Migraine Management and Physician Referrals


Red flags that would prompt a pharmacist to refer a patient with migraine to be evaluated by a physician.

Mark Percifield, PharmD: Jennifer, when would a referral to a physician for chronic management and/or preventative treatment be recommended? When do you decide that you recommend they see a physician?

Jennifer L. Mazan, PharmD: A good rule of thumb is to keep in mind the numbers: 2 or more headaches a week, or more than 15 per month, is the cutoff where we want to refer the patients to their physician for preventative medications. We also want to refer them if acute therapy is not as effective as it was previously, not consistently effective, or if the patients find their migraines significantly disabling.

Mark Percifield, PharmD: Timothy, what are some of the red flags that pharmacists should know of that would prompt an urgent visit to a physician for a headache?

Timothy Smith, MD, RPh, FACP, AQH: That’s a great question because sometimes pharmacists find themselves in the position to make those recommendations to patients, especially in community pharmacies where patients walk in off the street with headache complaints. There are a few red flags that we talk about, like migraine frequency, severity, and disability. Those particularly pertain to people getting the right diagnosis and getting the right therapy. Sometimes a headache can be a sign of a serious underlying condition. There are a few things to be on the lookout for to know when the patient needs to be referred for urgent care or if you need to call 911, if it’s appropriate. If a patient has a headache that is accompanied by systemic symptoms, such as fever or weight loss, that could be a sign of systemic illness, temporal arteritis, or some kind of malignancy. The systemic signs are 1 thing.

Neurologic signs include if a patient has had a seizure or vision loss, that’s different from the typical migraine aura of a scintillating scotoma that goes away in 20 or 30 minutes. If someone is having monocular vision loss, for example, or more prolonged vision disturbance, weakness, or sensory loss in any geographic distribution that’s accompanied by the headache, it could be a sign of something more important. Then we have concerns about how the headache comes on. If it’s a new presentation—even in a long-standing migraine sufferer—if they have different headache, or the worst headache of their life, this can be a sign of something changing. It might not just be their underlying migraine that’s bothering them. Some patients may have onset of their migraine, or headache attacks, at over 50 years old. If you’re older than 50 and you’ve never had a headache problem in your life, and now you have a significant, disabling headache, it still could be migraine, but the odds are that this needs to be imaged and evaluated because it could be something more sinister.

Other issues have to do with the actual onset of the attacks, including what they feel like and what triggers them. These would be things like what we call the thunderclap headache. This is when a patient has a sudden onset—like a lightning bolt or thunderclap. I’ve had patients describe it; they feel this sudden onset of a thunderclap, and they look around to see who hit them in the head. It’s bizarre that it comes on that suddenly, and this can be a sentinel headache for subarachnoid hemorrhage. This could be an acute emergency. If patients are having sudden onset like that—not just a rapid buildup, I’m talking about clear, out of the blue, like you got hit with a bat, as that’s the way patients describe it—that’s something that needs to be evaluated right away. Also, headache that comes on during intercourse, straining, or from coughing, could be a sign of increased intracranial pressure. It could be associated with a mass or an obstructing lesion in the ventricles or some other increased pressure event inside the head that needs to be evaluated, at least subacutely or acutely.

Then there are patients who have this pulsatile tinnitus with a headache that can be a problem. For example, if patients who have postural headaches stand up and their headache tends to come on acutely, that can be a sign of a spinal fluid leak, and that should be evaluated sooner than later. Those are some of the things to look for, but if pharmacists hear people describe those kinds of things, their advice should be to get in touch with their doctor right away. If they have that thunderclap headache or some kind of disturbance in their sensorium or a neurologic focal deficit, they might even consider calling 911 and having that patient cared for emergently.

Mark Percifield, PharmD: Unfortunately, I can relate to this. My daughter, who is 14 years old, was playing a volleyball game, and we thought she was having a sudden migraine attack. She was having intense head pain, and unfortunately, we found out she was having an aneurysm due to an AVM, or arteriovenous malformation. Fortunately, we got her to the medical professionals that were able to take care of her, and she’s doing great now, but it‘s a good thing to know that when you see those red flags, things are a little different than a normal headache. It’s very important to get checked out. Thank you for sharing that.

Transcript edited for clarity.

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