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More than any other page in my migraine section, this page represents my personal views of why our ability to identify and successful treat migraine patients has fallen so short.

Despite over 10 years of intensive educational efforts and hundreds of millions of dollars, only roughly 50% of patients with migraine are aware of their illness. Educational efforts have targeted mostly primary care physicians but they do not have the time needed to take an adequate headache history in a follow up visit. Add to this the patient who pre-announces their diagnosis and it is no wonder that many patients carry their misdiagnosis of tension or sinus headaches year after year. In my opinion the fix to this is the development of computerized history taking for headaches. In this manner, the physician would save time and the computer would ask all of the pertinent questions. To do this properly would require a large expenditure of both physician and programmer time and I have not found anyone willing to fund such a venture despite the fact that it would improve public health and actually benefit drug manufacturers. A simple single headache history taker is online to at least represent a start in this area. Perhaps someone will contact me and assist moving this idea forward.

Once a patient knows they have migraines, treatment is again not optimal. Most patients are either not told or do not understand that if they have any migraines, then all of their headaches (whether severe or more mild) represent a form of their migraine disease and will respond to their typical migraine medication. Instead, patients continue to treat their "tension" headaches with OTC medications, their "sinus" headaches with OTC sinus medications and antibiotics, and only use their migraine specific headache treatment for their worst headaches. This also leads to improper communication with their physicians as the doctor asks - "How often are your migraines?" and the patient answers once weekly and ignores the chronic low level daily headaches.

Many patients with migraines are not given migraine specific therapy. There is either a fear to use these medications despite their excellent safety record, or a fear of lawsuits. I have heard regional headache experts say they will not give the triptans to anyone over a certain age (commonly 55 or 65) only for fear of lawsuits. Statistically, heart attacks occur more commonly as one gets older and there is an increased chance of coincidence between taking a triptan and having a heart attack. I am not referring to the use of triptans in patients with angina (i.e. inadequate blood flow to the heart during exercise) where they should not be used. But heart attacks in most patients represents something called plaque rupture which is not triptan related but presumably caused the death of seeming healthy athletes.

Another frequent mistake in treating migraines is in the underuse of prevention therapy. I have heard estimates that about 50% of patients with migraine should be on prevention but only 5% are. I have seen patients coming to me on a preventative for one year which they felt was ineffective but their physician did not discontinue or change it. Worst, I have seen many patients have side effects of their preventatives which were not working. Patients and physicians both must take some responsibility for this. Only 50% of my patients whom I ask to keep a headache calendar actually do so. Many non-neurologists and even some neurologists are only comfortable with one or two treatments. It is ok to refer patients on if you are not comfortable but to continue your inadequate therapy without referral is not good medicine.

Migraine patients are subjected to too many tests. Some physicians commonly perform evoked potentials, EEG, and thermography on their patients. Many headache physicians will obtain MRI or CT imaging on patients with infrequent migraine despite guidelines to the contrary. (I am not referring to chronic daily headaches which does require imaging.) MRA is commonly being performed. From discussions with these physicians, it does appear the risk of lawsuit is the primary driving force.