Enhance Migraine Care by Stepping Up Physician-Patient Communication

May 1, 2007

Migraine has been shown to cause absenteeism and lower productivity at work as well as reduced quality of life.1 According to the US Headache Consortium Guidelines, migraineurs with severe or moderate attacks should be treated with specific antimigraine medications, and prevention is recommended in those with frequent headaches as well as attacks that remain disabling despite optimal acute treatment.

Migraine has been shown to cause absenteeism and lower productivity at work as well as reduced quality of life.1 According to the US Headache Consortium Guidelines, migraineurs with severe or moderate attacks should be treated with specific antimigraine medications, and prevention is recommended in those with frequent headaches as well as attacks that remain disabling despite optimal acute treatment.2

Researchers in the American Migraine Prevalence and Prevention (AMPP) study assessed 18,968 respondents who met criteria for migraine. Of these, 56.2% had received a medical diagnosis of migraine, and 13% were currently taking prophylactic therapy.3,4 In comparison with earlier study results, however, the overall number of migraine diagnoses made and the number of patients treated has improved. "We had estimated that only 5% of migraineurs were getting preventive medications, so we were pleasantly surprised," said Stephen Silberstein, MD, coauthor of the study and director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia. Earlier studies had shown that although preventive medicine may be indicated for 50% of patients with migraine, only 10% of these patients were receiving therapy.5

To conduct the study, a headache questionnaire was mailed to 120,000 US households. Migraineurs were identified according to the criteria of the International Classification of Headache Disorders, second edition (ICHD-2).6 The results showed that the 1-year prevalence of migraine was 17.1% in women and 5.6% in men. Prevalence peaked in middle life and was lower among adolescents and those older than 60 years. Of all migraineurs, 31.3% had an attack frequency of 3 or more per month, and 53.7% reported severe impairment or the need for bed rest. In total, 25.7% met criteria for preventive therapy; an additional 13.1% were deemed persons in whom preventive therapy at least should be considered. Most migraineurs treated their headaches with over-the-counter medications. Only 20.1% used prescription medication alone.

A COMMUNICATION SNAFU
In January, the National Headache Foundation released a consensus statement on migraine prevention, which stated that migraine is largely underdiagnosed and goes untreated because of poor doctor-patient communication as well as low patient awareness of available treatment options. The statement also emphasized that migraine be considered a chronic disorder with episodic manifestations and that physicians should emphasize to their patients that preventive treatment can include both prophylactic medications and lifestyle modifications. The results were based on the findings from the AMPP3,4 study as well as from the American Migraine Communication Study 1 (AMCS-1)7 and the American Migraine Communication Study 2 (AMCS-2).8

Migraine diagnosis and migraine treatment are especially sensitive to patient-doctor communication, according to Richard B. Lipton, MD, another coauthor of the AMPP study and professor in the Department of Neurology, Albert Einstein College of Medicine, Bronx, New York. "The guidelines about who should get migraine prevention are largely based on attack frequency and disability, and it turns out that communication about these issues is poor," he said.

The AMCS-1 by Lipton and colleagues found that health care providers tended to ask patients closed-ended questions about migraine frequency and paid scant attention to issues regarding impairment. "Health care professionals rarely ask the open-ended questions that would allow the patient to tell his or her story. As a consequence, providers dramatically underestimate life consequences of the patient's migraine," Lipton said. Physicians participating in the study mostly asked patients questions such as ""How often is your headache?" A response of 2 attacks per month may be misinterpreted, since 2 attacks may represent 2, 4, or even 6 actual headache days, depending on the average duration of the attacks. Lipton explained that this type of miscommunication can lead to suboptimal treatment.

The researchers examined communication between 28 health care providers (14 primary care physicians, 8 neurologists, and 6 nurse practitioners or physician assistants) and 60 patients. Office visits averaged 12 minutes in which time patients primarily responded to a health care provider's questions. Ninety-one percent of those questions were closed-ended or evoked a short answer. An average of 13 migraine-related questions, which primarily focused on attack frequency (63%), triggers (53%), and symptoms (48%), were asked during each visit. No health care practitioner used or referenced a migraine-assessment instrument, such as the Migraine Disability Assessment Scale (MIDAS), Headache Impact Test, or Migraine Assessment of Current Therapy questionnaire.

The most surprising findings from the study, according to Lipton, were that only 10% of health care providers' questions addressed impairment and that patients and providers were not aligned regarding migraine frequency in 55% of visits and severity in 34%.

"In our debriefing interview, we'd go back to the provider and ask about the severity of the patient's headaches. The provider would usually say that they weren't too bad because the patient didn't tell the provider that he was missing work or school or was unable to take care of children," Lipton said. "So the assumption is that the absence of reporting disability implies the absence of disability."

