Abstract
Objective: To assess the attitudes, knowledge, and practice patterns of US neurologists regarding migraine management relative to the US Headache Consortium Guidelines (the Guidelines).
Methods: Two samples of 600 neurologists each were selected from the American Academy of Neurology membership database. The first group received a Migraine Attitudes, Knowledge, and Practice Patterns (MKAPP) Survey. The second group received a Clinical Vignette (CV) Survey, presenting two patient histories and correspondent questions.
Results: The MKAPP Survey showed that most neurologists felt that migraine was primarily a disease of the brain with a well-established neurobiological basis (69%) and an important part of their practice (60%). Most (53%) indicated that they routinely used neuroimaging in evaluating severe headache, an approach not recommended by the Guidelines. Most favored acute treatment limits, but 36% did not agree with the Guidelines that acute treatment should be limited to 2 or 3 days/week. In the CV Survey, for vignette 1, most (91%) correctly diagnosed migraine, 31% requested neuroimaging in the absence of indications, 64% appropriately recommended a triptan, and 45% recommended a preventive medication in the absence of indications. For vignette 2, 78% diagnosed migraine, 71% appropriately ordered neuroimaging, 80% appropriately recommended a preventive medication, and 38% prescribed a triptan in face of clear contraindication.
Conclusions: Educational initiatives aiming to increase the awareness of the Guidelines among neurologists should highlight the full range of migraine symptoms that support the diagnosis, appropriate use of neuroimaging, indications for preventive treatments, issues of triptan cardiovascular safety, and preventing rebound headaches.
Physicians, including neurologists, are unable to keep up with the expanding volume of published medical literature regarding migraine and other conditions.1 Incorporating medical advances into clinical practice often lags behind the supporting literature.2,3⇓ As many as 20 years may pass before research findings become part of routine clinical practice.2 A 1998 review of published studies on the quality of medical care received by Americans reported that only three of five patients with chronic conditions received the best recommended care.4
Practice guidelines, including the US Headache Consortium Guideline (the Guidelines), are a strategy for defining best practices and are intended to modify physician behavior.2,5⇓ Guidelines are effective only if they are coupled with appropriate education and implementation strategies.5 The Guidelines provided a multispecialty consensus on the diagnosis and treatment of migraine,6–10⇓⇓⇓⇓ which has been used by many medical societies to establish their own guidelines, including the American Academy of Neurology (AAN).11
Though guidelines are an important step in improving the quality of care, population-based studies suggest that there are barriers to implementing optimal migraine treatment. The American Migraine Studies I12 and II,13,14⇓ conducted a decade apart, have confirmed that approximately 18% of women and 6% of men have migraine. Many migraine sufferers remain undiagnosed or misdiagnosed, and a substantial portion of the migraine population, who could benefit from newer therapies, does not receive them.12–14⇓⇓
As a prelude to developing educational practice improvement initiatives and guideline implementation programs, it is important to understand clinicians’ knowledge, attitudes, and practice patterns regarding migraine management relative to the Guidelines’ recommendations. Neurologists are an important target because headache disorders are a leading reason for outpatient neurologic consultations, accounting for almost one in five outpatient visits to neurologists.15,16⇓
Accordingly, we conducted two complementary studies to assess the knowledge, attitudes, and practice patterns of US neurologists relative to the US Headache Consortium Guidelines. In the first study, the Migraine Knowledge, Attitude, and Practice Patterns (MKAPP) Survey, neurologists answered questions regarding their attitudes and approach to managing migraine as well as their knowledge and acceptance of the Guidelines. The MKAPP also addressed barriers to effective care and the educational tools neurologists use and prefer to gain information in the field of headache. In the Clinical Vignette (CV) Survey, a second independent group of neurologists answered questions about their approach to diagnosis and management of two specific headache vignettes.
Methods.
Overview.
Participants for each study were actively practicing neurologists selected from the membership list of the AAN. The MKAPP and the CV Surveys were sent to independent samples of 600 randomly selected neurologists each in the fall of 2000. In each study, follow-up surveys were sent to nonresponders after 2 weeks. A third survey was sent when necessary. Nonresponders to all three surveys were telephoned to remind them to complete the survey.
To minimize the length of the survey, information from the AAN’s databanks regarding demographic features (age and sex), years in practice, type of practice, and practice setting was linked to the survey data collected for each respondent.
Development and format of MKAPP Survey.
The survey was developed by IMR, Inc. (Ft. Lauderdale, FL), a survey research company. Prior to developing the MKAPP Survey, neurologists specializing in headaches (n = 34) and other neurologists not specializing in headache (n = 28) were interviewed to assess their knowledge, attitudes, and beliefs regarding headache management and the Guidelines. The interviews and the Guidelines were used to develop draft questionnaires. These drafts were reviewed by an expert panel of neurologists and headache specialists and revised several times.
