Quantifying headache symptoms and other headache features from chart notes

OBJECTIVES: To describe a method for quantifying headache symptoms/features in family practice charts for patients diagnosed with headache NOS (not otherwise specified, ICD-9: 784) and to determine the share of NOS headache diagnoses with clinical data strongly suggestive of migraine or probable migraine headache. BACKGROUND: Headache is one of the most common pain symptoms that brings patients to a family physician. However, the majority of headache sufferers do not receive a specific headache diagnosis when they visit physicians. METHODS: We examined the chart notes of 454 patients exclusively diagnosed with one or more ICD-9 coded headache NOS diagnoses from July 1, 1995 through December 31, 1999 at a large suburban, university-affiliated practice. We developed a template containing 20 headache items combining International Headache Society diagnostic criteria and additional headache symptoms/features, and decision rules for coding symptoms/features and collected data from patient charts. We then developed decision rules and reclassified NOS headaches into categories strongly suggestive of migraine, probable migraine headache, or other diagnosis. Our main outcome measure is the consistency in the application of decision rules and diagnostic criteria. RESULTS: With this method we estimate 3 in 10 (29%) headache NOS patients may have had migraine (8%) or probable migraine headache (21%). Reclassified migraine visits averaged 6.5 migraine symptoms and reclassified probable migraine headache visits 4.7 migraine symptoms. Logistic regression analysis supports the consistency of diagnostic criteria for classifying headache based on coded symptoms/features--our model correctly predicted 96% of visits. Evidence of physical examination was recorded at 75% of visits suggesting that physician attention is focused on elimination of secondary headache. CONCLUSIONS: We think the use of our rigorous procedures reveals that a substantial amount of migraine and probable migraine headache may be missed in everyday practice. We hope our findings will provide a basis for the development of diagnostic methods more closely suited to the needs of nonspecialists, and contribute to a better standard of care for headache patients seen in primary care practice. Finally, we are hopeful that other researchers will consider using our template and guideline procedures in their efforts to identify diagnostic patterns and study headache and other health problems.     

A rational approach to migraine diagnosis and management in primary care

Migraine is a chronic neurologic disease estimated to affect approximately 50 million Americans. It is associated with a range of symptoms, which contribute to disability and substantial negative impacts on quality of life for many patients. Still, migraine continues to be underdiagnosed, undertreated, and optimising treatment for individual patients has proven difficult. As many migraine patients will be seen first in primary care settings, internists and other primary care providers are ideally positioned to improve diagnosis and migraine management for many patients. In this review, we discuss some of the challenges in diagnosing migraine and suggest strategies to overcome them, summarise the current understanding of migraine pathophysiology and clinical evidence on acute and preventive treatment options, and offer practical approaches to diagnosis and contemporary management of migraine in the primary care setting.

Key messages

• Migraine is a prevalent disease with substantial impact. Primary care providers are ideally positioned to improve care for migraine patients with streamlined approaches to diagnosis and management.
• A stepwise diagnostic approach to migraine involves taking a thorough headache history, excluding secondary headache, and identifying primary headache disorder using screening tools or ICHD-3 criteria.
• The FDA approved seven new migraine therapies from 2018 to 2020 (four monoclonal antibodies, two gepants, one ditan), expanding acute and preventive therapeutic options.

     

Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study

CONTEXT: Headache experts have suggested that to improve the recognition of migraine, patients with a stable pattern of episodic, disabling headache and a normal physical exam should be considered to have migraine in the absence of contradictory evidence. The premise upon which this approach is based-that is, that episodic, recurrent primary headache in the clinic is usually migraine-has not been evaluated in prospective clinical studies. OBJECTIVES: To (1) evaluate the diagnoses of patients consulting their physician with primary episodic headache and (2) compare clinic diagnoses and patient self-diagnoses with International Headache Society (IHS) headache diagnoses assigned on the basis of longitudinal data from patient diaries. DESIGN: Prospective, open-label study. During the screening visit, patients self-reported a headache diagnosis and then were assigned a headache diagnosis by their physician following his or her customary practice. Patients with a new physician diagnosis of migraine or nonmigraine primary headache were given diaries to record headache symptoms for up to 3 months or 6 attacks. Members of an expert panel, unaware of the clinic diagnosis, used diary data to assign a headache diagnosis to each attack and to each patient. SETTING: One hundred twenty-eight (128) practices in 15 countries including the United States. PATIENTS: A total of 1203 male and female patients between 18 and 65 years of age who consulted their physician with headache as a primary or secondary complaint. RESULTS: Overall, 94% of patients with a physician diagnosis of nonmigraine primary headache or a new clinic diagnosis of migraine had IHS-defined migraine (76%) or probable migraine (migrainous) (18%) headache on the basis of longitudinal diary data. A new clinic diagnosis of migraine was almost always correct: 98% of patients with a clinic diagnosis of migraine had IHS-defined migraine (87% of patients) or probable migraine (11% of patients) headache on the basis of longitudinal diary data. On the other hand, review of diaries of patients with a clinic diagnosis of nonmigraine revealed that 82% of these patients had IHS-defined migraine (48%) or probable migraine (34%) headache. Altogether, one in four patients (25%) with IHS-defined migraine according to longitudinal diary data did not receive a clinic diagnosis of migraine. CONCLUSIONS: These findings support the diagnostic approach of considering episodic, disabling primary headaches with an otherwise normal physical exam to be migraine in the absence of contradictory evidence. If in doubt of diagnosis or when assigning a nonmigraine diagnosis, strong consideration should be given to the use of a diary to confirm primary headache diagnosis.     

Migraine care among different ethnicities: do disparities exist?

OBJECTIVE: Evaluate whether, in a primary care setting, Caucasians (C) and African Americans (AA) with moderately to severely disabling migraines differed in regards to: utilizing the health-care system for migraine care, migraine diagnosis and treatment, level of mistrust in the health-care system, perceived communication with their physician, and perceived migraine triggers. BACKGROUND: Research has documented ethnic disparities in pain management. However, almost no research has been published concerning potential disparities in utilization, diagnosis, and/or treatment of migraine. It is also important to consider whether ethnic differences exist for trust and communication between patients and physicians, as these are essential when diagnosing and treating migraine. METHODS: Adult patients with headache (n = 313) were recruited from primary care waiting rooms. Of these, 131 (AA = 77; C = 54) had migraine, moderate to severe headache-related disability, and provided socioeconomic status (SES) data. Participants completed measures of migraine disability (MIDAS), migraine health-care utilization, diagnosis and treatment history, mistrust of the medical community, patient-physician communication (PPC), and migraine triggers. Analysis of covariance (controlling for SES and recruitment site), chi-square, and Pearson product moment correlations were conducted. RESULTS: African Americans were less likely to utilize the health-care setting for migraine treatment (AA = 46% vs. C = 72%, P < .001), to have been given a headache diagnosis (AA = 47% vs. C = 70%, P < .001), and to have been prescribed acute migraine medication (AA = 14% vs. C = 37%, P < .001). Migraine diagnosis was low for both groups, and <15% of all participants had been prescribed a migraine-specific medication or a migraine preventive medication despite suffering moderate to severe levels of migraine disability. African Americans had less trust in the medical community (P < .001, eta2 = 0.26) and less positive PPC (P < .001, eta2 = 0.11). Also, the lower the trust and communication, the less likely they were to have ever seen (or currently be seeing) a doctor for migraine care or to have been prescribed medication. CONCLUSIONS: Migraine utilization, diagnosis, and treatment were low for both groups. However, this was especially true for African Americans, who also reported lower levels of trust and communication with doctors relative to Caucasians. The findings highlight the need for improved physician and patient education about migraine diagnosis and treatment, the importance of cultural variation in pain presentation, and the importance of communication when diagnosing and treating migraine.     

