Your Visit to the Doctor

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Your Visit to the Doctor

Your initial visit with the doctor represents a crucial step towards securing effective control over your headaches.

Even though your headaches may have driven you to the depths of desperation, despair, and neediness, never forget that the management process involves a transaction be- tween two parties that will require your active participa- tion. The physician is not your savior; ideally he or she will serve as a compassionate, informed consultant who will advise you how best to direct your own ongoing head- ache management. Get this process off on the right foot. In this chapter we will offer suggestions as to how to maxi- mize the benefits obtained from your initial visit. Although headache is endemic in our society and headache sufferers fill the waiting rooms of our clinics and EDs, surprisingly few healthcare providers are proficient in the diagnosis and treatment of headache, and many have a distinct aversion

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to dealing with headache patients. Your initial visit to the doctor will be far more productive if you arrive for that visit adequately prepared.

What Does Your Doctor Need to Know?

Most of us find ourselves distinctly off balance when we attempt to relate our medical histories to an unfamiliar physician. Either we say too much, obscuring the few nuggets of truly important information under an avalanche of largely irrelevant verbiage, or we adopt a tight-lipped, stoical persona wherein information can be extracted by the physician only through a slow, tedious, and painful process; both scenarios tend to lead to frus- tration for one or both parties and, unfortunately, typically result in management plans that are suboptimal.

Appendix 3 is a headache questionnaire, and use of this questionnaire will insure that the clinician will receive the information that he or she requires to make an accurate diagnosis and assist you in developing an appropriate treatment program. The individual elements of that questionnaire will be explained in some detail.

Anchor in Time

As we have emphasized previously, most patients pre- senting with a chief complaint of headache have migraine, and migraine is a disorder which tends to persist and recur over an extended period of time. It is thus helpful to offer the physician an “anchor in time” as regards to the onset of your particular headache syndrome. When

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did you first begin experiencing significant headaches?

By “significant,” we typically mean headaches that were severe enough to force you to cease or greatly restrict your routine activities or headaches that caused you to become physically ill (i.e., nauseated). Did your first severe headache occur years ago, while you were in ele- mentary school, causing you to miss school? Or did you first develop a significant headache yesterday while run- ning to catch a bus? The former obviously would sup- port strongly a diagnosis of migraine, while the latter would raise concern as to the possibility of a secondary headache (see Chapter 2).

Recent Change?

Migraine is exceedingly prevalent, and migraineurs are not exempt from developing superimposed secondary headache. Put another way, migraineurs are just as likely as nonmigraineurs to develop meningitis, ruptured brain aneurysms, brain tumors, or posttraumatic intracranial hematomas. As discussed in Chapter 2, however, the most common reason for a change in the character or frequency of headache in an established migraineur is not the development of a secondary headache; much more frequently the change results from an alteration in the migraine itself, either spontaneously or in response to co- existing analgesic overuse, mood disorder, hormonal change, disrupted sleep, head trauma, concomitant medication, or prolonged stress. If there has been a change in the character or frequency of your headaches, specify when that change occurred, whether there may have been any factors contributing to that change (such as the

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ones just listed) and precisely how the headaches now are different.

What Is Your Headache Frequency/Severity Profile?

When first asked by a physician “how are your headaches?,” new headache patients almost invariably respond “terrible” or some other, more vivid adjective. This is a given; very few patients seek out medical attention for headaches that are “not a problem.” What the physician needs to know is (1) how often do you experience headache? and (2) how disabling are your headaches?

There are many ways to elicit this information, but one we have found to be useful is first to ask the patient: “Out of the last 30 days, how many days did you have a headache of any degree of severity—mild, moderate, or severe?” Patients who initially may have reported that they experience only three or four headaches per month (thinking that the physician wants only to hear about their most severe attacks) often respond, “Any headache?” Once assured that the physician does indeed wish to know about all headaches, the “three or four headaches a month” often expand to “Well, I have at least some headache every day.” Such information is critical to the development of an appropriate management plan;

the patient with infrequent episodic migraine, no matter how severe those attacks may be, is quite different from a patient who has daily or near-daily headache, and the treatment prescribed also is quite divergent.

To assess severity, we then ask “out of those [3, 15, 30, whatever] days, on how many of those days were you

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unable to perform your routine activities because of the headache, whether it involved the entire day or a portion of the day?” These we term “functionally incapacitating headache days.” Thus, a headache frequency/severity profile of 15/7 means that over the past month the patient experienced some degree of headache on 15 days and was incapacitated by the headache on seven of those days. This provides a concise and accurate “snapshot” of the patient’s headache status during that time and helps immeasurably to shape the management program.

Specifically, it enables the physician to answer the wa- tershed question in pharmacologic treatment of migraine:

does this patient require abortive therapy only, or does he or she require a course of prophylactic therapy in addition to appropriate abortive therapy?

To ensure accuracy in your estimation of your current headache frequency/severity profile, it may be particularly helpful to keep a headache diary over the month prior to your initial doctor’s appointment. An example of a simple headache diary is provided in Appendix 4.

