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3/9/21

ATTITUDES TOWARDS CAM IN MIGRAINES

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THE ATTITUDES OF PRIMARY CARE PROVIDERS IN SOUTH CENTRAL
PENNSYLVANIA TOWARDS COMPLEMENTARY AND ALTERNATIVE THERAPIES
IN MIGRAINE TREATMENT
By Stephanie E. Boyer
Abstract
Migraines are a common and debilitating medical issue. Many patients are turning to
complementary and alternative medicine to either augment or replace conventional medical
treatment for this. However, it is unclear what their primary care providers’ attitudes are toward
the use of CAM and the PCP’s knowledge base in this area. This study was designed to
determine PCPs’ attitudes towards CAM and if a brief educational presentation regarding CAM
modalities frequently used for migraines had any impact on their attitude towards CAM. There
was a pre survey, a Power Point presentation discussing common CAM used for migraines, and a
post survey. This was a small study, with 13 participants completing the pre survey and 10
completing the post survey. There was no significant difference between the pre and post
intervention groups (p=0.46, significance level of <0.05). However, both groups had a mostly
favorable attitude towards CAM. Gender, work setting, and credentials did not impact attitudes
towards CAM. Acupuncture, relaxation therapy, massage, and chiropractic care were the CAM
modalities that the providers felt the most comfortable discussing. The findings from this study
can be used as a guide for future educational offerings and CAM services in the area.
Suggestions for future research include offering a continuing medical education credit to boost
participation.
Keywords: Complementary and Alternative Medicine, Migraines

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Table of Contents
Chapter 1: Introduction ................................................................................................... 6
Background of the Problem .............................................................................................................6
Statement of the Problem.................................................................................................................6
Research Question ..........................................................................................................................7
Definition of Terms.........................................................................................................................7
Summary of the Problem .................................................................................................................8

Chapter 2: Literature Review ........................................................................................ 10
Why Patients Use CAM ................................................................................................................ 10
Types of CAM Used for Migraines ................................................................................................ 11
Barriers to CAM Use .................................................................................................................... 14
Importance of CAM Knowledge for Primary Care Providers ........................................................... 14

Chapter 3: Methodology ................................................................................................ 16
Research Design ........................................................................................................................... 16
Setting.......................................................................................................................................... 17
Sample ......................................................................................................................................... 17
Ethical Considerations................................................................................................................... 17
Instrumentation ............................................................................................................................. 17
Data Analysis ............................................................................................................................... 18
Summary of Methodology ............................................................................................................. 19

Chapter 4: Results .......................................................................................................... 20
Results ......................................................................................................................................... 20
Analysis of Results ....................................................................................................................... 25
Discussion .................................................................................................................................... 25
Limitations ................................................................................................................................... 28
Summary...................................................................................................................................... 29

Chapter 5: Conclusion .................................................................................................... 30
Summary of Findings .................................................................................................................... 30
Implications for Nursing................................................................................................................ 30
Recommendations for Further Research ......................................................................................... 31

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References ........................................................................................................................ 32

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List of Tables
Table
1. Demographics of participants
2. Familiarity with CAM methods and comfort in discussing them with patients
3. Factors that impact attitudes towards CAM

Page
22
24
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List of Charts
Figure
1. How likely participants were to refer to a CAM provider
2. To what extent is CAM a threat?
3. Discussion of CAM benefits with patients
4. Discussion of CAM risks with patients
5. Number who were very likely to refer for CAM by gender and credentials
6. Number who were very likely to refer for CAM by practice setting and credentials

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23
23
23
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Chapter 1
Introduction
Migraine is a common and debilitating neurological disease. It also causes significant
absenteeism and healthcare costs. It is estimated in 2016 that 36 billion dollars was spent on
indirect and direct costs for treatment in the United States (Bonafede, et al., 2018). Anxiety and
depression are common comorbidities associated with migraine. There are many treatments
involving conventional medicine, but many patients also turn to complementary and alternative
medicine (CAM) for migraine prevention and acute treatment.
Background of the Problem
Patients are utilizing complementary and alternative migraine treatments to replace or
augment their conventional medical treatment. Reasons for this include side effects, cost, and
disappointment with the results of their medications (Peters, Abu-Saad, Vydelingum, Dowson,
& Murphy, 2004). Data was compiled from the 2007 National Health Interview Survey
regarding migraines and CAM use. It was noted that migrainuers are more likely than the general
population to use CAM. Almost half of these adults tried a complementary or alternative therapy
for migraines. The patients using CAM had a higher education level, a history of anxiety and/or
back pain, and tended to live in the Western United States (Wells, Bertisch, Buettner, Phillips, &
McCarthy, 2011). The patients preferences for treatment do not always align with the health care
providers beliefs or recommendations (Wahner-Roedler, et al., 2006).
Statement of the Problem
In previous studies is other parts of the United States and other countries, there have been
a lot of variations in health care providers regarding the use of CAM treatments for various
ailments, including migraines (Wahner-Roedler, et al., 2006).

