CHALLENGES

Diagnosis

• Migraine is underdiagnosed, resulting in inappropriate management; worldwide, only 40% of migraine sufferers have been afforded a medical diagnosis.^1–3
• A mere 13.6% of chronic migraine sufferers report being referred to a specialist for the diagnosis and management of their migraine. Of those who do see a specialist, only 36% report receiving a diagnosis of chronic migraine.²
• Diagnostic imaging [Computed tomography (CT) and magnetic resonance imaging (MRI)] is over-used. Guidelines suggest that neuroimaging studies should not be performed in migraine sufferers who have a stable headache meeting the criteria for migraine and that imaging should not be performed for an uncomplicated headache.^4,5 Further evidence is required to determine the role of imaging in cases where patients present with headache that is atypical for them.⁴
• Some headache disorders are uncommon/rare, and referral to a headache specialist may be required to make/confirm a diagnosis.⁷

Treatment

• There is no definitive patient-specific approach, and the most appropriate plan depends upon patient-specific factors (eg, comorbidities, triggers, symptom profile, and response to therapy).^8,9
• Medication compliance and effectiveness are poor in acute attacks where there is significant nausea/vomiting or gastric paresis. Alternative modes of administration should be considered, including wafers, transdermal administration, nasal powders, sprays, and injections.¹⁰
• Recognition and appropriate management of comorbidities, including anxiety, depression, and obesity, are challenging.¹¹
• It is essential to encourage medication compliance and to educate patients about realistic expectations for symptom reduction.
• Medication overuse is common, potentially causing medication-overuse headache.³
• Healthcare providers need support for migraine education and improved familiarity with the newest investigational agents, including calcitonin gene-related peptide (CGRP) monoclonal antibodies.^7,12

References

1. World Health Organization. Headache. WHO fact sheets. (who.int/mediacentre/factsheets/fs277/en) Accessed 9/25/18.
2. Lipton RB, Serrano D, Buse DC, et al. Improving the detection of chronic migraine: development and validation of Identify Chronic Migraine (ID-CM). 2016;36:203-215.
3. Sinclair AJ, Sturrock A, Davies B, Matharu M. Headache management: pharmacological approaches. Pract Neurol. 2015;15:411-423.
4. Minen MT, Tanev K, Friedman BW. Evaluation and treatment of migraine in the emergency department: a review. 2014;54:1131-1145.
5. ABIM Foundation Choosing Wisely Campaign (www.choosingwisely.org/doctor-patient-lists/). Accessed on 9/25/18.
6. International Classification of Headache Disorders (ICHD) III criteria (ichd-3.org) Accessed 9/25/18.
7. Silberstein SD. Considerations for management of migraine symptoms in the primary care setting. Postgrad Med. 2016;128:523-537.
8. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American Headache Society evidence assessment of migraine pharmacotherapies. 2015;55:3-20.
9. Starling AJ, Dodick DW. Best practices for patients with chronic migraine: burden, diagnosis, and management in primary care. Mayo Clin Proc. 2015;90:408-414.
10. Becker WJ. Acute migraine treatment. Review article. Continuum. 2015;21:953-972.
11. Dougherty C, Silberstein SD. Providing care for patients with chronic migraine: diagnosis, treatment, and management. Pain Pract. 2015;15:688-692.
12. Orr SL, Aubé M, Becker WJ, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia. 2015;35;271-284.
13. Freitag FG, Shumate D. Current and investigational drugs for the prevention of migraine in adults and children. CNS Drugs. 2014;28:921-927.