Article

Does this patient with headache have a migraine or need neuroimaging?

Faculty of Medicine, Medicine, University of Toronto, Toronto, Ontario.
JAMA The Journal of the American Medical Association (impact factor: 30.03). 10/2006; 296(10):1274-83. DOI:10.1001/jama.296.10.1274 pp.1274-83
Source: PubMed

ABSTRACT In assessing the patient with headache, clinicians are often faced with 2 important questions: Is this headache a migraine? Does this patient require neuroimaging? The diagnosis of migraine can direct therapy, and information obtained from the history and physical examination is used by physicians to determine which patients require neuroimaging.
To determine the usefulness of the history and physical examination that distinguish patients with migraine from those with other headache types and that identify those patients who should undergo neuroimaging.
A systematic review was performed using articles from MEDLINE (1966-November 2005) that assessed the performance characteristics of screening questions in diagnosing migraine (with the International Headache Society diagnostic criteria as a gold standard) and addressed the accuracy of the clinical examination in predicting the presence of underlying intracranial pathology (with computed tomography/magnetic resonance imaging as the reference standard).
Two authors independently reviewed each study to determine eligibility, abstract data, and classify methodological quality using predetermined criteria. Disagreement was resolved by consensus with a third author.
Four studies of screening questions for migraine (n = 1745 patients) and 11 neuroimaging studies (n = 3725 patients) met inclusion criteria. All 4 of the migraine studies illustrated high sensitivity and specificity if 3 or 4 criteria were met. The best predictors can be summarized by the mnemonic POUNDing (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling). If 4 of the 5 criteria are met, the likelihood ratio (LR) for definite or possible migraine is 24 (95% confidence interval [CI], 1.5-388); if 3 are met, the LR is 3.5 (95% CI, 1.3-9.2), and if 2 or fewer are met, the LR is 0.41 (95% CI, 0.32-0.52). For the neuroimaging question, several clinical features were found on pooled analysis to predict the presence of a serious intracranial abnormality: cluster-type headache (LR, 10.7; 95% CI, 2.2-52); abnormal findings on neurologic examination (LR, 5.3; 95% CI, 2.4-12); undefined headache (ie, not cluster-, migraine-, or tension-type) (LR, 3.8; 95% CI, 2.0-7.1); headache with aura (LR, 3.2; 95% CI, 1.6-6.6); headache aggravated by exertion or a valsalva-like maneuver (LR, 2.3; 95% CI, 1.4-3.8); and headache with vomiting (LR, 1.8; 95% CI, 1.2-2.6). No clinical features were useful in ruling out significant pathologic conditions.
The presence of 4 simple historical features can accurately diagnose migraine. Several individual clinical features were found to be associated with a significant intracranial abnormality, and patients with these features should undergo neuroimaging.