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Research Question
What impact does education about popular complementary and alternative medicine
modalities have on primary care provider attitudes towards CAM to augment or replace
conventional medical treatment for migraines?
Definition of Terms
•

Migraine: a disorder of attacks which are recurrent. Migraine headaches occur
over a period of hours to days and are generally accompanied by other symptoms
including nausea, vomiting, photophobia, phonophobia, and some sufferers also
report having an aura prior to the start of the pain (Cutrer, 2018).

•

Complementary and alternative medicine (CAM): includes treatments that are
not part of conventional medical treatment. Complementary treatments are those
that augment conventional medicine and alternative therapies are used as a
replacement to conventional treatments (Wells, Bertisch, Buettner, Phillips, &
McCarthy, 2011)

•

Conventional medical treatment: for the purpose of this study conventional
medical treatment refers to migraine treatments, both prophylactic and abortive
therapies.

•

Integrative medicine: integrative medicine is a combination of alternative and
conventional medicine in a coordinated manner. It focuses on the patient as a
whole (Chow, Liou, & Heffron, 2016).

•

Primary care provider: primary care includes Internal Medicine, Family
Practice, and Pediatrics.

ATTITUDES TOWARDS CAM IN MIGRAINES
•

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Health care provider: for the purpose of this study, this includes Medical
Doctors (MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner (NP or
CRNP), and Physician’s Assistants (PA).

Assumptions
Assumptions for this study included that the participants would answer the questions
truthfully. To aide this, the participants were informed that their answers were anonymous. The
study was designed to assess attitudes of primary care providers in a specific geographical region
and the survey was distributed via email specifically to primary care providers. Another
assumption was that all participants work in primary care including Family Practice, Internal
Medicine, and Pediatrics.
Limitations
The limitations of the study were related to the number of participants out of the possible
participants. The study was designed to assess a specific geographical area that covers rural,
suburban, and some urban populations. The results of the study were not generalizable to larger
areas.
Summary of the Problem
Chronic and episodic migraines are a serious health concern globally, and South-Central
Pennsylvania is certainly affected. Due to physical limitations, depression and anxiety
(Amoozegar, 2017), lost wages, poor productivity, and mounting medical bills are some of the
plights these patients can experience (Migraine Research Foundation, 2019).
Patients are utilizing complementary and alternative migraine treatments to replace or
augment their conventional medical treatment. Reasons for this include side effects, cost, and
disappointment with the results of their medications (Peters, Abu-Saad, Vydelingum, Dowson,

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& Murphy, 2004). Is there a disconnect between patients and their primary care providers
regarding the use of CAM for migraine treatment? This subject was explored using the
knowledge to action theoretical framework. The study was to learn if after reviewing a Power
Point presentation about why migraine patients use CAM and what methods they are using, they
were more receptive to discussing CAM with their migraine patients. The next chapter discusses
what information is already known about CAM use in migraineurs and the knowledge of, and
attitudes towards CAM use. The information represents the United States and other countries.

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Chapter 2
Review of Related Literature
This chapter will discuss what is already known about CAM use among migraineurs and
also the attitudes of health care providers towards CAM. It is important to understand the
rationale for the opinions of each party.
Why Patients Use CAM
Several themes emerged when reviewing literature about migraines and CAM. Many
patients turned to CAM because they were not satisfied with the results of their conventional
treatment (Peters, Abu-Saad, Vydelingum, Dowson, & Murphy, 2004). This resonated in the
articles by D'Onofrio, Raimo, Spitaleri, Casucci, & Bussone (2017), Posadzki, et al. (2015),
Wells, Bertisch, Buettner, Phillips, & McCarthy (2011), and Goksel (2012) as well. Concerns
about medication side effects was also a concern for many patients (Grazzi, Egeo, Liebler, &
Padovan, 2017). While some CAM methods are costly, other patients turned to CAM because
the cost of the prescribed medications was too high. Many patients use conventional medicine,
but also use complementary and alternative treatments to augment the results (Wells, Bertisch,
Buettner, Phillips, & McCarthy, E, 2011). Lastly, some patients believe that all natural medicine
is good. While this is not entirely true, they would like to avoid conventional medicine related to
the belief that CAM is better (D'Onofrio, Raimo, Spitaleri, Casucci, & Bussone, 2017).
Wells, Bertisch, Buettner, Phillips, & McCarthy (2011) compiled data from the 2007
National Health Interview Survey regarding migraines and CAM use. They found that
migrainuers are more likely than the general population to use CAM and 49.5% of these adults
tried a complementary or alternative therapy for migraines. Commonly, the patients using CAM

