Enhancing the effectiveness of abortive therapy: a controlled evaluation of self-management training

Migraine

Migraine affects about 1 billion people worldwide, and up to 15% of adults in the United States have migraine attacks in any given year. Migraine is associated with substantial adverse socioeconomic and personal effects. It is the second leading cause of years lived with disability worldwide for all ages and the leading cause in women aged 15 to 49 years. Diagnostic uncertainty increases the likelihood of unnecessary investigations and suboptimal management. This article advises clinicians about diagnosing migraine, ruling out secondary headache disorders, developing acute and preventive treatment plans, and deciding when to refer the patient to a specialist.

Psychological therapies for the prevention of migraine in adults

BACKGROUND

Migraine is a common neurological problem associated with the highest burden amongst neurological conditions in terms of years lived with disability. Medications can be used as prophylaxis or rescue medicines, but are costly and not always effective. A range of psychological interventions have been developed to manage migraine.

OBJECTIVES

The objective was to evaluate the efficacy and adverse events of psychological therapies for the prevention of migraine in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL from their inception until July 2018, and trials registries in the UK, USA, Australia and New Zealand for randomised controlled trials of any psychological intervention for adults with migraine.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of a psychological therapy for people with chronic or episodic migraine, with or without aura. Interventions could be compared to another active treatment (psychological or medical), an attention-placebo (e.g. supportive counselling) or other placebo, routine care, or waiting-list control. We excluded studies where fewer than 15 participants completed each arm.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and outcome data at post-treatment and the longest available follow-up. We analysed intervention versus control comparisons for the primary outcome of migraine frequency. We measured migraine frequency using days with migraines or number of migraine attacks measured in the four weeks after treatment. In addition, we analysed the following secondary outcomes: responder rate (the proportion of participants with a 50% reduction in migraine frequency between the four weeks prior to and the four weeks after treatment); migraine intensity; migraine duration; migraine medication usage; mood; quality of life; migraine-related disability; and proportion of participants reporting adverse events during the treatment. We included these variables, where available, at follow-up, the timing of which varied between the studies. We used the GRADE approach to judge the quality of the evidence.

