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APP REVIEWS

Migraines

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Dr. Payal Agarwal
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As many of us know, migraines are a significant concern in primary care with an estimated 8% of Canadians known to be suffering from migraines (Martin, 2001). However, that is likely an underestimate as many patients do not seek medical treatment for their symptoms (Ramage-Morin & Gilmour, 2015 ). Even for those who are diagnosed, migraines can often be a challenge to primary care providers to deliver adequate relief of symptoms, leading to significant impact on work, sleep and quality of life. Many of our current treatments focus on analgesic medications, which can run the risk of worsening symptoms (CBC, 2014). The 2015 CFP guidelines on migraines highlight the importance of behaviour methods to manage migraines, including trigger identification and patient self-management (Becker et al., 2015; CBC, 2014). Yet, despite this focus, the most commonly given tool we give patients continues to be a one-page headache diary we print for our patients. The use of mobile apps to track migraine symptoms presents the opportunity for a more convenient and comprehensive tool that can help patients track and develop insights around their triggers, behaviours, symptoms and treatments. In 2013, there were at least 38 apps related to headaches available in the Google Play or Apple apps stores (Hundert, Huguet, McGrath, Stinson, & Wheaton, 2014).

We selected four of these apps to review for clinical use. While the apps provided varying levels of symptom, trigger and treatment tracking, none gave educational tools around behavioural techniques such as sleep hygiene or stress reduction. Overall, all apps in this field had at least some security and privacy concerns, which may limit their use in clinical practice.

Apps Reviewed

Migraine Buddy
3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars
Headache Diary (EcoHeadache)
2 stars2 stars2 stars2 stars2 stars
Headache Diary Pro
2 stars2 stars2 stars2 stars2 stars
iHeadache
1.5 stars1.5 stars1.5 stars1.5 stars1.5 stars

iHeadache

1.5 stars1.5 stars1.5 stars1.5 stars1.5 stars

This app is only available on iOS. It does track many clinically relevant parameters including the Migraine Disability Assessment and non-pharmacologic treatments. Unfortunately, its main limitation is that it was not originally created in English, leading to textual errors in the English version. Terms are sometimes shown in another language and an unfamiliar symbol is used for “average”. While a more advanced user can adapt to this, it will be difficult for many to understand. There is also no clear privacy statement and minimal app security. This app could be useful for someone who can adapt to the language quirks but the lack of a privacy statement is concerning.

Detailed Review View All

Features

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This app was designed to track headache symptoms for different headache types. Oddly, it does not let users specify the headache type, but, instead attempts to classify them based on an unknown algorithm. It allows for some customization of triggers — up to 5 entries — and settings for the use of generic versus trade names. A basic report can be created but it is not very useful for patients or clinicians. The data can be exported as a CSV file. There are no educational materials in the app.

Effectiveness

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Unfortunately, the app does not allow patients to track non-pharmacologic treatments. Furthermore, pain intensity can only be recorded as mild, moderate or severe instead of the more commonly used 10-point pain scale. The reports were difficult to understand and would not help patients make links between symptoms and treatment. The development team for the app did include a neurologist. While we could not find peer reviewed evidence of effectiveness, the app was the top rated app in an academic review on migraine apps.

Usability

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The app had several issues with usability. The controls were very small and users could easily select the wrong button. As well, there is no clear feedback on required fields. The app requires a user to answer Yes or No to all nine headache symptoms, which can be highly frustrating. There is minimal visual appeal and the reports produced are difficult to understand.

Privacy & Security

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We were unable to find a privacy statement for this app. While the app collects limited PHI (only an AppleID needed for download), it is unclear what is being done with the collected information. There is no password to the app, so anyone with the phone could have access to it.

Reliability

+-

The app does include a medication list with commonly used dosages which can help to eliminate errors in recording. However, attempts to automatically categorize headaches are worrisome and could lead to significant confusion or future medical errors. While the app was usually fast and responsive, it stopped working several times and required a full restart. It was developed by a non-for-profit group and was last updated in 2014. There is technical support via email and they responded within 24 hours. There is also a user’s manual to help troubleshoot problems.

Accessibility

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The app is available for free for iOS users. The language is generally well written and easy to understand. There are no clear accommodations for disabilities.

