Researchers report several differences in clinical communication by gender and there are controversial findings regarding gender bias in diagnosis and treatment.[14
] Physicians are more interpersonally engaged with patients who are more affectively expressive, and patients who ask questions elicit more information.[15
] These patient characteristics slightly favor the likelihood of female patients receiving more information and developing warm, friendly relationships with their clinicians.[14
] To avoid gender bias in our study sample and as migraine has higher prevalence in women worldwide; we chose to include only female migraineurs. Co-incidentally every referring physician was male, eliminating gender bias in patient-physician relationships in our study. Only migraineurs with certain triggers and common migraine without aura were included to give the sample uniformity. This led to comparable management plans and total compliance scores.
In our study, migraineurs’ ages did not have any significant correlation with perceived physician empathy, their subsequent improvement or compliance with management plan. Jin, Sklar, et al
] reviewed more than thirty articles related to the influence of age on therapeutic compliance. The majority of these articles showed that age was related to therapeutic compliance, although a few researchers found age not to be a factor causing non-compliance. Age was not found to affect compliance with prescribed medication in another survey.[18
] An investigation of medication compliance[19
] in headache patients found that age was not predictive for either compliance or non-compliance.
Statistically significant positive Pearson's correlations are seen between CARE Scores and decrease in migraine disability and symptoms over three months (P
< 0.05).  Thus, a significant positive relationship exists between perceived physician empathy and improved patient outcome in our study. Stewart[20
] reviewed several articles to ascertain whether physician-patient communication makes a significant difference to patient health outcomes. Most of the studies reviewed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes. Rakel et al
] discovered that when patients perceive clinicians as empathetic, the severity, duration and objective measures (IL-8 and neutrophils) of the common cold significantly change. A study[22
] involving diabetic patients confirmed the hypothesis of a positive relationship between physicians’ empathy and patients’ clinical outcomes, suggesting that physicians’ empathy is an important factor associated with clinical competence (physician competence) and patient outcomes.
Significant positive relationships are seen between perceived empathy and compliance with diet/meal timings, exercising, de-stressing/sleep pattern modification and medications . A statistically significant positive correlation is present between perceived empathy and self-reported total compliance with the management plan.  The rate of adherence among headache patients has generally been found to be poor. Misuse or overuse of symptomatic medication has been demonstrated to contribute to treatment failure, and one-fourth to one-half of patients are noncompliant with prophylactic headache medications and at least 40% non-adherent with appointment-keeping.[23
] Physician communication or the lack of it is probably one of the most important factors for patient non-compliance.[24
] In Spierings and Miree's telephone survey[27
] of headache patients, amongst those who had not complied with the recommended follow-up visit, 60.3% claimed dislike of the clinician seen and seeking care elsewhere as a reason. Patient-perceived physician empathy significantly influenced patient satisfaction and compliance via the mediating factors of information exchange, perceived expertise, inter-personal trust, and partnership in a Korean hospital out-patient department.[28
From , we infer that self-reported compliance is significantly correlated with decrease in migraine disability and symptoms. Significant positive relationships are seen between improved patient outcome and compliance with diet/meal timings, exercising, de-stressing/sleep pattern modification and medications. In Gaul, van Doorn, Webering, et al
.'s headache study[29
] in Germany, adherence to more than five of eight lifestyle change recommendations was associated with a significant reduction in headache frequency and ≥50% reduction of headache days per month. A group of Albanian clinic-based migraine patients was given a standardized course of didactic instruction regarding migraine biogenesis and management. In comparison to a control group, they were more compliant with prophylactic therapy prescribed and experienced a reduction in mean headache days per month and a greater reduction in functionally incapacitating headache days per month.[30
Study limitations include relying solely on patient reports which may have led to confounding. With self-reported compliance, we cannot predict the extent to which reported levels of compliance reflect actual patient behavior or a tendency to give desirable responses. We examined only a few patients per physician and were unable to establish a control group. Respondents varied in their social, economic and educational backgrounds and this has not been related with their perception of empathy or treatment compliance.
Our study found substantial positive associations between perceived physician empathy and migraineurs’ outcomes and compliance with management plans. This emphasizes the importance of empathy in migraineur-physician communication. We believe ours is the first study to discover strong associations between perceived physician empathy and migraineur outcome and compliance. Similar studies in multiple centers would help establish physician empathy as a core component of migraine management. In a broader context, our results provide a foundation for future research to establish the role of empathy in improving compliance and treatment outcomes across specialties.