Optimal Use of Acute Headache Medication
Optimal Use of Acute Headache Medication
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.
The efficacy of drug treatment is partly determined by medication adherence. Unfortunately, medication adherence is the Achilles heel of drug therapy, with only 50–75% of patients performing the behaviors required to optimally use medication.
Medication adherence is commonly considered a binary construct which classifies patients as "adherent" or "nonadherent." Recently, however, researchers are increasingly conceptualizing medication adherence as performance of the set of behaviors necessary to optimally use medication to manage a disorder. This conceptualization provides specific targets for assessment and intervention.
The adherence literature has focused almost exclusively on the behaviors required to optimally use medications that are taken on a fixed schedule ("fixed schedule medications"), such as antihypertensive, antiretroviral, and antidepressant medications. The adherence literature has devoted comparatively little attention to the behaviors required for optimal use of medications taken acutely to treat recurrent episodes of a disorder or symptom exacerbations ("acute medications"), such as medication used as needed to treat a headache episode. Although qualitative research suggests that optimal use of fixed schedule medication requires 3 medication-taking behaviors (establishing medication taking as part of a regular routine, keeping medication accessible at scheduled times for administration, and communicating relevant information to the prescriber), using acute medications optimally appears to require successful performance of more complicated sequences of behaviors, which are contingent on multiple symptom- and situation-specific factors. Therefore, optimal use of acute medication may be more challenging and more problematic than optimal use of fixed-schedule medication.
In the headache literature, medication adherence is of particular interest because of the increasing awareness about negative ramification of medication overuse, currently defined as overuse of a of medication (taking triptans, ergotamines, opioids, or a combination of analgesics on 10 or more days per month, or simple analgesics on 15 or more days per month) for over 3 months. Rates of overuse depend on the class of the medication, with 1 study finding 34.7% of people with migraine overusing simple analgesics, while 2.7% overuse ergotamine tartrate. Medication overuse headache is a disorder in which chronic headache (present on 15 or more days per month) develops or worsens during medication overuse, and resolves within 2 months of discontinuation of the overused medication. Medication overuse headache has a population prevalence of 1.5% and has been associated with high levels of headache-related disability. Medication overuse headache tends to difficult to treat with high rates of relapse (about 30% relapse within 1 year of detoxification), although the addition of behavioral treatment to pharmacotherapy has been associated with reduced relapse rates. This notable negative consequence of problematic use of acute headache medications has shone light on the importance of optimal use of acute headache medication, as well as the paucity of current information about use of acute headache medication.
The limited available literature has identified 2 additional problems in optimal use of acute headache medication: suboptimal timing of use and suboptimal choice of medication type. Between 40% and 85% of people with headache do not optimally time their use of acute headache medication, most often waiting to take abortive migraine medications until after they are most likely to be effective. Patients may also choose less effective types of medication when a more effective type of medication is available (eg, using a nonspecific pain medication rather than a migraine-specific medication to treat a severe migraine).
Major limitations of the current literature include the lack of holistic assessment of behaviors required for optimal use of acute headache medication, and lack of standardized assessments of these behaviors. Solely studying behaviors chosen a priori by investigators enhances the risk of overlooking potentially important behaviors required for optimal use of acute headache medication. Idiosyncratic assessment of these behaviors prevents comparison across studies, and consequently, development of a robust body of knowledge about optimal use of acute headache medication. A method of evaluating behaviors required to optimally use acute headache medications is prerequisite to developing instruments to assess performance of these behaviors, as well as interventions to increase the probability of successful performance of these behaviors. However, specific medication-taking behaviors people with headache are utilizing to manage headaches in the moment have not been elucidated.
Qualitative research is a standardized form of inquiry that is designed to gather in-depth, holistic information about a phenomenon utilizing detailed study of a few participants. At an early stage of inquiry, such as the current state of the literature on optimal use of acute headache medications, qualitative (as opposed to quantitative) studies can provide detailed information about little-studied phenomena and minimize reliance on researcher assumptions and biases which can overlook important information about a phenomenon. Qualitative studies are an important foundation upon which a program of empirical research can build, allowing the program of research to avoid "Type 3 errors," or the error of asking unnecessary or inconsequential empirical questions.
This paper presents a qualitative study of the behaviors required to optimally use acute headache medication and the barriers to successful performance of these behaviors.
