Identifying migraine in primary care settings

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Migraine disorders are largely unrecognized and untreated, despite the heavy burden they impose on individuals and society. Studies have shown that the symptom severity and disability associated with undiagnosed migraine are as burdensome as those associated with diagnosed migraine. Of those persons with migraine identified in population-based surveys, many were previously unaware that they had migraine. Furthermore, coexisting headache types and comorbid conditions contribute to misdiagnosis among those who consult a physician for headache. Patients who do seek medical attention for headaches usually visit their primary care providers. The purpose of this review is to highlight the distinguishing characteristics of migraine compared with other headache disorders, based on the new International Classification of Headache Disorders. To aid in diagnosis, simple screening tools, such as ID Migraine (Pfizer Inc., New York, NY), are recommended. The clinical interview and headache diary aid in refining the diagnosis or suggesting the need for further evaluation. Improved recognition of migraine in primary care will increase the rate of successful treatment with effective migraine-specific therapies. This will result in improved functionality and decreased pain, and may help prevent disease progression.

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Underrecognition and misdiagnosis of migraine

Recognizing migraine is challenging for several reasons. One reason is the lack of objective screening tools for identifying the disorder in the primary care setting. Clinicians rely on patients to recall and report highly subjective descriptions of headache pain and associated symptoms.9, 10 Variation among patients and between attacks in the severity and frequency of migraines and their symptoms presents another diagnostic challenge for clinicians.11 The frequency of severe headache is

Migraine case definition

Diagnosis of migraine at the first patient contact is important for effective treatment.8 Migraine classification was first standardized in 1988 by the International Headache Society (IHS) in The International Classification of Headache Disorders; these headache criteria were revised in 2004.17 The IHS classification has been widely used by researchers and clinicians. Most cases of migraine (IHS category 1) can be identified initially in the primary care setting based on the symptomatic

Tension-type headache

Tension-type headache and migraine are frequently confused despite the striking differences in severity and symptom profile. One hallmark of migraine attacks compared with other headache types is the associated disability that patients endure.22 There are also differences in pain features. Tension-type headaches cause mild-to-moderate pain, whereas migraine pain is usually severe. Tension-type headaches are characterized by bilateral, steady pain; migraine pain is usually unilateral and

Atypical migraine presentations

As previously mentioned, migraine is frequently misdiagnosed as tension-type headache or sinus headache. The reasons for this are varied, but tension-type headache is a frequent misdiagnosis because of the location of the pain, the occurrence of stress as a frequent trigger for attacks, and the bilateral nature of some migraine attacks. Although migraine attacks may begin or remain maximal on 1 side of the head, nearly half of all individuals with migraine report at least some bilateral

Screening instruments

Although the prevalence of migraine is high, medical consultation specifically for migraine is relatively low.3 A need for awareness of migraine symptoms and the available treatments is evident from the large numbers of persons with migraine who are undiagnosed and untreated. In a population-based study of >23,000 people in urban US locations, self-assessment of migraine was found to be relatively poor. Nearly half of the individuals who met IHS criteria for migraine did not recognize that they

Making a migraine diagnosis

Patients with migraine are expected to have a normal physical and neurological evaluation when they are not having attacks. Although there is no single diagnostic test for migraine, clinicians can identify many cases through heightened awareness of its prevalence and features and by using available screening tools. Figure 1 illustrates a basic stepwise approach to screening that can identify many individuals with migraine, as well as identify patients who may need additional evaluation. A

Summary

Although it remains largely unrecognized and untreated, migraine continues to place a heavy burden on the individual as well as on society. The symptom severity and resulting disability of people with undiagnosed migraine are as burdensome as those of diagnosed patients. By using a simple screening tool, such as ID Migraine, primary care providers can identify those patients who likely have migraine. Clinical interview and diary assessments can aid in refining the diagnosis or suggesting a need

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