Migraine Treatment Hampered by Improper Patient Interviews

BY BRUCE K. DIXON
Elsevier Global Medical News

SCOTTSDALE, ARIZ. (EGMN) NOV. 11, 2006 - Open-ended questions during the patient interview elicit the best information for guiding the management of patients with migraine headache, Dr. Richard B. Lipton said during a presentation held at the American Headache Society's annual symposium.

Yet closed-end questions focusing on headache triggers, frequency, and symptoms comprised most of the dialog between physicians and migraine headache patients, based on videotaped interviews in the American Migraine Communications Study (AMCS). And when individual assessments were compared, the patient and physician often differed in their assessments of headache frequency, disability, and impairment, said Dr. Lipton, who is professor and vice-chair of neurology at the Albert Einstein College of Medicine in the Bronx, New York.

Patients and physicians really weren't hearing and understanding each other during the office visit, he said. As a result of these misalignments, physicians underappreciated the need for preventive treatment and patients had incomplete knowledge about medication use and inappropriate expectations of their outcomes.

The AMCS findings were based on analyses of videotaped encounters between 60 patients, 80% of them women, and a geographically representative sample of 14 primary care physicians and 8 neurologists. The patients' average age was 42 and the average duration of migraines was 14 years with a frequency of 5 episodes per month.

Dr. Lipton and his coinvestigator Dr. Steven R. Hahn analyzed the structure of questions posed during the recorded physician-patient interviews. Closed-ended questions allowed patients to make selections while open-ended questions encouraged more wide-ranging dialog. A typical closed-end question, for example, was: 'Are the headaches on one side of your head or bilateral?' An example of an open-ended question would be: 'Tell me about your headaches.'

Framing the interview with closed-ended questions gleans only limited information, said Dr. Hahn, professor of clinical medicine at Albert Einstein. "Open-ended questions are the foundation of patient-centered interviewing, and they allow patients to recount their symptoms in the narrative context, focusing on the things that are most important to them."

Based on follow-up assessments after the interviews, 35 of the 60 patients were not receiving any therapy despite the fact that all had disabling headaches. The other 25 had been prescribed an average of two migraine-related drugs, primarily triptans, but many did not have an accurate understanding of how to use the drugs or the outcomes they could reasonably expect from drug therapy.

"So overall in this study, 55% of physicians and patients were misaligned on migraine frequency post visit, which is amazing to me. It seems to me that the question of how many headache days occur over a 3-month period would be something patients and physicians could agree on," Dr. Lipton said.

To assure sure that you and your patients have similar perceptions of symptoms, Dr. Lipton and Dr. Hahn recommended using an "ask, tell, ask" approach. First, ask the patient about the number of headache days. Then restate your understanding and tell the patient what you want him or her to know. Finally, ask the patient whether you have correctly stated the situation.

"We've learned that only 29% of migraineurs are very satisfied with the treatment they've received, and about half don't seek medical care, very often because of past dissatisfaction with treatment," Dr. Hahn said

The "ask, tell, ask" technique improves communication and thus will improve treatment, Dr. Lipton concluded.

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