Determinants of Suboptimal Migraine Diagnosis and Treatment in the Primary Care Setting

Misdiagnosis

Evidence suggests that misdiagnosis plays a large role in the suboptimal management of migraineurs. Studies have shown that as many as 59.7% of migraineurs were not given a diagnosis of migraine by their primary care provider [10]. Common mistaken diagnoses include tension-type headache [11], “sinus headache” [12], cervical pain syndrome or cervicogenic headache [13], and “stress headache” [14].

The reasons for these misdiagnoses is not certain. It may be that the patient and practitioner assume that location of the pain is suggestive of the cause [13]. This is even though more than half of those with migraine have associated neck pain [15]. A recent study suggests that 60% of migraineurs who self-reported a diagnosis of cervical pain have been subsequently diagnosed with cervicalgia by a physician [13]. If patients endorse stress as a precipitant or the presence of cervical pain, they are more likely to obtain a diagnosis other than migraine. The presence of aura in association with the headache appears to be protective against misdiagnosis [13].

Similarly, patients are often given a diagnosis of “sinus headache.” This diagnosis is often made without radiologic evidence of sinusitis and even in those with a more typical migraine headache [16]. In one survey, 40% of patients meeting criteria for migraine were given this diagnosis. Many of these patients did have nasal symptoms or facial pain without clear evidence or rhinosinusitis, and in some cases these symptoms would respond to migraine treatments [16]. This is a particularly important misdiagnosis to highlight, as attributing symptoms to sinus disease may lead to unnecessary consultations and even sinus instrumentation.

In addition to common misdiagnoses, many PCPs are unfamiliar with the “red flags” that may indicate a secondary headache disorder and are also unfamiliar with appropriate use of neuroimaging in headache patients [17].

Misuse of As-Needed Medications

Studies have suggested that a large proportion of PCPs will prescribe nonspecific analgesics for migraine rather than migraine-specific medications [18]. These treatments may include NSAIDs, acetaminophen, barbiturates, and even opiates. This appears to be the pattern even for those with severe attacks [18], suggesting that migraine-specific medications such as triptans may be underused in the primary care setting. Postulated reasons for this pattern include lack of physician knowledge regarding the specific recommendations for managing migraine, the cost of medications, as well as lack of insurance coverage for these medications [19]. Misuse of as-needed medications can lead to medication overuse headache (MOH), which is an underrecognized problem in the primary care setting [20]. In a survey of PCPs in Boston, only 54% of PCPs were aware that barbiturates can cause MOH and only 34% were aware that opiates can cause MOH [17]. The same survey revealed that approximately 20% of PCPs had never made the diagnosis of MOH [17].

Underuse of Preventive Medications

As many as 40% of migraineurs need preventive therapy, but only approximately 13% are currently receiving it [3]. Additionally, the average time from diagnosis of migraine to instituting preventive treatment is 4.3 years, and often there is only a single preventive medication trial if one is instituted [21]. The reasons for this appear to be complex. The physician factors contributing to the underuse of preventive medications include inadequate education, discomfort and inadequate time for assessments. Only 27.8% of surveyed PCPs were aware of the American Academy of Neurology guidelines for prescribing preventive medications [17].