First Contact — Headache in Primary Care

Topic: Migraine and New Generation Medications

Host: Mia Minen, MD, MPH, FAAN, FAHS [@MiaMinenMD]

Guest(s): Claire Sandoe, MD, MSC, FRCPC, Headache Fellow [@ClaireSandoe] | Michael J. Marmura, MD

Description: In recent years, many new medications have been developed and approved for the treatment of headache and migraine disorders. These evidence-based treatments, such as those that target calcitonin gene-related peptide (CGRP), often work better and are better tolerated than older medications which were not designed to treat headache and migraine. In this episode, we review each of these new agents to help primary care providers feel comfortable incorporating them into their treatment plan. How do newer medications differ from earlier medications for migraine and headache disorders? Do they offer patients a better quality of life? Are there any restrictions on who can prescribe these newer migraine medications? Hear the answers to these questions and others from Claire Sandoe, MD, MSC, FRCPC, a headache neurologist at Women’s College Hospital and Assistant Professor at the University of Toronto, and Michael J. Marmura, MD, Associate Professor of Neurology at Thomas Jefferson University with a specialization in headache disorders.

[01:42] How do newer medications differ from earlier medications for migraine and headache disorders?

[03:44] What does the data on new medications tell us about how they can help certain patient populations?

[05:40] Do these newer medications offer patients a better quality of life?

[07:31] How are medications specific to the 5-HT1F receptor, such as lasmiditan, opening up new avenues for treatment?

[08:27] How do you counsel patients who are concerned about the side effects of new medications?

[09:56] What’s next when it comes to the development of new migraine treatments?

[11:48] How does the side effect profile of newer medications compare to that of common older medications?

[15:06] Are there any restrictions on who can prescribe these newer migraine medications? Is there anything else health care providers need to know in terms of prescribing them?

Learn more about the American Headache Society’s First Contact - Headache in Primary Care program at https://americanheadachesociety.org/primarycare/, check out our Preventive Migraine Treatment page for more on preventive treatment at https://americanheadachesociety.org/topic/preventive-treatment/ and follow us on Twitter (@ahsheadache).

Topic: Migraine and Emergency Medicine

Host: Mia Minen, MD, MPH, FAAN, FAHS [@MiaMinenMD]

Guest: Benjamin W. Friedman, MD, MS [@benjaminbwf]

Description: When migraine or headache pain is at its peak and usual treatments aren’t effective, patients often turn to the emergency department for relief. In some cases, this may be the most appropriate choice—especially when headache red flags are present. However, limited access to care, treatments or education often causes patients to make unnecessary trips to the ED. What are some headache red flags that warrant referring to the ED? What treatments are administered to patients with migraine who come to the ED? What can be done to help patients avoid returning to the ED? We cover these questions and others with Benjamin W. Friedman, MD, MS, an emergency physician and clinical epidemiologist in the department of emergency medicine at the Albert Einstein College of Medicine.

[02:02] What are some headache red flags that should prompt someone to visit the emergency department?

[04:00] Are there specific circumstances or factors, such as with pregnant or older patients, that should prompt someone to go to the emergency department for headache?

[05:37] What treatments are given to patients with migraine who come to the emergency department? Does the American Headache Society have guidelines for deciding which medications to use?

[08:40] What should health care providers know about using metoclopramide and prochlorperazine to treat patients with migraine?

[10:17] If patients in the emergency department don’t respond to the top evidence-based treatments, what other treatment methods can be offered to them?

[13:34] Do opioids have a role in managing headache or migraine in the emergency department?

[15:52] How can emergency clinicians improve their approach when it comes to migraine?

[16:38] What can be done to help patients from returning to the emergency department?

Learn more about the American Headache Society’s First Contact - Headache in Primary Care program at https://americanheadachesociety.org/primarycare/, check out our Acute Treatment for Migraine page for more on rescue medications at https://americanheadachesociety.org/topic/acute-treatment/ and follow us on Twitter (@ahsheadache).

Topic: Migraine and Dentistry/Orofacial Pain

Host: Mia Minen, MD, MPH, FAAN, FAHS [@MiaMinenMD]

Guest: Marcela Romero-Reyes, DDS, PhD

Description: To visit the dentist or not to visit the dentist? This question is often debated by patients with migraine who experience orofacial pain, or facial pain involving the temporomandibular joint (TMJ), mouth, head or neck. Whether or not a patient has been diagnosed with migraine, it can be difficult to determine if orofacial pain needs attention from a dentist or orofacial pain specialist. This is why it’s important for primary care providers to learn about the connection between dental pain, orofacial pain and migraine. What type of doctor should someone with orofacial pain see? How do you distinguish orofacial pain from migraine? What is involved in the management of temporomandibular disorders (TMD) for patients who also have migraine? We dive into these questions and more with Marcela Romero-Reyes, DDS, PhD, a dentist, certified orofacial pain specialist and director of the Brotman Facial Pain Clinic at the University of Maryland School of Dentistry.

[01:31] What is the difference between dental and orofacial pain, and what type of doctor should be seen for each? 

[03:21] How do you distinguish orofacial pain from migraine?

[06:28] What have studies shown about the relationship between “TMJ” and migraine? Is “TMJ” the correct term to use?

[11:19] What is involved in the management of temporomandibular disorders (TMD) for patients who also have migraine?

[14:36] How can migraine differ from mid-facial pain?

Learn more about the American Headache Society’s First Contact - Headache in Primary Care program at https://americanheadachesociety.org/primarycare/ and follow us on Twitter (@ahsheadache).