MAIN RESULTS

We found 21 RCTs including 2482 participants with migraine, and we extracted meta-analytic data from 14 of these studies. The majority of studies recruited participants through advertisements, included participants with migraine according to the International Classification of Headache Disorders (ICHD) criteria and those with and without aura. Most intervention arms were a form of behavioural or cognitive-behavioural therapy. The majority of comparator arms were no treatment, routine care or waiting list. Interventions varied from one 20-minute session to 14 hours of intervention. No study had unequivocally low risk of bias; all had at least one domain at high risk of bias, and 20 had two to five domains at high risk. Reporting of randomisation procedures and allocation concealment were at high or unclear risk of bias. We downgraded the quality of evidence for outcomes to very low, due to very serious limitations in study quality and imprecision. Reporting in trials was poor; we found no preregistrations stipulating the outcomes, or demonstrating equivalent expectations between groups. Few studies reported our outcomes of interest, most only reported outcomes post treatment; follow-up data were sparse.Post-treatment effectsWe found no evidence of an effect of psychological interventions for migraine frequency in number of migraines or days with migraine (standardised mean difference (SMD) -0.02, 95% confidence interval (CI) -0.17 to 0.13; 4 studies, 681 participants; very low-quality evidence).The responder rate (proportion of participants with migraine frequency reduction of more than 50%) was greater for those who received a psychological intervention compared to control: 101/186 participants (54%) with psychological therapy; 37/152 participants (24%) with control (risk ratio (RR) 2.21, 95% CI 1.63 to 2.98; 4 studies, 338 participants; very low-quality evidence). We found no effect of psychological therapies on migraine intensity (SMD -0.13, 95% CI -0.28 to 0.02; 4 studies, 685 participants). There were no data for migraine duration (hours of migraine per day). There was no effect on migraine medication usage (SMD -0.06, 95% CI -0.35 to 0.24; 2 studies, 483 participants), mood (mean difference (MD) 0.08, 95% CI -0.33 to 0.49; 4 studies, 432 participants), quality of life (SMD -0.02, 95% CI -0.30 to 0.26; 4 studies, 565 participants), or migraine-related disability (SMD -0.67, 95% CI -1.34 to 0.00; 6 studies, 952 participants). The proportion of participants reporting adverse events did not differ between those receiving psychological treatment (9/107; 8%) and control (30/101; 30%) (RR 0.16, 95% CI 0.00 to 7.85; 2 studies, 208 participants). Only two studies reported adverse events and so we were unable to draw any conclusions.We rated evidence from all studies as very low quality.Follow-upOnly four studies reported any follow-up data. Follow-ups ranged from four months following intervention to 11 months following intervention. There was no evidence of an effect on any outcomes at follow-up (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review identified 21 studies of psychological interventions for the management of migraine. We did not find evidence that psychological interventions affected migraine frequency, a result based on four studies of primarily brief treatments. Those who received psychological interventions were twice as likely to be classified as responders in the short term, but this was based on very low-quality evidence and there was no evidence of an effect of psychological intervention compared to control at follow-up. There was no evidence of an effect of psychological interventions on medication usage, mood, migraine-related disability or quality of life. There was no evidence of an effect of psychological interventions on migraine frequency in the short-term or long-term. In terms of adverse events, we were unable to draw conclusions as there was insufficient evidence. High and unclear risk of bias in study design and reporting, small numbers of participants, performance and detection bias meant that we rated all evidence as very low quality. Therefore, we conclude that there is an absence of high-quality evidence to determine whether psychological interventions are effective in managing migraine in adults and we are uncertain whether there is any difference between psychological therapies and controls.

Making a new-patient headache education session more patient-centered: what participants want to know

Purpose: To describe the new-patient Education Session provided by the Calgary Headache Assessment and Management Program, analyze patient evaluations, and generate potential patient-centered improvements based on themes in patient feedback.Materials and Methods: Between 2008 and 2012, 1873 new patients attended the Education Session, and 913 evaluations were completed. Session objectives ratings were analyzed. Open-ended questions regarding most- and least-helpful components and suggestions for improvement were examined using thematic analysis.Results: Eighty-seven percent of respondents indicated they would recommend the session to others with headache. Median objectives ratings ranged from 9.0-10.0 out of 10 and were stable over time. Most-helpful themes included medication, types of headache, our program's multi-faceted management approach, medication overuse, triggers, and not feeling alone. Most respondents left the least-useful and suggestions sections blank or commented "nothing" or "not applicable". Least-useful themes included migraine overemphasis, insufficient or excessive medication content, participant over-disclosure, and lack of practical trigger management strategies.Conclusion: Most attendees found the Education Session useful. Those who did not provided valuable input that will allow us to modify the content. Our findings may benefit other headache programs seeking to implement or improve patient education programing. Implications for RehabilitationHeadache is a common and debilitating condition.Education is an important part of headache treatment, and has been associated with decreases in headache frequency, intensity, and disability, as well as increases in self-efficacy.A new-patient Education Session is a practical and inexpensive way to provide evidence-based medical and behavioral headache information.Quantitative and qualitative analysis of patient evaluations can help gauge relevance and direct content changes.

[Relaxation techniques and behavioural therapy for the treatment of migraine : Guidelines from the German Migraine and Headache Society]

Besides pharmacological and interventional possibilities nonpharmacological options, deriving from behavioural approaches may be helpful in the treatment of migraine. Already consulting a patient reduces frequency of attacks. Relaxation (especially progressive muscle relaxation), endurance sports, and biofeedback as well as cognitive behavioural therapy are effective in treatment of migraine. The combination of these treatment options also with pharmacological treatment increase the positive effects.

