Improving Medication Adherence in Migraine Treatment

DOI: https://doi.org/10.1007/s11916-015-0498-8

Abstract-Summary Medication adherence is integral to successful treatment of migraine and other headache.

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These studies broadly suggest poor adherence to both acute and preventive migraine medications, with studies using more objective monitoring reporting lower adherence rates.

The article concludes by discussing the future of research regarding adherence to

medications for migraine and other headaches.

Acute Medication Adherence to acute treatment is essential to good treatment outcomes both for indi- vidual attacks and over time.

The majority of available studies used prescription claims data to assess “persis- tence” (i.e., time from initiation to discontinuation of therapy) with acute medica- tion (almost always triptans) to serve as a proxy for adherence.

Claims data do not provide information about the frequency of headaches, the characteristics of treated and untreated attacks or the selection, sequencing, and tim- ing of treatment.

A recent prospective near-time electronic diary study, during which participants recorded their medication use soon after a headache episode [15, 16], found that, among patients prescribed a triptan, only 105/301 (35%) were adherent for at least two- thirds of their attacks over a 2–6 month period.

Studies of adherence require the collection of detailed information on prescrib- ing instructions as well as information about both attack characteristics and medica- tion-taking behavior.

Preventive Medication Claims-based analyses are more helpful for assessment of adherence to preventive medications.

Claims-based analysis indicates that only 16–56% (median = 24%) of patients are adherent to their preventive medication over a 6–12 month period, with lower rates occurring over time [17–19].

Hepp and colleagues evaluated adherence to preventive medication during ran- domized controlled trials of migraine prevention and found that 27–55% (median = 41%) of patients were adherent to medication over a 12-month span [20]. Adherence estimates using self-report range from 39–91% (median  =  74%); rates differ based on the method for measuring adherence (retrospective self-report, interview, or prospective diaries) and time frame over which adherence is mea- sured [17].

Adherence measured via self-report or prospective diaries tend to report adher- ence rates typically well above 70%, while claims-based data using persistence as a proxy for adherence typically report rates below 25%.

Need For Intervention Poor acute treatment efficacy and high migraine frequency (which could be reduced through more effective preventive treatment) are risk factors for the onset of chronic migraine in persons with episodic migraine [21–23].

Interventions are needed at the organizational, provider, and patient-level to

improve medication adherence for people with migraine and other headaches.

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Adherence-facilitation interventions targeting patient behaviors and beliefs have demonstrated efficacy and cost effectiveness in improving adherence among chronic diseases [24], although, to our knowledge, no headache- or migraine-specific stud- ies have been published to date testing these interventions to facilitate medication adherence.

Recommendations for improving medication adherence among parallel chronic disease literatures [25, 26] should be generalizable to migraine and other headaches.

Organizational Structure Encouraging use of patient portals for communication and refill requests can also improve adherence.

Adherence is also facilitated reminding patients of upcoming appointments. Strategies to increase appointment-keeping include patient reminders (e.g., text or E-mail messages, telephone calls), and shorter interval or more frequent follow up visits for patients with complex conditions, history of non-adherence, lacking social support, or other risk factors.

Systematic Monitoring of Adherence Monitoring of medication adherence should be a standard part of every follow-up visit [27].

Will provide more information about medication adherence than “How are you

using your acute medications?”

Patients should be encouraged to bring more objective measures of adherence, such as medication containers, for review during follow-up visits as a more objec- tive measure of adherence.

Ongoing self-monitoring affirms the importance of medication adherence to the

patient and formally engages the patient in the process of improving adherence.

Self-monitoring tools should assess patient-specific problematic medication- taking behaviors, such as taking a preventive medication every morning, or taking acute medication early during a headache episode.

If a particular aspect of medication adherence is problematic, monitoring barriers to performing that medication-taking behavior can provide additional information and strategies to maximize likelihood of adherence [28].

Follow-up monitoring of self-monitoring tools provides the opportunity for feed-

back and reinforcement by the healthcare provider for successful adherence.

Medication Regimen Adherence declines as the complexity of treatment regimen increases.

Since side effects are the most commonly cited reason for discontinuing pre- ventive migraine medications (i.e., topiramate, amitriptyline) [20], it is helpful to elicit potential barriers (e.g., side-effects, cost) and involve patients in decision- making and plan to form a collaborative treatment alliance between patient and provider.

Rehearsal and role playing the decision-making processes can reduce uncer-

tainty that delays optimal use of the more complex abortive regimens [28].

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Education Educating patients about the rationale and medication-taking behaviors for optimal use of preventive, analgesic, abortive, and other palliative agents is recommended.

Providers should advise patients that successful prevention requires consistent

daily use of preventive medications as well as judicious use of relief medications.

Education regarding preventive medication should include the expected time- frame for relief and expectations regarding dose adjustment of preventive medica- tion for optimal treatment [27].

Educating patients to recognize prodromal symptoms (including aura) enables them to promptly engage in appropriate timing of abortive therapies as well as behavioral strategies such as relaxation.

Stimulus Control Incorporating simple stimulus control strategies linking medication-taking to exter- nal cues such as a regular activity (e.g., meals, bedtime) provides reliable prompts for daily medication use.

Smart pill boxes, phone applications, and other tools to cue medication-taking

also promote regular adherence.

Medication reminder systems and cueing tools are widely available to track the

day and time-of-day use of medication.

Tools range from day-of-the-week pillboxes to mechanical dispensers to elec- tronic diaries and applications that “remind” patients to take a preset dose of medi- cation, track usage over time, and cue prescription renewals.

Behavioral Contracts Patients with persistent nonadherent or a history of medication overuse may benefit from a behavioral contract [27, 29].

Prescribers of controlled medications with risk for abuse commonly use behav-

ioral contracts [30].

Psychologists commonly use behavioral contracts in cases where patients engage in behavioral patterns that threaten their well-being or the therapeutic relationship, such as those with who engage in self-harm, aggression, or other behaviors which impede the therapeutic process [29].

Cognitive–Behavioral Strategies Headache patients were shown to persist in medication-taking when they felt more confident in their ability to control their migraines (i.e., self-efficacy) [31].

Providers may ask patients to rate or describe their confidence in self-monitoring headache, taking preventive medications as recommended, using abortive medica- tions optimally, and in applying behavioral skills outside of the clinic.

Patients with low self-efficacy for taking abortive medications can first become skilled at keeping the medications with them at all times, rehearse cues to identify prodromal symptoms, and ultimately to take the medication upon recognizing the prodromal cues.

Modeling of steps such as self-monitoring symptoms, recording in a diary, and rehearsing cognitive restructuring can enable the patient to observe and replicate decision-making and medication use strategies.

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[Section 11] Medication adherence is integral to successful treatment of migraine and other headache disorders.

An emerging literature demonstrates that, consistent with other medical condi- tions, patients with migraine and other headaches struggle to adhere to medication regimens [17, 32].

Despite the integral importance of medication adherence to successful pharma- cotherapy, a paucity of research exists examining medication adherence among those with migraine and other headaches.

The first focused migraine medication adherence review appeared nearly a decade ago when Rains and colleagues [17] identified fewer than ten articles on acute or preventive medication adherence.

This small existing literature paints a picture of poor medication adherence

across both acute and preventive migraine medications.

Acknowledgement A machine generated summary based on the work of Seng, Elizabeth K.; Rains, Jeanetta A.; Nicholson, Robert A.; Lipton, Richard B. 2015  in Current Pain and Headache Reports.

Ubrogepant: First Approval