A 35-year-old Black woman presents to the emergency department (ED) with a severe headache around her right temple and eye, which is accompanied by nausea, light sensitivity, and mental fog. She is a high school teacher and her headache began suddenly about 3 hours earlier while she was giving a presentation to her colleagues. She describes the pain as throbbing, severe, constant, and disabling. She denies having fever, motor weakness, or problems with gait and balance. The patient has experienced severe monthly headaches since the age of 12 years.
Her mother suffered from similar severe headaches when she was younger. The patient was diagnosed with menstrual migraines at the age of 25 years and was told to take ibuprofen as needed. Her headaches have significantly increased in frequency in the last year while she was completing graduate school studies. She thinks the headaches are an “occupational hazard” as most teachers she works with experience headaches.
The headaches usually start suddenly, 2 days before her menstrual cycle, and last from several hours to 2 to 3 days if not treated. The headaches are associated with nausea and light sensitivity 80% of the time. The patient notes that she has 2 to 4 headache days a month that are not associated with her menstrual cycle.
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She has been to the ED on 3 occasions for migraines in the last year. Medication history includes ibuprofen, which she notes works only 30% to 50% of the time, and topiramate, which she stopped after a week because of significant cognitive side effects and inability to focus at work. Her primary care physician (PCP) told her she cannot take propranolol because of her history of asthma but said that the headaches will subside when she goes through menopause. She has not tried any other preventive agents.
Diagnostic workup prior to this visit included a computed tomography (CT) scan and magnetic resonance imaging (MRI), both of which were negative for other secondary causes of headache (eg, tumors, bleeding, infections).
Discussion
Migraine is a chronic neuroinflammatory disorder that occurs across a patient’s lifespan. Patients can experience episodic exacerbations and age-dependent changes in clinical presentation and prevalence. Migraine affects approximately 15% of the US population1,2 and is more common than type 1 diabetes, asthma, and epilepsy combined.3,4 According to the American Migraine Foundation, 1 in 4 American households have a person with migraines. Women have a 3-fold higher prevalence of migraine compared with men, with 30% of women experiencing migraines in their lifetime.3
Racial disparities in migraine diagnosis and management are also found. The American Migraine Foundation noted that only 47% of Black patients and 50% of Hispanic patients with headaches have an official headache diagnosis compared with 70% of White patients.5 Black patients with migraine also report higher pain intensity than White patients but are less likely to receive acute pain medication. Only 14% of Black patients receive prescriptions for acute migraine medications compared with 37% of White patients.5 Migraines impose a substantial direct and indirect financial burden. The combined cost of direct medical expenses and lost productivity from migraines is $20 million in the US alone.3 On average, a person with migraine misses 9 workdays annually because of their condition.6
Migraine is one of the most common and debilitating diseases encountered by primary care providers (PCPs).4 Primary care is the predominant site for migraine consultation and management for 70.3% of patients, and migraine accounts for 5 to 9 million PCP office visits annually in the US.1,7 Most patients (73.5%) who present with migraine symptoms to a PCP are not referred to a neurologist and remain in primary care.8
Disease Course and Treatment
Migraines are often undiagnosed and undertreated. The understanding of migraines shifted in the late 1990s.9-11 Modern understanding of migraine pathophysiology radically changed the migraine treatment paradigm, ushering in a new era of migraine-specific therapies such as 5-hydroxytryptamine 1F (5-HT1F) receptor agonists and calcitonin gene-related peptide (CGRP) receptor antagonists (Table 1).12,13 Neuromodulatory devices approved by the Food and Drug Administration (FDA), including Cefaly, Nerivio, and Relivion, are guideline-recommended for acute treatment of migraines and gammaCore is approved to treat and prevent migraines in people older than age 12 years.14 As with any chronic disease, migraine prevention is the cornerstone of migraine management.15 Episodic migraine (EM) is 0 to 14 headache days per month and chronic migraine (CM) is 15 or more headache days per month.16