A migraine management training program for primary care providers: An overview of a survey and pilot study findings, lessons learned, and considerations for further research

BACKGROUND

There are five to nine million primary care office visits a year for migraine in the United States. However, migraine care is often suboptimal in the primary care setting. A prior study indicated that primary care physicians (PCPs) wanted direct contact with headache specialists to improve the migraine care they provide.

OBJECTIVE

We sought to further examine PCPs' knowledge of migraine management and assess the feasibility of a multimodal migraine education program for PCPs.

METHODS

We conducted a survey assessing PCPs' knowledge about migraine. We then held three live educational sessions and developed an email consultative service for PCPs to submit questions they had about migraine. We report both quantitative and qualitative findings.

RESULTS

Twenty-one PCPs completed the survey. They were generally familiar with the epidemiology of migraine (mean prevalence of migraine reported was 12.6% ± 10.1), the psychiatric comorbidities (mean prevalence of comorbid depression was 24.5% ± 16.7, mean prevalence of comorbid anxiety was 24.6% ± 18.3), and evidence-based behavioral treatments. Fifty-six percent cited cognitive behavioral therapy, 78% cited biofeedback, and 61% cited relaxation therapy as evidence based treatments. Though most were aware of the prevalence of psychiatric comorbidities, they did not routinely assess for them (43% did not routinely assess for anxiety, 29% did not routinely assess for depression). PCPs reported frequently referring patients for non-level A evidence based treatments: special diets (60%), acupuncture (50%), physical therapy (30%), and psychoanalysis (20%). Relaxation therapy was a therapy recommended by 40% of the PCPs. Only 10% reported referring for cognitive behavioral therapy or biofeedback. Nineteen percent made minimal or no use of migraine preventive medications. Seventy-two percent were unaware of or only slightly aware of the American Academy of Neurology guidelines for migraine. There was variable attendance at the educational sessions (N=22 at 1st session, 6 at 2nd session, 15 at 3rd session). Very few PCPs used the email consultative service (N=4).

CONCLUSIONS

Though PCPs are familiar with many aspects of migraine care, there is a need and opportunity for improvement. The three live sessions were poorly attended and the email consultative service was rarely used. We provide an in depth discussion of targeted areas for educational intervention, of the challenges in developing a migraine educational program for PCPs, and areas for future study.

Behavioral treatments for migraine management: useful at each step of migraine care

Migraine is a disabling and prevalent disorder. Migraine is most effectively treated with a stepped care approach, where patients initially receive a broad level of care (primary care) and proceed to receive increasingly specialized care throughout the course of treatment. Behavioral treatments for migraine modify behaviors of people with migraine with the intention to prevent migraine episodes and secondary consequence of migraine. Behavioral treatments can be incorporated into each level of the stepped care approach for migraine treatment. In this article, we provide a rationale for including behavioral treatment strategies in the treatment of migraine. We then describe and review the evidence for behavioral treatment strategies for migraine, including patient education, relaxation strategies, biofeedback, and cognitive behavioral treatment strategies. Finally, we describe how behavioral treatments can be integrated into a stepped care approach for migraine care.

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

Patients with chronic migraine (CM) headaches present some of the most difficult treatment challenges for headache practitioners. Attention to psychological and behavioral issues become significant treatment considerations as the frequency of a patient's headaches increases, there is increased disability secondary to headaches, and/or there is inadequate response to usually effective treatment. Recent research has identified a variety of risk factors (including medication overuse) that appear to be associated with the escalation of the frequency and severity of migraine headache and are amenable to behavioral (non-pharmacological) treatment. The present article will highlight therapies that may be effective in the treatment of patients with CM headache.

