In this article, we interviewed Richard B. Lipton, MD, MPH, Professor and Vice Chair of Neurology at the Albert Einstein College of Medicine, Director of the Montefiore Headache Center, NY, and co-researcher of the American Migraine Communication Study (AMCS), to determine what migraine patients can do to make their visits with healthcare professionals (HCPs) as productive as possible.
Q. At your headache clinic, how do you and your staff prepare for an initial visit with new migraine patients?
A. We send the patient a letter describing the practice, telling them what to expect and how to prepare for their first visit. We also send a questionnaire that asks about headache characteristics including attack frequency and how headache affects his/her life. We also ask about other illnesses and prior treatments for headache.
Q. Why is it important for patients to come prepared with a list of prior treatments—both over-the-counter and prescription?
A. Knowing what people took in the past—what worked, what did not work, and what caused side effects—is very helpful. It makes it easier for the patient to communicate and for the HCP to understand the patient’s experience, treatment wishes, and expectations. Often, patients can do this more accurately at home, with access to their medicine cabinet and pharmacist, than they can in my office.
Q. What can patients learn about migraine before going to see the HCP?
A. It is useful if patients are familiar with the symptoms that are commonly associated with migraine, like sensitivity to light and sound, so that they can highlight what symptoms they typically experience. Also, knowing about migraine treatment options, including behavioral, pain relieving and daily, preventive treatment, sets the stage for making treatment choices. Patients are sometimes surprised that there are medications that, when taken daily, can help to reduce the amount of migraines they get. It is helpful if they have given some thought to what types of treatments they might be open to, such as taking preventive therapy every day, to potentially reduce the number of migraines they get.
Q. So how can patients best prepare for their initial migraine discussion?
A. Patients should think about why they are going to the HCP now. When I see a patient who has had migraines for five years but has never been to an HCP before, I always want to know “why now?” Are they getting worse? Are the migraines beginning to have consequences at work or home? Is a family member or friend pushing them to seek medical care? The “why now” issue is very important because it needs to be addressed during the conversation and, ultimately, the treatment plan. It is also helpful if patients can describe how often and how long their migraines last. They should also plan to describe how severe the pain is, and the symptoms that come along with their migraines.
Q. What is the most important piece of information that patients should convey to their HCP about their migraines?
A. The single most important thing that patients can be prepared to discuss, in their own terms, is how migraine impacts their daily lives. Studies have shown that HCPs use information about migraine-related impairment to assess the severity of illness, the urgency of treatment and the need to get treatment right from the time of the initial visit. Unfortunately, although many HCPs respond to information about migraine-related disability once they have it, they typically do not ask the questions that will provide this information.
Q. How can a patient best communicate the impact of their migraines?
A. AMCS and other studies have shown that HCPs respond to conversations about the impact of migraine on patients’ lives, and respond less well to complaints of pain intensity. So, patients should communicate how migraine affects the things they do; for example, “I get so nauseated I can’t be around food, and I work in a restaurant,” or “I can’t stand loud noises and I missed going to a concert with my friends.” Explaining the emotional issues and whether they are thinking about migraines even when they are not having one is also important, such as “I’m concerned because I have a new baby at home. I have to have a backup plan in case I get a migraine and I need help caring for my baby. Migraines are in the back of my mind even on the days when I don’t have a migraine.”
Q. What about when discussing how often migraines occur—any tips for how patients can best discuss this with their HCP?
A. Patients should think about the difference between migraine days and migraine attacks because it is currently a huge area of miscommunication. HCPs often don’t make that distinction clearly, so it is very helpful if patients can do so. The HCP might say, “Well, how many migraines do you have per month?” This question is not clear. If a patient has three attacks, each of which lasts two days, the patient should say, “I have three migraine attacks, but each one lasts two days, so my life is impacted six days every month from migraine attacks.” Three one-day migraines are very different than three three-day migraines so it is important to be clear.
Q. What should patients expect after an initial migraine visit?
A. They should expect to leave with a diagnosis, or with a plan for firming up a diagnosis if the diagnosis is uncertain. They should also expect that the HCP will have an understanding of how migraine impacts their daily lives. They should have a clear treatment plan and understand when and how to take medications appropriately. Finally, they should know when their next follow-up visit will be scheduled.
Q. What do you encourage patients to do between visits?
A. All patients should leave an initial visit with a migraine diary, which contains places to record migraine experience, associated symptoms, medication, and potential triggers. The diary is easy to use and read, since it fits one month of information on a single page. The intent of the diary is to provide a foundation for the in-office discussion.
Q. Can you discuss the difference between a visit with a patient who is prepared and someone who is not?
A. The biggest difference is that, if the patient completes a diary, we do not need to spend time on migraine frequency and duration—those are well summarized. Instead, time can be spent discussing the patient’s concerns. I can focus on patient education, give advice on behavioral strategies, and discuss how to use medication more effectively. When a patient is not prepared, much of the visit is spent on collecting information, rather than education and management.
Q. How can diaries be of use in follow-up visits when discussing medication efficacy?
A. The diary is particularly important for discussions of medication efficacy, including pain relievers, triptans, and medications that are taken every day to help stop migraines before they start. For example, a patient might be having 15 or 20 migraines a month, and after initiating prevention, their attack frequency may fall to five attacks per month. The diary is very valuable, both as a record of how the patient is doing, and as an effective way of showing patients how much progress they have made.