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had a higher education level, a history of anxiety and/or back pain, and tended to live in the
Western U.S.
Types of CAM Used for Migraines
Complementary and alternative therapy defines a broad spectrum of treatments that
include neutraceuticals (D'Onofrio, Raimo, Spitaleri, Casucci, & Bussone, 2017), vitamin
supplements (Goksel, 2012), Homeopathy (Jong, Lundqvist, & Jong, 2015), chiropractic care
(Peters, Abu-Saad, Vydelingum, Dowson, & Murphy, 2004), massage (Posadzki, et al., 2015),
traditional Chinese medicine (Posadzki, et al., 2015), and relaxation techniques (Goksel, 2012).
Yang, et al. (2012) conducted a research study concerning accupunture with 31
participants. They were divided into 3 groups: traditional accupunture, control accupunture, and
migraine group (no treatment). Positron emision tomography – computed tomography (PET-CT)
scanning was used to assess brain metabolism in each group. The results of this small study
showed that the traditional accupunture group had less pain and increased glucose metabolism in
pain related brain areas than the control accupunture and the no treatment group (migraine
group). In a study by Wahner-Roedler, et al. (2006) 66% of physicians with the Mayo Clinic
health system that were surveyed reported that the understood the medical use of accupunture
and 21% felt very comfortable discussing this method of CAM with their patients. The
respondents were not asked specifically about migraine treatment, but did represent primary care
and a wide range of specialities.
Chiropractic care is another CAM method that is popular. In the same study by WahnerRoedler, et al. (2006), 76% of respondents understood the medicinal use and 38% felt
comfortable discussing and recommending this treatment to their patients. Biofeedback and
massage were the only methods that the providers felt more comfortable discussing at 47% and

ATTITUDES TOWARDS CAM IN MIGRAINES

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41% respectively. Wells, Bertisch, Buettner, Phillips, & McCarthy, (2011) found similar results
when reviwing the National Health Interveiw Survey to see what CAM methods migraneurs use.
Massage and chiropractic care were the most common manipulative theparies used.
Herbal therapies and supplements that were mentioned frequently include magnesium
(Goksel, 2012), riboflavin (D'Onofrio, Raimo, Spitaleri, Casucci, & Bussone, 2017), Co Enzyme
Q 10 (Wells, Bertisch, Buettner, Phillips, & McCarthy, E, 2011), Feverfew (D'Andrea, Cevoli, &
Cologno, 2014), and Butterber (Wells, Bertisch, Buettner, Phillips, & McCarthy, E, 2011).
Magnesium deficiency has been implicated in migraine headaches. While an optimal
dose was not established, intravenous and oral magnesium has been shown to reduce migraine
frequency, improvement of symptoms, and reduction in disease burden. Riboflavin, vitamin B2,
has been shown to help with migraine prevention (D'Onofrio, Raimo, Spitaleri, Casucci, &
Bussone, 2017). Goksel (2012) felt that riboflavin had level III evidence of efficacy which could
be from a report of an expert committee or descriptive study. In their meta-analysis, beta
blockers were 55% in effective in cutting migraines in half and riboflavin was 53% effective at
the 400 mg dose. This was not found to be effective in children.
Coenzyme Q10 is an antioxidant that is felt to play a role in migraine prevention. There is
level III evidence for adults and level II evidence for children. The theory is that coenzyme q 10
helps with mitochondrial dysfunction that is thought to be related to migraine. In the studies
reviewed by Goksel (2012), there were no adverse effects in the two studies reviewed and 61.3%
of patients were able to reduce their migraine days by at least 50%.
Butterber is an herbal supplement derived from a plant of the same name. The intact
plants contain elements that have carcinogens and hepatotoxic properties. However, the
commercially prepared products have these elements removed for safety (Goksel, 2012). It has