Behavioral treatment of migraine: current status and future directions

The empirical support for three behavioral treatments (relaxation, biofeedback and cognitive therapy) for managing migraine headaches in children and adults is reviewed. Meta-analyses and evidence-based reports show that these approaches are of considerable value, they appear to work equally well when applied individually, in groups or in limited contact formats. Meta-analyses comparing behavioral and prophylactic medication show equivalent results. However, outcomes are optimized when these treatments are combined. Researchers are currently seeking to identify factors predictive of response to behavioral approaches. Patients experiencing medication-overuse, refractory, cluster or post-traumatic forms of headache or comorbid conditions present special challenges that can require intensive, comprehensive and multidisciplinary approaches to treatment. Behavioral treatments have met with mixed success for menstrual migraine in the few studies that have been conducted. This review concludes by highlighting directions for future research efforts such as importing treatments to settings where headache patients most often seek care and developing algorithms for optimizing combinations of behavioral and pharmacological treatments to enhance effectiveness, reduce costs, minimize dosing requirements and improve adherence to needed medications. Other research efforts include developing treatments that target the underlying pathophysiology more directly, gaining a greater understanding of mediators and moderators of behavioral treatments, exploiting e-technology for assessment and treatment, and assessing outcome in multiple ways--such as quality of life.

Optimal use of acute headache medication: a qualitative examination of behaviors and barriers to their performance

OBJECTIVE

This study aims to qualitatively examine the behaviors required to optimally use acute headache medication and the barriers to successful performance of these behaviors.

BACKGROUND

The efficacy of drug treatment is partly determined by medication adherence. The adherence literature has focused almost exclusively on the behaviors required to optimally use medications that are taken on a fixed schedule, as opposed to medications taken on an as needed basis to treat acute episodes of symptoms, such as headaches.

METHODS

Twenty-one people with headache and 15 health care providers participated in qualitative phenomenological interviews that were transcribed and coded by a multidisciplinary research team using phenomenological analysis.

RESULTS

Interviews revealed 8 behaviors required to optimally use acute headache medication, including cross-episode behaviors that people with headache regularly perform to ensure optimal acute headache medication use, and episode-specific behaviors used to treat an individual headache episode. Interviews further revealed 9 barriers that hinder successful performance of these behaviors.

CONCLUSIONS

Behaviors required to optimally use acute headache medication were numerous, often embedded in a larger chain of behaviors, and were susceptible to disruption by numerous barriers.

Multimodal behavioral treatment of migraine: an Internet-administered, randomized, controlled trial

INTRODUCTION

Multimodal approaches in behavioral treatment have gained recent interest, with proven efficacy for migraine. The utility of the Internet has been demonstrated for behavioral treatment of headache disorders, but not specifically for migraine. The aim of the study was to develop and evaluate an Internet-based multimodal behavior treatment (MBT) program for migraine and to test hand massage treatment as an adjunct.

METHODS

Eighty-three adults, 58 women and 25 men, with at least two migraine attacks a month were recruited via advertisements. An MBT program aiming at improvements in life-style and stress coping was developed for this study and, together with a diary, adapted for use over the Internet. Participants were randomized to MBT with and without hand massage and to a control group, and were followed for 11 months. Questionnaires addressing issues of quality of life (PQ23) and depressive symptoms (MADRS-S) were used.

RESULTS

A 50%, or greater, reduction in migraine frequency was found in 40% and 42% of participants of the two groups receiving MBT (with and without hand massage, respectively), who statistically were significantly more improved than participants in the control group. No effect of hand massage was detected, and gender did not show any independent contribution to the effect in a multivariate analysis.

CONCLUSIONS

MBT administered over the Internet appears feasible and effective in the treatment of migraine, but no effect of hand massage was found. For increased knowledge on long-term effects and the modes of action of the present MBT program, further studies are needed.

