What is the impact of physician communication and patient understanding in the management of headache?

Abstract

Migraine is a common and debilitating condition. Despite the burden of disease and increasing availability of effective treatment, migraine management is unsatisfactory. Evidence in other chronic conditions indicates that effective physician communication results in better patient understanding and health outcomes.The current literature review was intended to evaluate evidence regarding the relationship of effective physician-provider communication to health outcomes and patient satisfaction among patients with migraine. The authors searched MEDLINE((R)) (1966-June 2007) and the Cochrane Database of Systematic Reviews for relevant publications. The search strategy combined the concepts of "headache disorders" and "physician-patient relations". 912 abstracts were identified, and 80 (9%) of them were included for data abstraction.There were no studies that met our eligibility criteria. Therefore we revised the eligibility criteria to allow for the inclusion of non-migraine primary headache disorders or the role of non-physician health care providers. Twelve published papers met the revised criteria. The findings from the limited evidence available suggests, but does not prove, that improvements in physician-patient communication could result in a significant decrease in the burden of suffering and health care resource utilization associated with migraine. More research is needed to assess the explicit role of physician-patient communication in the management of migraine.

Full text

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© 2007 Dove Medical Press Limited. All rights reserved
Neuropsychiatric Disease and Treatment 2007:3(6) 893–897
893
O R I G I N A L R E S E A R C H
What is the impact of physician communication
and patient understanding in the management
of headache?
Meenal Patwardhan1
Remy R Coeytaux2
Rajeshwari Deshmukh3
Gregory Samsa4
1Department of Medicine, Duke
University Medical Center, Durham,
NC, USA; 2Department of Family
Medicine, University of North
Carolina, Chapel Hill, NC, USA;
3Department of Rheumatology,
Oregon Health Sciences University,
Portland, OR, USA; 4Department of
Biostatistics and Bioinformatics, Duke
University, Durham NC, USA
Correspondence: Meenal B Patwardhan
Duke Center for Clinical Health
Policy Research, 2200 W. Main St.,
Suite 220, Durham NC 27705, USA
Tel +1 919 286 3399
Fax +1 919 286 5601
Email meenal.p@duke.edu
Abstract: Migraine is a common and debilitating condition. Despite the burden of disease and
increasing availability of effective treatment, migraine management is unsatisfactory. Evidence
in other chronic conditions indicates that effective physician communication results in better
patient understanding and health outcomes.
The current literature review was intended to evaluate evidence regarding the relationship of
effective physician-provider communication to health outcomes and patient satisfaction among
patients with migraine. The authors searched MEDLINE® (1966–June 2007) and the Cochrane
Database of Systematic Reviews for relevant publications. The search strategy combined the
concepts of “headache disorders” and “physician-patient relations”. 912 abstracts were identi-
fi ed, and 80 (9%) of them were included for data abstraction.
There were no studies that met our eligibility criteria. Therefore we revised the eligibility
criteria to allow for the inclusion of non-migraine primary headache disorders or the role of
non-physician health care providers. Twelve published papers met the revised criteria. The
fi ndings from the limited evidence available suggests, but does not prove, that improvements in
physician-patient communication could result in a signifi cant decrease in the burden of suffering
and health care resource utilization associated with migraine. More research is needed to assess
the explicit role of physician-patient communication in the management of migraine.
Keywords: communication, migraine, headache, outcomes, physician communication, patient
understanding
Background
Migraine is a common and debilitating condition which affects approximately 12% of
the US population. Half of the individuals with migraine suffer signifi cant impairment
in their daily activities and limitation in their productivity at work, school and home
(Stewart et al 1992; Lipton, Diamond et al 2001; Lipton, Stewart et al 2001). Despite
the evident burden of disease and increasing availability of effective treatment, the
management of migraine remains less than satisfactory. (Silberstein and Rosenberg
2000; Edmeads et al 2001; Lipton, Diamond et al 2001; Lipton, Stewart et al 2001).
While physicians who manage migraine are motivated to provide optimal headache
management, they are constrained by the limited time available for consultation and
multiple other medical conditions that compete for physician attention (Lipton et al
1998; South and Sheftell 2001). Ineffective communication (as perceived and reported
by patients) has been shown to be associated with dissatisfaction with care and poor
adherence to prescribed treatments among headache patients (Cottrell et al 2002). There
is also evidence that physician communication regarding a treatment plan, along with
distribution of educational materials, results in better patient understanding and better
health outcomes (Cottrell et al 2002; Foley et al 2005).