ATTITUDES TOWARDS CAM IN MIGRAINES

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been shown in studies to reduce the number of migraines in both adults and children (D'Onofrio,
Raimo, Spitaleri, Casucci, & Bussone, 2017).
Feverfew is the last supplement that is frequently mentioned in literature. This is a natural
anti-inflammatory agent which should not be taken by patients who are pregnant or taking anticoagulants. There is also a phenomenon called “post feverfew syndrome” which is said to
include insomnia, headaches, muscle and joint stiffness, and anxiety which occurs after long
term use. The mechanism of action is believed to include platelet aggregation, inhibition of
prostaglandin synthesis, inhibition of histamine release, and inhibition of serotonin release from
platelets (D'Andrea, Cevoli, & Cologno, 2014).
Three other methods are biofeedback, non-invasive vagus nerve stimulation, and Botox.
Botulinum toxin A, Botox, is a neurotoxin used to temporarily paralyze muscles. This method
has been well studied and per Goksel (2012), has level I evidence of effectiveness meaning that
there have been sufficient double-blind studies. The FDA approved Botox for the treatment of
chronic migraine in 2010, however, there is not enough evidence to support use in episodic
migraine patients. Biofeedback is a method that involves monitoring physiologic processes with
the intent of gaining voluntary control. Per Goksel (2012), this has level II evidence of
effectiveness. Finally, in a preliminary study by Grazzi, Egeo, Liebler, & Padovan (2017), noninvasive vagus nerve stimulation (nVNS) was well tolerated and effective in the 47 teenage
participants. Twenty-two of them did not need any abortive migraine medication, which was
46.8%. The other 25 participants took rescue medication within an hour of treatment, citing fear
of the migraine worsening. The researchers noted that invasive stimulators have been studied
further, they were trying to develop a device that could be used externally.

ATTITUDES TOWARDS CAM IN MIGRAINES

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Barriers to CAM Use
Various complementary and alternative medicine methods and their benefits have been
discussed. There have been various barriers to CAM use cited in the literature. One theme that
emerged is that not all of the methods have evidence of efficacy or they have conflicting
evidence (Posadzki, et al., 2015). Lack of knowledge about CAM was cited as a reason that
nurses in Sweden (Jong, Lundqvist, & Jong, 2015) and physicians in the Mayo Clinic health
system (Wahner-Roedler, et al., 2006) for not recommending any CAM to their patients. Cost of
complementary and alternative therapies was another theme. Peters, Abu-Saad, Vydelingum,
Dowson, and Murphy ( 2004) noted in their qualitative study that several of the participants were
interest in various CAM treatments, but they were too expensive to pursue.
Importance of CAM Knowledge for Primary Care Providers
Nationally, there is an increasing interest in CAM amongst health care providers. In an
analysis by Cowen and Cyr (2015), 66 out of 125 medical schools researched had CAM-related
content. Chow, Liou, and Heffron (2016) stated schools are offering these courses because there
is an increased interest in learning about CAM amongst medical students. The combination of
conventional and complementary medicine can facilitate the body’s natural healing response. An
integrative approach facilitates patient autonomy and shared decision making, which can
improve provider and patient relationships. The authors also stated “because many CAM systems
grew out of ancient traditions, exposure to integrative medicine practices can help students view
health and illness through the lens of other cultures.”
Pediatric health care providers are not excluded from discussion of CAM with patients
and their parents. It was noted by Sawni and Thomas (2007) that 84% of the United States
pediatricians they surveyed wanted access to continuing medical education on CAM, 49%

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reported that they personally used CAM, and 80% felt that CAM should be taught in medical
school.
Finally, CAM is being increasingly embraced in the field of nursing. Some nursing
programs are viewing CAM as another facet of hollistic care that is a hallmark of the nursing
model. While Helm (2006) felt that it was important for nurses to be knowledgable about the
benefits of CAM modalities, she warned that contraindications and interactions needed to be
discussed as well.
This chapter reviewed what is known about migraine patient use of CAM and attitudes of
health care providers towards and knowledge of the use of CAM in other areas of the country
and the world. The next chapter discusses the methodology that was used to gain knowledge
about health care providers’s attitudes towards CAM in South Central Pennsylvania.

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Chapter 3
Methodology
The purpose of this chapter was to describe the research method, sampling, gathering of
data, and statistical analysis of the data. The information obtained was used to determine the
comfort levels of primary care providers in South Central Pennsylvania in discussing CAM
therapies with their migraine patients.
Research Design
The interventional study was experimental and quantitative. Hundreds of primary care
providers in South Central Pennsylvania were invited to participate. The invitation to participate
included a cover letter, a pre-survey, a Power Point presentation on CAM use for migraines, and
a post-survey. Participants were given an initial survey to complete. In the pre survey, six
questions about the participants practice setting, credentials (MD, DO, CRNP, or PA), years of
practice, and gender was asked. This survey had questions regarding the providers’ attitudes
towards and knowledge about CAM use in general, along with questions about specific CAM
modalities.
The participants were asked to review a Power Point presentation about why patients
choose CAM to augment or replace conventional medical treatment for migraines and various
CAM modalities that are used. Several popular modalities were discussed.
After reviewing the Power Point presentation, the participants were asked to complete a
post survey. The post survey included the same nine questions about the attitudes towards and
knowledge of various CAM modalities for migraines. Demographics were not asked again. The
participants were asked if and how the presentation may have influenced their opinions on CAM
treatment for migraines.

