Identifying the Great Masquerader: Diagnosing Migraine in Primary Care

Migraine remains one of the most misunderstood forms of headache, despite its heavy burden on patients in the US. According to the American Migraine Foundation (http://bit.ly/qv9ZkV):

• Migraine affects 36 million Americans (about 12% of the population)
• Migraine is three times more common in women than in men, with a lifetime prevalence of about 30% in women
• Chronic migraine affects 3% of the population (at least 15 days of headache each month for at least six months)
• Migraine cost more than $20 billion each year (direct and indirect costs)

According to the American Headache Society Primary Care Migraine Partnership (http://bit.ly/rJhN5B), up to two-thirds of migraine sufferers seek care in the primary care setting. This, combined with the sheer numbers of migraine sufferers in the US and the severe impact of this condition on patients’ quality of life, highlights the need for expanded training and education on the recognition and appropriate management of migraine for primary care physicians.

IASP Launches Global Year Against Headache

The International Association for the Study of Pain (IASP) and the International Headache Society recently announced the launch of a year-long campaign to raise public awareness of headache disorders and educate health care professionals about specific topics related to headache.To help educate primary care physicians and other clinicians who diagnose and treat patients with migraine, the IASP has created a host of fact sheets and other resources. These include:

• “Epidemiology of Headache,” which provides information on comorbidity, course and prognosis, and the impact of migraine (http://bit.ly/s9GB0a)
• “Migraine,” which discusses symptoms and epidemiology, migraine aura and triggers, diagnostic criteria, and a review of therapy options (http://bit.ly/vFHV83)
• “Migraine and Hormonal Changes,” which explores the prevalence and impact of migraine in women, exploring gender-related issues in diagnosis, pathophysiology, and management (http://bit.ly/sVSHmB)
• “Vascular Changes in Migraine,” a resource that explains the vascular hypothesis of migraine, including a review of its history and experimental basis, a discussion of spontaneous and provoked migraine attacks, and information about the role of vasodilatation as a possible cause of migraine pain (http://bit.ly/t0hcPu)
• “Migraine and Neurophysiology,” which offers a brief summary of neurophysiological findings in migraine as a way of explaining the limited role of neurophysiology in migraine diagnosis (http://bit.ly/ttuNL5)

The accurate differential diagnosis of migraine can be a challenge for primary care physicians and other non-specialists due to the often complex clinical presentation of this condition, symptoms of which often overlap with other headache types. Because it “often presents as tension-type headache, sinus headache, probable migraine, ‘period’ headache, muscular neck pain, cyclic vomiting, and ‘stress’ headache,” migraine has been called the “great masquerader” (http://bit.ly/rAhAmm).

The National Headache Foundation reports that migraine is misdiagnosed as tension or sinus headache “almost as frequently as it is correctly diagnosed” in the primary care setting (http://bit.ly/sBGCj6), with some estimates pegging the rate of misdiagnosis as high as 50% of cases (http:// bit.ly/rXJwXP). This is in line with findings from other studies that looked at primary care physicians’ “knowledge, attitudes, and beliefs regarding migraine,” such as the study by Patwardhan and colleagues in Headache (http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2006.00427.x/abstract), which concluded that primary care physicians “need to acquire greater understanding about the epidemiology and pathophysiology of migraine and may require guidance in history taking and physical examination of migraine patients.”

To meet this perceived gap in knowledge and training regarding migraine, The International Association for the Study of Pain (see sidebar), The Primary Care Network (which offers CME programs such as “Chronic Migraine Dx; http://bit.ly/ uE463t), and other organizations have created resources designed to help primary care physicians better understand the diagnostic criteria and management strategies for this common painful condition.