The Role of General Practitioners in Migraine Management

Migraine in physicians and final year medical students: A cross-sectional insight into prevalence, self-awareness, and knowledge from Pakistan

BACKGROUND

Despite its high prevalence, migraine remains underdiagnosed worldwide. A significant reason is the knowledge gap in physicians regarding diagnostic criteria, clinical features, and other clinical aspects of migraine.

AIM

To measure the knowledge deficit in physicians and medical students and to assess the prevalence of migraine in the same population.

METHODS

An online questionnaire was developed and distributed among physicians and final year medical students on duty in various medical and surgical specialties of Allied and DHQ Hospitals, Faisalabad, between October 2018 and October 2019. Inclusion criteria were public practicing physicians who experience headaches, while those who never experienced headaches were excluded. Different questions assessed respondents on their knowledge of triggers, diagnosis, management, and prophylaxis of the migraine headache. They were asked to diagnose themselves using embedded ICHD-3 diagnostic criteria for different types of migraine. Graphs, tables, and figures were made using Microsoft Office 2016 and Microsoft Visio, and data analysis was done in R Studio 1.4.

RESULTS

We had 213 respondents and 175 fulfilled inclusion criteria, with 99 (52%), 58 (30%) and 12 (6.3%) belonging to specialties of medicine, surgery, and others, respectively. Both genders were symmetrically represented (88 male and 87 female). Fifty-two (24.4%) of our 213 respondents were diagnosed with migraine, with 26 (50%) being aware of it. Females had higher prevalence among study participants (n = 28, 32.2%) compared to males (n = 20, 22.7%, P = 0.19). A majority (62%) of subjects never consulted any doctor for their headache. Similarly, a majority (62%) either never heard or did not remember the diagnostic criteria of migraine. Around 38% falsely believed that having any type of aura is essential for diagnosing migraine. The consultation rate was 37% (n = 65), and migraineurs were significantly more likely to have consulted a doctor, and a neurologist in particular (P < 0.001). Consulters and migraineurs fared better in the knowledge of diagnostic aspects of the disease than their counterparts. There was no significant difference in other knowledge aspects between consulters versus non-consulters and migraineurs versus non-migraineurs.

CONCLUSION

Critical knowledge gaps exist between physicians and medical students, potentially contributing to misdiagnosis and mismanagement of migraine.

Assessing the performances of a chatbot to collect real-life data of patients suffering from primary headache disorders

Background

There are many scales for screening the impact of a disease. These scales are generally used to diagnose or assess the type and severity of a disease and are carried out by doctors. The chatbot helps patients suffering from primary headache disorders through personalized text messages. It could be used to collect patient-reported outcomes.

Objective

The aims of this study were (1) to study whether the collection and analysis of remote scores, without prior medical intervention, are possible by a chatbot, (2) to perform suggested diagnosis and define the type of headaches, and (3) to assess the patient satisfaction and engagement with the chatbot.

Method

Voluntary users of the chatbot were recruited online. They had to be over 18 and have a personal history of headaches. A questionnaire was presented (1) by text messages to the participants to evaluate migraines (2) based on the criteria of the International Headache Society. Then, the Likert scale (3) was used to assess overall satisfaction with the use of the chatbot.

Results

We included 610 participants with primary headache disorders. A total of 89.94% (572/610) participants had fully completed the questionnaire (eight items), 4.72% (30/610) had partially completed it, and 5.41% (33) had refused to complete it. Statistical analysis was performed on 86.01% (547/610) of participants. Auto diagnostic showed that 14.26% (78/547) participants had a tension headache, and 85.74% (469/547) had a probable migraine. In this population, 15.78% (74/469) suffered from migraine without probable aura, and 84.22% (395/469) had migraine without aura. The patient's age had a significant incidence regarding the auto diagnosis (P = .008<.05). The evaluation of overall satisfaction shows that a total of 93.9% (599/610) of users were satisfied or very satisfied regarding the timeliness of responses the chatbot provides.

