Optimal Management of Acute and Preventive Migraine - Episode 5
Experts in neurology, Drs Julio R. Vieira, Jessica Ailani, and Bradley Torphy review diagnostic tools available for migraine, including patient use of headache diaries.
Jessica Ailani, MD: These are all excellent points. Another way we can utilize tools to help us make diagnoses are headache diaries and sometimes other types of forms we can have patients complete to help us understand their disability. I wanted to ask both of you—and maybe, Julio, you can tell us first—how often are you having patients use headache diaries? And how often are you using any kind of patient-reported outcome measures in your clinic, like the MIDAS [migraine disability assessment] scale or the HIT-6 [Headache Impact Test], having them fill these things out? Or are there any other tools that help you not only understand the impact of the disease, make the diagnosis, but follow the patient through time to see how they're doing?
Julio R. Vieira, MD: Yes. There was a review paper a few years ago that showed that they analyzed 30 different tools. I didn't even know we have that many tools. And every time things start to get complicated, it's also harder for us to include those tools into our daily clinical life, and especially in our peers that we try to educate as well—general neurologists and primary care who are not used to using these different tools. Going back to what we were talking about before, I still believe that the ID-Migraine questionnaire is one of the best tools that can be spread out there, which shows the disability, nausea, and photophobia. Or sometimes people use the mnemonic “PIN”. P-I-N stands for “photophobia” “inability to function” “ad nauseam”. And that's an easy tool to be used.
Going back to the headache diary, I recommend every time. It's always useful. The only time which is sometimes hard to recommend is for those patients who have either daily headache or constant headache, which becomes very boring. And after a while, they're like, "Nah, forget it. I have headaches every day. Why would I even do this?" And then we try to flip the table and generate the diary in a way that's a reward. And we tell the patients to record good days and they're like, "Yay. I have a good day today" instead of recording every single day, which becomes boring. When studies were done about with diary, patients thought that they knew how many headaches they have without documenting and having a true diary. But study after study show that once you start recording, it's a whole different story. And most of the time they have more headaches than they thought. Going back to the other tools that you were mentioning, like the MIDAS or HIT-6, the headache specialists always try to utilize those tools, which are used for us to measure disability. But I don't think it's very common within the general neurologists and other providers.
Jessica Ailani, MD:I agree with your assessment of headache diaries. They can be very useful, especially in the beginning, but very difficult in someone who has daily or continuous headache. I often find they can be very demoralizing for those patients. We'll often use them when we're changing treatments or making adjustments just to ensure the patient has some response to treatment, or when they're using a frequently used acute medication just to see how things are going. But I also agree with the reward process of "Look, you're having headache-free days; just mark those down". And then, the patient-reported outcome tools can be very difficult. When a patient is very disabled, on the same point, even episodic migraine, many of the patients in a headache clinic are on the high disability side. It's very hard to measure changes in high disability; there is no change if your MIDAS levels are already at highly impacted, and you’re improved, but you're still highly impacted. It's very hard to say that that's making great strides of improvement, even though the patient can tell you they're much better and they're functional. Sometimes you come up with other creative ways to measure improvement: changes in emergency room visits, going back to work, how many hours are they working, missed social life functions. And there are other creative ways to evaluate how your patient is doing if you try to keep it consistent in the same patient.
What about you, Brad? Do you find headache diaries to be useful? Any tricks to offer our audience on ways to measure how a patient is doing over time?
Bradley Torphy, MD: I agree with your approach, Jessica, that the best use of headache diaries is early in the therapeutic relationship, and specifically, where I find it to be most useful is when we're having that discussion about possible triggers. And I'll give the example of when I describe tyramine. No, I don't necessarily advocate that patients cut out all things tyramine. But I do say, when you're keeping that diary, if you take a close look at those foods that are rich in tyramine, consider those suspects. And if you see them appearing often in your diary, then you know it may be a good idea to cut that out. But I agree. As time goes on and the therapeutic relationship continues, and we've been working together for a while, that utility does go down quite a bit. In our practice, we utilize the HIT-6 tests with every patient on every visit, and what we’ve found in our practice is that it's given us robust data. If we've decided we're interested in a certain topic—for example, in telemedicine—we were able to look at HIT-6 scores with our telemedicine patients, and it can give us rich information.
Jessica Ailani, MD: If you want to do research in your center, I agree with Brad. Also part of what Julio was saying is, in keeping those calendars, it becomes really important. It is very difficult to do even retrospective data when you're relying on methods like I have, which is, How are you feeling?, that doesn't really fly in any kind of retrospective data analysis at all.
Julio R. Vieira, MD: And it helps you to put symptoms in perspective to record certain triggers like menses, for example. And also, to set up a perspective on what the patient expects in their treatment and their relationship with you, because many times if the patients are not keeping a diary, they come in and they say, I still have headaches. But then you'll say, Let's keep a diary. The next visit, they come in, they kept a diary, and they're doing better, but still have that expectation. We need to differentiate between having tons of headaches or having headaches or migraines or not having any. One of the things that I try to tell my patients is, I think I can make you better. I'm not sure exactly by how much but there's got to be a relationship 1 day at a time. I will take it from there.
Jessica Ailani, MD: Setting expectations, goal setting, again, are very important points and something that has to be revisited, not necessarily every visit but frequently through the relationship of the health care provider.
Transcript Edited for Clarity