Identifying migraine in primary care settings
Section snippets
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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