CAM in the Real World: You May Practice Evidence-Based Medicine, but Your Patients Don't

Robert P. Cowan, MD, FAHS, FAAN

Disclosures

Headache. 2014;54(6):1097-1102. 

In This Article

Abstract and Introduction

Abstract

Background.—Complementary and Alternative Medicine (CAM) approaches are widely used among individuals suffering from headache. The medical literature has focused on the evidence base for such use and has largely ignored the fact that these approaches are in wide use despite that evidence base.

Discussion.—This article focuses on the uses of CAM by patients and suggests strategies for understanding and addressing this use without referring back to the evidence base. The rationale for this discussion pivots on the observation that patients are already using these approaches, and for many there are anecdotal and historical bases for use which patients find persuasive in the absence of scientific evidence.

Conclusion.—Until such time as the body of scientific literature adequately addresses non-conventional approaches, physicians must acknowledge and understand, as best as possible, CAM approaches which are in common use by patients. This is illustrated with a case study and examples from practice. This article does not review the evidence base for various CAM practices as this has been done well elsewhere.

Introduction

There is a French proverb, dating from the late 13th century that proclaims: "It is the poor craftsman who blames his tools." But there is a belief in headache medicine (and elsewhere) that, if only we had the proper tools, we could meet all our patients' expectations.

Similarly, there is another belief, widely held, perhaps not consciously, by many of our patients that the tools to manage their headaches exist, but their doctors, as "Western," evidence-based practitioners, are unaware, inappropriately skeptical, or simply arrogantly biased when it comes to implementing non-Western approaches. And so they seek these alternatives out, often clandestinely. And why? Because their doctors talk about the "dangers" of using anecdotal "evidence" in making decision treatments or the perils of using treatments that lack scientific foundation? Why do patients turn to folk remedies and other alternative approaches? Should we be trying to dissuade patients from "experimenting" with these nontraditional approaches?

Increasingly, over the last century or so, physicians have been spending more and more time at the altar of evidence-based medicine and implicitly rejecting treatments that lack a "rigorous" and "validated" evidence base. This has occurred despite ongoing discussion of the flaws and deficits in the vetting of and access to the "evidence" in evidence-based medicine.[1] Nonetheless, this approach has become the standard of practice for the doctors. But what about the patients? Do patients accept and practice evidence-based medicine?

No. As much as 82% of headache sufferers use complementary and alternative approaches.[2] There is limited evidence suggesting the vast majority of these treatments are harmful (regardless of the evidence they are helpful), and most have withstood "the test of time," having been handed down over hundreds, even thousands of years. Perhaps it is time to reconsider whether we are acting in our patients' best interests by discounting (or worse, dismissing) treatments not objectively evaluated. Perhaps, in the absence of these objective evaluations, it is time we gave weight to traditions and clinical experiences that, in some cases, span thousands of years and millions of clinical experiences in the hands of countless non-Western practitioners.

Toward this end, the following will describe practices which have little or no body of scientific literature supporting (or refuting) clinical benefit with respect to headache, but rather offer the internal logic of the system in which they are applied and the body of traditional medicine in which they reside. These are the medicines and methods our patients are using to treat their headaches, at times along with our prescribed approaches, sometime instead of them. The utility of this approach may be best demonstrated with a clinical vignette:

AG is a 58-year-old left-handed, post-menopausal female with a 43-year history of moderate to severe headaches. Her headaches are usually left sided and unaccompanied by aura or other premonitory symptoms. Her headaches typically last 8 to 12 hours, regardless of treatment, and occur on average, 8 days/month. She has not identified any temporal pattern, but has noted prominent light and sound sensitivity, frequent nausea (rare vomiting), and motion sickness. Her headaches are worsened by exercise, changes in her sleep or eating patterns, air travel, weather changes, and stress.

Her family history is positive for "sick" headaches in her mother, two maternal aunts, and her maternal grandmother. Both her sister and daughter have been diagnosed with migraine, as has the patient herself. Social history is benign: she is married, with two adult children, and does not smoke or drink. She is currently working as a school teacher.

The patient is here for a second opinion on her diagnosis and an opinion on the safety of her current treatment regimen. She brings with her a list of her current medications as follows:

Preventives: butterbur, feverfew, ginger, ginkgo biloba, bryonia, ignacia, magnesium, B2, B12, coenzyme Q10, tian ma gouteng wan, xiao yao wan, ming mu di huang wan, topiramate, and flunarizine.

