Does complementary and alternative medicine (CAM) use reduce negative life impact of headaches for chronic migraineurs? A national survey Lee et al. SpringerPlus (2016) 5:1006 DOI 10.1186/s40064-016-2362-7 R E S E A R C H Does complementary and alternative medicine (CAM) use reduce negative life impact of headaches for chronic migraineurs? A national survey Jieun Lee1, Amrita Bhowmick2 and Amy Wachholtz3* Abstract Background: Chronic migraine is a disabling condition that impacts multiple aspects of migraineurs’ lives. Although pharmacological treatments can help to treat the pain associated with migraine headache, chronic migraineurs often experience side-effects of pharmacological treatments. Those experiences may contribute to the observed growth in complementary and alternative medicine (CAM) use among migraineurs. Relatively little is known about the patterns of CAM treatment and the characteristics of chronic migraineurs. Therefore, the purpose of the present study is to investigate the characteristics of chronic migraineurs who use CAM treatment and the relationship among satisfac- tion with current CAM use, negative life impact, migraine outcomes, and psychiatric comorbidities among chronic migraineurs. Methods: 2907 participants were recruited from a well-known online migraine headache resource. All participants were US adults aged 18 years or older. Migraineurs are referred to this website through various routes (e.g., referral from healthcare providers, internet search, obtaining information from research papers, personal invitation from other users, and information shared on social media etc.). Participants completed a 30-min self-report-survey in the spring of 2014. Results: Almost half of the participants reported that they are currently using more than three different CAM treat- ments even though the majority of the participants reported neutral or dissatisfied with their current CAM treatment. Chronic migraineurs who use CAM treatments were more likely to experience prolonged or frequent migraine head- aches (p = .018, η2 = .0021), and experience greater negative life impact from their headaches (p = .000, η2 = .0172) compared to non-CAM users. CAM treatment satisfaction was inversely related to the number of psychiatric comor- bidities, frequency of migraines, and number of migraine symptoms (p’s < .05). However, CAM treatment satisfaction was more strongly correlated with migraine outcomes than psychiatric comorbidities. Conclusions: Chronic migraineurs often pursue multiple CAM treatments in spite of low levels of satisfaction with those treatments. Patients who experience relief from traditional treatments are less likely to seek the out additional CAM treatments. Thus it is often the sicker migraine patients who use CAM. More attention is needed to consider migraine treatment resistance, and psychological factors in planning the treatment of chronic migraineurs as those factors may play an important role in treatment choices by patients. Keywords: Chronic migraineurs, CAM treatment satisfaction, Psychiatric comorbidities, Migraine outcomes, Negative life impact © 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Open Access *Correspondence: amy.wachholtz@ucdenver.edu 3 Department of Psychology, University of Colorado Denver, Denver, CO 80204, USA Full list of author information is available at the end of the article http://creativecommons.org/licenses/by/4.0/ http://crossmark.crossref.org/dialog/?doi=10.1186/s40064-016-2362-7&domain=pdf Page 2 of 10Lee et al. SpringerPlus (2016) 5:1006 Background Migraine headaches are a common health condition which affects more than 10 % of the global adult popula- tion (Adams et  al. 2013). In the US, 14.2  % of US adults were affected by migraine or severe headaches (Burch et al. 2015). Migraine is a disabling condition that impacts not only productivity and attendance at work or school, but also quality of life at home. Pharmacological treatments of migraine headaches can help to relieve the pain and symptoms associated with migraine headache. However, migraineurs often experi- ence side-effects of pharmacological treatments and fre- quent use of medications can lead to medication overuse headaches (Adams et  al. 2013). The limits to pharmaco- logical treatments may explain high usage of complemen- tary and alternative medicine (CAM) among migraineurs (Wells et  al. 2011). The number of migraineurs who are using CAM treatment in conjunction with traditional medical treatments has been growing over the years (Eisenberg et  al. 1998; Jacobson et  al. 2009; Kaptchuck and Eisenberg 1998). Consistent with this pattern, a number