Behavioral medicine for migraine

Behavioral medicine is based on the biopsychosocial theory that biological, psychological, and environmental factors all play significant roles in human functioning. This article reviews empirically supported and efficacious behavioral approaches to the treatment and management of migraine including cognitive behavioral therapy and biobehavioral training (ie, biofeedback, relaxation training, and stress management). These techniques have demonstrated efficacy when learned and practiced correctly and may be used individually or in conjunction with pharmacologic and other interventions. Data are also reviewed regarding patient education, support groups, psychological comorbidities, modifiable risk factors for headache progression, strategies for enhancing adherence and motivation, and strategies for effective medical communication.

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

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.

Behavioral facilitation of medical treatment for headache--part I: Review of headache treatment compliance

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 facilitation of medical treatment for headache--part II: Theoretical models and behavioral strategies for improving adherence

This is the second of 2 articles addressing the problem of noncompliance in medical practice and, more specifically, compliance with headache treatment. The companion paper describes the problem of noncompliance in medical practice and reviews literature addressing compliance in headache care (Behavioral Facilitation of Medical Treatment for Headache--Part I: Review of Headache Treatment Compliance). The present paper first summarizes relevant health behavior theory to help account for the myriad biopsychosocial determinants of adherence, as well as patient's shifting responsiveness or "readiness for change" over time. Appreciation of health behavior models may assist in optimally tailoring interventions to patient needs through instructional, motivational, and behavioral treatment strategies. A wide range of specific cognitive and behavioral compliance-enhancing interventions are described, which may facilitate treatment adherence among headache patients. Strategies address patient education, patient/provider interaction, dosing regimens, psychiatric comorbidities, self-efficacy enhancement, and other behavioral interventions.

Optimizing migraine therapy: evidence-based and patient-centered care

Migraine is a chronic, intermittently debilitating neurovascular condition that affects the physical, mental and social aspects of health-related quality of life. Primary care provider interactions with migraine sufferers are common, highlighting the need for clinicians to provide optimal therapy. A comprehensive therapy plan should encompass the whole patient, via a patient-physician partnership where goals and strategies are mutually established. Key treatments include nondrug approaches, such as education and lifestyle modifications, to reduce the occurrence of attacks, as well as acute medications to address the immediate need for relief during an attack. Routine assessment and adjustment of therapy based on data recorded by patient diaries is paramount. Clinical trials support the use of triptans and dihydroergotamine for moderate-to-severe migraine and nonsteroidal anti-inflammatory drugs (alone or in combination with antiemetics or caffeine) for mild-to-moderate migraine, as the treatments of choice to reduce pain and disability time in a cost-effective manner. Published evidence also endorses stratified care, where medication selection is geared towards disease severity, instead of step care, where nonspecific mediations are given to all patients. Thus, patients with significant migraine-induced debilitation, as assessed by tools, such as the Migraine Disability Assessment Scale or the Headache Impact Test, are prescribed migraine-specific agents from the onset of therapy, thereby avoiding the inherent failures of step care. For individuals experiencing a high frequency of attacks or routine debilitation, preventive medications are warranted.

Methodological issues in clinical trials of drug and behavior therapies

Trials that compare drug and behavior therapies or evaluate combination therapy raise special methodological issues. This article reviews these methodological issues and, where possible, offers guidelines for addressing them. Sources of bias in the selection and recruitment of participants and in the measurement of treatment outcomes are discussed. In addition, methodological problems presented by the differing structures of behavior and drug therapy, by confounding variables, such as allegiance effects, differential expectations and preferences for drug or behavior therapy, and differential adherence with drug or behavior therapy also are reviewed. Issues in the selection of appropriate control groups are also discussed.

