SOLUTION: 1 PERCEPTION OF QUALITY OF LIFE IN MIGRAINEURS Utilizing a biopsychosocial approach

PERCEPTION OF QUALITY OF LIFE IN MIGRAINEURS

Utilizing a biopsychosocial approach to evaluate the

perception of quality of life in female migraineurs

Rachel Z.T. Miller

California School of Professional Psychology

Alliant International University

PSY6014

Dr. J. Green

Chapter 1

Introduction

Migraines are the third most common disease worldwide; with a global prevalence of approximately 14.7% (Steiner et al., 2013.) As one of the leading neurological disorders, migraines rank within the top 15 conditions that impose the highest burden upon the affected population (Sajobi et al., 2019.) An estimated 50% of adults report a current headache disorder, 30% of which reported having a migraine (World Health Organization (WHO), 2016.) In terms of disability, migraine disorders, are ranked the sixth highest cause of ‘years lived with disability’ (YLD) (WHO, 2016.) Migraineurs who report severe disability have also been associated with reporting a lower perception of quality of life (QOL) (Shaik et al., 2015.) The burden of experiencing migraines was found to be inversely correlated with QOL, compared to individuals who were ‘healthy’, where an increase in migraine frequency in related to a decrease in overall QOL scores (Shaik et al., 2015.) When assessing and providing care to patients among the migraineur population, the employment of a qualitative, biopsychosocial approach is supported by past research (Buse, 2009; Dansie & Turk, 2013; Okifuji & Turk, 2014; Ruiz de Velasco et al., 2003.) Authors support a biopsychosocial model by concluding that a comprehensive, multi-domain assessment that includes biological, psychological, and social facets is crucial in the comprehension of symptom associated with chronic, migraine pain (Dansie & Turk, 2013.) The following literature review will focus on the clinical and theoretical relevance in terms of properly understanding the burden of migraines, in addition to evaluating the perception of QOL in migraineurs; with aim to inform future management and treatment of migraines.

Statement of the Problem

Despite the number of patients suffering from chronic pain, in relation to headaches and migraines, the amount of qualitative, human-focused research is lacking. Understanding QOL in a migraineur plays a crucial role when providing treatment and management of migraines; especially when concentration is placed on each biopsychosocial aspect of the patient. According to Shaik et al. (2015), health professionals must focus on each domain of QOL, and related disabilities, during their evaluations in order to determine whether or not patients are receiving effective treatment and if said treatments have the ability to improve overall QOL.

Literature Review

Clinical Relevance

Migraine

According to a World Health Organization (WHO) report from April 2016, headache disorders are among the most common disorder of the nervous system (WHO), 2016.) On a worldwide scale, an estimated 50% of adults have a current headache disorder, and 30% of those individuals reported having migraines. Furthermore, an approximated 1.7- 4% of those individuals reported having a headache on 15 or more days within a one-month span (WHO, 2016.) A 2011 report courtesy of the National Health Interview Survey (NHIS) stated that 16.6% of adults experienced a severe headache or migraine within a 3-month span (Smitherman et al., 2013.) Highest prevalence is seen in biological females over males, at a rate of 3:1, and in age groups 54 years and younger; most specifically at the onset of puberty and then recurring between the ages of 35 and 45 (Smitherman et al., 2013; WHO, 2016.)

A migraine is a type of primary headache disorder that can be described as a severe throbbing pain or pulsating sensation, often times experienced unilaterally. Physiologically, migraines are caused by the production of inflammatory substances associated with the nerves and blood vessels located in and around brain and head (Mayo, 2020; WHO, 2016.) Symptoms of a migraine can progress through four stages: prodrome (occurring one-to-two days prior to onset of migraine), aura (occurring prior to or during a migraine), attack (lasting from four- to 72 hours from onset to end of migraine), and post-drome (lasting up to a day post-migraine) (Mayo Clinic, 2020.) All individuals who experience migraines may not progress through each symptomatic stage at equal rates or frequencies. Common physical symptoms of a migraine can include neck stiffness, mood changes, food cravings, constipation, nausea, vomiting, numbness or weakness, difficulty speaking, and sensitivity to light, sound, and smell; as well as auditory, olfactory, or other sensory hallucinations (Mayo, 2020; WHO, 2016.)

Quality of Life and Disability

Quality of life is an overarching term that can be used to represent an individual’s perception of their life. Taskapilioglu and Karli (2013), define QOL in the ‘way of perception of an individual in relation with his/her objectives, expectations, areas of interest and standards within his/her culture and fundamental values’ (Taskapilioglu & Karli, 2013.) Furthermore, authors define a specific aspect of QOL that corresponds with health-related status; which may include an individual’s ‘physical and mental health concept and relations… as well as a community’s perception of health and sources, conditions, policies, and applications affecting its functional status’ (Taskapilioglu & Karli, 2013.) The burden of experiencing migraines was found to inversely correlate with significantly lower QOL scores, compared to individuals who were ‘healthy’ and did not experience migraines (Shaik et al., 2015.) Reports show that an increase occurrence of migraines will negatively impact an individual’s perception of overall physical and psychological health, well-being, and functioning (Shaik et al., 2015) which aligns with the former definition of health-related QOL.

