Determinants of Suboptimal Migraine Diagnosis and Treatment in the Primary Care Setting
Socioeconomic Factors
Low socioeconomic status has been associated with an increased prevalence for all headache forms and an increased migraine attack frequency [42], but there appear to be few studies looking at the impact of low socioeconomic status and treatment. Lipton et al found that health insurance status was an important predictor of persons with migraine consulting a health care professional [43]. Among consulters, women were far more likely to be diagnosed than men, suggesting that gender bias in diagnosis may be an important barrier for men. Higher household income appeared to be a predictor for receiving a correct diagnosis of migraine. These researchers also found economic barriers related to use of appropriate prescription medications [43]. Differences in diagnosis and treatment may indicate racial and ethnic disparities in access and quality of care for minority patients [44].
Stigma
At least 1 study has reported that migraine patients experience stigma. In Young et al’s study of 123 episodic migraine patients, 123 chronic migraine patients, and 62 epilepsy patients, adjusted stigma was similar for chronic migraine and epilepsy, which were greater than for episodic migraine [45]. Stigma correlated most strongly with inability to work. Migraine patients reported equally high stigma scores across age, income, and education. The stigma of migraine may pose a barrier to seeking consultation and treatment. Further, the perception that migraine is “just a headache” may lead to stigmatizing attitudes on the part of friends, family, and coworkers of patients with migraine.
Conclusions and Recommendations
Migraine is a prevalent and frequently disabling condition that is underrecognized and undertreated in the primary care setting. Both physician and patient factors pose barriers to the optimal diagnosis and treatment of migraine. Remedies to address these barriers include education of both patients and physicians first and foremost. Targeting physician education in medical school and during residency training, including in primary care subspecialties, could include additional didactic teaching, but also clinical encounters in headache subspecialty clinics to increase exposure. Patient advocacy groups and public campaigns to improve understanding of migraine in the community may be a means for improving patient education and reducing stigma. Patients should be encouraged to seek out consultations for headache to reduce long-term headache disability. Management of comorbidities is paramount, and screening tools for migraine-associated disability, anxiety, depression, and medication use may be helpful to implement in the primary care setting as they are easy to use and time saving.
Recent surveys of PCPs suggest that the resource that is most desired is ready access to subspecialists for advice and “curb-side” consultation [17]. While this solution is not always practical, it may be worthwhile exploring closer relationships between primary care and subspecialty headache clinics, or perhaps more access to e-consultation or telephone consultation for more rural areas. Recently, Minen et al examined education strategies for PCPs. While in-person education sessions with PCPs were poorly attended, multiple possibilities for further education were identified. It was suggested that PCPs having real-time access to resources during the patient encounter would improve their comfort in managing patients. This includes online databases, simple algorithms for treatment, and directions for when to refer to a neurologist [46]. In addition, it may be worthwhile to train not only PCPs but also nursing and allied health staff so that they can provide headache education to patients. This may help ease some of the time burden on PCPs as well as provide a collaborative environment in which headache can be managed [46].
Corresponding author: William S. Kingston, MD, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale, AZ 85259.
Financial disclosures: None.