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Setting
The survey was distributed via email to primary care providers in the WellSpan Health
network. This included the following Pennsylvania counties: Adams, Cumberland, Franklin,
Lancaster, Lebanon, and York. The survey was completed on the provider’s computer or
smartphone, wherever they chose to complete it.
Sample
The survey was distributed to primary care providers in 5 counties South Central
Pennsylvania. This was a convenience sample determined by permission from WellSpan Health
which is based in York, Pennsylvania. Within WellSpan Health, there are currently 320 family
practice providers, 108 internal medicine providers, and 45 pediatric providers. In total, 473
providers received invitations.
Ethical Considerations
The survey was completely anonymous. The participants were advised at the beginning
of the survey that no identifying information was collected. Clarion University IRB approval was
obtained.
Instrumentation
The primary investigator collected data using Microsoft Forms, an online survey
platform. The survey tool was an abridged version of a survey developed by Wahner-Roedler,
Vincent, Elkin, Loehrer, Cha, & Bauer which was used in a study they published in 2006.
Permission to use and modify the survey was granted via email by two of the authors. The online
survey format was chosen because a URL could be shared with hundreds of primary care
providers in the South-Central Pennsylvania area very quickly. Authorization was also granted
by WellSpan Health to distribute the survey.

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The pre-intervention instrument was a 14-question survey. The first section contained 6
questions about the demographics of the participant. The second section contained 8 questions
regarding utilization and outcomes. The questions discussed overall opinions about CAM,
opinions about specific treatments, how in office discussions about CAM are initiated, and what
factors would aid a provider in wanting to discuss CAM further with their patients. After viewing
the Power Point presentation on CAM, the post intervention survey contained the same 8
questions about knowledge and attitudes towards CAM. The demographic questions were not
asked a second time.
Data Analysis
After the data was collected, then the process of data analysis began. A multivariate
analysis was used. The results compared the pre- and post-survey results to determine if the
intervention influenced the attitude of the participant towards CAM. Multivariate analysis was
chosen because this type of analysis examines the relationships between more than one variable
(NCSS, 2019). One of the goals was to determine if the participant’s gender, practice setting, and
credentialing influenced their choices. For example, would a Nurse Practitioner in Family
Medicine be more likely to recommend CAM than a Medical Doctor in Internal Medicine? Does
gender affect the likelihood of recommending CAM? However, for gender, there was an option
for “prefer not to say” and for practice setting there was an option for “other.” In the case of a
participant selecting “prefer not to answer”, that value would have received its own column. If a
participant would have answered “other” for practice setting this would have been tallied in the
“other” row unless a significant theme would have emerged, then it would have been listed
separately. The survey was distributed to primary care providers who are a Medical Doctor,
Doctor of Osteopathy, Nurse Practitioner, or Physician’s Assistant, but may unintentionally also

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be completed by someone with other credentialing. A list serve email list with family practice,
internal medicine, and pediatrics were used.
Summary of Methodology
This descriptive study was designed to determine the opinions of primary care providers
in South Central Pennsylvania regarding the use of complementary and alternative medicines for
the treatment of migraines before and after reviewing a presentation on CAM modalities
commonly used for migraines. The data was also used to determine relationships between the
participants practice setting, credentials, and opinions. The survey was distributed and analyzed
using an online survey platform.

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Chapter 4
Results and Discussion
Results
The survey was sent to 320 family practice, 108 internal medicine, and 45 pediatric
providers. In total, 13 participants completed the pre study and 10 participants completed the
post study. There were 5 MD’s, 3 DO’s, 4 CRNP’s, and 1 PA, consisting of 5 men and 8 women.
While all answers were anonymous, the credentials and practice setting were paired with the
gender of the participant. Most of the participants work in family practice with one internist and
one pediatric provider who answered the survey. The years of practice ranged from 1-25 with the
mean being 14.38 years. None of the nurse practitioners had formal CAM training previously
and 3 MD’s, 2 DO’s, and the PA did. The types of training included acupuncture, Reiki,
osteopathic manipulative treatment (OMT), and seminars on alternative medications.
Table 1: Demographics of participants

Total:
Practice setting
FP
IM
Peds
Gender
Male
Female
Attended CAM
training
Yes
No

MD
5

DO
3

NP
4

PA
1

3
1
1

3
0
0

3
1
0

1
0
0

4
1

0
3

1
3

0
1

3
2

2
1

0
4

1
0

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Chart 1:
How likely participants were to refer to a CAM provider (%)

Very Unlikely
Somewhat Unlikely
Neither
Somewhat Likely
Very Likely

0

10

20

30
Post

40

50

60

Pre

Chart 2:
To what extent is CAM a threat? (%)

