S8:E9 – Managing Migraine With A Primary Care Provider
In this episode of Spotlight on Migraine, host Molly O’Brien speaks with Caroline Stowe, DNP, FNP-BC, AQH, MSCP, a board-certified family nurse practitioner with additional training in headache medicine, about managing migraine disease with the support of a primary care provider. With more than 40 million Americans living with migraine and fewer than 1,000 headache specialists, many people find it hard to access specialty care. Caroline explains why you don’t have to wait to see a neurologist or headache specialist to receive quality migraine care, how primary care clinicians can help, and how to make the most of your next appointment.
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In this video:
- Why not every person with migraine disease needs a neurologist or headache specialist
- Which primary care clinicians can be part of your migraine care team
- Who may be a good fit for managing migraine with primary care, and when a referral makes sense
- Symptoms to share with your provider beyond pain, including what happens before, during, and after an attack
- How to describe the impact migraine is having on your life using headache days and other data
- How to bring up treatment options your provider may not be familiar with
- How care can move between primary care and specialty care as your needs change
This podcast was supported in part by Ipsen. AMD does not endorse their products or services, and all content is produced independently without influence from the sponsor.
TRANSCRIPT
Molly O’Brien: There are more than 40 million Americans who live with migraine and fewer than 1,000 headache specialists. You can see why it might be difficult to get an appointment, or you might have to wait a long time. Hi, I’m Molly O’Brien and this is Spotlight on Migraine.
Many people living with migraine find it difficult to access appropriate care. That said, does everyone with migraine need to see a neurologist or a headache specialist? Today we’re going to discuss just that. How can patients utilize their primary care providers to get the treatment that they need? We’re here to help you out. To break all of this down, I’d like to introduce our guest, Caroline Stowe.
Caroline Stowe is a board-certified family nurse practitioner with 16 years’ experience in primary care. She earned a Doctor of Nursing practice and holds an additional qualification in headache medicine. She has special interest in improving the recognition and management of migraine in primary care setting. She currently serves as director of clinical services at Healthvana and as adjunct faculty at George Mason University teaching graduate nursing students. All of her work emphasizes the important role that primary care clinicians can play in recognizing, diagnosing, and treating migraine, which makes her an excellent guest today. Caroline also serves on AMD’s Advanced Practice Provider Education Committee.
Thanks so much for being here.
Caroline Stowe, DNP, FNP-BC, AQH, MSCP: Thank you so much for having me.
O’Brien: Can you talk to us a little bit about how primary care providers can actually be a good point of contact for managing migraine?
Stowe: Yeah, definitely. So, I think you brought up the most important part, which is that just like many specialties, there are just not enough neurologists, there are not enough neurology practices, and definitely not enough headache specialists to meet the number of people in this world who have migraine, right? And I think that’s one of the most important things that patients need to hear.
Primary care providers can diagnose, they can manage patients with migraine very successfully. And for patients with a fairly typical presentation, right – no red flags, a normal neurologic exam, and migraine that responds to, you know, sort of a standard acute preventative treatment – primary care is exactly where you need to be, right? So, we love our specialists. We work as a team, really, together. But what we like to do in primary care is sort of set them up. Set up the neurologist, set up the headache specialist, we’ve tried and failed these things, or this is not looking quite right, now we need this very expert look at it. And so I always like to call out that a neurologist and a headache specialist aren’t necessarily the same thing either, right?
Headache medicine is its own area of expertise, and not every neurologist wants to treat migraine, not every neurologist has that extensive headache training. In fact, I was trained by a general neurologist who then went and got more headache training, Dr. Charisse Litchman, I’m just going to call her out because she was life-changing for me in terms of my headache training. So I just like patients to know that you don’t necessarily need a neurologist because you have migraine. What you need is a clinician who’s comfortable recognizing migraine, treating it appropriately, and recognizing when your presentation needs another level of expertise.
O’Brien: I love hearing that, and I think it’s so important that, yes, we love our neurologists, we love our headache specialists, not every person with migraine necessarily needs to see someone with that headache specialty or with a background in neurology. Which is a great thing to point out, yes, because not all neurologists know a ton about migraine, or they don’t want anything to do with it, they’re focused on other avenues. So, that’s great to point out.
