Limitations of current pain scales used by health care professionals who manage patients with migraine, and considerations for using patient diaries to help monitor symptoms and recommend appropriate therapy.
Jill Dehlin, RN: Dr Starling, you were talking a bit about all the different phases of migraine, and for many of us, the pain scales aren’t really appropriate. Now that I’m on a CGRP monoclonal antibody, I may have a low level of pain but a high level of disability because of the cognitive problems, the word finding issues, the inability to do simple math, or the executive functions that fly out the window. I think it’s really important that health care providers understand that a migraine attack is a certain phase, but there are other phases that can go along with that, which may be just as debilitating as the headache phase.
Amaal J. Starling, MD: You’re exactly right. During these appointments with patients, the first thing I say when I’m talking about the diagnosis is,” You have the diagnosis of migraine. Migraine is a genetic neurologic disease.” The next thing I say is that “The word migraine is not synonymous with headache. Migraine is a lot more than just a headache,” and I go through the spiel that you mentioned. What we focus on in that initial appointment and definitely in follow-up appointments is function. We all talk about headache diaries, right? We all want patients to keep these diaries because it helps us determine care.
Now, as physicians and health care providers, if we’re going to ask our patients to keep a diary of their symptoms, we must look at it on the follow-up visit. If we don’t, that’s just mean and inappropriate. If you ask a patient to keep a log of their symptoms, please look at it in that follow-up visit. It is really important to look at it because it can help us make treatment recommendations. But how do I ask people to keep their symptom diary?
I don’t do it based on a pain scale like you’ve mentioned. I do it based on function. I like the stoplight diary—green, yellow, red. Green is a day that individuals are able to function. Yellow is a day where their function is impaired but they’re still able to get what they need to do done. Red is a day where they’re disabled, they’re in bed, they’ve had to call out sick from work, they’ve had to call in family to help with their kids, and they’re completely out of commission on that day. I always tell my patient population that our goal is for the green revolution. We’re always looking for as many green days as possible. I flip through that symptom diary and look for a progression toward those green days.
I would recommend that we always ask for people to keep a symptom diary rather than a headache diary because it’s about function, not solely about head pain. Also, first and foremost, if you ask people to keep a diary of symptoms, please look at it. When you do look at it, if you see that symptoms are spread out randomly throughout the month, focus on prevention. But if you see that they’re clustered in a week or two, that’s when you focus on the breakthrough pain. It can be really helpful for how we address our treatment recommendations next.
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Transcript Edited for Clarity