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

Suboptimal Management of Migraine Comorbidities

There are several disorders that are commonly comorbid with migraine. Among the most common are anxiety, depression, medication (and caffeine) overuse, obesity, and sleep disorders [22]. A survey of PCPs reveals that only 50.6% of PCPs screen for anxiety, 60.2% for depression, and 73.5% for sleep disorders [17]. They are, for the most part, modifiable or treatable conditions and their proper management may help ease migraine disability.

In addition, the presence of these comorbidities may alter choice of treatment, for example, favoring the use of an serotonin and norepinephrine reuptake inhibitor such as venlafaxine for treatment  in those with comorbid anxiety and depression. It is also worthwhile to have a high index of suspicion for obstructive sleep apnea in patients with headache, particularly in the obese and in those who endorse nonrestorative sleep or excessive daytime somnolence. It appears that patients who are adherent to the treatment of sleep apnea are more likely to report improvement in their headache [28].

Given the time constraints that often exist in the PCP office setting, addressing these comorbidities thoroughly is not always possible. It is reasonable, however, to have patients use screening tools while in the waiting room or prior to an appointment, to better identify those with modifiable comorbidities. Depression, anxiety, and excessive daytime sleepiness can all be screened for relatively easily with tools such as the PHQ-9 [29], GAD-7 [30] and Epworth Sleepiness Scale [31], respectively. A positive screen on any of these could lead the PCP to further investigate these entities as a possible contributor to migraine.

Patient Factors

In addition to the physician factors identified above, patient factors can contribute to the suboptimal management of migraine as well. These factors include a lack insight into diagnosis, poor compliance with treatment of migraine or its comorbidities, and overuse of abortive medications. There are also less modifiable patient factors such as socioeconomic status and the stigma that may be associated with migraine.

Poor Insight Into Diagnosis

Despite the high prevalence and burden of migraine in the general population, there is a staggering lack of awareness among migraineurs. Some estimates state that as many as 54% of patients were unaware that their headaches represented migraine [32]. The most common self-reported diagnoses in migraineurs are sinus headache (39%), tension-type headache (31%) and stress headache (29%) [14]. In addition, many patients believe they are suffering from cervical spine–related pain [13]. This is likely due to the common presence of posteriorly located pain, attacks triggered by poor sleep, or attacks associated with weather changes [13]. Patients presenting with aura are more likely to report and to receive a physician diagnosis of migraine [14]. Women are more likely to receive and report a diagnosis of migraine compared with men [32].

There are many factors that play a role in poor insight. Many patients appear to believe that the location of the pain is suggestive of the cause [13]. Many patients never seek out consultation for their headaches, and thus never receive a proper diagnosis [33]. Some patients may seek out medical care for their headaches, but fail to remember their diagnosis or receive an improper diagnosis [34].

Poor Adherence

The body of literature examining adherence with headache treatment is growing, but remains small [35]. In a recent systematic review of treatment adherence in pediatric and adult patients with headache, adherence rates in adults with headache ranged from 25% to 94% [35]. In this review, prescription claims data analyses found poor persistence in patients prescribed triptans for migraine treatment. In one large claims-based study, 53.8% of patients  receiving a new triptan prescription did not persistently refill their index triptan [36]. Although some of these patients switched to an alternative triptan, the majority switched to a non-triptan migraine medication, including opioids and nonsteroidal anti-inflammatory drugs [36].

Cady and colleagues’ study of lapsed and sustained triptan users found that sustained users were significantly more satisfied with their medication, confident in the medication’s ability to control headache, and reported control of migraine with fewer doses of medication [37]. The authors concluded that the findings suggest that lapsed users may not be receiving optimal treatment. In a review by Rains et al [38], the authors found that headache treatment adherence declines “with more frequent and complex dosing regimens, side effects, and costs, and is subject to a wide range of psychosocial influences.”

Adherence issues also exist for migraine prevention. Less than 25% of chronic migraine patients continue to take oral preventive therapies at 1 year [24]. The reasons for this nonadherence are not completely clear, but are likely multifactorial. Preventives may take several weeks to months to become effective, which may contribute to noncompliance. In addition, migraineurs appears to have inadequate follow-up for migraine. Studies from France suggest that only 18% of those aware of their migraine diagnosis received medical follow-up [39].

Medication Overuse

While the data is not entirely clear, it is likely that overuse of as-needed medication plays a role in migraine chronification [40]. The reasons for medication overuse in the migraine population include some of the issues already highlighted above, including inadequate patient education, poor insight into diagnosis, not seeking care, misdiagnosis, and treatment nonadherence. Patients should be educated on the proper use of as-needed medication. Limits to medication use should be set during the physician-patient encounter. Patients should be counselled to limit their as-needed medication to no more than 10 days per month to reduce the risk of medication overuse headache. Ideally, opiates and barbiturates should be avoided, and never used as first-line therapy in patients who lack contraindications to NSAIDs and triptans. If their use in unavoidable for other reasons, they should be used sparingly, as use on as few as 5 to 8 days per month can be problematic [41]. Furthermore it is important to note that if patients are using several different acute analgesics, the combined total use of all as-needed pain medications needs to be less than 10 days per month to reduce the potential for medication overuse headache.