No threat

Slight threat

Moderate threat

Extreme threat

0

10

20

30
Post

Chart 3:

40

50

60

Pre

Chart 4:
Number who were very likely to refer for
CAM by gender and credentials

Number who were very likely to refer for
CAM by Practice Setting and Credentials
2.5
2
1.5
1
0.5
0

2
1.5

1
0.5
0
Medical
Doctor

Doctor of
Nurse
Osteopathic Practitioner
Medicine

Family Practice

Internal Medicine

Physician's
Assistant
Pediatrics

Male

Female

70

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Chart 5:
Discussion of CAM benefits with patients

76-100%

51-75%

26-50%

1-25%

0%
0

5

10

15

20
Post

25

30

35

40

45

30

35

40

45

Pre

Chart 6:
Discussion of CAM risks with patients

76-100%

51-75%

26-50%

1-25%

0%

0

5

10

15

20
Post

25
Pre

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Table 2: Familiarity with CAM methods and comfort in discussing them with patients.

Acupuncture
Pre
Post
Chiropractic
Pre
Post
Massage
Pre
Post
Homeopathy
Pre
Post
Herbal
Pre
Post
Megavitamin
Pre
Post
Biofeedback
Pre
Post
Spiritual
Pre
Post
Aromatherapy
Pre
Post
Energy Healing
Pre
Post
Magnetic
Pre
Post
Naturopathy
Pre
Post
Relaxation
Pre
Post

I am unfamiliar with
this therapy

I have limited
familiarity with this
therapy

I understand medicinal
uses, but do not feel
comfortable counseling
patients

Understand medicinal
uses of this therapy and
feel comfortable
counseling patients.

0
0

23.1
10

23.1
30

53.8
60

0
0

15.4
10

7.7
20

76.9
80

0
0

0
0

23.1
20

76.9
80

7.7
0

61.5
50

15.4
40

15.4
10

0
0

69.2
50

0
30

30.8
20

15.4
10

61.5
40

15.4
40

7.7
10

7.7
10

53.8
30

30.8
50

7.7
10

15.4
30

38.5
20

23.1
30

23.1
20

0
20

69.2
60

23.1
20

7.7
0

46.2
44.4

42.2
44.4

0
11.1

7.7
0

38.5
33.3

53.8
55.6

7.7
11.1

0
0

15.4
30

61.5
40

23.1
30

0
0

0
0

23.1
10

23.1
30

53.8
60

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Table 3: Factors that impact attitudes towards CAM

Personal experience
Pre
Post
Recommendations
family/friends
Pre
Post
Recommendations
Colleagues
Pre
Post
Recommendations
Specialist
Pre
Post
Case CAM journal
Pre
Post
Case medical journal
Pre
Post
Retrospective case/journal
Pre
Post
Prospective trials
Pre
Post
Evidence physiologic
mechanism
Pre
Post
Clinical experience
Pre
Post

No
impact

Minimal impact

Moderate impact

High impact

Definite
impact

7.7
0

0
0

23.1
20

30.8
40

38.5
40

0
0

0
10

61.5
40

23.1
10

15.4
40

0
0

0
0

38.5
30

46.2
30

15.4
40

0
0

0
0

38.5
30

30.8
50

30.8
20

0
10

41.7
30

25
20

16.7
40

16.7
0

0
10

23.1
10

15.4
30

46.2
40

15.4
10

0
0

0
10

38.5
20

53.8
60

7.7
10

0
0

0
10

7.7
10

61.5
60

30.8
20

0
0

0
0

30.8
66.7

61.5
22.2

7.7
11.1

0
0

0
0

30.8
11.1

30.8
44.4

44.4
38.5

ATTITUDES TOWARDS CAM IN MIGRAINES

25

Table 4: Provider Beliefs

Patients whose physicians are
knowledgeable about CAM
practices, in addition to
conventional medicine, have
better clinical outcomes than those
whose physicians are only familiar
with conventional medicine.
The spiritual beliefs and practices
of PROVIDERS play an important
role in healing.
The spiritual beliefs and practices
of PATIENTS play an important
role in healing.
Providers should have knowledge
about the most prominent CAM
treatments.
I believe that CAM treatments
have true impact on the treatment
of symptoms, conditions, and/or
diseases.
While we need to be cautious in
our claims, a number of CAM
therapies hold promise for the
treatment of symptoms,
conditions, and/or diseases.