Although many impairments experienced by patients participating in the AMCS-1 were not addressed during visits to clinicians, debriefing interviews with patients conducted by Lipton's team revealed that headaches had profound effects on patients' lives. "When patients had the chance to tell their story, they often said they were afraid of losing their jobs because of time lost to migraine," he said. "We discovered an incredible underestimation of headache disability, which emphasizes why these patients aren't given preventive medication for migraine. The physician just doesn't understand that the patients are impaired." Of the 60 patients in the study, 35 were not given prophylactic treatment, although 20 of these patients met the AMPP study criteria for preventive treatment.

AMCS-2
Based on the results of the AMCS-1, Lipton and colleagues devised techniques to help health care providers communicate more effectively with patients who have migraine and went on to complete the AMCS-2, which examined physician-patient interaction to determine how clinician-patient communication affects migraine treatment.

Eight primary care physicians, 5 neurologists, 2 nurse practitioners, and 66 patients participated in the follow-up study. They all were interviewed independently following office visits.

Lipton and colleagues gave health care providers specific recommendations for improved communication. Open-ended questions provide a more complete picture of a patient's migraine- associated disability, the researchers found. They recommended that providers engage in patient-centered interviewing, use continuers to explore patient's understanding, utilize the "ask-tell-ask" method for patient education, and discuss prevention therapy with candidates in a balanced and thorough way. They also emphasized that open-ended questions, such as "How do your headaches impact your daily life?" "How does migraine affect things such as work and family?" and "How does having migraine make you feel overall-even when you aren't having one?" should be posed to assess impairment and frequency.

Lipton's team also taught the providers the simple communication theory, "ask-tell-ask," which is a strategy for obtaining correct information. In this system, the provider asks the patient for information. After the patient tells the provider the information, the provider asks the question once again to confirm.

"When we repeated the experiment, we found that doctors got in touch with patient-related disability and understood it much better. Doctors and patients were better aligned with their understandings of attack frequency," Lipton said. "Also, both doctor and patient satisfaction went up."

Only 29% of the providers used the "ask-tell-ask" approach. However, in 55% of observed office visits, providers asked open-ended questions about how migraines affected patients' daily activities during and between attacks. Because of this, 75% of patients shared personal experiences about how migraine disrupts their lives even when they were not having an attack.

Seventy-four percent of clinicians discussed migraine preventive medication with their patients-a tremendous increase compared with how often clinicians discussed preventive therapy in the AMCS-1 study, Lipton pointed out. Ninety-four percent of patients said they were satisfied with their visit, and 67% said their communication was better in that visit than in previous visits with other health care providers.

The average length of the office visit was about 9.5 minutes in the AMCS-2, which was shorter than the length of AMCS-1 office visits, which averaged 12 minutes. "We didn't expect that the time of the appointments would be reduced by more than 1 minute," said Lipton. "When you let the patient tell his story, it takes less time than when the patient is asked closed-ended questions, so it is more efficient to ask the patient open-ended questions. This is what the communication literature says, by the way-and I had read it, but I did not believe it."

Through personal experience, Silberstein has found that patients limit the description of their attacks by only telling physicians about their worst migraines. He recommends that rather than asking a patient how many attacks he has had in the past month, a physician should ask about how many pain-free days the patient has had.

Both Silberstein and Lipton recommend that physicians provide patients with MIDAS questionnaires while they are in the waiting room. "It's a very valuable tool," Silberstein remarked. "A high MIDAS score will mean that a patient needs prevention."

IMPACT OF PROPHYLAXIS
The aforementioned National Headache Foundation consensus statement on migraine prevention encouraged clinicians to assess a patient's migraine-related impairment during and between attacks and also included revised guidelines for prophylactic therapy (Table).

 Table -National Headache Foundation 2007 guidelines for initiating prophylactic therapy
Characteristic 
Frequency of headache ≥ 2 per month, with disability ≥ 3 days per month. 

In a recent Italian study that prospectively monitored changes in quality of life in 102 patients taking prophylactics to treat migraine without aura, all patients benefited from prophylactic therapy.9 Treatments included flunarizine (42 patients), propranolol or metoprolol (23 patients), amitriptyline or selective serotonin reuptake inhibitors (22 patients), valproate, or topiramate (Topamax) (8 patients); and other drugs (7 patients).

The mean number of headache days per month dropped from 8 to 5 and the mean monthly consumption of acute drugs was reduced from 7.4 to 4 in 102 persons with migraine without aura who were receiving prophylactic therapy. Patients had a marked reduction in MIDAS score, with a median score of 25.5 at the patients' second visits and 8.0 at their third visits.