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Neuropsychiatric Disease and Treatment 2007:3(6)
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Patwardhan et al
We sought to evaluate the state of the research that pertains to
the relationship of effective physician-provider communication
to health outcomes and patient satisfaction among patients with
migraine. We conducted a systematic review of the published
literature with the objective of identifying research studies that
assessed the impact of patient understanding and physician com-
munication on migraine management and patient wellbeing.
Methods
We searched MEDLINE® (1966–June 2007) and the Cochrane
Database of Systematic Reviews for relevant publications.
The search strategy combined the concepts of “headache
disorders”, “physician-patient relations”, “communication”,
“patient education”, “health knowledge, attitudes, practice”,
and “patient understanding”. This search was supplemented
by a review of the reference lists of included articles.
We did not expect to retrieve a large number of studies
that assessed the impact of physician communication and
patient understanding in the area of migraine. Therefore,
during the process of retrieving literature we also included
studies that evaluated (a) the impact of communication
(imparted by any individual) and patient understanding in
migraine; and (b) the impact of communication and patient
understanding in other non-migraine headaches, where no
secondary cause was identifi ed. (Note that although we
included these studies, our literature search was intended to
be comprehensive only for our research question.)
Abstracts of all articles included in the search were inde-
pendently screened by two reviewers, and a full-text article
was obtained if either reviewer selected it for inclusion.
Explicit criteria were developed to select full-text articles for
data abstraction. We included studies if they were relevant to
patient understanding as a result of physician communication,
whether they were randomized control trials or observational
studies. We excluded articles if the study includes patients
with several other diagnoses, and fewer than half of them
have a diagnosis of migraine, and if it was a review article.
The two reviewers independently evaluated studies for
inclusion using these inclusion criteria. Disagreements were
resolved through discussion. Electronic data abstraction forms
were developed and piloted for the research question. For each
article selected for inclusion, one investigator abstracted relevant
data onto the electronic data abstraction form, and the other
investigator ascertained the accuracy of the abstracted data.
Results
We identifi ed 912 abstracts, 80 (9%) of which were included
for data abstraction. The inter-rater agreement for full-text
selection of articles was good (kappa of 0.75). When we
reviewed these full-text articles we could not retrieve
any article that explicitly assessed the impact of physi-
cian communication and patient understanding on patient
outcomes in migraine. However we identifi ed twelve articles
that provided some studies whose results could be extrapo-
lated to our research question.
Eight published articles examined the impact of
communication imparted either by a physician in conjunction
with other individuals or by a non-physician, on migraine
outcomes. A brief description of these studies follows.
Lemstra conducted a randomized control trial, in Canada,
that involved 76 patients and compared migraine-related
outcomes associated with a multidisciplinary intervention in
a non-clinical setting to a control group (Lemstra et al 2002).
The intervention included a management approach consisting
of exercise, education, lifestyle change and self-management.
The multidisciplinary intervention was associated with
signifi cant improvement in pain frequency, intensity and
duration, as well as functional status, health status, quality
of life, health-related disability, and depression. The impact
of the individual components of the intervention was not
formally assessed. However, patients reported that supervised
group exercise sessions, physical therapist’s advice, and
neurologist’s advice and education to be the most effective
treatment parameters included in the intervention.
McGrath randomly assigned 73 adolescent migraine
patients in Canada to one of three study arms: (a) self-
administered management consisting of an 8-chapter
treatment manual and cassette tapes; (b) the same education
delivered by a therapist; or (c) a control arm that consisted
of education about migraine triggers and instruction on how
to use a brainstorming technique to deal with stressful situa-
tions (McGrath et al 1992). Both interventions were effective
in reducing headaches compared to the control intervention.
The clinical gains were maintained after one year.
Holroyd et al (1989) conducted a randomized controlled
trial in the USA that compared standard abortive medication
therapy administered to 34 recurrent migraine sufferers with
and without an educational intervention that promoted self-
management. This study demonstrated that self-managed
patients had fewer migraine attacks and showed larger
reductions in headache activity; both improvements were
statistically signifi cant.
Centonze et al (1998) incorporated an intervention, the
Cognitive Educational Model, in the medical management
of 30 patients with migraine in Italy. The intervention
consisted of an educational session delivered by a physician,

