Addressing the Crisis of Diagnosis and Management of Migraine in Primary Care: A Summary of the American Headache Society Front Line Primary Care Advisory Board

Introduction

Migraine affects over 36 million people in the United States, often from adolescence throughout adulthood, and is the second leading cause of disability worldwide. ¹ Over half (52.8%) of all visits for migraine take place in primary care settings. ² However, many primary care providers (PCPs) receive little formal education about headache medicine, and there is substantial under-diagnosis and under-treatment of migraine in this setting. Only 28% of PCPs were familiar with the American Academy of Neurology guidelines for migraine prevention and only 40% were familiar with the American Board of Internal Medicine Foundation Choosing Wisely Campaign recommendations to limit opioids and imaging for migraine. ³ Only 34% were aware that opioids are associated with worsening of headache. Close to 40% of adults with migraine need preventive therapy, but only 13% actually receive it. ⁴ This deficiency is compounded by an average delay of four years between migraine diagnosis and the start of preventive medication. ⁵ Given the relative scarcity of neurologists (with a projected shortfall of 18% by 2025) ⁶ as well as headache specialists nationally, ⁷ it is challenging to meet the urgent specialty care needs of the headache population. Thus front line providers need to be equipped to begin to address the demands.

The AHS Board of Directors and Education Committee established the improvement of migraine care in Front Line-Primary Care clinical settings as an organizational priority. As a first step, AHS commissioned the creation of an advisory board to guide the development of strategies to help close management gaps for patients. On November 21, 2019, an advisory board consisting of health professionals representing various front line fields of headache medicine was convened at the annual Scottsdale Headache Symposium of the American Headache Society. Advisory board members were recruited through outreach to organizations or their representatives including the American Association of Nurse Practitioners, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Academy of Family Practice. Certain geographic areas were also targeted to identify family medicine and internal medicine residency programs in regions without a headache center. The advisory board consisted of physicians and advance practice providers representing internal medicine, family medicine, obstetrics and gynecology, adult neurology, pediatric neurology, and headache medicine.

The overall goal of the advisory board was to learn how to more effectively meet the needs of clinicians in internal medicine, family medicine, advanced practice, and obstetrics and gynecology in their efforts to help patients with headache. Objectives included (1) assessing ways to reach educators (e.g., residency directors, those who work on continuing medical education), (2) assessing the content that should be included in the creation of new headache educational programs, and (3) gaining a better understanding of what ongoing support and tools would be beneficial to bringing headache education to the front lines. The following summarizes the discussion and suggestions from this meeting.

The Problem from the Perspective of Primary Care

Discussion centered on the lack of routine inclusion for headache medicine as a topic on specialty medical examinations and coverage in medical school or residency curricula. It is important to collaborate with other societies in order to clearly convey the need for better headache medicine education. Such discussions might take place with various national organizations affecting resident education in the above-mentioned areas. A priority may be engaging chief residents who often operationalize curriculum development. Thus, efforts might also need to be made to target them from the ground up.

Strategies and Suggestions

Strategies and suggestions from the advisory board can be found in Table 1. They include: 1. key partners and strategies, 2. content of headache education materials, 3. important tools and resources for headache education on the front lines, and 4. considerations for implementing migraine screening tools on the front lines. There are concrete steps that can be enacted now and questions for consideration (Table 2).

Table 1:

Strategies and Suggestions from the American Headache Society Front-Lines Primary Care Advisory Board