Strongly
agree
Pre
23.1
Post
40

Somewhat
agree
Pre
69.2
Post
60

Neither
Pre
0
Post
0

Somewhat
disagree
Pre
0
Post
0

Strongly
disagree
Pre
0
Post
0

Pre
38.5
Post
20
Pre
53.8
Post
80
Pre
38.5
Post
70
Pre
46.2
Post
50
Pre
38.5
Post
30

Pre
15.4
Post
20
Pre
46.2
Post
20
Pre
61.5
Post
30
Pre
38.5
Post
40
Pre
61.5
Post
70

Pre
23.1
Post
30
Pre
0
Post
0
Pre
0
Post
0
Pre
15.5
Post
10
Pre
0
Post
0

Pre
15.4
Post
10
Pre
0
Post
0
Pre
0
Post
0
Pre
0
Post
0
Pre
0
Post
0

Pre
7.7
Post
20
Pre
0
Post
0
Pre
0
Post
0
Pre
0
Post
0
Pre
0
Post
0

Analysis of Results
The results were tallied within Microsoft Forms. A paired t-test or similar analysis was
considered and attempted, but due to the small sample size this was not found to be effective or
appropriate. The data was analyzed by comparing percentages for each answer from the pre- and
post- survey results.
Discussion
The likeliness of referring to a CAM provider (Chart 1) was assessed in the pre- and postsurvey. Prior to the intervention, 46% of the respondents were very likely to refer to a CAM

ATTITUDES TOWARDS CAM IN MIGRAINES

26

provider and 23% were somewhat unlikely to make this referral. However, after the intervention,
50% of the respondents were very likely to refer to a CAM provider and no one responded
“somewhat unlikely”. The overall shift in the measure was a positive one. There was also a
decrease in the perception of threat from CAM modalities (Chart 2). Initially, 15% of the
respondents felt that CAM represented a moderate threat, 60% felt that it was a slight threat, and
46% felt that CAM was no threat. In the post survey, no one felt that CAM was a moderate
threat, 40% felt that CAM represented no threat and 60% felt that CAM was a slight threat.
When looking at the likelihood of referring to a CAM provider in regard to gender,
practice settings, or credentials, prior to the intervention, 2 MD’s, 2 DO’s, and 1 CRNP were
already very likely to refer to a CAM provider. The demographics were only asked in the pre
intervention survey. Out of this group, 3 were Family Practice, 1 Internal Medicine, and 1 in
Pediatrics. Ten of the thirteen participants work in a Family Practice setting, so this could be a
factor in why more Family Practice respondents felt this way. Out of the 6 respondents who were
“very likely” to refer to a CAM provider, 4 of them were women and 2 were men. However, out
of the 13 respondents to the initial survey, 8 were women and 5 were men. The survey showed
that there were men and women who had favorable opinions of CAM, but due to the small
sample size it could not be determined if gender was influential.
Next, there is a question of how many participants discuss risks (Chart 4) and benefits
(Chart 3) of CAM with their patients. To maintain continuity with the questions, the participants
were asked in both surveys how often they discuss the risks and benefits of CAM with their
patients. Initially, 50% of the respondents spoke about CAM benefits 50% of the time or less.
This dropped to 40% in the post survey. Because the first survey, intervention, and second
survey could all be conducted in one sitting, the participants did not have time to change their

ATTITUDES TOWARDS CAM IN MIGRAINES

27

practices. Two of the possible explanations for this change could be that there were 3 less
respondents to the second survey and after the intervention, more providers may have been more
inclined to have the conversation with their patients. In regards to discussion of CAM risks, 8%
stated that they do this 76-100% of the time and 8% stated that they do this 51-75% of the time.
In the post survey, no one stated that they had this discussion 76-100% of the time and 20%
stated that they had this discussion 51-75% of the time. CAM treatments are not without risk at
all. For example, in the Power Point, it was discussed that Butterbur can be hepatotoxic. It may
be of concern that there is not as much discussion about potential harms. This may also be partly
due to limited knowledge on the providers’ parts about various CAM modalities.
Table 2 outlines the respondents’ level of familiarity with various CAM treatments. This
was also derived from the Mayo Clinic survey that was used, so most, but not all the methods are
ones that are commonly used for migraine specifically. Categories that showed improvement in
familiarity were acupuncture, chiropractic care, megavitamin therapy, and biofeedback. A lower
percentage of participants reported no or limited familiarity with these modalities and a higher
percentage reported that they understood the medicinal uses. The scores regarding familiarity
with aromatherapy dropped from the pre to post surveys. It is possible that since 13 people
answered the first survey and only 10 answered the second, that some of the participants that
were familiar with this did not complete the second survey.
Factors that impact attitudes towards CAM is displayed in Table 3. In the post survey,
personal experience (40%), recommendations from family or friends (40%), recommendations
from colleagues (40%), and clinical experience (38.5%) had a “definite impact” for several of the
respondents. A large number of respondents felt that following were “high impact”:
recommendations from a specialist (50%), case in a CAM journal (40%), and retrospective case

