Simple screening tool improves headache management in primary care

PHILADELPHIA – A simple, three-item screening tool significantly increased headache diagnoses and triptan prescriptions, and significantly decreased opioid prescriptions, based on data from a 5-week intervention at two primary care clinics.

The screen can be administered by a medical assistant and is highly accurate for diagnosing migraine, Dr. Kevin Brennan said at the annual meeting of the American Academy of Neurology.

Of more than 16,000 patients with headache who were referred to a specialty headache clinic from primary care, up to 65% were already taking opioid pain medications, while as few as 10% were taking triptans, said Dr. Brennan, director of the Headache Physiology Laboratory at the University of Utah, Salt Lake City. The problem is inaccurate diagnosis and coding, he said.

"The predominant code for these referred patients was 784, which is a symptom code for headache, and provides no diagnostic utility. If you don’t diagnose, there is a much lower likelihood of appropriately treating," he explained.

The university’s headache clinic receives most of its patients from 10 primary care practices in the region. Over a 2-year period (2008-2010), there were more than 50,000 headache visits in these practices. Of these, approximately 17,000 arrived at the specialty clinic with an actual headache diagnosis, Dr. Brennan said.

The numbers were revealed after an anecdotal observation that many patients were arriving for specialty treatment with a symptom code instead of a diagnosis code, and already taking inappropriate medications.

Dr. Brennan and his colleagues launched a quality improvement project to attempt to boost both appropriate diagnoses and appropriate treatments.

About a third of the referred patients were taking opiates at the time of referral. Other inappropriate medications were antianxiety drugs, barbiturates, antidepressants, antiemetics, nonsteroidal anti-inflammatories, benzodiazepines, decongestants, and muscle relaxants. Only 9% of the referred patients were taking a triptan.

"We wanted to see why we were getting so many of these patients," Dr. Brennan said. "And when we started looking at the medications and diagnostic codes, our initial reaction was ... something I can’t say."

The data showed that headache simply was not being diagnosed. Instead, the most common code was the one that identifies headache as a symptom, Dr. Brennan explained.

To address the problem, the headache research team implemented an easy migraine screen into the patients’ electronic medical records. The ID Migraine algorithm is a three-item screen that can be administered by a medical assistant. It showed 81% sensitivity and 75% specificity for migraine in a validation study.

If a patient answers yes to the three questions (headache disability, nausea, and sensitivity to light), the likelihood of migraine is very, very high, Dr. Brennan said. If the screen is positive, a treatment and medication algorithm is displayed.

The screen was piloted at two clinics during a 5-week period in 2013. The clinics were chosen because they had the best rates of headache diagnostic coding. Prior to the intervention, 41% of the codes were the 784 headache symptom code, 17% of patients received a triptan, and 18% of patients received an opioid.

Five weeks later, the symptom code was reduced to 33% of headache encounters – a 20% improvement. There was a 36% relative increase in the number of triptan prescriptions and a 37% decrease in the number of opioid prescriptions.

The underdiagnosis of headache at the primary care level boils down to one thing, Dr. Brennan said: Time – or the lack of it.

"There’s not enough time in medical school to learn about headache," he said, noting that doctors in training spend an average of 3 hours on headache during an entire school career. Neither do most primary care doctors have enough time during a typical office visit to address headaches. And the idea remains entrenched that headache patients are "difficult" and that migraine is hard to diagnose, he added.

"Right now, we’re herding cats," Dr. Brennan said. "We’re trying to work with the medical directors and get them to implement [screening]. But they still come back saying, ‘Migraine is so hard to diagnose.’ With this system, it’s not hard," he said. "Headache is primary care. It’s more common than asthma and diabetes combined. There’s no excuse for not diagnosing it."

There was no outside funding for the study. Dr. Brennan had no financial disclosures.

[email protected]

PHILADELPHIA – A simple, three-item screening tool significantly increased headache diagnoses and triptan prescriptions, and significantly decreased opioid prescriptions, based on data from a 5-week intervention at two primary care clinics.

The screen can be administered by a medical assistant and is highly accurate for diagnosing migraine, Dr. Kevin Brennan said at the annual meeting of the American Academy of Neurology.

Of more than 16,000 patients with headache who were referred to a specialty headache clinic from primary care, up to 65% were already taking opioid pain medications, while as few as 10% were taking triptans, said Dr. Brennan, director of the Headache Physiology Laboratory at the University of Utah, Salt Lake City. The problem is inaccurate diagnosis and coding, he said.

"The predominant code for these referred patients was 784, which is a symptom code for headache, and provides no diagnostic utility. If you don’t diagnose, there is a much lower likelihood of appropriately treating," he explained.

The university’s headache clinic receives most of its patients from 10 primary care practices in the region. Over a 2-year period (2008-2010), there were more than 50,000 headache visits in these practices. Of these, approximately 17,000 arrived at the specialty clinic with an actual headache diagnosis, Dr. Brennan said.

The numbers were revealed after an anecdotal observation that many patients were arriving for specialty treatment with a symptom code instead of a diagnosis code, and already taking inappropriate medications.

Dr. Brennan and his colleagues launched a quality improvement project to attempt to boost both appropriate diagnoses and appropriate treatments.

About a third of the referred patients were taking opiates at the time of referral. Other inappropriate medications were antianxiety drugs, barbiturates, antidepressants, antiemetics, nonsteroidal anti-inflammatories, benzodiazepines, decongestants, and muscle relaxants. Only 9% of the referred patients were taking a triptan.

"We wanted to see why we were getting so many of these patients," Dr. Brennan said. "And when we started looking at the medications and diagnostic codes, our initial reaction was ... something I can’t say."