Topic: Migraine and Optometry/Ophthalmology

Host: Mia Minen, MD, MPH, FAAN, FAHS [@MiaMinenMD]

Guest: Kathleen B. Digre, MD [@kathleen_digre]

Description: Approximately 33% of patients with migraine experience fully reversible visual (most common), sensory, or other central nervous system symptoms—known as aura—prior to or during migraine attacks. These symptoms are commonly confused with other neurological disorders by patients and clinicians alike. Understanding the basics of migraine aura can help health care providers make accurate diagnoses and provide appropriate medical care. What is aura? When should someone seek medical attention when experiencing visual disturbances? What treatment options are available for patients with migraine aura? Get answers to all of these questions and more from Kathleen B. Digre, MD, Distinguished Professor of Neurology and Professor of Ophthalmology at the University of Utah.

[02:32] Why is the term “ocular migraine” incorrect, and what should we use instead?

[04:29] Where can you find definitions of the different types of headache disorders?

[05:20] What is aura? What are its symptoms?

[06:42] Does aura occur in one or both eyes?

[07:07] What is retinal migraine?

[09:26] What are common mistakes that patients and health care providers make when it comes to understanding migraine with aura?

[11:28] When should someone experiencing visual disturbances seek medical attention?

[13:28] What treatment options are available for patients with aura?

Learn more about the American Headache Society’s First Contact - Headache in Primary Care program at https://americanheadachesociety.org/primarycare/, check out our Migraine with Aura page for more on the symptoms and treatment for migraine with aura at https://americanheadachesociety.org/topic/migraine-with-aura/ and follow us on Twitter (@ahsheadache).

Topic: Migraine and Psychology/Psychiatry

Host: Mia Minen, MD, MPH, FAAN, FAHS [@MiaMinenMD]

Guest: Noah L. Rosen, MD, FAHS [@NoheadachesNoah]

Description: Both migraine and psychiatric disorders are common conditions that often go unrecognized, underserved and undertreated across the globe. The relationship between migraine and psychiatric disorders is complicated, and people dealing with both need informed care from a primary care provider who understands the nuances and connections between these conditions. Are there pharmacological treatments that may be considered to co-treat migraine and psychiatric comorbidities? What evidence is there for the efficacy of older drugs versus newer options for migraine and psychiatric disorders? We discuss these questions and more with Noah L. Rosen, MD, FAHS, Associate Professor of Neurology and Psychiatry at the Zucker School of Medicine at Northwell Health.

[01:40] What is the connection between migraine and psychiatric disorders?

[05:18] Are there behavioral therapies for migraine? How do you encourage patients to try them?

[07:23] What is cognitive behavioral therapy? How can it help patients?

[08:52] What are the options for raising awareness among health care providers about behavioral therapy and addressing the stigma patients often face?

[10:15] Are there pharmacological treatments that exist for both migraine and psychiatric disorders?

[14:25] What evidence is there for the efficacy of older drugs versus newer options for migraine?

Learn more about the American Headache Society’s First Contact - Headache in Primary Care program at https://americanheadachesociety.org/primarycare/. Check out our Behavioral Treatment for Migraine page for more information on behavioral therapies at https://americanheadachesociety.org/topic/behavioral-treatment/ and follow us on Twitter (@ahsheadache).

About 60% to 70% of women with migraine experience attacks associated with hormonal changes. Hear Dr. Susan Hutchinson and Dr. Catherine Stika answer frequently asked questions about hormones and migraine, including hormonal treatment options and how to have these conversations with your migraine patients.

The First Contact Headache in Primary Care podcast breaks down topics in headache medicine for primary care providers and other healthcare professionals who care for patients with headache disorders. The program’s goal is to provide educational resources to empower healthcare professionals and improve headache and migraine care for patients.

Learn more on the Primary Care website.

Many women notice a reduction in migraine activity during pregnancy, especially in the second and third trimesters. But when should patients be concerned about headache during pregnancy? Learn from Dr. Susan Hutchinson and Dr. Catherine Stika about some headache red flags for pregnant patients, how to manage migraine after delivery and more.

The First Contact Headache in Primary Care podcast breaks down topics in headache medicine for primary care providers and other healthcare professionals who care for patients with headache disorders. The program’s goal is to provide educational resources to empower healthcare professionals and improve headache and migraine care for patients.

Learn more on the Primary Care website.

It’s important for healthcare providers to discuss pregnancy-safe treatment options with their migraine patients. From changes in medications to treatment at home, find out how to help women manage their migraine while pregnant in this podcast episode with Dr. Nina Riggins, Dr. Susan Hutchinson and Dr. Catherine Stika.

The First Contact Headache in Primary Care podcast breaks down topics in headache medicine for primary care providers and other healthcare professionals who care for patients with headache disorders. The program's goal is to provide educational resources to empower healthcare professionals and improve headache and migraine care for patients.

Learn more on the Primary Care website.

While migraine has not been proven to affect fertility, pregnancy can significantly impact migraine symptoms. Join Dr. Deena Kuruvilla in her conversation with Dr. Susan Hutchinson and Dr. Catherine Stika on treating and supporting patients with migraine who are planning to become pregnant.

The First Contact Headache in Primary Care podcast breaks down topics in headache medicine for primary care providers and other healthcare professionals who care for patients with headache disorders. The program's goal is to provide educational resources to empower healthcare professionals and improve headache and migraine care for patients.

Learn more on the Primary Care website.

More than half of women with migraine report attacks just before and during their period. In this episode, Dr. Jelena Pavlovic discusses how hormonal changes can affect women’s migraine and how to diagnose and treat menstrual migraine with Dr. Susan Hutchinson and Dr. Catherine Stika.

The First Contact Headache in Primary Care podcast breaks down topics in headache medicine for primary care providers and other healthcare professionals who care for patients with headache disorders. The program's goal is to provide educational resources to empower healthcare professionals and improve headache and migraine care for patients.

Learn more on the Primary Care website.