of studies investigating the prevalence and pat- terns of CAM treatment in migraineurs have been slowly growing, however, previous studies were conducted within individual headache clinics with limited popula- tions (Adams et al. 2013; Wells et al. 2011). Relatively little is known about the patterns of CAM treatment and the characteristics of migraineurs in the general community; therefore, the current study focuses on migraineurs who are recruited nationwide from across the US. Due to technological advancement and widespread internet access in recent years, most people search for health-related information on the internet and also seek emotional and instrumental support from the internet community. Considering this trend, the present study analyzed the data collected from a community- based website for migraine headache in the US. Previous study (Wachholtz et  al. 2015) found that chronic migraineurs often experienced high levels of dissatisfaction with medical and CAM treatments for migraine headaches. This study further indicated that chronic migraineurs tended to seek multiple treatments instead of focusing on a single treatment. This tendency may occur because migraineurs use CAM treatments not only to treat their migraine symptoms but also to improve the quality of life by preventing headaches or by increasing their energy levels (Wells et al. 2011). Previous studies (Lipton et  al. 2003; Malone et  al. 2015; Smither- man et  al. 2011; Wachholtz et  al. 2015) indicated that migraine headache was associated with negative impacts in different domains of life (e.g., physical function, social function, role function, mental health). However, rela- tively little is known about the relationship between satisfaction with CAM use and the negative life impacts of migraine among migraineurs. In order to address gaps in previous studies mentioned above, the present study investigated the data collected on the web-community in order to provide insights into (1) the characteristics of chronic migraine sufferers, (2) chronic migraineurs who use CAM treatment compared to who do not use CAM treatment; (3) the prevalence of different types of CAM use; and (4) the details of negative life impact affected by migraine; and (5) the relationship among satisfaction with current CAM use, negative life impact, migraine outcomes, and psychiatric comorbidi- ties among chronic migraineurs. Methods Participants 2907 participants were recruited from a well-known online migraine headache resource (Migraine in Amer- ica, website: https://migraine.com/). All participants were US adults aged 18  years or older have been diagnosed with chronic migraine by their physicians who are diag- nosed chronic migraine using ICD-9 criteria. However, 197 participants did not complete the survey or did not meet criteria of being diagnosed with chronic migraine; these individuals were excluded in the analysis of the present study. Among 2710 completing participants, the majority of participants were female (92.8  %; shown in Table  1). More than half of the participants were older than 40 years old. Most of the participants (75 %) experi- enced their first migraine symptoms more than 10  years ago and 25  % of the respondents reported experiencing migraine symptoms lasting more than 4  h at least 20 times per month. Regarding symptoms associated with migraine, head pain and sensitivity to light were most common, followed by sensitivity to sound, difficulty con- centrating, nausea, and mood change (Table 1). The most common comorbid disorders associated with migraine were depression and anxiety, followed by chronic pain, irritable bowel syndrome, and chronic fatigue. Almost 70  % of the participants experienced at least one psy- chiatric comorbiditity. The most commonly reported triggers to migraine headaches were stress and envi- ronmental triggers, followed by lack of sleep (Table  2). Almost 70  % of the respondents reported taking special steps to avoid triggers while only 34 % of the participants reported keeping a journal to track their migraine epi- sodes. Lastly, more than half of the participants either avoided or stopped migraine medications due to side effects (Table 2). Procedures All methods were approved by the University of Massa- chusetts IRB and all participants indicated their consent https://migraine.com/ Page 3 of 10Lee et al. SpringerPlus (2016) 5:1006 to participate in the study prior to answering any of the study questions. Migraineurs are referred to this web- site through various routes (e.g., referral from healthcare providers, internet search, obtaining information from research papers, personal