Starting Treatment For Your Patients With Migraine and Headache Disorders

Hope O’Brien, MD:
Welcome to NHF Insights, the National Headache Foundation’s podcast created with the support of our industry partners. We bring you fireside chats with experts on what’s new in migraine and headache care. I’m your host, Dr. Hope O’Brien. I’m a board-certified neurologist and headache specialist and board president of the National Headache Foundation. This episode is starting treatment, part of our new Healthcare Provider Series, and today we’ll explore when providers can intervene earlier to improve outcomes, the common pitfalls when starting treatment, how to set expectations and build effective care plans, and then practical strategies to keep patients engaged.

Let me introduce today’s guest, Dr. Merle Diamond. Dr. Diamond is a board-certified internal medicine specialist with training in emergency medicine. She’s nationally and internationally recognized as an expert in headache medicine. She is UCNS and AQH certified in headache medicine at the Diamond Headache Clinic, which her father, Dr. Seymour Diamond founded. And he is also the founder of the National Headache Foundation. Welcome, Dr. Diamond. It is such an honor to be here with you.

Merle Diamond, MD:
Thank you, Dr. O’Brien.

Hope O’Brien, MD:
You started your career in emergency medicine where a lot of patients with migraine land. So, tell me, what drew you to headache medicine based on your experience?

Merle Diamond, MD:
I wanted to do something that was different than my father and kind of break my bones that way. But eventually, I had worked at the clinic all during my childhood, and I just started liking the patients. I would help fill in at times, and I really enjoyed the clinical experience. And my father was just a master at speaking to patients and hearing their stories, and it was sort of the opposite of emergency medicine, and I really enjoyed it. And so, I asked if I could come work there, and my dad said okay.

Hope O’Brien, MD:
So as an emergency care physician, in what way would you say they could intervene in terms of helping them manage patients?

Merle Diamond, MD:
I think that’s really important because that might be the first place somebody goes when they have their first migraine or when they don’t have a diagnosis and they have these recurrent disabling pain. And so that would often be a place where somebody might get a diagnosis, or if they don’t get a diagnosis, they get a treatment. And I think as an emergency physician, as an emergency care provider, the thing I would carry today is that we recognize what migraine is, there a really good tools that you could have access to, giving patients somebody that they can follow up with in primary care, or not, depending on what’s going on with them, and that this is a treatable disorder and that you don’t have to sit in a bright, noisy emergency room with lights and noise, and you can get good care.

Hope O’Brien, MD:
That’s I think critical, is getting good care and getting that patient to the right provider. And we know that primary care physicians are busy balancing their time and listening to the patient. So, what are some common mistakes, would you say, or maybe opportunities that providers can make in starting treatment for patients with migraine?

Merle Diamond, MD:
I think it’s really important to listen to the patients’ story. And we have a limited, especially primary care, has a very limited period of time they get to interact with patients. And I think if somebody comes in and they leave it as their third or fourth issue, it’s important to back up and talk about that again and probably make a separate appointment so that the patient can tell their story and they can get a therapy done. If it gets brushed away, they may never talk about it for another couple of years or until they’re in some kind of crisis. So, hearing that as a part of the message. Something my dad taught me many years ago, I was like, why are all these people sitting in your waiting room with a headache? I just didn’t understand it. And he said, if they’re sitting in the waiting room in the middle of a day when they’re supposed to be at work, they’re immobilized by their disability and that’s important to pay attention to.

Hope O’Brien, MD:
Are there common misconceptions about migraine that you wish providers would be knowledgeable about?

Merle Diamond, MD:
Yeah, I think to protect the provider to some extent, they don’t get a lot of education in headache medicine in general. We learn to watch for the dangerous things, but not the common disorders that we see. And migraine is the most common disabling headache that we see in primary care or in a neurology office. So, it’s really important to give them tools so they know what questions to ask.

There’s a misconception that it’s going to take too much time. And what I would say is there’re really good tools available to get a good history, to make a plan. I think one of the most important things is this isn’t a one stop shop. We’re not at McDonald’s or something, and this is a relationship you’re going to have with the patient over time. And if you express interest, they’re going to open up and you’re going to find out some of the things you can do to help them.

Hope O’Brien, MD:
Are there any tools or advice you can give a provider in terms of if they have very limited time. And what question, what’s that important question that they can ask that will maybe be a red flag, as you know what, we need to talk about, well, we make the diagnosis and then what’s the treatment?