Headache Diary (EcoHeadache)

2 stars2 stars2 stars2 stars2 stars

This app is only available on iOS. It does track many clinically relevant parameters including the Migraine Disability Assessment and non-pharmacologic treatments. Unfortunately, its main limitation is that it was not originally created in English, leading to textual errors in the English version. Terms are sometimes shown in another language and an unfamiliar symbol is used for “average”. While a more advanced user can adapt to this, it will be difficult for many to understand. There is also no clear privacy statement and minimal app security. This app could be useful for someone who can adapt to the language quirks but the lack of a privacy statement is concerning.

Detailed Review View All

Features

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The app has an extensive list of parameters for tracking headaches. Users can customize these lists fairly easily. The app produces a report summary, as HTML or CSV, that would be clinically useful for physicians. It also creates summary graphs for patients but they can be confusing. Unfortunately, there are no other educational tools or features to encourage engagement.

Effectiveness

+-

The app tracks many clinically important parameters including a 10-point pain scale, multiple triggers, the Migraine Disability Assessment and both pharmacologic and non-pharmacologic treatments. We could not find evidence of involvement by a clinical expert or any peer review studies on efficacy. However, the app was one of the top rated in an academic review by migraine experts. Although the app creates graphs that summarize different parameters, they are confusing and may have limited usefulness for patients. However, the table based reports may help patients better understand and manage their disease.

Usability

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The app controls were intuitive and easy to learn. It was relatively quick and easy to enter most information about a migraine, except for medication dosing which is clunky and error prone. Unfortunately, the app’s overall usability is limited by the poor English translation from its original language. Sometimes words appear in other languages, and the use of a symbol to represent average is very confusing. Some users will be able to adapt to this with time, but others will find it severely limiting.

Privacy & Security

+-

We were unable to find a privacy statement for this app. While the app collects limited PHI (only an AppleID needed for download), it is unclear what is being done with the collected information. There was no password for the app, so anyone with the phone could have access to it.

Reliability

+-

The app was fast and did not crash during our testing. The error handling was mixed. While there validity checks on the start and end times of a migraine there were no error checks on medication dosing. The app has not been updated since 2014. There was a very basic help page but no obvious technical support.

Accessibility

+-

The app costs $3.99 on the iTunes store. The language used was is awkward, with foreign language words appearing at times. This significantly impacts the accessibility of this app. There are no obvious accommodations for disabilities.

Headache Diary Pro

2 stars2 stars2 stars2 stars2 stars

This is a simple app that is only available on Android. The interface has limited visual appeal but is easy to learn and use. It lacks the ability to track many important clinical features including associated headache symptoms, impact on disability and non-pharmacologic treatments. The reports produced by the app are easy to understand and can be exported in PDF and CSV format. There is minimal app security and no privacy statement to be found. Overall, this app could be useful for someone who needs a very simple interface, but is limited by missing clinically important variables and no privacy statement.

Detailed Review View All

Features

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The app, designed to track headache symptoms, lacks the ability to record many important data points such as the presence of an aura or the use of non-pharmacologic treatments. There is some ability to customize the existing list of triggers and medications. The reporting and export features are well done and could be useful if presented to a clinician. There are no engagement features such as education tools or reminders.

Effectiveness

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The inability to track non-pharmacologic treatments severely limits the ability of this app to provide comprehensive support to improve patient self-efficacy. We were not able to find documentation of medical input in the creation of the app or any peer reviewed evidence on its effectiveness.

Usability

+-

The interface is simple with dated visuals. It was surprisingly easy to learn and use. Entering information about headaches was quick and efficient. The reports did present data in graph form which can be helpful to patients when interpreting results.

Privacy & Security

+-

We were unable to find a privacy statement for this app. While the apps collect limited PHI (only an Android account needed for download), it is unclear what is being done with the collected information. There is no password to the app, so anyone with the phone could have access to it.

Reliability

+-

The app was fast and there were no crashes during testing. However, there was minimal error handling, allowing patients to enter migraines in the future. The app has not been updated since 2014 and there is no obvious technical support.