Okay, so let’s talk a little bit more about different types of primary care providers because we kind of group it into one category. Some people out there might just think we’re talking about a primary care doctor, but that’s not necessarily the case. Can you talk to us about which types or which types of certifications – however you want to put it – which types of primary care providers can provide migraine care?
Stowe: Of course, we have our amazing physicians, our MDs and DOs. We have our nurse practitioners, which I’m a nurse practitioner. We have our physician associates, otherwise known as physician assistants, depending on which state you’re in. All of these individuals can diagnose, they can prescribe within their scope of practice, and I always like to call out pharmacists. I’ve been in primary care practices who have amazing PharmDs that are incredibly valuable for medication, education, management. Our RNs are actually, so we’re talking about really a team-based approach.
So we have the primary care provider, which is the advanced practice provider, NP or PA, or the physician. We have our PharmDs. And then RNs can play a really important role as well, although their scope is different, right? They can help with education and headache diaries and medication adherence, that sort of thing, lifestyle counseling, and then just navigating the healthcare system, right, when you have questions. And so, I like to call out too physical therapists are incredibly helpful here. So, it is just primary care is such a cool place.
We know a little bit about a lot, as I always say. But the one thing that if you have a primary care provider who has some additional initials behind their name, ask about that, right? So, after my name, I have a long list of them. One of them is AQH, which is an additional qualification in headache disorder.
I’m a primary care nurse practitioner who has seen enough headache patients and treated enough headache patients that I could sit for an exam in headache medicine. And so, there are websites where you can look up for these providers, and then you can identify, hey, this primary care provider really loves migraine. They really love headache disorders, and so I know that they are going to be a wonderful expert for me. That being said, you don’t have to have any initials behind your name to be an expert in headache and migraine management. Many times you have people like myself or even anybody listening that has migraine. And so, there’s nothing more exciting than to be able to help people in a condition that you experience yourself as well.
O’Brien: Absolutely. Especially when they know what you’re going through physically is so helpful and beneficial. You touched on this a moment ago, but can you talk to us about who might be a good candidate to work with a primary care provider to manage their migraine?
Stowe: Yeah, and I think most people think, oh, only like mild migraine, right, just like infrequent. But primary care can manage a really broad spectrum of migraine. And so, I generally think a good candidate is someone who has, you know, a very obvious presentation that’s consistent with migraine, that’s stable, predictable, there’s no red flags. And we talk about in the neurologic exam, you know, no concerning secondary headache features.
We really manage primary headache disorders in primary care. For secondary headaches, those really need to be referred outright. It’s very easy to remember. There are many acute and preventative treatments, including antinauseas and neuromodulators, that primary care can manage, you know, sort of in-house. And so, if a patient’s having a reasonable response to treatment, that’s another great sign that you’re in the right place. But even patients with frequent or disabling migraine can start in primary care, right?
And preventative treatment is well within primary care management. And truly, the best part about primary care is that we can manage comorbid conditions as well, which is my favorite part, right? So if a patient has hypertension or they have depression, if you don’t manage those conditions as well, you’re not going to manage your migraine well. And so, who’s better equipped to do both than primary care.
O’Brien: And I love that you brought that up because I actually listened to an interview with Dr. Katherine Gergen Barnett – she’s out of Boston Medical Center – she talks a lot about primary care and just how…she used this quote that I loved. “Your primary care provider, your primary care team is like the quarterback of your health.” And I thought that was such a good explanation because, like you said, migraine does not function in a silo. Our bodies do not function in a silo.
There are other factors. And your primary care has all that history, has all that knowledge. So if you’re working on, yeah, like you said, hypertension or anxiety and depression, your primary care provider knows that information and can work with you to say, okay, well if we work on this, that can help. If we work on this, maybe that will help with migraine, too. So I love that you brought that up because primary care is like the hub.
Stowe: Right, exactly. It’s true. And, you know, we really have the advantage because we understand the whole patient. So much of specialty, and I’ve worked in specialty, where we say, well we’re going to refer you back to your PCP to manage that, right, which is just another visit that patient has to take time away from work or set up.
And we’ve all been there, right? We all live in this US healthcare system where this specialist doesn’t get the information from this PCP and you think that it’s all shared, but it’s not. And so primary care really is well-equipped and set up, especially if you love your primary care provider. I think many of us do. Many of us love our headache specialists as well.
