Our study is the first of its kind to identify social media as a vehicle to investigate common CIM approaches used by migraine patients for headache relief. There have however been other online survey studies. Lee et al. administered a 30-min self-report survey on an online migraine headache resource (Migraine in America, www.migraine.com) to investigate if CIM produced a negative life impact of headaches for chronic migraine patients [11]. They found that approximately half of the participants reported using three CIM treatments and yet, felt dissatisfied or indifferent to their treatment strategy [11]. They also found that migraine patients who use CIM were more likely to have more frequent migraine headaches [11].

With a 95% confidence interval, our study shows that a true mean lies between the 95% of the values we have acquired, and only a 5% possibility that it does not. Only 20.2% of participants in our study seek guidance for their CIM strategies specifically by a healthcare provider (MD, DO, NP, PA), while over 50% of patients seek guidance using multiple other strategies such as research the internet, guidance from a fellow migraine sufferer, or guidance from a Naturopathic provider. It is crucial that physicians query patients about their use of herbs, supplements, and vitamins with their standard treatment, provide realistic expectations, and identify potential treatment adverse effects, drug-drug interactions and existing evidence base. Patients using butterbur for example [12], must be counseled to obtain pyrrolizidine-alkaloid-free formulations due to the potential for hepatotoxicity. Liver function must be closely monitored while using this supplement.

In combination with supplements such as magnesium and riboflavin for the prevention of migraine, many patients used meditation, relaxation, acupuncture, deep breathing exercises, guided imagery, yoga, cognitive behavioral therapy, biofeedback, mindfulness training, and craniosacral therapy concurrently with the majority (56.4%) using 2 or more of these treatments.

Of those, 76.7% of respondents found the combination of CIM treatments moderately to very effective. This finding supports the existing literature that these strategies are favorably used in combination among the general population [13] and in other select populations [14–16].

The evidence for using mind-body relaxation techniques recommended by the US Headache Consortium Guidelines [17] is based on the Agency for Health Care Policy and Research Technical Review, which found relaxation training (progressive muscle relaxation, autogenic training, meditation or passive relaxation), electromyography (EMG) biofeedback, and thermal biofeedback combined with relaxation training to have high quality (Grade A) evidence from well-performed research studies for the prevention of migraine [18]. Mindfulness training always differs from meditation through the practice of both informal and formal self-reflection during the day, while meditation is defined to be during a specific time of day at a specific place.

From our study, 30.3% of patients found perceived manipulation or body-based practices such as acupuncture, chiropractic maneuvers, etc. alone provided moderately to very effective treatment.

Finally, only 30.4% of respondent patients using cannabis as a treatment for moderate/severe migraine found it moderately to very effective. As early as the third and fourth centuries BCE, Ayurvedic preparations used cannabis for “diseases of the head” like migraine [19]. It is postulated that cannabis shows potential to interrupt glutamate signaling leading to cortical spreading depression, serotonin release from platelets and cranial blood vessel dilation caused by nitrous oxide and calcitonin gene-related peptide [20].

Medical cannabis is becoming a popular addition to mainstream pharmaceutical therapies due to rapidly changing marijuana laws and increased availability throughout the country. While some studies have shown a possible benefit of cannabis for the treatment of migraine [21] and medication overuse headache [21], properly constructed placebo-controlled trials are required to determine its true efficacy and adverse effects.

If patients and providers can have shared goals about integrative medicine use in migraine, they can have an open, non-judgmental dialogue about the risks and benefits of various approaches. The C.A.R.E mnemonic [22] can be used when discussing CIM approaches with patients. Patients may have a specific perspective regarding treatment options based on their previous treatment experiences. It can be helpful to ask about their history with conventional treatments while also avoiding judgement. When reviewing integrative treatment options, it is imperative to counsel patients on their limitations so that they have appropriate expectations. Finally, in order to adequately educate patients on CIM, it is helpful to explore where the patient’s interest in CIM stems from. See Table 2.

Many patients use CIM because it fits in with their attitudes about health [23]; addressing these beliefs, as well as potential benefits and complications, will improve patient-provider communication and more patient-centered care.