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Treating patients with migraine: What PCPs need to know
There is a 6-month waiting list for an appointment at Montefiore Headache Center, which Richard B. Lipton, MD, directs — with similar circumstances playing out at other clinics for migraine and headache care.
With the lack of resources, the number of affected patients and the degree of disability that severe headaches can create for patients, primary care clinicians can have a significant impact on patient’s lives by taking a leading role in managing headache and migraine.
“Treating patients with migraine can be very rewarding. You are improving the lives of people made miserable with a few simple steps, as opposed to a much more complicated procedure such as a bypass or transplant,” he told Healio Primary Care.
Lipton, American Headache Society president from 2000 to 2002 and author or co-author of at least 100 headache studies, sat down during the recent American Headache Society Scientific Meeting to discuss ways PCPs can treat migraine, when patients should be referred to a specialist and more. – by Janel Miller
Healio: Studies suggest that PCPs already have very long to-do lists during limited appointment windows. Why should migraine be added to patient-physician discussions?
Lipton: I have a lot of sympathy for PCPs. These clinicians have many more medical conditions to contend with in a lot less time than I usually do. And often times, the potential of a patient having migraine comes up as an afterthought as the patient’s office visit for those other conditions is winding down. If a patient does this, the PCP should not rush things; if he or she feels comfortable treating headaches that are potentially migraine, the clinician should make another appointment with the patient that is exclusively about the headaches.
“Data show that 40 million people in the U.S. have migraine. But not all of these cases are serious and require a specialist. Primary care doctors can seize the moment to take advantage of a big opportunity to make a difference in a patient’s life.
Healio: What should a PCP do at that follow-up visit?
Lipton: The PCP should ask open-ended questions. While I’m aware that open-ended questions are often terrifying to PCPs, studies have shown that these types of queries increase both physician and patient satisfaction and take only about 10 minutes.
The questions should ascertain the patient’s headache history, the location and duration of their pain; if warnings of the approaching headache, such as mood change, occur; if an aura is present during the headache; and headache’s impact on their ability to function.
PCPs will find that in most patients, an over-the-counter ibuprofen is all the patient needs to get back to their normal lives. But if a patient says that they have or more headache days a month and that the attacks serious hinder with their jobs, family time and/or education, the PCP needs to discuss the preventive therapies that the FDA approved last year — Aimovig (erenumab-aooe; Amgen, Novartis), Ajovy (fremanezumab-vfrm, Teva) and Emgality (galcanezumab-gnlm, Lilly) — find out what other medications he or she has tolerated and at what dose, review the patient’s comorbidities and then make a treatment recommendation based on the compiled information.
Healio: What other treatment options exist for patients with migraine?
Lipton: I often recommend patients try candesartan, topiramate or an oral beta-blocker. There are also onabotulinumtoxinA injections that can sometimes be prescribed, but PCPs would have to convince a lot of patients to utilize this treatment to see the financial investment in the injections pay off.
Healio: If used responsibly, would opioids be an acceptable migraine treatment?
Lipton: I agree with the American Headache Society and the American Academy of Neurology guidelines regarding opioid treatment in patients with migraine, largely because studies show opioids lead to headache progression and in some instances, patients go from episodic to chronic migraine status. Editor’s note: Links to information regarding The American Headache Society and The American Academy’s stances on potentially acceptable opioid use in patients with migraine can be found at the end of this story.
Healio: When should a PCP refer a patient with headache to a neurologist, headache or pain specialist?
Lipton: There is not a one size fits all answer here. PCPs who have focused on their career on migraine may never refer out. These PCPs should ask the questions and offer treatment as I mentioned earlier. Conversely, it is perfectly acceptable for other PCPs who have made diabetes their specialty, OB/GYN their specialty and so on, to suggest to a patient that he or she see a specialist. PCPs should also refer out if they suspect the headache is being caused by a cerebral hemorrhage or if the pain is not subsiding in the manner the patient’s medication indicates that it should.
For more information:
AHS.org. “Opioids and migraine.” https://americanheadachesociety.org/news/opioids-migraine/. Accessed July 13, 2019.
AAN.org. “Opioids for chronic noncancer pain A position paper of the American Academy of Neurology.” https://n.neurology.org/content/83/14/1277. Accessed July 15, 2019.
References:
AHS.org. “Opioids and migraine.” https://americanheadachesociety.org/news/opioids-migraine/. Accessed July 13, 2019.
AAN.org. “Opioids for chronic noncancer pain A position paper of the American Academy of Neurology.” https://n.neurology.org/content/83/14/1277. Accessed July 15, 2019.
Lipton RB, et al. Patterns of diagnosis, consultation, and treatment of migraine in the US: Results of the OVERCOME study category: Epidemiology, pharmacoeconomics, and outcomes research of headache. Presented at: American Headache Society Annual Scientific Meeting; July 11-14, 2019; Philadelphia.
Disclosures: Healio Primary Care was unable to determine Lipton’s relevant financial disclosures prior to publication.