Migraine has been shown to cause absenteeism and lower productivity at work as well as reduced quality of life.1 According to the US Headache Consortium Guidelines, migraineurs with severe or moderate attacks should be treated with specific antimigraine medications, and prevention is recommended in those with frequent headaches as well as attacks that remain disabling despite optimal acute treatment.2
Researchers in the American Migraine Prevalence and Prevention (AMPP) study assessed 18,968 respondents who met criteria for migraine. Of these, 56.2% had received a medical diagnosis of migraine, and 13% were currently taking prophylactic therapy.3,4 In comparison with earlier study results, however, the overall number of migraine diagnoses made and the number of patients treated has improved. "We had estimated that only 5% of migraineurs were getting preventive medications, so we were pleasantly surprised," said Stephen Silberstein, MD, coauthor of the study and director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia. Earlier studies had shown that although preventive medicine may be indicated for 50% of patients with migraine, only 10% of these patients were receiving therapy.5
To conduct the study, a headache questionnaire was mailed to 120,000 US households. Migraineurs were identified according to the criteria of the International Classification of Headache Disorders, second edition (ICHD-2).6 The results showed that the 1-year prevalence of migraine was 17.1% in women and 5.6% in men. Prevalence peaked in middle life and was lower among adolescents and those older than 60 years. Of all migraineurs, 31.3% had an attack frequency of 3 or more per month, and 53.7% reported severe impairment or the need for bed rest. In total, 25.7% met criteria for preventive therapy; an additional 13.1% were deemed persons in whom preventive therapy at least should be considered. Most migraineurs treated their headaches with over-the-counter medications. Only 20.1% used prescription medication alone.
A COMMUNICATION SNAFU
In January, the National Headache Foundation released a consensus statement on migraine prevention, which stated that migraine is largely underdiagnosed and goes untreated because of poor doctor-patient communication as well as low patient awareness of available treatment options. The statement also emphasized that migraine be considered a chronic disorder with episodic manifestations and that physicians should emphasize to their patients that preventive treatment can include both prophylactic medications and lifestyle modifications. The results were based on the findings from the AMPP3,4 study as well as from the American Migraine Communication Study 1 (AMCS-1)7 and the American Migraine Communication Study 2 (AMCS-2).8
Migraine diagnosis and migraine treatment are especially sensitive to patient-doctor communication, according to Richard B. Lipton, MD, another coauthor of the AMPP study and professor in the Department of Neurology, Albert Einstein College of Medicine, Bronx, New York. "The guidelines about who should get migraine prevention are largely based on attack frequency and disability, and it turns out that communication about these issues is poor," he said.
The AMCS-1 by Lipton and colleagues found that health care providers tended to ask patients closed-ended questions about migraine frequency and paid scant attention to issues regarding impairment. "Health care professionals rarely ask the open-ended questions that would allow the patient to tell his or her story. As a consequence, providers dramatically underestimate life consequences of the patient's migraine," Lipton said. Physicians participating in the study mostly asked patients questions such as ""How often is your headache?" A response of 2 attacks per month may be misinterpreted, since 2 attacks may represent 2, 4, or even 6 actual headache days, depending on the average duration of the attacks. Lipton explained that this type of miscommunication can lead to suboptimal treatment.
The researchers examined communication between 28 health care providers (14 primary care physicians, 8 neurologists, and 6 nurse practitioners or physician assistants) and 60 patients. Office visits averaged 12 minutes in which time patients primarily responded to a health care provider's questions. Ninety-one percent of those questions were closed-ended or evoked a short answer. An average of 13 migraine-related questions, which primarily focused on attack frequency (63%), triggers (53%), and symptoms (48%), were asked during each visit. No health care practitioner used or referenced a migraine-assessment instrument, such as the Migraine Disability Assessment Scale (MIDAS), Headache Impact Test, or Migraine Assessment of Current Therapy questionnaire.
The most surprising findings from the study, according to Lipton, were that only 10% of health care providers' questions addressed impairment and that patients and providers were not aligned regarding migraine frequency in 55% of visits and severity in 34%.
"In our debriefing interview, we'd go back to the provider and ask about the severity of the patient's headaches. The provider would usually say that they weren't too bad because the patient didn't tell the provider that he was missing work or school or was unable to take care of children," Lipton said. "So the assumption is that the absence of reporting disability implies the absence of disability."
Although many impairments experienced by patients participating in the AMCS-1 were not addressed during visits to clinicians, debriefing interviews with patients conducted by Lipton's team revealed that headaches had profound effects on patients' lives. "When patients had the chance to tell their story, they often said they were afraid of losing their jobs because of time lost to migraine," he said. "We discovered an incredible underestimation of headache disability, which emphasizes why these patients aren't given preventive medication for migraine. The physician just doesn't understand that the patients are impaired." Of the 60 patients in the study, 35 were not given prophylactic treatment, although 20 of these patients met the AMPP study criteria for preventive treatment.
