Expert Opinion: Adherence to Prophylactic Migraine Medication

Abstract

CASE This 33-year-old woman is seen in headache consultation with a 15-year history of migraine without aura occurring about 8 times monthly with an inconsistent response to triptans. She was tried on amitriptyline 25 mg at bedtime by her primary care physician but stopped on her own after 1 week because she was no better even though she was aware that the medication may take 6 weeks to work and that the dose may need to be higher. A neurologist placed her on topiramate, which she took inconsistently because she “forgot” and reported that the medication was not effective. Questions: What is the difference between compliance and adherence? How often are migraineurs non-adherent with preventive medications and why? What can physicians do to improve adherence? EXPERT COMMENTARY There is no commonly accepted indication for starting a prophylactic treatment. According to European Federation of Neurological Societies Task Force guidelines, prophylactic drug treatment should be considered and discussed with the patient when important life domains are severely impaired, the frequency of attacks is 2 or more per month, acute treatment fails, or when auras are very disturbing. However, in daily migraine care, one cannot simply expect the same efficacy of drugs as in clinical trials, because prophylactic treatment is not uncommonly prematurely discontinued by the migraineur for no apparent clinical reason. The term “compliance” is still commonly used to indicate a patient’s correct following of medical advice. Non-compliance has thus sometimes been regarded as a manifestation of irrational behavior or willful failure to observe instructions. Nowadays, health care professionals prefer to talk about “adherence” to a regimen, a less authoritarian term proposed for the extent to which patients follow agreed recommendations regarding treatment. It emphasizes the importance of the patient’s participation. Regardless of the nomenclature, this poorly understood phenomenon is a significant problem in headache care,because it prevents achievement of the full benefits of medications. It is possible that most evaluations of efficacy and tolerance of migraine prophylactics to date have been biased in this respect. A large number of studies have addressed the degree of patient nonadherence to medication in other medical conditions, Case history submitted by: Randolph W. Evans, MD, 1200 Binz #1370, Houston, TX 77004, USA.