WASHINGTON – Strategies to increase adherence to headache therapy work best when multiple modalities are used together at every visit throughout the duration of treatment, according to Jeanetta C. Rains, Ph.D., of Elliot Hospital in Manchester, N.H.

"The more comprehensive the approach, the more adherence can be improved," she said at the annual meeting of the Society of Behavioral Medicine.

Relatively few studies have addressed the issue of adherence in headache treatment, but the literature definitively shows that "nonadherence with headache medication regimens is common," said Dr. Rains, who has reviewed the literature on headache treatment compliance and empirically based adherence enhancing strategies.

"And patients who don’t take their medication or who overuse symptomatic medications can aggravate their headache, create a pattern of medication-overuse headache, or transform an episodic headache into a chronic daily headache," said Dr. Rains, who directs the center for sleep evaluation at Elliot Hospital.

One large study of patients with severe headache found that 11% did not fill their initial prescriptions (high cost and concerns about side effects were common reasons) and that 70% did not adhere to their abortive medication regimen.

Other studies have shown that 25%-50% of headache patients do not adhere to their preventive medication regimen, and commonly avoid or delay the use of abortive medication because they want to "wait to see if it’s a migraine or if it’s severe," she said. Concerns about adverse effects and dependency or addiction also are cited as factors in avoiding or delaying use of abortive medications.

This makes education critical. For effective patient education about headache and forms of treatment, physicians should use simple, everyday language; limit instructions to three or four major points; supplement verbal with printed instructions; ask patients to restate the plan; and involve family members or significant others. "And remember, repetition increases retention," she said.

Moreover, "the way we engage is important," Dr. Rains said. Adherence increases "not only when we give more information to patients, but also when we ask patients about their feelings and opinions, and when we praise them when they’re doing well."

She advised forming a collaborative alliance, discussing barriers to treatment, and being supportive of patients who have difficulty meeting their goals. "At the end of a visit, you can ask your patient to rate how important it is for him or her to do the things you’ve been talking about. Then you can ask the patient to rate his or her confidence level for adhering to the treatment plan."

Behavioral strategies can help to target the many psychosocial determinants of adherence, as well as the fact that patients’ motivation for treatment often shifts over time, Dr. Rains said.

She suggested using the following strategies:

• Assess and treat comorbidities and behavioral concerns. Unaddressed depression, anxiety, somatic preoccupation, and low self-efficacy can each affect adherence and subsequent outcomes. "Patients who are depressed, for instance, are three times less likely to take [their prescribed regimens]," she said.

• Simplify the treatment regimen. Studies consistently show that adherence decreases as the number of medications and daily doses increase.

• Consider past behavior and prior experience. Positive prior experiences with medication can enhance response, while negative expectancies may worsen symptoms and amplify side-effects. Differentiating current treatment from past failures is key, she said.

• Predict a positive but realistic outcome.

• Associate any positive outcome to the patient’s behavior and perseverance.

There is no sure way to assess and track adherence accurately, but more objective, multimodal measures are best, Dr. Rains said.

Face-to-face interviewing is the most widely used tool but also the least reliable, as "self-reporting actually overestimates adherence by 30%, compared with more objective monitoring," she said. Diaries and questionnaires are better, and electronic measures are better still. "Yet, even the most objective measures are not entirely reliable," she said. "Studies have shown, for instance, that some patients dump their canisters in anticipation of their visits, and that electronic daily diaries are sometimes completed on the day of their visit."

Mechanical and electronic tools can "remind" patients to take a preset dose and track their use, but these tools do not address a patient’s conscious decision to alter a regimen, she warned.

This is why "a comprehensive, ongoing approach to assessing adherence is important," she said. Physicians generally respond to treatment failures by altering their recommendations for drug choice or for dosing rather than assessing adherence, and this, she emphasized, is a mistake. "All patients," she said, "are candidates for adherence facilitation."

Dr. Rains reported that she had no relevant disclosures.

Multimodal Approach Advocated for Nonadherent Headache Patients