From the Global Burden of Disease Survey 2010 (GBD2010) conducted by WHO, headache disorders are ranked the third highest cause of YLD, and migraine disorders, specifically, are ranked the sixth highest cause of YLD (WHO, 2016.) An additional report from the GBD2010 states that that neurological diseases account for approximately 3% of YLD, one-third of which are related to migraines (Lancet, 2012.) According to Sajobi et al. (2019), 90% of migraineurs report attacks to be of moderate to severe pain, 75% report a reduced functionality due to migraine attacks, and roughly 33% report being stuck to bed rest due to migraine attacks (Sajobi et al., 2019.) Rates of severe disability are increased among individuals who experience migraines, both of which are associated with a lower QOL scores (Shaik et al., 2015.)

Theoretical Relevance

Qualitative Measures

Ruiz de Velasco et al. (2003) suggest that future research must seek to employ qualitative methodologies in order to assess quality of life and well-being of migraine patients; specifically listing the importance of including focus groups and clinical interviews into design protocol (Ruiz de Velasco et al., 2003.) In support of this claim, Buse et al. (2009) state that relying on closed-ended questions, such as questionnaires and medical forms, may limit healthcare professionals and their ability to accurately evaluate the migraine status of their patients (Buse et al., 2009.) Furthermore, researchers conclude that healthcare professionals may underestimate headaches or migraine frequency as result of inadvertently focusing on reported number of migraine attacks, as opposed to specifying on reported number of migraine days (Buse et al., 2009.) Therefore, past research supports to notion that qualitative, open-ended questions may be more beneficial in regards to assessing and providing care to various populations of migraineurs.

Biopsychosocial Approach

Originally proposed by George Engel in the 1960s, the biopsychosocial model was developed based on the limitations of the historically dominant approach to medicine- the biomedical model (Engel, 1977.) In terms of limitations of the biomedical model- Engel criticized the model for having a narrow approach to healthcare evidenced by the operational assumption that disease can be solely accounted for by biological variables that have deviated from the norm (Engel, 1997.) In attempt to eliminate this limitation, Engel suggested that a biopsychosocial model was necessary in order to successfully understand the origin of a disease or disorder, and to effectively apply treatments. Furthermore, Engel states that “a medical model must also take into account the patient, the social context in which [the patient] lives, and the complementary system devised by society to deal with the disruptive effects of illness…” (Engel, 1977, pg 132.)

In accordance with Engel’s notions, Dansie and Turk (2013) affirm ‘the first step in successful pain management is a comprehensive biopsychosocial assessment’(Dansie & Turk, 2013.) Past research states that the negative impacts of experiencing a migraine can expand to affect aspects of daily life including family, work, and social relationships; reporting most significant negative effects on family environment and psychological well-being (Ruiz de Velasco et al., 2003). When specifically assessing patients with chronic pain, reports state that chronic pain affects the individual as well as their partners, relatives, friends, and colleagues (Dansie & Turk, 2013.) Therefore, an assessment that includes biological, psychological, and social presentation is crucial to in order to properly treat patients with chronic pain. In support of a biopsychosocial approach, Morgan et al. (2016) suggest that pharmaceutical approaches to migraine treatment may be limited to the exclusion of social, cognitive, and emotional factors that are associated with the onset, aura, and attack symptoms of a migraine (Morgan et al., 2016.) Additional authors, Okifuji and Turk (2014), suggest that comorbid disorders may benefit from a biopsychosocial approach to treatment that is comprised by an integration of medical, physical, and psychological assessments of patients in need (Okifuji & Turk, 2014.)

Purpose of the Study

The purpose of this study is to evaluate and the perception of quality of life in females who experience migraines in a variety of severities. Evaluations will focus on determining which QOL domains are most affected by experiences of migraine; as well as establishing what relationships, if any, exist between severity of migraine and QOL domains. Additional aims seek to utilize gained information to inform future migraine management and treatment plans. A qualitative research design will be used in the form of a semi-structured clinical interview; navigated via a biopsychosocial approach.

Research Question

Upon evaluation of the perception of QOL in a female migraineur, the interviewer will seek to determine: 1) what is the overall relationship between migraine severity and quality of life in a migraineur? 2) according to the perception of a migraineur, which specific quality of life domain(s) is/are most negatively affected by migraine status?

Chapter 2

Methods

Research Design

Qualitative

A qualitative research design will be utilized for the current study in the form of a semi-structured clinical interview. In addition to a qualitative research design to, a biopsychosocial approach provided aim to this study. As previously mentioned, past research supports to notion that qualitative, open-ended questions are more beneficial during the assessment process of the experience of migraineurs in terms of quality of life.