And so if you can get them to communicate, even better. But truly, even sometimes the paperwork that you need, right, whether it’s, you know, the stuff for FMLA or anything, your primary care is well-equipped for all of that. And so it’s just a nice sort of central place to have everything managed.
O’Brien: You’ve mentioned a lot of things that primary care providers are able to do to help treat migraine. Is there anything else that you can think of that primary care providers can do to help patients manage, or that is just out of scope or PCPs are not able to do to help a patient with migraine?
Stowe: It really comes down to what the PCP is comfortable doing, right? So I’ve worked in a large primary care practice and there are some providers who are really comfortable with joint injections, just like ortho stuff. The skin biopsies they had really extensive training in residency or in a certain program, so they’re comfortable doing that.
And there are others that say like, I can do Botox, right, I can do nerve blocks. But many times that’s not a comfort level for a primary care provider. If they see a neurologist or a headache specialist, that’s something that they’re doing every single day.
And they can probably get you in and out pretty quickly for that whenever you’re due. So I would say that, you know, when you’re getting…there’s also some infusion therapy, that’s not going to happen with your primary care, right? And even some inpatient treatment where some patients are really, you know, in a severe state, they need to be seen inpatient.
Your primary care can help coordinate, but really a headache specialist needs to be involved for that sort of thing. So a lot of this is insurance dependent, right, a lot of this is really what’s available to you. But primary care should be able to help you figure out what your next steps are and where you need to go next.
O’Brien: What are some benefits of seeing a PCP to help manage migraine?
Stowe: For me, when I think about primary care and having them, you know, manage migraine, it’s that access piece and it’s the continuity piece, right? I know you and I have even reviewed just like the ability to get in touch with different providers. And certainly some specialists are better than others and some primary care providers are better than others as well. But, you know, your PCP already knows your medical history. They already have your other diagnoses. They often know your family and social context, right?
I feel like in primary care, I’m more likely to see someone’s kids come with them or grandparents or parents or something than I am in specialty. And so that matters because migraine doesn’t live in isolation, just like we talked about, right? So it gives you the opportunity in primary care to really manage migraine before it becomes a crisis.
We don’t want people repeatedly going to urgent care or the emergency department because they don’t have an effective rescue plan, right? So primary care can really monitor, you know, the trajectory over time essentially and recognize when episodic migraine is turning into chronic migraine and get ahead of it. And that’s really where I see the benefits of having a PCP involved.
O’Brien: So there are a few different scenarios in which people might call on their primary care provider and especially when they’re dealing with migraine. Maybe a person is just getting into this migraine world. They don’t even know that they have migraine. They just know that they’re seeing spots or getting with throbbing pain. Some people might not suspect that they have migraine. Some people might not have a diagnosis.
There’s also a period in which people might have had migraine as a kid, then it sort of went into “remission” and now symptoms are back because of aging or life events. It’s sort of reappearing. Some people might have managed migraine okay on their own before, like maybe they used over-the-counter medications, but that’s just not really doing the trick anymore and they need a little bit more help and expertise.
Are there any other scenarios that kind of you can think of where people might want to bring up having migraine or they might suspect it or bring up these symptoms with their primary care provider? And if so, how can patients really start this conversation? Maybe they’ve never even talked about migraine with their primary care before. Maybe they don’t know that it is migraine to talk about it. So how can folks bring it up?
Stowe: What I want patients to hear is that you should bring up any of this stuff earlier than you think that you should. So don’t wait until you have headache days that are happening half the month where you’re missing work every other week. I bring it up when your headaches are starting to cause interference with activities.
For me, that’s the biggest piece, that disability piece. Like if you’re not able to make it to your kids’ soccer games or you’re missing work or when you get home from work, you’re going straight to bed because you just can’t. All day long, you’ve been able to hold it off with your giant bottle of Advil from Costco, right, or Excedrin Migraine. It’s just things are starting to not… Don’t wait until… Because that’s the thing about migraine.
If we can get ahead of it before it gets worse, then we’re going to make a huge difference for that sort of thing. And if you’re ever thinking is this normal? You’re Googling, you’re ChatGPTing your symptoms at night, bringing up to your PCP. Tell them, I was Googling, I was this. At this point, we all do it and we all know that our patients do it. So the biggest thing that I always say are if you’ve had migraine at any point in your life, or if you’ve had headaches, because sometimes it’s just a little confusing, we’ll call them all the same thing, headache days. You hear us say headache days, right, because what can feel like a migraine on one day and a headache on the other, we want all of them to be under control.
