Determinants of Suboptimal Migraine Diagnosis and Treatment in the Primary Care Setting

Physician Factors

Although migraine and headache are a leading cause of physicians visits, most physicians have had little formal training in headache. In the United States, medical students spend an average of 1 hour of preclinical and 2 hours of clinical education in headache [7]. Furthermore, primary care physicians receive little formal training in headache during residency [8]. In addition to the lack of formal training, there is also a lack of substantial clinic time available to fully evaluate and treat a new headache patient in the primary care setting [8]. Headache consultations can often be timely and detail-driven in order to determine the correct diagnosis and treatment [9].

Misdiagnosis

Evidence suggests that misdiagnosis plays a large role in the suboptimal management of migraineurs. Studies have shown that as many as 59.7% of migraineurs were not given a diagnosis of migraine by their primary care provider [10]. Common mistaken diagnoses include tension-type headache [11], “sinus headache” [12], cervical pain syndrome or cervicogenic headache [13], and “stress headache” [14].

The reasons for these misdiagnoses is not certain. It may be that the patient and practitioner assume that location of the pain is suggestive of the cause [13]. This is even though more than half of those with migraine have associated neck pain [15]. A recent study suggests that 60% of migraineurs who self-reported a diagnosis of cervical pain have been subsequently diagnosed with cervicalgia by a physician [13]. If patients endorse stress as a precipitant or the presence of cervical pain, they are more likely to obtain a diagnosis other than migraine. The presence of aura in association with the headache appears to be protective against misdiagnosis [13].

Similarly, patients are often given a diagnosis of “sinus headache.” This diagnosis is often made without radiologic evidence of sinusitis and even in those with a more typical migraine headache [16]. In one survey, 40% of patients meeting criteria for migraine were given this diagnosis. Many of these patients did have nasal symptoms or facial pain without clear evidence or rhinosinusitis, and in some cases these symptoms would respond to migraine treatments [16]. This is a particularly important misdiagnosis to highlight, as attributing symptoms to sinus disease may lead to unnecessary consultations and even sinus instrumentation.

In addition to common misdiagnoses, many PCPs are unfamiliar with the “red flags” that may indicate a secondary headache disorder and are also unfamiliar with appropriate use of neuroimaging in headache patients [17].

Misuse of As-Needed Medications

Studies have suggested that a large proportion of PCPs will prescribe nonspecific analgesics for migraine rather than migraine-specific medications [18]. These treatments may include NSAIDs, acetaminophen, barbiturates, and even opiates. This appears to be the pattern even for those with severe attacks [18], suggesting that migraine-specific medications such as triptans may be underused in the primary care setting. Postulated reasons for this pattern include lack of physician knowledge regarding the specific recommendations for managing migraine, the cost of medications, as well as lack of insurance coverage for these medications [19]. Misuse of as-needed medications can lead to medication overuse headache (MOH), which is an underrecognized problem in the primary care setting [20]. In a survey of PCPs in Boston, only 54% of PCPs were aware that barbiturates can cause MOH and only 34% were aware that opiates can cause MOH [17]. The same survey revealed that approximately 20% of PCPs had never made the diagnosis of MOH [17].

Underuse of Preventive Medications

As many as 40% of migraineurs need preventive therapy, but only approximately 13% are currently receiving it [3]. Additionally, the average time from diagnosis of migraine to instituting preventive treatment is 4.3 years, and often there is only a single preventive medication trial if one is instituted [21]. The reasons for this appear to be complex. The physician factors contributing to the underuse of preventive medications include inadequate education, discomfort and inadequate time for assessments. Only 27.8% of surveyed PCPs were aware of the American Academy of Neurology guidelines for prescribing preventive medications [17].

There may be an underestimate of the disability experienced by migraineurs, which can explain some of the underuse of preventive medications. While many PCPs endorse inquiring about headache-related disability, many do not used validated scales such as the Migraine Disability Assessment Score (MIDAS) or the Headache Impact Test (HIT) [17]. In addition, patients often underreport their headache days and report only their severe exacerbations unless clearly asked about a daily headache [22]. This may be part of the reason why only 20% of migraineurs who meet criteria for chronic migraine are diagnosed as such and why preventatives may not be offered [23].

After preventatives are started, less than 25% of patients will be adherent to oral migraine preventive agents at 1 year [24]. Common reasons for discontinuing preventives include adverse effects and perceived inefficacy [22]. Preventive medications may need a 6- to 8-week trial before efficacy is determined, but in practice medications may be stopped before this threshold is reached. Inadequate follow-up and lack of detail with regard to medication trials may result in the perception of an intractable patient prematurely. It has been suggested that a systematic approach to documenting and choosing preventive agents is helpful in the treatment of migraine [25], although this is not always practical in the primary care setting.

Another contributor to underuse of effective prophylaxis is related to access. Treatment with onabotulinumtoxin A, an efficacious prophylactic treatment approved for select chronic migraine patients [26], will usually require referral to a headache specialist, which is not always available to PCPs in a timely manner [7].

Nonpharmacologic Approaches

Effective nonpharmacologic treatment modalities for migraine, such as cognitive-behavioral therapy and biofeedback [27], are not commonly recommended by PCPs [17]. Instead, there appears to be more focus on avoidance of triggers and referral to non–evidence-based resources, such as special diets and massage therapy [17]. While these methods are not always inappropriate, it should be noted that they often have little or no evidence for efficacy.

Patients often wish for non-medication approaches to migraine management, but for those with significant and severe disability, these are probably insufficient. In these patients, non-medication approaches may best be used as a supplement to pharmacological treatment, with education on pharmacologic prevention given. Neuromodulation is a promising, novel approach that is emerging as a new treatment for migraine, but likely will require referral to a headache specialist.