Migraines: 6 Things a Neurologist Wants PCPs to Know

December 2, 2019
Jordan Rosenfeld

When a patient presents to their primary care physician with a headache, it's not always diagnosed as the migraine it is. These 6 tips from a neurologist can help.

When patients come to their primary care physician with a headache, it’s not always diagnosed as the migraine it is, according to Cristina Wohlgehagen, MD, a neurologist at Texas Health Presbyterian Hospital in Dallas.

Here are 6 things Wohlgehagen would like primary care physicians to know and consider about patients with migraines:

1. There’s no harm in referring to a headache specialist

Wohlgehagen acknowledges that physicians are more pressed for time than ever before. Many of her migraine patients come to her after having suffered for years without finding the right treatment.

“I take the stance of, if you have a migraine, see a headache specialist. Why not start with the person who knows from the get go?”

2. Create a migraine questionnaire you can give patients

However, she realizes that many physicians will try to tackle the headache problem themselves, and so she recommends that physicians have a standard headache intake questionnaire that can be filled out if the patient reports chronic or severe headaches.

“A lot of the people coming to a doctor and saying, ‘I have headaches’ actually have migraines, which is easier to treat than the average person thinks,” she says.

The questionnaire can ask such questions as whether the headache is associated with light and sound sensitivity, whether nausea or food aversion accompanies it, as well as listing the frequency and severity of them. If the patient meets the criteria for migraine, then the physician can refer out to a specialist or attempt treatment.

3. Offer preventive medicines

Wohlgehagen finds that many of the patients who come to her were never offered migraine preventive medications by their physician, which she feels is a missed opportunity, especially for younger people. When offering medications, Wohlgehagen urges physicians to stick to those that are migraine-specific for symptomatic treatment and to counsel patients to treat early in the course of the migraine attack. It is okay to redose but limit use to 9 days per month. Consider offering preventive medications if a patient has more than 2 or 3 headaches a month. Antidepressants, antiepileptics, and antihypertensive medications can help with migraine prevention.

NEXT: Yoga, Young Patients, & Weaning

4. Offer alternative options and supplements

In her clinic, Wohlgehagen offers alternative approaches for those who either wish to go without medication or who want to try additional treatments. She recommends migraine patients see a nutritionist, consider practicing yoga, and attend to their mental health with a psychiatrist or counselor as part of a larger lifestyle program to support overall health and reduce migraine triggers. She reinforces the importance of hydration and sleep, which patients often do not realize can be triggers.

In addition, she recommends a specific set of supplements that she finds especially helpful to migraine patients:

• Magnesium 500 mg daily
• Coenzyme Q10 300 mg daily
• Riboflavin 400 mg daily

Check vitamins D and B12 as well as thyroid. An improperly functioning thyroid can also contribute to migraines, so Wohlgehagen runs a blood panel if one hasn’t been done already. “We want to make sure there are not other things going on in the patient’s body that are easy to treat that might be increasing the burden of headache,” she says.

5. Don’t let young people fall through the cracks

Physicians should try to keep track of their younger patients with migraines, who often fall through the cracks or don’t get the treatments they need, only to suffer chronic migraines when they are older.

“Something happens in the transitional years from young adulthood to mid-thirties and people [disappear from] the clinic. Then they come to me in their thirties when their headaches are escalating. I feel we’re missing a great opportunity when people are still young to help them get their lifestyle in order.”

6. When to wean off medication

On the other end of the age spectrum, Wohlgehagen says that migraines tend to improve as people get older, especially after menopause in women. In these cases it may be worthwhile to try weaning patients off their medications to see if they can be managed with lifestyle modifications instead. And, of course, women who are or wish to become pregnant should be weaned off as quickly as possible.

Additionally, she says, some migraines are seasonal, so helping patients keep track of their occurrence can allow the physician to tailor a treatment approach that fits the migraine cycle.

Most importantly, Wohlgehagen urges physicians to remember that, “You can’t cure migraine but you can reduce the burden by lifestyle modifications.”

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