Eric P. Baron, DO, is a board-certified headache specialist and neurologist at Cleveland Clinic Headache Center in Cleveland, OH. He is also the creator of the popular website, Virtual Headache Specialist.
As I opened the exam room door for a follow-up appointment with a 67-year-old patient, he said, “If I was a younger man and able to have a family, I’d name my first born after you.”
At first, I felt incredibly happy for my patient, Frank, but I also felt sadness. For most of his life, Frank had been suffering from something that could have been avoided.
"I thought of how different his life could have been had one of his physicians simply asked if he had headaches early on."
— Eric P. Baron, DO
A debilitating symptom
Frank had been suffering from chronic migraine since his late teens. Chronic migraine is defined as 15 or more headache days per month, with at least eight of them being migraine.
Do you feel like a failure when you can’t treat a patient?
Frank regularly saw his PCP and didn’t have a lot of other medical issues. During his first visit with me, Frank described his struggle with daily headaches and frequent migraine attacks. He said his doctors had never asked about headaches, so he never felt it was relevant to mention.
Frank’s headaches weren’t “just headaches” though. They were migraines, and they were severe. Over the years, he had a hard time with jobs, often missing work. He had a hard time forming lasting romantic relationships from always canceling plans, stuck in bed—he was never able to marry and have a family.
But it didn’t have to be this way. A simple first-line migraine preventive treatment and a conversation about how daily OTC pain medicines would only sustain chronic migraine indefinitely (with worsening severity), was the answer to relieving Frank of his chronic, daily headaches. This is the quality-of-life improvement that we all seek for our patients as physicians.
Others should have stepped up
Following my neurology residency, I completed a headache medicine fellowship. Being a headache specialist is a subspecialty of neurology which offers the chance to make a tremendous difference in many patients’ lives that are many times stuck in the dark, depressing, and debilitating rut of migraine.
Unfortunately, Frank’s is a very common story that I see. For this reason, the most important question, to me, becomes, “How do we reverse this story at an early stage?”
There are also many patients who are asked about headaches and receive treatment from their doctor, yet still suffer for many years. Improvements such as Frank’s can and should be seen—well before patients tell me, “You’re my last hope.”
Upon taking their history, I most often realize that they haven’t seen improvement, because nothing has really been done—the appropriate treatments haven’t been tried.
What I love about being a headache specialist is that you can often change a patient’s life with a few simple questions and appropriate correlating treatment adjustments.
So, what’s going on here? Why aren’t more patients referred to headache specialists like me much sooner?
"How can we as physicians be better and truly reshape our patient’s lives who are affected by migraine?"
— Eric P. Baron, DO
Living with a disability
For many decades, until recently, migraine was swept under the rug and viewed as “just a headache.” However, migraine is not a simple headache. It is a common, debilitating, life-altering neurobiological disease. More than 39 million in the US and 1 billion globally are impacted by migraine, and 1 in 4 households have someone with migraine in the family.[] It affects more than 1 in 5 women and 1 in 16 men.[]
The World Health Organization now ranks migraine as the second-leading cause of years lived with disability, after lower back pain.[] For women in their prime working years, ages 15 to 49, it is the number-one cause of years lived with disability.
So, as you can see, migraine is a neurological disorder that should be on the radar of any patient entering any physician’s office for early management or referral.
So, what simple things can we do as physicians to prevent stories like Frank’s? How can we intervene early to release the grip of migraine from pulling patients down like quicksand into the dark depths of chronic migraine and its associated misery?
Early intervention is key
As a headache specialist who sees stories and cases like Frank every day, I believe there are two simple things all physicians can do.
First, physicians can screen every patient for migraine by asking if they have headaches. If they do, the quickest screen for diagnosing migraine is the validated ID Migraine questionnaire.[] Simply ask the patient the following questions.
In the past 3 months, have you:
1. Had nausea or a sick-to-your-stomach feeling?
2. Been more sensitive to light (than without a headache)?
3. Felt head pain so severe it affected your ability to work, study, or do what you needed to do in a day?
If they answer yes to three out of three, there is a 97% chance of migraine; if they answer yes to two out of three, there is a 93% chance.
If present, every migraine patient needs an effective acute treatment. If they are averaging four or more migraines per month, preventive therapy is recommended. These simple steps can prevent the dark, migraine-related downward spiral seen in many patients.
New treatments and therapies
The second thing physicians can do is to become familiar with newer migraine acute and preventive options—it’s a whole new world for migraine patients. The American Headache Society recently stated that the newer CGRP (calcitonin-gene related peptide) migraine specific medications should be considered as first-line options—something to try if traditional treatments are not helping or tolerated.[]
In 2018, the first ever migraine specific preventive medicines became available: CGRP monoclonal antibodies. Prior to this, everything used was adopted from other specialties (eg, antiseizure, antidepressant, antihypertensive drugs) with variable benefit and tolerability. In 2020, another CGRP class (gepants) became available, making them the first new acute migraine class since 1992, when sumatriptans came out. These newer options have fewer side effects and medical contraindications, as they target specific CGRP migraine pathways.
"As physicians, it's important to remember that early migraine identification and intervention is essential."
— Eric P. Baron, DO
The more that migraine continues without an effective abortive and preventive strategy, the more it will slowly evolve into chronic migraine, and your patients could end up with a story like Frank’s.
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