The American Headache Society (AHS) recommends migraine preventive management for patients with 6 or more migraine headache days per month.14 The AHS guidance outlines strategies for optimal drug selection of preventive treatment and agents with established efficacy in migraine prevention.14 The AHS also recommends considering use of neuromodulatory devices as an adjunct to the existing treatment plan for all patients requiring preventive treatment.14
Clinicians Need More Migraine Training
Despite the relatively high prevalence and morbidity associated with migraine, more than one-quarter of PCPs (28%) lack familiarity with the AHS recommendations and 53% fail to prescribe migraine preventive medications.17 The average gap between diagnosis and initiation of preventive medications is 4 years and the majority of patients with episodic migraines who meet criteria for preventive therapy are not prescribed treatments. Suboptimal migraine preventive management results in frequent office visits, increased disability, barbiturate and opioid overuse, absenteeism, and increased rates of urgent care and ED visits. The inadequate use of preventive management strategies is concerning given the high rates of migraine-related disability and high percentage of ED visits with migraine as the chief complaint (25%).18
No standardized approach exists for teaching headache medicine in medical school, PA, or nurse practitioner (NP) programs. Education in headache medicine varies from institution to institution. On average, less than 2 hours are dedicated to headache disorders in medical schools despite the very high prevalence of headache disorders in the general population. Most graduates do not receive the training needed to recognize and treat headache disorders during residency.17
The American Migraine Prevalence and Prevention (AMPP) study showed that PCPs are hesitant to prescribe migraine preventive medications because of the lack of understanding of AHS treatment guidelines and novel therapies.8
Another barrier is the lag time between publication and uptake in clinical practice. On average, it takes 17 years from the publication of research findings to implementation in clinical practice. According to Haines and Jones’s Translation Model, these long delays result in suboptimal patient care outcomes. To build an overall culture change, multiple dissemination approaches to aid PCPs with complex migraine preventive management should be utilized.19
Preventive migraine therapies include pharmacologic (Table 2) and biobehavioral therapies, as well as neuromodulation devices for migraine patients with 6 or more migraine headache days per month. The AHS launched the First Contact — Headache in Primary Care website16 to provide access to current information from headache specialists and to provide educational resources for PCPs.
Case Resolution
The patient with severe monthly migraine was diagnosed with episodic menstrually-related migraines. She was prescribed frovatriptan 2.5 mg to be started 2 days prior to the onset of menses for menstrual migraine prophylaxis (2.5 mg twice daily for 6 days). She was also prescribed rimegepant as needed for acute headache (75 mg for a total of 8 doses a month). Rimegepant is an orally disintegrating tablet that has a fast onset of action. She wanted a fast-acting medication that did not need to be taken with water because it is difficult for her to leave the classroom when her headache starts. She is very pleased with her treatment outcome: since starting frovatriptan, she has experienced only 1 or 2 moderate headaches a month, for which she takes rimegepant, which works within 15 to 20 minutes.
Conclusion
When possible, migraine should be managed by a primary care provider. However, many primary care providers do not utilize the full spectrum of migraine preventive management options and prescribe preventive medications mostly for patients with chronic migraines. The lack of familiarity with the current AHS recommendations could be the single most important factor contributing to the failure to treat migraines preventively. Adherence to the latest AHS migraine preventive management recommendations helps to improve inadequate preventive treatment, minimize barbiturate and opioid overuse, and decrease the average 4-year gap between diagnosis and initiation of preventive medications.
Providers can also download the free Android or Apple app Primary Care Migraine© developed by The National Headache Foundation (www.pcmigraine.com).
Vera Gibb, DNP, APRN, FNP-C, AQH, CCTP, is an assistant professor in the Graduate Studies Department of The University of Texas Medical Branch at Galveston School of Nursing, Galveston, Texas. She practices at Village Medical, Friendswood, Texas. Safa’a Al-Arabi, PhD, RN, MPH, MSN, is an associate professor and the Clinical Nurse Leader (CNL) Track Administrator in the Graduate Studies Department of The University of Texas Medical Branch at Galveston School of Nursing.