invitation from other users, and information shared on social media etc.). IP address logging prevented participants from responding to the survey multiple times. Participants were not compen- sated in any way for their participation in the survey. Par- ticipants completed a 30-min self-report-survey in the spring of 2014. Materials The survey included questions regarding demograph- ics, migraine symptoms and diagnosis, general impact of migraine, and medications and treatments of migraine headache. A subset of questions was selected for analy- sis in the present study: demographics (e.g., gender, age), questions related to migraine onset, frequency of head- ache symptoms, comorbid disorders, triggers to migraine, and headache treatments (both conventional and CAM). Participants indicated which CAM therapies they were currently using or had historically used from an exten- sive list. The present study used CAM definition adopted by Cochrane Collaboration, which defined CAM as “all practices and ideas self-defined by their users as pre- venting or treating illness or promoting health and well- being” (Zollman and Vickers 1999, p. 693). Total scores for current CAM treatments were created by adding the numbers of therapies each participant selected. For those who selected “other” participants were asked to specify Table 1 Patient demographics, and  migraine characteris- tics N % Gender Female 2514 92.8 Male 196 7.2 Age in years <18 0 0 18–24 189 7 25–39 914 33.7 40–54 1294 47.7 >55 313 11.5 First migraine symptoms <1 year 38 1.4 1–5 years 267 9.9 6–10 years 348 12.8 10+ years 2057 75.9 Migraine symptoms frequency lasting 4+ hours per month 1–4 times 464 17.1 5–9 times 564 20.8 10–14 times 513 18.9 15–19 times 488 18 20+ times 681 25.1 Symptoms associated with migraine head- ache Head pain 2552 94.2 Sensitivity to light 2374 87.6 Nausea and/or vomiting 2047 75.5 Diarrhea, constipation 786 29 Difficulty concentrating 2090 77.1 Fatigue 1941 71.6 Neck pain 1877 69.3 Dizziness/lightheadedness 1588 58.6 Sensitivity to sound 2172 80.1 Visual changes 1391 51.3 Weakness 1190 43.9 Mood change 1601 59.1 Sensitivity to smell 1650 60.9 Numbness/tingling 908 33.5 Vertigo 761 28.1 Puffy eyelid 608 22.4 Food cravings 542 20 Other 381 14.1 Table 2 Triggers to  migraine and  side effects of  migraine medications N % Triggers to migraine Stress 1557 57.5 Environmental (weather etc.) 1589 58.6 Lack of sleep 1382 51 Hormones/menstrual cycle 1179 43.5 Certain food or drinks 1254 46.3 Missing meals 1096 40.4 Certain smells 1058 39 Alcohol/drugs 709 26.2 Physical activity 603 22.3 Sexual activity 165 6.1 Other 392 14.5 Any special steps to avoid these triggers 1793 66.2 Currently keep a journal to track migraine episodes 937 34.6 Avoided using a medicine due to side effects 1689 62.3 Stopped using a medicine due to side effects 1709 63.1 Side effects Nausea/vomiting 613 22.6 Stomach ache 363 13.4 Rebound headaches 898 33.1 Dizziness 594 21.9 Other 1237 45.6 Page 4 of 10Lee et al. SpringerPlus (2016) 5:1006 the type of therapies they are currently using and each response was assigned into different categories of current CAM use (i.e., bodywork, mental well-being, Eastern- based practices, nutritional therapy, and others). Satisfac- tion with current pharmacological treatments and CAM treatments was assessed by one question: “how satisfied are you with your current therapies for migraine?” Partic- ipants were asked to rate how much they are satisfied on 5-point Likert scale ranging from extremely dissatisfied (coded as 0) to extremely satisfied (coded as 4) for each category of CAM (Table  3). The same scale was applied to satisfaction with pharmacological treatments. Negative life impact was measured by 6 statements (1) Migraines affect my ability to maintain relationships; (2) Migraines have impacted my professional achieve- ment; (3) I have lost a job due to my migraines; (4) I’ve lost friends due to my migraines; (5) Migraines contrib- uted to my divorce/separation; and (6) Migraines impact my relationship with my child/children). Total score for negative life impact was a summation of the negative life items endorsed. Data analysis Descriptive statistics, analysis of variance, and Pearson’s R correlation analyses were used to describe participant’s demographic information and migraine characteristics and examine relationships among different variables in the survey data. Path analyses were performed to inves- tigate differential relationships among satisfaction with CAM treatment and pharmacological treatment, number of psychiatric co-morbid disorders, migraine frequency, number of migraine symptoms, and