Primary Care Physicians Could Be First Line of Defense in Migraine Care

Migraine can be safely diagnosed in the primary care setting and advanced medications are available.

There is a shortage of neurologists nationwide, and primary care physicians can help fill the gap in migraine care, a headache expert says.

Migraine is one of the most common disabling medical conditions, according to the American Migraine Foundation. In the United States, 1 in 4 households has a family member who suffers from migraine, and migraine affects 1 out of 7 people globally, the foundation says.

Recent advancements in migraine care and research make treating migraine in the primary care setting easier, says Loretta Mueller, OD, a headache specialist and family physician at Cooper University Health Care, which is based in Camden, New Jersey. "There has been a boom of new therapies in recent years and a lot more research going on. It is a good time to be treating headache and researching headache. The newer medications that are out generally are tolerated better than the older medications, and many of them work much quicker than the older medications."

Primary care physicians have several medication options for migraine that have become available over the past four years, she says. "The newer ones that have come out since 2018 include injected monoclonal antibodies that target the calcitonin gene-related peptide, which is migraine specific. We also have new oral medications called gepants that also target the calcitonin gene-related peptide. Two of the oral treatments are for as-needed use once a headache starts—rimegepant, which is Nurtec ODT, and ubrogepant, which is Ubrelvy. We also have a new medication that is only for headache prevention—atogepant, which is Qulipta. Nurtec ODT can also be used for prevention, when taken every other day."

Detecting migraine in the primary care setting

Diagnosing migraine is appropriate for the primary care setting, Mueller says. "It is not a procedural field, so every primary care physician who has an interest in headache should be able to treat migraine. It is just a matter of having the time to sit down and provide the care as well as having the education about what to look for. The reality is that most of what you are going to see in a primary care practice is migraine. So, if primary care physicians were taught to start with the diagnosis of migraine and work backwards from there, we would have a lot more patients who could be easily treated for migraine."

To diagnose migraine, primary care physicians should review the patient's medical history and schedule a visit to focus on the patient's headaches, she says.

"The medical history is key as well as dedicating an office visit specifically for headaches rather than just having a by-the-way complaint when a patient is in the office for high blood pressure or another condition. The primary care physician should focus only on headache during a visit. I see nothing but headache patients on a hospital's neurology floor, and it takes me an hour with a new patient, but we do have migraine identifiers such as ID Migraine, which is only three questions: Have you not been able to function at least one day out of the past three months because of your headaches? Do you ever get nauseous with your headaches? Do you ever get light sensitivity with your headache? If two out of those three are positive, there is about a 93% chance that the condition is migraine. If all three are positive, there is a 98% chance that the condition is migraine."

Primary care physicians can use tools to rule out more serious causes of headache  such as SNOOP, Mueller says.

• 'S' is for systemic symptoms such as cancer.
   
• 'N' is for neurologic abnormalities.
   
• The first 'O' is onset of rapid escalation of pain within seconds or the so-called thunderclap headache that can be a marker for aneurysm or brain bleed.
   
• The second 'O' is for onset of new headache over the age of 50.
   
• 'P' is for prior headache history, where a change in headache history such as increased severity or frequency could be signs of a serious condition.

Treating migraine in the primary care setting

The treatment of migraine requires a holistic approach to care, Mueller says. "It comes down to a clinical judgment call. There is no single algorithm as is the case for other conditions such as a diagnosis of Lyme disease calling for a specific antibiotic. There is some art in the treatment of migraine because many of these patients have other comorbidities such as depression and anxiety. You look at the whole picture."

Migraine treatment can be complicated, she says. "There are many treatment options. For example, how many medications do you go through or how many classes of medications do you go through with the patient in shared decision-making. A lot of migraine care requires shared decision-making. Some patients definitely have a preference as to what they are looking for or side effects that they do not want. Some migraine medications have weight gain associated with them."