Conclusion

The study confirmed that it was possible to obtain such a collection remotely, and quickly (average time of 3.24 min) with a high success rate (89.67% (547/610) participants who had fully completed the IHS questionnaire). Users were strongly engaged through chatbot: out of the total number of participants, we observed a very low number of uncompleted questionnaires (6.23% (38/610)). Conversational agents can be used to remotely collect data on the nature of the symptoms of patients suffering from primary headache disorders. These results are promising regarding patient engagement and trust in the chatbot.

Translation and Transcultural Validation of Migraine Screening Questionnaire (MS-Q)

Introduction:

Between 30 to 59% of patients with migraine without aura are undiagnosed and improperly treated, because primary care physicians are either too busy or unfamiliar with criteria for diagnosing migraine.

Aim:

The aim of our study was to translate the Migraine Screen Questionnaire (MS-Q) to BHS (Bosnian/Croatian /Serbian) language and to test reliability and validity of the translation on a sample of primary care patients.

Material and Methods:

The study was designed as cross-sectional, multi centric, diagnostic accuracy trial of an instrument for screening patients who visit general practitioners, with an aim to reveal migraine without aura. The instrument was the MS-Q, originally written in English and validated in Spanish population, and in this study being translated to BHS language.

Results:

Translation of the MS-Q to BHS language showed good diagnostic accuracy (sensitivity 80.0% and specificity 87.2%) and reliability (Cohen kappa 0.648) for migraine without aura, with significant screening yield among previously undiagnosed patients of 72.7%. The study also confirmed high percentage of patients with hidden MWA (52.9%) revealed by the MS-Q and ICH criteria that would otherwise remain undiagnosed.

Conclusion:

The MS-Q translation to BHS language could be considered as valid and reliable clinical instrument for revealing migraine without aura, similar by its performance to original questionnaire. It has considerable screening yield, discovering majority of patients with previously undiagnosed migraine without aura, whose definite diagnosis should later on be confirmed by the attending physicians using the ICH criteria.

Nurses improve migraine management in primary care

Introduction

Migraine is a common disorder with a high burden. Adequate treatment results in improvement of quality of life. Migraine patients are mainly treated by general practitioners (GPs), but there is still room for improvement. This study investigated whether primary care nurses could improve the treatment of migraine patients compared to usual care as provided by the GPs.

Participants and methods

We conducted a non-randomized controlled prospective trial in 235 patients diagnosed with migraine with or without aura according to ICHD-II criteria, aged between 18 and 65 years. Patients with migraine treated only by their GP were compared to management by a nurse supervised by a GP.

Results

In the intervention group, fewer migraine patients were referred to a neurologist ( p < 0.001). The reduction in monthly migraine days compared to baseline was more apparent in the intervention group at six ( p = 0.09) and nine months ( p = 0.006). There was no significant change in dichotomized HIT score ( p = 0.076). Change in satisfaction of patients did not differ significantly ( p = 0.070).

Conclusions

The care administered by a headache nurse in the primary care setting supervised by a GP resulted in fewer referrals to the neurologist and more migraine-free days per month, but no change in HIT score. There was no difference in satisfaction scores between both groups.

Headache from the doctors' perspective

BACKGROUND

General practitioners (GPs) and neurologists are involved in treating headache patients in Portugal. Having migraine themselves might influence the way they perceive and treat migraine patients.

OBJECTIVE

To identify clinicians' perceptions about migraine, their own headache status and management of their own migraine.

METHODS

An observational cross-sectional survey of GPs and neurologists using anonymous questionnaires including demographic data, headache and migraine status and migraine perception questions.

RESULTS

Of 348 respondent physicians, 20% were neurologists and 53% were females with an average age of 48 years. The majority had an interest in migraine and considered it disabling (93%), although 65-85% reported management difficulties, GPs more often than neurologists. Satisfaction with current treatment options was high (69-79%). 63 physicians suffered from migraine and 81% felt it influenced their perception of the disease. Portuguese physicians preferentially treat their own migraines with NSAIDs (33%), analgesics (29%) and triptans (20%).

CONCLUSION

Portuguese physicians treating migraine patients have realistic perceptions about the disease and those with migraine feel their perception is influenced by their experience. Although reporting management difficulties, the majority of physicians are satisfied with current treatment options for migraine.