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    Article: Implementation and evaluation of existing guidelines on the use of neurophysiological tests in non-acute migraine patients: a questionnaire survey of neurologists and primary care physicians.
    P Rossi, J Schoenen, M Bolla, C Tassorelli, G Sandrini, G Nappi
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    ABSTRACT: The main aims of this study were to evaluate: the diffusion, use and perception of the usefulness of the 2004 EFNS guidelines on neurophysiological testing in non-acute headache patients; the frequency with which the different neurophysiological tests were recommended in non-acute migraine patients by physicians aware or unaware of the guidelines; and the appropriateness of the reasons given for recommending neurophysiological tests. One hundred and fifty physicians selected amongst the members of the Italian societies of general practitioner (GPs), neurologists and headache specialists were contacted via e-mail and invited to fill in a questionnaire specially created for the study. Ninety-two percent of the headache specialists, 8.6% of the neurologists and 0% of the GPs were already aware of the EFNS guidelines. A significantly higher proportion of headache specialists had not recommended any neurophysiological tests to the migraine patients they had seen in the previous 3 months, whereas these tests had frequently been prescribed by the GPs and neurologists. Overall, 80%, 42% and 42.6% of the reasons given by headache specialists, neurologists and GPs, respectively, for recommending neurophysiological testing in their migraine patients were appropriate (P < 0.01). The diffusion of the EFNS guidelines on neurophysiological tests and neuroimaging procedures was found to be very limited amongst neurologists and GPs. The physicians aware of the EFNS guidelines recommended neurophysiological tests to migraine patients less frequently and more appropriately than physicians who were not aware of them. The most frequent misconceptions regarding neurophysiological tests concerned their perceived capacity to discriminate between migraine and secondary headaches or between migraine and other primary headaches.
    European Journal of Neurology 05/2009; 16(8):937-42. · 3.69 Impact Factor
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    Article: Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 2nd Edition, 2012.
    Lars Bendtsen, Steffen Birk, Helge Kasch, Karen Aegidius, Per Schmidt Sørensen, Lise Lykke Thomsen, Lars Poulsen, Mary-Jette Rasmussen, Christina Kruuse, Rigmor Jensen
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    ABSTRACT: Headache and facial pain are among the most common, disabling and costly disorders in Europe. Correct diagnosis and treatment is important for achieving a high quality of care. As a national organisation whose role is to educate and advocate for the needs of patients with primary headaches, the Danish Headache Society has set up a task force to develop a set of guidelines for the diagnosis, organisation and treatment of the most common types of headaches and for trigeminal neuralgia in Denmark. The guideline was published in Danish in 2010 and has been a great success. The Danish Headache Society decided to translate and publish our guideline in English to stimulate the discussion on optimal organisation and treatment of headache disorders and to encourage other national headache authorities to produce their own guidelines. The recommendations regarding the most common primary headaches and trigeminal neuralgia are largely in accordance with the European guidelines produced by the European Federation of Neurological Societies. The guideline provides a practical tool for use in daily clinical practice for primary care physicians, neurologists with a common interest in headache, as well as other health-care professionals treating headache patients. The guideline first describes how to examine and diagnose the headache patient and how headache treatment is organised in Denmark. This description is followed by individual sections on the characteristics, diagnosis, differential diagnosis and treatment of each of the major headache disorders and trigeminal neuralgia. The guideline includes many tables to facilitate a quick overview. Finally, the particular problems regarding headache in children and headache in relation to female hormones and pregnancy are described.
    The Journal of Headache and Pain 02/2012; 13 Suppl 1:S1-29. · 2.43 Impact Factor
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    Article: Mígreni : greining og meðferð í heilsugæslu
    Anna Margrét Guðmundsdóttir, Emil L. Sigurðsson
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    ABSTRACT: Neðst á síðunni er hægt að nálgast greinina í heild sinni með því að smella á hlekkinn View/Open OBJECTIVE: The main objective of this study was to evaluate the diagnosis and treatment of patients with migraine at the Solvangur Health Care Center in Hafnarfjordur. MATERIAL AND METHODS: Information about all those who had been diagnosed with migraine (ICD-9 346.0-346.9 and ICD-10 G43.0-G43.9) during the period from 1990 to 2000 at the Solvangur Health Care Center was gathered rectrospectively. The data was collected from November 2004 to may 2005. RESULTS: A total of 490 individuals had been diagnosed with migraine during the study period. The prevalence being just above 2%. Almost one fourth of the patients had symptoms for decades before the diagnosis was made. At diagnosis 15% had 2-4 attacks per month and approximately 8% had five or more attacks per month. One fifth of the patients had migraine with aura. 25% of the patients had been diagnosed with depression and 20% had some form of anxiety. One third of the patients had been investigated with CT of the brain, and nearly 90% received drug prescription for their migraine. CONCLUSIONS: We conclude that only part of patients with migraine are being diagnosed and treated by their family physicians. Large proportions of these patients are being investigated by CT which is rarely needed to make the diagnosis. Most of the patients are being treated with drugs and half of the patients are receiving treatment with triptans. With more decisive diagnosis we could be able to reduce use of computerized tomography and in that way reduce cost. Tilgangur: Tilgangur þessarar rannsóknar var að skoða greiningu og meðferð sjúklinga með mígreni meðal skjólstæðinga Heilsugæslunnar Sólvangi í Hafnarfirði. Efniviður og aðferðir: Upplýsingum um alla þá sem höfðu sjúkdómsgreininguna mígreni (ICD-9 346.0-346.9 og ICD-10 G43.0-G43.9) árin 1990-2000 á Heilsugæslustöðinni Sólvangi Hafnarfirði var safnað saman afturvirkt. Gagnasöfnun fór fram á tímabilinu nóvember 2004 til maí 2005. Niðurstöður: Alls greindust 490 einstaklingar með lögheimili á upptökusvæði stöðvarinnar, með mígreni á tímabilinu 1990-2000, algengið var rúmlega 2%. Tæplega fjórðungur sjúklinganna höfðu haft einkenni í meira en 10 ár áður en sjúkdómurinn var greindur. Við greiningu reyndust um 15% vera með 2-4 köst á mánuði og um 8% með fimm eða fleiri höfuðverkjaköst á mánuði. Fimmtungur sjúklinga var með fyrirboða (aura). Um fjórðungur sjúklinga höfðu einnig þunglyndisgreiningu og fimmti hver sjúklingur var með kvíðagreiningu. Þriðjungur sjúklinganna hafði farið í tölvusneiðmynd af höfði og tæplega 90% sjúklinganna fengu útskrifuð lyf hjá lækni við mígreni. Ályktun: Líklegt má telja að aðeins hluti sjúklinga með mígreni fái meðferð hjá heimilislæknum vegna síns sjúkdóms. Stór hluti hópsins fer í tölvusneiðmynd af höfði sem ekki er nauðsynleg til greiningar. Langflestir þessara sjúklinga fá lyfjameðferð, þar af hefur helmingur þeirra verið meðhöndlaður með triptan-lyfjum. Með markvissari greiningu mígrenis gæti verið unnt að fækka tölvusneiðmyndum og á þann hátt draga úr kostnaði.
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Keywords

11 neuroimaging studies
 
4 criteria
 
5 criteria
 
95% confidence interval [CI]
 
abnormal findings
 
clinical examination
 
cluster-type headache
 
computed tomography/magnetic resonance imaging
 
gold standard
 
inclusion criteria
 
International Headache Society diagnostic criteria
 
likelihood ratio
 
mnemonic POUNDing
 
neurologic examination
 
possible migraine
 
predetermined criteria
 
reference standard
 
significant intracranial abnormality
 
third author
 
undefined headache
 

Michael E Detsky