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from Current Medical Research and Opinion
Posted 01/17/2003

Summary

Despite repeated initiatives over the past decade, migraine remains under-recognised, under-diagnosed and under-treated in everyday clinical practice. The Migraine in Primary Care Advisors (MIPCA) group has produced new guidelines for migraine management to attempt to rectify this situation. MIPCA is a group of physicians, nurses, pharmacists and other healthcare professionals dedicated to the improvement of headache management in primary care, who have also worked closely with the Migraine Action Association (the UK patients' group) in the development of these guidelines.

The principles of the new MIPCA guidelines are:

• To arrange specific consultations for headache.
• To institute a system of detailed history taking, patient education and buy-in at the outset of the consultation.
• To utilise a new screening algorithm for the differential diagnosis of headache, which can be confirmed by further questioning, if necessary.
• To institute a process of management that is individualised for each patient, using a new algorithm. Assessing the impact on the patient's daily life is a key aspect of diagnosis and management.
• To prescribe only treatments that have objective evidence of favourable efficacy and tolerability.
• To utilise prospective follow-up procedures to monitor the success of treatment.
• To organise a team approach to headache management in primary care.

Introduction

Migraine is a common, painful headache disorder that affects 10% or more of the general population, is more common in women than in men, starts in childhood and adolescence and is most prevalent in young adults and middle-aged people.^[1] Migraine is a markedly disabling condition,^[2] and exerts a significant burden on the sufferer in terms of pain, suffering and impaired quality of life (QOL).^[3] This results in a large economic burden on society, both in terms of direct medical costs of care and indirect costs due to lost work time and working at reduced productivity.^[4] However, migraine is a heterogeneous condition, with headache attacks varying in frequency, duration, symptomatology and associated disability, both between sufferers and between attacks in the individual sufferer.^[2]

Despite the relative seriousness of the condition, studies consistently show that migraine is currently not well managed in primary care. Only about 50% of sufferers currently consult their physician for care.^[5] Physicians only diagnose migraine correctly in about 50% of presenting sufferers and many patients are provided with therapies that they find ineffective, many relying on suboptimal over-the-counter (OTC) medications.^[5] Follow-up is frequently poor, and many patients lapse from care.^[5] Lack of effective care for migraine can lead to problems. Chronic daily headache (CDH), which can be a consequence of poor migraine management, is a significant, and often hidden, cause of morbidity.^[6] The consequence is that patients with CDH and migraine form by far the majority of headache patients seen by secondary care physicians.^[7]

Migraine is therefore under-recognised, under-diagnosed and under-treated in everyday clinical practice.^[8] This situation has not changed markedly over the past decade,^[9,10] despite great strides in the development of new migraine therapies, especially the introduction of the triptan drugs. Currently, there are no consistent guidelines for the management of migraine and other headaches in primary care clinical practice. Indeed, two sets of guidelines are available to physicians in the UK that do not agree on basic principles, those of the British Association for the Study of Headache (BASH)^[11] and those of the Migraine in Primary Care Advisors (MIPCA).^[12] Historically used guidelines, for example those available in the UK,^[11] USA^[13] and Germany,^[14] tend to recommend the following general scheme:

1. Implementation of a full diagnostic procedure using the International Headache Society (IHS) criteria;

2. A step-wise approach to care, where treatment is initiated with low-end therapies (e.g. simple analgesics) and migraine-specific therapies (e.g. the triptans) are only used when all other therapies have failed.

These guidelines, while comprehensive, are perhaps better suited for specialist use than in primary care. They require a significant investment in time and effort for the physician and the patient, with no guarantee of success in the short term. There is another, more subtle point, in that, after years of promotion of these types of guideline, there have been no major inroads into the way many primary care physicians manage migraine.^[9,10] The inescapable conclusion is that this historical approach does not seem worthwhile to primary care physicians. There is a wide gap between what often happens in primary care practice and what specialists are recommending, the end result being the poor consultation, diagnostic and treatment success rates seen for migraine.

Reasons for this may include:

1. Patients may not recognise that they need medical care to control their migraine;

2. Primary care physicians have limited time to deal with each patient and may find the IHS diagnostic criteria too complex and unwieldy for everyday use;

3. The step-care treatment strategy is not time-efficient and may not be clinically- or cost-effective;

4. Many therapies used for migraine are ineffective and/or may be associated with unwanted side-effects;

5. Follow-up procedures are inefficient or lacking altogether.^[8]

New guidelines for migraine are urgently needed that can identify and screen patients in need of care, develop and use new and simpler diagnostic tools and algorithms and utilise best management for migraine, using evidence-based medicine wherever possible. This article describes the development of new guidelines for migraine in the UK, critically reviewing the evidence for revised screening, diagnostic and management procedures, and presents simple algorithms designed for practical use in primary care. We took the opportunity to update the existing MIPCA Guidelines to include relevant material from recent US guidelines and to reflect the latest clinical data. This process was conducted in two meetings held under the auspices of MIPCA, where a group of primary care physicians, practice nurses and other healthcare professionals (including representatives of the UK patients' group, the Migraine Action Association) reviewed and endorsed changes to the existing guidelines.

http://www.medscape.com/viewarticle/446557