Duration

Indicate to your physician the duration of your typical headache attack and the range of duration you have experienced in the past. This information can be invaluable in assisting the physician to make an accurate diagnosis.

For example, cluster headaches may have migrainous features, but cluster attacks typically last an hour or less . . . a much shorter time than usually is observed in migraine. Alternatively, patients who have migraine and at

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times experience attacks that are prolonged for days (“status migrainosus”) will require medications that are designed specifically to treat such prolonged attacks.

Triggers

Some triggers are linked so commonly to migraine that their existence in a given patient may assist the physician in confirming that diagnosis. In addition, viewing the list of triggers provided may get you thinking about components of your life, lifestyle and diet that may be contributing to your headache syndrome.

Menstrually Associated Migraine

If you are female, note for the physician whether or not your headaches seem to be more of a problem during or just around menses. As noted in Chapter 3, the headache attacks of MAM may assume a very different form than migraine attacks that occur during other times of the month, and the treatment prescribed may differ accord- ingly. If you do have MAM, indicate to the physician whether your MAM simply involves a greater tendency for you to experience your typical migraine attacks or whether the MAM is different, involving a prolonged headache that lasts for days.

Is It Migraine?

These individual questions primarily are intended to confirm an IHS diagnosis of migraine. Are your attacks ever accompanied by nausea? light sensitivity? sound

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sensitivity? Is the head pain increased by routine physical activity? Is the pain ever lateralized to one side? Is it ever pulsatile (ie, pounding or throbbing)? Remember, to establish a history of migraine one need not experience all of these individual components with every attack. A diagnosis of migraine simply requires an affir- mative answer to the following question: have you in your lifetime experienced five or more attacks of un- provoked head pain that lasted 4 to 72 hours, was severe enough to inhibit or even prohibit routine activity and was accompanied by nausea, light/sound sensitivity or both?

Aura This is a tough one. Aura is a subjective phe- nomenon that often is difficult to describe or quantify.

The headache-associated visual blurring that one physician characterizes as aura, another may dismiss as simply reflecting low blood pressure from the dehydration that commonly accompanies acute migraine. If you have experienced headache-associated visual flashing, blind spots, hallucinations of geometric patterns, other unusual visual phenomena or numbness and tingling (especially if one sided, spreading and involving the face and hand), these symptoms well may represent aura and should be reported to the physician. Frankly, however, the absence versus presence of aura rarely makes much difference in the management program eventually developed.

Medications Previously Tried

This, too, is a tough one, but the information can be of enormous assistance to you and to your physician. List

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all abortive and prophylactic medications you have tried in the past for your headaches, along with the duration of therapy (for the prophylactic therapies), the maximum dose attained (again, for the prophylactic therapies), your response (including any side effects experienced) and the reason the medication was discontinued. Appendix 5 may assist you in this process.

Previous Tests Performed

Have you had a brain imaging study in the past (MRI or CT)? If it was a CT, did you receive intravenous contrast dye? Where and when was the study performed, and what were the results? Ideally, you should bring to your visit the scans and copies of the formal reports.

Have you had any other tests in the past that are relevant to your headache syndrome? For example, have you ever undergone a lumbar puncture? If so, was the opening pressure normal, and were the cerebrospinal fluid analyses normal? Again, ideally, you should bring along copies of the formal reports. Have you been hospitalized for headache in the past? If so, try to bring along a copy of your discharge summary.

Past Medical History

Have you ever been hospitalized? if so why? Have you ever needed to take medication chronically for a condi- tion other than headache? if so, for what? Specifically, do you have any history of high blood pressure (hyperten- sion), heart disease, diabetes or stroke? What is your

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smoking history? Are you actively using alcohol, and if so, how much and how often? Do you have any aller- gies? If so, and particularly if they relate to specific drugs, describe them.

Current Medications

List all of your current medications, their dosages and the reasons for which you are taking them. Include OTC agents (egs, aspirin, acetaminophen, Excedrin, Excedrin Migraine, BC powders, Goody powders, etc). In the case of abortive medications taken for headache, specify how many days per week on average you take the particular medication, how many you typically take on one of those days and the maximum number you take within a given day. Finally, specify how much caffeine you tend to con- sume on an average day.

Family History

Most importantly, is there any family history of migraine (“sick headaches”)? If so, has it afflicted a first-degree relative (ie mother, father, sister, brother, son, daughter)?

Is there any family history of brain aneurysm or brain tumor?

Social History

Are you married? Do you have children? Are you em- ployed? What is your living situation? How do you spend a typical day?

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General Symptom Review

Rather than an exhaustive litany of every physical symptom you have ever experienced, what the physician needs to know is the following:

1. Are you having a problem with your sleep? If so, are you typically having problems falling asleep, are your awakening multiple times in the night or earlier in the morning than you want to?

2. Are you suffering from an active mood disorder (chronic anxiety, panic attacks, depression, or some combination thereof)? If you are depressed, is it a fa- tiguing, deenergizing depression, an agitated depression with a strong anxiety component, or both?

3. If female, are you having problems with hormonal imbalance (e.g., breakthrough bleeding, irregular menses, absence of menses), or have you recently undergone a change in your hormonal status (e.g., started or stopped an oral or injectable contraceptive, started or stopped hormone replacement therapy, spontaneous menopause).