If they’re more frequent, they’re more severe, they’re associated with new symptoms, those aura symptoms, I want to know right away that you’re having…something’s different. If you’re not responding to your medication, that’s worth discussing too. If all of a sudden your medications are not as effective as they once were.
So I personally am a big fan of data. So if you can show up to your appointment and instead of saying, I’m just having a lot of headaches, you can say I’m having recurring headaches that are interfering with my life. And I want to talk about that. And I think that’s important to say it out loud and not right when the PCP has their hand on the doorknob. Like not when you’re trying to get out the door, right? Do it right from the start, say, hello, how are you? How are your kids, everything. And say, I have a list. I love when patients have a list.
I have a list of things that I really want to make sure we get through here. Now your PCP may say, pick the top three, pick the top two. Perfect. That’s fine. But if you need a separate appointment just for this, it’s worth making.
O’Brien: What are some symptoms that patients really do need to mention? And this is kind of tricky because some people talking to their primary care provider might not know that it could be migraine. But hopefully they have some ideas if they’re watching this podcast. But what are some things that are really important that maybe people will leave out because they don’t really think it’s a big deal or that they just don’t associate with headache?
Stowe: Yeah, I think that’s a great question because when we think about migraine or headache, often patients tell us about pain, right? But migraine is so much more than pain. I want to know about what’s happening before the headache. You know, whether you’re having increased yawning or you’re feeling more fatigued or neck stiffness, the food cravings, irritability, some mood changes, things like that. Hiccups is one of my favorite ones. When patients say they get hiccups before, they know they’re about to get a migraine because of hiccups.
O’Brien: I have never heard that. That’s amazing.
Stowe: I love it. You know, we want to know about aura as well. And now the majority of what we think about is visual, right? People think spots and dots and that sort of thing, but certainly there are other symptoms, numbness, tingling, speech or language changes, things like that. And the timing of those and the progression of those symptoms. Because you know, in order for this to be, you know, a typical aura associated with a migraine, those are fully reversible symptoms. So for some reason, your aura is not reversible then we’re looking at something else. And we need to know about that, right? That changes our next steps and plan.
And then of course, during the attack, if you’re having nausea, vomiting, light sensitivity, sound sensitivity, all that sort of stuff, dizziness, let us know about that. We love to treat symptoms. We want you to have options that if you do have nausea, which for me is the worst part of it all, like I want to Zofran now, right? So you want to make sure you have that on hand. And then afterwards, we want to know what’s happening after you have your headache or your migraine attack, mood changes, or, you know, sort of this brain fog.
There’s so many symptoms and don’t ever let somebody tell you, oh, that can’t be part of your migraine because it truly can, right? Who’s to say that, I mean, I would never have thought hiccups was going to be something, right, on my bingo card. But I definitely have seen it and have seen enough of it. And it is in the literature. So I would say all of those things as best as you can. But if you’re listening to this podcast and you’re sitting here thinking, she said something about, I’ve never heard before. If I haven’t mentioned it, or you haven’t read about it or seen it mention it and see. And you know, your PCP should say that’s a new one.
Okay, cool. Let’s track it and see if this is something that’s telling you you’re about to have a headache. Because again, if we can get ahead of it, the earlier you take your medication, your abortive, the better off you are.
O’Brien: People with migraine who know it, who’ve been in the trenches for a while, really do understand this, how it can affect every avenue aspect of life from your social life, family life, family planning, dating, work, employment, school, all of these areas. And people without migraine might not really take that into consideration. And it’s also kind of tricky because migraine affects everyone differently.
So some people might be able to accomplish certain things or do certain things in the midst of an attack while others can’t. So from the primary care perspective, how important is it for patients to talk about their quality of life or the impact that migraine is having on their life? It’s a headache, I should say.
Stowe: Like it’s truly, we have scales that measure level of disability. It is how we essentially decide is the medication working for you? And just like you mentioned, you can have patients who have headache disorder, migraine disorder, who are not on any prescriptions whatsoever.