Key partners and strategies	Working with residency directors to incorporate headache medicine into the curriculum is an important long-term strategy to increase the number of front line providers who feel comfortable treating headache. This approach will not, however, address immediate needs for better headache education. Partnering with other health society (physician and advanced practice provider) organizations in family medicine, internal medicine, and obstetrics and gynecology was deemed a priority by promoting headache education nationally and at regional/chapter meetings. Participants emphasized the need to carefully consider who the speakers would be at specific programs i.e. some organizations might want a headache specialist and others might want a primary care provider to give the talk. Given the constraint on resources, one practical option might be to encourage headache fellows and attendings across the country to serve as advocates and disseminators of headache knowledge at these smaller meetings. Importantly, participants emphasized that we need to change “the dread” around treating headache. The fact that PCPs report a sense of “dread” is significant. The lack of the proper tools to manage migraine likely makes them feel helpless when faced with migraine patients, but it is also notable that the lack of early proper treatment may in fact be making the disease state more difficult to treat thus perpetuating that feeling of “dread”. It was concerning to hear these feelings shared by PCPs as these feelings are part of the migraine stigma that patients with migraine disease face regularly. It is clear that there is a need to empower clinicians with the tools they need to treat patients appropriately, and it is possible that in doing so, we will not only improve patient health, but may also in fact, help to change the stigma surrounding migraine as we ease that sense of dread that physicians feel in regards to these patients. We need to educate clinicians that because most people have episodic migraine, PCPs could really treat these patients and serve a public health role by reducing progression to chronic migraine. Participants also emphasized that education programs directed at primary care specialties may need to be tailored to address more specific pediatric, OB/GYN, and geriatric related considerations.
Content of Headache Education Materials	Meeting participants identified two priority categories for headache educational materials: The undiagnosed patient: How do you triage? Do you need to send the patient to the emergency department right away? If not emergent, do you need urgent or non-urgent imaging? How do you decide between computerized tomography versus magnetic resonance imaging? What, if any, additional work-up is needed? What evidence is there to help me make decisions about work up? How can this evidence be conveyed to the patient? The diagnosed patient: How do I rapidly initiate a management plan? Do treatment algorithms exist? Furthermore, educational tools should include important pearls: Education about triptans: drug choice, how to use, misperceptions about hazards, what really is a triptan failure Education about headache myths (e.g. Is it okay to use triptans if patients experience migraine aura?) How to counsel patients about preventive medications including how to up titrate them and the cost of such treatments.
Important tools and resources for headache education on the front lines	The creation or gathering of educational tools so that there is a one-stop shop to find necessary resources is essential. Tools will likely need to be multimodal to accommodate different ways of learning. Examples might include podcasts, on-line programs, point of care applications (apps), pathways for non-headache specialists similar to the American Society for Colposcopy and Cervical Pathology 8, articles for the society magazines with group specific resources e.g. AFP, AAN Neurobytes of hot topics (~5 minutes), and an ongoing e-newsletter about headache updates. There are existing guidelines and tools that can be used to decrease the need to build the program without a foundation of existing materials.
Considerations for implementing migraine screening tools on the front lines	In the case of migraine, PCPs could screen for migraine on an annual intake form. Through this method, PCPs could also inquire about migraine disability using a validated migraine disability screen. Larger centers with electronic health records (EHR) could use these screens within the EHR. However, given the limited resources for PCPs, the issue of where to integrate this into the workflow is still a concern. Even if screening is feasible, actions to take for a positive screen have limitations. An important analogy exists; it is hard for PCPs to ask about mental health (e.g. PHQ2 or instruments querying for suicidality) because the PCPs do not typically have resources to act on a positive screen. Similarly, if they do not have access to a neurologist/headache specialist and do not know how to treat patients with headache, it is unlikely the PCPs will inquire about headache. PCPs need simple actionable tools such as algorithms that can be effectively disseminated through their respective national organizations.

Table 2:

Concrete Immediate Steps to Improve Educational Resources for Front-Lines Primary Care Providers and Questions for Consideration

Concrete Immediate Steps: Create a box of pearls on how to take triptans: as soon as possible, may repeat the dose x hours later, may pair it with an NSAID, side effects, may cycle through and try different triptans-failure of one triptan does not mean that you don’t try others and always check to see if patient took it right away. Create additional resources and work on dissemination efforts of resources that inform people how to find a headache specialist (American Migraine Foundation site) and behavioral therapists Have more procedure course slots available at AHS meetings

Questions for Consideration: How can PCPs easily access headache educational tools in one place? How to develop a hierarchy or algorithm for managing episodic and chronic migraine as well as status migrainosus, and how to indicate which are most cost effective/ highlight treatments in special populations? Can we work with other societies to bring the Headache 101 course to their meetings? In addition to having more procedure workshops at AHS meetings, bring the headache procedures workshop to other procedural meetings of other societies. For example, ACP has a meeting yearly on procedures. Should we offer a headache presentation there accompanied by procedure training? How can we utilize online simulation classrooms including advanced video viewing online so the procedures can be taught more efficiently and in depth?

Finally, but importantly, PCPs recommended an AHS recognition campaign. PCPS stated that if other societies knew about the AHS that they might presume it targets only neurologist/headache specialists. A campaign with wide outreach to PCPs could raise awareness that the AHS also serves front line providers and wants to actively include this in Society activities. The AHS Primary Front Line of Headache Care Special Interest Group (SIG) has been committed to enhancing the educational, patient care and research activities of the AHS in the field of Primary Care. There may also be further opportunities to expand the Primary Front Line SIG’s activities in raising awareness of the AHS.

Conclusion:

We are excited for this new collaboration with front line providers from various disciplines across the country. We believe this collaboration will help to combat this huge public health burden. Moreover, the cross talk will be beneficial for headache specialists to better understand primary care issues applicable to headache medicine.