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Original Paper

Received: January 8, 2013


Accepted: August 25, 2013
Published online: January 21, 2014

Eur Neurol 2014;71:157164


DOI: 10.1159/000355278

Headache from the Doctors Perspective


Raquel Gil-Gouveia a, b
a

Department of Clinical Neurosciences (UNIC), Instituto de Medicina Molecular (IMM), Faculdade de Medicina de
Lisboa, and b Headache Center, Hospital da Luz, Lisbon, Portugal

Key Words
Migraine Headache Neurologists Family physician
Self-assessment Medical education Treatment

Abstract
Background: General practitioners (GPs) and neurologists
are involved in treating headache patients in Portugal. Having migraine themselves might influence the way they perceive and treat migraine patients. Objective: To identify clinicians perceptions about migraine, their own headache
status and management of their own migraine. Methods: An
observational cross-sectional survey of GPs and neurologists
using anonymous questionnaires including demographic
data, headache and migraine status and migraine perception questions. Results: Of 348 respondent physicians, 20%
were neurologists and 53% were females with an average
age of 48 years. The majority had an interest in migraine and
considered it disabling (93%), although 6585% reported
management difficulties, GPs more often than neurologists.
Satisfaction with current treatment options was high (69
79%). 63 physicians suffered from migraine and 81% felt it
influenced their perception of the disease. Portuguese physicians preferentially treat their own migraines with NSAIDs
(33%), analgesics (29%) and triptans (20%). Conclusion:
Portuguese physicians treating migraine patients have realistic perceptions about the disease and those with migraine
feel their perception is influenced by their experience.

2014 S. Karger AG, Basel


00143022/14/07140157$39.50/0
E-Mail karger@karger.com
www.karger.com/ene

Although reporting management difficulties, the majority of


physicians are satisfied with current treatment options for
migraine.
2014 S. Karger AG, Basel

Introduction

Primary headaches are the most common neurological


disorders [1] and a leading cause of medical consultation
[24]. Providers are often untrained and unmotivated to
diagnose and treat headache patients [410] and many
have an inappropriate perception of the burden of headache disorders [4, 11] or consider headaches a somatoform disorder [1214]. This results in misdiagnosis [6, 11,
15] and ineffective treatment [6, 7, 11], which increases
patient dissatisfaction and insecurity [15] with consequent doctor shopping, unnecessary testing and inadequate self-treatment. The net result is an increase of
healthcare costs, individual suffering [9, 16] and the likelihood of headache chronification.
We often fail to consider the doctors perspective
treating a headache patient can be demanding. Most
medical degree curricula and residency training programs include limited information on headaches [4, 17,
18] resulting in scarce training in headache diagnosis a
task relying exclusively on clinical expertise [19]. Management of these patients implies knowledge of a wide
range of therapeutic options, detailed counseling and poRaquel Gil-Gouveia, MD
Hospital da Luz
Avenida Lusada no 100
PT1500-650 Lisboa (Portugal)
E-Mail rgouveia@hospitaldaluz.pt

tential life-long follow-up. Clinicians need information


[4, 18, 20], time and motivation to deal with these patients, and suffering from headaches themselves may influence physicians motivation.
Our objective was to survey clinicians most likely to be
involved in managing headache patients in Portugal
(general practitioners (GPs) and neurologists) in order to
identify their perceptions about headache and migraine.
Secondary objectives included determination of headache and migraine prevalence in this sample and the most
common self-treatment options.