They’re living their best lives with their daily Advil, daily Excedrin Migraine. I do not recommend, okay, we’re going to end up with medication overuse headache or medication adaptation headache. But I sort of giggle, but when I have a patient that comes in with their Costco-sized bottle and you can hear it in their bag, they are really doing their best to try and make it work.
And so, I always say to be really careful not to put the burden on patients to somehow prove they’re sick enough. Because that migraine stigma is real. The minute it starts to affect your life, we need to hear from you immediately, please, so that we can help. Because once it starts to progress, it’s just that much more difficult to get it under control. So let us help. We want to hear from you right away.
O’Brien: What can patients do or how can we approach a conversation with our primary care provider to make sure that our doctor believes us that, “This is impacting my life; I’m really affected”? Is there any way to approach the conversation or, like you said, bring the data?
Stowe: Yeah, exactly. And if patients say like, I’m having so many headaches, then I’ll say, that sounds incredibly frustrating. Let’s get to the bottom of it. Can we talk about numbers and impact essentially, right? So if you can say I had eight headache days last month, three of those caused me to miss work or family events. And I took my sumatriptan four times, of which three times it worked on the first time and take a second one, two times it works.
So I’m saying a lot of numbers, but it’s incredibly useful, right? Obviously, we talked about the tracking, the headache days, all the severity, that sort of thing. Because if you are somebody who’s still having a period, right, we can look and see if there’s a menstrual migraine, you know, piece there that often gets overlooked. But it all arrows down to disability and function, right?
We really love a list of treatments you’ve already tried. Don’t get mad at us if we say, would you be willing to try it again for certain reasons? A lot of times we think we tried something and it’s done and it didn’t work. But how long did you try it, right? Well, we know there are certain medications that take up to six weeks to see full effects, sometimes three to six months.
So if you tried something and you had, you know, intolerable side effects, boom, done, that’s totally fine. But if you tried something and then you just stopped, we might say, you know, try it again. You know, some people will get really low doses of sumatriptan, and I’m like, that’s a baby dose, you can go all the way up, you know what I mean?
Like, I want you to have big doses and because they’re most effective and, you know, in certain folks. So all to say that we want to know why you stopped the medication, right? We want to know if the sumatriptan works sometimes. Well maybe if we combine it with, you know, naproxen or something, and all of a sudden it’s this perfect little ball of happiness for you, right, it can change things. So it’s also helpful for insurance purposes, right? We all know prior authorizations are an important part of what we do. We get very good at them. So we need all that information for there.
Yes, I am, you know, you have to have a whole team and truly even like the neuromodulators. I mean, I talk about Nerivio a lot because you can’t hurt your patient with it really. And you can give it to all kinds of people. And even for brand-new primary care providers, brand-new headache specialists, you can start them off with Nerivio and give that patient, you know, or we just want to make sure they have tools in their toolkit. So we just want to make sure we’re not repeating therapies that you’ve already tried and failed because that’s annoying. We want to get you to the right thing the fastest.
O’Brien: And kind of stemming off of that, I want to ask you a question that might be weird but…say there’s someone who has migraine or they know about it or they suspect it and they are looking into it. They are Googling their symptoms. They’re Googling treatments. Maybe they come across our AMD’s website, and they see all these things. But their primary care provider, just they don’t focus on migraine. They focus on a lot of stuff. So maybe someone’s interested in neuromodulation, but your primary care hasn’t heard of it before because that’s not what they do every single day, all day.
What’s a good way to approach, or is there a good appropriate way to approach options with your primary care provider that they might not know about? We obviously don’t want to tell people how to do their jobs. But sometimes you’re in a situation where like you have a little bit more knowledge of maybe the route you want to go down. So is there a good way to bring stuff like that up?
Stowe: Yeah, I say absolutely because medicine changes so rapidly and there should be no healthcare provider out there that knows it all, right?
O’Brien: Very true.
Stowe: Every day we have new things coming out and headache medicine particularly has changed dramatically in the last several years. So I am big on…I think the key is really walking in as it’s going to be a collaboration, right? Rather than walking in and saying, I want you to prescribe this medication, just a little off-putting, right? So something like I’ve been researching this, or my friend said that they’re taking this or X, Y, or Z. And I found this information from AMD and I’m wondering, would you be comfortable looking at it with me?
