Dawn A. Marcus, MD
University of Pittsburgh School of Medicine
Neurologist, Coordinator of Headache Research
The Pain Evaluation and Treatment Institute
Good medical care begins with good communication
Accurate and open communication is the beginning of good medical care. This is especially true for headache patients, because a correct diagnosis depends almost entirely on information the patient gives the doctor. Unfortunately, both doctors and patients can fail to express their thoughts clearly and accurately. Doctors may not clearly explain their diagnosis and treatment recommendations. Patients may not clearly express their fears and concerns about their headaches. Patients may also be so anxious that they don’t hear or understand what their doctor is telling them. Doctors often complain that they simply don’t have enough time to deal with all of the questions many patients ask. Unfortunately, patients may react by thinking that their doctors are ignoring their needs and concerns.
Often, what doctors say is very different from what patients hear. For example, a doctor trying to reassure a patient that her headaches aren’t caused by a serious problem might say, “You don’t have any serious medical problems.” In response, the patient might think, “Oh no! Everybody thinks I’m faking my headaches. I can’t even find a doctor who takes me seriously.” Or, if the doctor explains that migraine is a condition caused by abnormal blood vessels in the brain, the patient might think, “Oh no! My uncle died of a burst blood vessel in the brain.”
There is even a difference between what patients want most from their doctors and what doctors think patients want from them. A study has shown that what patients want most from their doctors is a willingness to answer questions and a willingness to teach them about their treatment. On the other hand, doctors think that what matters most to their patients is headache expertise and understanding and compassion.
Both you and your doctor need to communicate clearly to effectively treat your headaches. Here are some simple steps you can take to improve your communication skills so your concerns are expressed and your needs are met.
1. Stay focused on the most important questions.
When you are first discussing headaches with your doctor, you will be asked many questions about symptoms, other illnesses, family history, and headache triggers. It takes a long time to answer these questions, but the information your doctor obtains is very important for reaching a correct diagnosis and recommending effective treatment. Don’t try to get all of your questions answered during the first visit. Decide what you need to know at this visit and what questions can be saved for a later visit.
2. Learn as much as you can about your headaches.
It’s important to understand your diagnosis. Ask your doctor directly, “What’s causing my headaches?” You should understand, though, that you may not get an answer during your first visit. Modern medicine is very good at figuring out what you don’t have. With headaches, it is often more difficult to figure out what you do have. Headaches are diagnosed by matching your headache description to typical headache patterns. When your headache pattern is not typical, this can be difficult. Your doctor may need to review old tests, order new tests, or confer with a colleague. Even if you don’t receive a specific headache diagnosis, this doesn’t necessarily mean that your headaches are caused by something serious or are not treatable. You can help by understanding as much as possible about headache types and what causes them. On the other hand, if you don’t describe your symptoms accurately, it might delay diagnosis. If, for example, you say your headaches come back several hours after treatment when you really have rebound headaches (which are caused by medication overuse), proper diagnosis and treatment might be delayed.
3. Share your concerns and reactions.
Don’t be afraid to rephrase what your doctor has told you to be certain you have understood it correctly. Doctors find it much easier to answer direct, specific questions like, “Do you mean to say I have a serious disease of the blood vessels?” Or, “I don’t think I’m depressed; I’m just very frustrated with these headaches, but my family doesn’t take me seriously.”
4. Learn as much as you can about your treatment plan.
Headache treatment can be complicated. Acute care medicines cannot be taken more than a few days per week, while preventive medicines must be used daily in order to work. Acute care medicines are taken to stop a headache that has already started, while preventive medicines are taken every day to prevent headaches from recurring. Some doctors will have their nurses explain medication instructions to you. Many patients find written instructions to be most helpful, so feel free to ask for them. Remember, you can also ask your pharmacist to answer any questions about your medication that weren’t answered in the doctor’s office.
5. Build an open and trusting relationship with your doctor.
Successful headache treatment depends upon an open relationship with your doctor. That relationship will be built over time. Your goal should be to have a few important questions answered during each visit, knowing that there will be future visits for addressing additional concerns.
