Despite a promising increase in the number of patients who receive preventive medications for migraine, a wide gap remains to effectively meet patient needs and reduce the burden of migraine.
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GUEST EDITOR IN CHIEF
Susan W. Broner, MD, is a headache specialist and is board certified in both neurology and headache medicine. She is the medical director of the Weill Cornell Medicine Headache Program where she is involved in both clinical care, teaching, and research. She has a special interest in underserved populations and in migraine in women. She has published numerous articles on headache in peer-reviewed journals, has spoken at national and international conferences and received the American Academy of Neurology Palatucci Advocacy Leadership Award. She has been involved with the World Health Organization headache initiative, Lifting the Burden, and founded the American Headache Society Underserved Populations in Headache Medicine special interest group. She has been an ad hoc reviewer for the journal Headache, has contributed to numerous headache educational initiatives via lectures, podcasts, and webinars and has provided expert opinion for several lay press and television groups. Additionally, she has been named as one of the New York SuperDoctors, having been nominated annually by peers from 2014 to 2023.
MIGRAINE IS THE SECOND-MOST disabling condition globally in years lived with disability, and first in women younger than 50 years of age.1 The cost of migraine in the US is considerable. Available data suggest migraine costs to be $22 billion annually, of which at least half is related to loss of productivity and missed work.2 Although 18% of women and 6% of men experience migraine, it often goes underdiagnosed and undertreated—the 2004 American Migraine Prevalence and Prevention study found that almost 39% of patients with a diagnosis of migraine met the study guidelines for benefitting from prophylactic medication, but only 13% indicated that they were taking a migraine preventive medication.3 By 2018, a study looking at close to 20,000 people meeting criteria for migraine revealed that while 40% were eligible for migraine prevention, only 16.8% were using a preventative and only 22% were using a triptan acutely.4 Though it is heartening to see slight improvement in the numbers of people receiving prevention, there remains a large gap in meeting patient needs and reducing the burden of migraine.
How do we improve this gap? In the macrocosm, critical elements include increasing government funding of headache research; expanding headache medicine education in medical school, residency, and beyond; and improving our understanding and addressing the disparities of care in different populations. On the individual level, though, as we try to reach patients through our medical lens, we can find our patients unable to be adherent to medication regimens or lifestyle recommendations, ultimately leading to frustration on the part of the physician and the patient. Therefore, improving communication skills might be key in achieving more accurate diagnoses, effective treatment plans, better patient adherence, and, ultimately, better outcomes.
Data on communication styles confirm that there appears to be a mismatch between what physicians and patients experience in encounters. This can lead to misdiagnoses, nonadherence, and unsatisfactory outcomes. In the American Migraine Communication Study (AMCS), more than 90% of physicians who interviewed patients with migraine used closed-ended or short-answer questions and did not focus on impairment. With this approach, more than 50% of physician–patient dyads were misaligned regarding the understanding of frequency and impairment. As an outcome, 80% of those patients in need of a preventive did not receive one, and half the visits did not discuss prevention.5 In a prospective study looking at neurologists interviewing patients with chronic migraine, most conversations did not include questions about monthly headache days and disability, and open-ended questions were rare. A diagnosis was discussed in less than 10% of the dialogues and less than 40% discussed a treatment plan.6
Although patient diaries and questionnaires, such the Headache Impact Test and the Migraine Disability Assessment Questionnaire, are useful to help gather data on frequency and disability, other tools exist that focus on enhancing dialogue to improve patient outcomes. These include ask-tell-ask structured conversations with open-ended questions, directly identifying patients’ goals, developing specific, measureable, achieveable, realistic, and time-bound (SMART) goals, and following up on these goals in subsequent appointments.
Ask-tell-ask is a method used in many disciplines of medicine to improve patient–physician communication. It has been shown to be effective in enhancing understanding between the provider and the patient, and in headache medicine specifically, it can be used to ask about frequency and disability—including migraine days, total number of headache days per month, and the effect on the patient’s life. The model involves asking open-ended questions, summarizing the answers from the patient, and then asking the patient to confirm or disavow your understanding. This feedback loop can lead to a concordance in the information.
In addition to being effective for information gathering, open-ended questions have been shown to be efficient, despite the concern that they will take more time. In the AMCS I and II studies, ask-tell-ask with open-ended questions led to a reduction in visit time from 11 minutes to 9.5 minutes.7 Open-ended follow up questions that I find particularly helpful include, “How often are you completely free of headache symptoms?” and, “How do your headaches impact your life?” These are quick check-ins on disability and interictal burden, which can be significant. With a better understanding of frequency and disability, we can diagnose and present treatment options, but we must also understand our patient’s goals, which may not be the same as ours.
SMART goals have been shown to be effective for helping people make changes in many areas of life, including health. SMART goals allow you and the patient to develop specific, measurable, achievable, and time-bound goals that can lead to better outcomes. It can be used to focus on lifestyle factors and can also be used to lay out a treatment plan based on the patient’s most important goals, along with a timeframe in which to revisit the goals. This allows for participatory planning between the provider and the patient, motivating the patient to improve adherence to the plan. Repeating this process in subsequent visits, and adjusting treatments, accordingly, can lead to outcomes that are satisfying to both the patient and the provider.
There has been an expansion of our understanding of migraine and other headache disorders. With new treatment options and updated guidelines, we have the chance to make meaningful changes in our patients’ lives and reduce the significant burden of migraine. Although improvements in headache education for students, residents, and practicing physicians continue—and while we address the disparities in headache medicine—we also need to focus on the way we communicate with our patients, moving past a top-down approach. Communication skills at their essence are the delivery system that can lead to actual implementation for individual change, with patient outcomes being the final measure as to whether we succeed as practitioners.
REFERENCES 1. Steiner TJ, Stovner LJ, Jensen R, Uluduz D, Katsarava Z, Lifting The Burden: the Global Campaign against Headache. Migraine remains second among the world’s causes of disability, and first among young women: findings from GBD2019. J Headache Pain. 2020;21(1):137-146. doi:10.1186/s10194-020-01208-0 2. Hazard E, Munakata MS, Bigal ME, Rupnow MFT, Lipton RB. Burden of migraine in the United States: current and emerging perspectives on disease management and economic analysis. Value Health. 2009;12(1):55-64. doi:10.1111/j.1524-4733.2008.00404.x 3. Lipton RB, Bigal ME, Diamond M, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68(5):343-349. doi:10.1212/01.wnl.0000252808.97649.21 4. Lipton RB, Nicholson RA, Reed ML, et al. Diagnosis, consultation, treatment, and impact of migraine in the US: results of the OVERCOME (US) study. Headache. 2022;62(2):122-140. doi:10.1111/head.14259 5. Lipton RB, Hahn SR, Cady RK, et al. In-office discussions of migraine: results from the American Migraine Communication Study. J Gen Intern Med. 2008;23(8):1145-1151. doi:10.1007/s11606-008-0591-3 6. Buse DC, Gillard P, Arctander K, Kuang AW, Lipton RB. Assessing physician-patient dialogues about chronic migraine during routine office visits. Headache. 2018;58(7):993-1006. doi:10.1111/head.13314 7. Buse DC, Rupnow MF, Lipton RB. Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clin Proc. 2009;84(5):422-435. doi: 10.1016/S0025-6196(11)60561-2.
