Acute and Preventive Therapy for Migraine - Episode 6
Key opinion leaders discuss the process of determining and measuring individualized treatment goals to ensure patients with migraine receive the most effective management.
Neil Minkoff, MD: Some of the issues that you raised are finding the right patient and managing expectations. We need to set goals, measure outcomes, and managing expectations. I’ll pivot over to Dr Dodick for a moment. How do you do that? Then, how do you measure whether those goals are being met? What are the tools that you use, or ask patients to use, to evaluate how they’re doing, compared with the goals that you’ve agreed upon?
David W. Dodick, MD: That’s a good question. It really differs depending on the patient. I see patients who have pain every waking moment of every single day. If I were looking to get them pain-free, then we’re going to have a very disappointed patient and a doctor. My goals, objectives, and the way I establish expectations for that patient is going to be different than the patient who has 8 days of migraine per month. By and large, the way I track it is the same. I’m interested in knowing how many days in a month the patient has had a migraine headache. But I’m also interested in knowing the functional impairment caused by that headache.
I use a stoplight analogy. I’ve been using it for a long time because patients understand it. We have red, yellow, and green. Red means stop. You’re stopped, can’t function, and are usually flat in bed or at least not moving. Yellow means slowed. You’re moving and able to function somewhat, but you’re impaired. There’s no doubt about it. Green means go. You do have a headache, but you’re able to function almost near-normally during that migraine headache. That’s really helpful to patients.
They don’t need any more explanation than that. Then, they keep a diary. They track that. It’s especially for patients who have a lot of headaches. If I can turn a red diary green, even though the diary may be populated, patients are very happy. That’s one way to track it.
The other way to track it is to use a validated instrument. I use the MIDAS, or the Migraine Disability Assessment scale. That tracks time lost. Do you remember back, I said it’s about measuring the time that people are losing.
Neil Minkoff, MD: Yes.
David W. Dodick, MD: I look at the family and social activities, leisure activities, and work. How much time are they losing completely? And how much time is their productivity at 50% or less? It also tracks the number of headache days over the last 3 months and the average intensity of the pain. I can get important metrics out of that 1 instrument. That’s generally what I follow. I follow it from a preventive treatment standpoint.
From an acute treatment standpoint, Dr Nahas talked about 2-hour pain freedom. That’s what we use to approve acute treatments. We can’t always can we get patients consistently pain-free within 2 hours. I’d like to see them pain-free in 15 or 20 minutes. Frankly, 2 hours is too long to wait. But realistically, with the tools that we have, I’m looking to restore patients’ ability to function at 2 hours. They may be pain-free, but they may be so burdened with [adverse] effects that they can’t get off the sofa.
I like a good composite measure of both efficacy and tolerability. That means, if I took you from severe to mild without any [adverse] effects, I’ve gotten you almost back to normal function. For a patient, that can be dramatic. I’m looking at 2-hour restoration of normal function. That’s the expectation I set for the patient. And if they can be pain-free in an hour, that’s fantastic.
Neil Minkoff, MD: More globally than just about the pain and tracking of these things, do you track those with your patient? How often are you reviewing something like a MIDAS score or a diary?
David W. Dodick, MD: All the time. Whenever I see them.
Neil Minkoff, MD: Every time?
David W. Dodick, MD: Yes, we review it whenever I see them in follow-up. That’s what they’re monitoring and what we’re tracking together. But migraine is about more than just the pain. One thing we’ve ignored for too long is that on days without migraine headache, patients can have other symptoms. They may have cognitive impairment, photophobia, nausea, vertigo, and a variety of other symptoms. I’m also interested in whether there’s functional impairment on days without headache. I track that, as well. As a field, we’re going to be talking more and more about that interictal, or between-attack, function.
Neil Minkoff, MD: Dr Nahas, do you have similar strategies you’re using in your clinic?
Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: Absolutely. We all use slightly different ways of communicating and measuring, but Dr Dodick put it perfectly. We’re looking at the total individual and the burden that migraine is placing upon them. We’re focusing not just on the symptoms, but on the function. We have to maximize all of that. There are a number of different ways to measure it. You have to talk with your patient and figure out what’s the best way for them. For patients with frequent or everyday headache, it doesn’t necessarily make sense for them to write down every detail every single day. It can be discouraging.
I’ve had a lot of patients tell me they quit their calendars because they were too focused on their disease. It was depressing, and they weren’t getting any better. I said, “Alright, let’s take a step back. Let’s focus on the good. How about we’ll assume that you have a headache all the time, or you have migraine symptoms that are affecting you all the time. On the days that you feel good, let’s put a happy face or a star on the calendar. That’s something to remind you of what we’re striving for. Our goal is going to be seeing more of those days and less reliance on medication. But the medication that you have is working for you and not causing a lot of adverse events, or other drug interactions.” That’s what it boils down to. I couldn’t have said it much better, and I’m almost sorry I tried.
Neil Minkoff, MD: No, you did great. You said a couple things I want to come back to, but I want to get another perspective on why we do this. What we’re hearing from our colleagues who are treating the patients is an emphasis on diaries, focusing on function and not just pain, symptom control, and tracking good and bad days. Dr Stephens, your access to what the patients are reporting is very different, right? How are you looking at this more from an overall standpoint in management of big populations? How does your organization look at preventive care and goals for prevention?
Kevin Stephens, Sr., MD: That’s a very good question. We look more at outcome data. The outcome data we look at are focused on medication. We look at prescriptions, including what drugs patients are prescribed and how often they refill them. That’s 1 indicator we track.
The second indicator is frequency of visit. We know this information because the providers give us a claim. If they go to a neurologist, PCP [primary care physician], or specialist, the providers code it. We know what the principal diagnosis is.
Then, we look at the conduct of a patient. If they go to the emergency department, for example, we look at those things. We review all the emergency department claims, particularly with the diagnosis. We call someone who keeps going back and forth to the emergency department 2 or 3 times a month a frequent flyer. That tells us that something is going wrong. Then, we reach out to the patient and try to get them to be proactive in their medication and treatment so they can do preventive care, as opposed to waiting until they get to the point where they have to seek emergency care.