The Role of Adherence and Triggers in Headache Management

Key Points:

Best outcomes of care result from sticking to your plan through excellent communication with a provider.
You best select if, when and how to use advice through self-observation, including the use of a calendar or diary.
Success is improved by review of triggers and their management.
Top of the list headache triggers include changes in sleep and exercise, lack of stress management and a proper eating plan.

Adherence: what is it and why does it matter?

“Adherence” and “compliance” are terms that are used to refer to a patient’s role in their medical care. “Compliance” refers to the degree to which patients follow medical recommendations of their health care providers (HCP). “Adherence” is a preferable term in headache care because it refers to collaboration between the patient and the HCP. The patient plays a vital role in the success of his or her headache management. While an HCP may provide medical advice and prescriptions, it is the patient who ultimately chooses if, when, and how to implement that advice.

Effective headache treatment can include both pharmacological (medication) and non-phammacologic (behavioral) components. Adherence challenges in pharmacological treatment may include misuse of medication (including unfilled, overused, underused, incorrectly used, and unadvised discontinuation of prescribed medications). Some of these behaviors can have severe consequences. For example, overusing medication can lead to a “medication overuse headache” or a “rebound headache.” Combining medications without medical advice can lead to dangerous interactions and side effects. Taking medications too early (before the pain of migraine begins) or too late into an attack can limit their effectiveness.

Following the behavioral components of headache treatment can be even more challenging. This may include keeping appointments and a headache calendar or diary if the HCP prefers, practicing proper sleep hygiene, 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.

Motivation and behavior change

Making behavior changes such as weight loss or smoking cessation can be extremely difficult. The psychologist Albert Bandura developed social learning theory to help explain human behavior and change.

The theory states that there are two vital components to successful behavior change:

Self-efficacy (the confidence in one’s ability to perform an action).
Outcome efficacy (the belief that a behavior or a set of behaviors will have a desirable result).

Therefore, in order to accomplish a goal, one must both want to change and have the knowledge and tools necessary to complete the change. Behavioral change and achieving goals can occur in small steps.

One theory of behavioral change proposes that behavior change can be broken down into five stages:

Precontemplation (the patient is not thinking about changing behavior and does not recognize the need or a problem).

Contemplation (the patient recognizes a need or problem and begins to think about changing behavior and may be developing a plan, but has not taken any action).

Preparation (the patient has done research, developed a plan and may begin making minor changes or actions).

Action (the patient is actively engaged in the behavior change or new actions).

Maintenance (the patient is continuing behaviors necessary to maintain changes).

This theory can be applied to many types of behavior change including starting an exercise regimen, quitting smoking, or following a healthy diet. This model helps patients recognize that even what seems like small steps are important in reaching a goal and that a “lapse” or “relapse” is not a failure, but rather a step back from which the patient can recover.

Partnership and Communication with your HCP

Open patient-provider communication is essential for effective headache treatment. You and your HCP must work together as a team to manage your headaches. You should see your doctor for an accurate diagnosis of your headache and to rule out any injury or illness that may be the cause of your headache. Your HCP needs to know about the frequency and severity of your headaches, triggers, and how they affect your life.

This may start with keeping a headache calendar and sharing that information with your provider. You should work with this individual to create a headache management plan which would ideally include preventing more headache, reducing current frequency of headache and successful relief when treating a headache with pain drugs.

This plan may include behavioral techniques that you can learn with a professional or on your own as well as medication. You and your doctor may try many treatment options before you discover what works best for you. This plan should be evaluated regularly and may be updated as needed.

See Articles for “How to Talk to Your Practitioner About Your Headaches” for more advice on preparing for your appointment and speaking with your doctor about your headaches.

What can you do to manage your headaches?

The most important things that you can do to control your headaches are:

Communicate openly with your HCP about how headaches affect your life.

Identify your personal triggers and work with the HCP for ideas to reduce them.

