Patients with migraine often face significant barriers in access to evidence-based care, with approximately one-quarter of those with episodic migraine and less than 5% of those with chronic migraine receiving appropriate treatment [1-4]. Access to care is especially challenging for women, racial and ethnic minority groups, and patients living in rural areas [5]. Novel health care delivery models may improve care access when resources are limited and projected to worsen [2,6]. Studies have demonstrated that telemedicine improves access to migraine care, and that it is associated with favorable outcomes including patient and provider satisfaction [7,8]. Internet or smartphone app-based remote assessment and monitoring of migraine [9,10] may increase the efficiency of care delivery and facilitate telemedicine, electronic [11], and face-to-face visits while delivering migraine educational content. Headache clinicians are comfortable treating patients through telemedicine and most have indicated a high level of interest in prescribing migraine apps [12] while citing the importance of integrating remote monitoring data into the electronic health record (EHR) [13]. Smartphone-based apps may also improve diagnosis [14], deliver educational content [15], guide behavioral treatment [16-18], and advance clinical trials [19]. There are improvement opportunities with respect to accessibility of apps for headache [20].

We implemented a novel smartphone app-based Migraine Interactive Care Plan (MICP) integrated with the EHR (Epic, Epic Systems) in our community neurology practice, and potentially available to other institutions using Epic EHR. Development and testing of the MICP has been previously published [15]. Feasibility of the MICP was demonstrated in a pilot implementation study, but usability did not reach a predetermined threshold of 75% of users completing at least one electronically assigned task 127/171 (74.3%) [15].

Access to the MICP was ordered by a provider at the time of a face-to-face neurology consult and integrated into the existing EHR app (ie, Epic MyChart platform). This integration allowed patient access to their medical record, care team messaging, and appointment management. The MICP was designed to facilitate remote monitoring of adult patients with migraine, deliver educational content, and streamline care delivery. Key features of the MICP included (1) weekly assessments of headache days, treatment days, reduced function, and absenteeism; (2) monthly assessments of patient satisfaction (Likert scale) with their migraine treatment plan; (3) Migraine Disability Assessment (MIDAS) survey [21] assessment every 3 months; (4) scheduled delivery of migraine education content; and (5) weekly assessment of medication compliance and concerns and electronic messaging with the care team if needed.

In this study, we aimed to identify opportunities to improve MICP usability by surveying MICP users to assess their satisfaction and preferences and whether they differ based on migraine frequency or type of preventive treatment.

This quality improvement project was granted an exemption waiver for written consent from the Mayo Clinic (IRB 20‐000606). All respondents electronically signed the Health Insurance Portability and Accountability Act (HIPAA) agreement before starting the survey. No compensation was offered to complete the survey. All survey responses were deidentified before analysis, and the data were on a secure server.

A novel electronic survey was developed and formatted (on Qualtrics). Between December 6, 2021, and December 30, 2021, all MICP users (n=184) who completed MICP enrollment and completed at least one task received an email invitation to a secure web-based survey with a personalized letter from a physician on the migraine care team (NPY) explaining the goals of the survey and encouragement to voluntarily participate. The survey cohort had all completed a neurological headache consultation within a general community neurology practice before enrollment in the MICP. Weekly email reminders were sent by a study coordinator to nonrespondents for a total of 4 weeks. Only 1 survey completion was allowed. Demographic variables, including age and sex, were retrieved from the EHR for respondents and nonrespondents and were compared using the t test. Categorical variables were summarized. The overall survey response rate was defined by the percentage of surveys returned. The analysis of the results from each individual question included only the completed response to the question and nonresponses to individual questions were excluded. Survey responses were compared between subsets determined by patient reported headache frequency (0 to 8 days, 9 to 14 days, or 15 or more days), survey self-reported treatment with and without botulinum toxin and calcitonin gene-related peptide (CGRP) antagonist therapy. The Wilcoxon rank-sum test was used for continuous variables and χ² test or Fisher exact test for categorical variables using a 2-tailed α level of 5%. Missing survey response data were excluded from analysis. Analysis was performed using SAS software (version 9.4; SAS Inc).

We assessed the satisfaction and preferences of MICP and did not observe differences based on migraine frequency or type of preventive treatment. However, analysis of all respondents highlight that the most notable MICP improvement opportunities include allowing patients to enter free text observational data and adjust the frequency of monitoring.

In addition, we observed that most respondents prefer to track headache outcomes that are of interest to clinicians engaged in migraine management, including headache days, treatment days and response, and functional impairment [22]. Most respondents in this study preferred weekly tracking as well as the option to change the frequency of tracking reminders along with the ability to enter free text data and observations and rate the severity of pain on a 1 to 10 pain scale, all of which were not included in the MICP. Most respondents were not interested in monitoring non-headache data such as diet, exercise, caloric intake, or heart rate. Most respondents agreed that the educational content delivered was useful but that the content lacked personalization. Most respondents were satisfied with the MICP and felt that it helped them communicate with their care team, supporting ongoing use in our practice.

We present survey findings from a unique group of patients that used a novel digital tool directly interfacing with the EHR within a community neurology practice. We assessed preferences for a broad range of features that may both inform migraine care and promote patient engagement. We compared respondents with nonrespondents and between subsets of patients. The low response rate was similar to other survey studies of the same population [6,30,31].

Limitations include the small sample size, and the overall survey response rate was low, reducing the reproducibility and generalizability of our findings. In addition, the study was underpowered to detect differences in user preferences based on headache frequency or treatment type. Most patients in the survey likely had chronic migraine or frequent episodic migraine as is typical of our specialty practice. The majority of patients were treated with botulinum toxin injections or CGRP antagonist therapy at the time of the study, and the majority of patients reported less than 15 headache days per month, likely reflecting the effectiveness of their current treatment plan. We did not retrospectively review records to confirm the migraine diagnosis documented in the medication record. In addition, most of the population we assessed were white and female, with high migraine frequency and access to a neurology specialty clinic and for these reasons our observations are not generalizable to other patient populations or health care systems. Finally, we did not reassess the frequency or level of engagement of MICP users who completed the survey, increasing potential response bias.

Most MICP users were motivated to track clinically actionable data, including headache frequency, medication treatment with response, functional impairment, and pain intensity; features that should be maintained in the MICP and similar tools that others may develop. Opportunities to improve the MICP that may be useful for other similar remote monitoring tools include allowing patients to (1) change the frequency of assessments and notifications; (2) record personal observations or comments through free text, which may include headache triggers, accompanying symptoms, and prodrome and postdrome symptoms; (3) report headache severity using a 1 to 10 pain scale; and (4) tailor headache education based on frequency and severity (episodic vs chronic migraine). To balance the needs for patient engagement with the changes above, the MICP may be simplified by requiring a monthly assessment of headache days, treatment days, function, and satisfaction with treatment plan without MIDAS every 3 months. Remote assessment and monitoring of patients with migraine is feasible, and continued work to refine remote monitoring tools informed by patient preferences and reassessment of user preferences within diverse and larger populations, including both episodic and chronic patients with migraine, is needed.