Recurrent migraines have been shown to be associated with missed work days and impaired performance, the costs of which total around $13 billion each year.10 In a study of the clinical and economic impact of topiramate for migraine prophylaxis, it was found that patients on prophylactic therapy had 29 fewer migraine days and 78 fewer hours of migraine-related disability per year than those migraineurs who were not receiving prophylactic therapy.11 In a recent review of the literature, Silberstein reported that the prophylactic medications with the best-documented efficacy are the ß-blockers, amitriptyline, divalproex, and topiramate.12 Another study by Silberstein and colleagues also showed that prophylaxis reduced the need for acute migraine therapy, visits to physicians or emergency departments, and neuroimaging exams.13

REDUCING NONADHERENCE
Health care providers must ask patients the right questions to overcome common communication barriers that result from lack of patient adherence to prophylactic therapy, according to Todd D. Rozen, MD, a neurologist at the Michigan Head Pain and Neurological Institute in Ann Arbor. "A little communication between patient and physician will go a long way," he said. He recently led a study of patients with migraine, which showed that good communication between health care providers and patients improved a patient's willingness to take preventive medication.14

"I think most physicians do not have a lot of time when seeing patients, thus they will choose the preventive agents they feel most comfortable with, although these agents may have an adverse-effect profile that the patient is not comfortable with," Rozen said. "For example, weight gain is the biggest complaint of women being treated for migraine, and sadly most migraine preventives will cause weight to increase."

Rozen led a study of 150 patients (114 women, 36 men) with a history of migraine. The patients filled out a 10-question survey, in which they ranked, in order of importance, characteristics of migraine preventive treatment. The most important issue for the patients surveyed was to be involved in the decision-making process when a prophylactic agent was prescribed. Patients ranked explanation of possible adverse effects by health care providers as the second most important issue.

"A patient is less likely to refuse a prophylactic if you give him the rationale about your choice," Rozen said. "Often, if you present the patient with the possible adverse-effect profile of an agent, the patient will often tell you up front whether he will be willing to take it." In this way, the physician and patient can come to an agreement about a prescription such that the patient will be more likely to adhere to the therapeutic regimen. To save time in his practice, Rozen uses preprinted sheets that describe the adverse effects of prescribed medications.

Lipton agrees that poor communication contributes to poor adherence with migraine treatment. "Part of the problem with preventive therapy is that patients are started on initial doses that are too high, or it takes too long for the medication to kick in. Then the patient experiences adverse effects and he quits his medication regimen," he said. "For example, if a patient beginning topiramate therapy feels his feet begin to tingle, he often just stops the medication out of fear of the effect. Because he stopped taking the medicine, he gets a breakthrough migraine and develops an overall negative impression of preventive therapy. But if a physician explains that the tingling may stop if the patient stays on topiramate and that his migraine frequency can thus be ameliorated, the patient is more willing to stay on therapy."

At the same time, Lipton emphasizes that most physicians do not have the time to tell all of their patients about every adverse effect of their medication. "That's why my rule of thumb is to tell patients which effects are most likely," he said. "We often send patients home with handouts, and I recommend that they look up information about the drugs online. But I remind them that adverse effects are rare."

In Rozen's study, the majority of migraineurs reported that they wanted the effectiveness of a prescribed prophylactic therapy for migraine to be well established in the medical literature. The patients also did not mind using more than 1 preventive agent at a time to achieve greater control over their migraines.

It is also important to emphasize that prophylactic therapy is not 100% effective, said Lipton. "If patients get a reduction of 50% to 70% in attack frequency, that's really good, but patients may have expectations that are unrealistic," he said.

Because Silberstein runs a migraine center, he said it is the rule, not the exception, for his patients to take prophylactic therapy. "One of the biggest reasons why preventive medications don't work is because patients don't take them," he said. "They don't like having to take pills because it means they're sick, they don't like the side effects, or they stop getting headaches and they forget that they need to take the medication."

FOLLOW-UP
Scheduling follow-up visits with patients can send a message that the physician is taking their pain seriously, said Lipton. "Unlike other chronic diseases, physicians often do not schedule a follow-up appointment, assuming that the patient will come back if they have a problem," he said.

At the end of an office visit, it is also helpful for the physician to ask whether the patient has any additional questions or concerns, according to Lipton. It is also best to have patient education material on hand.

Lipton finds it helpful to refer patients to the American Council on Headache Education (http://www.achenet.org). A nurse practitioner also may be a good resource in helping patients learn basic information about headaches and control. "The more the patient knows before I see him, the better it is for the both of us," said Lipton.

References:

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