How Neurologists Can Bolster the Patient Relationship in Migraine Treatment: Q&A with Dawn Buse, PhD, FAHS

Insights on building the strongest connection possible between neurologists and patients with migraine

Neurologists and their patients share a unique relationship. It takes active investment and open communication from both parties in order to achieve effective treatment and get patients the care they deserve. We spoke with Dawn Buse, PhD, FAHS, to get some insight into strategies that neurologists can use to make sure they’re doing the most for their patients and fostering a positive relationship.

Are there any common mistakes healthcare professionals make when trying to connect with a patient with migraine?

One mistake we can make as healthcare professionals is that we may be so enthusiastic and earnest in our desire to help patients that we may be more ready to take action than they are. We should always consider what the patient needs “right now” and meet them there. They may be early on in their readiness to change and may be looking for information and education. Or they may be further along in their journey and ready for active treatment and interventions—whether they are pharmacologic, interventional or behavioral.

What is the most important thing a healthcare professional can do to build a relationship with a patient?

The doctor-patient relationship is, at its essence, a relationship between two people. It is important that there is open, honest communication in order to establish mutual respect and trust. Not only should the patient feel respected, but the healthcare professional should feel respected, too. And if, on either side, there are problems, the first way to address it is with effective communication.

Another way to establish positive therapeutic relationships is by managing expectations. This may include setting expectations for realistic treatment outcomes, types of treatments that they can expect (as well as those that they should not expect to receive, such as opioids, if that if your policy) as well as the expectations related to patient engagement, medication adherence and conduct within the context of care. In rare cases, this is best managed with a treatment contract. If a patient has seen multiple providers before coming to you, setting expectations may help set the stage for good outcomes. This may include outlining what you’re going to bring to the shared treatment planning and management processes and what you will expect from them. Let them know that there are things that they will need to do on their part as the patient and things you’ll do on your side as the healthcare professional.

Another area where we want to set realistic expectations is in how quickly therapies may work. We want to let patients know what to expect in advance in terms of timing of therapeutic onset so that they don’t stop or discontinue a preventive medication on their own before it is given a fair trial. We also want to let them know that they may experience expect side effects so that if they experience them they do not feel alarmed. Ask them to enter timing, efficacy and side effect data into a diary so that you can review it together at the next appointment and address issues as they arise. The more information you can give a patient about what to expect, the more likely they are to adhere to their treatment, share concerns with you, not make medication or treatment decisions on their own and feel trust in the relationship.

After trust has been established, what next steps are needed in order to maintain the relationship?

For successful ongoing management, one must continue listening to the patient. We want to ask the patient at every visit about how migraine affects their life and what their most important goals or objectives are. Let them tell us—in their own words—what they care about. Then we can match their goals with a treatment plan and use their own stated values to help motivate them. Shared decision making can lead to positive treatment outcomes and good adherence to treatment. We always want to explain our rationale for treatments that we recommend and engage in a discussion with the patent about his/her concerns, history, and preference, ultimately agreeing upon treatments that are selected and prescribed or recommended.

It is important for every patient to learn about the healthy lifestyle habits that can significantly impact outcomes including sleep, stress management, exercise and maintaining a healthy weight, healthy diet, hydration, and nutrition. It is best to make these recommendations as well as any referrals for behavioral treatment alongside pharmacologic prescriptions, so that they are perceived by the patient as being important, powerful interventions and actions. Writing behavioral and lifestyle recommendations on a prescription pad and/or including them in the electronic health summary that patients are given at the end of a visit also helps to validate their importance.

If we assign homework such as asking a patient to keep a headache diary, we have to remember to ask about it and review it at the next visit. If we make a referral to physical therapy, behavioral therapies or recommend exercise or any other healthy lifestyle changes, it is essential that we follow up at the next visit ask about any challenges and/or any successes. Patients, rightfully so, feel offended if we don’t ask about the work that they did, and may not continue to do it if we do not validate the effort that they are making toward good outcomes.

You’re a healthcare professional and you come across a patient who is seeking out multiple opinions and who has had failures with other providers—how do you advise them?

As a healthcare professional with expertise in headache, you will come across patients who may have seen multiple providers before you. They may have seen different types of providers. Perhaps they moved from a primary care provider to a neurologist, and now they’re seeing a headache specialist. Or maybe they’ve seen multiple providers within a geographic location, traveled from city to city, or maybe they’ve already been to an inpatient headache center. During your initial visit with that patient, it is important to not only gather their history but have a conversation about what has and has not worked for them, as well as their preferences and current goals and expectations. For the patient who has had previous disappointments and treatment failures, it is really important that they feel heard and are able to express their feelings and goals. As a healthcare professional, you can learn through conversation what treatments were not effective or tolerated previously and set realistic expectations with this patient about how your work together can proceed.

And remember: there are always reasons why people switch providers that may have nothing to do with the provider. It may be health insurance costs, geography or other simple kinds of preference issues. So, when you see a patient who has seen multiple providers, it is best is to engage in open communication so you can figure out what happened and establish a good plan for the two of you going forward.

Treating patients with migraine does not have to feel like an insurmountable task. For more information about treating this disease and interacting with patients, visit the American Migraine Foundation’s resource library.