Migraine Diagnosis and Treatment: A Knowledge and Needs Assessment of Women's Healthcare Providers

Allison M. S. Verhaak PhD; Anne Williamson PhD; Amy Johnson MD; Andrea Murphy APRN; Matthew Saidel MD; Abigail L. Chua DO; Mia Minen MD, MPH; Brian M. Grosberg MD

Disclosures

Headache. 2021;61(1):69-79. 

In This Article

Discussion

In this comprehensive assessment of women's healthcare providers' migraine knowledge, practice patterns, and educational needs, several themes emerged, particularly with regard to provider headache knowledge and relation to practice patterns. It is worthwhile to state that one would not necessarily expect women's healthcare providers to have received extensive education or training in headache medicine, given their typical scope of practice. However, given the frequency that migraine is managed in the primary care clinic, and the frequency in which female patients consider their women's healthcare provider to be their PCP, it is important to consider how migraine is understood and managed in these patients, in order to better develop targeted educational programs to improve headache treatment and patient outcomes. In this study, respondents reported serving as PCP for an average of one-third of their caseload, which is similar to percentages reported in other studies.[19,20]

Survey respondents estimated the prevalence of migraine in the US population as 18% (correct response: 12%); interestingly, this estimation is approximately the prevalence rate for women in the US population, and may reflect the survey sample of women's healthcare providers. The majority of respondents reported feeling somewhat comfortable or very comfortable with diagnosing migraine. However, only slightly more than half of respondents reported routinely asking about headache symptoms at annual visits, which could increase the likelihood of under-diagnosis and under-treatment of headache symptomatology. Although more than half of respondents reported feeling comfortable with prescribing medications for migraine, several knowledge gaps with regard to medication management of migraine emerged. First, only a small percentage of providers were familiar with guidelines for prescribing medications (i.e., AAN and Choosing Wisely), and the majority of providers did not routinely prescribe preventative medications, citing discomfort with doing so. This is problematic, as previous research suggests that nearly 40% of patients with migraine need preventative treatment, yet only 13% of patients receive it.[21] These results also appear to suggest differences in survey responses based on primary care versus women's healthcare providers, as approximately 80% of respondents in the original survey study by Minen et al[17] reported prescribing preventative medications, compared with 13% prescribing preventatives in the present study. With regard to MOH, nearly half of survey respondents reported having made the diagnosis; however, many were less aware of medications that may result in MOH, with the exception of barbiturate-containing combination analgesics. These knowledge gaps appear to translate into practice patterns, as respondents reported prescribing acetaminophen, NSAIDs, and barbiturate-containing combination analgesics most frequently to their patients. More specifically, less than 50% of respondents reported prescribing migraine-specific medications. Previous studies have also reported a high frequency in which non-headache medicine specialists prescribe medications that are not migraine-specific.[22] Reasons for this may include knowledge gaps (lack of education related to migraine-specific medications) or barriers within the healthcare system (e.g., insurance coverage for specific medications), and additional research in this area would likely be beneficial.

With regard to behavioral health assessment and treatment in the context of migraine, respondents believed that approximately one-third of individuals with migraine experience anxiety and depression symptoms. Prior research estimates up to 47% of migraine patients experience depression, and up to 58% experience anxiety.[17] Approximately half of respondents reported that they assess for anxiety and depression during annual visits with patients. Given the proposed bidirectional relationship between migraine and mental health concerns, it is important for mental health screening procedures to be routine and standardized within migraine treatment.[23] With regard to evidence-based non-pharmacological treatment of migraine, one-third to one-half of respondents did not correctly identify biofeedback, CBT, or relaxation. In addition, nearly zero providers reported referring patients for these services, citing lack of referral knowledge, lack of provider availability, insurance issues, and patient skepticism as major barriers. For many patients, utilizing non-pharmacological treatments, such as CBT, would likely be of great benefit due to their efficacy (Grade A evidence), safety, and long-term benefits. It can be especially helpful, as migraine can be comorbid with modifiable health behaviors and mental health concerns, and in situations in which patients are unable or not willing to take particular medications.[24,25]

There is a general concern for overimaging in the migraine population; however, this trend was not observed in this study sample, as nearly half of providers cited a general discomfort with ordering MRIs for their patients. In addition, for those who would order imaging, less than half of providers would order MRI for known red flags, including headache with neurologic symptoms (e.g., altered level of consciousness, weakness, numbness, visual loss, double vision, and/or difficulty with speech or language), headache not responding to treatment, worsening headache, and new type of headache.[26] These findings are somewhat similar to the original Minen et al study,[17] with the exception of ordering MRI for headache with neurologic symptoms, for which 74.7% of respondents said that they would, compared with 47.8% of this study sample. Interestingly, women's healthcare providers were more apt to send their patients to the emergency department (ED) for the same symptoms or concerns, with over three-quarters of the sample stating they would send a patient for headache with neurologic symptoms. Less than 1% of respondents reported discomfort with sending patients to the ED. Taken together, these findings suggest limited knowledge of headache-related red flags, as well as lack of thorough diagnostic workup to rule out secondary causes of headache.[27] In addition, if patients are routinely being sent to the ED, this may further delay differential diagnoses, decrease specialized care, and increase the financial burden on the patient. These findings further support the need for additional education for healthcare providers who may be the first line of diagnosis and care for headache.