Merle Diamond, MD:
I think the important thing there is everybody’s looking for that short list of questions you can have. I think ID Migraine is still a good place to go. Richard Lipton published it many years ago. But it’s nausea, it’s sensitivity to light and sound, and it’s disability. Something my dad talked about so long ago. If you ask those three questions and you get positives, then it’s probably migraine. You can ferret out all the little pieces that will help you to guide the patient, but first you need that diagnosis.

Once you make that diagnosis, there’s so many different tools that you can give to your patients, like how do they eat, are they skipping meals, just lifestyle things. And there’re really good tools that you can hand to them that you can put in your EMR to document what’s going on with them. And it saves time in the visit because the questions are there. And if there’s something particular like, oh, you stop at someplace and have like 300mg of caffeine before you go to work every day, or how was your sleep, or just all those different places where migraine kind of comes out. I think the lovely thing about headache patients is that you do get to know them over time, and their lives are rich as they get better. It’s a big deal.

Hope O’Brien, MD:
It is a big deal. And I like how you said you listen to them. You get to know them. You learn their lifestyle. For many patients, I know that that we encounter, they can be a little bit resistant to starting treatments. And so, when you see maybe that they’re not getting better or things are getting worse for them, how do you set the tone and start that conversation about now’s the time?

Merle Diamond, MD:
A lot of patients don’t want to take a prescription medicine or what natural do you have. And I think those are all really important things to endorse and to hear, because there are a lot of more natural things that patients can do: regular sleep, not skipping meals, hydrating well, some vitamins that can work for them. And then if they’re still having high disability, how do you introduce that piece of, you know maybe we need a prescription medicine now. And so, when somebody is taking a lot of whatever cocktails they use to treat their individual headaches at home, one of the things I always ask patients is can you predict when you take that, that more than 50% of the time you get to do what you want to do that day. And there’s an aha moment there like, no, generally I don’t. And then addressing what their discomfort is with medications, because I think that’s important to sort out.

Hope O’Brien, MD:
Yeah, absolutely.

Merle Diamond, MD:
And that not everything has to be a medication. There are lots of interventions we can do that aren’t medications. So, you have to meet the patient where they are to some extent. But also, if nothing is working for them in all those natural things that they’re doing or all of these other tools that they’re using, introduce that concept of there are medicines that are very safe that can help lessen your disability.

Hope O’Brien, MD:
I agree with that. And I think for many of our patients, we talk about treatment goals and what are those goals. And I think we have guidelines that we as providers go by in terms of what is the goal for treatment. And for some patients it’s, yes, they want to be able to function. For others, they just want to be able to just stop an attack and have that headache go away. How do you balance that? Because for many of our patients, as we know, there are treatment options that just don’t work for them in terms of getting rid of that everyday headache.

Merle Diamond, MD:
I think that that’s really important. And again, go back to diagnosis. Does somebody have 4 migraines a month or have 12 migraines a month. Those are two very different patients generally. And if they’re two very different patients, they need two different plans. The patient who’s very intermittent but can’t tolerate missing work or school or whatever, we’re going to want to give them a treatment that can work effectively. And you have to share that sometimes it takes a try or two to find the right one, that some of the medications may not be tolerated or may not do the job in the way we want to. I think you introduce the fact that some patients just don’t even want to have a headache. And we have some newer things that we can do that if the patient can recognize the headache before pain, wake up in the morning and know, oh, this is a headache day for me. And they can treat it and they get no disability. It’s a holiday. It’s really great. And so, we’re so much better at using those tools and introducing it. But if I try to talk to somebody about what’s that faint hint in the morning when you wake up without a headache, how do you know it’s a headache day? But again, having that conversation and being able to move forward with it, it’s one of the beautiful things in headache.

Hope O’Brien, MD:
Yeah. And I think that’s one of the reasons I know that I went into headache medicine is this is a condition that can be treated and you can really make a difference in a patient’s life. So, with that, we have now more medicines than we did. I know when you started diagnosing and treating migraine, I’m sorry, I’m going to take advantage of the fact that you’ve been doing this a long time.

Merle Diamond, MD:
That’s ok. I know

Hope O’Brien, MD:
So, talk about layering. And if one medicine doesn’t work, what do you do then? Do you stop it? Do you add medicines?

Merle Diamond, MD:
Well, I think there’s a couple of really important concepts. The first concept is who needs prevention. And I know we’ll talk more about that in another episode, but who needs a prevention and who just needs an acute therapy. And also sharing with the patient that just because you need prevention now doesn’t mean you always need prevention. This is where you are today. We’re going to meet you where you are. And then as your headaches change, as you grow older, as different life events happen, we have to move forward with you. So, I think that’s really, really important.

