Headache specialist tackles 'undertreated' condition
From the December ACP Observer, copyright © 2004 by the American College of Physicians.
By Christine Bahls
Headache specialist Vincent T. Martin, ACP Member, points out a clinical paradox he deals with every day: Headache is much more common than asthma, diabetes or hypertension among the general patient population. Yet headache treatment is virtually ignored in training programs and is much less understood by physicians than these other conditions.
"Headache sufferers are an underserved group of patients," said Dr. Martin, professor of medicine at the University of Cincinnati College of Medicine and co-director of the Cincinnati Headache Center. "Headache matters, and you need to give it due respect."
Giving headache some respect is exactly what Dr. Martin and co-editor Elizabeth W. Loder, FACP, an assistant professor of medicine at Harvard Medical School's Spaulding Rehabilitation Hospital, have done in their new book, "Headache."
The latest in the ACP Key Diseases series, the book was written by and for primary care physicians. It gives detailed information on how to diagnose headaches, with preventive and prescribing strategies and maintenance regimens. It also focuses extensively on migraine, which affects 25 million Americans.
"It is the first textbook on headache geared specifically to primary care physicians," said Dr. Martin, who has suffered from chronic migraines himself. "With as many as one in four primary care patients having a headache disorder, we felt a book was long overdue."
Dr. Martin recently spoke with ACP Observer about treating headache in the primary care setting.
Q: Are internists seeing more patients with chronic headaches?
A: It's possible, but there has also been an increased recognition rate. In 1989, the percentage of undiagnosed migraine patients was more than 50%, but in recent years we've narrowed that down a bit.
But there is still a huge number of patients who either don't consult their physician for headache or who are misdiagnosed if they do present. A lot of barriers in primary care prevent successful treatment.
Q: What are some of those barriers?
A: Patients don't come in because they feel they can manage with over-the-counter drugs or don't think there is much the doctor can offer them.
And many doctors are not well-versed in recognizing headache disorders, so patients don't always get a proper diagnosis. Often, patients present with more than one type of headache, but the physician will ask them to describe their "headaches." The patient will then report symptoms of more than one headache disorder—often migraine and tension-type headaches—and the physician will not be able to make a diagnosis. You can tease out a diagnosis of migraine by asking patients to describe their most severe headaches.
Headache patients often have multiple complaints and comorbid diseases such as depression, anxiety and allergic disorders. That leaves little time to discuss headache. I tell internists that patients should come in separately to address their headache complaints.
Finally, there is prejudice among the general population and physicians toward headache patients. When a patient comes in with headache, the physician may think he will be a complainer, hard to deal with or someone who wants narcotics. Physicians don't view headache as a neurochemical event but as patients' inability to modulate stress in their life, and that's a huge problem.
Q: How many migraineurs are there?
A: About 12% of the American population. If you screen patients in the waiting rooms of primary care physicians, that percentage goes as high as 29% because patients with chronic illness have a higher likelihood of having migraine. Over 50% of primary care patients who complain of headache have migraine.
Q: In your book, you say that a major challenge with headache and migraine is to shift from episode-driven treatment to more comprehensive, preventive care. How should physicians make that switch?
A: The first goal is to try to avoid trigger factors for migraine. The migraine brain is hypersensitive to any change in the environment, whether it's disturbed sleeping habits, irregular eating schedules or stress. We therefore encourage patients to practice "healthy neurological lifestyles" by avoiding fasting, practicing good sleep hygiene, and exercising and minimizing stress as much as possible.
You can discover what a given patient's triggers might be through the use of a headache diary. You'd be amazed at how many patients will actually make those changes to avoid known triggers.
One of the biggest triggers is caffeine, and I've had some patients improve just by gradually weaning them off. But in the end, many patients still have a nervous system that overesponds to the environment. You could probably remove all triggers and they would still have headaches.
If patients have more than three to five days per month with migraine, they may be candidates for preventive therapies such as beta-blockers, tricyclic antidepressants, calcium channel blockers or anticonvulsants.
Q: Analgesic overuse is reported in up to 38% of patients with chronic daily headaches. How do you stop patients from taking too many medications?
A: You need to educate them not to consume abortive migraine medications more than two days per week. If they are taking daily abortive medication, they may need to be gradually tapered off over several weeks.
A number of abortive medications—including narcotics, acetaminophen, triptans and butalbital-containing medications—can lead to medication overuse headaches. However, the biggest offenders are caffeine-containing medications such as combination analgesics sold over the counter. The physician has to take a good history of over-the-counter medication use to identify them.
This is not to say that patients shouldn't use these abortive medications, but they should be prescribed in small parcels. We tell clinicians not to prescribe more medications than patients would use two days per week. Some physicians give 60 fiorinal a month, and then the patient wants more in two weeks. I've had some patients referred to me who were taking 10 to 12 fiorinal a day. It becomes a real challenge to get these people off medications.
Q: Which diagnostic tests do physicians over-or underuse?
A: They probably overuse MRIs and CT scans. If someone has a stable pattern of migraine, the yield for imaging that patient is astronomically low.
What might be underused is the lumbar puncture in the headache patient who is obese. Idiopathic intracranial hypertension is picked up with a spinal tap, measuring the pressure space where the spinal fluid is. Elevated opening pressures are more than 250 milliliters of mercury.
Q: When should you refer patients to a headache specialist?
A: Patients with headaches on 15 or fewer days per month can be seen in the primary care setting. If they have more than 15 a month, they may need more comprehensive care and are probably better served in a headache center. There are about 150 centers across the country.
Q: Which complementary therapies can help?
A: Riboflavin, magnesium and feverfew have been shown to be effective as migraine preventatives. A new one, coenzyme Q—which has been used to help mitochondrial disorders—is also used in migraine prevention.
Q: How should physicians manage difficult headache patients?
A: You want to help patients realize that they can manage this disorder. If patients think that everything is being inflicted upon them with no chance of changing the situation, they will do poorly.
Patients who do the worst are those who come in and say, 'Doctor, heal me.' They don't want to do anything but take a pill and be cured.
You don't want to enable people, but you need to realize that migraine and headache are real diseases that have a neurochemical basis. You need to have compassion for the headache patient.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
You can order "Headache" online or call ACP Customer Service at 800-523-1546, ext. 2600, or 215-351-2600. Refer to product #330300430.
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