Control universal triggers by maintaining a healthy lifestyle of regular sleep, exercise and eating
plan, and practicing relaxation and stress management techniques.

Take supplements and medications as prescribed and discuss any questions, concerns, or side effects with your HCP.

Adhere to the decisions you make.

Seek professional help if necessary.

What are headache triggers?

Headache triggers are factors that may lead to a headache or make it more likely for you to have an attack. They vary for each individual, however, there are some common triggers. The best way to identify these is to keep a “headache diary” in which you record when you have a headache as well as what you eat, drink, when you sleep, your hormonal cycle (for women), medications taken, factors in the environment, weather, and any other changes.

Keeping a headache diary for one to two months helps identify any triggers or patterns to avoid or change to improve your headaches. You can use this information to identify your triggers yourself and also take this diary with you to your next medical appointment.

Some of the most common headache triggers and suggestions for maintaining a healthy lifestyle:

Diet and nutrition

Eating appropriate portions, healthy foods, and maintaining a healthy weight are all very important habits for people who suffer from headaches. It is very important that you eat a well-balanced diet with meals scheduled on a regular basis throughout the day (including breakfast).

It is important to include healthy choices such as fresh fruits and vegetables, lean meats, poultry and fish, other sources of protein, and whole grains. Whenever possible, choose fresh foods to avoid chemicals in overly processed or preserved foods which trigger headache. Skipping a meal or waiting too long to eat or becoming dehydrated can trigger a headache. Caffeine and alcohol overuse or withdrawal can also trigger headaches.

In addition, some people think that certain cheeses, chocolate, red wine, tea and coffee and other foods trigger their headaches. You can keep a food diary to determine if specific foods are related to your headaches.

Sleep

It is important to maintain a healthy and regular sleep cycle. Most people feel that sevent to eight hours a night is an appropriate amount of sleep for an adult, but you should pay attention to your own body to learn your own sleep needs. It is important to maintain a regular sleep and wake cycle—both during the week and on the weekends, and avoid getting too little or too much sleep. Be aware that less than six hours and more than nine hours is a proven provoker for next day headache.

Environmental factors

Environmental factors such as bright or flickering lights, strong smells such as perfume, and changes in the weather including a drop in barometric pressure (which often occurs before a storm) may trigger a headache. You may not be able to control all of these factors, but there may be changes that you can make in your home and work environment that may make it less likely to trigger a headache.

In addition, you may want to keep an eye mask and ear plugs on hand in case of a headache. Many people find that they can help stop a headache if they are able to lie down in a dark, quiet, room and relax or sleep.

Psychological and emotional factors

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.

Hormonal factors (for women)

Many women find that their headaches frequently occur during certain times of their menstrual cycle—often just before or at the beginning of their menstrual flow. You may want to keep a headache diary and note the timing of your headaches. If you find that they are related to your menstrual cycle, you should talk to your HCP about treatment options. In addition, you should be aware that maintaining a regular and healthy lifestyle including proper diet, sleep, exercise, stress management, and relaxation will be particularly important for you during this time each month.

Pregnancy is a unique time for women with headaches

Many women find that they experience headaches early in the pregnancy but feel much better as the pregnancy progresses. If you are pregnant or considering becoming pregnant, it is very important to communicate this to your provider. Many headache medications can harm a developing fetus, and your HCP can help provide the best care for you and your baby.

Lifestyle

You may find that factors such as intense exercise or long-distance travel, especially across time zones, trigger your headaches. You may also find other factors both at home and in the workplace that triggers your headaches. It may not be possible to eliminate or avoid these triggers, however, you should carefully review your lifestyle determining your stress factors in all areas of your life—including occupational or academic, family, social, financial, and personal. When making decisions always try to choose the healthier option, as that will help you avoid headache attacks.

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 makes 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.

Most 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.

Dawn C. Buse, PhD. Director of Psychology, Albert Einstein College of Medicine, Bronx, NY.