A headache specialist suggests 3 questions that can help maximize a short follow-up visit with these complex patients.
Headache patients can be challenging to see for follow-up visits as often, the headache condition is not the only reason for the appointment. Headache, especially migraine, is comorbid with depression, fibromyalgia, sleep disorders, obesity, and childhood maltreatment, to list just a few. Given the constraints imposed by today’s 15-minute limit for follow-up appointments, it can be a challenge to cover all the clinical bases.
For example, a headache patient may come in to talk about hormones or depressive symptoms and while in the exam room, ask for a refill of their bultalbital, hydrocodone, or a triptan medication. Perhaps there is not much time left in the appointment and the provider would like to assess how the patient is doing before writing the refill.
There are many questions that can help focus the appointment time and provide information to guide the refill decision; which ones to ask will depend on the specific patient and how familiar the clinician is with their headache presentation. Here are 3 very important questions that may not be top of mind in the primary care setting and that can help clarify the patient’s clinical situation and medication needs.
First: Ask about headache days -- not just number of headaches>>>
Question 1. How many headache days per week or month are you experiencing?
Too often, the question asked is how many migraines per month are you experiencing? The patient may reply, “Two migraine headaches per month.” And the provider is then content to write the refill.
This question and reply, however, do not give the full picture.
Each migraine attack could potentially last up to 72 hours if not successfully treated-so, one headache may mean three days of compromised activity. Additionally, the patient may have many other “headache” days per month that do not feel severe enough to be called migraine and may not even feel important enough to talk about.
Here is an example from my practice a number of years ago: A female patient requested a refill on her triptan which she stated worked well for her migraines. I wrote the refill, thought the visit was concluded, but when I put my hand on the door to leave, she said, “Doctor, we haven’t talked about my other headaches. The ones I get almost every day.” She went on to tell me she was getting a low-grade headache every day and was taking an OTC combination analgesic (acetaminophen, caffeine, aspirin) at a rate of about 8-10 a day and had recently seen a GI specialist for gastritis. That’s when I realized she was in medication overuse and in need of a preventive medication.
Next: Migraine is more than a headache>>>
Question 2. Are you consistently migraine-free and back to full function after you take your headache medication?
We commonly ask if a medication is working well and the patient may say “yes,” as the treatment may be working reasonably well, ie, the headache usually resolves in an acceptable amount of time. However, the patient may be left with unmet needs and not offering that information. For example, many migraine patients may be happy with an oral triptan (eg, sumatriptan, rizatriptan) for most of their migraine attacks. However, nausea is present in about 73% of migraine attacks and a patient may delay before taking the oral medication. In other cases, the patient may vomit and not be able to take the oral migraine medication at all. As a result, the migraine attack can escalate and cause undue disability, perhaps even requiring a trip to an emergency department or urgent care center.
The majority of migraine patients would benefit from a non-oral rescue migraine treatment in their migraine toolbox such as sumatriptan injectable or a nasal delivery of sumatriptan or zolmitriptan. Some patients may be able to give themselves injectable ketorolac for rescue.
Next: When migraine threatens employment>>>
Question 3. Are you afraid you are going to lose your job because of your frequent migraine attacks?
Tremendous disability can be associated with migraine attacks, causing patients to lose hours and days from work every month. Patients may not be aware that if they work for a company with 50 or more employees, they may be eligible to have an FMLA (Family Medical Leave Act) form on file. The form legitimatizes that they have a chronic condition that may require periodic absences from work. The patient and health care provider have to estimate how many hours or days per month could be missed due to exacerbations of this chronic condition and list this on the form. Typically, once this form is completed, it is good for 1 year. Patients may be tremendously relieved once the FMLA form is on file. I give the patient the responsibility to contact their company’s human resources department to determine eligibility and to complete their part of the form before bringing it to me to complete my part.
Asking these 3 questions can be very helpful in improving headache management of patients in primary care. In some cases, it may be necessary to ask a patient to come back for a “headache-focused” visit if the frequency and/or severity of the headache attacks are not being managed well.