Primary Care is the Answer to the Migraine Care Gap, Says Headache Specialist

According to the Global Burden of Disease (GBD) study, migraine is second among the world's causes of disability and first among causes of disability among women.

When Christopher Gottschalk, MD, professor of clinical neurology, director of headache medicine, and section chief, general neurology, at the Yale School of Medicine, spoke recently with Patient Care Online about the essential role of primary care in treating migraine headache he cited the GBD numbers as well as the arithmetic chasm between the number of people in the US diagnosed with migraine (~40 million) and of headache specialists (~500-600).

Migraine care, he said, is something primary care should adopt as "part of everyday life." More of the conversation follows here.

Christopher H. Gottschalk, MD, is professor of clinical neruology, director of headache medicine, and section chief, general neurology, at the Yale School of Medicine in New Havent, CT. Gottschalk also is current president of the Alliance for Headache Disorders Advocacy.

The following has been lightly edited for clarity and style.

Patient Care. I want to go back to your early mentor Richard Lipton and talk about the role of the primary care physician in migraine care. Recently, Dr Lipton and colleagues released the data on the first cohort of the OVERCOME trial, looking at patterns of US migraine care. And they found that lifetime consultation in primary care for migraine has been fairly consistent at about 70%. They feel that migraine should be managed outside of the specialist’s office. I'm curious about your thoughts on migraine care in primary care.

Christopher Gottschalk. I certainly endorse the idea that migraine is a disease that should be readily recognized and managed in primary care for all kinds of reasons. Starting with the fact that given how common it is, and what a burden it places on society, it meets all the criteria for a disease that should be a target of primary care management. It affects many, many people. It affects women more than men, it affects them most of all at the peak years of child bearing and productivity.

As you well know, I'm sure according to the Global Burden of Disease Study migraine is in fact the top one or two cause of disability in the world, certainly a much more important cause of disability than any other neurologic disease, in terms of the number of people that it affects and the amount of time that it takes from people over the course of their life. So given that it is so common and so disabling, it should be something that primary care will recognize—will seek out, recognize, and manage routinely.

Then there's the simple workforce issue, with something like 40 million patients in the US who meet criteria for migraine, and about 500 to 600 certified migraine specialists in this country, which will slowly increase but never meet the levels of anything like being able to provide care for all of those migraine patients. It's simply a numbers game—that we are here to treat the most complex cases the most puzzling cases, the ones that are refractory to standard treatments. But absolutely, given the number the size of this pool of patients and their needs, this is entirely something that can be done in primary care. The good news again being this [migraine management] is not difficult. This is not something that is as challenging as some of the other diseases that they treat on a routine basis from cardiovascular disease to autoimmune disease.

The key is providing primary care early and consistently with adequate education about the goals of care, about the treatment expectations, about the options, and then also about effective diagnosis, which is often derailed by older ideas about what they might be. So I fully agree that this is something that primary care can and should adopt as part of their everyday life.

For other videos in our interview series with Dr Gottschalk:

CGRP Inhibition for Migraine: Side Effects are Few but Pay Attention for These

Oral Gepants: Christopher Gottschalk, MD Tells the Origin Story, Highlights Broad Efficacy

Migraine Medicine Transformed: Christopher Gottschalk, MD Discusses How We Got to CGRP Inhibition

Before Migraine Was a Disease: Headache Expert Christopher Gottschalk, MD, Remembers his Roots