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Tools for Managing Migraine
medical consultation. Providers have also been encouraged to use evaluation, whereas no change reassures that serious underlying
diagnostic screeners in waiting rooms or to have them completed by disease is unlikely.
patients before the initial headache evaluation. 4. How often and how effectively do you use medication to treat
headaches? This answers the possibility of medication overuse and
An alternative use for diagnostic screeners is as an education tool to the effectiveness of the treatment strategy being used by the patient.
clarify the diagnosis of migraine, for example assisting patients in
understanding which features of the migraine syndrome are important A survey of 315 physicians who completed the Continuing Medical
in determining which headaches are migraine. This may be particularly Education form of Patient-Centered Strategies indicated that 65% were
useful in patients believing that some of their headaches are ‘sinus’ or using this questionnaire as a screening tool for migraine and 95% used
‘tension’ headaches even when the headaches fulfill IHS criteria for the publication to become better prepared to treat patients with
migraine. Patients can evaluate several of their headaches prior to a migraine.
6
These questions were incorporated into an international
follow-up visit and the information they collect can then be used as a consensus criteria diagnostic screen for headache patients in primary
focal point of communication around migraine diagnosis. In this way, the care. The assumption was that the majority of headache patients
migraine diagnostic tool can individualize the diagnostic process for seeking medical consultation in primary care have migraine.
7
This point
the patient. Several diagnostic tools that are available to clinicians and was later confirmed in an international study authored by Tepper where
patients are described below. it was reported that over 90% of patients seeking evaluation for
headache in primary care were suffering from migraine.
8
ID Migraine
4
Among patients in a primary care waiting room who had headaches that 3-Question Headache Screen
9
interfered with their ability to work, study, or enjoy life or said they The screening tool was studied in a large (3,014-subject) clinical trial
wanted to discuss their headaches with a physician, the following three where positive responses to the screener were compared with IHS
questions identified those with likely migraine. diagnostic criteria and clinical impression. The screening tool identified
78% of subjects with IHS migraine and 74% of subjects diagnosed by
1. Has a headache limited your activities for a day or more in the last clinical impression.
three months?
2. Are you nauseated or sick to your stomach when you have a 1. Do you have headaches that interfere with work, family, or social
headache? functions?
3. Does light bother you when you have a headache? 2. Do your headaches last at least four hours?
3. Have you had new or different headaches in the last six months?
A positive response to two of these three questions has an 81%
sensitivity and 75% specificity for IHS diagnosis of migraine; in A positive answer to questions 1 and 2 with a negative answer to
addition, the ID Migraine Screener was found to have a positive question 3 was considered positive for migraine. Even though the
predictive value of 93.3% in the primary care setting. ID Migraine is screening tool may have utility in population-based studies, it is less
widely used because it is simple and can be self-administered. ID effective as an aid to communication compared with ID Migraine or the
Migraine can effectively illustrate to patients that migraine diagnosis Impact-Based Recognition Questionnaire.
requires more than just a headache; in addition, it often helps patients
confirm family histories of migraine. Menstrual Migraine Screener
On the surface it would seem that associating migraine with menses
Impact-based Recognition
5
would be straightforward. However, this is not always the case and can
This migraine recognition tool was one of the earliest tools developed be particularly challenging when migraines are frequent or menses is
for migraine recognition and is somewhat more complex than the unpredictable. The Menstrual Migraine Assessment Tool is a useful tool
others. It can be readily adapted as a template for patient education and to establish a woman’s awareness of an association of migraine and
understanding several key components of migraine. Unlike the other menses. This tool can be useful in deciding which women need to be
diagnostic tools, Impact-based Recognition is not scored. However, provided with specific diaries or calendars for tracking migraine and
clinicians can use patients’ answers as education points in subsequent menses and the effectiveness of therapeutic strategies directed at
office visits. menstrually related migraine. Diagnostic sensitivity can be augmented
by providing women with the definition of menstrually related migraine.
1. How do headaches interfere with your life? The patient’s answer
defines disability, establishes rapport, and directs intensity of Menstrual Migraine Assessment Tool
10
therapeutic intervention. Among patients in an obstetric/gynecology waiting room, the following
2. How frequently do you experience headaches of any type? This three questions elicited responses that indicated that the individuals
differentiates episodic from chronic migraine, differentiates migraine were likely to have migraine related to menses.
from short duration headaches such as cluster headache, and helps
identify the need for preventive interventions. 1. Do you have headaches that are related to your period (i.e. occur
3. Has there been any change in your headache pattern over the between two days before the onset of your period until the third day
last six months? A change suggests the need for in-depth of your period) most months?
US NEUROLOGY 69
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