And what I always say is that you don’t have to know everything. You don’t even have to know exactly what’s wrong with a patient. But your PCP should be willing to look something up, to learn, to collaborate, or even refer, when appropriate, right? Because there are so many resources online for healthcare providers when it comes to migraine, they’re all free, right? And I know you can link some of those here. They’re incredibly useful.
But there are going to be some PCPs, just like some neurologists that say, headache’s not my thing. Let me refer you to somebody who can better help on this particular piece. And that’s still appropriate because that’s the other thing is that just because you refer doesn’t mean that a PCP has failed, right? Referral is part of good primary care, right? And so we don’t need to manage it all, but certainly patients should feel comfortable. If you don’t have that comfort level, if you feel like you’re getting pushback or you have a bad experience, it might be time to look for a new primary care provider.
O’Brien: Is it possible to go from seeing a specialist to manage migraine back to your primary care provider? When might that be a good option or opportunity if you have the choice or not?
Stowe: Think of it almost like a step up, step down kind of model of care, right? So maybe a headache specialist established the diagnosis, they found the effective regimen and the patient’s been stable, right? So if that treatment plan is really straightforward, the PCP is comfortable taking it over, there’s no reason every stable patient must remain indefinitely in specialty care, right? And it can go both ways. If the PCP established the diagnosis, they started them on treatment, then things worsen, they can go back up to the specialist and then come back down again when things are stable.
So, you know, I do think that this frees up specialty for patients who truly need that level of care. We also like, I love keeping all my patients in primary care. So that’s why having that relationship. When I first started practicing as a nurse practitioner, I could call every specialist. I worked on the Eastern shore of Virginia. I can call every specialist because there was one of each on the Eastern shore and talk with them and say, this is what I’m thinking. And it was a really incredible opportunity to work together as a team on the shore.
And so we said, this is the diagnosis. This is what’s working. Here’s what we’ve tried. And here are the circumstances. I want to see this patient again, right. And so all of that’s documented. We would love for patients to come back to primary care and let them take over some of those prescriptions and some of that care and just continue the good care that specialty has done.
O’Brien: Great. So as we wrap up here, a couple of just kind of like flash bang questions for you to wrap the episode up straightforward. What’s one thing that everyone should know about managing migraine with primary care provider?
Stowe: For me, I think is that you don’t have to wait for a neurologist or headache specialist to start getting good migraine care. It can start with your PCP today.
O’Brien: What’s one piece of advice you would give them before their next appointment with a primary care provider?
Stowe: Yeah, this will touch back on that. You know, don’t just tell your provider how much your head hurts, tell them how migraine’s affecting your life, right? How many days of work did you miss and how many dinners did you skip, that sort of thing. So for me, it comes down to quality of life and disability.
O’Brien: Anything else you think that we should touch on before we wrap up here? I feel like we covered so much stuff. It’s been a lot of fun, but I’ll leave it to you. Anything else you want to say, final message?
Stowe: I think what I want patients to know or any healthcare provider that’s listening is that, you know, we’re here to work together and to collaborate together. So tracking obviously is very important. I think every headache specialist says it all the time. We are obsessed with tracking, right? We love it. It’s data.
Tell the whole story, right? So if you can include your symptoms before, during, and after the headache and not just the pain, we want to know about those other symptoms. And then come back, right? Don’t just never return…migraine treatments rarely here’s a prescription, see you next year.
O’Brien: If only.
Stowe: Treatment needs follow-up and adjustment. I know I wish. But really and truly, you know, I think that it’s very easy to feel sort of downhearted and downtrodden. You try something and you’re like, this didn’t work. And so what I tell my patients is this is plan A. We always have plan B and C and D, and I will go down the alphabet with you. Trust me, we will get you to where you need to be however it is, we need to get you there. But just, it’s never just plan A. We have lots and lots of plans for you.
O’Brien: I love it. With that, Caroline Stowe, thanks so much for joining us today. It’s been a great episode, and I’ve loved discussing all of this with you today. We really appreciate all of your knowledge and expertise.
Stowe: It’s been a pleasure. Thank you so much, Molly. So nice to see you.
O’Brien: And that wraps up this episode of Spotlight on Migraine. We hope you’ll like and subscribe. For the Association of Migraine Disorders, I’m Molly O’Brien. We’ll see you next time.
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