Sinusitis in children and adolescents with chronic or recurrent headache: a case–control study

The aim of this study was to determine the frequency of misdiagnosis of sinus headache in migraine and other primary headache types in the children and adolescents with chronic or recurrent headaches. Children with chronic or recurrent headaches (n = 310) were prospectively evaluated. Data collection for each patient included history of previously diagnosed sinusitis due to headache, and additional sinusitis complaints (such as fever, cough, nasal discharge, postnasal discharge) at the time of sinusitis diagnosis, and improvement of the headache following treatment of sinusitis. If sinus radiographs existed they were recorded. The study included 214 patients with complete data. One hundred and sixteen (54.2%) patients have been diagnosed as sinusitis previously and 25% of them had at least one additional complaint, while 75% of them had none. Sinusitis treatment had no effect on the headaches in 60.3% of the patients. Sinus graphy had been performed in 52.8%, and 50.4% of them were normal. The prevalence of sinus headache concomitant with primary headache, and only sinus headache was detected in 7 and 1%, respectively, in our study. Approximately 40% of the patients with migraine and 60% of the patients with tension-type headache had been misdiagnosed as “sinus headache”. Children with chronic or recurrent headaches are frequently misdiagnosed as sinus headache and receive unnecessary sinusitis treatment and sinus graphy.     

Providing Care for Patients with Chronic Migraine: Diagnosis,Treatment, and Management

Chronic migraine, a subtype of migraine defined as ≥ 15 headache days per month for ≥ 3 months, in which ≥ 8 days per month meet criteria for migraine with or without aura or respond to migraine‐specific treatment, is a disabling, underdiagnosed, and undertreated disorder associated with significant disability, poor health‐related quality of life, and high economic burden. The keys to caring for chronic migraine patients include: (1) making a proper diagnosis; (2) identifying and eliminating exacerbating factors; (3) assessing for medication overuse (patients with chronic headache often overuse acute medications); and (4) continued management. Communication between patient and physician about treatment goals is important. The patient management guidelines presented in this article should help physicians improve treatment success and proactively address common comorbidities among their patients with chronic migraine.     

A headache diagnosis project

BACKGROUND: Despite the availability of objective criteria, the diagnosis of migraine is thought to be missed frequently in primary practice. OBJECTIVE: To determine the most important questions assisting in the clinical diagnosis of migraine headache. METHODS: A cohort of 461 patients referred to headache specialists in Canada was assessed using a pro-forma questionnaire that was completed by the patients alone or administered by the physicians themselves. A final clinical diagnosis was recorded after a complete clinical evaluation. In a subsequent validation study, three questions derived from the results of the first phase of the study were administered to a new cohort of 128 patients, and diagnoses of "migraine" or "not migraine" were recorded according to the decision generated in the first part of the study. The final clinical diagnosis was taken as the "gold standard" for diagnosis, and the results from the two independently derived diagnostic methods were compared. RESULTS: Statistical analysis of the responses from part 1 of the study yielded three questions (related to daily occurrence, unilaterally, and functional impairment) that distinguished between pure migraine and other headache diagnoses with high reliability and validity. The sensitivity and selectivity of the three-question protocol exceeded 91%. CONCLUSIONS: The use of three questions related to headache frequency, laterality, and impact on functioning may represent an attractive screening instrument in primary care practice, alerting physicians to the diagnosis of migraine in patients or to the possibility of a second or alternative headache diagnosis in patients in whom their diagnosis of migraine previously has been made. The presence of multiple headache syndromes in individual patients, as is common in tertiary referral practice, may reduce the discriminating power of the three-question protocol.     

Diagnostic issues in migraine

Headache poses diagnostic challenges to the clinician for many reasons. It is an extremely common complaint, and may be associated with acute illness or serious pathology such as brain tumor or cerebral aneurysm. However, the majority of patients experiencing recurrent headache in the population suffer either from a variant of tension-type headache or migraine. Because migraine is more likely to be disabling, it becomes the most likely diagnosis for any patient presenting with recurrent headache interfering with function. Although the diagnostic criteria developed by the International Headache Society in 1998 are useful as a guide, migraine may be more readily recognized in a clinical setting by its consideration at the top of the differential for patients presenting with recurrent headache. This article reviews the standard diagnostic criteria for migraine, while also addressing the primary and secondary headache syndromes that may be considered in a differential diagnosis. The indications and roles for specific investigative procedures such as neuroimaging are reviewed. Specific emphasis is placed on the clinical recognition of migraine in the context of an assortment of headache conditions.     

