A new tool can help streamline the diagnosis and treatment of migraine in the primary care setting, according to new research.
Early results from a small pilot study showed that the tool, essentially a medical record “best practice alert”, reduces referrals to specialists and MRI studies.
The idea behind the tool is to give primary care physicians “fingertip access” to patients’ electronic health record (EHR) prompts, leading to the best management and treatment of migraine, co -investigator, Scott M. Friedenberg, MD, Vice Chairman of Clinical Practice, Geisinger Medical Center, Danville, Pennsylvania, said Medscape Medical News.
When clinicians walk into a headache diagnosis in a patient’s EHR, a pop-up asks a handful of questions and “prompts them to choose the right medications, so that if they just click a button, they can order the medications immediately,” Friedenberg said. .
The results were presented at the 2022 annual meeting of the American Headache Society (AHS).
Fewer referrals, MRI tests
The researchers reviewed the records of 693 referrals in general neurology. About 20% of patients were referred for headaches. In approximately 80% of these cases, the final diagnosis was migraine and/or chronic daily headache.
Doctors had documented criteria for identifying migraine, such as sensitivity to light, nausea, and lack of social activity or work, in less than 1 percent of cases. There’s about an 80 percent chance that if a headache meets two of those three criteria, it’s a migraine, Friedenberg noted.
About 60% of participants with headaches were referred without a treatment trial. About 20% were referred after trying two drugs and 30% were referred after trying one drug.
“In many cases, we are asked to assess people with primary headaches or uncomplicated headaches that have not been treated,” Friedenberg said.
Investigators developed the tool, and its most recent version was tested by 10 physicians at two sites for 3 months. These doctors weren’t trained in headaches, they were just taught how to use the tool.
Results showed referrals for neurology consultations dropped by 77% and MRI orders dropped by 35% after using the tool. This translated into a savings of $192,000.
However, use of the tool did not significantly impact physician prescribing habits.
Often undertreated migraine
“When you explore it, the only thing that changed was the medications they were comfortable with, so they increased the prescriptions of steroids and non-steroids, but the preventatives didn’t change, the narcotics have not changed and the CGRP [calcitonin gene-related peptide] the inhibitors haven’t changed,” Friedenberg said.
Although the belief that patients are “not sick enough to treat” may help explain why clinicians have not changed their prescribing habits, the reality is that many patients suffer from migraine and need treatment. , he added.
Friedenberg pointed out that previous research suggests that 60% or more of patients with a primary headache or migraine are undertreated.
The tool should increase awareness and comfort level with migraine diagnosis and treatment among primary care physicians, he noted. “We hope it will be easier for them to do the right thing and have neurology as a readily available partner,” Friedenberg said.
“Primary care physicians are incredibly busy and under incredible pressure, and anything you can do to help facilitate that is positive,” he added.
The researchers now plan to train pharmacists to co-manage headaches with general practitioners, as is done for example for diabetic patients. That should lead to a reduction in the burden on physicians, Friedenberg said.
The next step is to conduct a larger study at the 38 sites of the Geisinger Health Complex. Half of the sites will use the new tool and the other half will continue to use their current headache management process.
“The study will compare everything from ordering MRIs to neurology referrals and prescriptions, how often patients go to the emergency department, how often they go to the clinic, whether the provider is happy with the tool and whether the patient’s headache improves,” Friedenberg said.
Lessons for clinical practice
Jessica Ailani, MD, director of the MedStar Georgetown Headache Center and associate professor in the Department of Neurology at Georgetown University, co-chaired the session in which the research was presented and called the project “really fantastic.”
The study offers “many lessons” for clinical practice and has shown the tool to be effective in improving migraine diagnosis, said Ailani, who is also AHS secretary.
“There’s a long wait to see specialists, and most migraines can be diagnosed and basic management can be done by primary care doctors,” she said. Medscape Medical News.
“The next step would be to work on a way to improve prescriptions for migraine-specific treatments,” she added.
Ailani noted that AHS would be keen to find ways to engage in “collaborative work” with investigators.
Investigators and Ailani have not reported any relevant financial relationship.
American Headache Society (AHS) 2022 Annual Meeting: Scientific Session 1, OR-5. Presented June 10, 2022.