negative life impact. In order to explore the discrepancies in the characteris- tics of CAM users and non-CAM users, two CAM use groups were created; participants who are using at least one CAM treatment currently was considered as CAM users and participants who are not using any CAM treatment currently were classified as non-CAM users. One-way ANOVA was conducted on different outcomes with two CAM use groups. Three satisfaction groups were created in order to explore how satisfaction with current CAM use impact on negative life impact and fre- quency of migraine; (1) Satisfied Group, which includes participants answering either highly satisfied or satisfied with their current CAM treatment, (2) Neutral Group, which includes participants reporting neutral satisfac- tion with current CAM treatment, and (3) CAM Dissat- isfaction Group, which includes participants responding either highly dissatisfied or dissatisfied with their current CAM treatment. One-way ANOVAs were performed on different outcomes with three CAM Satisfaction Groups. Results The characteristics of CAM users versus non‑CAM users Figure  1 shows that CAM users are more likely to expe- rience prolonged or frequent migraine headaches spe- cifically lasting longer than 4 h for more than 20 days per month, have more years of suffering from migraine head- aches, are more likely to visit headache specialist, and experience more negative life impact, and tend to experi- ence depression and anxiety. One-way ANOVA tests were performed to deter- mine statistical differences in migraine frequency, migraine years, and negative life impact between CAM users and non-CAM users. As shown in Table  4, there was a significant effect of CAM status on negative life impact (p =  .000, η2 =  .0172), years since first migraine (p  =  .018, η2  =  .0021), migraine frequency (p  =  .001, η2  =  .0038), number of migraine symptoms (p  =  .000, η2  =  .1253), number of psychiatric comorbid disorders (p = .000, η2 = .0266) and triggers to migraine (p = .000, η2  =  .0555). These results indicated that CAM users experienced significantly more negative life impact, suf- fered from migraine lasting more than 4  h for more days per month and for more years, experienced more Table 3 ANOVA of  migraine factors comparing groups on CAM use status F(df‑btw, df‑tot) p η2 Negative life impact 47.382 (1, 2709) .000 .0172 Years since first migraine 5.585 (1, 2709) .018 .0021 Frequency of migraine symptoms lasting 4+ 10.290 (1, 2709) .001 .0038 Number of migraine symptoms 388.026 (1, 2709) .000 .1253 Number of psychiatric comorbid disorders 74.105(1, 2709) .000 .0266 Triggers to migraine 1361.729 (1, 2709) .000 .0555 Fig. 1 Comparisons of responses (in percent) by CAM use status (N = 2710) Page 5 of 10Lee et al. SpringerPlus (2016) 5:1006 migraine symptoms and more psychiatric comorbidities, and identified more triggers to migraine compared to non-CAM users. The prevalence of patterns of CAM use The prevalence and patterns CAM use were summarized in the Table  4. Each participant was instructed to select CAM treatment that they were currently using and was also allowed to select more than one CAM treatment. According to the Table 4, avoiding light, hot/cold therapy, diet, taking vitamin supplements, acupuncture, chiro- practic, and relaxation/meditation were the frequently used CAM treatment among the participants of the pre- sent study. Almost half of the participants reported that they are currently using more than three different CAM treatments even though the majority of the participants reported neutral or dissatisfied with their current CAM treatment (Table 4). The details of negative life impact affected by migraine headache As shown in Table  5, nearly half of the participants responded that migraine headache affected various aspect of their life such as their professional advancement, their interpersonal relationships, and their marriage. The relationship between satisfaction with current CAM use and quality of life and migraine headache One-way ANOVA tests were performed to see whether there were significant differences in negative life impact and frequency of migraine headache among three CAM satisfaction status groups. Results indicated that there were significant differences in negative life impact (p  =  .000, η2  =  .0287), frequency of migraine lasting more than 4 h per month (p = .000, η2 = .0550), number Table 4 Type and  numbers of  current CAM use and  CAM use satisfaction (N = 2477) Type of CAM therapy # reporting Mental well-being Hypnosis 2 Stress reduction 2 Relaxation/meditation 45 Deep breathing 4 Biofeedback 17 Pet therapy 1 Singing 