Original Article:  http://www.practiceupdate.com/expertopinion/644

Dr. Patricia Elliott, Associate Professor, C.E. Woodson Endowed Professorship in Family Medicine, and Vice Chair for Clinical Affairs in the Family Medicine Department at the University of Texas Medical Branch at Galveston, speaks with PracticeUpdate about managing patients with migraines from a primary care perspective.

PracticeUpdate: Dr. Elliott,migraine is one of the most disabling conditions in the country, with a significant impact on quality of life. Would you talk about your approach to these patients as a primary care physician?

Dr. Elliott: Headache is probably the most common pain problem that we see in family medicine and primary care; only back pain may be its equal. An estimated 28 to 32 million Americans experience migraine, and it is slightly more common in females than in males. Migraine tends to be under-diagnosed or not diagnosed. Understanding how migraine presents, how to diagnose it, and how to treat it in a way that helps our patients maintain their normal functioning is important for primary care clinicians.

The headache history

I spend quite a bit of time with patients when they first come to me because of a complaint of recurrent headaches. I spend about 45 minutes, taking a thorough history and doing a physical examination. The history is key to understanding their problem.

As I talk to patients, I listen to their description of their headache. What is the location of the headache? How often is it occurring? How long does it last? What is the nature of the headache and the pain? Does it radiate anywhere? What are the associated symptoms? Nausea? Vomiting? Light sensitivity (photophobia)? Sound sensitivity (phonophobia)? I also try to understand its intensity and its effect on their normal daily activities.

I want to know how long the headache lasts. If it lasts anywhere from 4 hours or up to 3 days, that can be definitely a sign of migraine. Two other characteristics are indicative. Occurrence on only one side of the head is an important feature, although a migraine can be bilateral. (Historically, migraine was thought to be only unilateral.) Also, a headache with an intense, pulsating quality to it that significantly affects the patient’s normal functioning could be migraine. If at least one of the following is present—nausea, vomiting, photophobia, or phonophobia—the probability is high for migraine. In addition, if the patient has had at least four or five attacks of that quality, migraine is likely.

There are two basic types of migraines: those without aura, which were formerly called common migraines, and those with aura, which were formerly called aplastic migraines. Migraines often get misdiagnosed as sinus headaches. The symptoms may be similar, but the features I have just described can make the distinction. Aura is one of the main differentiators. If the patient experiences any kind of neurologic symptoms that precede the headache, occurring anywhere from minutes to an hour beforehand—they can sense the headache coming on—then we usually think in terms of migraine.

I also ask patients what they have taken for their headaches. It is important to obtain a thorough medication history. This should include not only prescription medications but also over-the-counter medications and any herbal medications and supplements. I need to understand the effects of those agents. Does it take the headache away? Does the headache come back? How many doses are required to make the headache go away?

The headache diary 

One of the best tools for assessing patients’ headache pattern is a headache diary. Ideally, you would have patients complete a headache diary for the month before you see them. Headache diaries used to be recorded in written format on paper, but now people have smart phones and apps for a headache diary. The headache diary helps capture when the headache occurs, what the potential food triggers might be, what kind of activity triggers the headache, and so forth. For women, it is important to understand any relationship with the menstrual cycle. Family history may also point toward migraine, as, in some cases, migraine is familial.

Indications for MRI or a neurology consult

PracticeUpdate: Which patients do you send for an MRI?

Dr. Elliott: In addition to the history, the physical examination may reveal neurologic components to the headaches. I may see findings that are of concern neurologically. In that case, I will definitely send the patient for an MRI, and possibly for a neurology consult. An example is if the headache pattern has changed—it’s not the patient’s usual headache. The patient may be experiencing progressively more intense headaches, or headaches that are not responding to medications. There may be new triggers, or more triggers—such as increased stress—raising the intensity. A change in the pattern warrants imaging. MRI is preferred over CT.

Primary care physicians need to partner with the specialists to better understand the approaches to headache management and help their patients. They need to be available to the patient, because the patient will often go to see the primary care physician during an acute attack, not the neurologist.

Treatment: Limitations of stepped care

The traditional approach to treating migraine was a stepped-care approach. We would start with an NSAID or another type of moderate-strength pain reliever and see how it worked. If it was not effective, then we would step up the therapy to ergotamine or something similar. We might introduce a barbiturate. The next step would be to add a triptan. As a last resort, we would add a narcotic.

The problem with the stepped-care approach is that we miss the opportunity to institute a truly effective treatment, one that meets the patient’s goals. We focus on trying to reduce the frequency or the severity of the headache, and thereby the associated disability.

Although we try to avoid escalating to the use of multiple headache medications, we can end up with a new problem. The more medication patients keep taking, the more they may develop a chronic headache or rebound headaches, for which they need to use still more medicines. This is exactly what we were trying to avoid.

