Open-Ended Question Reveals Impact of Migraine

LOS ANGELES — Health care providers asked lots of questions during videotaped, real-life office visits by patients with migraines, but almost always failed to ask the one question that would indicate whether they should prescribe a preventive medication.

That question is: “Can you tell me how your headaches impact your daily life?”

The American Migraine Communication Study, presented at the annual meeting of the American Headache Society, found that providers asked an average of 13 questions in the average 12-minute office visit with a patient seeking care for migraine headaches.

Of those questions, 91% were closed-ended or short-answer questions that patients could respond to with one or two words. An example of a closed-ended question would be: “Is your headache pain one-sided?” as opposed to, “Can you tell me about your headache pain?”

In more than three-fourths of 60 videotaped office visits, not a single open-ended question was asked, reported Dr. Steven R. Hahn, professor of clinical medicine at the Albert Einstein College of Medicine, New York.

Both providers and patients knew they were being videotaped in the observational linguistic study conducted in community-based private practices. Separate postvisit interviews were conducted with patients and the 14 primary care providers, 8 neurologists, and 6 nurse-practitioners or physician assistants who agreed to participate.

Most of the questions posed by providers addressed headache frequency, yet more than half the time their understanding of their patients' headache frequency was not aligned with patients' own reports once the visits concluded.

Similarly, their understanding of their patients' headache severity was misaligned with their patients' perspective following 34% of visits.

Just 10% of office visits touched upon the degree of impairment experienced by migraine patients, even though an expert consensus panel in 2005 cited impairment as a key determinant in decisions about whether to consider or prescribe preventive agents.

The 2005 American Migraine Prevalence and Prevention Study guidelines recommend preventive agents for patients with frequent headaches that severely affect their lives, defined by at least one of the following: migraines on more than 6 days/month; more than 4 days/month of missed school/work due to migraine; or more than 3 days/month of severe impairment or bed rest due to headache.

The guidelines call for consideration of preventive medication for patients with less severe impairment, such as 3 days/month of migraine with some impact on daily function.

Preventive medications might include anticonvulsants, blood pressure medications, antidepressants, serotonin antagonists, or unconventional treatments such as magnesium salts or vitamins.

Among 60 patients in the communication study, 20 met the criteria for preventive therapy but were not receiving preventive medication.

In office visits with 10 of these patients, prevention was never discussed. In the remaining visits, prevention was discussed and medication prescribed in two and was discussed but no medication was prescribed in three.

Dr. Hahn agreed with audience members who deplored the brevity of office visits addressing a topic as complex as migraines. However, he said, time constraints are a reality. “I can tell you from this study that one question very quickly reveals the information that was missing from these encounters,” he said.

The open-ended question—“Can you tell me how your headaches impact your daily life?”—would often be enough to elicit a succinct description of impairment that could guide decision making about preventive therapy, he said.

“It is actually a time-efficient approach,” Dr. Hahn added.

LOS ANGELES — Health care providers asked lots of questions during videotaped, real-life office visits by patients with migraines, but almost always failed to ask the one question that would indicate whether they should prescribe a preventive medication.

That question is: “Can you tell me how your headaches impact your daily life?”

The American Migraine Communication Study, presented at the annual meeting of the American Headache Society, found that providers asked an average of 13 questions in the average 12-minute office visit with a patient seeking care for migraine headaches.

Of those questions, 91% were closed-ended or short-answer questions that patients could respond to with one or two words. An example of a closed-ended question would be: “Is your headache pain one-sided?” as opposed to, “Can you tell me about your headache pain?”

In more than three-fourths of 60 videotaped office visits, not a single open-ended question was asked, reported Dr. Steven R. Hahn, professor of clinical medicine at the Albert Einstein College of Medicine, New York.

Both providers and patients knew they were being videotaped in the observational linguistic study conducted in community-based private practices. Separate postvisit interviews were conducted with patients and the 14 primary care providers, 8 neurologists, and 6 nurse-practitioners or physician assistants who agreed to participate.

Most of the questions posed by providers addressed headache frequency, yet more than half the time their understanding of their patients' headache frequency was not aligned with patients' own reports once the visits concluded.

Similarly, their understanding of their patients' headache severity was misaligned with their patients' perspective following 34% of visits.

