Comments by group members indicate several factors that can interfere with a patient’s ability to follow treatment recommendations. For example, avoiding known dietary triggers by consistently identifying preservatives and additives used in food preparation can be arduous. In addition, the high cost of abortive medications may make it difficult, and in some cases impossible, for patients to buy such medications, especially if they do not have prescription insurance coverage. Insurance companies’ limits on the types and amount of medication covered and on which physicians a subscriber may see can also interfere with effective migraine management. In addition, behavior patterns among migraine sufferers may interfere with obtaining effective therapy. Examples included patients’ reports of their reluctance to “accept that the migraine is coming” and take the necessary steps to ward it off.
Finally, participants indicated that dissatisfaction with the perceived attitude of their physicians had contributed to their lack of treatment follow-through. Attendees reported a perception that some physicians do not understand their problem or take it seriously. These findings are consistent with those of a previous study with migraine patients,21 as well as studies with other health care consumers, both healthy and ill.22,23
Recurring themes of fear, anger, and frustration were associated with both the impairments in quality of life and perceived barriers to effective care. However, while participants were eager to discuss the pain, functional disability, and management problems associated with migraines, they denied emotional distress. This denial is surprising, considering the emotional charge obvious in many of their statements (eg, “I’m not the mom I wanted to be,” “I feel like I’m letting everybody down”) and the important role that emotional distress plays in chronic tension-type headaches.24 Possibly participants did not differentiate emotional distress from the physical disability caused by migraines or were inclined to emphasize pain and disability but minimize emotional reactions in an effort to legitimize frequent migraines as a serious medical problem.
Participants’ comments suggest interventions that could be taken by physicians to improve their understanding of patients’ headaches and needs and to develop the collaborative relationship that people who have migraines appear to desire.
First, physician behavior in response to migraine concerns is important. Patients want their physicians to indicate that they are listening and taking their concerns seriously before offering treatment. One means of indicating understanding is to reflect the concerns that the patient has expressed (eg, “It sounds as if these headaches are really interfering with your daily life, your work, and taking care of your children”) and to ask the patient what he or she expects treatment to achieve. Such an exchange could initiate a mutually beneficial collaborative relationship: The patient feels understood and heard while the physician gains a better understanding of what the patient desires in treatment. Ultimately, the result may be greater success with therapy.
Physicians should listen for clues related to the severity and impact of headaches on patients’ lives. A patient’s complaint of “headaches” might inadvertently be dismissed unless the physician determines whether the headaches are actually migraines and the extent to which they interfere with daily life.
Consistent with other findings,25,26 the patients in this study seemed to be as interested in being offered the time to ask questions about headaches and medications as they were in obtaining pain relief. Some people who have migraines need general information about migraines and migraine management. Maintaining brochures from the National Headache Foundation, the American Council for Headache Education, or the American Headache Society in waiting rooms and directing patients to these resources may be helpful. However, generic information is merely a first step in meeting patients’ needs. Periodically reviewing the patient’s headache diary with an eye for patterns, possible triggers, and responses to treatment can provide the basis for a specific, individualized migraine management plan.
Providing abortive drug samples so that patients can determine whether a medication is effective and tolerable before paying the high cost of a prescription is extremely helpful for many people, especially those without prescription insurance coverage. Participants in this study and others21,22,27 also want physicians to maintain an open mind with regard to complementary and alternative treatments for migraine. This is especially the case for women in their reproductive or child-rearing years, who may be concerned about the side effects and risks of medications.
Time constraints may make these ideas difficult to implement. Migraine patients may require a longer appointment or may need a second appointment if the complaint is voiced as an afterthought during an unrelated visit. Working as a team, however, the physician and patient can do a great deal to reduce the disability and cost associated with migraines.