Behavioral Facilitation of Medical Treatment for Headache—Part I: Review of Headache Treatment Compliance

Abstract

Noncompliance or nonadherence with medical regimens represents a major challenge to the practice of medicine including the treatment of headache. Indeed, medication use patterns are particularly relevant to headache because of the potential for headache therapies to induce medication-overuse headache. Previous research has demonstrated that adherence to long-term medication therapy for various chronic illnesses averages only about 50%. The rate of adherence among headache patients has been found to be similarly poor. Misuse or overuse of symptomatic medication has been demonstrated to contribute to treatment failure, and one-fourth to one-half of patients are noncompliant with prophylactic headache medications and at least 40% nonadherent with appointment-keeping. Adherence declines with more frequent and complex dosing regimens, side effects, and costs, and is subject to a wide range of psychosocial influences. Subjective reports of adherence are likely not only to overestimate but also to be discordant with more objective measurements. As the first of 2 articles, this paper describes the problem of noncompliance in medical practice and reviews literature addressing compliance specific to headache management. A companion paper (Behavioral Facilitation of Medical Treatment for Headache--Part II: Theoretical Models and Behavioral Strategies for Improving Adherence) summarizes social learning models proposed to characterize the multiple determinants of adherence and guide behavioral adherence-enhancing interventions, and then presents cognitive and behavioral strategies that may facilitate treatment adherence with headache patients.

Behavioral medicine for migraine and medication overuse headache

“…Common adherence problem areas in headache treatment include misuse of medication (including unfi lled, overused, underused, incorrectly used, and nonadvised discontinuation of prescribed medications or treatments), appointment keeping, record keeping (eg, maintaining a headache diary), and unwillingness or inability to follow clinical suggestions. Improper medication use may not only limit relief but may also aggravate the primary headache condition (eg, lead to medication overuse or rebound headache) [13].…”

Challenges of nonpharmacologic interventions in chronic tension-type headache

“…When analgesic overuse is identified, discontinuation of the offending medication is warranted, along with increasing patient responsiveness to appropriate treatment. The latter goal may be accomplished through multiple means [43], including instruction in appropriate use of analgesics, introduction of a preventive medication to decrease headache frequency, and use of behavioral strategies to increase medication adherence [44][45][46]. Combining behavioral treatment with initiation of preventive medication may facilitate reductions in headache activity more than initiation of preventive medication alone [47], although more studies of this strategy focusing specifically on TTH are needed.…”

“…The efficacy of any intervention, pharmacologic or behavioral, certainly is constrained by the extent to which the patient adheres to the intervention [44][45][46]. Indeed, compliance with out-of-session homework assignments has been associated consistently with improved psychotherapy treatment outcomes [50,51].…”

Application of behavioral therapies in adult and adolescent patients with chronic migraine

“…The combination of both pharmacological and nonpharmacological treatment has been shown to be superior to each individually [39] and appear to maximize long-term therapeutic benefit [40]. In addition, effective non-pharmacological strategies help to ensure pharmacological treatment compliance which has been shown to be a significant problem with headache patients [24,25].…”

“…Assessment of compliance with previous pharmacological and non-pharmacological interventions needs to be assessed as it has been shown to be an important treatment issue in headache and other medical patients [24,25]. There is a vast literature that concludes that many of these patients fail to take abortive medications [26,27] and preventive medications [28,29] as prescribed.…”