1 Psychotherapy 1 Total 73 Bodywork Message 1455 Chiropractic 72 EFT (tapping) 1 Osteopathic 2 Exercise 18 Physical therapy 18 Pressure point 5 TMJ work 1 Cranial sacral therapy 3 Muscle stretches 1 Total 1576 Eastern-based practices Acupuncture 724 Acupressure 10 Chinese herbs 7 Yoga 17 Cupping 1 Reiki 7 Total 766 Table 4 continued Type of CAM therapy # reporting Nutritional therapy Vitamin supplements 2032 Diet 1464 Butterbur 19 Tea 2 Caffeine 11 Total 3528 Others Aromatherapy 19 Avoid light 2311 Avoid other triggers 14 BenGay/biofreeze 5 Homeopathy 3 Cannabis use 10 Prayer 3 Metaphysical healing 1 Hot/cold therapy 1885 Total 4251 Number (%) Current CAM use (number of methods used) 0 356 (13.1) 1 429 (15.8) 2 632 (23.3) 3 557 (20.6) 4 or more 736 (27.2) Current CAM use satisfaction Strongly dissatisfied and dissatisfied 861 (31.7) Neutral 991 (36.6) Strongly satisfied and satisfied 625 (23) Page 6 of 10Lee et al. SpringerPlus (2016) 5:1006 of migraine symptoms (p = .000, η2 = .0149) and number of psychiatric comorbid disorders (p = .003, η2 = .0048) among three groups (shown in Table 6). In order to further examine group differences, Scheffe post hoc tests were performed. Post-hoc test results revealed that CAM Dissatisfaction Group experienced significantly more negative life impact compared to CAM Neutral Group and CAM Satisfaction Group whereas CAM Neutral Group experienced significantly more nega- tive life impact than CAM Satisfaction Group (Fig.  2). Similar patterns were observed for migraine headache fre- quency. As shown in Fig.  2, CAM Dissatisfaction Group experienced significantly more frequent migraine head- ache compared to CAM Neutral Group and CAM Satis- faction Group. There were significant difference between CAM Neutral Group and CAM Satisfaction Group indi- cating that CAM Neutral Group experience more frequent migraine headaches than CAM Satisfaction Group (Fig. 2). Number of migraine symptoms and psychiatric comor- bid disorders revealed similar patterns; CAM Dissatis- faction Group experienced significantly more migraine symptoms and psychiatric comorbidities compared to CAM Neutral Group and CAM Satisfaction Group whereas there were no significant differences between CAM Neutral Group and CAM Satisfaction Group (Fig.  2). Lastly, as shown in Fig.  2, different pattern was observed on triggers to migraine; CAM Satisfaction Groups identified significantly more triggers than CAM Neutral Group and CAM Dissatisfaction Group whereas no significant difference was observed between CAM Neutral Group and CAM Dissatisfaction Group. Path analysis of treatment satisfaction (CAM treatment) on negative life impact of migraine Figure  3 showed the differential relationships among treatment satisfaction of CAM use, migraine outcomes, psychiatric comorbid disorders, and negative life impact. CAM treatment satisfaction was significantly negatively related to number of psychiatric comorbidities, frequency of migraine, and number of migraine symptoms. CAM treatment satisfaction was more strongly correlated with migraine outcomes (e.g., frequency and migraine symp- toms) compared to psychiatric comorbidities. However, migraine outcomes and psychiatric comorbidities were all significantly positively related to negative life impact. Discussion Consistent with previous studies (Adams et al. 2013; Gaul et al. 2009; Lambert et al. 2010; Malone et al. 2015; Rossi et  al. 2006; Wachholtz et  al. 2015), the present study revealed that CAM users were more likely to have comor- bid mental health issues, suffered from more intense headaches for a longer period of time, and experienced more negative life impact of migraine compared to Non- CAM users. These results suggest that individuals may seek out alternative sources of healing when standard biomedical treatments do not meet their needs, are too expensive, considered too dangerous, or the side effects of treatments are too overwhelming. In spite of common use of CAM treatments as the last resort to treat intense intractable pain, migraineurs usually do not inform their medical providers about their CAM use (Lambert et  al. 2010; Rossi et al. 2006). This result highlights the impor- tance of investigating the patterns of CAM use among chronic migraineurs. A number of studies (Adams et  al. 2013; Gaul et  al. 2009; Lambert et  al. 2010; Rossi et  al. 2006) examined migraineurs’ CAM using patterns but most studies were conducted in headache clinics so the present study investigated the CAM use among chronic migraineurs in the community settings. According to the current study, managing triggers such as avoiding light and applying hot and