Objective: To review the impact of migraine and explore the barriers to optimal migraine diagnosis and treatment.
Methods: Review of the literature.
Results: Several factors may play a role in the inadequate care of migraine patients, including issues related to poor access to care, diagnostic insight, misdiagnosis, adherence to treatment, and management of comorbidities. Both patient and physician factors play an important role and many be modifiable.
Conclusions: A focus on education of both patients and physicians is of paramount importance to improve the care provided to migraine patients. Patient evaluations should be multisystemic and include addressing comorbid conditions as well as a discussion about appropriate use of prevention and avoidance of medication overuse.
Migraine is a common, debilitating condition that is a significant source of reduced productivity and increased disability [1]. According to the latest government statistics, 14.2% of US adults have reported having migraine or severe headaches in the previous 3 months, with an overall age-adjusted 3-month prevalence of 19.1% in females and 9.0% in males [2]. In a self-administered headache questionnaire mailed to 120,000 representative US households, the 1-year period prevalence for migraine was 11.7% (17.1% in women and 5.6% in men). Prevalence peaked in middle life and was lower in adolescents and those older than age 60 years [3]. Migraine is an important cause of reduced health-related quality of life and has a very high economic burden [4]. This effect is even more marked in those with chronic migraine, who are even more likely to have professional and social absenteeism and experience more severe disability [4].
Migraine and headache are a common reason for primary care physician (PCP) visits. Some estimates suggest that as many as 10% of primary care consultations are due to headache [5]. Approximately 75% of all patients complaining of headache in primary care will eventually be diagnosed with migraine [6]. Of these, as many as 1% to 5% will have chronic migraine [6].
Despite the high frequency and social and economic impact of migraine, migraine is underrecognized and undertreated. A survey of US households revealed that only 13% of migraineurs were currently using a preventive thrapy while 43.3% had never used one [3]. This is despite the fact that 32.4% met expert criteria for consideration of a preventive medication [3]. The reasons for underrecognition and undertreatment are multifactorial and include both patient and physician factors.
Physician Factors
Although migraine and headache are a leading cause of physicians visits, most physicians have had little formal training in headache. In the United States, medical students spend an average of 1 hour of preclinical and 2 hours of clinical education in headache [7]. Furthermore, primary care physicians receive little formal training in headache during residency [8]. In addition to the lack of formal training, there is also a lack of substantial clinic time available to fully evaluate and treat a new headache patient in the primary care setting [8]. Headache consultations can often be timely and detail-driven in order to determine the correct diagnosis and treatment [9].
