HEALTHCollaboration is key to managing migrainesNew guidelines from the American Academy of Family Physicians, the American College of Physicians--American Society of Internal Medicine and the American Headache Society tell primary care physicians how to treat headaches.By Susan J. Landers, amednews staff. Dec. 9, 2002. Washington -- Primary care physicians already treat the majority of migraine headache patients in the nation, and now there is a set of guidelines to help them with this task. Two groups that together represent nearly 200,000 primary care physicians developed the guidelines, which detail how migraines can be successfully treated and, in many cases, prevented. "Headaches are the seventh leading reason patients in the United States visit their physicians," said Eric W. Wall, MD, MPH, who represented the American Academy of Family Physicians in developing the guidelines. The American College of Physicians--American Society of Internal Medicine was the other lead organization and the American Headache Society provided assistance. "It is important that physicians know the evidence supporting migraine headache treatment that is currently available and discuss treatment options with patients who have migraine headaches," Dr. Wall said. In addition, "Migraine patients should know that migraines can and should be treated at once," said Kevin B. Weiss, MD, chair of the ACP-ASIM's Clinical Efficacy Assessment Subcommittee.
28 million people in the U.S. have migraines.
"We don't want patients suffering longer than needed. We want to help them get on their feet and functioning," Dr. Weiss said. The new guidelines speak directly to the primary care physician, Dr. Wall said. "In the past, most practice guidelines for migraine headache have come out of the specialist community," he said. But the estimated 28 million migraine patients in the country are far too many for specialists alone to handle. Guidelines developed by specialists did tend to be voluminous, said Mark Stillman, MD, section head for the Headache Program at the Cleveland Clinic. "To have something written and placed in a general journal might actually nudge physicians to read them," he said. The guidelines appear in the Nov. 19 Annals of Internal Medicine. Managing headaches challenging, but doableAlthough long-term management of headaches is challenging, the guidelines say, rapid and consistent treatment can yield good results. "It's not that hard to manage headaches correctly if you have the time and the inclination," Dr. Stillman said, acknowledging that many primary care physicians often operate on a very tight schedule. Nevertheless, he said, "Some of the best headache specialists I know are internists." Headaches have many potential causes. Most arise from the primary headache disorders that include migraine, cluster and tension-type headaches. Secondary headaches, which have an underlying cause, are much less common.
Red wine, chocolate, soft cheese and lack of sleep often trigger headaches.
The first line of attack is to engage patients and make them active participants in their treatment, Dr. Wall said. Otherwise, the guidelines are doomed to fail, he stressed. Physicians should start with a thorough patient history, Dr. Stillman said. "As with anything in the field of pain, history is everything. Sitting and listening to a patient and getting an appropriate history will, 90 times out of 100, give you the correct diagnosis." Headache patients should keep a diary to identify their headache triggers, advised Richard Lipton, MD, professor and chair of neurology at the Albert Einstein College of Medicine in New York City. Red wine, chocolate, soft cheese and lack of sleep are among the most frequently identified migraine triggers, Dr. Lipton said. Primary care physicians and patients often begin the treatment response to a severe headache by ruling out life-threatening causes. "Someone develops a headache, and the doctor and patient are worried that it's a brain tumor, a stroke or a serious infection," Dr. Lipton added. But "oftentimes, once a life-threatening cause is ruled out, the next step of assigning a specific diagnosis isn't taken," he said. Proper treatment of migraines depends very much on the proper diagnosis. Migraines must be distinguished from the other types of headaches, including the often overdiagnosed sinus headache, Dr. Stillman said. "There are designer medications out there for aborting migraines, and if you go ahead and throw one of those expensive medications at something that isn't a migraine, there is a good chance it won't work, and then the patient gets discouraged and starts doctor-shopping," Dr. Stillman said. Treatment recommendationsBefore turning to the high-priced drugs, the new guidelines recommend that nonsteroidal, anti-inflammatory drugs be tried. The familiar, over-the-counter medications include aspirin and ibuprofen as well as naproxen sodium and a combination of acetaminophen plus aspirin and caffeine. But acetaminophen alone has not been proven to work for migraines. If NSAIDs don't work, the guidelines recommend prescribing one of the more recently developed groups of drugs called triptans. First marketed in the early 1990s, there are now six different triptans available, with a seventh due on the market soon. The drugs also have been effective in treating the nausea and vomiting that can accompany a migraine. While not everyone should be treated with triptans, Dr. Lipton said, many people who could benefit from them do not receive them for various reasons that include diagnosis, treatment and follow-up barriers. Avoid the reboundAnother treatment goal is to reduce the use of back-up and "rescue medication," Dr. Weiss said. "Patients should know that more isn't necessarily better when treating migraines. And medication overuse can actually lead to more headaches, sometimes called 'rebound' headaches." Chronic headaches can lead to people taking medication almost on a daily basis, Dr. Wall said. "It can become a cycle of ever-increasing ibuprofen use." Migraines can sometimes be prevented or attacks made less frequent, according to the guidelines. "The revelation for me as a primary care physician is the undertreatment of migraines with regard to preventive medications," Dr. Wall said. Some people were getting two, three or four migraines a month, and no one was addressing preventive treatment, he said. Often, patients don't tell their physicians how frequently their headaches occur, Dr. Wall said. "At the same time, a lot of physicians are treating episode by episode and, while those treatments work and are quite effective, I actually think you could reduce the number that people get and how badly they get them. Some people are laid low for days at a time," he said. ADDITIONAL INFORMATION:Making the pain go awayGuidelines designed to help primary care physicians treat their patients who have migraine headaches recommend the following:
Source: Annals of Internal Medicine, Nov. 19 WeblinkArticle, "Pharmacologic Management of Acute Attacks of Migraine and Prevention of Migraine Headache," Annals of Internal Medicine, Nov. 19 (vol. 137, issue 10) (http://www.annals.org/issues/v137n10/ffull/200211190-00014.html) Copyright 2002 American Medical Association. All rights reserved.
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