Both doctor and patient need to learn how to convey clear messages to each other. As a patient, you can help your doctor respond more clearly by asking direct, specific questions and making certain that you understand the answers.
What you should expect from your doctor
Duckro PN, Richardson WD, and Marshall JE.
Taking control of your headaches. How to get the treatment you need.
New York: The Guilford Press, 1995
Any healthcare professional who is going to treat you for chronic headache should also be a person you feel comfortable with. The following are some characteristics that often contribute to a positive doctor-patient relationship. They are essential qualities in a comprehensive headache clinic. You have a right to expect such characteristics in the person to whom you are entrusting so much.
Your doctor should:
- Demonstrate genuine care for you and interest in your problem.
- Be a good communicator, educating patiently and understandably.
- Be able to discuss psychological factors without giving you the message that your pain is not “real.”
- Be flexible and listen attentively to your questions and observations.
- Adjust the treatment plan to reflect new information.
- Not answer every increase in headache only with new or more medication.
- Work patiently with you even when the headache does not lend itself to a quick solution.
- Be willing to consider multiple factors contributing to the same headache problem.
- Be ready and able to coordinate efforts with all other members of the treatment team, including you.
- Include you in goal setting.
- Take time -- to listen to you, to follow through on coordination of treatment, to give you feedback, to educate you.
What they say vs. what they mean: How doctors and patients can miscommunicate
What They Say
Doctor: Tell me about your headaches, Mrs. Jones.
Patient: Well, it all started when I was 3 years old. ...
Doctor: Yes, yes, that’s fine. How frequent are your headaches? Do you have an aura?
Doctor: I see you brought your MRI scan. I’ll show it to you. See, this is the brain, and this is the skull. And see these little white spots? They’re high-signal intensity abnormalities on T2- weighted images that can occur with headache.
Doctor: Migraine is caused by abnormal blood vessels in the brain. Serotonin imbalance within the brain causes the blood vessels to react abnormally and cause headache.
Patient: So will I need surgery? Is it serious? Is it fatal?
Doctor: You don’t have any serious problem and you don’t need surgery. Are you depressed?
Patient [with tears welling up in her eyes]: Not at all!
Doctor: For people with your particular condition, we often use antidepressants. And we’ll have you meet with the psychologist. They have good treatments for you. Biofeedback and relaxation are also effective migraine therapies.
Patient: How do I take these?
Doctor: Just take one pill before you go to bed and I’ll see you back in 4 weeks.
Patient: Okay. Before you go, I wanted to ask a few questions. Here’s a list I wrote down for you.
Doctor: Here’s a couple of pamphlets and we’ll answer any questions you may still have at your next visit.
What They Mean
A new headache patient—and I’m already 20 minutes behind!
I brought 10 years worth of charts for him to review and he never even looked at them!
Doesn’t she realize I’ve already read 10 years worth of records about her? Why did she bring all of these if she’s going to tell me every detail that’s in them anyway!
This is a normal MRI scan. There is no tumor or abnormal blood vessels. Often small white spots are seen in patients with chronic migraine, but they are not a sign of any disease or damage.
Does he think I have a brain tumor? Are those spots an infection?
Migraine is not serious. There is no reason to worry.
Abnormal blood vessels! My uncle died of a brain aneurysm -- is that what I’ve got? What’s serotonin, and how did I get it?
She’s not even listening to me! She seems very anxious and high-strung. Could be a mood disorder -- not unusual with chronic headache. Maybe that’s why she’s not focusing on what I’m telling her. Luckily some migraine medications treat both.
Not again! My husband doesn’t believe me, my boss thinks I’m a faker. I can’t even find a doctor who’ll take my headaches seriously.
She’s in denial. Maybe this mood problem is more serious than I thought! Antidepressants are great headache preventive medications, so that would be a good choice.
He really does think I’m just crazy. I’ll try these pills and see if they help. I’m so desperate at this point I’d try anything!
She needs to take this every day for several weeks before it will work.
I wonder what the side effects are. I’ll take it a couple of times and see if it works.
She brought 4 pages of questions! I don’t have time to answer 4 pages worth of questions today...