The final MKAPP Survey collected data on 1) the importance of headache in the physicians’ practice; 2) headache continuing medical education (CME) in the last 2 years; 3) profile of current practice patterns; 4) use of preventive medications in migraine management; 5) use of acute treatments for migraine; 6) use of nonpharmacologic treatment; 7) approach to patient education; 8) approaches to diagnosis and evaluation; 9) practices in assessing coexisting conditions; 10) knowledge of the Guidelines, including awareness and understanding of, attitude toward, and satisfaction with the Guidelines; 11) self-reports of level of agreement with and level of adherence to key principles of Guidelines-based care. Additional questions assessed the prevalence of migraine in the physician or in a close relative (spouse, child, parent, sibling) or both. Response options were “agree,” “disagree,” or “have no opinion.”
Development and format of CV Survey.
Clinical vignettes and questionnaires were also developed by IMR, Inc., based on the interviews described above. Draft vignettes and follow-up questions were revised based on several rounds of comments from the expert panel.
The final CV Survey consisted of two patient histories (see the supplementary material on the Neurology Web site; go to www. neurology.org). The questionnaire asked how likely the neurologist would be to take specific steps in the diagnostic evaluation and management of each patient. Response options were “definitely would not,” “probably would not,” “unsure,” “probably would,” and “definitely would” take specific steps in managing each of the patients.
In brief, the first patient was a 35-year-old woman with a stable pattern of typical migraine without aura (2 days/month) unsuccessfully treated with over-the-counter medication. She had no headache “red flags” and an unremarkable neurologic examination. The patient had never had a neuroimaging procedure. According to the Guidelines, she had no indication for neuroimaging, EEG, or lumbar puncture.
The second patient was a 45-year-old African American man with hypertension and hypercholesterolemia who presented with headaches of increasing frequency. His headaches clearly met the International Headache Society (IHS) criteria for migraine17 but lacked some typical features: They were bilateral but pulsating and severe; they were associated with photophobia and phonophobia but not nausea. The headaches had progressed over the last year from a frequency of one per month to a frequency of eight per month and were associated with medication overuse. According to the Guidelines, he had indication for preventive medication.
Data management and analysis.
Electronic data files were first converted into an analytic data set. Range checks and frequency distributions were then generated to examine the data. All data management and analysis tasks were performed using SAS statistical software for Windows (version 7; Cary, NC). In exploratory analyses, frequency distributions and cross-tabulations were constructed and examined.
Results.
Study 1: MKAPP Survey.
Sample characteristics.
Of the targeted sample of 600 neurologists, 147 (24.5%) participated in the MKAPP. Table 1 presents the demographic characteristics of the participating sample. Participants in the study had a median age of 46 years and were predominantly men (75.5%) and white (61.2%); most were US medical graduates (64.6%) and board certified in neurology (64.6%). They had been in practice for a median of 10 years. Predominant practice types were university-based (20.6%), neurology group (18.5%), and solo (12.3%) practices. Twenty-eight percent reported that they focused on headache.
Table 1 Distribution of demographic characteristics among neurologists participating in the physicians’ surveys
Overall, participants saw a median of 40 patients/week, 10 of whom were headache patients. Fifty-six percent of the sample saw ≥6 headache patients/week, and 34.7% saw ≥11 headache patients/week. The most common headache types were migraine and tension-type headache, followed by chronic daily headache.
Attitudes about migraine and its treatment.
Most neurologists felt that migraine was primarily a disease of the brain with a well-established neurobiological basis (69%); only 11% disagreed, and the remainder did not respond or had no opinion (table 2). Sixty percent considered headache an important part of their practice. Fifty-seven percent felt treating headache was an important part of their contribution to the community. Despite these positive attitudes, respondents indicated that patients with headache consumed more time (49%) and had more psychiatric problems (50%) and that interactions with these patients were more emotionally draining than with other patients (35%). Some neurologists felt that many patients with headache were motivated to maintain their disability (24%). Most neurologists (55%) felt reimbursement did not cover the extra time patients with headache required. Only a minority wanted to increase the number of patients with headache they saw (24%) or the proportion of their practice devoted to headache (18%).
