Miriam E. Tucker

July 09, 2015

Washington, DC — Neurologists frequently fail to ask patients with chronic migraine the right questions, new research suggests.

Findings from an analysis of audio-recorded neurologist-patient encounters were presented at the recent American Headache Society (AHS) 57th Annual Scientific Meeting by Richard B. Lipton, MD, director of Montefiore Headache Center and vice chair of neurology, and the Edwin S. Lowe Chair in Neurology, Albert Einstein College of Medicine, New York, New York.

Previous work by Dr Lipton's group in episodic headache suggests that the use of open-ended questions — as opposed to those that elicit just yes/no answers — and a technique called "ask-tell-ask," in which the physician repeats the patient's answer for clarification before asking the next question are rarely used. But when they are used, they elicit answers that lead more often to accurate diagnosis and appropriate treatment.

Funded by Allergan, the study is reportedly the first to analyze clinical encounters for chronic migraine.

"Chronic migraine is underdiagnosed, undertreated and disabling.… Effective communication is vital for accurate diagnosis, treatment planning, and optimizing patient adherence," Dr Lipton said during his presentation.

Dr Lipton and colleagues analyzed transcriptions of audio recordings from 35 encounters between 20 neurologists and patients with chronic migraine between August 2013 and January 2014. From an original 67 recordings, the 35 met criteria for sufficiently robust dialogue to allow for coding of the communication parameters of interest.

Of the 35, 9 were initial visits with the neurologist, 25 were follow-up visits, and 1 was a visit with patient who had returned to see the same neurologist for the first time in 3 years.

The patients were mostly female, white, and insured, with a mean age of 46 years. The physicians were mostly male. Half (50%) wrote 51 to 100 migraine prescriptions per month, and 43% wrote more than that. More than half (57%) saw 51 to 100 patients with migraine per month, while 29% saw fewer than that.

"Depressing" Results

The average encounter lasted 11 minutes and included an average of 17 headache-related questions. Most questions (82%) were closed-ended, mostly eliciting yes/no answers, such as "Do you have nausea?" or "Are you sensitive to light?"

"The disadvantage of those sorts of questions is they don't promote a dialogue or allow the patient to tell a story," said Dr Lipton.

In contrast, he said, a question such as "Tell me about your headaches and how they affect your life?" would elicit more information. "Many physicians are afraid to ask any open-ended questions for fear the patient will go on and on and on till the end of the day. Empirically that's not the case, but there are relatively easy methods for stopping people who do go on too long."

Headache/migraine frequency was assessed in 27 (77%) of the dialogues, but only 1 used the "ask-tell-ask" method. Of those 27, 19 (70%) discussed frequency in terms of migraine quantity, with smaller numbers using the terms "attacks" or "episodes" or "headaches." In only 1 encounter were the terms "headache days" and "headache-free days" used.

"The term 'chronic migraine' was used in just 5 conversations, mostly without reference to the patient's own condition. "There was essentially no clear communication about migraine diagnosis at all…. With only one physician discussing frequency in terms of headache days, accurate diagnosis of chronic migraine is not possible, likely leading to underdiagnosis," Dr Lipton commented.

Headache-related disability was discussed in just 8 of the 35 dialogues (23%), and only 1 of those used an open-ended question, "which I actually find a little scary," he said.

Treatment plans were established in 13 of the encounters (37%), but the patients' understanding of the plan wasn't clarified and expectations for the treatment were missing from all the dialogues.

"It was pretty depressing reading through these transcripts," Dr Lipton noted, adding that he is now planning to conduct an intervention study similar to the previous one in order to see whether training physicians in questioning techniques will improve outcomes in chronic migraine.

Limited Training

Commenting on the findings for Medscape Medical News, session moderator Robert Shapiro, MD, PhD, professor in the Department of Neurological Sciences at the University of Vermont, Burlington, said the education that doctors receive about how best to interact effectively with patients who have migraine is extremely limited.

Dr Shapiro pointed out that the wording of questions is particularly important in assessing patients with chronic migraine. For example, the question "How many days do you have headaches?" might lead to a patient mentioning only the days with severe and disabling headache and leave out days with milder headaches to which they've become acclimated.

"We need to know that to get a full sense of how frequent and burdensome the whole picture is. The only way to find out is to ask the reverse question, 'How many days are you completely free of headache?'"

Dr Shapiro also said he has patients fill in a lengthy intake form before they arrive for their appointments.

"We read it very carefully, and then use the appointment time to fill in any gaps. We also ask if there's anything we didn't ask that we should have."

During the question-and-answer period, an audience member noted that having patients bring in headache diaries could help with the assessment and reduce the need for long back-and-forth discussions during visits.

Dr Shapiro is a medical advisor to a new company called BonTriage, an online portal for patients to fill in detailed questionnaires — designed with expert input — about their chronic conditions before medical visits. It then generates an editable narrative report that can be entered into the patient's electronic health record.

Headache is the first condition for which the company has produced a questionnaire, but there are plans to include sleep disorders, mood disorders, chronic pain, and other chronic conditions.

"It's a much more efficient and much less burdensome way for patients to provide a good history for their doctors," said Dr Shapiro.

This study was funded by Allergan Inc. Dr Lipton has received honoraria and/or research support from Allergan, American Headache Society, Autonomic Technologies, Boston Scientific, Bristol Myers Squibb, Cognimed, CoLucid, Electrocore, Eli Lilly, eNeura Therapeutics, GlaxoSmithKline, Merck, Nautilus, Neuroscience, Novartis, Teva, Vandanta, and Zogenix. He also holds stock options with eNeura. Dr Shapiro receives consulting fees/honoraria from Eli Lilly and has equity/stock interests in BonTriage.

American Headache Society (AHS) 57th Annual Scientific Meeting. Presented June 20, 2015. Abstract OR9.


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