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MIGRAINE HEADACHE: SETTING EXPECTATIONS FOR PREVENTION AND IMPROVED COMMUNICATION

The severity and frequency of a patient’s migraine syndrome should dictate the need for introducing a prophylactic or stabilizing agent. Once this need is recognized, the prophylactic regimen should be tailored to fit the needs of that particular individual. The selection process should take into account the patient’s comorbidities, gender, lifestyle, and personal preferences. Women of reproductive age, for example, should be aware of the potential teratogenic effects of anticonvulsants as well as their interaction with oral contraceptives. In addition, patients desire to actively participate in the decision-making process when selecting and prescribing a prophylactic agent.¹ The clinician must discuss the nature of migraine headache, the purpose and mechanism of action of the selected prophylactic agent, and its potential adverse effects.¹

The primary outcome standard for the design of clinical trials of prophylactic agents for migraine, as set by the International Headache Society (IHS), is a minimum 50% reduction in the frequency of headache attacks when compared to the baseline.² This standard should also be applied in clinical practice when judging the effectiveness of a prophylactic agent. Monitoring headache frequency with a diary or calendar, as discussed below in greater detail, is an important part of gauging the effectiveness of a prophylactic regimen for migraine.

Both the physician and the patient should keep in mind that most prophylactic agents do not produce an immediate clinical effect. With most of these drugs, a lag of 4-6 weeks before realizing the full therapeutic effect is common. This fact must be clearly explained to the patient. Furthermore, a full therapeutic dose may not be possible to achieve at the time of initiation of the medication; for example, topiramate requires a titration phase of several weeks. Many prophylactic agent “failures” are the result of using subtherapeutic doses for suboptimal periods of time or the physician setting unrealistic expectations for the patient.

THE HEADACHE DIARY

In clinical practice, patients may be unable to recall the characteristics and frequency of individual headache attacks. They may exhibit a bias toward the most recent or more severe headache attacks. Furthermore, clinical features may change during the course of an attack and from one attack to another. The use of a headache diary or calendar makes it possible to record the features of each attack and to increase the accuracy of an objective description of and the reported frequency of the attacks, thus avoiding recall bias.³ Two types of headache diaries, both discussed in greater detail below, are available for clinical use: the diagnostic headache diary and the headache calendar.

In patients who are taking prophylactic agents, a diary helps the clinician gauge the effectiveness of the therapeutic regimen. Another benefit demonstrated in clinical trials is an increased level of satisfaction and a perception of improved communication with the physician in patients who use a headache diary.⁴ Complicated report forms with detailed descriptions may be difficult for patients to complete during a migraine attack and are best avoided.² The basic elements to be included in any headache diary or calendar are the frequency, intensity, and clinical features of the attacks. Additional data may include concomitant symptoms, triggers, and responsiveness to acute therapy.

The diagnostic headache diary

This tool is used on a daily basis for a minimum of 30 days until a clear picture of the patient’s headache diagnoses and patterns of drug use can be obtained.³ Specialized headache centers often mail a diagnostic diary to their patients, along with appropriate instructions for its completion, at least 4 weeks before the first office appointment.⁵ The intent of this type of record-keeping instrument is not to make a diagnosis in the absence of a complete history and examination. Rather, through proper validation, these instruments have become reliable tools to assist the clinician in the formulation of a working headache diagnosis. One of these diaries was adapted to an electronic format to be used for educational purposes or as a diagnostic tool for general practitioners.⁶

The headache calendar

Once the diagnostic diary has been correctly completed for a sufficient period of time and the first medical consultation is completed, the patient may be able to switch to the second type of headache diary, the headache calendar.³ At this point, patients should have been educated about the features of their headaches and should be able to enter these data into their calendars. These instruments are typically more abbreviated and easier to complete than the diagnostic diaries. Patients are instructed to have their calendars readily available and to bring them to their follow-up office visits.

A printable version of a headache calendar has been made available online by the American Headache Society via the American Council for Headache Education (ACHE) program at the following address: http://www.achenet.org/resources/diary.php.

CONCLUSION

Using tools to objectively record a patient’s migraine headache history can assist both the physician and the patient in making informed and effective decisions about the initiation and continuation of successful prophylactic migraine therapy. Once the need for a prophylactic agent is recognized, the severity and frequency of the syndrome can dictate a customized approach to prophylaxis based on patient-specific factors.

REFERENCES

1. Rozen TD. Migraine prevention: what patients want from medication and their physicians (a headache specialty clinic perspective). Headache. 2006;46:750-3.

2. Tfelt-Hansen P, Block G, Dahlof C, et al, for the International Headache Society Clinical Trials Subcommittee. Guidelines for controlled trials of drugs in migraine: second edition. Cephalalgia. 2000;20:765-86.

3. Nappi G, Jensen R, Nappi RE, et al. Diaries and calendars for migraine: A review. Cephalalgia. 2006;26:905-16.

4. Baos V, Ester F, Castellanos A, et al, for the I-Max Study group. Use of a structured migraine diary improves patient and physician communication about migraine and treatment outcomes. Int J Clin Pract. 2005;59:281-6.

5. Jensen R, Bendtsen L. Principles and tools: questionnaires, structured interviews, diaries and calendars. In: Olesen J, ed. Classification and diagnosis of headache disorders. Oxford: Oxford University Press 2005: 1159-67.

6. Nielsen KD, Rasmussen C, Russell MB. The diagnostic headache diary—a headache expert system. Stud Health Technol Inform. 2000;78:149-60.