Table 2 Attitudes about migraine and its management among neurologists participating in the Migraine Knowledge, Attitudes, and Practice Patterns Survey
Participating neurologists strongly supported patient education and patient participation in management (86%). Most felt that it was important to address patient expectations (82%) and preferences (73%), at least in part because considering patient preference improves compliance (79%). There was general support for the use of headache diaries (58%) and a belief that using diaries would improve compliance (69%) and help the patients to understand their disease (72%). Most asked about family planning in women of childbearing potential (56%). Most neurologists recognized that an adequate treatment trial was required to evaluate a drug (82%) and that noncompliance might interfere with that evaluation (76%). Most participants felt that it was worthwhile to devote time to a back-up treatment plan (69%) and that doing so would improve compliance (65%). Participants recognized that medication overuse might make it more difficult to reduce disability (77%) and that reducing interfering medications might improve compliance (78%), but some did not agree that patients might not reveal their use of these medications (31%).
Neurologists thought that it was important to re-evaluate treatment after a period of stability (73%) and that doing so might reduce costs (47%). Finally, most agreed that nonpharmacologic treatment should be considered (69%).
Learning about headache and the Guidelines.
Sixty-four percent of survey participants had participated in headache-related CME in the last 2 years, and 46% had received ≥6 hours of CME regarding headache. The most popular sources of headache education included medical journals (85%), medical meetings (68%), and dinner programs (44%). Internet-based education was rarely used (13%). The AAN Continuum series was occasionally or frequently used by 41%, but 48% perceived it as an important approach for updating neurologic knowledge.
Participants were interested in learning approaches that might improve patient compliance through patient self-management (68%). They were also interested in methods that would improve documentation and coding (62%) and in patient registries if these approaches increased reimbursement (41%).
Attitudes about the Guidelines varied, with just 4.8% using them frequently, whereas a little more than one-third used the Guidelines occasionally (36%). Although one-third found the Guidelines useful, only 5% thought that they were unhelpful. The remainder had not yet formed or reported an opinion.
Diagnosis.
Most neurologists (84%) try to assign a specific headache diagnosis to each patient. Attitudes were mixed about the IHS criteria17: Twenty-seven percent felt they were too complicated for practice, 30% felt they were useful, and 31% had no opinion (data were missing for the remaining 12%). Most agreed with the Guidelines that a neurologic exam was obligatory (82%), but some felt it was not always indicated (5%). However, most respondents indicated that they used MRI or CT in evaluating severe migraine (53%), and 58% felt that MRI or CT can reveal actionable issues in patients with severe migraine even after a normal neurologic exam.
Acute treatment.
Participating neurologists were generally aware of issues of medication overuse. Though the majority recommended limiting acute treatment to 2 or at most 3 days/week (64%), a significant minority (36%) did not agree with the Guidelines recommendation. Many neurologists felt that patients could self-monitor and guard against medication overuse (46%). Most neurologists agreed with the Guidelines recommendation that triptans are indicated for moderate to severe migraine (79%). Few felt that triptans should be reserved for those who have tried and failed at least two other prescription medications (12%). Most agreed that nonoral therapy should be considered in patients with nausea and vomiting (71%) and that rescue medication was important (68%).
Preventive treatment.
Most participants agreed that preventive treatment should be considered for patients who have frequent or disabling attacks (85%) and that amitriptyline, propranolol, timolol, and divalproex sodium are efficacious preventive treatments (81%). Most felt that patients prefer long-acting agents (51%) and that these agents improve compliance (55%). Most agreed that concomitant illnesses should be considered when selecting from among the effective preventives (80%) and that this strategy improves compliance (80%).
Study 2: CV Study.
Sample characteristics.
Of the target sample of 600 neurologists, 150 (25%) returned the surveys. Table 1 presents the demographic characteristics of the participating sample. Participants had a median age of 45 years and were predominantly men (85%) and white (65.3%); most were US medical graduates (73%), active members of the AAN (58%), and board certified in neurology (78%). They had been in practice for a median of 12 years. Predominant practice types were solo (21%), university-based (21%), or neurology group (20%) practices. Only 4.7% of these neurologists reported that they focused on headache.
Vignette 1.
In this patient with clear-cut migraine, 91% would probably or definitely diagnosis migraine without aura, whereas 9% would diagnose tension-type headache. The majority (52%) probably or definitely would order routine laboratory studies. Sixty-one percent of respondents indicated that they probably or definitely would not order a neuroimaging procedure. Thirty-one percent said that they probably or definitely would image this patient despite the Guidelines’ recommendation to avoid imaging when the neurologic exam is normal and features that suggest structural disease are lacking. In terms of acute treatment, 47% would probably or definitely recommend a nonsteroidal anti-inflammatory agent (with or without an antiemetic), 64% would recommend an oral triptan, and 55% would recommend a nonoral triptan. Just 4.7% would recommend narcotic-containing compounds, whereas 28.6% would prescribe nonnarcotic combination-of-ingredients products. Surprisingly, 45% of respondents would probably or definitely recommend a preventive medication. Ninety-two percent would probably or definitely teach the patient to identify and avoid headache triggers, but 60.6% of respondents were unsure or probably or definitively would not recommend relaxation training or another behavior treatment. The overwhelming majority (91.4%) probably or definitely would advise the patient about the risks of acute medication overuse.
