My first thought after reading the 3 articles on headache in this month’s Journal of Family Practice, focusing on the evidence basis for headache care, current practice, and efforts to enhance outcomes, is that headache and erectile dysfunction have a lot in common—a connection well beyond, “Not tonight, Dear, I have a headache.”
One study, by Verhagen and colleagues (page 1064), systematically reviews over-the-counter treatment for episodic tension-type headache. They find that NSAIDs and acetaminophen are effective for tension-type headache, when appropriately differentiated from migraine—supporting the adage, “Take two aspirin and call me in the morning.”
Walling and her colleagues (page 1057) evaluate the current practice of family physicians treating migraine and find that 80% of patients diagnosed with migraine are prescribed a triptan (admittedly, they did not look at how many patients were incorrectly diagnosed). Dr. Walling also finds that many patients used over-the-counter medicines to treat their headaches.
Indeed, in another article, Landy et al (page 1038) find that 70% of migraine patients—before an educational and system intervention—were using over-the-counter analgesics to treat their headaches. By using a brief migraine education DVD (lasting 38 minutes) and a follow-up screening tool, they were able to enhance diagnose and improve patient and physician satisfaction with care.
So, how does this information all add up? First, you can’t treat a condition without making a correct diagnosis. It is estimated that 13% of the US population suffer from migraine, making this condition more common than diabetes, asthma, or osteoarthritis. While tension-type headache is the most common primary headache type, most patients are successful at self-medication. Thus, migraine is the most likely diagnosis in patients presenting to our offices with headache. The history (guided by 2004 International Headache Society diagnostic criteria) and brief physical exam reliably rule out serious causes of headache and effectively direct therapy. The bottom line: think migraine, not tension or sinus headache, when seeing your patients.
After personally participating in an intervention similar to the one used in Dr. Landy’s study, I was stunned that I hadn’t appropriately diagnosed and treated many of my long-term patients with migraine. They never told me and I never asked.
Which brings me back to erectile dysfunction. Before Viagra, doctors and patients ignored ED. But, armed with easy to use diagnostic tools and an effective treatment, I have successfully intervened with many patients who were silently suffering. Family physicians can substantially improve our patients’ lives by proactively screening for such disorders.
Unfortunately, like Viagra, triptans are an imperfect treatment. Nearly half of the patients who tried triptans discontinued their use because of ineffectiveness or side-effects. Dr Landy’s study finds that only about 40% of patients were “satisfied/very satisfied” with medication even after appropriate diagnosis and the use of triptans. Nonetheless, 48% of patients were “satisfied/very satisfied” with the quality of migraine care.
This point I think is very important. It highlights that accurate physician diagnosis is important to patients even if ideal treatment is suboptimal. My guess is that these headache sufferers found comfort from the physician’s caring attitude and appropriately addressing their concerns. Headache treatment is more than handing out pills, but addressing the whole patient and their medical, psychological, and social needs. While practice guidelines and diagnostic criteria are easy to learn their successful application to real patients remains challenging. As family physicians we are reminded daily that the successful implementation of science is grounded in the art of medicine.