American Headache Society collaborates with PCPs to improve migraine care
A new advisory board commissioned by the American Headache Society is developing strategies to improve migraine care in primary care offices.
The board represents physicians in internal medicine, family medicine, obstetrics and gynecology, neurology and headache medicine. They are collaborating to better equip front-line primary care providers with the education and support needed to more effectively diagnose and treat headache disorders, according to Mia T. Minen, MD, MPH, a headache specialist and associate professor of neurology and population health at NYU Langone Health, and colleagues.
“The American Headache Society (AHS) is committed to working with primary care providers,” Minen told Healio Primary Care. “This is a collaboration with the primary care providers, and the work is being informed by what they say is needed in the field.”
Gaps in knowledge
In a paper recently published in Headache, Minen and colleagues reported that more than half of migraine consults occur in primary care settings, but many PCPs lack formal education on headache medicine.
The authors cited previous data that showed only 28% of PCPs were familiar with migraine prevention guidelines from the American Academy of Neurology, and 40% were familiar with recommendations from the American Board of Internal Medicine Foundation Choosing Wisely Campaign to limit opioids and imaging for migraine. Furthermore, only 34% of PCPs were aware of the link between opioid use and worsening of headache.
Additional data demonstrate “substantial under-diagnosis and under-treatment,” according to the authors. Although about 40% of adults with migraine require preventive therapy, only about 13% receive it. On average, there is a 4-year delay between migraine diagnosis and initiation of preventive treatment.
Improving migraine care
The new advisory board convened in November 2019 at the American Headache Society’s annual Scottsdale Headache Symposium to discuss the limited coverage of headache medicine in medical school, residency curricula and specialty medical examinations. The board members developed suggestions and strategies to help overcome this issue, which include:
- collaborating with residency directors to include headache medicine in curriculum;
- partnering with health societies to promote headache education at regional and national meetings;
- encouraging headache fellows and attendings to advocate and disseminate headache knowledge at meetings;
- providing tools such as podcasts, online programs and apps that will empower PCPs to treat patients with migraine appropriately;tailoring education programs for pediatricians, OB-GYNs and geriatricians;
- educating clinicians about triptans and headache myths;
- offering tips on how to counsel patients about preventive treatments; and
- implementing migraine screening tools on annual intake forms.
“Now that we have held the in-person advisory board meeting, we are working on developing grand rounds presentations as well as other educational materials,” Minen said
Advice for PCPs
WHO now considers migraine as the second-most disabling condition worldwide, according to Minen. She stressed that it is a common condition, affecting approximately 12% of the United States population.
“Given its high prevalence and disability, migraine should be diagnosed and treated,” Minen said. “Unfortunately, migraine may be misdiagnosed as just a tension type headache or even sinusitis. Like sinus headaches, migraine may also have autonomic features, which can be confusing. However, sinus headaches are not usually so disabling that they keep people home from work.”
The key to managing migraine is understanding the diagnostic criteria, according to Minen. A simple three-question validated screen — ID-Migraine — is available for use in the primary care setting.
In terms of treatment, Minen said PCPs should offer medications such as triptans to patients with moderate to severe attacks who do not respond to NSAIDs. These are “fairly safe” treatments, she said. The main contraindications are for patients with a history of stroke or myocardial infarction and those with uncontrolled hypertension.
“Patients should be counseled to take them at the onset of the attack — that is when they are most effective,” Minen said. “For patients who have on average 4 or more headache days a month, there are also preventive treatments.”
Preventive medications include supplements such as vitamin B2 (riboflavin, 400 mg) and magnesium (400 mg); certain classes of blood pressure, anti-depressant and seizure medications; and a new class of migraine medications known as calcitonin gene-related peptide antagonists.
“PCPs should be comfortable using a few of the migraine medications before referring to neurology,” Minen said. “They already use some of these medications [such as] candesartan and propranolol for other health conditions.”
There is also evidence that behavioral therapies — including cognitive behavioral therapy, relaxation and biofeedback — are effective in migraine prevention. Previous research published in BMJ by Kenneth A. Holroyd, PhD, and colleagues, and in JAMA by Scott W. Powers, PhD, ABPP, FAHS, and colleagues, show combining behavioral therapy with pharmaceutical medication “is best for migraine prevention,” Minen said.
“Lastly, there are also devices that have been developed and are FDA approved for abortive and preventive migraine therapy,” she said. – by Stephanie Viguers
* Editor’s note: This interview reflects the views and opinions of Minen and not AHS.
Disclosures: Minen reports no relevant financial disclosures. Please see the paper for all other authors’ relevant financial disclosures.