WASHINGTON – Primary care providers are generally familiar with the prevalence and initial diagnosis of migraine but less so with the specifics of treating migraine or its psychiatric comorbidities.
Many primary care providers (PCPs) are uncomfortable with prescribing preventive medications, preferring to rely on abortives and other acute attack treatments, Dr. Mia Minen said at the annual meeting of the American Academy of Neurology. Her study on PCP knowledge of migraine also revealed a “concerning” lack of attention to depression and anxiety among migraine patients.
“Most of our participants did know that these are common comorbid conditions,” said Dr. Minen of New York University. “But only half of them were assessing patients for anxiety, and only 30% for depression. This is a significant problem, because we think there’s a bidirectional relationship here – treating the psychiatric problems may actually help the migraines as well.”
Migraine accounts for 5 million-9 million primary care visits each year, she said, and many migraine patients are managed by their PCPs. “Unfortunately, as many as 60% of these patients are unrecognized as having migraine,” and many go for as long as 4 years before being properly diagnosed. “Primary care physicians have limited time with patients, and a migraine intake and assessment is time-consuming – as is managing the patient. Studies show that treatment is often suboptimal, with simple analgesic prescribing. And few of those who do qualify for preventive treatment actually get it.”
Her study aimed to discover what PCPs know – and need to learn – about migraine.
The first portion was framed in three semi-structured 15-minute interviews, moderated by headache specialists. Eleven physicians from different backgrounds attended these. They were asked what they perceived as their knowledge gaps in migraine diagnosis and treatment, and what difficulties they had encountered in those areas.
“About half said they would order an MRI for a new type of headache,” Dr. Minen said. A quarter didn’t know that an MRI was indicated for a headache with neuralgic symptoms, and only a third knew to order one when a headache worsened or remained unresponsive to treatment.
“These four conditions are situations in which headache experts typically agree that imaging is necessary,” Dr. Minen said. “Our findings indicate that primary care physicians might not actually be ordering imaging studies in situations where it should be done.”
Participants were generally unaware of the AAN’s guidelines on preventive medications, or the “Choosing Wisely” campaign to limit opioids and imaging in migraine patients, except in particular cases.
While most had heard of medication overuse headache, they were uncertain about how to diagnose it and unaware of some of the medications implicated in it. Participants were comfortable with some abortive medications (sumatriptan and naratriptan) and only prescribed opioids as a last resort. Antiemetics were rarely offered without a specific patient request.
There was uncertainty and discomfort about prescribing preventive medications, particularly topiramate. Several physicians said that patients often don’t comply with a daily regimen, so they preferred to stick with abortives. None had used botulinum toxin.
The second part of the study was a more specific, online survey completed by about 80 PCPs.
Most (60%) weren’t familiar with the recommendation about limiting opioids. While 60% said they knew that nonsteroidal anti-inflammatories could spark medication overuse headache, only half know that butabital-containing drugs could. A third knew about the risks for it with acetaminophen and narcotics, and only 13% about the association of triptans with medication overuse headache.
Few patients were apparently referred to evidence-based nonpharmacologic treatments, like biofeedback and cognitive behavioral therapy (just 1% and 3% of physicians said that they did so).
“Doctors apparently just don’t know that these alternatives are supported by strong evidence,” Dr. Minen said.
She had no financial disclosures.
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