Using diagnostic tools to assess migraine
Jessica Ailani, MD: These are all excellent points. Another way to use tools to help us make diagnoses is the headache diary and sometimes other types of forms that patients can fill out to help us understand their disability. I wanted to ask you both—and maybe, Julio, you can tell us first—how often do your patients use headache diaries? And how often do you use patient-reported outcome measures in your clinic, such as MIDAS? [migraine disability assessment] scale or the HIT-6 [Headache Impact Test], have them complete these things? Or are there other tools that help you not only understand the impact of the disease, make the diagnosis, but also follow the patient over time to see how they are doing?
Julio R. Vieira, MD: Yes. A review article a few years ago showed that they had analyzed 30 different tools. I didn’t even know we had so many tools. And every time the going gets tough, it also becomes more difficult for us to include these tools in our day-to-day clinical life, and especially among our peers that we’re also trying to educate – the general neurologists and primary care who are not used to using these different tools. Going back to what we were talking about before, I continue to believe that the ID-Migraine questionnaire is one of the best tools that can be distributed there, which shows disability, nausea and photophobia. Or sometimes people use the “PIN” mnemonic. PIN stands for “photophobia” “inability to function” “ad nauseam”. And it is an easy to use tool.
Going back to the headache diary, I recommend every time. It’s always useful. The only sometimes difficult time to recommend is for patients who have either daily headaches or constant headaches, which becomes very annoying. And after a while, they’re like, “No, forget it. I get headaches every day. Why would I even do that?” And then we try to flip the table and generate the log in a rewarding way. And we tell patients to log the good days and they say “Yay. I have a good day today” instead of logging every day, which gets boring. When studies were done on the diary, patients thought they knew how many headaches they had without documenting and having an actual diary. But study after study shows that once you start recording, it’s a whole different story. And most of the time they have more headaches than they thought. Going back to the other tools you mentioned, like the MIDAS or the HIT-6, headache specialists are still trying to use those tools, which we use to measure disability. But I don’t think it’s very common among general neurologists and other providers.
Jessica Ailani, MD:I agree with your assessment of headache logs. They can be very helpful, especially at first, but very difficult in someone who has daily or continuous headaches. I often find that they can be very demoralizing for these patients. We often use them when changing treatments or making adjustments just to make sure the patient is responding to the treatment, or when using a frequently used acute medication just to see how things are going. But I also agree with the “Look, you have headache-free days, just write them down” reward process. Also, patient-reported outcome tools can be very difficult. When a patient is severely disabled, on the same point, same episodic migraine, many patients in a headache clinic are on the high disability side. It is very difficult to measure the changes in the case of a high handicap; there is no change if your MIDAS levels are already heavily impacted, and you have improved, but you are still heavily impacted. It is very difficult to say that there is a big improvement, even if the patient can tell you that he is much better and that he is functional. Sometimes you find other creative ways to measure improvement: changes in ER visits, return to work, number of hours worked, missed social activities. And there are other creative ways to assess your patient’s condition if you’re trying to keep it consistent in the same patient.
What about you, Brad? Do you find headache diaries helpful? Any tips to offer our audience on ways to measure a patient’s condition over time?
Bradley Torphy, MD: I agree with your approach, Jessica, that the best use of headache diaries is at the beginning of the therapeutic relationship, and specifically where I find it most useful is when we have this discussion about possible triggers. And I will give the example of when I describe tyramine. No, I’m not necessarily advocating that patients cut out all things tyramine. But I say, when you’re keeping this journal, if you’re looking closely at tyramine-rich foods, consider these suspects. And if you see them popping up often in your journal, then you know it might be a good idea to delete that. But I agree. As time passes and the therapeutic relationship continues, and we have been working together for a while, that usefulness diminishes a little. In our practice, we use HIT-6 testing with every patient at every visit, and what we’ve found in our practice is that it has provided us with strong data. If we have decided that we are interested in a certain topic, for example telemedicine, we have been able to review HIT-6 scores with our telemedicine patients, and this can give us rich information.
Jessica Ailani, MD: If you want to do research in your center, I agree with Brad. Part of what Julio was saying is that by keeping those calendars, it becomes really important. It’s very hard to do even retrospective data when you rely on methods like mine, ie, How do you feel?
Julio R. Vieira, MD: And it helps to relativize the symptoms to record certain triggers such as periods for example. And also, to put into perspective what the patient expects from their treatment and their relationship with you, because often if patients don’t keep a diary, they come and say, I still have headaches. But then you say, let’s keep a diary. The next visit, they come, they keep a diary, and they’re better, but they still have that expectation. We have to tell the difference between having tons of headaches or having headaches or migraines or not having any. One of the things I try to tell my patients is that I think I can make you better. I don’t know exactly how much but there must be a relationship 1 day at a time. I’ll take it from there.
Jessica Ailani, MD: Setting expectations, setting goals, again, are very important points and something that needs to be revisited, not necessarily at every visit, but frequently through the relationship with the care provider health.
Transcript edited for clarity