Methods
An observational survey was conducted in hospital and by
community-based GPs and neurologists between the September
15 and December 31, 2009.
The source population included 3,688 GPs and 269 neurologists regularly visited by representatives of the study sponsor
(Almirall), corresponding to 72.8 and 71.7% of the total number
of GPs and neurologists registered in Portugal [21]. During the
study period, visits were distributed by geographical convenience
and targeted to include 150 neurologists and 1,350 GPs. 500 questionnaires were distributed 400 to GPs and 100 to neurologists.
The study design was similar to a previous French study of the
same sponsor [22] participating physicians completed an anonymous questionnaire and returned it anonymously to the study center. The questionnaire included three sections: the first section collected demographic information (age, gender, medical specialty,
work area, duration of practice and interest in headaches disorders), the second section had multiple-choice questions about disease impact and severity, patient expectations, satisfaction with
treatment options and management issues, and the third section
related to self-reported headaches (occurrence of headache during
life, in the last year, the previous day and migraine self-diagnosis,
age of onset, headache frequency, self-treatment choices and medication overuse).
Inclusion criteria were being an active working GP or neurologist in Portugal during the study period and willingness to participate; devolution of a blank or imperceptible questionnaire was
the only exclusion criterion (for the questionnaire see online supplementary material; www.karger.com/crd/doi/10.1159/000355278).
Descriptive statistics used frequencies, means and standard deviations; comparative statistics used the 2 test for differences in
frequency distributions and Students t test to compare means.
Missing cases were excluded analysis by analysis. Statistical tests
were two-tailed with an of 0.05 and calculated with SPSS 16.0
software.
No participant was offered or received any incentive for participation. Ethics committee authorization was not required as the
survey had neither intervention nor patient data. The Portuguese
National Committee for data protection dispensed authorization
because neither nominative physician data nor any type of patient
information was collected.
The study was initiated by Almirall and coordinated by its area
medical advisor in cooperation with the author. The author as-

158

Eur Neurol 2014;71:157164


DOI: 10.1159/000355278

sisted in developing the study protocol and the initial statistical


analysis plan. Descriptive statistics were delegated to a contract
company (Keypoint, Lisbon, Portugal). The author had full access
to all data of the study and performed comparative statistics, exploitation of study results and wrote the article, having final responsibility for the decision to submit for publication.

Results

Study Participants
The response rate was 69.6% (n = 348) and slightly
higher for neurologists (71%) than for GPs (65%). 18
screened physicians failed to fulfill their specialty. The final population represents 19% of Portuguese neurologists and 5% of Portuguese GPs.
The mean age of participants was 47.7 (2475) years
and average duration of medical practice was 22.5 (246)
years (table 1). Most of the respondents were female
(53%) and who were younger than males (45.5 10 vs.
50.5 9 years, p< 0.0001). Demographic characterization
of both specialty groups revealed differences, as neurologists were younger, more often males and few practiced
in a rural area. The majority of physicians (301, 87%) declared having some or a high interest in migraine, although 50% of the doctors reported seeing less than 5
migraine patients monthly (table1).
Migraine Perception
Migraine was considered as a disease by 96% of inquired physicians, the vast majority considered it disabling (56%) or very disabling (37%). These perceptions
did not differ between medical specialties, area of practice, average monthly migraine patients or self-reported
migraine diagnosis (p = n.s.). Female physicians were
more likely to consider migraine as very disabling than
males (24 vs. 13%, p = 0.009). Older and more experienced doctors were more likely to have less interest in
migraine (p= 0.001). Physicians self-reporting a low interest in migraine were more likely not to perceive migraine as a disease (12 vs. 2%, p = 0.006) and were also
more likely to consider migraine as not being disabling
(21 vs. 4%, p< 0.0001).
Management difficulties were reported by most clinicians and on some topics GPs did so more often than
neurologists (fig.1). The majority (87%) of physicians always or most often schedule a follow-up visit for migraine
patients, irrespective of gender, medical specialty, professional experience or self-reported migraine (p= n.s.).
Most of the inquired physicians reported being satisfied or very satisfied with available acute (79%) and preGil-Gouveia

Always
Do migraine patients consult not
mentioning migraine?

Often

Rarely/never

Missing

**

Is it difficult to convince patients


that migraine is not secondary?

**

Does medical nomadism


complicate management?

Do migraine comorbidities
complicate management?
Is treating migraine too timeconsuming?

**
**

Are patients expectations high?

Fig. 1. Migraine perception by Portuguese


0%

physicians. GPs more often than neurologists: *p< 0.001; **p< 0.0001.

