Dawn C. Buse, Ph.D., is a licensed clinical psychologist and Director of Behavioral Medicine, Montefiore Headache Center. She is also Assistant Professor in the Department of Neurology at Albert Einstein College of Medicine of Yeshiva University and Assistant Professor in the Clinical Health Psychology Doctoral Program of Ferkauf Graduate School of Psychology of Yeshiva University. She serves on the American Headache Society’s Education Committee and Electronic Media Committee, and the “Occupational Burden of Headache-Outcome Measures for Headache” working group of the World Health Organization “Lifting the Burden” campaign. Matthew S. Robbins, MD, is Assistant Professor of Neurology, Albert Einstein College of Medicine, Chief of Service for Neurology at the Weiler/Einstein Division of Montefiore Medical Center, and Director of Inpatient Services, Montefiore Headache Center. Drs. Buse and Robbins collaborated on this joint interview which is posted in two parts. This interview is Part 2.

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Questions

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Evelyn Corsini, MSW:

In Part I of your interview, you summarized findings from the World Health Organization (WHO) about headache disorders, which they showed are ubiquitous, prevalent, and disabling, as well as under-recognized, under-diagnosed, and under-treated worldwide. Your research has demonstrated that this is inclusive of the United States. In addition, as the WHO has described, you believe that these issues are due to the lack of formal undergraduate medical training in headache disorders.

Please describe your recommendation for the best practice elements of a headache evaluation and management plan.

Dawn C. Buse, Ph.D., and Matthew S. Robbins, MD: Treatment and management of migraine and other primary headache disorders is a complex, multi-dimensional process. Since we work in a specialized headache treatment program, we often see patients who have had years of unrelieved pain, and who have spent much time on their own trying to develop a good treatment plan without ever talking about this with a healthcare provider.

Successful clinical management of a headache disorder usually requires the following steps:

1. Exclude secondary headaches
2. Diagnose primary headache disorders
3. Assess severity, headache-related disability, burden, and impact
4. Assess triggers and exacerbating factors
5. Assess comorbidities and related psychological constructs, which may enhance or interfere with treatment
6. Gather data on prior treatment and its effectiveness and formulate a treatment plan
7. Follow and modify the treatment plan as needed over time

EC: For healthcare providers who are not pain specialists, and so may not be trained in completing a clinical headache evaluation and in developing a treatment plan, can you recommend headache screening questions and provide suggestions about which responses require follow-up?

DB & MR: The assessment of headache should start with a thorough medical evaluation to rule out an acute medical condition, disease state, or structural abnormality. This includes performing a thorough neurological and general physical examination and taking a complete medical and social history.

There is a mnemonic, SNOOP, that can be easily remembered and used to identify red flags for the presence of underlying disorders that may be a cause of acute or subacute headache.¹

Systemic symptoms or illness (including fever, persistent or progressive vomiting, stiff neck, pregnancy, cancer, immunocompromised state, or anticoagulation).

Neurologic signs or symptoms (including altered mental status, focal neurologic symptoms or signs, seizures, or papilledema).

Onset is new (especially in those aged 40 years or older) and sudden.

Other associated conditions (e.g., headache is subsequent to head trauma, awakens patient from sleep, or is worsened by Valsalva maneuvers).

Prior headache history that is different (e.g., headaches now are of a different pattern or are rapidly progressive in severity or frequency).

Once secondary causes are excluded, a primary headache diagnosis should be assigned using the the 2nd Edition of The International Headache Classification (ICHD-2) criteria.^2,3

EC: Please describe the new index that you and colleagues are developing.

DB & MR: We have been involved with the “Lifting the Burden” working group of The Global Campaign to Reduce the Burden of Headache Worldwide collaboration among the WHO, international headache non-governmental organizations, academic institutions, and individuals worldwide to develop the Headache Under Response to Treatment (HURT) Index, an 8-item self-administered questionnaire addressing headache frequency, disability, medication use and effect, perceptions of headache ‘control,' and knowledge of diagnosis.

The HURT Index is a patient self-report, paper and pencil instrument. Responses can fall into three areas: white (no action needed), yellow (action suggested), and red (action required). Each question is linked to a specific clinical action, based on guidelines -- when available -- and expert clinical consensus. The HURT is intended for use by healthcare providers in both primary and specialty care to assist monitoring and assessing treatment in order to achieve the best outcomes. The HURT Index is currently being validated in multiple countries and in multiple languages and will be available to healthcare providers free of charge.^4,5

EC: Please recommend other resources that healthcare providers can access and use to educate both themselves, and their patients, about headache disorders.

DB & MR: The “Lifting the Burden” working group has developed a range of management aids for healthcare providers and persons with headaches. They have created a set of information brochures for patients regarding various subtypes of headache and treatment. The brochures are available free of charge through the World Headache Alliance (WHA) website (www.w-h-a.org), which links to the "Lifting the Burden" Campaign, or directly through the "Lifting the Burden" website: (http://www.l-t-b.org). The brochures have been translated into multiple languages.

The American Headache Society® (AHS) website (http://www.americanheadachesociety.org) provides a range of educational materials for healthcare providers. The American Headache Society Committee for Headache Education (ACHE) section of that website offers information for patients and the general population. The National Headache Foundation website (http://www.headaches.org) also provides information for healthcare providers and patients.

1. Dodick DW. Diagnosing headache: clinical clues and clinical rules. Adv Study Med. 2003;3(2): 87-92. Available at: http://www.jhasim.com/files/articlefiles/pdf/journal_p87(V3-2)AmbulatoryM.pdf
2. Lipton RB, Bigal ME (eds). Migraine and Other Headache Disorders. New York, New York: Taylor & Francis, 2006.
3. Lipton RB, Bigal ME, Amatniek JC, Stewart WF. Tools for diagnosing migraine and measuring its severity. Headache. 2004;44:387-398.
4. Buse DC, Steiner JF, Serrano D, Reed ML, Lipton RB. The Headache Under-Response to Treatment (HURT) Index: An outcome measure to improve management of headache, especially in primary care (abstract). Neurology. 74(Suppk2):A323,2010.
5. World Health Organization. Lifting the Burden. HURT Index (v 2.2). Available at: http://www.l-t-b.org/assets/96/AB9C64EE-D800-01AB-1FAC446E25B0DF88_document/HURT_NY_revision.pdf