Accessibility

+-

The app costs $2.99, but there is a free “lite version” that lacks the ability to customize triggers or use most reports. We do not recommend this. The language in the app is simple and is easy for most people to understand.

Migraine Buddy

3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

The newest of the group, this app offers a friendly, inviting interface that is easy and efficient to use. The app tracks important non-pharmacological triggers and treatments and even attempts to automatically track the user’s sleep through cell phone usage. However, the downside is a possible concern around privacy and security. Users can log into the app using social media accounts; the app has a feature to share symptoms to social networks. The privacy statement says the app reserves the right to sell data to a third party. Overall, this app has great potential to help people manage their migraines but it requires a clear discussion with patients around the possible privacy risks and links to social networks.

Detailed Review View All

Features

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This migraine tracking app had the most comprehensive set of features; the app includes customization, notifications and social network integration. It takes into consideration the challenges of migraine sufferers with features such as “Bug Me Later”. It also tracks sleep patterns, which is a useful feature on its own. There are many reports to help understand the data, but data can only be exported in HTML which limits the ability to use the information in other systems. Unfortunately, the app does not include any significant patient education tools.

Effectiveness

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Although there is no peer-reviewed evidence on effectiveness, a neurologist was part of the development team. The app tracks all triggers recommended by clinical guidelines, uses a 10-point pain scale and emphasizes non-pharmacologic treatments. The reports are useful and can help patients improve self-management.

Usability

+-

A great interface! It is friendly, inviting and easy to use. There is great use of visuals and it is quick and easy to enter the details of a migraine. It includes a small onboarding process that explains how to use the app.

Privacy & Security

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The app collects PHI including email and location. Although there is a privacy statement, it is difficult to find, and users are not presented with it prior to use. The statement clearly states that anonymized data may be sold to third parties. The data collected through the app is likely stored on an international cloud-based server.

Reliability

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The app generally works quite well. On loading, it can sometimes take five to 10 seconds to synchronize data, which is longer than ideal. There is proper error handling and feedback for the user. There have been many updates in the last year and there is an email address for technical support.

Accessibility

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The app is free and available for both iOS and Android. The language is friendly and easy to understand. The mediation list uses only trade names, which may be confusing for some. There were not clear accommodations for disabilities.

What Experts Say

Watch our interview with leading specialist Dr. Lay regarding Migraines.

Patient Experiences

They’re words most patients hope to hear when they visit their family doctor: “There’s nothing seriously wrong with you.” For migraineurs, however, these words offer little comfort. In fact, sometimes, the attempt to reassure just frustrates. As one patient, Candice, told the U.S. based Migraine Research Foundation “When I am seen by a doctor, I am not taken seriously. I’m a victim of ignorance about migraines. I’m just tired of being pushed off as some doctor’s headache (no pun intended)!” Another patient, 20-year-old Chelsea, says “I have gone to doctor after doctor, but they only look at MRIs and tell me that nothing is wrong.”

According to Canadian patients diagnosed with migraines, the condition prevents them from participating in activities (26 per cent), makes them feel left out of things (26 per cent), prevents them from driving from time to time (53 per cent) and limits getting a good night’s sleep (76 per cent). About a third of diagnosed migraineurs report that their educational opportunities and job opportunities are limited.

References

  1. Becker, W. J., Findlay, T., Moga, C., Scott, N. A., Harstall, C., & Taenzer, P. (2015). Guideline for primary care management of headache in adults. Canadian Family Physician, 61(8), 670-679.
  2. CBC. (2014). Migraines affect Canadians’ sleep, driving and work
  3. CBS News
  4. Hundert, A. S., Huguet, A., McGrath, P. J., Stinson, J. N., & Wheaton, M. (2014). Commercially Available Mobile Phone Headache Diary Apps: A Systematic Review. JMIR mHealth and uHealth, 2(3), e36. doi: 10.2196/mhealth.3452
  5. Martin, S. (2001). Prevalence of migraine headache in Canada. Canadian Medical Association Journal, 164(10), 1481-1481-a.
  6. Ramage-Morin, P., & Gilmour, H. (2015 ). Prevalence of migraine in the Canadian household population. Retrieved from http://www.statcan.gc.ca/pub/82-003-x/2014006/article/14033-eng.htm.
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