Vignette 2.
Seventy-eight percent of the neurologists would probably or definitely diagnosis migraine without aura, whereas 12% would diagnose tension-type headache in this case. For this patient, 71% of neurologists indicated that they probably would appropriately order a neuroimaging procedure. Relatively few neurologists were inclined to order an EEG (7%) or a lumbar puncture (4%). Routine laboratory studies (81.4%) and EKG (61.3%) probably or definitely would be ordered by the majority.
The responses suggested that nonsteroidal anti-inflammatory agents would probably or definitely be recommended by 45.3% of respondents, narcotics by 8.6%, nonnarcotic combination products by 32%, oral triptans by 38%, and nonoral triptans by 16.7%. Eighty percent of the physicians surveyed recommended a preventive treatment in this case. Amitriptyline (47%) and divalproex sodium (38%) were the preferred options. Switching from angiotensin-converting enzyme inhibition to a β-blocker would be recommended by 46.7%.
Ninety-four percent of the physicians probably or definitely would advise the patient about the risks of medication overuse. Whereas 90% would probably or definitely teach the patient to identify and avoid headache triggers, 46% of the respondents were unsure or probably or definitely would not recommend relaxation training or another behavioral treatment.
Discussion.
We have presented the results of two complementary studies designed to understand the beliefs, attitudes, and knowledge of neurologists regarding migraine management as well as their knowledge, acceptance, and use of the Guidelines. Each study included about 150 neurologists.
In the MKAPP Survey, about two-thirds of participants felt that migraine was a legitimate brain disease with a firm neurobiological basis, consonant with the pathophysiology of migraine.18,19⇓ A similar number regarded it as an important part of their current practice. A small minority (18%) wanted to increase the proportion of their practices devoted to headache, perhaps because of the perception that patients with headache are more time consuming than other patients and that reimbursement is inadequate, given the incremental effort required (see table 2). For the minority who felt that migraine patients were motivated to maintain their disability, these negative feelings might act as a barrier to good care and contribute to patients’ dissatisfaction with the treatment.20 Additional efforts to promote education about the burden of migraine and the impact of migraine on the quality of life are required.
Regarding the diagnosis of migraine, the neurologists in the MKAPP Survey presented divergent views about the IHS criteria.17 About one-third thought the criteria were too complex for use in clinical practice. As the Guidelines recommend the use of the IHS criteria, this is a potential barrier to Guidelines-based care. Some neurologists (18%) felt that the neurologic exam was not obligatory; the Guidelines recommend a neurologic examination. The majority reported using MRI or CT when evaluating severe migraine or felt that they could diagnose structural disorders in patients with severe migraine, even in those with a normal neurologic exam. According to the Guidelines, a normal neurologic examination is required to exclude secondary headache before diagnosing migraine, and neuroimaging in migraine sufferers who have a normal exam and no red flags is not indicated.10,17⇓
Results of the CV Survey reinforce results from the MKAPP regarding issues in diagnosis. Vignette 1 presented a typical case of migraine without aura unsuccessfully treated with over-the-counter medication. Although most neurologists correctly identified migraine, 9% diagnosed tension-type headache, though the patient clearly met IHS criteria for migraine.17 Perhaps the absence of aura contributed to the confusion with episodic tension-type headache. For vignette 2, a clear-cut case of migraine that lacked aura, unilateral pain, and nausea, 78% correctly diagnosed migraine, but 22% did not, perhaps because they rely on features that were absent to make the diagnosis.
For vignette 1, the majority of the physicians would not order a neuroimaging procedure, in agreement with the Guidelines,10 but a full 31% said that they probably or definitely would image this patient. As the patient did not have any of the indications for neuroimaging set forth in the Guidelines, this result suggests that a subgroup of neurologists may tend to overutilize diagnostic technology, reinforcing the results of the MKAPP Survey.10,21⇓ Thus, educational efforts should focus on migraine diagnoses and particularly on the full spectrum of features that support that diagnosis. In addition, indication for neuroimaging should be stressed.