Future Directions in Behavioral Headache Research: Applications for an Evolving Health Care Environment

Three decades of research has produced effective behavioral treatments for migraine and tension-type headache, yet the full fruition of this research has not been realized. Further development and dissemination of behavioral treatments is needed to impact the large numbers of those with headache who potentially could benefit from these interventions. At the same time, an evolving health care environment challenges researchers and providers to employ greater efficiency and innovation in managing all chronic disorders. Hopefully, the recently published clinical trials guidelines for behavioral headache research will serve as a catalyst for production of quality empiricism that, in turn, will generate enhanced behavioral strategies and will optimize health care resource utilization. This article describes 10 areas of critical needs and research priorities for behavioral headache research, including: replication and extension of seminal studies using improved methodology; analysis of barriers to implementation of behavioral treatments; development of referral and treatment algorithms; behavioral compliance facilitation with medical interventions; development of a headache self-management model; integration of behavioral intervention within traditional medical practice; identification and management of comorbid psychopathology among headache patients; prevention of disease progression; analysis of behavioral therapeutic mechanisms, and development of innovative treatment formats and applications of information technologies.

Initiating and optimizing acute therapy for migraine: the role of patient-centered stratified care

Migraine is a chronic, intermittently disabling condition that affects physical, mental, and social aspects of health-related quality of life. Because patients seeking assistance with migraine most often present to primary care providers, these healthcare professionals play critical roles in the diagnosis and treatment process. A comprehensive migraine management plan involves a partnership between the patient and healthcare professional where treatment goals and strategies are established. Elements of such a plan should include preventive strategies to reduce the frequency and effects of future attacks as well as the use of acute treatments to address the immediate need for relief during an attack. Approaches to prevention include education, lifestyle modification, and, often, appropriate medication. Many medications have been used for acute treatment. Nonspecific agents include nonsteroidal anti-inflammatory drugs (NSAIDs), single or combination analgesics (sometimes including antiemetics or caffeine), and narcotics. Migraine-specific medications include ergot alkaloids and triptans (5-hydroxytryptamine(1B/1D) agonists). Various professional organizations have created guidelines to help providers in choosing appropriate management interventions. Clinical approaches to the patient with migraine include step care, whereby all patients begin on a simple or nonspecific treatment, stepping up to the next level of therapy if treatment is unsuccessful; or stratified care, whereby first-line therapy is tailored to the severity of the patient's pattern of headache. Studies have demonstrated that for more disabled headache patients, the stratified-care approach results in more robust headache response with less disability and greater cost-effectiveness than step care. Patient satisfaction studies demonstrate that the use of migraine-specific abortive medications (triptans) is associated with a higher satisfaction rate than over-the-counter preparations, NSAIDs, and analgesic combinations. Patients who initially reported satisfaction with the latter medications also reported a preference for triptan therapy. Healthcare professionals can assist patients, not only by choosing the most appropriate medication but also by assessing whether the level of benefit the patient is currently receiving could be improved.

Behavioral interventions for tension-type headache: overview of current therapies and recommendation for a self-management model for chronic headache

Behavioral treatments (relaxation, biofeedback, cognitive-behavioral therapy) have been empirically validated for migraine and tension-type headaches, with recent meta-analyses yielding 37% to 50% reductions in tension-type headache, comparing favorably with 33% reduction from medication prophylaxis (amitriptyline). Research has moved toward increasing availability and cost effectiveness through alternative delivery formats and combining and comparing them with standard medications. Further modifications would make standard behavioral treatments available and conducive to primary care settings where most patients receive treatment. Beyond the current behavioral and drug treatments, we propose a fundamental shift in conceptualization and treatment for headache.

Improving adherence and persistence: a review and assessment of interventions and description of steps toward a national adherence initiative

OBJECTIVES

To identify the effectiveness of adherence interventions reported in the literature, to identify interventions being conducted and/or sponsored by large chain pharmacies and pharmaceutical manufacturers, and to seek input from a panel of pharmacists who address adherence issues on a daily basis as to the steps that should be taken to advance a national initiative to increase awareness of the importance of and opportunities associated with medication adherence and persistence.

MAIN OUTCOME MEASURE

Effectiveness of the adherence interventions reported in the literature.