A stratified, multifactorial approach is preferred

A stratified approach is better. This is based on making a disability assessment—understanding how the migraine affects the patient’s quality of life. This takes into consideration the headache’s frequency, the severity, the degree of disability that the patient is experiencing, and other types of conditions that the patient may have.

At each patient visit, you would evaluate how the regimen that you have developed is working for that patient. It’s not just medications that you need to consider. The decision criteria are multifactorial. How is the regimen helping the patient in terms of decreasing the amount of disability and helping him or her to be more functional and have a better quality of life?

Various tools are available for this assessment, such as the Midas questionnaire and the headache impact test (HIT). With self-administered tests, the patients score themselves to see where they are. You can then see if current headaches are having a high impact, a medium impact, or a low impact on their life. That will help you select the best treatment.

In this approach, you will not waste time by routinely stepping up the therapy. If the headaches have a high impact on the patient’s life, you want to start with a treatment that will really work. That may mean using triptans with other medications. You may want to start prophylactic medication right away. Tailoring the treatment for your patient based on the impact of the migraine on their quality of life is a much better approach.

Integrative approach

PracticeUpdate: Do you also use alternative approaches, such as magnesium, vitamin B, and other therapies?

Dr. Elliott: I use everything. I embrace the idea of an integrated approach to migraine management. It is important to balance out the various factors that may be at play. Hormonal factors in female patients are one example. Quite a few patients may have a slight magnesium deficiency, in which case magnesium oxide supplementation can be very helpful. Other vitamin therapies that can be useful include vitamin B2 (riboflavin) and vitamin D. Several good studies have evaluated the use of butterbur, at a dosage of 75 mg twice daily. Beta blockers can work as prophylaxis for some patients. We use a combined approach that may complement pharmacologic therapies with vitamins and minerals.

I also incorporate other integrative approaches such as relaxation techniques and attention to sleep patterns. Biofeedback has been shown to be very helpful. However, patients have to practice these modalities before they have a headache, because when they are in the midst of an intense headache, it is very difficult to engage in relaxation techniques or biofeedback. Massage therapies can also be tried.

In taking the patient history, I inquire about sleep patterns. Sleep has an impact on pain. Migraine patients need to maintain consistency in their sleep–wake cycle. They should get the same amount of sleep—and a good amount of sleep, such as 8 or 9 hours—every night. Bedtime and wake-up time should be consistent. If people get into a sleep-deficit mode, they then decide to sleep in on the weekend, thinking they will get up and feel fine. When, instead, they wake up with a headache, it is because they have disrupted their sleep–wake cycle. I advise patients not to sleep in on the weekend. I tell them to get up at the same time they normally would during the week. They can go back for a rest after an hour or so. Keeping consistency in the sleep–wake cycle is an important part in treating headache.

Acute vs chronic management 

In developing a management strategy for a patient, I need to understand what the patient needs for an acute attack and what he or she needs to help prevent a future attack. Effective management for an acute attack will help the patient get the headache under control quickly and be relieved of pain.

Headache prevention means trying to prevent patients from getting as many headaches as they have been. There are many approaches we can consider. Sometimes the choice depends on other comorbidities within the patient. And people have different triggers. The headache diary is important here. I share some of my own triggers with my patients, but I tell them that they need to understand their own headaches. Food triggers can cover a range of substances, such as monosodium glutamate, nitrates and nitrites, and some unusual triggers such as citrus or tomato products. Other triggers may be light, stress, or even exercise.

Beta blockers have been used in the prevention of migraine for a long time. Neuroleptic drugs have also been used. Topiramate is a first-line drug. Valproic acid, divalproex, and other neuroleptics are still being used.

Depression and anxiety

PracticeUpdate: What is the role of depression and stress-related anxiety? Is it a chicken-and-egg relationship in migraine, where one may exacerbate the other?

Dr. Elliott: There is definitely an association between depression and migraine. Patients who have a chronic pain syndrome and migraine should be screened for depression and anxiety. Those conditions need to be addressed. One concern, however, is that some of the medications for migraine potentially interact with depression. It can be a challenge to balance that, and to counsel your patients appropriately. You don’t want to not treat the depression. There are multiple ways to address the depression, and also anxiety. Then you need to deal with the chronic pain and the headaches, because they can be quite disabling and debilitating. If you don’t address the pain, and you don’t address the depression, you will not achieve effective management for your patient.

Start the medication early

One of the issues that comes up with patients regarding their medications is its expense. Some patients will wait until the headache is full-blown before they will take their medication, because they don’t want to waste it, or use it up. I tell my patients, “Don’t ever wait.” Once a headache gets to a point of extreme intensity, it is much more difficult to get it to respond. I counsel patients to be aware of when a headache is coming on. They may not have an actual aura, but they sense that a headache is coming—they can feel the changes in their body. That’s when they need to take their medication—right away, before the headache gets too intense. That is how to get the best benefit from the treatment plan.