Optimizing Migraine Care

Optimizing Migraine Care

The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study. Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations. Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will, in most cases, be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid or butalbital-containing...

Improving Quality of Life for Migraineurs

One of the unmet needs of the migraine population is the identification of individuals who actively require treatment. When migraine is left untreated or inadequately treated, increased medical costs and decreased productivity result. Of the roughly 25 to 30 million Americans with active migraine, around 6 million have the chronic variant, meaning they have suffered headaches at least 15 days per month for at least 3 consecutive months. Chronic migraine accounts for a disproportionate share of the economic burden associated with migraine generally. Prevention or suppression of headaches associated with chronic migraine assumes paramount importance. It can be challenging for physicians to choose the most appropriate therapy for treating migraine, and there are many issues to consider when determining the most appropriate management strategies. Clinicians must ask themselves if their patients are in need of acute therapy only or prophylactic therapy in addition to acute therapy. Although guidelines are available to assist clinicians in prescribing prophylactic therapy, treatment needs and responses vary from patient to patient. Arriving at an effective treatment regimen may take time, and patients should be warned not to expect instant success. A commitment from patients to adhere to prescribed treatment strategies typically will be required to achieve a successful outcome. Open communication between providers and patients and the provision of educational materials are essential to fostering positive outcomes. Ensuring Adherence The importance of patient education cannot be overestimated. My colleagues and I have conducted studies in which migraineurs attended a headache school taught by lay instructors. Patients who received this type of education—which focused on the biology of migraine as well as acute and chronic...