How Can Patient History Improve the Diagnosis of Chronic Migraine?

SAN DIEGO—Accurate diagnosis of chronic migraine may improve when patients use a “lumping” strategy versus a “splitting” strategy when sharing their headache history with providers, according to research presented at the 58th Annual Scientific Meeting of the American Headache Society.

Chronic migraine can be challenging to diagnose, especially for less experienced providers, said Priyanka Yadav, MBBS, a neurology resident at the University of Kentucky in Lexington. The International Classification of Headache Disorders, third edition, defines chronic migraine as headaches occurring on at least 15 days per month for three months, at least eight of which have features of migraine. Patients with chronic migraine can experience headaches similar to those of patients with tension-type headache. As a result, headache history is vital to achieving a correct diagnosis, Dr. Yadav added.

Although a provider may have sufficient information about the patient’s headache history, diagnosis may still be confusing if patients describe their headache history using a splitting strategy, in which patients distinguish multiple types of headache. For example, a patient may report that he or she had two types of headache that occurred over the previous three months. “This [history] can be confusing because inexperienced providers may not recognize that patients with chronic migraine experience headache days similar to [those of] tension headache,” said Dr. Yadav.

Priyanka Yadav, MBBS

Dr. Yadav and colleagues hypothesized that a lumping strategy would help neurologists to reach a correct headache diagnosis, as opposed to the splitting strategy. In the lumping strategy, patients describe one type of headache. For example, a woman may report having a continuous, background, mild, pressure-like pain throughout her head, which can evolve into intense, throbbing pain associated with nausea and light and sound sensitivity, said Dr. Yadav.

For the study, researchers sent an unannounced electronic multiple choice quiz to 19 neurology residents at the University of Kentucky. The quiz assessed the residents’ ability to recognize the correct headache diagnoses of various case vignettes of episodic migraine, chronic tension-type headache, and chronic migraine. In addition, residents were asked to recognize the chronic migraine criteria. The main outcome measure was frequency of chronic migraine recognition as a function of history style, presented in either the lumping or splitting format.

The response rate to the quiz was 100%. Results indicated that correct recognition of chronic migraine was more likely when the headache history was presented in a lumping format, as opposed to a splitting format. “When presented with the splitting style, participants often thought that the patient had two headache diagnoses (eg, chronic tension-type headache and episodic migraine), instead of one unifying diagnosis (eg, chronic migraine),” said Jonathan H. Smith, MD, coauthor and Assistant Professor of Neurology at the University of Kentucky College of Medicine.

Participants were poor at recognizing that features of these primary headache disorders can coexist to contribute toward a uniform diagnosis of chronic migraine. “These results have strategic implications for how physicians should organize and teach the headache history,” said Dr. Yadav.

—Erica Robinson

Suggested Reading

Moriarty M, Mallick-Searle T. Diagnosis and treatment for chronic migraine. Nurse Pract. 2016;41(6):18-32.

Eross E, Dodick D, Eross M. The Sinus, Allergy and Migraine Study (SAMS). Headache. 2007;47(2):213-224.