#4 Are You Afraid of Patients with Migraines?

March 30, 2016 | By Matthew Watto, MD

An approach to diagnosis and management of chronic migraine headache.

If headache patients strike fear in your heart, then this is the show for you. In this episode The Curbsiders interview Internist and Headache Specialist Dr. Glen D. Solomon to deconstruct the topics of migraine and chronic tension type headaches. Dr. Solomon is currently a Professor and Chair of the Department of Internal Medicine at Wright State University and a former director of the Headache Medicine Fellowship at the Cleveland Clinic.

Take Home Points:

1. Take a simple approach to the diagnosis of chronic headache syndromes.
   1. If patient is “sick” with their headache, then call it a migraine.
   2. If patient is not nauseous or debilitated with their headache, then call it chronic tension type headache.
   3. One in 1,000 will have cluster headaches. Other causes are even more rare than that
2. Rationale for preventive therapy: there are a number of drug classes to choose from and they more or less all cause 50% reduction in headache frequency for about two-thirds of patients. Therefore, tailor your therapy based on side effects and comorbid conditions.
3. Pitfalls:
   1. Stop thinking you need a Specialist. Primary Care Physicians can and should handle most headache cases.
   2. Don’t talk too much. Let the patient talk and DON’T interrupt them.
   3. Failure to start prophylaxis. Don’t be afraid. Know the side effects for each drug class and give patients at least a one month trial at therapeutic doses before calling treatment a failure.

Links

Read by QxMD – an app for keeping up with the literature

Cephalgia – An International Headache Journal

Headache – The Journal of Head and Face Pain

Buettner, C et al. Simvastatin and Vitamin D for migraine prevention. Ann Neurol. 2015 Dec;78(6):970-81. doi: 10.1002/ana.24534. Epub 2015 Nov 13.

Some other articles that we found helpful…

Most recent review we could find on migraine prophylaxis

Preventive Migraine Treatment. Continuum (Minneap Minn). 2015 Aug;21(4 Headache):973-89. doi: 10.1212/CON.0000000000000199.

Migraine treatment guidelines from American Academy of Neurology

Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1337-45. doi: 10.1212/WNL.0b013e3182535d20.