There may be an underestimate of the disability experienced by migraineurs, which can explain some of the underuse of preventive medications. While many PCPs endorse inquiring about headache-related disability, many do not used validated scales such as the Migraine Disability Assessment Score (MIDAS) or the Headache Impact Test (HIT) [17]. In addition, patients often underreport their headache days and report only their severe exacerbations unless clearly asked about a daily headache [22]. This may be part of the reason why only 20% of migraineurs who meet criteria for chronic migraine are diagnosed as such and why preventatives may not be offered [23].
After preventatives are started, less than 25% of patients will be adherent to oral migraine preventive agents at 1 year [24]. Common reasons for discontinuing preventives include adverse effects and perceived inefficacy [22]. Preventive medications may need a 6- to 8-week trial before efficacy is determined, but in practice medications may be stopped before this threshold is reached. Inadequate follow-up and lack of detail with regard to medication trials may result in the perception of an intractable patient prematurely. It has been suggested that a systematic approach to documenting and choosing preventive agents is helpful in the treatment of migraine [25], although this is not always practical in the primary care setting.
Another contributor to underuse of effective prophylaxis is related to access. Treatment with onabotulinumtoxin A, an efficacious prophylactic treatment approved for select chronic migraine patients [26], will usually require referral to a headache specialist, which is not always available to PCPs in a timely manner [7].
Nonpharmacologic Approaches
Effective nonpharmacologic treatment modalities for migraine, such as cognitive-behavioral therapy and biofeedback [27], are not commonly recommended by PCPs [17]. Instead, there appears to be more focus on avoidance of triggers and referral to non–evidence-based resources, such as special diets and massage therapy [17]. While these methods are not always inappropriate, it should be noted that they often have little or no evidence for efficacy.
Patients often wish for non-medication approaches to migraine management, but for those with significant and severe disability, these are probably insufficient. In these patients, non-medication approaches may best be used as a supplement to pharmacological treatment, with education on pharmacologic prevention given. Neuromodulation is a promising, novel approach that is emerging as a new treatment for migraine, but likely will require referral to a headache specialist.
Suboptimal Management of Migraine Comorbidities
There are several disorders that are commonly comorbid with migraine. Among the most common are anxiety, depression, medication (and caffeine) overuse, obesity, and sleep disorders [22]. A survey of PCPs reveals that only 50.6% of PCPs screen for anxiety, 60.2% for depression, and 73.5% for sleep disorders [17]. They are, for the most part, modifiable or treatable conditions and their proper management may help ease migraine disability.
In addition, the presence of these comorbidities may alter choice of treatment, for example, favoring the use of an serotonin and norepinephrine reuptake inhibitor such as venlafaxine for treatment in those with comorbid anxiety and depression. It is also worthwhile to have a high index of suspicion for obstructive sleep apnea in patients with headache, particularly in the obese and in those who endorse nonrestorative sleep or excessive daytime somnolence. It appears that patients who are adherent to the treatment of sleep apnea are more likely to report improvement in their headache [28].