ATTITUDES TOWARDS CAM IN MIGRAINES

28

study in a journal (60%). This information is important to determine was factors are truly
influential to primary care providers and the use of CAM.
There was a question regarding beliefs of the respondents. There were 6 statements about
spirituality and beliefs about CAM and the responses that were offered were on a 5-point Likert
scale. The results are shown in Table 4. All of the participants either somewhat or strongly
agreed with “Patients whose physicians are knowledgeable about CAM practices, in addition to
conventional medicine, have better clinical outcomes than those whose physicians are only
familiar with conventional medicine.”, “Providers should have knowledge about the most
prominent CAM treatments.”, and “While we need to be cautious in our claims, a number of
CAM therapies hold promise for the treatment of symptoms, conditions, and/or diseases.” The
thoughts on the importance of the spiritual beliefs of the providers varied wildly. Those that
strongly agreed dropped from 38.5% to only 20% in the post survey while those that strongly
disagree rose from 7.7% to 20%. In regard to the spiritual beliefs of the patients being important,
the percentage that strongly agreed went from 53.8 to 80% and the remaining respondents all
somewhat agreed.
Limitations
The study was quite limited because there was a relatively small number of respondents.
Out of 473 invitations, 13 responded to the first survey and only 10 completed the second one.
The COVID 19 pandemic was likely a factor because many providers were either out ill or
distracted by additional or a change in responsibilities. It also appears that as a baseline, many of
the providers taking the survey already were recommending at least one CAM modality to their
patients. It is possible that providers that do not have favorable opinions of CAM decided not to
participate. The email invitations for this survey included a link to the pre survey, instructions to

ATTITUDES TOWARDS CAM IN MIGRAINES
open the Power Point attached to email and review it, and the link of the post survey. It is
possible that some of the participants did not scroll down to the second survey link. It is also
possible that not everyone reviewed the Power Point.
Summary
While the intervention did not prove the intervention to be effective, it did show that
many of the respondents already had a favorable opinion towards some CAM modalities.
Information on what influences opinions regarding the effectiveness of CAM were also
determined and can be used to guide complementary and alternative services within the health
system and the geographical area.

29

ATTITUDES TOWARDS CAM IN MIGRAINES

30

Chapter 5
Conclusion
Summary of Findings
Many patients are utilizing complementary and alternative migraine treatments to
replace or augment their conventional medical treatment and migraineurs are more likely to
use CAM than the general population (Wells, Bertisch, Buettner, Phillips, & McCarthy, 2011).
This study was conducted to both learn about the attitudes of primary care providers in South
Central Pennsylvania and to determine if a brief intervention discussing common CAM
modalities that are used for migraine influenced their attitudes towards CAM. Overall, the
intervention did not have a statistically significant effect on the participants’ attitudes, but
several of the participants were already recommending at least some CAM modalities to their
patients. Also, gender, credentials, and practice setting did not appear to have an impact on
the respondents on CAM for migraine treatment in this group. Personal and clinical
experience with CAM were the most impactful on the providers’ attitudes towards CAM and
recommendations from colleagues and case studies were the second most impactful. Not
many of the providers were discussing potential harms from CAM, but many were already
discussing the potential benefits.
Implications for Nursing
Implications for nursing and healthcare include the possibility of offering more CAM
training either in workplaces or in nursing, medical, or physician assistant programs. Many of the
respondents felt that providers should have knowledge about common CAM modalities. Health
systems in the area may be inclined to offer more CAM services and/or work with insurance
companies to have some coverage for services. Knowing that the providers in this study were

ATTITUDES TOWARDS CAM IN MIGRAINES

31

influenced by personal experience, case studies, and recommendations from colleagues, as
possible future intervention could include the opportunity for the providers to experience some
CAM modalities and could help guide CAM related publications in the future.
Recommendations for Further Research
For future research, it may be more beneficial to provide the intervention in some sort of
credited medical education credits to encourage participation. This could be done in an online or
in person format. A pre and post survey could be completed at that time. The survey for this
study was an abridged version of a preexisting survey. Creating a custom survey may be more
specific to the diagnoses being studied and/or the CAM modalities being discussed. Future
research could also include questions about CAM use for other diagnoses, including
fibromyalgia, back pain, or anxiety. Migraines are a common problem nationwide and many
patients are turning to CAM due to dissatisfaction with conventional medical treatments (Peters,
Abu-Saad, Vydelingum, Dowson, & Murphy, 2004). Based on the findings in this small scale
survey there is a possibility that more primary care providers in the area may be eager to refer
patients for CAM treatments and perhaps complete additional training regarding CAM
themselves.

ATTITUDES TOWARDS CAM IN MIGRAINES

32

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