cold packs were the most commonly used CAM treatment among chronic migraineurs. Next frequently used CAM treat- ments include nutritional therapies. These results can be explained by people’s tendency to select the CAM meth- ods that are most easily available when treating migraine symptoms and trying CAM for the first time. More extensive therapies such as massage, acupuncture and chiropractic treatment were also frequently used CAM treatments among the participants of the current study but were less popular than home-based CAM options, Table 5 Negative life impact of  migraine headaches (N = 2710) Event N (%) Migraine affect my ability to maintain relationships 1027 (37.9 %) Migraines have impacted professional advancement 1207 (44.5 %) I have lost a job due to my migraine 612 (22.6 %) Migraines impact my relationship with my child/children 476 (17.6 %) I’ve lost friends due to my migraines 183 (6.8 %) Migraines contributed to my divorce/separation 1029 (38 %) Table 6 One-way ANOVA in negative life impact, migraine outcomes, and  psychiatric comorbid disorders by  current CAM Satisfaction Groups F(df‑btw, df‑tot) p η2 Negative life impact 36.564 (2, 2476) .000 .0287 Frequency of migraine symptoms lasting 4+ 71.965 (2, 2476) .000 .0550 Number of migraine symptoms 18.643 (2, 2476) .000 .0149 Number of psychiatric comorbid disorders 5.916 (2, 2476) .003 .0048 Page 7 of 10Lee et al. SpringerPlus (2016) 5:1006 which were consistent with the results from previous studies (Gaul et al. 2009; Rossi et al. 2006). These results may suggest important clinical implications for chronic migraineurs. Individuals with chronic migraine may experience difficulty in engaging in more extensive CAM treatments on a consistent basis due to their physical disability associated with migraine and economic costs related to these non-home based CAM practices. How- ever, they may be more willing to try methods they can practice at home such as managing triggers, monitoring Fig. 2 Scheffe test: three satisfaction groups on outcomes. Note: Arrow signs indicate statistically significant different between two satisfaction groups Page 8 of 10Lee et al. SpringerPlus (2016) 5:1006 their pain and symptoms, and self-pain-management techniques such as meditation/relaxation and activi- ties that enhance mental well-being (e.g., pet therapy, music, prayer). According to the current study, almost half of the chronic migraineurs identified various triggers to their migraine headaches; however, only 35  % of the participants reported keeping a journal to track migraine episodes. Education for tracking migraine episodes will enhance chronic migraineurs’ ability in managing trig- gers to migraine. Two of the most frequently identi- fied triggers to migraine among chronic migraineurs in the present study were stress and lack of sleep. Those two factors can contribute to the development of other comorbid disorders such as psychological problems and sleep disorders when those become chronic, therefore, it should be important for health care providers to provide sleep hygiene education and make a referral to psycho- therapy interventions such as sleep education or stress management therapy when treating chronic migraineurs. Like most chronic illnesses, migraine headaches pro- foundly impact individuals’ health as well as his/her fam- ily and vocational life. Previous research suggested the impacts of migraine headache on different aspects of life (Lipton et  al. 2003; Malone et  al. 2015; Smitherman et  al. 2011; Wachholtz et  al. 2015) and the impact of migraine in physical and social functioning was even greater for migraineurs compared to individuals who struggle with other chronic illnesses (Solomon et al. 1994). The present study revealed that chronic migraine headaches placed similar burden on migraineurs to non-chronic migraineurs as chronic migraine not only causes physical disability but also brings social disability due to its chronicity and breath of symptoms associated with migraine. Thus, a multi-dis- cipline approach in treatment planning can be beneficial in assisting chronic migraineurs. In addition to traditional pharmacological treatments, various CAM treatments such as psychosocial treatments, nutritional treatments, and bodywork therapies can be recommended to chronic migraineurs in order to manage their migraine symptoms. It should also be noted that migraines may be treat- ment resistant. The majority of the participants in the present study reported that they suffered from migraine headaches for more than 10  years and either avoided or stopped migraine medications due to side effects. Furthermore, high