Family Physicians can Help Their Migraine Patients Find Relief

In the general population, 93 percent of men and 99 percent of women experience headaches. With all of those aching heads, family physicians are perfectly suited to diagnose, treat, and prevent headaches in their patient population.

In Wednesday morning's "Migraine, Tension, and Cluster Headache: Primary Care for Primary Headaches" session, Duren Ready, MD, and Jeffrey Unger, MD, FAAFP, covered the diagnosis and treatment options for primary headaches— those that are not a symptom of another underlying condition—that can be performed in a family physician's office without referring the patient to a neurologist.

Duren Ready, MD

Duren Ready, MD

Jeffrey Unger, MD, FAAFP

Jeffrey Unger, MD, FAAFP

"Neurology training teaches you: Where's the lesion? Where's the lesion in migraine? There isn't one. It's a global hypersensitivity. Neurologists are not (often trained) to know how to work with someone with depression, anxiety, or insomnia, and unless they (experience) migraines, they're just not that interested," said Ready, who is program director, Central Texas Headache Fellowship and senior staff physician, Headache Clinic, Baylor Scott & White Health, Temple, Texas. "We can take better care of them. You will be amazed. You don't have to do it full time like I am, but you can effectively take care of these patients. They don't want to go see someone else. They want to be with you."

The vast majority of people who come to the clinic with a headache are suffering from migraines, although many self-diagnose with "sinus headaches" or "allergy headaches." But migraineurs are born with a genetically predisposed sensitive neurological system that can be triggered by stress, hormone changes, skipping meals, specific foods, sleep disruptions, medication overuse, weather, or minor head trauma.

"These patients are disabled. It really impacts other work. So what we need to do as clinicians is to teach patients to live within that sensitivity, to bring up the amount of safety to protect against migraines, and to allow migraineurs to function normally as best as we can," said Unger, who is director, Unger Primary Care Concierge Medical Group, Rancho Cucamonga, Calif., and Director of Metabolic Studies, Catalina Research Institute.

Once the migraine is diagnosed, which can be done without imaging in patients who experience nausea, photophobia, auras, or other disability during their headaches, the clinician can work with the patient on preventative measures. Unger stressed educating patients on behavioral modifications, including not skipping meals, exercising, getting proper sleep, avoiding triggers, stopping smoking, not taking analgesics more than twice a week, limiting coffee to two cups a day, and having a written plan.

"The single biggest predictor for success in any human endeavor is commitment. Having that written plan enforces a responsibility," Ready said, noting that the written plan also assists the physician in determining where the weaknesses in the plan exist.

Ready and Unger also highlighted a variety of preventative treatment options, including the range of triptans, herbal preventatives, and Botox injections.

They also outlined several migraine rescue strategies, including Olanzapine 10mg PO, Quetiapine 100mg PO, and IV Magnesium Sulfate, as well as occipital nerve block and sphenopalatine ganglion block using a SphenoCath. Both can be done in the office by a family physician.

"These work really well, and you can do them and get paid for them as well," Unger said.