Just 10% of office visits touched upon the degree of impairment experienced by migraine patients, even though an expert consensus panel in 2005 cited impairment as a key determinant in decisions about whether to consider or prescribe preventive agents.

The 2005 American Migraine Prevalence and Prevention Study guidelines recommend preventive agents for patients with frequent headaches that severely affect their lives, defined by at least one of the following: migraines on more than 6 days/month; more than 4 days/month of missed school/work due to migraine; or more than 3 days/month of severe impairment or bed rest due to headache.

The guidelines call for consideration of preventive medication for patients with less severe impairment, such as 3 days/month of migraine with some impact on daily function.

Preventive medications might include anticonvulsants, blood pressure medications, antidepressants, serotonin antagonists, or unconventional treatments such as magnesium salts or vitamins.

Among 60 patients in the communication study, 20 met the criteria for preventive therapy but were not receiving preventive medication.

In office visits with 10 of these patients, prevention was never discussed. In the remaining visits, prevention was discussed and medication prescribed in two and was discussed but no medication was prescribed in three.

Dr. Hahn agreed with audience members who deplored the brevity of office visits addressing a topic as complex as migraines. However, he said, time constraints are a reality. “I can tell you from this study that one question very quickly reveals the information that was missing from these encounters,” he said.

The open-ended question—“Can you tell me how your headaches impact your daily life?”—would often be enough to elicit a succinct description of impairment that could guide decision making about preventive therapy, he said.

“It is actually a time-efficient approach,” Dr. Hahn added.

LOS ANGELES — Health care providers asked lots of questions during videotaped, real-life office visits by patients with migraines, but almost always failed to ask the one question that would indicate whether they should prescribe a preventive medication.

That question is: “Can you tell me how your headaches impact your daily life?”

The American Migraine Communication Study, presented at the annual meeting of the American Headache Society, found that providers asked an average of 13 questions in the average 12-minute office visit with a patient seeking care for migraine headaches.

Of those questions, 91% were closed-ended or short-answer questions that patients could respond to with one or two words. An example of a closed-ended question would be: “Is your headache pain one-sided?” as opposed to, “Can you tell me about your headache pain?”

In more than three-fourths of 60 videotaped office visits, not a single open-ended question was asked, reported Dr. Steven R. Hahn, professor of clinical medicine at the Albert Einstein College of Medicine, New York.

Both providers and patients knew they were being videotaped in the observational linguistic study conducted in community-based private practices. Separate postvisit interviews were conducted with patients and the 14 primary care providers, 8 neurologists, and 6 nurse-practitioners or physician assistants who agreed to participate.

Most of the questions posed by providers addressed headache frequency, yet more than half the time their understanding of their patients' headache frequency was not aligned with patients' own reports once the visits concluded.

Similarly, their understanding of their patients' headache severity was misaligned with their patients' perspective following 34% of visits.

Just 10% of office visits touched upon the degree of impairment experienced by migraine patients, even though an expert consensus panel in 2005 cited impairment as a key determinant in decisions about whether to consider or prescribe preventive agents.

The 2005 American Migraine Prevalence and Prevention Study guidelines recommend preventive agents for patients with frequent headaches that severely affect their lives, defined by at least one of the following: migraines on more than 6 days/month; more than 4 days/month of missed school/work due to migraine; or more than 3 days/month of severe impairment or bed rest due to headache.

The guidelines call for consideration of preventive medication for patients with less severe impairment, such as 3 days/month of migraine with some impact on daily function.

Preventive medications might include anticonvulsants, blood pressure medications, antidepressants, serotonin antagonists, or unconventional treatments such as magnesium salts or vitamins.

Among 60 patients in the communication study, 20 met the criteria for preventive therapy but were not receiving preventive medication.

In office visits with 10 of these patients, prevention was never discussed. In the remaining visits, prevention was discussed and medication prescribed in two and was discussed but no medication was prescribed in three.

Dr. Hahn agreed with audience members who deplored the brevity of office visits addressing a topic as complex as migraines. However, he said, time constraints are a reality. “I can tell you from this study that one question very quickly reveals the information that was missing from these encounters,” he said.

The open-ended question—“Can you tell me how your headaches impact your daily life?”—would often be enough to elicit a succinct description of impairment that could guide decision making about preventive therapy, he said.

“It is actually a time-efficient approach,” Dr. Hahn added.