voice in treatment and the therapeutic relationship. Tell me more.

It’s important for any provider who is caring for patients to understand this. We were trained in medical school to listen to our patients, and what’s fascinating is that I’ve discovered – and it’s taken all of my training and all of the time I’ve spent caring for patients – that there is therapeutic value in allowing someone to share their story and letting their story be heard. For patients with migraine, where the world tells them migraine isn’t that big of a deal and to just push through, being able to share the impact migraine has on your life is important. It’s not only extraordinarily validating, but it can help you determine the best course of care.

When I ask most patients what they hope for, they will tell me, it’s a cure. I wish I could give that to them, but I find, when I listen more, that a lot of patients will then say, if I can’t have a cure, then I want less impact – I want my headaches to be less frequent or less severe; I would like them to be less disabling. Because one of the things that is unique to migraine is that it is a neurological disease where individuals have disabling attacks that are extraordinarily unpredictable. So both recognizing that impact and then targeting that impact is very important.

As a result of listening to the patient voice, the therapeutic alliance increases, the therapeutic relationship improves, the patient trusts me more, and the patient is more likely to follow the recommendations I make. The patient is more likely to actually tell me what they are really doing and what they are not doing. Sometimes we write prescriptions that are never filled. Sometimes the prescriptions are filled but the medications aren’t taken. But building that trust and rapport so you can understand what’s happening and why – that puts us in a position to understand what the patient’s needs and goals are so we can more effectively match our treatment plans to them.

What are some of the most surprising things you’ve learned in your research studies?

We know that things like depression and anxiety are highly co-morbid and often co-exist with migraine. But in one study we learned that it’s not just depression and anxiety that people are dealing with. It’s frustration, anger, guilt, and stigma, too – other factors that we rarely talk about in clinical settings. That’s important.

I’ve also been struck by how eager people are to be in our clinical trials for integrative treatment options. There’s this perception that people either do an integrative medicine option or take medications – that it’s an either/or thing. But in one of our studies, we found that integrative approaches can sometimes teach patients how to better tune into their own migraine and learn how to take their medication earlier in the disease process. They actually do a better job of taking their medication because they are paying attention to their body better. That’s another finding that demonstrates how important it is to use all modalities at our disposal, and how integrative options may actually improve medication use.

What are the challenges of rigorously testing integrative medicine approaches?

When I’m making decisions about my patients and what is best for them, I go to the evidence. If there is no evidence that any integrative options are effective, it would not be standard of care for me to make that recommendation. I want to do rigorous studies because I’m not only interested in providing the highest-quality care for my patients, but because I’m not the only provider caring for patients with headache. There are 45 million Americans – more than one billion people worldwide – who live with migraine. We have providers all over the world who are looking for good options and are looking to the evidence to guide them. It’s critical for integrative medicine treatment research to be as rigorous, if not more so, than research on pharmacological or other treatment options, so that integrative approaches will be considered for patients.

Two of the biggest challenges for doing any kind of research are time and funding. That’s why I’m so honored to have been awarded a $3.2 million NIH-funded grant to study integrative treatment options for migraine. It gives me the capacity to conduct very rigorous clinical trials. I’m so appreciative of the NIH supporting this kind of research, but also appreciative of the time and effort required of patients to participate. Integrative treatment options often involve more than just taking a pill. For patients, it takes time, energy, and effort, which are often more valuable than money. That can be a challenge.

But, that said, it’s so exciting to have this clinical trial that we’re doing right now. The intervention is online, and all the study visits are online to make it as easy as possible for patients. We are able to recruit patients from across the entire country who are interested in non-drug treatment approaches for migraine. [For those interested in participating in this clinical trial, called BE WELL with Migraine™ (Brain Education and WELLness with Migraine™), see here.]

What are your thoughts on the state of the headache field today?

This is a very exciting time to be in the field of headache medicine. We have had so many new FDA-approved treatments in the last 5 to 10 years. We are learning so much more about the neurobiology of migraine. And now we have more research in the integrative medicine space, too.

As a provider, I think this is wonderful because we have so many more tools available to offer patients. It’s also a great time for patients because there are so many new efforts in patient advocacy. This not only offers you the opportunity to have your voice heard, but also to connect with other people with migraine.

This disease makes you sensitive to light, noise, and often to sound. You have an attack, and you have to go into a quiet, dark room by yourself. It is, by its very nature, isolating. So many people with migraine don’t know other people with the disease. So these efforts to shine light on the field and connect people are very exciting. There’s really so much opportunity for us all.

Kayt Sukel is a freelance writer based outside Houston, Texas.

Image credit: 123RF Stock Photo.