numbers of chronic migraineurs in the current study reported either neutral or dissatisfac- tion with either pharmacological treatments or CAM treatments, which was consistent with previous stud- ies (Malone et  al. 2015; Wachholtz et  al. 2015). In spite of its limited benefit, chronic migraineurs are known to attempt multiple CAM treatments and this treat- ment-seeking-pattern may occur because (1) traditional Fig. 3 Path analysis of CAM treatment on negative life impact Page 9 of 10Lee et al. SpringerPlus (2016) 5:1006 pharmacological treatments do not properly address their pain and symptoms associated with migraine; and (2) CAM treatments help chronic migraineurs to reduce negative impact of migraine by improving their physical and mental wellbeing. Examining the negative effects of migraine in different domains of life is well established in previous research, however, a closer look at the relationship between treat- ment satisfaction with CAM use and negative life impact by investigating factors affecting both treatment satisfac- tion with CAM use and negative life impact has not been conducted in previous studies. According to the present study, when migraineurs had greater satisfaction with alternative medicine treatment, they concurrently had lower levels of negative life impact, less frequently suffered from prolonged migraine headaches, experienced less symptoms associated with migraine, and were less likely to experience psychiatric comorbidities. We would postulate that these results occur because “satisfaction” means that migraineurs have experienced some symptom relief with their CAM treatment, where as “dissastified” suggests that they have not experienced relief from CAM treatments, so they are still suffering and may not see an end to their headaches leading to greater psychiatric comorbidities. Therefore, satisfaction with CAM treatments may play protective factor for negative effects of migraine head- ache in daily functioning. In order to further explore the relationship between CAM treatment satisfaction and negative life impact, the present study examined migraine outcomes (e.g., migraine frequency and number of migraine symptoms) and psychiatric comorbidity (e.g., anxiety, depression, bipolar disorder, PTSD etc.) and how those factors are associated with CAM treatment satisfaction and nega- tive life impact. The results of the present study showed that the inverse relationship between CAM treatment satisfaction and psychiatric comorbidities was weaker than the inverse relationship between CAM treatment satisfaction and migraine outcomes although psychiatric comorbidities and migraine outcomes were all strongly associated with greater levels of negative life impact. These results may indicate that CAM treatment may affect mental well-being of chronic migraineurs posi- tively but in a lesser degree compared to the degree that the effectiveness of CAM treatments affects migraine outcomes. One partial explanation for this is that rela- tively few numbers of CAM treatments identified in the present study were devoted to improving mental health well-being. In the present study, psychiatric and psychological factors may play the important roles as a contributing factor (i.e., stress as one of the most fre- quently identified triggers to migraine) as well as a pre- cipitating factor (i.e., psychiatric comorbidities were the most common comorbid disorders among chronic migraineurs) to migraine headache. Psychiatric comor- bidities may also be a risk factor to negative life expe- riences. For instance, chronic migraineurs may blame migraine headache for their disabilities when their dis- abilities are actually due to their psychiatric comor- bidities (Wachholtz et al. 2015) or their pain experience caused by migraine may have been amplified due to psychiatric comorbidities. These results are significant because they emphasized the importance of treating psychiatric comorbidities in chronic migraineurs since appropriate care of the psychiatric comorbidities can directly affect quality of life and/or indirectly to increase quality of life by reducing migraine symptoms. Previous study (Pistoia et al. 2013) indicated that combined treat- ments to target both migraine symptoms and psycho- logical co-morbidities in order to enhance the quality of life for chronic migraineurs are important, however, only few studies (Kleiboer et  al. 2014) investigated the effectiveness of psychological treatments on chronic migraineurs. Limitations Despite the contributions of the present study to the field, there are some limitations. Although the present study recruited participants from