Grounded Theory

The development of the interview questions will be guided by a biopsychosocial approach. When assessing quality of life, interview questions will be founded in and represented by each of the three domains: biological, psychological, and social. For instance, a question regarding the participant’s perception of their health status, three separate questions may be posed in order to assess the participant’s perception of their physical (biological) health and their mental (psychological) health, as well as their feelings regarding another’s perception of their health (social).

Participants

The current study will recruit a single participant (n=1) via “word-of-mouth”, through a mutual contact of the researcher. The participant will go through a baseline screening process in order to provide personal and medical information indicating demographic and migraine status. Eligibility requirements will include the participant meeting the migraine-specific inclusion criteria that have been outlined in the International Headache Society stating descriptions and diagnostic criteria for migraine with aura and migraine without aura (International Headache Society, 2019.) The participant must meet the following diagnostic criteria either for migraine with aura or for migraine without aura, whereas symptoms are not better accounted for by another International Classification of Headache Disorder- 3rd edition (ICHD-3) diagnosis:

Migraine with aura:

At least two attacks fulfilling criteria B and C

One or more of the following fully reversible aura symptoms:

Visual

Sensory

speech and/or language

motor

brainstem

retinal

At least three of the following sex characteristics:

at least one aura symptom spreads gradually over ≥5 minutes

two or more aura symptoms occur in succession

each individual aura symptom lasts 5-60 minutes

at least one aura symptom is unilateral

at least one aura symptom is positive

the aura is accompanied, or followed within 60 minutes, by headache

Migraine without aura:

At least five attacks fulfilling criteria B through D

Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

Headache has at least two of the following four characteristics:

unilateral location

pulsating quality

moderate or severe pain intensity

aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

During headache at least one of the following:

nausea and/or vomiting

photophobia and phonophobia

(International Headache Society, 2019.)

Additionally, the participants must 1) be 18 or older, 2) not be currently pregnant, nor six-months post-partum, 3) not possess an official neurological or cardiovascular disease diagnosis, and 4) not possess a history of life-threatening trauma.

Procedure

The current study is a semi-structured, one-on-one, in-person interview involving the researcher and the participant where the researcher follows a pre-determined Interview Guide (Appendix A). Upon recruitment of the sole participant, a Research Volunteer Informed Consent form (Appendix B) will be signed and baseline information will be obtained during initial contact via online communication (i.e. emailing). Screening will include: demographics (i.e. name, age, and ethnicity), current migraine status, and current disease status. After obtaining baseline data, the researcher and the participant will agree on a pre-scheduled interview date and time. The one-on-one semi-structured interview will be conducted in a private room at the Alliant International University San Diego campus. Prior to beginning the interview, the participant will be made aware that the entirety of the interview will be audio recorded and transcribed verbatim. Full transcription of the interview along with researcher comments is provided in Appendix C.

Provisions of Trustworthiness

Data trustworthiness is founded in four key components: creditability, transferability, dependability, and confirmability (Shenton, 2004.) Creditability, in preference to internal validity, will be justified by adopting well established research methods, developing familiarity with participating person, and ensuring honesty from participating person. Transferability, in preference to external validity, will be warranted via the acknowledgement that the current study is operating from a qualitative research design represented by n=1. Therefore, the researcher understands that the results from this particular study cannot be assumed to be generalizable to other participants or populations; specifically, participants who do not identify as female, as well as any other population that have experienced migraines in a variety of severities. Future research that utilizes the same methodology must be conducted in order to assess the true transferability of results to outside settings. Dependability, in preference to reliability, will be addressed via the implementation and thoroughly clarification of design elements; which include the operational details of the variables of interest and the data gathering and coding procedures. Confirmability, in preference to objectivity, will acknowledge the naturally occurring short comings that are associated with qualitative research. This includes the potential subjective nature of the research design, as well as inevitable researcher biases; of which semi-structured interviews are susceptible.

Chapter 3

Results

Participant Demographics

The sole participant (n=1) of the current study is 62-year-old and identifies as a non-Hispanic, Caucasian-American, cisgender, heterosexual female She has two children and is a resident of the state of Washington; previously living in many other states and countries such as Bangladesh, Louisiana, California, Oregon, and Hawaii. The participant states that an important aspect of her own positionality resides in her career as a medical doctor, as she was, not only the first to earn a doctorate, but also, the first member in her family to attend college. She has been a practicing internist for over 30 years and currently works as a traveling physician as she is licensed to work Washington, California and Hawaii. The participant states that she was raised in low-income neighborhoods, and within a low-socioeconomic status family; but currently resides in a higher-economic class.

