Bedside Manner: Collaborating With Your Doctor for Migraine Treatment

One of the keys to treating migraine headaches successfully is to work well
with a doctor who listens to you.

As a migraine sufferer, I have noticed that this can be as difficult from the patient end as it frequently is from the doctor end.

Bedside Manner: Collaborating with Your Doctor for Migraine Treatment
As patients, we are trained to look at doctors as our superiors. We treat them
as authority figures, and they frequently behave as such.

But if you find a doctor who treats you as an equal, you have the opportunity
to collaborate with your doctor to prevent and treat migraine attacks.

Following are some guidelines and recommendations to help you as the patient to effectively work with your doctor to treat your head pain.

1. Start by choosing a doctor who will collaborate with you.

The first step in beginning a collaborative process is to choose a doctor who
will be open to it in the first place, and not simply issue orders.

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This might be a neurologist or headache specialist, but it could also be your
primary care provider.

A doctor who is willing to consider your research and ideas seriously may not
need the same level of expertise as one who is used to simply telling patients
what to do. The reason is that if you present an idea, a willing doctor will often conduct some research in return, and get back to you with the most recent data. This is why a primary care provider is just fine. A dedicated approach can help to offset the lack of specialized knowledge.

2. State your situation and goals super clearly when you first bring up your migraine headaches.

Once you identify a doctor to work with you, your next step in the collaborative process is to provide as clear (and preferably concise) description as possible regarding your head pain and what you do and do not know about it. If you have other medical conditions which are comorbid, let your healthcare provider know.

You also need to explain what your migraine treatment goals are.

  • Are you trying to figure out the root cause of your head pain?
  • Identify your triggers?
  • Reduce your head pain?
  • Eliminate it?

3. If you have chronic migraine, be super clear about that too!

Chronic migraine seems to be a situation which is strangely easy to overlook.
This is probably because for most people, migraine attacks are episodic in
nature, and only strike a few times per month.

If you have frequent headaches, or headaches every single day, you might
want to repeat that fact several times. The phrase “more than 15 days per month” may be helpful as that number of migraine attacks is the diagnostic
criteria for defining chronic migraines.

4. Make sure your doctor knows your headache pain isn’t just painful.

It’s messing with your life.Because of the subjective nature of the pain experience, it can be very difficult to get your point across about the importance of treating head pain simply by complaining about the pain itself.

You can often get a better response by explaining the ways in which migraine
pain is affecting your quality of life in terms of daily activities. This can also be useful for goal setting. For example, if migraine attacks are interfering with your job, you could explain that you are missing days of work, getting poor evaluations, and endangering yourself trying to drive home. You could say that one of your goals is to eliminate these problems through effective migraine treatment and preventative medications or herbs.

5. Conduct your own research.

The next thing to know about collaborating on a migraine treatment plan with your healthcare provider is that it does involve some legwork on your part.

There is no simple, quick fix to migraine pain. Migraine sufferers have
significant variances in pain levels, triggers, causal factors, and treatment
responses.

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There is no cure for migraines, and researchers are still struggling to understand what migraines are and what can be done about them. That means that even though doctors are trained to help you, even they may have more questions than answers about migraines.

So it is up to you to pull your weight and help to search for answers and understanding. Forget what you have learned about taking a passive approach to managing your health.

Instead, become an active participant. Make it your responsibility and not just your doctor’s to learn about your migraines and some of the potential options for treatment of migraine pain.

6. Ask for potential treatment options and present your own.

Even a primary care provider should have a pretty solid grasp of first-line
acute and preventative treatment medications and supplements for head pain.

So ask your doctor to let you know any ideas they have.

But you also should be doing your research as discussed above, and it may
lead you to ideas of your own.

Some of these might involve off-label uses of medications, alternative
therapies, supplements, and lifestyle changes.

You can and should bring these up directly to your doctor. The right provider
may be willing to help you experiment, given that your ideas are not
contraindicated.

7. Do not simply take orders from your doctor.

When it comes to working with doctors, I would say one of the most common
mistakes patients make is passively following orders.

I suspect this starts in childhood. As a kid, your parents probably told you to
listen to the doctor and do exactly as you are told. This makes sense when you are a child, but as an adult, the advice doesn’t really apply anymore. Doctors reinforce the behavior in many cases by continuing to act as authority figures even with grown-up patients. I would not necessarily say you should avoid all doctors who attempt to give you orders. Many of them are simply behaving the way they are expected to by patients. But I would say you should choose a doctor who was willing to work with you in a different way. You should then actually remember to follow through on that when you are at your appointments. If your doctor attempts to issue an order, it is perfectly
okay for you to question it, or assert that you would prefer a different path. A good doctor will immediately understand, respect your decision, and help you come up with an alternative pain management plan.

