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Promising New Tool for Better Migraine Management in Primary Care

A new tool can help streamline diagnosis and treatment of migraine in the primary care setting, new research suggests.

Early results from a small pilot study showed that the tool, essentially a medical record “best-practice alert,” reduces specialist referrals and MRI studies.

Dr Scott Friedenberg

The idea behind the tool is to give primary care physicians “fingertip access” to prompts on patients’ electronic health record (EHR), leading to best migraine management and treatment, co-investigator, Scott M. Friedenberg, MD, vice chair of clinical practice, Geisinger Medical Center, Danville, Pennsylvania, told Medscape Medical News.

When clinicians enter a headache diagnosis into a patient’s EHR, a pop-up asks a handful of questions and “prompts them with the right medications so if they just click a button, they can order the medications straight away,” Friedenberg said.

The findings were presented at the American Headache Society (AHS) Annual Meeting 2022.

Fewer Referrals, MRI Testing

Researchers reviewed charts for 693 general neurology referrals. About 20% of the patients were referred for headache. In about 80% of these cases, the final diagnosis was migraine and/or chronic daily headache.

The physicians had documented criteria for identifying migraine, such as sensitivity to light, nausea, and missed social activity or work, in fewer than 1% of cases. There’s roughly an 80% chance that if a headache meets two of these three criteria, it is a migraine, Friedenberg noted.

About 60% of the participants with headache were referred with no treatment trial. About 20% were referred after having tried two medicines, and 30% were referred after trying one medicine.

“In many cases, we’re being asked to evaluate people with primary headache or uncomplicated headache that has not been treated,” said Friedenberg.

The investigators developed the tool, and its most recent iteration was tested by 10 physicians at two sites for 3 months. These doctors did not receive education on headache, they were just taught how to use the tool.

Results showed that referrals for neurology consults dropped 77% and MRI ordering dropped 35% after use of the tool. This translated into a savings of $192,000.

However, using the tool didn’t significantly affect prescribing habits of the physicians.

Migraine Frequently Undertreated

“When you drill it down, the only thing that changed were medications they were comfortable with, so they increased steroids and nonsteroidal prescribing, but preventives didn’t change, narcotics didn’t change, and CGRP [calcitonin gene-related peptide] inhibitors didn’t change,” Friedenberg said.

Although believing patients are “not bad enough to treat” might help explain why clinicians did not change prescribing habits, the reality is that many patients have migraine and should be treated, he added.

Friedenberg pointed out that previous research suggests that 60% or more of patients with a primary headache or migraine are undertreated.

The tool should increase awareness about, and comfort level with, diagnosing and treating migraine among primary care doctors, he noted. “We hope it will make it easier for them to do the right thing and have neurology as a readily available partner,” said Friedenberg.

“Primary care doctors are incredibly busy and incredibly pressured, and anything you can do to help facilitate that is a positive,” he added.

The researchers now plan to train pharmacists to co-manage headache along with primary care doctors, as is done, for example, for patients with diabetes. This should result in a reduction in physician burden, said Friedenberg.

The next step is to conduct a larger study at the 38 sites in the Geisinger health complex. Half the sites will use the new tool, and the other half will continue to use their current headache management process.

“The study will compare everything from MRI ordering to neurology referrals and prescribing, how often patients go to the emergency department, how often they have a clinic visit, whether the provider is satisfied with the tool, and if the patient’s headaches are getting better,” Friedenberg said.

Lessons for Clinical Practice

Jessica Ailani, MD, director at MedStar Georgetown Headache Center and associate professor in the Department of Neurology at Georgetown University, co-chaired the session in which the research was presented and called the project “really fantastic.”

The study offers “many lessons” for clinical practice and showed that the tool was effective in improving diagnosis of migraine, said Ailani, who is also secretary of the AHS.

“There’s a long wait time to see specialists, and most migraine can be diagnosed and basic management can be done by primary care physicians,” she told Medscape Medical News.

“The next step would be to work on a way to improve prescriptions of migraine-specific treatments,” she added.

Ailani noted that the AHS would be keen to find ways to engage in “collaborative work” with the investigators.

The investigators and Ailani reported no relevant financial relationships.

American Headache Society (AHS) Annual Meeting 2022: Scientific Session 1, OR-5. Presented June 10, 2022.

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