Clinical Characteristics of Migraine and Episodic Tension-Type Headache in Relation to Old and New Diagnostic Criteria

Eighty-one patients were diagnosed as having migraine, tension headache or both according to previously used criteria. Then we performed a standardized interview to determine the frequency and severity of headache characteristics used in the new operational diagnostic criteria of the International Headache Society (IHS). In every patient the original diagnosis fulfilled also the IHS criteria, but in 9 patients the criteria were only fulfilled in half or less of the attacks, and applying the IHS criteria they also achieved an additional diagnosis. In one patient these attacks did not fulfill the pain criteria and in 8 (4 migraine, 4 tension headache) they did not fulfill the criteria for accompanying symptoms. Overall the IHS criteria are sensitive and specific, but they may possibly be improved with regard to accompanying symptoms. The present study suggests that recording of frequency and graded severity of characteristics using a headache diary may further improve the distinction between the different types of headache.     

Predicting the number of headache visits by type of patient seen in family practice

OBJECTIVES: To examine the number of visits involving a headache diagnosis among patients to four family practice sites between July 1, 1995 and December 31, 1998. BACKGROUND: Although the majority of care-seeking headache sufferers are seen in the primary care setting, few studies have attempted to document the relationship between type of headache as diagnosed by the family practice physician, and number of the patient's headache visits. Design.-Secondary analysis of administrative claims data. METHODS: We compared headache visits per person-year by the age and sex of patient among patients classified according to headache diagnosis received: tension-type only; headache not otherwise specified (NOS) only; migraine only; tension-type and headache NOS; tension-type and migraine; headache NOS and migraine, and migraine, tension-type, and headache NOS. Patients with an International Classification of Diseases (version 9) code of 346 were considered to have a diagnosis of migraine, with 307.81 representing tension-type headache, and 784 representing headache NOS. Age was measured from date of birth to initial visit in the study period and patients were subdivided into 5-year age groups. Person-years "at risk" for each diagnosis was measured from the time of initial visit during the study period to December 31, 1998. RESULTS: We examined data from 4112 patients who made 9322 visits with a headache diagnosis. We found that the average number of visits per person-year increases as the number of different types of headache diagnoses increased and were greatest for patients having migraine as opposed to headache NOS and tension-type diagnoses. CONCLUSIONS: Headache type is an important predictor of the number of office visits involving a headache diagnosis in family practice. Patients with multiple headache diagnoses have more visits. Patients with combinations of headache diagnoses involving migraine are the most frequent visitors.     

Simple and efficient recognition of migraine with 3-question headache screen

OBJECTIVE: To correlate the results of a new 3-question headache screen to 3 established methods of diagnosing migraine: the International Headache Society diagnostic criteria, physician's clinical impression, and presence of recurring disabling headaches. BACKGROUND: A simple tool to recognize patients who experience migraine may facilitate diagnosis of this debilitating and frequently undiagnosed condition. METHODS: Primary care physicians and neurologists in the United States enrolled 3014 adults with a diagnosis of migraine based on one of the following: International Headache Society criteria, an investigator's clinical impression, or presence of recurring disabling headaches. Each patient completed a 3-question headache screen: (1) Do you have recurrent headaches that interfere with work, family, or social functions? (2) Do your headaches last at least 4 hours? (3) Have you had new or different headaches in the past 6 months? A diagnosis of migraine was suggested by a yes answer to questions 1 and 2 and a no answer to question 3. RESULTS: The 3-question headache screen identified migraine in 77% of the study population; including 78% of the patients enrolled based on International Headache Society criteria, 74% based on clinical impression, and 68% because of recurring disabling headaches. CONCLUSIONS: Positive 3-question headache screen results agreed well with migraine diagnoses based on International Headache Society criteria, clinical impressions, and presence of recurring disabling headaches. These findings support use of the 3-question headache screen to recognize migraine.     