8. Accept or reject suggestions based on your body and needs, and explain your reasons.

Continuing off of the recommendation above, you may wonder how you
should evaluate the options which are presented to you for treatment of
migraine.

If you are not going to automatically do as you are told, how do you decide
what to try and what not to try?

There are a number of potential considerations. Even though your doctor is
the medical expert, you are the expert in your own needs. You can make
decisions based on parameters such as:

  • Potential side effects of headache medicine.
  • Potential long-term adverse health effects of a treatment plan.
  • Comorbid conditions for which a given headache treatment might not
    be appropriate.
  • Past experiences with similar medications.
  • … And so forth.

For example, first-line migraine drugs tend to have both long-term health
concerns and unpleasant acute side effects.

Although some migraine patients are perfectly okay with that, others may not
be. If you simply do not want to take a beta blocker because you are concerned about your cardiovascular health, for example, you should let your
doctor know that you are rejecting the suggestion and the reason.

When your doctor understands why you do not want to go certain route, that
information will be helpful in generating suggestions which may be a better fit for you. Plus, irrationally stubborn patients do exist. You do not want your doctor to mistake you for one if you have a solid reason for rejecting a suggestion.

9. If there is something you want to try, request cooperation.

Sometimes, you might come up with a route to investigate what your doctor
might not have proposed, but might be open to exploring.

For instance, you might be interested in trying a medication with an off-label
use. While that medication might not regularly be recommended, if it is not
contraindicated and if there is a sound theory as to why it might work, your
doctor may be willing to write a prescription.

Here are some examples of ideas which I came up with and upon which I have received cooperation:

  • Before I found out I have migraines, I was already aware that I have
    myofascial pain. As this condition seems like a “cousin” to fibromyalgia. I was interested in testing an SNRI for off-label pain management.
  • Interestingly, my doctor proposed this on her own, but I’m certain that if I had proposed it, it would’ve been accepted as well.
  • Because I have menstrual migraines which are worse when my
    progesterone levels are low and better when they are higher, I wanted
    to see whether taking progestin would help. When I proposed this idea,
    my doctor was willing to write me a prescription.
  • Finally, I wanted to find out if I did have migraines. Trying sumatriptan
    (Imitrex) seemed like an easy way to test the theory. When I proposed
    this idea, my doctor also wrote me a prescription.

If you are curious about my results, the SNRI and the progestin failed, but the sumatriptan succeeded. In this fashion, I deduced that I do have migraines (not just cervicogenic headaches), and that they are chronic.

In the past, no doctor ever even suggested to me that I might have chronic migraines, or thought of prescribing me Imitrex to see what would happen.

I also may have learned some other things regarding hormones and neurotransmitters, but I am still working toward piecing it all together.

The point is, this illustrates how when you work with your doctor, rather than
simply passively awaiting orders, you can achieve more in terms of diagnosis
and treatment.

10. Follow your doctor’s instructions when you come up with a treatment plan together.

Let’s say that you and your doctor do come up with a treatment plan based on
your shared migraine research.

To continue to do your part in the collaborative process, you need to follow
through on the treatment plan, following the directions your doctor gives you.If you skip doses or stop your treatment early without consulting first with your doctor, you could stand in the way of the research you are now essentially conducting on yourself. This will not help you or your doctor to manage your migraine attacks.


11. Keep a daily headache log.


It is also important to maintain a headache diary as you are working with the
doctor on pain management. Every day, record the events of the past 24 hours. I find it easiest to do this each morning regarding the day prior.

In your headache diary, include:

  • All medications, supplements, and other treatment protocols for that
    day.
  • Lifestyle decisions and events from that day which could have had an
    impact on your pain levels.
  • If you are menstruating, you should record where you are in your cycle.
  • The levels of your pain throughout the day.
  • The locations of your pain throughout the day.
  • The types of pain you have experienced throughout the day.
  • Any other migraine symptoms you have experienced throughout the
    day.
  • Your mental state, if it was unusually stressed.

By recording these details, you are collecting data for both you and your
doctor to use.

