Migraine Headache, Evidence-Based Guidelines, and the AAFP
Am Fam Physician. 2002 Dec 1;66(11):2050.
The article by Aukerman and colleagues1 in this issue of American Family Physician is a well-written summary of the evidence supporting the diagnosis and treatment of acute migraine headache. Readers may be unaware of the important role played by the American Academy of Family Physicians (AAFP) in developing the evidence-based recommendations discussed in this article.
In the early and mid-1990s, the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality) created evidence-based practice guidelines for clinicians. Many physicians may be familiar with (and may still have on their bookshelves) a series of AHCPR guideline booklets for the treatment of urinary incontinence, back pain, otitis media, and other conditions. These booklets summarized the most rigorous evaluation of the medical literature on common clinical conditions.
In the waning years of guideline production, I was asked to serve as AAFP representative and co-chair of a newly established panel to develop evidence-based practice guidelines for the diagnosis and treatment of acute migraine headache. Matchar and colleagues2 performed an impressive series of meta-analyses of the existing literature on the diagnosis of acute migraine headache (principally, the role of neuroimaging in establishing a diagnosis) and the pharmacologic and nonpharmacologic treatment of migraine (the acute attack and preventive therapy). Just as the guideline panel was about to release its initial report, the AHCPR abruptly changed direction, and only the meta-analyses in their raw form were released for publication.
Because this work was not in a usable format for clinicians, key representatives from the American Academy of Neurology (AAN) contacted the AAFP, the American College of Physicians (now the American College of Physicians–American Society of Internal Medicine [ACP–ASIM]), the American College of Emergency Physicians (ACEP), and others to complete the work of Matchar and colleagues.2
Tom Gilbert, M.D., and I represented the AAFP during a series of meetings over more than a year to hammer out readable summaries of Matchar's data2 and reach conclusions that physicians could use in their practices. The AAFP's extensive background in evaluating evidence-based medicine came in very handy during these meetings. Two key factors had to be dealt with as the group attempted to summarize the evidence: the biased interpretation of existing evidence and an overall lack of solid evidence regarding key practices in the clinical approach to management of the migraine headache. The receptiveness of all key representatives and their collective dedication to “sticking to the evidence” resulted in a unique collaboration (the U.S. Headache Consortium) that produced the series of migraine documents that can be found on the AAFP Web site ( www.aafp.org/clinical/migraine).
However, even our efforts to clarify the information were not enough. Aukerman and colleagues1 have performed another valuable service in putting the information contained in these reports into an even more readable format that is far more likely to be used by family physicians. More work must be done if this information is to be put into practice. To this end, the AAFP has furthered its collaboration with the ACP–ASIM and the AAN in developing useful tools and information to be used in primary care practices.
As Aukerman1 and others note, migraine headache is a widely prevalent condition that can cause enormous disability. The clinical approach to diagnosis and treatment is often frustrating for patients and physicians. The lack of real evidence to support much of our treatment of this condition is appalling. Nevertheless, the collaboration of the AAFP with other interested organizations to develop a solid research base (particularly in the primary care setting) that can translate its findings to clinical practice is a model that will serve our patients well in the future.
Eric M. Wall, M.D., M.P.H., is medical director and vice president of Medical Affairs at LifeWise Health Plan of Oregon, Portland, Ore.
Address correspondence to Eric M. Wall, M.D., M.P.H., LifeWise, 2020 SW 4th Ave., Suite 1000, Portland, OR 97201. Reprints are not available from the author.
1. Aukerman G, Knutson D, Miser WF. Management of the acute migraine headache. Am Fam Physician. 2002;66:2123–30,2140–1.
2. Matchar DB, McCrory DC, Gray RN. Toward evidence-based management of migraine. JAMA. 2000;284:2640–1.
Copyright © 2002 by the American Academy of Family Physicians.
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