one major US migraine headache website and have similar demographics to US migraineurs, the participants of the present study may not be representative for all migraineurs as it was self- selected sample, which is the standard method of collect- ing data in on-line survey study. In addition, the present study measured symptoms associated with migraine as well as the negative life impact caused by migraine head- aches. Future studies need to include questionnaires as well as qualitative methods such as individual interviews as well as focus group data in order to provide more detailed pictures of the negative impact of migraine head- ache as well as the experiences of chronic migraineurs who seek self-care resources on-line. Conclusions The present study contributed to the field by increasing our knowledge about migraine characteristics, CAM use patterns, and the differential relationships among CAM treatment satisfaction, migraine headache outcomes, psychi- atric comorbidities, and negative life impact among chronic migraineurs. Chronic migraineurs usually pursue multiple CAM treatments in spite of low levels of satisfaction with their treatments as they tend to suffer from more severe symptoms of migraine and more psychiatric comorbidities without significant improvement from traditional medi- cal treatments. Consistent with previous literature, chronic migraineurs experience a broad range of migraine symptoms Page 10 of 10Lee et al. SpringerPlus (2016) 5:1006 and those symptoms negatively affect various aspects of chronic migraineurs’ life. This shows the complex nature of migraine headache compared to other chronic illnesses and therefore calls for multidisciplinary approach to treatment. CAM treatment may play a protective factor against nega- tive life experiences among chronic migraineurs. However, CAM treatments may have a limited benefit for psychiatric comorbidities. More attention is needed to consider psychi- atric and psychological factors in planning the treatment of chronic migraineurs as those factors may play an important role in disease process of migraine headache. The implemen- tation of psychosocial interventions for chronic migraineurs, the proper referral system to psychiatric and psychological treatments by treatment providers, and the establishment of clinical guidelines for evidence-based CAM treatments that target mental well-being in the context of headache clinics can enhance the quality of life among chronic migraineurs. In order to develop clinical guidelines of CAM treatments that focus on mental wellbeing as well as psychiatric and psychological treatments, future studies should examine lon- gitudinal changes based on different types of CAM use that target mental well-beings. Authors’ contributions JL participated in the development of main concepts for the present manu- script, performed the statistical analysis and the interpretation of the data, and wrote the manuscript. AW participated in the design of the present study, acquired the data, provided guidance and feedback in data analysis and data interpretation, and helped to draft the manuscript. AB participated in the study design and coordination of data collection, and helped to draft the manuscript. All authors read and approved the final manuscript. Author details 1 Psychology Department, Chung-Ang University, 84 Heukseok-ro, Dong- jak-gu, Seoul, Korea. 2 VP Community Development, Health Union LLC, 1 International Plaza, Philadelphia, PA 19113, USA. 3 Department of Psychology, University of Colorado Denver, Denver, CO 80204, USA. Acknowledgements Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number K23DA030397 to Amy Wachholtz. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Competing interests The authors declare that they have no competing interests. Ethics approval and consent to participate All methods were approved by the University of Massachusetts IRB and all par- ticipants indicated their consent to participate in the study prior to answering any of the study questions. 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A national survey Abstract Background: Methods: Results: Conclusions: Background Methods Participants Procedures Materials Data analysis Results The characteristics of CAM users versus non-CAM users The prevalence of patterns of CAM use The details of negative life impact affected by migraine headache The relationship between satisfaction with current CAM use and quality of life and migraine headache Path analysis of treatment satisfaction (CAM treatment) on negative life impact of migraine Discussion Limitations Conclusions Authors’ contributions References