I think sometimes patients are very shy about using prevention, that I don’t want to have to take a medicine for my headache every day. Is it that bad? Well, you’re coming to me to talk about it, so probably. And then hearing what they’re comfortable with, because we have oral medications, we have injections, we have devices. There’re so many different opportunities. And then getting back to if one thing isn’t working, don’t chase it with more. Once you’ve done every permutation of a certain medication, if it doesn’t work, we need to move forward. There are other things. Or we can put that medicine with another medicine.

And again, because we understand the mechanisms of migraine now, not thoroughly. I’m sure in other ten years we’ll have other mechanisms but that’s the way medicine is. And again, I remember today I saw one of my patients who for years she used an over-the-counter medicine and swore to me it was always going to work for her. And we had a long tug of war about how it wasn’t really working for her. And she came in today and she’s down to a couple of migraines a month if so, and she knows how to handle them. But we’ve gone through the whole permutation of I only take over-the-counter things. I don’t want any medicine, to like whatever you say, Dr. Diamond. Because she was desperate at a point because things weren’t working. And I think what I learned the most from seeing her today is that she has confidence now. She doesn’t have to worry about her headaches because she knows what to do.

Hope O’Brien, MD:
That’s a great story. It actually leads to my next question is how do you keep patients engaged especially if they’re coming to you and you prescribe a medication, it didn’t work, or there may be access issues?

Merle Diamond, MD:
Well, I just got that note this morning from one of my patients that everything I prescribed was like $1,000 or something. And so how do we access things and how do we make it available to patients in an appropriate fashion. And so many different issues we have to deal with today, and if we have to deal with them, it’s even harder for the patients. So, I try to remain open about like, let’s see how else we can do this so that patients can stay engaged.

So, I’ll share with you that, these are all Seymour stories, sorry, but that’s my dad. But he made everybody keep a headache diary. And I still occasionally see one of his patients. And they’ll always come in with their diaries. And I’m like, that’s really nice. Very different than what our patients today come in with the different options like Migraine Buddy or whatever. But his patients always bring it in, and I always know what medicine they’ve taken at what time of the day?

Hope O’Brien, MD:
On paper, is it on paper?

Merle Diamond, MD:
On paper. Your father told me I had to do that. And I’m like, okay. And it’s good because that does keep the patient engaged. Also, I think headache patients will often come in with things they’ve read in magazines or online and ask me questions about it. So, staying well versed with what’s going on and also being able to answer those questions. Because there’s so many different available pieces of information on the internet, some of which is good and some of which is scary. It’s important to walk patients through so they actually can navigate the right things.

Hope O’Brien, MD:
That is a great point. And speaking of that, where would you recommend a primary care provider go to access reliable information about migraine?

Merle Diamond, MD:
Well, I think, again, National Headache Foundation has been a forefront runner in like that accessibility information for both providers and patients. And it’s reliable information. And it doesn’t just come from one source. We pull from so many different people with so many different backgrounds, and we try to advocate for what the patient needs. And you need an organization that’s really growing and changing, so it’s important that we’re up to speed in terms of our education pieces.

There’s Primary Care Migraine for primary care doctors. I have to say I go on there as well looking at things, because I need to find out how other people are doing things. And so, it’s a really great resource for providers of all levels. And also, sometimes patients sneak in there and they want to read it, learn about it as well.

Hope O’Brien, MD:
Absolutely. I agree, and I know we talked a lot about migraine, but really all headache disorders. I think the National Headache Foundation is a great resource and available on your phone and on your laptop

Well, this has been an amazing discussion Dr. Diamond. Thank you so much for sharing your expertise about early intervention and treatment strategies and helping providers feeling more confident in managing headache disorders from the start.

Thank you so much our listeners, for joining us. We hope this episode gives you practical tools to improve patient care. Also for your patients, we’ve created a companion series where patients can go to recognize symptoms, communicate clearly, and come prepared for visits. To find the full series, visit headaches.org

Thank you again for listening. And till next time.

This episode of NHF Insights was supported by AbbVie and Pfizer. The content was developed independently by the NHF.

Resources

1. National Headache Foundation website https://headaches.org
2. ID Migraine https://headaches.org/resources/headache-tests
3. National Headache Foundation’s Primary Care Migraine CME https://www.pcmigraine.org

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