20%

40%

60%

80%

100%

Table 1. Demographic characteristics of the study population

Total sample

Neurologists

General practitioners

Difference of specialties

330 (18 missing)

71 (20%)

259 (74%)

NA

158 (45%)
184 (53%)
(6 missing)

47 (66%)
22 (31%)
(2 missing)

106 (41%)
151 (58%)
(2 missing)

p < 0.0001

47.710.0
(10 missing)

43.810.3
(1 missing)

48.79.6
(8 missing)

p < 0.0001

274 (79%)
55 (16%)
13 (4%)
(6 missing)

69 (97%)
0
2 (3%)
(0 missing)

189 (73%)
55 (21%)
10 (4%)
(5 missing)

p < 0.0001

22.59.8
(24 missing)

19.810.6
(2 missing)

23.19.5
(19 missing)

p < 0.013

62 (18%)
239 (69%)
43 (12%)
(4 missing)

27 (38%)
39 (55%)
5 (7%)
(0 missing)

32 (12%)
193 (75%)
32 (12%)
(2 missing)

p < 0.0001

Approximate number of migraine patients, monthly


174 (50%)
5
99 (28%)
610
51 (15%)
1120
20 (6%)
21
(4 missing)

11 (15%)
17 (24%)
29 (41%)
14 (20%)
(0 missing)

154 (59%)
77 (30%)
20 (8%)
6 (2%)
(2 missing)

p < 0.0001

With migraine (% of total)

21 (30%)

Speciality
Gender
Male
Female
Age average (SD)
Place of practice
Urban
Rural
Both
Years of medical practice (SD)
Self-reported interest in migraine
High
Some
None

63 (18%)

40 (15%)

n.s.

NA = Not applicable; n.s. = not significant (p > 0.05).

Doctors Headache

Eur Neurol 2014;71:157164


DOI: 10.1159/000355278

159

Yes
Having migraine influences your
perception of the disease?

Missing

51

Having migraine influences the way you


treat migraine patients?

45

Do you discuss your own migraine with


patients?

13

32

Would you if asked by the patient?


0%

Fig. 2. Perception of own migraine by clini-

No

20%

40%

60%

80%

100%

cians.

Table 2. Importance of acute treatment characteristics for all physicians (n= 348)

Headache relief after 2 h


Rapid return to normal activity
Tolerability
Single dose

Rated as most
important

Rated as least
important

Rating
score

Missing
cases, n

300 (86%)
22 (6%)
9 (3%)
6 (2%)

1 (0.3%)
55 (16%)
32 (9%)
233 (67%)

1.10.4
2.60.8
2.70.7
3.60.8

22
22
23
23

Physicians had to rate each item according to importance from 1 most important to 4 least important.
Rating score reflects average scoring for each item SD.

ventive (67%) treatment options for migraine. The majority of physicians rated the most important characteristic of acute treatment to be the ability of providing fast
pain relief (<2 h) and as the least important the single
administration (table 2). When prescribing preventive
drugs, 40% of physicians expect a 50% reduction in headache frequency and 31% expect a 70% reduction of attacks. There was no difference between medical specialties, medical experience, gender, or self-reported migraine diagnosis (p= n.s.).
Self-Reported Headache
Thirty physicians (9%) did not complete the questionnaire about self-reported headaches. 138 physicians did
not report headaches (54% of whom were females) and
180 had previous headaches of which 80% had a headache
in the previous year and 16% had had a headache the previous day.
Considering physicians with previous headaches, the
frequency of headache episodes was 15 or more days per
160

Eur Neurol 2014;71:157164


DOI: 10.1159/000355278

month in 3 physicians (2%), 13 episodes monthly in 56


(31%), and less than 1 headache episode monthly (10 or
less per year) in 76 (42%) individuals.
A self-reported diagnosis of migraine was made in
35% (n= 63) of physicians with headache (18% of the
total sample; table 1), 60% of whom were women
(female:male ratio 1.5), most of them (68%) reported a
temporal relation between attacks and menstruation.
Migraine symptoms had started at an average age of
16.5 7.5 (range 540) years. Average migraine frequency in this sample was 1.4 1.3 episodes monthly, ranging
from less than 1 per month to a maximum of 7. The remaining physicians reported non-migraine headaches
(56% females).
Most clinicians with migraine reported that it influences their perception of the disease (fig.2) and indeed
self-reported migraine was associated with a higher interest in this pathology (p= 0.024) and with the perception
of a higher migraine-associated disability (p= 0.003) but
not with considering migraine as a disease.
Gil-Gouveia

Yes

Missing

37 (59%)

Do you use only a single dose for relief?

58 (92%)

Is this drug tolerable?


18 (29%)

Are you able to return to normal activities?

52 (82%)

Do you obtain pain relief at 2 h?


0%

Fig. 3. Characteristics of self-chosen acute

No

20%

40%

60%

80%

100%

treatment.

