A new survey shows that almost 70% of headache specialists report having episodic migraine (EM), much higher than the lifetime incidence of EM in the general population. Overall, only about 30% of respondents said they have no personal history of any of seven possible headache types.
The survey also showed that many clinicians prefer treating episodic migraine and are least keen on managing new daily persistent headache (NDPH). This might reflect the ease with which EM can be treated compared with other headache types, the researchers speculate.
“The more likely you are to be able to treat a disorder, the more likely you are to like it,” said coauthor Randolph Evans, MD, clinical professor, Department of Neurology, Baylor College of Medicine, Houston, Texas. “And I can tell you that episodic migraine is easier to treat than chronic migraine” and is much more common.
Dr Evans experiences migraines himself, occasionally with visual aura. The new results were published in the March issue of Headache.
For this analysis, the researchers approached 749 physician members of the American Headache Society and invited them to participate in the email survey, which included 25 questions. These questions were grouped into six sections: demographics, professional quality of life and satisfaction, future practice plans, burnout, “likeability” of headache disorders, and personal history of headache disorders.
Responses to the first sections were published in Headache last year. It showed, among other things, that headache medicine specialists have one of the highest rates of professional burnout (57.4%) and experience widespread dissatisfaction with their practice environment, including work schedules, government regulations, insurance company policies, and malpractice concerns.
The new paper presents results from the last two survey questions.
The response rate was 15.8% (118 physicians). Of these, 64.4% were male, the mean age was 51.41 years, and the mean number of years in practice was 18.82.
Neurologists made up the bulk of respondents (85.6%). Other specialties represented were pediatric neurology, internal medicine, anesthesiology/pain, pediatrics, and family medicine.
For each of seven headache categories, respondents were asked to rate the statement “I like to treat this disease or symptom.” They chose from a scale of 1 to 5, with 5 being “strongly agree.”
The survey found that the most liked type of headache was EM (mean response, 4.69), followed by episodic cluster (mean, 4.37), chronic migraine (mean, 4.20), chronic cluster (mean, 3.68), postconcussion syndrome (mean, 3.66); refractory migraine (mean, 3.62), and NDP (mean, 3.52).
It’s possible that the results reflect how well patients with the different headache types respond to treatment. For example, said Dr Evans, NDP “is one of the most difficult to treat types of headache,” partly because the cause is unknown.
“In other words, regular, run-of-the-mill migraine is easier to treat.”
The next question asked respondents about their personal history of headache. The survey found that 69.5% had experienced EM (85.7% among women and 60.5% among men). This, noted the authors, is much higher than the lifetime incidence of EM in the general population (43% in women and 18% in men).
As well, 13.6% of respondents reported personally experiencing chronic migraine.
Only 28.0% indicated they had no personal history of any of the seven possible headache types.
Another survey by Dr Evans and colleagues, published inNeurology in 2003, found a much higher prevalence of migraine among US neurologists. This finding, said Dr Evans, was replicated in surveys on other areas, including Canada, Taiwan, Germany, Spain, France, and Norway.
The authors surmise three possible explanations for this:
- Neurologists are better able to self-diagnose or to remember headaches with particular features;
- Migraine is associated with the choice to become a neurologist; and
- Occupational stress increases the risk for migraine.
Dr Evans believes this last explanation has merit. “I think that being a neurologist or being a headache specialist is stressful in itself, that occupational stress may increase the risk of developing migraine.”
He’d like to determine the prevalence of migraine among different occupations but acknowledges that such a survey would be difficult to do. There might, for example, be a controversy as to what constitutes a stressful occupation; people often think their own job is more stressful than someone else’s, he said.
Dr Evans said he found it “fascinating” that so many neurologists and headache specialists have migraine. He doesn’t think this “clustering of disease” occurs in other specialties: for example, oncologists probably don’t have more cancer than the general population.
The low response rate is an important limitation to the study, said Elizabeth Loder, MD, chief, Division of Headache and Pain, Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, when asked to comment.
“We don’t know how the other 80 plus percent of headache specialists would have responded.”
Before looking at the findings, Dr Loder ranked the seven headache types in order of which she herself most likes to treat. Her ranking was similar to those of survey respondents, except that she ranked NDPH sixth and refractory migraine seventh: the reverse order to the study results.
She noted that the authors didn’t ask doctors whether they “preferred” to treat one headache disorder over another but rather how much they “like” to treat each disorder.
“Liking to treat something is strictly speaking not the same thing as preferring to treat something, although I can see they are probably closely correlated,” she said.
She also stressed the importance of not confusing liking to treat something with liking patients. “I have many patients for whom existing treatments don’t work well. I still like those patients very much, and wish I could do more to help them. I’m sure that’s true for other headache specialists as well.”
It’s not surprising, she added, that doctors like to treat disorders for which they have effective treatment options. “Doctors like to help people, and they like patients to be satisfied with their treatment.”
She pointed out that clinicians have better, more effective treatment choices for people with episodic migraine and episodic cluster headache, and that although chronic forms of the disorder do respond to treatment, “on balance they do not respond quite as well.”
There are fewer treatment options for postconcussion syndrome or for NDPH. However, as Dr Loder noted, even the ranking of NDPH, at 3.52 (out of 5), is “quite high, indicating that doctors on balance ‘like’ treating this more than they don’t.”
By definition, refractory migraine isn’t responding to treatment, so it’s no surprise that doctors don’t “like” to treat it as much as other disorders, she added.
Dr Loder herself experiences episodic migraine without aura, but her headaches have improved greatly over the years. Triptans work “incredibly well” for her, she said, adding that she wishes these drugs were available over the counter in the United States as they are in other countries, such as England.