Starting Points

Migraine sufferers differ in their management needs, largely due to the variation in severity of symptoms and their impact on the sufferer.^[2] Although severely affected sufferers tend to receive more medical care than those less affected, a significant proportion of those with severe pain and disability remain undetected, undiagnosed and under-treated in clinical practice.^[8] Initiatives are needed to improve migraine care in several areas to provide a service focussed on the individual patient's needs.

As primary care physicians are the medical service most commonly used by migraine sufferers, it makes sense to coordinate headache management services around them. Unfortunately, the education of primary care physicians about headache is usually limited to the exclusion of serious but rare secondary (sinister) headaches, rather than the management of the common benign primary headaches. Primary care physicians also have severe limitations to the time they can give each patient, as little as 8-10 minutes for complex consultations. Simple, clear and unified guidelines are therefore needed to allow the primary care physician to deal with patients with headache. The overall goals should be to:

• Accurately diagnose and provide appropriate treatment for the majority of patients who can be managed in primary care.

• Rapidly identify and refer the minority of patients who need to be seen by a specialist.^[21]

• To achieve this, a consultation of 15 minutes or more may be needed.

The means to achieve these goals are as follows:

• Encourage migraine sufferers to engage with the healthcare system, to consult their primary care provider and receive appropriate treatment.

• Motivate currently consulting migraine patients to continue to seek help to optimise their treatment.

• Provide physicians with simple but comprehensive guidelines to allow them to diagnose migraine differentially from other headaches.

• Encourage physicians to provide prescription medications that have been proven to be effective.^[21]

The original MIPCA, Headache Consortium and Primary Care Network guidelines contain several common recommendations, which can be used as the basis for new guidelines:

1. Improve patient counselling and buy-in;

2. Conduct a careful diagnosis;

3. Assess the illness severity accurately, incorporating assessments of the impact to the sufferer;

4. Provide an individual treatment plan for each patient, with the choice of treatment being evidence-based wherever possible;

5. Implement follow-up procedures to monitor the outcome of therapy.^[21]

The rest of this section describes how these concepts can be translated into a practical scheme for the management of migraine in primary care. Points 1-4 above need to be dealt with at the patient's initial consultation. Point 5 is dealt with at follow-up consultations. It should be noted that these general principles also have application beyond migraine to all areas of headache management.

Organising Headache Management in Primary Care

Headache is an important clinical condition and needs to be taken seriously by the patient and physician. To this end, a special consultation should be arranged so that the physician has sufficient time to evaluate the patient efficiently, while the patient realises that the physician takes their headache seriously and has time to prepare to discuss it in detail. By the end of the first consultation, the physician should have diagnosed the headache condition and either instituted an appropriate treatment, or referred the patient to a specialist if a sinister headache is suspected. The physician should supply the patient with clear knowledge of their headache and what they should do to improve it. Both the physician and the patient need to agree on a management plan, and how it is implemented and monitored. This is a lot to achieve, but it has to be done to ensure that the patient adheres to the agreed management plan and does not lapse from care. Once the first consultation is over, it is important to set in place follow-up procedures to motivate patients to persevere with their treatment and return for further care.

Many migraine patients who consult a physician will have suffered from the condition for several years. They therefore bring with them a history that can be ascertained with careful questioning. Migraine patients are frequently well educated about their condition, and have a clear idea of what they are suffering from. This knowledge can be used to aid diagnosis and treatment choices. On the other hand, some patients are at the end of their tether following years of suffering, and may have to be managed carefully by the physician.

Patient Counselling and Buy-in

Taking a careful history is essential and a key task of the first consultation. Several good history questionnaires are available, covering headache, other symptoms, influencing factors and current and previously used medications (Figure 4). No single symptom defines migraine and the physician can use the history to create a clinical profile representative of the headache pattern. The history should cover:

• Headache: the impact, type, severity, location, duration, frequency, timing and family history.

• Other symptoms: visual, sensory, gastrointestinal and neurological (e.g. slurred speech and loss of coordination).

• Influencing factors: diet, lifestyle, hormonal and environmental.

• Current medication taken for headaches and other conditions.^[22]

Patients need good education about their condition. People with headache are often motivated to understand their condition and physicians should provide them with information on the nature and mechanisms of their disorder. The physician should have a range of leaflets available, and can guide patients to professional organisations such as The Migraine Action Association (www.migraine.org.co.uk), The Migraine Trust (www.migrainetrust.org) and The World Headache Alliance (www.w-h-a.org) that can provide further information via publications and websites. The UK Migraine Action Association has a particularly useful booklet on migraine that is specifically designed for patient use.^[23] There are also excellent short books on migraine and other headaches that can be recommended to the patient.^[21,24]

Patient buy-in to the course of treatment can be optimised by effective communication between the patient and their physician. Patients should be told that migraine cannot be cured, but can be effectively controlled. Patients should also be encouraged to manage their condition themselves, making decisions about lifestyle alterations and how and when to take their medications. Physicians should encourage their patients to participate in their own management and effective communication between the physician and patient has been shown to improve care delivery.^[25] Patient preference is an important consideration in the choice of treatment. Patients may rate such factors as speed of response, overall headache relief, a lack of side-effects, or convenience as the most important characteristics of treatment.^[21] Conducting a careful physical examination can aid this buy-in process, as it reinforces to the patient that the physician takes their condition seriously.

Diagnosis of Headache

Since their first publication in 1988, the IHS diagnostic criteria have transformed research into migraine and the management of the condition by providing a standardised means of identifying migraine patients for physicians.^[26] Migraine is defined as shown in Table 1.

Diagnostic Criteria for Migraine Aura.