SPARTACUS: underdiagnosis of chronic daily headache in primary care

Despite the burden of chronic daily headache (CDH), general practitioners' (GPs) ability to recognize it is unknown. This work is a sub-study of a population-based study investigating GPs' knowledge on their CDH patients. Patients diagnosed with CDH through the screening questionnaire were interviewed by their GPs who indicated if subjects were known as patients suffering from CDH with medication overuse (MO), CDH without MO, episodic headache (EH) or non-headache sufferers. Our study showed that 64.37 % of CDH sufferers are misdiagnosed by their GPs. However, overusers are better known to GPs.

How general practitioners treat migraine patients—evaluation of a headache guideline

Aim: The aim of the study was to evaluate the pharmacological treatment of migraine patients by general practitioners before referral to a neurologist. First, was the pharmacological treatment in accordance with the Dutch College of General Practitioners headache guideline? Second, which migraine characteristics were associated with receiving migraine-specific medication?

Methods: Migraine patients (age ≥18 years) who visited the neurology outpatient clinic for the first time were included. Migraine characteristics and pharmacological status were collected retrospectively for each patient from the general practitioner’s referral letter, hospital record and a headache characteristics questionnaire.

Results: A total of 420 migraine patients were included. Only 18.3% of the patients with two or more migraine attacks per month were using prophylactic medication. Furthermore, only 11.7% of patients with symptoms of nausea and/or vomiting were using anti-emetic medication. More than half of patients (51.7%) were using triptans and were likely to have typical migraine symptoms and a long history of migraine.

Conclusions: Migraine prophylactic medication and anti-emetics are underutilized in the primary care setting for migraine patients in the Netherlands, when compared to the general practitioners guideline. It is important to enhance the knowledge of general practitioners regarding the diagnosis of migraine, and to increase awareness of the headache guideline.

Results of a 2-year retrospective cohort study of newly prescribed triptan users in European nationwide practice databases

Objective: This study was conducted to characterize prescription refill patterns for triptans among European patients with new prescriptions of triptans.

Background: Persistency with prescriptions of triptan monotherapy for migraine headache among newly prescribed users in European primary-care practices has not been well described.

Methods: Using electronic medical databases in the UK ( N = 3618), France ( N = 2051) and Germany ( N = 954), we conducted a retrospective cohort analysis to identify refill patterns over 2 years among migraineurs receiving new prescriptions of triptan monotherapy in 2006.

Results: Of all patients, >33% of migraineurs with new triptan prescriptions received ≥1 refill of their index triptan prescriptions (UK, 44.3%; France, 34.2%; Germany, 37.7%). More than 50% never received index-triptan refill prescriptions (UK, 55.7%; France, 65.8%; Germany, 63.3%). Small proportions of patients (<7.0%) switched to alternative triptans, and even fewer switched to different prescription-medication classes (UK and Germany, 2.3%; France, 4.0%). More than 48% of patients received no further prescriptions for migraine after index prescriptions (UK, 48.5%; France, 54.9%; Germany, 54.7%). After the second year, >83.0% of patients in each country had no further prescriptions for migraine medications, <14.0% remained persistent with index prescriptions, <4.0% switched to other triptans, and <3.0% switched to alternative medication classes.

Conclusions: In migraine patients who received new prescriptions of triptan monotherapy from their primary-care physicians, poor triptan prescription refill frequency was observed in Europe. Although consistent with potential clinical challenges in migraine management, our findings should be interpreted with caution given certain inherent limitations associated with the database study design. Further research is warranted to confirm our findings and to identify reasons for, or predictors of, triptan discontinuation.

Predictors of outcome in patients consulting their general practitioners for headache: a prospective study

Headache is the most common neurological symptom presenting to general practitioners (GPs). Identifying factors predicting outcome in patients consulting their GPs for headache may help GPs with prognosis and choose management strategies which would improve patient care. We followed up a cohort of patients receiving standard medical care, recruited from 18 general practices in the South Thames region of England, approximately 9 months after their initial participation in the study. Of the baseline sample (N=255), 134 provided both full baseline and follow-up data on measures of interest. We determined associations between patients' follow-up scores on the Headache Impact Test-6 and baseline characteristics (including headache impact and frequency scores, mood, attributions about psychological/medical causes of their headaches, satisfaction with GP care and illness perceptions). Greater impact and stronger beliefs about the negative consequences of headaches at baseline were the strongest predictors of poor outcome at follow-up.