Headache as a warning symptom of impending aneurysmal subarachnoid haemorrhage

About half of the aneurysm patients admitted to neurosurgical departments experience warning symptoms in the form of minor bleeding episodes days or even several months before a major haemorrhage occurs. Headache is the most common symptom of this warning leak, occurring in 9 out of 10 patients. The onset of headache is sudden and is unusual in severity and location, being unlike any headache the patient has otherwise experienced. It is frequently accompanied by transient nausea, vomiting, visual disturbances or meningism. Medical advice may be sought by the patient but all too often the diagnostic importance of a warning headache is missed. It is misinterpreted as attacks of migraine, tension headache, the 'flu, sinusitis, or a "sprained neck". A more vigilant attention to the presence of a warning headache probably offers the greatest opportunity for altering the otherwise serious natural history of aneurysmal subarachnoid haemorrhage. If a warning headache is suspected, lumbar puncture is the examination of choice, once CT scanning has ruled out an intracranial mass lesion.     

Prevalence of migraine in patients with systemic lupus erythematosus

OBJECTIVE: To determine the prevalence of migraine in patients with systemic lupus erythematosus (SLE), and to examine the relationships between headache type and other clinical, serologic, and treatment features of the disease. BACKGROUND: Headaches are common in SLE and are a significant source of patient disability. The exact prevalence of headaches in patients with SLE is unknown. The classification of headache syndromes in SLE is also unclear. Previous studies were based on small numbers of patients and the headache types and criteria to define headache types varied widely. METHODS: Four hundred fourteen patients meeting American College of Rheumatology criteria for the diagnosis of SLE were sent the University of California, San Diego Migraine Questionnaire. Patients who completed the questionnaire had their medical records reviewed for constitutional, respiratory, cardiac, vascular, skin, musculoskeletal, other neuropsychiatric, hematologic, renal, and immunologic manifestations of the disease. Recent corticosteroid, nonsteroidal anti-inflammatory drug, antimalarial, and immunosuppressive medications were also recorded. RESULTS: One hundred eighty-six patients completed the questionnaire. Sixty-two percent of patients reported headaches: 39% met diagnostic criteria for migraine and 23% met criteria for nonmigrainous headache. Of the patients with migraine, 56% met criteria for migraine without aura and 44% met criteria for migraine with aura. There were no significant associations between headache type and other clinical, serologic, or treatment features of the disease. CONCLUSIONS: There is a high prevalence of migraine in patients with SLE, and patients should be routinely evaluated for migraine symptoms.     

The prevalence and impact of migraine on US Military officer trainees

Objective.— To determine the prevalence and impact of migraine in US Army officer trainees. Background.— The prevalence of migraine in military officer trainees, frequency of diagnosis, pharmacologic management, and the impact of migraine on military training has not been previously determined. We sought to elucidate the above and also to identify trainee characteristics associated with impaired training performance because of the disabling effects of migraine. Methods.— An anonymous voluntary migraine questionnaire was administered to 1389 consecutive US Army Reserve Officer Training Corps cadets upon completion of 5 weeks of military training. Headaches were classified as definite migraine or possible migraine. Migraine frequency, prior diagnosis, number of missed or suboptimal training days attributable to migraine, patterns of analgesic use, and trainee characteristics associated with impaired training performance were identified. Results.— In total, 741 of 1389 (54%) officer trainees completed the migraine questionnaire, including 582 males and 159 females. The prevalence of definite migraine was 18% in all cadets including 14% in males and 31% in females. Migraines had been previously diagnosed in only 10% of trainees meeting criteria for definite or possible migraine. During training, male trainees experienced a mean of 0.70 migraines/month compared with female trainees at 1.4 migraines/month. Only 3% of trainees meeting criteria for definite or possible migriane had ever been prescribed triptans. Eight percent of cadets experienced impaired training performance because of migraine resulting in 63 days of suboptimal or missed training. Characteristics associated with impaired training performance included a prior diagnosis of migraine, screening positive for definite migraine vs possible migraine, and a higher baseline frequency of migraine. Conclusions.— Migraine is common yet underdiagnosed and undertreated in US Army officer trainees and adversely impacts military training. We identified characteristics which place military trainees at risk for impaired training performance. We predict that improved diagnosis and treatment of migraine would result in improved training performance.     