The data showed that headache simply was not being diagnosed. Instead, the most common code was the one that identifies headache as a symptom, Dr. Brennan explained.

To address the problem, the headache research team implemented an easy migraine screen into the patients’ electronic medical records. The ID Migraine algorithm is a three-item screen that can be administered by a medical assistant. It showed 81% sensitivity and 75% specificity for migraine in a validation study.

If a patient answers yes to the three questions (headache disability, nausea, and sensitivity to light), the likelihood of migraine is very, very high, Dr. Brennan said. If the screen is positive, a treatment and medication algorithm is displayed.

The screen was piloted at two clinics during a 5-week period in 2013. The clinics were chosen because they had the best rates of headache diagnostic coding. Prior to the intervention, 41% of the codes were the 784 headache symptom code, 17% of patients received a triptan, and 18% of patients received an opioid.

Five weeks later, the symptom code was reduced to 33% of headache encounters – a 20% improvement. There was a 36% relative increase in the number of triptan prescriptions and a 37% decrease in the number of opioid prescriptions.

The underdiagnosis of headache at the primary care level boils down to one thing, Dr. Brennan said: Time – or the lack of it.

"There’s not enough time in medical school to learn about headache," he said, noting that doctors in training spend an average of 3 hours on headache during an entire school career. Neither do most primary care doctors have enough time during a typical office visit to address headaches. And the idea remains entrenched that headache patients are "difficult" and that migraine is hard to diagnose, he added.

"Right now, we’re herding cats," Dr. Brennan said. "We’re trying to work with the medical directors and get them to implement [screening]. But they still come back saying, ‘Migraine is so hard to diagnose.’ With this system, it’s not hard," he said. "Headache is primary care. It’s more common than asthma and diabetes combined. There’s no excuse for not diagnosing it."

There was no outside funding for the study. Dr. Brennan had no financial disclosures.

[email protected]

PHILADELPHIA – A simple, three-item screening tool significantly increased headache diagnoses and triptan prescriptions, and significantly decreased opioid prescriptions, based on data from a 5-week intervention at two primary care clinics.

The screen can be administered by a medical assistant and is highly accurate for diagnosing migraine, Dr. Kevin Brennan said at the annual meeting of the American Academy of Neurology.

Of more than 16,000 patients with headache who were referred to a specialty headache clinic from primary care, up to 65% were already taking opioid pain medications, while as few as 10% were taking triptans, said Dr. Brennan, director of the Headache Physiology Laboratory at the University of Utah, Salt Lake City. The problem is inaccurate diagnosis and coding, he said.

"The predominant code for these referred patients was 784, which is a symptom code for headache, and provides no diagnostic utility. If you don’t diagnose, there is a much lower likelihood of appropriately treating," he explained.

The university’s headache clinic receives most of its patients from 10 primary care practices in the region. Over a 2-year period (2008-2010), there were more than 50,000 headache visits in these practices. Of these, approximately 17,000 arrived at the specialty clinic with an actual headache diagnosis, Dr. Brennan said.

The numbers were revealed after an anecdotal observation that many patients were arriving for specialty treatment with a symptom code instead of a diagnosis code, and already taking inappropriate medications.

Dr. Brennan and his colleagues launched a quality improvement project to attempt to boost both appropriate diagnoses and appropriate treatments.

About a third of the referred patients were taking opiates at the time of referral. Other inappropriate medications were antianxiety drugs, barbiturates, antidepressants, antiemetics, nonsteroidal anti-inflammatories, benzodiazepines, decongestants, and muscle relaxants. Only 9% of the referred patients were taking a triptan.

"We wanted to see why we were getting so many of these patients," Dr. Brennan said. "And when we started looking at the medications and diagnostic codes, our initial reaction was ... something I can’t say."

The data showed that headache simply was not being diagnosed. Instead, the most common code was the one that identifies headache as a symptom, Dr. Brennan explained.

To address the problem, the headache research team implemented an easy migraine screen into the patients’ electronic medical records. The ID Migraine algorithm is a three-item screen that can be administered by a medical assistant. It showed 81% sensitivity and 75% specificity for migraine in a validation study.

If a patient answers yes to the three questions (headache disability, nausea, and sensitivity to light), the likelihood of migraine is very, very high, Dr. Brennan said. If the screen is positive, a treatment and medication algorithm is displayed.

The screen was piloted at two clinics during a 5-week period in 2013. The clinics were chosen because they had the best rates of headache diagnostic coding. Prior to the intervention, 41% of the codes were the 784 headache symptom code, 17% of patients received a triptan, and 18% of patients received an opioid.

Five weeks later, the symptom code was reduced to 33% of headache encounters – a 20% improvement. There was a 36% relative increase in the number of triptan prescriptions and a 37% decrease in the number of opioid prescriptions.

The underdiagnosis of headache at the primary care level boils down to one thing, Dr. Brennan said: Time – or the lack of it.

"There’s not enough time in medical school to learn about headache," he said, noting that doctors in training spend an average of 3 hours on headache during an entire school career. Neither do most primary care doctors have enough time during a typical office visit to address headaches. And the idea remains entrenched that headache patients are "difficult" and that migraine is hard to diagnose, he added.

"Right now, we’re herding cats," Dr. Brennan said. "We’re trying to work with the medical directors and get them to implement [screening]. But they still come back saying, ‘Migraine is so hard to diagnose.’ With this system, it’s not hard," he said. "Headache is primary care. It’s more common than asthma and diabetes combined. There’s no excuse for not diagnosing it."

There was no outside funding for the study. Dr. Brennan had no financial disclosures.

[email protected]