Abstract and Introduction
Abstract
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.
Introduction
The efficacy of drug treatment is partly determined by medication adherence. Unfortunately, medication adherence is the Achilles heel of drug therapy, with only 50–75% of patients performing the behaviors required to optimally use medication.
Medication adherence is commonly considered a binary construct which classifies patients as "adherent" or "nonadherent." Recently, however, researchers are increasingly conceptualizing medication adherence as performance of the set of behaviors necessary to optimally use medication to manage a disorder. This conceptualization provides specific targets for assessment and intervention.
The adherence literature has focused almost exclusively on the behaviors required to optimally use medications that are taken on a fixed schedule ("fixed schedule medications"), such as antihypertensive, antiretroviral, and antidepressant medications. The adherence literature has devoted comparatively little attention to the behaviors required for optimal use of medications taken acutely to treat recurrent episodes of a disorder or symptom exacerbations ("acute medications"), such as medication used as needed to treat a headache episode. Although qualitative research suggests that optimal use of fixed schedule medication requires 3 medication-taking behaviors (establishing medication taking as part of a regular routine, keeping medication accessible at scheduled times for administration, and communicating relevant information to the prescriber), using acute medications optimally appears to require successful performance of more complicated sequences of behaviors, which are contingent on multiple symptom- and situation-specific factors. Therefore, optimal use of acute medication may be more challenging and more problematic than optimal use of fixed-schedule medication.
In the headache literature, medication adherence is of particular interest because of the increasing awareness about negative ramification of medication overuse, currently defined as overuse of a of medication (taking triptans, ergotamines, opioids, or a combination of analgesics on 10 or more days per month, or simple analgesics on 15 or more days per month) for over 3 months. Rates of overuse depend on the class of the medication, with 1 study finding 34.7% of people with migraine overusing simple analgesics, while 2.7% overuse ergotamine tartrate. Medication overuse headache is a disorder in which chronic headache (present on 15 or more days per month) develops or worsens during medication overuse, and resolves within 2 months of discontinuation of the overused medication. Medication overuse headache has a population prevalence of 1.5% and has been associated with high levels of headache-related disability. Medication overuse headache tends to difficult to treat with high rates of relapse (about 30% relapse within 1 year of detoxification), although the addition of behavioral treatment to pharmacotherapy has been associated with reduced relapse rates. This notable negative consequence of problematic use of acute headache medications has shone light on the importance of optimal use of acute headache medication, as well as the paucity of current information about use of acute headache medication.
The limited available literature has identified 2 additional problems in optimal use of acute headache medication: suboptimal timing of use and suboptimal choice of medication type. Between 40% and 85% of people with headache do not optimally time their use of acute headache medication, most often waiting to take abortive migraine medications until after they are most likely to be effective. Patients may also choose less effective types of medication when a more effective type of medication is available (eg, using a nonspecific pain medication rather than a migraine-specific medication to treat a severe migraine).
Major limitations of the current literature include the lack of holistic assessment of behaviors required for optimal use of acute headache medication, and lack of standardized assessments of these behaviors. Solely studying behaviors chosen a priori by investigators enhances the risk of overlooking potentially important behaviors required for optimal use of acute headache medication. Idiosyncratic assessment of these behaviors prevents comparison across studies, and consequently, development of a robust body of knowledge about optimal use of acute headache medication. A method of evaluating behaviors required to optimally use acute headache medications is prerequisite to developing instruments to assess performance of these behaviors, as well as interventions to increase the probability of successful performance of these behaviors. However, specific medication-taking behaviors people with headache are utilizing to manage headaches in the moment have not been elucidated.
Qualitative research is a standardized form of inquiry that is designed to gather in-depth, holistic information about a phenomenon utilizing detailed study of a few participants. At an early stage of inquiry, such as the current state of the literature on optimal use of acute headache medications, qualitative (as opposed to quantitative) studies can provide detailed information about little-studied phenomena and minimize reliance on researcher assumptions and biases which can overlook important information about a phenomenon. Qualitative studies are an important foundation upon which a program of empirical research can build, allowing the program of research to avoid "Type 3 errors," or the error of asking unnecessary or inconsequential empirical questions.
This paper presents a qualitative study of the behaviors required to optimally use acute headache medication and the barriers to successful performance of these behaviors.
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