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Physician communication in headache
followed by a session in which the patient took notes
from the educational session, followed by an explanatory
session conducted by an ancillary health care provider. This
approach was associated with signifi cant improvements in
patients’ understanding of migraine as well as a decrease in
the number of headache attacks per month and medication
use. Outcomes of physician-imparted education were not
separately assessed.
Nicholson et al (2005) from USA studied the effective-
ness of a self-administered patient-directed intervention that
included tailored messages for patients. In a before-after
study, the investigators enrolled 33 patients with migraine,
and studied the impact of an intervention that included an
educational component, skills training component, and
weekly tailored messages. Outcomes of the intervention
were assessed through an analysis of a daily diaries and
self-report questionnaires. Overall 62% patients reported
at least 50% reduction in headache frequency. Headache-
related disability, behavioral/emotional factors, and headache
management self-effi cacy also showed signifi cant improve-
ment as a result of the intervention.
Baos et al (2005), in prospective study, conducted
in Spain, evaluated the benefi ts of a structured migraine
diary for recording information on response to therapy
for a pre-study migraine attack and three consecutive
migraine attacks in 97 patients. The investigators claim that
patients who used a structured migraine diary reported both
improved communication with their doctor about migraine
as well as improved satisfaction with their overall medical
care provided by their doctor. In addition, most physicians
reported that the diary enabled them to better communicate
with their patients about migraine, and all reported that it
enabled them to assess differences in pain intensity and
disability across patients.
Another prospective observational study of 789 patients
in USA demonstrated that that the use of appropriate patient
and physician educational interventions (that were part of a
migraine-management program) improved patient-oriented
outcomes and satisfaction (Campinha-Bacote et al 2005).
Rothrock et al (2006) studied the impact of addition of
patient education to routine medical management on the
clinical status of migraine patients. In a randomized clinical
trial setting conducted in USA, 100 patients were randomized
to receive or not receive a standardized course of didactic
instruction, imparted by trained lay migraineurs) regarding
migraine biogenesis and management. The investigators
concluded that intensive education of migraine patients by
trained lay instructors reduced their mean Migraine Disability
Assessment Scores and may convey signifi cant benefi t to
migraine patients in terms of reduction in mean headache
days per month, functionally incapacitating headache days
per month, analgesic overuse and need for abortive therapy
(Rothrock et al 2006).
During our search we identifi ed four articles describing
results of studies that examined the impact of communication
imparted by any individual (irrespective of whether he/she
was a physician) in non-migraine headaches disorders. We
describe these studies briefl y below.
A randomized controlled trial conducted in USA
assessed the impact of physician communication on health
outcomes in the treatment of chronic headache (Foster et al
2004). The study was designed to evaluate the effective-
ness of the Trager approach, which combines manipulative
therapy and relaxation training. Thirty-three patients with
migraine, tension-type headache, or cluster headache were
randomized to one of three arms: (a) medical management
of headache without discussion about medication usage
(control); (b) medical management in combination with the
Trager approach without discussion about medication usage;
and (c) medical management plus weekly physician visits
for 6-weeks during which medication usage was discussed,
patients’ headaches over the past week were reviewed, and
patients’ questions answered. There were no statistically
signifi cant differences between the three study groups in
terms of the primary headache diary endpoints, but patients
randomized to the group that included weekly physician
visits demonstrated a decrease in mean headache duration
and improved scores on self-reported health-related quality
of life as compared to the control group.
Fitzpatrick, from the United Kingdom, interviewed
95 patients (53% had migraine) before and after a new-patient
consultation with a neurologist for headache (Fitzpatrick
and Hopkins 1981). Thirty-four patients (36%) reported
dissatisfaction with at least one aspect of their doctor’s
actions; of these, 26 (76%) reported being dissatisfi ed with
communication from the doctor. Most of these patients cited
lack of expansion upon the doctor’s diagnosis or “expressed
criticism of more specifi c aspects of the diagnosis that were
not explained such as the causes of the diagnosed illness
or the implications of the diagnosis for the patient’s future
life.” Patients who reported dissatisfaction with their doctor’s
communication were signifi cantly more likely to be non-
compliant with prescribed medications, as documented at a
one-year follow-up.
A study conducted by Harpole et al (2003) from USA
evaluated the impact of a headache management program

