This study was conducted with the primary aim to describe the journey of patients with migraine in a tertiary headache center in Sao Paulo, Brazil until their first appointment. In order to answer this objective, medical charts from patients who attended to a tertiary headache center were reviewed, collecting information about patients’ history registered in the first attendance. As main results, diagnostic methods, treatments and preventive strategies previously used by patients were reported.
More than half of patients reported to have previously performed laboratory tests, cranial tomography and magnetic resonance imaging. However, guidelines do not recommend the use of any medical exams for migraine diagnosis [17,18,19]. The use of unnecessary strategies to investigate signs and symptoms may have different impacts, especially for patients, such as the exposure radiation present in tomography and magnetic resonance imaging. Viana et al. (2016) have shown that most patients also perform a great number of unnecessary exams, of which 40% includes radiation exposure .
Regarding treatments previously performed, most patients used preventive drugs and acupuncture. The use of preventive drugs is in accordance with several guidelines which state that the cure is not the aim of migraine management. We have not listed the option of effective treatment without side effects. The medication list refers to previous experiences, we believe patients experiencing effective treatments without side effects are less likely to reach a tertiary headache center, or they may be fitting into the “I have not used for a long time” category. Especially in cases of chronic disease, treatment has the objective to reduce frequency and intensity of crises [17,18,19]. The use of alternative therapies is not recommended due the lack of evidence on its efficacy in migraine treatment. Only acupuncture has shown satisfactory results when compared to topiramate in a clinical trial and is recommended by the Latin American consensus for the treatment of chronic migraine [21, 22]. Thus, although prescribed by nonspecialized assistance, the treatment seems to be in accordance with recommendations.
Vincent and colleagues (1999) have previously reported the primary headache care delivered by nonspecialists in Brazil. In order to assess this objective, the study interviewed 414 patients with questions such as the duration of headache, the need for medical assistance, types of diagnoses provided by nonspecialists, the sort of investigations and treatments prescribed. Patients reported that had seen on average 3 health assistants before the appointment with a specialist and a headache beginning on average 11 years before. As observed in the present study, patients performed a great number of investigative procedures, such as electroencephalography, computerized tomography, and sinus and skull x-rays. Regarding prescribed treatment, a prophylactic strategy was adopted by 48.9% of migraine patients, involving benzodiazepines, tricyclic antidepressants, beta-blockers, flunarizine, anticonvulsants, pizotifen and nonpharmacologic strategies such as use of new glasses, diet and homeopathic treatment . These data are consistent with those presented in this study, showing that migraine patients are benefited from specialized care and that misdiagnosis is still observed twenty years later. Furthermore, data suggests the use of a large amount of unnecessary health resources by migraine patients, generating burden to both, patients and society. The need for conduction of a study estimating economic burden of migraine in Brazil, to assess the real impact of these practices, is highlighted.
Patients’ experience about drugs used in the treatment and as a preventive approach was assessed, describing how they classify medicines regarding their efficacy and the occurrence of side effects. Preventive drugs were classified by patients as without beneficial effects or when the beneficial effects are observed, side effects are also reported. The preference of Brazilian patients for migraine preventive therapy was previously assessed and the effectiveness was the most important aspect of the treatment by 92.7% of the sample. The occurrence of adverse events was the third of seven aspects in the classification of most important, by 32.4% of the patients . These data reinforce the need for investment in technologies that combine both effectiveness and safety, which are of great concern of migraine patients.
The sample was further stratified by the type of migraine, as episodic or chronic. The prescription of magnetic resonance imaging test, acupuncture, psychotherapy, use of preventive drugs and use of topiramate without beneficial effects was most likely to be observed among those with chronic disease. The use of anesthetic blockages was more frequent among patients with episodic disease. To date, this is the first study to assess differences in the treatment performed before the attendance with specialist comparing patients with different types of migraine. When resource utilization is compared, chronic migraine patients seems to report more visits to general practitioners, neurologists, nurse and physician assistant, diagnostic testing and other exams and the use of drugs . So, the journey of patients, stratified by the type of migraine, still needs to be further addressed by other studies to confirm the associations found.
Other outcomes were reported by the study, including the presence of anxiety and depression, through the standardized instruments GAD-7 and PHQ-9. A greater frequency of anxiety was observed when compared with depression symptoms, once 68.8% of patients presented some level of anxiety and 66%, some level of depression. This result corroborates the association between anxiety and migraine, more robust than depression, as reported in a Brazilian study recently published . Other results such as sociodemographic characteristics are consistent with those published in the country [26, 27].
Although international guidelines states that most primary and medication-overuse headaches may be adequately managed on primary healthcare, the same reports also highlight the cases where referral to a specialist is necessary . This need for referral is reinforced by data shown in the present study.
Important to add the referral pattern, as previous migraine diagnosis. Patients come to our headache center by self-referral, and the vast majority had already a migraine diagnosis.
This study has several limitations, specially related to the source of information. When using information from medical charts, data is dependent on the quality of registration which may compromise the available reports. Another limitation is the retrospective nature of the interview, in which patients were asked to remember all the procedures previously performed. However, this study adds important knowledge about treatment of migraine in Brazil.