In the MKAPP Survey, attitudes regarding the principles of management, acute treatment, and preventive treatment were generally consistent with the Guidelines’ recommendations. For vignette 1, most neurologists selected a triptan, which is appropriate according to the Guidelines.10 The Guidelines recommend using migraine-specific agents in patients such as this one, with moderate or severe migraine.10 For vignette 2, acute treatment options (probably or definitely recommended) include nonsteroidal anti-inflammatory drugs (NSAIDs) (45%), narcotics (9%), nonnarcotic combination products (32%), oral triptans (38%), and nonoral triptans (17%).10,21⇓ Because this patient has multiple risk factors for coronary artery disease, including age, sex, hypertension, and hyperlipidemia, triptans should not be first-line therapy.22 At an attack frequency of eight per month, the Guidelines’ caveat to “guard against medication overuse” pertains.6 For that reason, among others, a prescription NSAID may be a better choice than a narcotic or a combination product. Most neurologists chose an acute treatment option that was suboptimal for this patient. Happily, the large majority followed the Guidelines’ general principles for managing patients with migraine headache. For example, 94% of neurologists would advise this patient of the risks of medication overuse and respondents would also address trigger avoidance (90%) and schedule a follow-up visit (94%). Nonetheless, 36% failed to endorse the Guidelines’ recommendation that acute treatment should be limited to 2 or at most 3 days/week.
Surprisingly, 45% of respondents would probably or definitely recommend a preventive medication for the patient in vignette 1, despite the Guidelines’ recommendation that suggests preventive medications for frequent or disabling migraines or for patients that failed acute treatments.10 At an attack frequency of two per month with no prior acute prescription drug use, a preventive drug is not indicated for this patient. For vignette 2, 87% of neurologists would recommend a preventive treatment for this patient. At eight migraine attacks per month, preventive treatment is indicated. In both cases, a significant percentage of neurologists were unsure or probably or definitively would not recommend relaxation training or another behavioral treatment (60.6% in case 1 and 46% in case 2). The Guidelines recommend nonpharmacologic measures especially when used in conjunction with pharmacologic measurement.9
Caution is needed when interpreting both studies. First, despite three mailings and a phone call, we achieved a participation rate of only 25%. Though this is typical for surveys of physicians,23 it raises the possibility of participation bias. Because participants and nonparticipants were similar in age, years in practice, and other variables, the participating sample appears representative. Second, the practice patterns in questionnaire surveys are evaluated by self-report rather than a review of clinical records. These reports may be influenced by selective recall and by social desirability. Third, the practice patterns in the CV Survey were evaluated using clinical vignettes rather than responses to actual patients. Clinical vignettes obviate the need for time-consuming and expensive audits of medical records or the presentation of standardized patients. However, vignettes are crafted to eliminate the ambiguities of real-life patients.24 Previous studies demonstrated that responses to clinical vignettes accurately reflect practice patterns revealed by review of medical records, supporting this method as a valid approach for assessing process and quality of care.25
These two studies complement prior work that has assessed barriers to effective migraine care: Many patients with migraine do not consult doctors, many who do consult do not receive a correct diagnosis, and many patients are not provided with the appropriate treatment.20 The American Migraine Study I and II have demonstrated the persistence of these barriers over the period from 1989 to 1999.12–14⇓⇓ Only 10 to 15% of migraine sufferers consult neurologists or headache specialists.14
Practice guidelines are one approach to addressing barriers to care by providing systematically developed statements that assist the practitioner and patient in making appropriate health-care decisions regarding specific clinical conditions.26 As evidence-based guidelines summarize current knowledge on optimal care, it is assumed that guideline implementation will improve the quality of medical care. However, guidelines have little impact unless physicians are aware of them and choose to implement them. Only 10% of physicians change a practice behavior on the basis of reading a guideline.27 Multimodal interventions are therefore needed to help practitioners understand the need for guideline implementation and provide low-burden strategies to make changes within their practice settings.
As a step toward improving migraine diagnosis and treatment, the US Headache Consortium Guidelines provides a multispecialty consensus on the diagnosis and treatment of migraine.6–10⇓⇓⇓⇓ The results of the MKAPP and the CV Surveys demonstrate that most neurologists practice high-quality headache medicine. They also highlight the need to translate the Guidelines into clinical practice. Important targets for educational messages include 1) improving diagnosis by improving the full range of symptom clusters that define migraine; 2) appropriate use of neuroimaging; 3) appropriate selection of acute treatment; 4) steps for avoiding medication overuse and rebound headache; 5) indications for preventive treatment; 6) use of nonpharmacologic interventions.
Acknowledgments
Funded by a grant from Merck, Inc.
Footnotes
-
Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the June 8 issue to find the title link for this article.
- Received November 13, 2002.
- Accepted February 17, 2004.
References
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