What Can I do while Waiting for an Appointment? Patient Compliance, Adherence

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Medically Reviewed by:
Dr. Werner J. Becker Neuroscience Professor,
Dept of Clinical Neurosciences Foothills Medical Centre University of Calgary
Calgary, Alberta

Interview Topic -­‐ Patient Compliance, Adherence and Appointment Preparation

1) What is Patient Adherence and Compliance?

Dr. Dawn Buse, psychologist in headache treatment (New York) defines patient adherence and compliance as terms used to describe a patient's role in their medical care. Compliance specially refers to a patients' ability to follow instructions from their physician. Although it is the physician that provides medical advice and prescriptions, it is the patient who ultimately chooses if, when, and how to implement that advice.

2) I have heard the term Headache Hygiene used. Can you tell us what that is?

Headache Hygiene is the practice of taking care of yourself in a way that will reduce the likelihood, frequency, intensity, and severity of headaches. It is normally made up of two components: Lifestyle Changes and Trigger Avoidance. Lifestyle Changes refer to things you can introduce, increase or eliminate. A few examples are regular sleep patterns, exercising regularly, reducing or eliminating stress and avoiding known triggers. Trigger Avoidance simply refers to avoiding a known trigger like a specific food that invokes a migraine, sleep irregularities, stressful events, environmental changes and exercise triggers. A more detailed explanation of Headache Hygiene can be found at http://www.achenet.org/resources/headache_hygiene__what_is_it

3) What do motivation and behaviour changes mean, in relation to a headache patient?

Making any behaviour change such as losing weight or quitting smoking requires the patient to incorporate motivation and behavioural changes. Usually, a new behaviour (positive) must replace a negative behaviour. A specific example might be that if a patient is sleeping in (and this contributes to their bad headaches) a regular sleep pattern is generally recommended. All behaviour changes should happen in small steps.

4) What is record keeping and why is it so important?

When a patient is waiting for an appointment they can record their headache symptoms on what is called a Headache Diary. A patient records their suspected triggers such as foods, Patients bring completed Headache Diaries (that includes migraine types) to their physician for analyses which allows the doctor to identify patterns in their headache frequency and it also tells the physician what works, and what does not.

Dr Joel Saper (Ann Arbor, Michigan) discusses in his interview in the book Chronic Daily Headache about the benefits of a Headache Diary. He suggests: A headache diary helps us identify the frequency of the pain, what may “trigger” the headache, and various other patterns related to duration (of pain felt), response to medication, and so forth. “Pain memory” is notoriously poor because during severe painful attacks memory is not functioning well, and trying to remember back a month or two with respect to headache frequency or other related details is generally poor for everyone. A diary helps to correct that.»

For a comprehensive list of potential triggers, a downloadable diary and instructions visit http://www.headache-­‐help.org/identify-­‐migraine-­‐triggers

5) I understand good headache management rests largely on the patient -­‐ can you identify some ways in which the patient can help themselves and prepare for an appointment?

Following the behavioral components of headache treatment can be even more challenging. This may include keeping appointments, keeping a headache calendar or diary if the physician prefers, practicing proper sleep hygiene (discussed above -­‐ see link under Headache Hygiene question), exercising regularly, practicing stress management and incorporating relaxation techniques into daily life, maintaining a healthy weight or losing weight, reducing or eliminating caffeine and not smoking.

6) What is relaxation training and stress management?

When you are tense your body turns on the sympathetic nervous system or "flight or fight" response. This state make you more vulnerable to a headache. The goal of relaxation training is to learn how to activate the "relaxation response". The "relaxation response" is defined as your ability to make your body release chemicals and brain signals that make your muscles and organs slow down and increase blood flow to the brain. Some medications have this effect; however they may also have unwanted side effects. You can train your body and brain to relax just as well without drugs while remaining conscious and aware at the same time. There are several ways to achieve this state including diaphragmatic (deep) breathing, visual imagery, progressive muscle relaxation, and other techniques that you can practice on your own. These techniques will cause the relaxation response in your body which includes slow, deep regular breathing, slow and regular heart rate, increased circulation (which you can feel with warmer hands and feet), lowered metabolic rate and reduced muscle tension.

Behavioral headache management is most successful when you identify triggers and start a plan to avoid or reduce them, practice regular lifestyle habits, practice relaxation and stress management and adhere to the plan you have created with or without your HCP. You will find that some triggers are impossible or difficult to eliminate or avoid; however, you may be able to make some changes in your lifestyle which may help your headaches including eating nutritious meals on a regular schedule, getting regular exercise, maintaining a regular sleep pattern and using techniques to manage stress. You can also use relaxation techniques to help avoid headaches or reduce the pain and duration of a headache once it has started. Mostly importantly adhere to what you start, to give your plan sufficient time to become a habit. You may also benefit from guidance and assistance from a professional in making healthy lifestyles changes, managing stress, and incorporating relaxation techniques into your life.

7) Is avoiding psychological stress something that patients can learn to do?

Many people who suffer from headaches report that stress and multiple demands in their life can lead to headaches. While it may not be possible to reduce or eliminate the amount of stress in your life you can learn ways to manage stress, organize your time, learn to say "no" to unrealistic demands, ask for help when necessary, and teach your family and friends about the importance of taking care of yourself. You should try to schedule some time during each day to relax both your body and mind. You may find that it is helpful to schedule exercise, a walk, or a yoga class, or you may be comfortable finding time during the day to do a relaxation exercise such as deep breathing or visual imagery. This is as easy as imagining you are sitting on a beautiful, tropical beach while you are sitting at your desk.

8) For what reasons would headache patients chose a behavioral treatment?

Behavioral therapies are ideal for patients who (1) prefer non pharmacological treatment; (2) the patient has poor tolerance to medications; (3) medications cause the patient severe side effects; (4) the patient does not respond to medication; (5) the patient is pregnant, or planning a pregnancy; (6) there is a history of excessive use of analgesics or pain medicines.

* this Question and Answer Interview does not allow us to mention a complete, comprehensive list of behavioral therapies, but the main points are addressed.

* there is scientific evidence to support that when self-­‐management strategies were introduced, patients were better able to manage their chronic conditions such as chronic headaches, arthritis, asthma, diabetes, and low back pain have proven effective in reducing symptoms, disability, and, in some cases, medical costs.


  1. American Council for Headache Education. Headache Hygiene Poster http://www.achenet.org/resources/headache_hygiene__what_is_it
  2. Buse, DC Wolff's Headache and Other Head Pain: Behavioural Management of Headache - 8th Edition, 721-722
  3. Headache Network Canada - www.headachenetwork.ca
  4. Help for Headaches - Identify Migraine Triggers
  5. Help for Headaches - book: Chronic Daily Headache pg 90, Behaviour Modification Chart http://www.headache-help.org/identify-migraine-triggers
  6. Saper, JR - interview, Chronic Migraine in Chronic Daily Headache

The opioids (narcotics) cause progression of the illness (Chronic Daily Headache), not termination, and will actually make the individual much worse over time. It is easier and quicker to give the patient a pain killer than to "get into the trench" and try solve the problem. Patients with chronic daily headache require time, diligence, and frequent access from their physician.

Interview: Dr. Joel Saper, MHNI
-from the book Chronic Daily Headache

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The book Chronic Daily Headache features
an article reviewed by a Headache Neurologist
entitled "Why Some Headache Patients do
not Improve"!