Objective Parameters of Experience

The participant was eligible to participant in the current study based on meeting all of inclusion criteria; most importantly- the diagnostic criteria for both migraine with aura and migraine without aura. According to the participant, her experience with migraines began during the on onset of puberty, subsided for many years, and states that symptoms have reappeared with the onset of menopause, roughly 10 years ago. Based on this account from the participant, it could be assumed that migraine status interconnects with hormone levels, or another biological trigger; however, the participant did not discuss these types of triggers during the interview.

In terms of propositional attitudes towards her past and current experiences with migraines, the participant may have presented with a predisposition towards intellectualization or rationalization coping strategies; as evidenced by the participant applying logical explanations and/or justifications to her perception of migraine experiences. Based on these prospective assumptions, it may be possible that the participant also possesses a predisposition towards defense mechanisms founded in suppression or denial, with aim to ignore, avoid, or push away unwanted, stress-inducing, or anxiety-provoking emotions.

Process of Interview

The one-on-one semi-structured interview lasted approximately 45 minutes and was conducted at the researcher’s residence; where the participant has previously, therefore, it was not an unknown environment. As a result of the researcher and participant being previously introduced, the interpersonal interactions were laid-back and unformal, as well as low-pressured and natural. Overall, the participant presented calm and emotionally positive, yet simultaneously uncomfortable with divulging overly-personal information. She wanted clarification on many questions, specifically if the questions were pertaining to current migraine status or past migraine status. Content of answers were mostly concise and ‘straight-to-the-point’, meaning the participant tended towards answers that reflected logical thinking rather than emotional thinking. Answers were non-tangential and the participant rarely continued talking without prompt from the researcher.

Coding Analysis & Synthesis

The coding analysis identified several themes that have been separated into categories that can, essentially, define as the participant’s perception of migraine experiences: 1) empowerment versus suffering, 2) feeling humbled, 3) feeling withdrawn, 4) social fear, 5) responsibility for internal responses, 6) physical symptomology, and 7) cognitive symptomology.

Empowerment versus Suffering

After all pre-determined questions had been reviewed, the researcher asked the participant: ‘what else would you like me to know?’ The participant took this time to illuminate a viewpoint which clearly differentiates the experiences that occur during a migraine attack, compared to the experiences after, or outside of, a migraine attack.

“I think people can respond to their migraines in different ways. They can have a migraine and feel empowered… They can manage through it, they can fight through it, they can function through it, and they come at the end- feeling like… I’m a strong person that I persevere.”

This crucial point made by the participant aligns with the statements of beforementioned studies when referring to the concept of suffering, and how the perception of suffering during a migraine (or any physical condition) compares to the perception of suffering before or after a migraine; often times referred to as interictal period.

“A woman or man can have a migraine and say, ‘what’s wrong with my body’… ‘I don’t trust my body anymore?’ Now, that’s why, and they end up distrustful of their body. And it’s the suffering that comes from those different responses.”

Feeling Humbled

The participant expressed feelings of humility which were associated the instances of migraine-induced disability and/or inability. When recalling perceptions of a migraine, the participant explains that feelings of being humbled occur outside, or after, the migraine attack. For instance, the participant explains that a person should feel humbled when finding themselves in a situation where they are temporarily, and personally, disabled or have the inability to work.

“What if…I was having some kind of visual… visual disturbance… at work, and I knew that if that continued for the next three hours I would be unable to work. Then that is eventually humbling.”

Feeling Withdrawn

When asked how migraines affect the participant’s mental health, both in the past and currently, the participant spoke less about actual psychological symptoms that can be directly connected to a disorder (i.e. anxiety/depression), and more about psychological well-being connected to a feeling. Although the participant was not able to describe her perception of ‘withdrawn’ in more detail, secondary descriptors pertained to feelings of inactivity or resourcefulness. Upon being prompted by the researcher, the participant also made a clear distinction that her perception of being ‘withdrawn’ does not translate to ‘protecting’ oneself.

“I’m in, pulled inward, in order to be resourceful. Pulled in to keep my resources. To keep doing whatever I need to do.”

Social Fear

An interesting point during the interview was when the participant was asked about her experience with migraines in relation to her social life:

“[The migraine] didn’t limit me in any way. I would notice it and kind of think it was interesting, or bizarre. But I certainly never would have told a soul about it, and I probably never said it. I don’t think anyone has ever heard me say it before…”

These statements made by the participant may suggest that she had been very secretive about her migraine status so far in her life. It could be assumed that feeling the need to be secretive regarding migraine status would result in unconscious, negative effects on quality of life in; also suggesting that the participant is not yet aware of such affects. Upon being asked to tell the researchers “in what ways [she] may need assistance during a migraine attack’, the participant responded in a precise and serious manner; unlike any other response throughout the entire interview process.

“I have never, ever, ever needed assistance.”

These statements of logical certainty were followed by more emotional perspectives, where the participant explained that the experience of migraines causes her to feel fear. She stated that her fear related to being afraid that she might need help or assistance, or afraid that someone might become aware of her health status. Conclusions based on the participant’s responses may suggest that, in theory, it is impossible for her social life to be affected if no one possesses knowledge of her health status.

