Headache diagnosis can be "a pain" all year 'round, but particularly irksome when you have summer plans. Neurologist Peter McAllister, MD, serves up some apps to help with that.
Dr McAllister is Medical Director at the New England Institute for Neurology and Headache and Chief Medical Officer for the New England Institute for Clinical Research and Ki Clinical Research, both in Stamford, Conn.
Summertime, and the livin’ is easy…except, it seems, for us doctors.
Years ago, I vaguely recall a summer lull in the office action, with families heading off to the beach or the mountains, kids tucked in at sleep-away camp, when life seemed to slow down, relax a bit, and we all caught our collective breath. Not so much now. The traffic on the highway to my office is every bit as busy in July as January, and scorching temperatures have done nothing to decrease the seemingly endless queue of patients clamoring to be seen immediately.
I’ve often heard from my friends in primary care that the last thing they want to hear from a patient is, “Doc, I’ve got this new headache . . .” I think I have a sense of why this is so year 'round, and maybe moreso in the summer.
First, we’re all busy-primary, specialty, everyone. And if you ask most primary care providers (PCPs), they’ll tell you that the evaluation of a headache patient is cumbersome, time consuming, and likely to extend well beyond the slotted patient visit. Secondly, for many PCPs, discerning a painful but benign headache (such as migraine) from a nefarious one (brain tumor, or sentinel aneurysmal bleed, for example) is a minefield best avoided.
So, in the spirit of a more relaxing summer, I will attempt to make your office headache assessments quick, painless, and accurate, by introducing an old validated instrument, along with some cool smartphone-based applications (apps). My goal is to acquaint you with useful tools to make your clinic life, like a perfect summer day, light and breezy-at least when it comes to headache patients’ evaluation and treatment.
A bit of history: Way back in 2003 (when my summers were easy), Richard Lipton, MD, and colleagues from the Montefiore Headache Center in New York, asked headache patients presenting to a PCP office to answer a long list of questions about their head pain. They kept culling the list while making sure sensitivity and specificity were maintained. The final product, called ID Migraine, asks 3 simple questions:
A positive response to 2 questions indicates migraine as the diagnosis, with 93% sensitivity, increasing to 96% with 3 affirmative answers. Best of all for the busy practitioner: ID Migraine screening takes all of thirty seconds to complete.
Apps for smartphones and our many other devices didn’t debut until 5 years after Richard Lipton’s ID Migraine study, or I’m certain the ID Migraine questionnaire would have been launched as an app. We now have millions of these do-it-yourself programs at our fingertips. Here are a few I use in my practice that help me manage all types of headache patients (Full disclosure: I have no ties, financial or otherwise, to these products).
If I have a complicated headache patient and I’m not really sure what’s going on, I turn to BonTriage for help (see Figure 1 for screenshots). This app, developed by Alan Rapoport, MD, at UCLA, and Robert Cowen, MD, at Stanford, utilizes the latest in machine learning to arrive at virtually any headache diagnosis listed in the International Classification of Headache Disorders, 3rd edition compendium.
Want to diagnose episodic cluster, hemicrania continua, or spontaneous intracranial hypotension headache? This app will do it for you, by asking a series of detailed questions, altering them along decision trees depending on the patient’s responses. Ask your headache patients to download the free Bontriage app, answer as prompted, and email you the diagnosis. Easy as summertime pie.
Once you have established that your patient has a primary headache of some sort, a critical key to success is having them keep, for a while anyway, a headache diary. This gives an accurate sense of the number of headache days per month, the severity (disability), and triggers. And while paper and pencil calendars are fine, there are 2 apps I find especially useful for interested patients.
The first isMigraine Buddy, developed by Healint, which bills itself as “the number one migraine app in the world, with 1.5 million users” (screenshots in Figure 2.) Available in 5 languages, Migraine Buddy is intuitive and the site contains useful articles of interest to headache sufferers. If your patient prefers a stripped-down approach when tracking migraines,iHeadache (Better QOL, Inc.) is the app for them (screenshots in Figure 3). Easy and straightforward, iHeadache was developed by a headache specialist for his patients. He then commercialized the app and it caught fire quicker than a summer bonfire on the beach.
Back to your summer
So, with your patients diagnosing and tracking their headaches, you’ll have more summer time to kick back. Of course, you’ll need your own apps, too! TryiHydrate to keep up your hot weather fluid intake, Grill King for your grilling needs,Spotify for that perfect summer play list, and of course Lush Cocktails, to whip up a classic lakeside libation.