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Mistakes in Migraine Care

iHeadache Electronic Headache Diary

More than any other page in the migraine section, this page represents Dr. Loftus’ personal views of why the medical community’s ability to identify and successfully treat migraine patients has fallen so short.

Mistake #1: Migraine Headaches are misdiagnosed

Despite over 10 years of intensive educational efforts and hundreds of millions of dollars, roughly only 50% of patients with migraine headaches are aware of their illness. Educational efforts target mostly primary care physicians but they do not have the time needed to take an adequate headache history in a follow up visit. Add to this the patient who pre-announces their diagnosis and it is no wonder that many patients carry their misdiagnosis of tension or sinus headaches year after year.

Mistake #2: Not treating all of your headaches as migraines.

Once a patient knows they have migraines headaches, treatment is again not optimal. Most patients are either not told or do not understand that if they have any migraines, then all of their headaches (whether severe or more mild) represent a form of their migraine disease and will respond to their typical migraine medication. Instead, patients continue to treat their "tension" headaches with over the counter (OTC) medications, their "sinus" headaches with OTC sinus medications and antibiotics and only use their migraine specific headache treatment for their worst headaches. This also leads to improper communication with their physicians when their doctor asks - "How often are your migraines?" and the patient answers once weekly and ignores the chronic low-level daily headaches.

Mistake #3: Not using optimal care

Many patients with migraines are not given migraine specific therapy. There is either a fear to use these medications despite their excellent safety record or a fear of lawsuits. Some regional headache experts have said they will not give a triptans to anyone over a certain age, commonly 55 or 65, only for fear of lawsuit. Statistically a heart attack occurs more commonly as one gets older and there is an increased chance of coincidentally taking a triptan and having a heart attack. Heart attacks, in most patients, represent something called plaque rupture, which is not related to triptan use but presumably causes the death of seemingly healthy athletes. Triptans are contraindicated for patients with angina (i.e. inadequate blood flow to the heart during exercise) and should not be used.

Mistake #4: Underuse of migraine prevention

Another frequent mistake in treating migraines is in the underuse of preventative therapy. There are estimates that about 50% of patients with migraine headaches should be on preventative therapy but only 5% are. Patients have come to Dr. Loftus on a preventative medication for over a year which they felt was ineffective but their physician did not discontinue or change it. Worse many of these patients have had side effects from these preventatives that were not working. Patients and physicians both must take some responsibility for this. Only 50% of my patients whom he asks to keep a headache calendar actually do so. Many non-neurologists and even some neurologists are only comfortable with one or two treatments. It is ok for a physician to refer a patient on if they are not comfortable but for a patient to continue inadequate therapy without a referral to a new physician is not good medicine.

Mistake #5: Looking for the cause of migraines and over testing, rather than focusing on treatment

Migraine patients are subjected to too many tests. Some physicians commonly perform evoked potentials, EEG, and thermography on their patients. Many headache physicians will obtain MRI or CT imaging on patients with infrequent migraine despite guidelines to the contrary. MRA is commonly being performed. There are times when imaging is warranted such as with Chronic Daily Headache but from discussions with some physicians, it appears the risk of lawsuit is the primary driving force behind over testing.