CHESS – A Negative Trial of Self-Management as a Migraine Treatment: What’s the Next Move?

Findings from the Chronic Headache Education and Self-management Study (CHESS) showed that self-management did not improve migraine symptoms, but there is reason for optimism, nonetheless.

A recent trial has tested the effectiveness of a group educational and supportive self-management program for people living with migraine – with disappointing results.

The study, a randomized controlled trial called the Chronic Headache Education and Self-management Study (CHESS), found that while participants were generally positive about the intervention, there were no statistically significant improvements in migraine outcomes a year after the intervention, in the more than 700 people who took part in the research.

But, despite the disappointing results, there is reason to remain optimistic about self-management as an approach to treat headache, even if the specific program tested in the current study did not meet expectations.

“This study demonstrated that a brief self-management intervention did not result in better migraine outcomes compared to a control arm. But much can be learned from the publication of negative findings, and I am glad to see this was published,” said Kevin Hommel, a psychologist and researcher from Cincinnati Children’s Hospital, US, in an email to Migraine Science Collaborative. Hommel, who studies the use of technology to improve self-management of chronic conditions, was not part of the current study.

The trial results appeared in the March 28, 2023, issue of Neurology. The CHESS team also published a “process evaluation” in BMC Neurology that dives into possible reasons why CHESS did not show positive effects. That article appeared on January 7, 2023.

It’s checkmate for CHESS
CHESS was a UK-based multicenter trial comparing a group education and supportive self-management intervention to usual care. The study population was diverse, including a mixture of people with chronic migraine or tension-type headache, some with a diagnosis and others without one, some taking medication for headaches and others not doing so.

People in the intervention group created headache diaries and participated in what was a two-day program. The group sessions involved discussions about headaches and their management, relaxation sessions, distraction techniques, and problem solving.

After the group sessions, study subjects took part in a one-on-one session with a nurse. During that time, subjects received an assessment of their headache type, along with advice on how to best manage their headache with drugs, as well as on lifestyle change and goal setting. Follow-up telephone support was also made available.

Meanwhile, those in the usual care control group received a relaxation CD, along with results of a headache classification interview conducted before randomization, and suggestions about managing their headaches with medications.

The researchers collected follow-up data by mail at four, eight, and 12 months after randomization. The primary outcome of the study was the Headache Impact Test (HIT-6) at 12 months, which is a measure of headache-related quality of life. Secondary outcomes included the Chronic Headache Quality of Life Questionnaire, which is another headache-related quality-of-life measure, along with overall health-related quality of life; headache days, duration, and severity; anxiety and depression; pain self-efficacy; and social activity. The investigators also collected qualitative data to understand participants’ more subjective experiences.

Since, of the 736 study participants, only nine had tension-type headache, the researchers focused their analysis on the other 727 individuals who had migraine, half of whom were randomized to the self-management intervention group and the other half to the usual care control group.

The study found no significant differences between the intervention and control groups on the study’s primary outcome, HIT-6, at 12 months. Similarly, most secondary outcomes did not differ between groups, including headache days, duration, and severity.

“In conclusion, our data effectively exclude the possibility that this short intervention is effective for the treatment of chronic migraine, or chronic tension-type headache and episodic migraine,” the study authors wrote in their paper. “There remains a need to identify more effective treatments for people living with the sometimes disabling symptoms of chronic migraine, or chronic tension-type headache and episodic migraine.”

One positive from the study was that the intervention was cost effective. While the UK’s universal healthcare system differs from insurance-based systems, Hommel emphasized how important cost-effectiveness analyses are for health research.

“We need to include more types of these analyses in studies and demonstrate cost benefit to make the case for reimbursement from insurers [in countries outside the UK],” according to Hommel.

Why did CHESS fail?
The authors wrote that the negative results of the trial are “surprising since the CHESS intervention targeted the key modifiable psychological variables known to be predictive of poor prognosis in chronic headache disorders, had a solid theoretical underpinning, intervention fidelity was high, and it was well regarded by participants and facilitators.”

So what went wrong? While that is still unclear, there are a number of reasons that may explain why the CHESS intervention did not meet with success.

One potential reason that Hommel pointed to “was the intensity and duration of the intervention program. The program itself was quite brief with no follow-up intervention – we know from work in other chronic diseases that the effects diminish after an intervention is withdrawn,” he wrote to MSC.

Another reason why CHESS was unsuccessful may have been due to the selection of study participants, which “may not be the same as those diagnosed with chronic migraine by a headache specialist…. [I]t is possible we included some participants who did not meet diagnostic criteria for chronic migraine, or chronic tension-type headache and episodic migraine. The population recruited were, however, the population who would have been offered the CHESS intervention if it was shown to be successful: meaning our findings are directly applicable to clinical practice in primary care,” the authors explained in their paper.

Along similar lines, Hommel told MSC, “Certainly, the selection of participants might have impacted the findings, but I commend the study team for using the type of sample they did, as it is a better ‘real world’ test of the intervention.”

Despite the disappointing results, Hommel remains optimistic that self-management programs may still have a place in migraine care.

“I definitely believe more comprehensive, intensive, and sustained self-management interventions are likely to yield positive results in headache studies, as they have in other conditions,” Hommel said.

Fred Schwaller, PhD, is a freelance science writer based in Germany. Follow him on Twitter @SchwallerFred

References
Supportive self-management program for people with chronic headaches and migraine: A randomized controlled trial and economic evaluation.
Underwood et al.
Neurology. 2023 Mar 28;100(13):e1339-52.

Chronic Headache Education and Self-Management Study (CHESS): a process evaluation.
Ellard et al.
BMC Neurol. 2023 Jan 7;23(1):8.