This study specifically expanded upon the original PCP survey, in that it queried use of and comfort with prescribing hormone therapies in the context of different migraine diagnoses. Findings suggest that the women's healthcare providers were generally comfortable with prescribing hormonal contraceptives to migraine patients with and without aura. However, prescribing patterns suggest that providers were less likely to prescribe estrogen-containing contraception in the context of migraine with aura, while a wider variety of contraceptives, including those containing estrogen, were prescribed to patients with migraine without aura. Patients with migraine with aura are at an elevated risk of stroke compared with patients with migraine without aura, and research suggests this risk is even higher with use of estrogen-containing contraceptives.[28,29] Study findings suggest a general understanding of these risks, although a limited number of providers reported that they would still be comfortable prescribing estrogen-containing hormonal contraceptives to their patients with migraine with aura. Currently, the ACOG and World Health Organization consider migraine with aura to be an absolute contraindication for the use of combined hormonal contraception. The International Headache Society (IHS) acknowledges the risk, but also states that prescriptive decisions should be made on a case-by-case basis, considering patient risk factors[30] Study results highlight the need for additional education and understanding of risk factors in women's healthcare providers in determining the best course of action regarding hormonal contraceptives.

Respondents reported serving as PCPs for approximately one-third of their caseload. Additional analyses revealed that residents and fellows reported serving as PCP for a higher percentage of their patients than did attendings, and that serving as a PCP more frequently was associated with a greater comfort level with prescribing medications for migraine. One possible reason for level of training as a predictor of frequency serving as PCP may be due to the clinic setting in which these providers are seeing patients. Previous studies suggest that women may be more likely to utilize their women's healthcare provider (i.e., gynecologist or obstetrician) as their PCP if they are younger, have fewer years of education, are of lower socioeconomic status, have small children, and report illicit substance use.[20] It seems possible that residents and fellows may be in clinic settings for training purposes that are different from their attending counterparts, and may therefore be caring for different patient populations, including those who may be at-risk. These results also point to the importance of headache educational interventions at the residency/fellowship level, to ensure evidence-based, specialized care for their patients within these clinic settings.

Next Steps

Study results highlight the need and desire for targeted educational interventions for women's healthcare providers, including increasing knowledge and understanding of both pharmacological and non-pharmacological interventions, as well as diagnostic considerations. Prior studies have explored migraine management training programs for PCPs, and have observed challenges to implementation, including low attendance to live educational sessions, limited use of email consultative service, and clinical demand as a likely barrier to participation.[18] Other studies suggest that programs may be more successful when conducted during scheduled education/training time, and/or when endorsed by supervisors/mentors.[31] Given these previous findings, as well as this study's finding that residents/fellow may serve as PCP more frequently for their patients, future studies aim to develop and implement a case-based, headache education curriculum in pertinent residency programs, including primary care/internal medicine and gynecology/obstetrics. Enhanced education and exposure to headache medicine during residency training will likely lead to increased provider knowledge and comfort in diagnosing and treating migraine, as well as improved patient outcomes and satisfaction with care.

Study Limitations

The present study was limited to women's healthcare providers at select locations in Connecticut, and results may therefore not be generalizable to other settings or other types of healthcare providers. In addition, due to the nature of how participants were invited to complete the survey (via email, from one contact person at each institution of study), it is impossible to ascertain the exact number of potential participants to determine the response rate. As a result, the present study's response rate of nearly 30% is an approximation. The study's authors recognize the limitations in this response rate; however, other studies examining response rate of physicians and physician specialists for web-based surveys found response rates to range from 5%-35%.[32–34] Additional studies examining factors that impact physician survey response rates are likely warranted. Some aspects of the survey also lacked specificity with regard to how respondents evaluate or diagnose patients. For example, it is unknown how respondents assess for depression and anxiety in their patients (questionnaire versus clinical interview versus chart review). In addition, it is unknown what criteria respondents use to formally diagnose migraine in their patients. It would likely be beneficial to further explore these diagnostic considerations in future studies.

Study Strengths and Conclusion

This was a comprehensive survey developed by experts in the fields of headache medicine and obstetrics/gynecology, and expanded upon the original survey created by Minen and colleagues[17] to include questions specific to women's healthcare provider knowledge and practice. A diverse group of practitioners were surveyed, from physicians to advanced practice providers, in many different practice settings, including academic health centers, healthcare systems, and private practices. Study findings highlight the knowledge, as well as the knowledge gaps, of women's healthcare providers, supplying the foundation for future research seeking to expand access to headache-specific educational curriculum to improve provider performance and patient outcomes.

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