• The presence of at least three of the following four characteristics:
  
  
  • One or more fully reversible aura symptoms.
    
    
  • One or more aura symptoms develop gradually over more than 4 minutes, or two or more symptoms occur in succession.
    
    
  • No single aura symptom lasts more than 60 minutes.
    
    
  • The migraine headache occurs less than 60 minutes after the end of the aura symptoms.
    
    
  • Secondary (sinister) headaches have to be excluded as the cause of the aura symptoms.
    
    
  • There are also several rare subtypes of migraine characterised by aura symptoms that differ from those described above.

From these diagnostic criteria, it is important to note that no single headache feature and no single non-headache symptom are absolutely required for diagnosis. For example, a patient with severe bilateral headache associated with photophobia and phonophobia can be diagnosed with migraine, just as the more typical patient with unilateral, throbbing headache that is worsened by activity and accompanied with nausea. Migraine diagnosis using the IHS criteria is therefore somewhat of an art and requires a flexible approach rather than the simple 'ticking of boxes'. It is therefore perhaps better suited to the specialist or research setting than to primary care. Primary care physicians need a means of identifying patients with rare or secondary (sinister) headache who are best referred to a specialist and a simple and rapid means of diagnosing migraine and other common headaches. Two simple questionnaires have recently been developed to screen for headache diagnosis, which can then be confirmed, if necessary, using further questioning:

• The impact-based recognition questionnaire of the US Primary Care Network.^[17]

• A new diagnostic screen developed by MIPCA, which also incorporates an impact question.

Impact-based Recognition of Migraine^[17]

The impact-based recognition scheme of the US Primary Care Network consists of four questions:

1. Do your headaches interfere with your ability to work or engage in family and social functions? (This quickly separates medically relevant headaches from those more trivial in nature. Migraine is considered the default diagnosis for headache that significantly interferes with a person's ability to function, which then necessitates questions on migraine-specific associations, such as the presence of nausea, sensory sensitivity, positive family history, and in women, menstrual association.)

2. Has the pattern of your headache changed over the last 6 months? (This is designed to alert the physician to sinister headache conditions. A new or different headache mandates a thorough diagnostic approach, while a stable headache pattern provides reassurance to the physician and patient.)

3. How frequently do you have any kind of headaches? (This alerts the physician to the possibility of chronic headache patterns.)

4. What are you doing to treat your headaches? (This screens for medication overuse and the effectiveness of self-treatment efforts.)

The New MIPCA Diagnostic Screen

A short series of four questions is used to screen patients with headache at their first visit to the clinic:

1. What is the impact of the headache on the sufferer's daily life? (high impact = migraine or chronic daily headache; low impact = acute tension-type headache);

2. How many days of headache does the patient have every month? (> 15 days = chronic headache; </= 15 days = intermittent migraine);

3. For patients with chronic daily headache, on how may days per week does the patient take analgesic medications? (>/= 2 = analgesic-dependent headache; < 2 = non- analgesic-dependent headache);

4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks? (yes = migraine with aura; no = migraine without aura).

Two further brief investigations should be conducted in addition to these four questions:

1. Sinister headache should be excluded before asking the first question. (Sinister headaches tend to appear de novo in young children or mature adults, or present as a change in character compared with older patients' usual headache attacks. They are new-onset, acute headaches that are associated with a range of other symptoms (e.g. rash, neurological deficit, vomiting and pain or tenderness). Signs of neurological change or deficit do not disappear when the patient is pain-free between headache attacks. They may also be associated with an accident or head injury, infection or hypertension.^[27]) A full neurological examination is essential if sinister headache is suspected.

2. Once a pattern of chronic headaches is established (Question 2), the physician should investigate whether short-lasting headaches (e.g. cluster headache or short, sharp headaches) are the cause. (These headaches are severe, short lasting headaches [cluster headache: 15-180 minutes; short, sharp headaches: </= 30 seconds] that can occur up to several times per day, and which require separate diagnosis and treatment.^[21,27])

Using these two questionnaires, sinister, chronic and intermittent headaches can be recognised efficiently and rapidly in the outpatient setting, even when the patient is being evaluated for other complaints. Chronic headaches can be differentiated into short-lasting and chronic daily headaches, and patients identified who have analgesic dependence. Acute tension-type headache can be differentiated from migraine and attacks of migraine with aura distinguished from those of migraine without aura. Specific questioning (including possibly the IHS criteria) can then confirm these findings, if needed.

In general, any episodic, acute, disabling headache can be given a default diagnosis of migraine.^[19] Migraine generally starts during childhood and adolescence and peaks in severity during young adulthood to middle age, before declining in older age (in women, there may also be a peak at the menopause).^[1] Attacks are more common in women than in men. Migraine attacks typically occur up to four times per month and last from 4 to 72 hours each. The main symptom is a headache that is usually moderate-to-severe in intensity, throbbing, one-sided and exacerbated by activity. Most migraine headaches are accompanied by photophobia and/or phonophobia and nausea, with vomiting being less frequent. Patients are symptom-free between their attacks.^[28,29] However, people with migraine rarely have a stereotyped headache pattern, but almost inevitably experience a variety of headache presentations from migraine to migraine-like and tension-type headache.^[30] All of these different presentations have been shown to be reflections of the migraine process and respond in a similar fashion to migraine-specific medications.^[30] All these features can be elicited from the patient by simple questioning once migraine is suspected.

Some of the main headache subtypes may share certain features, but are straighforward to differentiate due to their different overall presentations, allowing for the accurate differential diagnosis of headache (Table 2).^[21]

http://www.medscape.com/viewarticle/446557_3