“I was fearful. Fearful and worried. Worried that I might need assistance. And that’s how it affected me socially. Because I’m fearful that I may need to ask for help.”

Responsibility for Internal Responses

When asked for her opinion on, or to compare, internal versus external triggers, the participant makes another distinction between a trigger and a personal response to said trigger. Conclusions based on the participant’s responses may suggest that she values taking responsibility for her own action, or emotional responses, to both internal and external stimuli. Instead of immediately listing off or comparing types of triggers, the participant emphasized the importance of the sense of stress, insecurities and other ‘negative’ emotions to be a key cause of migraines. It can be assumed that, regardless of the type of trigger, the participant believes that she is ultimately responsible for the form of response that is produced, whether that responses causes a migraine, or not.

“An internal trigger… is that something that for some reason, pushes my button or… my sense of insecurity or that ‘not good enough’… that creates that…like ‘I’m incompetent’ or ‘not good enough’… That would be the internal stressor. Something in the outside world that promotes that… or exposes that. I’m not gonna blame the outside thing for that that’s clearly my own manufacturer.

Physical Symptomology

Based on the participant’s current career, and especially compared to the social or psychological domain viewpoints, the participant clearly possessed an increased awareness of her biological perception of a migraine or migraine attack. She possessed a vast knowledge-base as evidenced by the ability to explain what physiologically occurs during the occurrence of a migraine, and also, the ability to explain her somatic and physical experiences during a migraine.

“[People with migraines] have a vasospasm. Their blood vessels that go to their brain will first be vaso-spastic. And that’s often when you get the aura. And then sometimes they release, and then that’s when people can get the pounding headaches and nausea…”

When asked to explain her past and current symptomology related to her experiences with migraines, the participant concisely described what she called ‘visual disturbances’, what professionals may dub aura and/or vertigo, as well as head pains; where she grades the visual auras to be much more challenging to deal with, compared to sole head pains.

“Typically, I get some sort of visual aura, or a mild sense of vertigo. And then some period, some period following that, I will get a pain in my head… the visual disturbances that I’ve had have been the most challenging.”

Cognitive Symptomology

In addition to physical symptomology, the participant also described symptoms that are more related to cognitive functionality, rather than physical functionality. In her experiences with migraine attacks, the participant described issues with comprehension, along with surreal, ‘out-of-body’ experiences. The participant notes that these symptoms are noticeable, yet do not fully affect her ‘ability to function in the planet’; despite some of the symptoms drastically decreasing functionality. The participant also describes these cognitively-related migraine experiences similar to that of deja-vu, although she states it might simply be a subtle ‘weird feeling’, or a surreal sensation.

“I couldn’t read the computer. I was missing parts of the words… And I didn’t feel like I could completely comprehend, or remember how to spell. I think it was literally, I think it was the part of your brain that interprets written speech.”

Chapter 4

Discussion

New Understandings

Based on the single participant’s responses, the perception of migraine-related experiences that were assumed by the researcher were found to be incorrect. The participant emphasized feelings and experiences that the researcher did not anticipate. For instance, when answering questions within the ‘psychological’ domain, the researcher previously considered this domain to primarily effect mental health in terms of specific symptoms related to psychopathology. Instead, the participant mentioned feelings and thought processes that affect psychological well-being; which are represented by the code analyses: ‘feeling withdrawn’ and ‘social fear’. Although both of these codes interconnect to the psychological domain, the ‘feeling withdrawn’ code seems to relate more to the impact on mental health, and the ‘social fear’ code seems to relate more to the motives founded in perceived social consequences. Further interviewing is needed to more fully comprehend the bases and motivations that lead to the participant responding as socially withdrawn and fearful.

Similar to past research and literature, more information is needed to understand the overall perceptions and experiences of migraineurs. If and when additional interviews occur within the current study, the interview guide will need to be reinvented and edited to that it doesn’t share the original viewpoint that a patient will ‘move’ towards either the biological, psychological, or social domains of life. If it is somewhat true that a patient does tend towards one of the three domains, the interview guide must supplement more in-depth facets within each domain. This point is supported by past research that the perceptions and experiences of patients (or a person) are vast and complex; especially in terms of mental health and/or healthcare.