Response to Ayurvedic therapy in the treatment of migraine without aura

Migraine patients who do not respond to conventional therapy, develop unacceptable side-effects, or are reluctant to take medicines resort to complementary and alternative medicines (CAM). Globally, patients have been seeking various non-conventional modes of therapy for the management of their headaches. An Ayurvedic Treatment Protocol (AyTP) comprising five Ayurvedic medicines, namely Narikel Lavan, Sootshekhar Rasa, Sitopaladi Churna, Rason Vati and Godanti Mishran along with regulated diet and lifestyle modifications such as minimum 8 h sleep, 30-60 min morning or evening walk and abstention from smoking/drinking, was tried for migraine treatment. The duration of the therapy was 90 days. Out of 406 migraine patients who were offered this AyTP, 204 patients completed 90 days of treatment. Complete disappearance of headache and associated symptoms at completion of AyTP was observed in 72 (35.2%); mild episode of headache without need of any conventional medicines in 72 (35.2%); low intensity of pain along with conventional medicines in 50 (24.5%); no improvement in seven (3.4%) and worst pain was noted in three (1.4%) patients, respectively. In 144 (70.5%) of patients marked reduction of migraine frequency and pain intensity observed may be because of the AyTP. Though the uncontrolled open-label design of this study does not allow us to draw a definite conclusion, from this observational study we can make a preliminary assessment regarding the effectiveness of this ayurvedic treatment protocol.

A survey of family doctors on the likeability of migraine and other common diseases and their prevalence of migraine

A survey of 148 family doctors attending a continuing medical education migraine update lecture was performed to assess whether family doctors like to treat migraine and other common disorders and the prevalence of migraine. Doctors were asked to respond to the following statement using a five-point Likert scale (from 1, strongly disagree to 5, strongly agree): 'I like to treat patients with this disease or symptom'. The response rate was 53% with a mean age of 51.5 years. Doctors reported liking to treat general medical conditions more (mean = 4.40) than migraine (mean = 3.38) and other neurological diseases (mean = 3.20). Doctors reported a personal history of migraine in the prior 1 year of 22.8% and 45.6% lifetime, with 17% becoming aware for the first time that they personally had migraine after attending the lecture. Respondents with a personal history of migraine liked to treat migraine more than those without a history.

Prevention of episodic migraines with topiramate: results from a non-interventional study in a general practice setting

The majority of patients with migraine headaches are treated in non-specialized institutions though data on treatment outcomes are largely derived from tertiary care centers. The current non-interventional study explores efficacy and tolerability outcomes of patients with episodic migraines receiving topiramate as preventive agent in a general practice setting. A total of 366 patients (87% female, mean age 41.8 +/- 11.6 years) were eligible for migraine prevention and treated with flexible dose topiramate for 6 months (core phase), and optionally for a total of 12 months (follow-up phase). Overall, 261 patients (77.7% of safety analysis set, SAF) completed the core phase. Reasons for discontinuation included adverse events (2.1%), lost to follow-up (1.8%), other reasons (1.5%), and end of therapy (0.3%) though in the majority of patients who discontinued no reasons were listed. The median daily dose at endpoint was 50 mg/day (range, 25-187.5 mg/day). The median days with migraine headaches decreased from 6.0 to 1.2 days (p < 0.001), median pain intensity score decreased from 17.0 to 3.2 points (p < 0.001). In women with reported menstruation-associated migraine, the median number of migraine attacks decreased from 4.0 to 0.9 (p < 0.001). Absenteeism as well as triptan use decreased significantly, and significant improvements in activities of daily living and quality of life were reported. The most frequently reported AEs were paraesthesia (4.2%) and nausea (3%). Results suggest that migraine prevention with topiramate in a general practice is generally well tolerated and associated with a significant improvement in migraine headaches and related functional impairment.