METHODS

First, a literature search was conducted using MEDLINE, International Pharmaceutical Abstracts, CINAHL, and PsycINFO. Keywords were medication or drug and compliance or adherence or persistence and control group. Second, pharmaceutical manufacturers and chain pharmacies were surveyed. Third, an advisory panel reacted to the research findings and formulated a series of action steps that could support or be part of a national initiative to increase adherence.

RESULTS

Reported adherence-related interventions were grouped into five categories--adherence aids, refill or follow-up reminders, regimen simplification, written and oral education, and comprehensive management. Median adherence increases ranged from 6% to 25% for these categories. Interviews with 10 chain pharmacies revealed that adherence is an important issue. Most chains have some form of adherence program in place, but current initiatives are product-focused rather than patient-focused. Interviews with 15 manufacturers revealed that they currently use a variety of adherence interventions and want to partner with pharmacies to implement and assess the initiatives. The advisory panel developed a series of action items for implementing a national adherence initiative.

CONCLUSION

Comprehensive interventions can improve adherence and are mutually beneficial for patients, pharmacies, and manufacturers. Pharmacists must be able to assess patients' adherence, identify the reasons for nonadherence, and develop patient-specific interventions. Studies have shown that the most successful interventions have some follow-up component and address the underlying reason(s) for nonadherence. Pharmacies and pharmaceutical manufacturers have tried various adherence interventions, such as patient education and refill reminders. There is a growing sense that a national adherence initiative is needed to coordinate pharmacists' efforts to address this public health problem, and the American Pharmacists Association is well positioned to take a leadership role in such efforts.

Ergotamine and dihydroergotamine: history, pharmacology, and efficacy

Ergotamine and dihydroergotamine share structural similarities with the adrenergic, dopaminergic, and serotonergic neurotransmitters. As a result, they have wide-ranging effects on the physiologic processes that they mediate. Ergotamine and dihydroergotamine are highly potent at the 5-HT1B and 5-HT1D antimigraine receptors and, as a consequence, the plasma concentrations that are necessary to produce the appropriate therapeutic and physiologic effects are very low. The broad spectrum of activity at other monoamine receptors is responsible for their side effect profile (dysphoria, nausea, emesis, unnecessary vascular effects). Both ergotamine and dihydroergotamine have sustained vasoconstrictor actions. In acute migraine treatment, their mechanisms of action involve constricting the pain-producing intracranial extracerebral blood vessels at the 5-HT1B receptors and inhibiting the trigeminal neurotransmission at the peripheral and central 5-HT1D receptors. The scientific evidence for efficacy is stronger for dihydroergotamine than for ergotamine. Their wide use is based on long-term experience.

Self-management approaches for people with chronic conditions: a review

The purpose of this paper is to provide an overview of self-management approaches for people with chronic conditions. The literature reviewed was assessed in terms of the nature of the self-management approach and the effectiveness. Findings are discussed under the headings of: chronic conditions targeted, country where intervention was based, type of approach (e.g. format, content, tutor, setting), outcomes and effectiveness. The last of these focused on reports of randomised controlled studies.

Self-management approaches for people with chronic conditions: a review

The purpose of this paper is to provide an overview of self-management approaches for people with chronic conditions. The literature reviewed was assessed in terms of the nature of the self-management approach and the effectiveness. Findings are discussed under the headings of: chronic conditions targeted, country where intervention was based, type of approach (e.g. format, content, tutor, setting), outcomes and effectiveness. The last of these focused on reports of randomised controlled studies.

Effectiveness of interventions to improve patient compliance: a meta-analysis

OBJECTIVES

This article summarizes the results of 153 studies published between 1977 and 1994 that evaluated the effectiveness of interventions to improve patient compliance with medical regimens.