Anything Else?

Is there anything else relevant to your headaches or general health that you feel it is important for your physician to know? While this is not the place to undertake an endless soliloquy testifying to the severity of your headaches and the impact they have had on your life, it is a good place to give the physician some idea as to how your headaches specifically have affected your day-to-

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day life. For example, are your headaches causing you to miss work? to miss school? Have they caused you to be fired? Are they causing a serious problem in your mar- riage? This subjective information, combined with your headache frequency/severity profile and a simple, stan- dardized disability scale, will assist him or her in better assessing your current status.

What to Take with You to Your First Appointment The authors have found it difficult to be confronted by a new headache patient who comes bearing a large stack of unselected and largely irrelevant past medical records, CT and MRI scans and X-rays. Combined with a rambling tangential history, the forty-five minutes typically allotted for a new patient are rendered pa- thetically inadequate. To maximize the benefit to be obtained from your visit, come to your visit armed with the following:

1. A completed headache questionnaire and list of previous headache therapies (Appendixes 3 and 5).

2. A headache diary that pertains to the last thirty days (Appendix 4); from this you should be able to cal- culate your headache frequency/severity profile (ie total headache days per month/functionally incapacitating headache days per month).

3. Copies of the reports of any brain or neck imaging studies you have had (MRI scans, CT scans, cervical spine X-rays); ideally you should bring the brain scans themselves as well, either the originals that can be loaned to you or copies of those originals.

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4. Copies of hospital discharge summaries from any headache-related hospitalizations.

5. If you have seen a physician in the past specifically for the complaint of headache, it may be helpful to bring a copy of that physician’s initial report; if your headache questionnaire is complete and accurate, however, it rarely will help to bring additional records (e.g.

copies of notes from your follow-up visits).

What Is Not Helpful for Your Doctor to Hear

You require and deserve a treatment plan for your headaches, but it cannot be emphasized enough that any treatment plan developed must be a product of you and your physician working together. While it is true that the treatment plan is intended primarily to reduce the frequency and severity of your headaches, inherent in the development of that plan is the implication that you will be self-empowered and so largely capable of managing your headaches independently.

Patients who are noncompliant with the treatment plan will be frustrated with the results. Not infrequently, patients will start a prophylactic medication for migraine, experience side effects, stop that medication without call- ing the prescribing physician and then eventually return for clinic follow-up complaining that their headaches have failed to improve. The lesson here is that if you want to improve, follow the treatment program; if the treatment prescribed is proving to be absolutely intolerable, call to request a switch to another medication or an earlier follow up appointment.

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A final word: many severely afflicted headache patients often present for their initial appointments ex- claiming that (1) “I’ve heard so many great things about you [directed to the physician]. I just know you’re going to be the one to help me with my headaches”; and (im- mediately following this exclamation of faith), or (2) “I’ve tried everything. Nothing works.” What such patients are telling us is that their “locus of control” has shifted from internal to external. In other words, the physician is now responsible for the patient’s headaches. In addition, the second comment often indicates that the patient is des- tined to fail any therapeutic intervention attempted, whether because of inherent psychopathology, secondary gain (ie, the patient is deriving some type of pos- itive reinforcement from being ill) or a simple case of the

“give-ups.” Surprisingly enough, not everyone who is chronically ill truly wants to get well. Happily, such patients are relatively few and are vastly outnumbered by individuals afflicted with headache who are both deter- mined to improve and dedicated to doing their part in what it takes to achieve that improvement.

The Neurological Examination

Your initial visit to the physician for evaluation of headache should involve a thorough neurological evaluation.

Such examinations are complex and somewhat difficult for the lay person to understand. Most of the tests that are part of this examination may seem silly to the patient, but they do have their well-founded purposes.

The physician first will test your ability to deduce and comprehend language, and he/she also will evaluate

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your intellectual function, memory and mood. Much of this the physician can assess while taking your medical history. The physician will examine your eyes with an ophthalmoscope, looking at the optic nerve (which leads from the back of your eye to the brain) and the blood ves- sels surrounding that nerve; this area provides an actual window into the brain, and by examining the eye with an ophthalmoscope the physician can determine whether the pressure within your head is normal or increased.

The pupils are examined and observed for their reaction to light. The physician will note how your eyes move when you are asked to gaze in different directions. The symmetry of the face and tongue and their movement is checked, along with facial sensation. The physician may look into your throat and make you gag slightly with a tongue depressor (this is not particularly fun). He/she then will examine your muscle strength and check the reflexes in your arms and legs. The physician will search for disturbances in the sensory system by observing your reaction to stimuli applied to the skin, your ability to de- tect slight movements of the toes and your ability to de- tect vibration. He/she will test your coordination and your ability to walk. The physician may check for ten- derness over your sinuses or specifically examine the temporomandibular joints as you open and close your mouth. He/she may examine the arteries of the neck and temples and the muscles of the neck and shoulder regions.

You would be amazed to know how useful these simple tests can be in determining which patients require further testing.