Psychological Aspects of Weekend Headache Sufferers in Comparison with Migraine Patients

Sometimes the relaxation after stress may trigger a migraine attack. This is the principle that underlies that particular variant of migraine called "weekend headache". We hypothesize the presence in weekend headache prone subjects of a particular psychological background, different from that of common migraine sufferers. In order to detect possible differences supporting our hypothesis, we studied 104 new outpatients: 46 patients suffering from headache only on weekends (23 males and 23 females) and 58 matched common migraineurs (26 males and 32 females) with no weekend predilection. The psychological assessment was performed using the following psychometric tools: MMPI, BDI, STAIX1-X2. A clinical assessment of each patient was also carried out. Significant differences were found after statistically analyzing the test results. Most of the MMPI scales were found to be more elevated in both male and female weekend headache sufferers. From a clinical point of view, the weekend headache attacks proved to be similar to those of common migraine, but with a significantly higher incidence of concomitant symptoms. Our study confirms the important role that psychological factors play in the pathogenesis and clinical development of migraine and leads us to conclude that a psychic tension component is associated with the vascular one in weekend headache.     

Use of Health Care Services in Childhood Migraine

The use of health care services in childhood migraine was studied in a representative population sample of 53 children with migraine. These children elong to a 1-year age cohort that has been followed since birth. Migraine was diagnosed at the age of 8 to 9 years according to the International Headache Society criteria of migraine in 95 of 3580 children (2.7%). At the time of the present study, 84 of the 95 children were clinically examined at the age of 11 to 13 years. Fifty-three of them (62.4%) still had migraine and 32 did not. Of these 53 children, 31 (51.8%) had consulted a doctor because of headache. The most important factors linked to the consultation rate were aura symptoms and maximal frequency of attacks. The children who had consulted a doctor more often had nausea and more often came from densely populated areas. They had missed school days more often because of headache than those who had not consulted a doctor.     

Variability of reported headache symptoms and diagnosis of migraine at 12 months

Assignment of a diagnosis of migraine has been formalized in diagnostic criteria proposed by the International Headache Society. The objective of the present study is to determine the reproductibility of the formal diagnosis of migraine in a cohort of headache sufferers over a one-year period. The study was performed in a community cohort taking part in a long-term prospective health survey, the GAZEL study. Two thousand five hundred individuals reporting headache in the GAZEL cohort were sent two postal questionnaires concerning headache symptoms and features at 12-monthly intervals. Replies to the questions allowed a migraine diagnosis to be attributed retrospectively using an algorithm based on the IHS classification scheme. The response rate was 82% for the first questionnaire and 69% for both questionnaires. Of the 1733 subjects providing information at both time-points, the agreement rate for the diagnosis of strict migraine (IHS categories 1.1 or 1.2) was 77.7% (kappa = 0.48), with 62.2% of the patients with this diagnosis (IHS categories 1.1 or 1.2) at Month 0 retaining the same diagnosis at Month 12. When diagnostic criteria were widened to include IHS category 1.7 (migrainous disorder), the agreement rate of the diagnosis was similar at 77.6% (kappa = 0.52), but 82% of the patients with this diagnosis (IHS categories 1.1 or 1.2 or 1.7) at Month 0 now retained the same diagnosis at Month 12. In conclusion, the one-year reproducibility of reporting of migraine headache symptoms is only moderate, varies between symptoms, and leads to instability in the formal assignment of a migraine headache diagnosis and to diagnostic drift between headache types. This finding is compatible with the continuum model of headache, where headache attacks can vary along a severity continuum from episodic tension-type headaches to full-blown migraine attacks.