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Optimal Management of Acute and Preventive Migraine - Episode 3

Challenges of Migraine Diagnosis

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Drs Bradley Torphy and Julio R. Vieira share insight on approaching the diagnosis of migraine as well as current challenges in diagnosis.

Jessica Ailani, MD: In this segment, we’re going to be talking about migraine diagnosis, a challenge that many of us still face in clinic. The challenge is to be able to take an excellent history. Sometimes it involves getting our patients to tell us their story. That sounds relatively easy. Unfortunately, patients are often told it’s not a big deal. That’s to such a great extent that by the time they come to see us in clinic about headaches, they’ve been having, they focus on 1 or 2 key aspects and aren’t used to telling their entire story from start to finish. It’s important that we focus on a couple of key items and allow the patient space to tell us their history from the start, so we can pick up on key elements of the diagnosis. Hopefully, this segment will get you to understand those key segments you need to hear from the patient to make the appropriate diagnosis of migraine.

Brad, I thought we’d start with you. What are the essential parts of making the diagnosis of migraine? Is this something we’re pulling out of air, or are there criteria involved in making the diagnosis?

Bradley Torphy, MD:It’s such a good question. One challenge in making that diagnosis of migraine is that patients are not used to telling their stories. If we think about it, migraine is most often in primary care. Primary care providers may have dealt with diabetes and hypertension, and when their hands are on the doorknob and they’re ready to leave, the patient finally gets a chance to talk about her headaches. Patients aren’t used to going in depth with the provider and sharing information that could be helpful. In our practice, we start by saying, “Tell me about your headache. Tell me what you think I need to know.” I know that can be challenging. We’re all on the clock. We have a lot of time to see our patients. If we spend a little time up front letting the patient share her story, then afterward we can focus on specific questions we have.

After the patient has had an opportunity to share her story, what she thinks might be important—we probably are going to get most of the information from that part of the history—we focus on a few key things: migraine light sensitivity, phonophobia, photophobia, nausea. Those are key features of migraine. For a lot of providers, if they’re not specifically focused on migraine and headache, looking at the ICHD-3 [International Classification of Headache Disorders, third edition] classification, it can be daunting. But Richard Lipton’s ID Migraine is a very valuable tool, not only in the neurology setting but also in primary care. Is there photophobia and phonophobia with your migraine? Is there impact—are you missing work or school? Is there nausea? If patients answer yes to 2 of 3, there’s a positive predictive value of over 90% that the patient has migraines. Listening to the patients can be challenging, but we can garner a lot of information.

Jessica Ailani, MD: This is a great tip. ID Migraine is something I encourage my residents and fellows to use to pick up those key elements when a patient is telling you their history.

Julio, we talked about the challenges of making the migraine diagnosis. What are some of the factors we see in the literature that suggest problems with underdiagnosis of migraine? Does anything in the literature suggest this is an underdiagnosed disease?

Julio R. Vieira, MD: That’s interesting. Unfortunately, we have a very suboptimal diagnosis of migraine. We’re a rare breed as headache specialists. We’re used to dealing with migraine, but a lot of clinicians—neurologists but also primary care—have a lot of difficulty diagnosing migraine. There are numbers that show us the consultation patterns and suboptimal migraine diagnosis and care. There are certain data showing that the United States had consortium therapies and migraine-specific pharmacology therapies. They usually require prescriptions for the migraine-specific medications. Looking at those data, two-thirds of patients have consulted a health care professional in the past year before having a diagnosis of migraine. Patients usually end up seeing either their primary care provider or general neurologist. Unfortunately, we’re not having those diagnoses.

There are also data from epidemiological studies, like the American Migraine study, showing similar data. Also, 68% of women and 57% of men who have migraine express that they have seen a health care professional in a previous year. Unfortunately, they didn’t have a diagnosis of migraine at that time. Similarly, the AMPP study, the American Migraine Prevalence and Prevention study, showed 45.5% of patients with episodic migraine—those who have migraine frequency on the low side. However, those who have headache-related disability have seen a physician in the previous year.

A few issues were identified in those epidemiological studies. Predictors for potential migraine consultation include—it seems obvious—having health insurance. A lot of people lack health insurance and do not seek a provider. Others include a higher level of headache-related disabilities—the worse they are, the more likely they are to seek help—and a greater report of headache pain intensity that usually helps patients seek care.

Other studies, like the CaMEO study, show that among subjects with migraine, about 40% who have chronic migraine end up seeing a physician at the time of enrollment. They were able to identify several predictors that were likely to have brought the patients to seek care. Health insurance was the biggest, with 4.6 times higher odds of a person seeking care. Also, higher BMI [body mass index] was a common factor, with those overweight and especially obese more likely to seek care. Other factors are older age, those with greater migraine-related disability, and those with greater-severity migraine symptoms—the ones who are not doing as well. Only 4.5% of participants who end up seeking care have appropriate treatment for chronic migraine.

They also identified 3 obstacles for care: having a consultative health care professional for migraine, having received an accurate diagnosis, and having been prescribed minimum acute and preventive pharmacological treatments. For headache specialists, it seems to be so obvious and easy for us to recommend patients. But as clinicians, including general neurologists and primary care, we’re not doing a good job with that.

As our colleagues were saying, the first thing is to obtain a very good history and identify those features. Most of the time, when we’re collecting our data, we use the ICHD-3 criteria to ask all the questions that our questionnaires usually collect. But I agree with Dr Torphy that the ID Migraine is such a great tool that we can propose it to clinicians—general neurologists and primary care as well. Going back to what Dr Andrew Charles was talking about, for patients who have aura, sometimes it’s not easy to identify, particularly the sensory aura. Sometimes it gives you tingling on the fingertips. Sometimes it gives you changing tastes, like metallic taste. Sometimes, when I ask my patients, they’re like, “What are you talking about? Yes, I have that.”

Transcript Edited for Clarity