You also will find this data useful in managing your medication use. For
example, if you are taking Imitrex, it is useful to know when you took your last dose, and how many doses you’ve taken within the previous week and month.

12. Find a channel of communication through which you can update your doctor and ask questions between your appointments.

It is inconvenient and unaffordable to continuously schedule clinic appointments when you are trying to manage a long-term issue. For this reason, you should ask your doctor if there is a means to communicate between your appointments.

I’m fortunate in that my clinic has an online messaging system which only I
and a couple other patients make any use of.

Since my doctor monitors it on a daily basis, it allows me to get quick
responses to questions or concerns. If you have access to such a convenient channel, it is your responsibility to use it wisely.

Following are some appropriate uses of such a channel:

  • If there is a problem with getting your medication (i.e. renewal issues),
    you should inform your doctor right away.
  • If you would like to try raising or lowering your dose, you can ask
    without an appointment in most cases.
  • If you would like to provide a general update on your status, this is
    typically appreciated after a few weeks on a medication.
  • If you have a question about side effects or how to use your medication
    appropriately, this too can be communicated without an appointment.
    Following are some inappropriate uses of such a channel:
  • Sharing your latest theories and interesting articles you have
    discovered online about migraines or other issues.
  • Asking for elaborate physiological explanations of mechanisms
    involved in pain or medication use.
  • Asking about health concerns—related or otherwise—for which you
    would normally need to make a clinic appointment for a proper
    examination or a detailed conversation.

If you have questions which require an appointment, you will need to make
one.

13. Be patient. Do not test too many ideas at once. Keep variables limited.

In experimental design, it is best to keep independent variables limited.
Ideally, you should only be testing one thing at a time. Otherwise, it can be
difficult to figure out which variable is responsible for a change, whether
positive or negative.

Plus, you cannot be sure how different treatments will interact with one
another. This too can confound your data if you have too much going on at
any one time.

A third drawback is that it can take time not only for your body to adjust to a
new medication, but also to adjust to coming off of one.

That means that you can easily get in over your head by trying out too many
medications or supplements at one time.

To avoid these complications, try and put restrictions on how many migraine
treatments you are simultaneously testing.

I would suggest testing one preventative treatment at a time and one acute
treatment at a time. It should be fine to overlap these trials since acute
treatment should have acute results which should be obvious regardless of
any preventative treatment plants you are trying.

14. Work with your doctor to deal with insurance/cost issues.

When it comes to treating migraines or any other types of headaches,
insurance can be an issue.

This is particularly the case if you have other conditions which may be playing a role in your migraines and which are specifically excluded by insurance providers (TMJ being the biggest culprit).

So you will need to actively collaborate with your doctor not only to treat your
condition, but also to handle problems involving your insurance. Preferably,
you will want to prevent such issues from arising when possible.

The best way to do that is to educate yourself on your insurance company’s
attitudes and restrictions regarding migraines and any comorbid health
conditions you may have.

This too is an area where I can provide a personal example to illustrate what I
mean.

I have a jaw which is misaligned and which contributes to my pain issues.
While learning about jaw problems, I found out that almost every insurance
provider in the US excludes all coverage for “TMJ” or “TMD.” When I became aware of that, I made sure to mention it to my provider while discussing the role that my jaw plays in my head pain. Acknowledging what I said, she agreed not to write down anything about my jaw at any point of time in the paperwork which the insurance company would see.

From my experience, most doctors are willing to be flexible when it comes to
the language they use when submitting their paperwork. So you should
always bring this up during your appointments if it is relevant.

15. If you have actually found a doctor who collaborates with you as an equal, express your gratitude.

Finally, one last recommendation for fostering useful collaboration with your
doctor is to acknowledge it when it happens.

Even though your doctor is just doing their job, you probably already know
from experience that finding someone truly willing to listen to you and respect you as a patient can be a challenge.

So saying “thank you” on a regular basis can’t hurt. Any exemplary professional can sure stand to hear it more often. Being a doctor can be a
stressful job, and your compliments could brighten your provider’s day.

By Working Proactively With Your Doctor on Your Migraines, You Can Facilitate Your Care

You now have some recommendations for approaching your healthcare in a
different way. Instead of viewing your doctor as an authority figure and taking a passive approach to treating your migraines, consider viewing yourself as an active participant, and working as an equal alongside your doctor to find solutions.

Doing this will give you practice at advocating for yourself, and will help both
you and your doctor to learn more about your health situation and maybe
even generate more ideas for headache treatments.