Abortives: peppermint oil, lavender, passion flower, rosemary, chamomile, rose hips, valerian, boswellia, rizatriptan, diclofenac sodium.

Rescues: coriander seed, mustard oil, apple vinegar, dihydroergotamine (DHE) intramuscular (IM), promethazine, and parenteral ketorolac.

We often see patients who report having tried "everything under the sun." If you work in a secondary or tertiary headache center, it is rare to see a patient who has not tried "the usual suspects." And while we might not see as elaborate an alternative treatment strategy as AG presents, many of us will have seen some or all of these in one or another patient. If not, then your entire patient population is made of the more than 50% of patients who never tell their physicians about their complementary and alternative treatments.[3]

But what do we tell a patient who comes to us with this kind of a story? The clinical history seems pretty straightforward, yet she is presenting with a treatment strategy that bears little resemblance to anything in our training. More importantly, what do we even know about many of the substances AG is ingesting?

Some of the more common responses that have been reported to me by my patients (when they come to me for the third or twenty-third opinion) are:

  • There is no scientific basis for these "so-called" natural cures. Stop them, you're wasting your money and might even be harming yourself.

  • Have you considered seeing a Pain Psychologist? Generally, when a patient goes to such extremes, there is some underlying psychiatric issue.

  • There is a variety of prescription medications that may be more effective for you, and these other things you are taking might be interfering with the real medicines, making them ineffective.

While there may be an element of truth in each of these responses, they all beg the issue, and not very subtly, that most of us have no clue what most of these substances are or what they do and don't do, why they might be prescribed, and whether they are likely to interact with prescription medicines that are being taken at the same time.

Obviously, we cannot be expected to know about every treatment option in every medical system under the sun. The armamentarium of the homeopathic or Classical Chinese healer or Ayurvedic doctor is every bit as complex as that used in Western medicine. Each practitioner is obligated to provide enough information to allow our patients to make informed decisions about their health care. Moreover, we need to know enough about different therapies to help protect our patients from potentially dangerous practices, and finally, we need to be as non-judgmental as possible without compromising our own critical thinking. A description of Ayurvedic medicine is included in this issue by Dr. Trupti Gokani.

What is an appropriate response to patient AG? Is it sufficient to explain that these are not substances that are generally accepted as efficacious in Western medicine? Should headache physicians be knowledgeable in the risks and benefits of medicines that are not commonly prescribed and for which there is no easily accessible or reliable literature? As physicians, we are custodians of a body of knowledge, to be sure, but our charge is patient care and that charge will often take us out of our comfort zone. If the only standard we apply is evidence-based medicine, or standard-of-practice medicine, or FDA-approved medicine, not only will we fall short of fulfilling our charge, but we will miss clinical opportunities which could well transform how we manage disease. And perhaps more importantly, we do a disservice to our patients when we do not explore every avenue open to them.

Every one of the medicines (for want of a better word) that AG is taking has some basis in the treatment of headache in one or another medical system.[4] Some have an evidence-based rationale, while others have a historical rationale dating back thousands of years. Some are based on a Western diagnosis such as migraine without aura, while others are based on a classical Chinese medicine diagnosis of cool, damp headache, or an Ayurvedic diagnosis headache due to too much pitta dosha (see Dr. Gokani's accompanying explanation). A couple trace back to traditional American folk treatments. It is not reasonable, practical, or perhaps even appropriate for Western physicians to be skilled in classical Chinese, Ayurvedic and homeopathic medicine. But an awareness of the reality that other medical systems exist, and perhaps more importantly, are practiced by our patients, is critical to our ability to properly care for patients. When these differing approaches conflict or complement each other, shouldn't we broaden our knowledge base to allow for interaction?

That this is not the current practice is evidenced by the fact that more than 50% of complementary and alternative medicine (CAM) users do not discuss their CAM activities with their health care provider.[2] Contrast this with data indicating that less than 20% of headache specialists routinely use CAM in their practice, while more than 90% ask their patients if they presently or in the past have tried CAM approaches for their headaches.[3] What we have here is a failure to communicate.

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