It is believed that the quality of data is accurate, however, incomplete due to lack of quantity as result of a shorter interview duration. Based on researcher reflections both during and after the interview, here are some example questions topics that could be supplemented in future interviews:

specific symptomology,

comparing self to others,

adding past/present experiences

adding more psychological/mental health questions

negative vs. positive experiences

other physical/emotional experience that are similar/different to a migraine

more interictal-type experiences

Trustworthiness

In terms of trustworthiness regarding legitimacy of results, a limitation of the current study may have related to the researcher’s prior knowledge of the participant’s current career as a physician; which may have led to the researcher feeling intimidated when asking questions from the ‘biological domain’, as opposed to social or psychological domains. This point also brings into question potential biases of the researcher, who is a clinical psychology doctoral student; therefore, possessing tendencies that involve viewing the world through a ‘psychological lens’; as opposed to assuming a biological or social focal point. Another notable limitation is the researcher’s own positionality associated with perception of quality of life in relation to personal experiences with migraines; meaning that it is possible that the researcher transferred personal experiences onto the participant and onto the results- both consciously or unconsciously.

Personal Experience

As the interviewer, I felt personally moderately uncomfortable throughout the entire questioning protocol. I felt hypervigilant towards the participant’s needs and did not want to ‘over-step’ any boundaries which would have led to the participant feeling uneasy during the interview. My in-the-moment feelings reflected that of not wanting the keep the participant longer than she expected to be there, or to ask too-private of questions. Although the participant answered every question, seemingly, open and honestly, it also appeared that the participant wanted to be ‘done’ almost as soon as the interview began. Based on my perception of the participant’s shifts in comfortability, related to some types of questions more than others, I developed one primary assumption: the participant is unaware, or unable, to comprehensively recount her mental-health experiences with migraines. Based on the participant’s ability and willingness to answer questions, it may be possible that the participant never truly thought about migraines from the viewpoint of a ‘psychological domain’, and instead, tends towards a ‘biological domain.” If this assumption possesses any base in reality, it may offer answers as to which domain most affects her unconscious and conscious experiences with migraines, of course, still from the viewpoint of the researcher.

Overall, the interview went well; but I would like to become more comfortable with ‘ad-libbing’, or having the ability to ask the participant to expand on thought processes or feelings regarding their experiences. In the future, I would also like to possess comfortability with deviating from my original list of interview questions, and be able to let the interview flow naturally, as opposed to seeming too structured in my questioning. I believe, with time and more participants, that I can grow into becoming more comfortable and attuned to the qualitative research process. My viewpoint towards utilizing a biopsychosocial approach to evaluate the perception of quality of life- in any patient- remains constant and in accordance with the conclusions set forth by in past research suggesting that future studies should explore, consider, and comprehend the multiple domains that influence functional disability and symptom treatment in individuals with chronic pain (Dansie & Turk, 2013; Shaik et al., 2015).

References

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Dansie, E.J., & Turk, D.C. (2013.) Assessment of patients with chronic pain. British Journal of Anesthesia, 111(1), 19-25.

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International Headache Society (2020, April 29). Part 1: The primary headaches- Migraine. https://ichd-3.org/1-migraine/

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*Morgan, M., Cousins, S., Middleton, L., Warriner-Gallyer, G., & Ridsdale, L. (2016.) Patients experiences of a behavioral intervention for migraine headaches: a qualitative study. The Journal of Headache and Pain, 17(16).

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Shaik, M.M., Hassan, N.B., Tan, H.L., & Gan, S.H. (2015.) Quality of life and migraine disability among female migraine patients in a tertiary hospital in malaysia. BioMed Research International, 523717.

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Appendix A

Interview Guide

General

Give me a description of your overall migraine status

How would you describe the severity of your migraine?

Explain how migraines may change your day-to-day life

Month-to-month?

Social

How do migraines affect aspects of your social life?

Tell me in what ways you may need assistance during a migraine attack

Psychology

How do migraines affect aspects of your mental health?

Explain how your life may be changed outside of the actual migraine attack

Biology

How do migraines affect aspects your physical health?

Explain your physical experience of a migraine attack

Tell me in what ways that your migraines may be triggered

Explain what goes inside a person’s body during a migraine

Tell me the difference between internal and external triggers

Appendix B

I, __________________________________________voluntarily give my consent to serve as a participant in a qualitative research study conducted by __________________________, a graduate student in a qualitative research course at California School of Professional Psychology (CSPP-San Diego). I have received an explanation of the general nature and purpose of the study and the specific reason why I am being interviewed. I have been informed of the kind of questions to be asked. Furthermore, I understand that some of the questions might be uncomfortable. I understand if I experience any discomfort (at any time) during the interview, I am free to terminate my participation in the interview. I understand that a pseudo name will be used to protect my true identity.

In addition, I agree to be audiotaped and/or videotaped for the purpose of data analysis.

The results will only be used for education and instructional purposes and will not be shared outside of this course. Finally, I understand that the validity of the results of the study is not established.

Volunteer’s Name ________________________

Guardian’s Name _________________________

Volunteer/Guardian’s Signature __________________________________Date: _____________

(or Parent/Guardian)

Interviewer Signature __________________________________________Date _____________

Interview Transcript

Interviewer (I):

Give me a description of your overall migraine status.

I can repeat the question…

Participant (P):

When you say overall migraine status- do you mean lifelong or do you mean at this current moment?

