DR. LIPTON: What’s the relationship between migraine and other forms of cardiovascular disease?
DR. KURTH: That’s a good question. There are some theories about the increased vascular risk factors in patients with migraine that may explain the increased risk of ischemic stroke. In this scenario, it is plausible that migraine may also increase risk of other ischemic vascular events. Indeed, recent prospective studies have identified migraine with aura as a risk factor for myocardial infarction or other ischemic vascular events; however, the totality of evidence, compared with just that on ischemic stroke, is much lower because there aren’t as many studies showing a link.
The difference of the association between migraine and coronary events seems to be that the association is not limited to younger individuals (as with ischemic stroke). It’s not so clearly linked to subgroups such as those who smoke or use oral contraceptives, so the mechanism may be different. However, we need more evidence and particularly need to understand the precise mechanisms before we scare patients with the idea that migraines will increase their risk for various vascular events in the future.
DR. LIPTON: How do you think a primary care doctor should address the concerns that their patients with migraine with aura might express?
DR. SILBERSTEIN: Migraine is a risk factor for other disorders. The drugs that we use to treat migraine may either aggravate another disorder or be a contraindication. In terms of general health, we have to ensure that patients don’t smoke or drink excessively, and if they’re using hormonal contraception, the concern would be with migraine with aura in the presence of hypertension and smoking.
Most of our patients are generally young and healthy; it’s the elderly patient we tend to worry about. However, if there are no risk factors for coronary artery disease and they’re not hypertensive, diabetic, or obese or are non-smokers, we can treat them in the same way that we treat the younger patients.
DR. KURTH: Migraine should be simply viewed as marker of an increased risk of vascular events. While we’re trying to determine mechanisms that would allow the identification of patients with migraine who are at an increased risk of vascular events, assessing cardiovascular risk factors in a patient with migraine is necessary. It is specifically important to tell patients with migraine with aura to quit smoking and discuss the increased risk of vascular events with women patients who are taking oral contraceptives.
Whether there’s anything additional that a migraine patient can do, is unclear at this point. It is also unclear whether a preventative migraine medication will change the increased risk of vascular events and whether the acute medication is relevant to the increased risk. This is unlikely to be the case, as the association is limited to migraine with aura, although all patients with migraines take medication. I think the assessment of cardiovascular risk factors, as with any other patient, is beneficial.
DR. LIPTON: I think your earlier point that the absolute risk is low even when the relative risk is high, is very pertinent. Let me now focus on the issue of using oral contraceptives in women who have migraine with aura. Do you have a view on that, Dr. Silberstein?
DR. SILBERSTEIN: I think that one can use hormonal contraception in women with migraine with aura as long as they are not smoking, are not hypertensive, and understand that if there’s any change in the aura, it’s perfectly reasonable to use progesterone-only contraception, which is just as effective but may induce slightly more headache-related adverse events. That would be, in general, my first choice. There have been some patients in the past who needed hormonal contraception for other reasons or who did not benefit from progesterone-only contraception. I would put them on hormonal contraception as long as they’re monitored carefully for new or increased aura symptoms.
DR. LIPTON: Posing this question to all of you: do you have any specific advice for primary care clinicians who examine headache patients in the setting of diagnosis, assessment, and peaking epidemiologic factors.
DR. SILBERSTEIN: The best learning is that when a patient comes to the office complaining of a recurring headache, think of migraine; don’t think of tension headaches, cluster headaches, or sinus headaches. You will consequently ask the rest of the questions and prescribe migraine-specific medication or drugs that have been proven to be effective.
The next thing you need to do is ask your patient “Do you have headaches more often than not?” Again, the strategy would be different for patients with very frequent headaches. Clinicians always need to consider the scenario that patients with very frequent headaches may be overusing medication.
DR. BUSE: I advise HCPs to gather a complete picture of their patient by asking about functioning in all aspects of life and how their life has been affected by headache. This includes assessment of headache-related disability, quality of life, and medical and psychiatric comorbidities. Asking these types of questions will not only enhance data gathering, but will also give the patient permission to share additional information. If questions about impact on life, disability, and comorbidities are not asked, patients may not spontaneously provide this information. However, knowledge of comorbidities; headache impact; headache-related disability; and impact on family, social, occupational, and academic functioning is incredibly important in truly understanding the scope, burden, and severity of the condition. This information will allow for the development of tailored and effective treatment plans that optimally incorporate available pharmacologic and nonpharmacologic treatments and tools that are effective and appropriate.
DR. KURTH: I think it’s certainly important to spend time with the patient to obtain important information, as we have discussed, and to educate the patient about potential symptoms and changes in the migraine presentation that may cause a patient to return to the clinic. It may also be important to create a long-term relationship with the patient. We know that, specifically for patients with a high headache frequency, it’s quite difficult to find the right treatment, and therapy may have to be changed several times before a patient finds a treatment plan that works for him/her.
With regard to the cardiovascular risk factors, education is important. It’s also important that the clinician talks about the possibility that the headache pain resulting from a migraine may disappear but the aura symptoms may continue, especially for the elderly. We may need to follow-up with migraine patients who don’t have headache pain anymore because that may be an indication of an increased risk for other diseases.
A migraine patient is not just a patient with headache who you can send home with pain medication. We need to think about maintaining a long-term relationship and care for patients with migraine.
DR. LIPTON: In summary, we have talked about the diagnosis, assessment, and epidemiology of migraine. Regarding the diagnosis, while excluding secondary headache is certainly important, the faculty agrees that it is important to investigate the patient with an unusual headache or physical examination and consider migraine as a diagnosis first. Although migraine is a neurologic disease, care for patients with migraine mostly takes place in primary care settings. Therefore, only 10% to 15% of migraine patients consult neurologists and only 2% visit headache or pain specialists.33 The treatment of headache is mostly done in primary care settings, creating tremendous opportunity to improve headache outcomes. Primary care doctors should refer the patient to another specialist if the diagnosis is unclear, if the patient is not responding to treatment, or if levels of disability remain high despite efforts to treat.
We’ve established that migraine is an extraordinarily common disorder, affecting 18% of women and 6% of men.23,33 We’ve talked about the fact that migraine is a disabling disorder and that communication about disability is key in making an informed treatment decision while considering disability. We’ve talked about a number of comorbidities of migraine that influence both prognosis and treatment choices. Finally, we’ve talked about the relationships between migraine and psychiatric disorders, migraine and stroke, and migraine and heart attack, which indicate that migraine does not occur in isolation and that it certainly is not just a headache disorder but rather, a very common and treatable disorder in primary care.
With that, I’d like to thank the faculty—Dr. Silberstein, Dr. Buse, and Dr. Kurth—for their terrific participation and The Medical Roundtable for the opportunity to participate in this educational endeavor.