References
1. Lipton RB, Nicholson RA, Reed ML, Diagnosis, consultation, treatment, and impact of migraine in the US: results of the OVERCOME (US) study. Headache. 2022;62(2):122-140. doi:10.1111/head.14259
2. Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: figures and trends from government health studies. Headache. 2018;58(4):496-505. doi:10.1111/head.13281
3. American Migraine Foundation. Migraine Facts. Accessed May 3, 2023. https://americanmigrainefoundation.org/resource-library/migraine-facts/
4. Biglione B, Gitin A, Gorelick PB, Hennekens C. Aspirin in the treatment and prevention of migraine headaches: possible additional clinical options for primary healthcare providers. Am J Med. 2020;133(4):412-416. doi:10.1016/j.amjmed.2019.10.023
5. American Migraine Foundation. Looking at racial disparities in migraine and headache care, why they exist and what we can do about them. Interview with Dr. Jessica Kiarashi. AMF website. Accessed May 4, 2023. https://americanmigrainefoundation.org/resource-library/racial-disparities-in-migraine-care/
6. Bonafede M, Sapra S, Shah N, Tepper S, Cappell K, Desai P. Direct and indirect healthcare resource utilization and costs among migraine patients in the United States. Headache. 2018;58(5):700-714. doi:10.1111/head.13275
7. Minen M, Shome A, Halpern A, et al. A migraine management training program for primary care providers: an overview of a survey and pilot study findings, lessons learned, and considerations for further research. Headache. 2016;56(4):725-740. doi:10.1111/head.12803
8. Takaki H, Onozuka D, Hagihara A. Migraine-preventive prescription patterns by physician specialty in ambulatory care settings in the United States. Prev Med Rep. 2017;9:62-67. doi:10.1016/j.pmedr.2017.12.009
9. Aguirrezabal I, Pérez de San Román MS, Cobos-Campos R, et al. Effectiveness of a primary care-based group educational intervention in the management of patients with migraine: a randomized controlled trial. Prim Health Care Res Dev. 2019;20:e155. doi:10.1017/S1463423619000720
10. Gifford LS, Butler DS. The integration of pain sciences into clinical practice. J Hand Ther. 1997;10(2):86-95. doi:10.1016/s0894-1130(97)80063-4
11. Trachsel LA, Munakomi S, Cascella M. Pain theory. StatPearls [Internet]. StatPearls Publishing; April 20, 2022. Accessed May 3, 2023.
12. Bohm PE, Stancampiano FF, Rozen TD. Migraine headache: updates and future developments. Mayo Clin Proc. 2018;93(11):1648-1653. doi:10.1016/j.mayocp.2018.09.006
13. Migraine and Headache Treatments. MPR. Updated March 10, 2023. Accessed May 3, 2023. https://www.empr.com/charts/migraine-and-headache-treatments/
14. Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society consensus statement: update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153 10.1111/head.14153
15. Robbins MS. Diagnosis and management of headache: a review. JAMA. 2021;325(18):1874-1885. doi:10.1001/jama.2021.1640
16. Katsarava Z, Buse DC, Manack AN, Lipton RB. Defining the differences between episodic migraine and chronic migraine. Curr Pain Headache Rep. 2012;16(1):86-92. doi:10.1007/s11916-011-0233-z
17. American Headache Society. First contact – headache in primary care. Accessed May 4, 2023. https://americanheadachesociety.org/primarycare
18. Robbins MS, Victorio MCC, Bailey M, et al. Quality improvement in neurology: headache quality measurement set. Headache. 2021;61(1):219-226. doi:10.1111/head.13988
19. White KM, Dudley-Brown S, Terhaar MF. Translation of Evidence Into Nursing and Healthcare. (3rd ed). Springer Publishing Company; 2019