We’re going to talk within the past year. Think about your current status. The current status of your migraines.

I can elaborate- How would you describe the severity of your migraines within the past year?

Severe, very severe.

Can you tell me more about that, please?

The last migraine. I had visual disturbances. Okay? Which was frightening, very frightening.

Explain how migraines may change your day to day life.

Can the answer be zero?

I: Yes, so would it be correct to say that migraines do not affect your day-to-day life?

Yes.

So, what about month to month?

Most months? Zero.

And then tell me about the entire year, in reference to being affected by your migraine status

One time, in the past year, I had a really bad migraine. It was severe. Actually, it was two times when the migraines were severe.

Okay, so regarding frequency, is it correct that the number of severe migraines in the past year was two?

Yes.

So, how do migraines affect aspects of your social life?

Currently? Not at all.

And what about in the past, how did they affect your social life?

Not at all. Still, Not at all.

And so, currently, tell me in what ways you may need assistance during a migraine attack.

I have never, ever, ever needed assistance.

So, what does go on for you during a migraine attack?

I was fearful. Fearful and worried. Worried that I might need assistance. And that’s how it affected me socially. Because I’m fearful that I may need to ask for help.

And so, that is referring to the past year, or last year?

Yes.

Would you explain it in any other way for your past? In your past?

In the past, I never thought I might need help.

How do migraines, affect aspects of your mental health. Currently.

How the migraine affects my mental health and mental health effects my migraine. Yes, ok. And the migraine affecter. In the last year, none at all.

And, what about in the past?

In the past, it can affect it can make me feel withdrawn. Yes, withdrawn.

Yes, that is a great word, what other feelings were a product of your migraine experience?

Withdrawn. Like, I’m withdrawn.

Can you explain withdrawn?

I’m in, pulled inward, in order to be resourceful. Pulled in to keep my resources. To keep doing whatever I need to do.

Okay, that makes sense.

Yes, it’s that feeling, or inaction.

So, does that sound correct to say that withdrawn is related to protecting yourself.

It can be… no. I’m just pulling in to do what I need to do.

Ok, moving on a bit. How do migraines affect aspects of your physical health? In the last year.

It affected my vision affected your vision,

How so?

I couldn’t see out of my eyes. I couldn’t see. I couldn’t, I couldn’t read the computer. I was missing parts of the words. Yeah. And I didn’t feel like I could completely comprehend, or remember how to spell. A few words, kind of, not that extreme, but it’s just a touch of that.

Would that you think you could describe that as like, more like an issue with cognitive functioning?

No, I don’t think it was cognitive, I think it was literally, I think it was the part of your brain that interprets written speech.

Okay, so with that said, explain your physical experience of a migraine attack.

Like, typically? Ok, so typically I get some sort of visual aura, or a mild sense of vertigo. And then some period, some period following that, I will get a pain in my head. That’s the whole thing.

You mentioned typical? Is there anything than that is atypical, a migraine that is different from the rest?

One, or, the two last year, the visual disturbance was very different than the ones I had all those other years. The visual disturbance, I had in the past was more like, like… you’re maybe a little motion sick. Maybe felt like… like it wasn’t enough light in the room or saw something

You’re saying this is what happened in the past?

Those are, those were the ones I had all my life, and the one that then was a change of pattern in my thought was the ones last year that had this kind of more like… look at a word and it’s not all there kind of thing, and not be able to, sort of, completely comprehend. The thing think that I was feeling like I couldn’t do that maybe I couldn’t comprehend, but I was comprehending. It looked like a foreign word like there was a word I knew… it was a weird so it was like a word I knew, and I know I know it. I’m thinking like, do I know that word is that the right way to spell that word, but it’s a word I know, so it was this odd thing like that. It was very interesting. It’s very interesting.

So, tell me in what ways your migraines may be triggered.

I have a few theories. One, chocolate can make me have a pain migraine. Okay, I don’t care about pain migraines. I don’t care about that too much. I’m pretty sure that’s true. Chocolate can do that. And then other migraines, perhaps, are can be triggered by something else. A sense of stress or… Okay, or something like that but I don’t have, I’ve never been able to find a reproducible… I can’t reproduce that theory completely.

I guess follow up question then, so chocolate is then more like an external trigger? Would that be correct?

Yes, yes

So, then when you’re saying that there’s other ones, other triggers, that are like… something else. Yes, but do they still fall under the external category or do you think it’s…

Oh, well a a sense of stress would always be internal because it’s how I respond to something not what happened.

And the next question is more general and it doesn’t necessarily apply to yourself. So, please explain just what goes on inside a person’s body during a migraine.

They’re there [participant pointing to temples with forefingers.] They have vasospasm. Their blood vessels that go to their brain will first be vaso-spastic. And that’s often when you get the aura. And then sometimes they release, and then that’s when people can get the pounding headaches and nausea and whatever else they get. Okay. That’s what happens in my understanding.

