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

Adherence issues also exist for migraine prevention. Less than 25% of chronic migraine patients continue to take oral preventive therapies at 1 year [24]. The reasons for this nonadherence are not completely clear, but are likely multifactorial. Preventives may take several weeks to months to become effective, which may contribute to noncompliance. In addition, migraineurs appears to have inadequate follow-up for migraine. Studies from France suggest that only 18% of those aware of their migraine diagnosis received medical follow-up [39].

Medication Overuse

While the data is not entirely clear, it is likely that overuse of as-needed medication plays a role in migraine chronification [40]. The reasons for medication overuse in the migraine population include some of the issues already highlighted above, including inadequate patient education, poor insight into diagnosis, not seeking care, misdiagnosis, and treatment nonadherence. Patients should be educated on the proper use of as-needed medication. Limits to medication use should be set during the physician-patient encounter. Patients should be counselled to limit their as-needed medication to no more than 10 days per month to reduce the risk of medication overuse headache. Ideally, opiates and barbiturates should be avoided, and never used as first-line therapy in patients who lack contraindications to NSAIDs and triptans. If their use in unavoidable for other reasons, they should be used sparingly, as use on as few as 5 to 8 days per month can be problematic [41]. Furthermore it is important to note that if patients are using several different acute analgesics, the combined total use of all as-needed pain medications needs to be less than 10 days per month to reduce the potential for medication overuse headache.

Socioeconomic Factors

Low socioeconomic status has been associated with an increased prevalence for all headache forms and an increased migraine attack frequency [42], but there appear to be few studies looking at the impact of low socioeconomic status and treatment. Lipton et al found that health insurance status was an important predictor of persons with migraine consulting a health care professional [43]. Among consulters, women were far more likely to be diagnosed than men, suggesting that gender bias in diagnosis may be an important barrier for men. Higher household income appeared to be a predictor for receiving a correct diagnosis of migraine. These researchers also found economic barriers related to use of appropriate prescription medications [43]. Differences in diagnosis and treatment may indicate racial and ethnic disparities in access and quality of care for minority patients [44].

Stigma

At least 1 study has reported that migraine patients experience stigma. In Young et al’s study of 123 episodic migraine patients, 123 chronic migraine patients, and 62 epilepsy patients, adjusted stigma was similar for chronic migraine and epilepsy, which were greater than for episodic migraine [45]. Stigma correlated most strongly with inability to work. Migraine patients reported equally high stigma scores across age, income, and education. The stigma of migraine may pose a barrier to seeking consultation and treatment. Further, the perception that migraine is “just a headache” may lead to stigmatizing attitudes on the part of friends, family, and coworkers of patients with migraine.