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Patwardhan et al
that included structured individual and group sessions with
a program manager. Fifty-four patients with chronic head-
ache (61% had a diagnosis of migraine) were referred to the
program. As a group, these patients demonstrated a signifi cant
improvement in their headache-related disability, functional
health status, and satisfaction with care over six months.
Blumenfeld and Tischio (2003) conducted a prospective
cohort study of 422 patients with primary headache who
participated in a headache management program within
a multi-specialty medical group in USA. The headache
management program included an educational session
instructed by a neurologist and a nurse practitioner that
was intended to improve communication, enhance patients’
knowledge about their headache condition, and motivate
patients to make appropriate life-style changes. Completion
of the program was associated with signifi cantly improved
scores on the 36-item short form health survey and migraine-
specifi c questionnaires, as well as a decrease in the number
of primary care and emergency department visits. Ninety
two percent of patients reported subjective improvement
upon completion of the program. The degree to which the
educational session contributed to these improved outcomes
was not assessed.
Discussion
The impact of physician communication and patient
understanding on patient outcomes has not been studied
in migraine. The studies that we chose to describe provide
indirect evidence to suggest that the quality of care for
migraine can be improved with better patient under-
standing. One study (Lemstra et al 2002) highlighted
the importance of a neurologist’s advice and education.
Another study (Holroyd et al 1989) demonstrated that an
educational intervention that promoted self-management
was associated with improved clinical outcomes. Several of
the studies reviewed provide evidence that suggests patient
satisfaction correlates with physician-patient communica-
tion or patients’ understanding of their headache condition
(Fitzpatrick and Hopkins 1981; Harpole et al 2003; Baos
et al 2005; Campinha-Bacote et al 2005).
The role of physician communication and patient
understanding has been assessed in other conditions (Ong
et al 1995; Stewart 1995; Lewin et al 2001). The general
conclusion of these studies is that improved physician
communication and the provision of patient-centered care
results in better patient satisfaction. Further, although it is
diffi cult to quantify the benefi ts/effects of communication
on patient health status, there is some evidence that suggests
that better physician communication has a positive impact on
health care outcomes as well (Greenfi eld et al 1985; Wiggers
et al 1990; Simpson et al 1991; Stewart 1995).
Some, but not all, of the positive impact especially studied
in diabetes, hypertension, asthma, and multiple sclerosis is
due to enhanced medication adherence resulting from better
communication (Kaplan et al 1989; Von Korff and Myers
1997; Gavin et al 1999; Ciechannowski 2001; Piette et al
2004; Thorne et al 2004).
Considering the fact that migraine patients are amongst
the most dissatisfi ed with the medical care they receive, and
that half of all patients with migraine who make the initial
effort cease their quest for medical care, migraine may be
the one for which improved physician communication might
have the most signifi cant public health impact (Hu et al
2000). Further, migraine is characterized by episodic events
that must often be prevented or treated by the patient herself/
himself, usually without the benefi t of physician at the time
of the event. Patient understanding regarding the causes of,
treatments for; and methods of prevention for migraine, is
therefore critically important. Among other things, patients
need to possess the knowledge about their migraine triggers,
prodromal signs, healthful behaviors that can prevent
frequent migraines, how to differentiate migraine from other
possible headache etiologies, whether any medications are
required, if medications are required which medications to
take and when to take and when to repeat it, the exact dosage,
what non-pharmacological approaches may be appropriate,
when to seek medical attention for severe or “different”
headaches, and how to avoid medication overuse/abuse and
prevent transformation of episodic migraine to chronic daily
headache.
Physicians and other health care providers are uniquely
qualifi ed to help educate their migraine patients in most
of these areas. Such education is much more likely to be
achieved with effective communication. Since evidence
suggests that improvements in physician-patient communica-
tion could decrease the burden of suffering and health care
resource utilization associated with other chronic conditions,
it may be reasonable to assume that similar results can be
expected in the outcomes of migraine. Further, since there
is little evidence that low adherence with medications is
disease- or regimen- specifi c (Haynes et al 2006), improved
communication that results in better medication adherence
can also be extrapolated to migraine.
In conclusion, despite the paucity of research that directly
studies the impact of physician-patient communication in
the management of migraine, the accumulation of indirect

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evidence suggests (albeit does not prove) the following links
between improved patient-provider communication and
outcomes of migraine:
• Improved patient-provider communication results in
greater satisfaction with individual medical encounters;
• Over time, improved patient-provider communication
results in increased patient knowledge and empowerment;
• Improved patient knowledge and outcome results in
improved patient self-management; and
• Improved patient self-management results in improved
satisfaction with medical care and improved clinical
outcomes.
To these putative linkages we would also note that while
the ultimate responsibility for improving patient-provider
communication lies with the physician, time constraints in the
clinical encounter suggest that much of this communication
might be successfully delegated to other providers.
Future research priorities include making each of these
linkages more direct, and in examining how non-physician
providers can best be integrated into the care of patients
with migraine.
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