So, can you tell me the difference, can you give an example of an internal trigger compared to an external trigger.

I think, for me an internal trigger… is that something that for some reason, pushes my button or my… my sense of insecurity or that not good enough… or that kind of stressor, the thing that that makes something that’s happening that an inside… that creates that like that, like I’m incompetent or not good enough or whatever, that kind of thing. That would be the internal stressor. Okay, something in the outside world that promotes that. Or exposes that. Yeah, I’m not gonna blame the outside thing for that that’s clearly my own manufacturer. Yeah.

And you mentioned something previous to the interview about hormones

Yes, internal. Oh yeah, so I think there’s biological, hormonal fluctuations. That used to be, for me, a migraine. That would be a reliable migraine pattern. Both initiating and then at the end of the, you know, hormonal changes.

And then, while you said chocolate for an external trigger, are you what other external triggers, are you aware of? With yourself or with someone else?

With some people, some people drinking wines red wines, some other kind of foods. I don’t… I’m not convinced for myself that the sunlight can do that but when I was young I used to think that sort of the glary light of the June day in California… glary light used to do that. But then as I got older I wasn’t convinced with that so other people have light and dark and computers and all that kind of stuff.

Earlier you mentioned motion sickness…

Before, I don’t think my I get motion sickness [during a migraine] but motion sickness does not seem to promote a full-out migraine for me. That’s just something… I feel motion sick sometimes when I’m getting the aura but it’s just because motion sickness is a familiar thing for me. What I think is it’s not really motion sickness is just… it’s a way I described that weird vision thing. I don’t get nausea with my migraine so I don’t never get the full-out motion sickness because I don’t get nauseous.

Similar to the first question I asked, describe your, in general… or what symptoms do you associate with a migraine. You mentioned one is not nausea.

I guess really for me, it’s the visual disturbance. Yeah, that one… the visual disturbances that I’ve had have been the most challenging. Even that early was one was most challenging. And the end just a head pain. Think that’s all. I used to also get, now I’m saying that… a sense of like, an out of body or déjà vu… or deja vu is not the right word… sometimes I used to try to describe it as that. It was that, like the world was weird or something… like oh I saw this before, no you didn’t know, like it was a weird I don’t know if there’s a better way to describe that because it also was this weird feeling in my head that the reality was like, not real or something that wasn’t strong enough that it affected in my behaviors or ability to function in the planet. It was very subtle. Very subtle. And I think that was part of the aura too.

And that was something that limited your functioning?

It didn’t limit me in any way… I noticed it. I would notice it and kind of think it was interesting, or bizarre. But I certainly never would have told a soul about it, and I probably never said it. I don’t think anyone has ever heard me say it before, I don’t think.

What else would you like me to know?

I think what I was saying before… I think people can respond to their migraines in different ways. They can have a migraine and feel empowered, that they have something difficult. They can manage to it, they can fight through it, they can function through it, and they come at the end, feeling like it’s not good, but I’m a strong person that I persevere. Or, a woman or man can have a migraine and say, “what’s wrong with my body. Why is my body doing this, I don’t trust my body any more? My body just when I want to do something fun my body did this I have to take this medication. Why me, why me?.” Now, that’s why, and they end up distrustful of their body. And it’s the suffering that comes from those different responses that are interesting.

Does that mean you relate to the first one?

Yes, yes, I relate to the first one. I acknowledged a possibility that my stuff may not be as bad as other people. But I think, I think, to get to say I can do it, I can do it, I can get through something I can figure it out I can find a way I can. And then still function, and not miss a day of work or anything, whatever, is empowering.

That makes sense.

Notice that if I, if I can’t see. Then… then there’s several things that I would be unable to do. And so, that is also humbling to know that there are possible… different manifestations that could be more personally disabling. Humbling.

Humbling. Like you think you would feel that after the attack?

I think that humbling is that after the fact. During the… during the probably more likely during the time that something’s happening that ends up humbling you, you’re probably much more… I’m probably much more in a weaker, some other weaker… My pejorative weaker confused or scared or something, uncertain. Not in the empowered state. During. What if I had, if I was having some kind of visual, when I have had the visual disturbance, that… at work, and I knew that if that continued for the next three hours I would be unable to work. Then that is eventually humbling. But in the moment, more discouraging and maybe even scary. Maybe even all those different words… embarrassing.

So, I feel like then, the way you describe migraines and how they affect you, or how they negatively affect you, would be during a migraine… compared to the in between time of a migraine.

True, that is true. Yeah, so definitely more, but effect yeah I like the biological symptoms, it’s actually as I’m saying this out loud is it makes it a very good subject, then right because… Because certainly it has much more impact than just it’s a sprained ankle. Because I’m going to say it empowers me. I can work through it. But now I’ve given it too much power… it has too much power, doesn’t it?

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