Migraine management: A guide for providers to optimize preventive and acute treatments

Headache is one of the most common complaints seen by health care providers. There are various types of primary headache disorders, with the most common being migraine, tension headache and cluster headache.

Migraine is a fairly common neurological condition, estimated to affect up to one out of every six Americans. It is one of the leading causes of disability for women aged 18 to 50 years. Therefore, it is critical as a provider to be able to properly assess if your patient has optimal migraine and headache care.

While assessing pain severity and headache frequency are typical questions to ask your patient, there are additional ways to evaluate the overall burden and impact of headaches. A patient’s ability to function can provide valuable insight into how their headache or migraine affect their daily life. It’s essential to have an educational discussion about function to help determine whether preventive or acute treatments are optimized.

When initiating the conversation about the functional impact of migraine, ask how headache attacks affect patients’ daily activities. For example, inquire about how often they miss work or school due to their headache attacks. A widely used tool in clinical practice for assessing this impact is the Migraine Disability Assessment (MIDAS) questionnaire. Headache Impact Test (HIT-6) is another migraine screener that can be used to assess impact and burden.

Work and school are not the only areas that can be impacted by migraine. Several large-scale population studies have demonstrated how migraine can impact social connections, including with friends and family. Each patient’s migraine attacks may impact them in a unique way, so it’s important to understand how migraine affects them.

Along with asking how migraine attacks affect a person’s lifestyle, it’s equally important to inquire whether their current medication effectively restores their ability to function. This is a critical way to establish whether their current abortive regimen is actually effective. For example, if a patient reports that their migraine rescue medication is working, but when asked if they can return to work after taking it, they respond with “no,” then the medication is not truly effective. The same goes for if the patient says they need to rest after taking their abortive medication.

It’s also important to ask about the frequency of rescue medication use. For instance, if a patient is taking their rescue medication daily, it could indicate that their preventive treatment is not working effectively.

When developing an abortive and preventive treatment plan with a patient, it’s essential to assess their specific needs. Some patients may respond better to treatments with lower adherence demands, like a once-monthly calcitonin gene-related peptide monoclonal antibody injection. Likewise, some patients may prefer a treatment with flexibility in terms of being abortive or preventive, such as rimegepant.

After crafting a migraine treatment plan with your patient, it is vital to properly monitor how their migraine impact and burden changes. Functional improvements can be ascertained by the above-mentioned scales (MIDAS and HIT-6), and also by asking questions about being able to work, socialize or maintain daily activities. Conversely, if their function remains limited, it’s essential to address it and alter the treatment plan. This approach ensures that various aspects of how migraine impacts the patient are addressed, beyond just the headache pain. Migraine attacks can affect each patient differently, so it’s important to understand how migraine specifically impacts their individual experience.

For more information:

Fred Cohen, MD, can be found at www.headache123.com and @fredcohenmd on TikTok.

References:

• Amed F. Br J Pain. 2012;doi:10.1177/2049463712459.
• Burch R, et al. Headache. 2018;doi:10.1111/head.13281.
• Buse DC, et al. Mayo Clin Proc. 2016;doi:10.1016/j.mayocp.2016.02.013.
• Cohen F, et al. BioDrugs. 2022;doi:10.1007/s40259-022-00530-0.
• Cohen F, et al. Headache. 2024;doi:10.1111/head.14709.
• Lipton RB, et al. Headache. 2008;doi:10.1111/j.1526-4610.2001.01156.x.
• Yang M, et al. Cephalalgia. 2010;doi:10.1177/03331024103798.