METHODS

The compliance interventions were classified by theoretical focus into educational, behavioral, and affective categories within which specific intervention strategies were further distinguished. The compliance indicators broadly represent five classes of compliance-related assessments: (1) health outcomes (eg, blood pressure and hospitalization), (2) direct indicators (eg, urine and blood tracers and weight change), (3) indirect indicators (eg, pill count and refill records), (4) subjective report (eg, patients' or others' reports), and (5) utilization (appointment making and keeping and use of preventive services). An effect size (ES) r, defined as Fisher's Z transformation of the Pearson correlation coefficient, representing the association between each intervention (intervention versus control) and compliance measure was calculated. Both an unweighted and weighted r were calculated because of large sample size variation, and a combined probability across studies was calculated.

RESULTS

The interventions produced significant effects for all the compliance indicators (combined Z values more than 5 and less than 32), with the magnitude of effects ranging from small to large. The largest effects (unweighted) were evident for refill records and pill counts and in blood/urine and weight change studies. Although smaller in magnitude, compliance effects were evident for improved health outcomes and utilization. Chronic disease patients, including those with diabetes and hypertension, as well as cancer patients and those with mental health problems especially benefited from interventions.

CONCLUSIONS

No single strategy or programmatic focus showed any clear advantage compared with another. Comprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions.

Psychological treatments for migraine

Psychological and behavioral treatments for migraine are described and evidence for their efficacy is reviewed. Treatments for children, adolescents, and the elderly, and for menstrual migraine are then discussed. Biofeedback, relaxation, and stress-coping treatments have all demonstrated effectiveness. These treatments are effective for the majority of migraine sufferers and treatment effects are reliably maintained for periods of at least one year. Little is known about the mechanism behind the efficacy of psychological treatments. Suggestions for future research on treatment mechanisms, enhancement of treatment effectiveness, and increasing the acceptance of psychological treatments are provided.

Neglected topics in the treatment of chronic pain patients--relapse, noncompliance, and adherence enhancement

Although published treatment outcome studies for chronic pain have provided favorable support for the efficacy of many pain clinics and the use of specific modalities such as biofeedback and relaxation, there are several factors that mitigate against euphoria. Two related factors that influence interpretation of these reported outcomes are discussed, namely, noncompliance with therapeutic recommendations during treatment and subsequent to treatment termination, and relapse. Conceptual and methodological problems for establishing the prevalence of noncompliance and relapse are reviewed. Several factors that contribute to noncompliance (individual differences, nature of disease or injury, characteristics of the prescribed treatment regimen, health-care provider-patient relationship, and contextual) are discussed. The literature reveals that noncompliance with treatment regimens is quite prevalent across diverse treatment modalities and pain syndromes. The incidence of relapse following initially successful treatment of persistent pain also appears to be high, ranging from 30% to 60%. Studies on arthritis and heterogeneous pain clinic populations suggest that noncompliance and relapse are related; however, this association is less well established for headache patients. Strategies for assessing compliance (i.e., self-report, behavioral, biochemical, and clinical outcome) and the perspectives' of patients and health-care providers on the application of self-care recommendations are discussed. Strategic planning and adherence enhancement tactics to facilitate maintenance of post-treatment gains are described.

Long-term maintenance of improvements achieved with (abortive) pharmacological and nonpharmacological treatments for migraine: preliminary findings

This report presents the first prospective comparison of the long-term maintenance of reductions in recurrent migraine headaches achieved with (abortive) pharmacological and nonpharmacological (combined relaxation training and thermal biofeedback training) treatments. Nineteen of 21 (90%) successfully treated patients (50% or greater reduction in headache activity) were contacted for follow-up evaluation 3 years later. Migraine sufferers who had been treated with ergotamine were less likely to still be relying on the treatment they had received and more likely to have additional medical treatment for their headaches and to be using prophylactic or narcotic medication than were migraine sufferers who had been treated with relaxation/biofeedback training. However, daily headache recordings revealed that patients in both treatment groups continued to show lower headache activity at 3-year follow-up than prior to treatment. Although preliminary, these findings raise the possibility that improvements achieved with nonpharmacological treatment are more likely to be maintained without additional treatment than are similar improvements achieved with abortive pharmacological treatment.