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Migraines May Be Underdiagnosed

Posted on: Tuesday, 18 March 2003, 06:00 CST

University of Pittsburgh neurologist says migraine headaches are under-diagnosed

University of Pittsburgh Medical Center -– Migraine headaches, suffered by millions of Americans and debilitating for many, are significantly under-diagnosed by physicians, according to a University of Pittsburgh neurologist writing in the March 19 issue of the Journal of the American Medical Association.

"A review of a number of studies suggests that far more people actually suffer migraine headaches than popularly thought," said Robert Kaniecki, M.D., assistant professor and director of the Headache Center at the University of Pittsburgh Medical Center. "Many people who are diagnosed as having 'tension' or 'sinus' headaches are, in fact, suffering migraines."

Migraine is a significant public health problem, with more than 28 million sufferers in the United States. More women than men have migraines, as 18 percent of women and 6 percent of men reporting migraine at some point. The cost to the U.S. economy is approximately $17 billion annually in health care and lost labor costs.

"A comprehensive approach to migraine management involves steps taken to limit the frequency of attacks and to address the individual headaches rapidly and effectively," Dr. Kaniecki said.

Treatments for acute attacks can include the use of high doses of non-steroidal and anti-inflammatory drugs such as aspirin, ibuprofen, naproxen, tolfenamic acid or a combination of acetaminophen, aspirin and caffeine.

Also, migraine-specific medications such as those from a family of drugs known as triptans are also frequently used and are considered to be the most effective products on the market.

According to Dr. Kaniecki, prescription and non-prescription products are used by 9 percent of the population to treat headaches each week, matching hypertension as the most-treated medical condition.

One of the most over-diagnosed forms of headache, according to Dr. Kaniecki, is the sinus headache, which he says exists only in theory. Recent research has shown that the majority of patients diagnosed with sinus headache actually have headaches meeting criteria for migraine.

"The United States is the only country in the world to have such a thing as 'sinus headache.' A study done in 2002 showed that of 3,038 people who reported that they had sinus headaches, only eight actually had sinus infections," Dr. Kaniecki said.

"Over 50 percent of patients with migraine are undiagnosed, and in this group, 42 percent carry the label of 'sinus headache' and 32 percent the diagnosis of 'tension headache,'" Dr. Kaniecki said. The result of the over-diagnosis of sinus headaches is an excessive number of prescriptions written to treat the phantom sinus infection, including mass doses of antibiotics and decongestants. This, he said, may be a major contributor to antibiotic resistance.

A primary reason for the under-diagnosis is a lack of physician education, he said.

"Only 48 percent of internal medicine and 62 percent of family practice residency graduates report being very prepared to treat patients with headache," Dr. Kaniecki said.

The tools for assessing headache are most important so that the physician and patient can work together to determine the best diagnosis and treatment.

"The first step is to find out if there are secondary origins of headache, such as a brain tumor or aneurysm. We then assess the patient for a primary headache subtype such as migraine, tension, or cluster," Dr. Kaniecki said.

"Once that step is complete, we assess the frequency of episodes to determine whether the patient has an episodic or chronic form of this headache," he added.

The International Headache Society defines chronic headache as attacks that occur more frequently than 15 days a month for more than 6 months. More than 4 percent of adults in the U.S. suffer from chronic headaches that are daily or near-daily.

"Episodic tension-type headache annually affects some 38 percent of U.S. adults, yet rarely requires medical attention given the typical absence of disability or concerning symptoms," Dr. Kaniecki said. The pain is generally mild to moderate, usually bilateral, and non-throbbing, with stress as the most common trigger.

"Migraine symptoms may be quite variable," he said. Although typically seen as a one-sided throbbing headache associated with nausea and sensitivities to light and noise, migraine may also be associated with neck pain or sinus drainage and congestion.

"If one has a stable pattern of disabling headache occurring as episodes over months to years, it almost always represents migraine," Dr. Kaniecki said.

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