Table 3. Acute treatment options for physicians migraines

Missing data, n
Analgesics (group)
Paracetamol
Aspirin
Combination analgesics
Others
NSAIDs (group)
Ibuprofen
Naproxen
Others
Migraine-specific (group)
Triptans
Ergots
Others (group)
Opioids
Antiemetics

Regular use
reported1

Single drug used


most often

Drugs taken in the


last 3 months1

5
50 (79%)
25
10
12
3
55 (87%)
23
10
22
27 (43%)
21
6
10 (16%)
1
9

10
18 (29%)
8
4
5
1
21 (33%)
10
3
8
14 (22%)
13
1
0
0
0

4
40 (63%)
26
5
8
1
42 (67%)
NI
NI
NI
22 (35%)
19
3
7 (11%)
5
2

1
More than one option was possible; percentages refer to total migraine-suffering physicians so may add up
to more than 100%. NI = No information.

Migraine Treatment
Physicians use NSAIDs, analgesics and migraine-specific drugs to treat their headaches (table3). They mostly
reported being satisfied (43, 68%) or very satisfied (11,
17%) with their acute treatment, and average satisfaction
scored on a 10-cm scale was 6.9 1.7 (range 2.110) cm.
Regarding their chosen acute treatment, most physicians
considered it to be tolerable and reported obtaining pain
relief within 2 h (fig.3).
Gender and medical specialty did not influence the
choice of acute treatment or treatment satisfaction (p=

n.s.). Older (49.4 vs. 40.8 years, p= 0.002) and more experienced doctors (25.1 years of practice vs. 16 years, p=
0.001) used ibuprofen as a rescue drug more often.
Seven (11%) physicians reported acute treatment overuse, involving paracetamol (4), triptans (2) and NSAIDs
(1). Four physicians (6%) used a headache diary. Nine
(14%) clinicians were currently using headache preventives, on average for 27 46 months (ranging from
2months to 10 years), that included topiramate (4), flunarizine (2), sodium valproate (1), propanolol (1), and
fluoxetine (1).

Doctors Headache

Eur Neurol 2014;71:157164


DOI: 10.1159/000355278

161

Discussion

This study represents the first Portuguese survey


aimed at investigating physicians perspectives about migraine and its management, including the two medical
specialties most likely to treat migraine patients GPs
and neurologists. This study was based on a similar study
conducted in France [22], by the same sponsor, which
however only included neurologists.
Participation in our study was very good (70%), especially when compared with the similar French survey
[22], but the sample was also biased by its recruitment
method, which is a clear limitation of this study. We cannot exclude a participation bias and another limitation
was the inability to obtain data about sociodemographic
characteristics of the Portuguese practitioners. These design limitations were also present in the French study
[22], which means that our sample may not be representative, so generalization of our findings is limited. Nevertheless, only 18% of our sample reported a high interest
in migraine, only 18% reported having migraine and 50%
reported consulting less than 5 migraine patients monthly facts that argue against the interest bias.
Our sample was of a mature clinical population, as
over half the responding physicians had more than 26
years of medical practice. Maybe reflecting this fact is the
observation that most physicians in this sample have
quite adequate and realistic perceptions about migraine
the vast majority (96%) considered migraine a disease (in
accordance with the French study [22] yet contrasting
with an American study [23]), 65% recognize that the majority of patients do not consult for migraine [10, 24], 87%
recognize the need of a schedule for follow-up visits for
migraine patients and report realistic expectations about
acute and preventive treatment outcomes. In our sample
the low interest in migraine negatively influenced the perception of its disability but not the perception of migraine
as a disease. Gender also influenced disability perception,
as female physicians were more likely to rate migraine as
very disabling, independently of having migraine themselves and of having a close relative or friend with migraine. This is an interesting finding, as gender is not
found to influence quality of live or disability in migraine
patients [2528]. One possible explanation might be that
female physicians are more empathic [29].
All management difficulty scenarios presented were
rated as frequent by both GPs and neurologists, although
more often by GPs, suggesting that they feel less confident
when dealing with migraine patients. Lack of confidence
in managing a frequent non-life-threatening condition
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Eur Neurol 2014;71:157164


DOI: 10.1159/000355278

can relate to less pre- or postgraduate training [4, 6]. A


GPs skills can be improved by training programs [30],
although it is uncertain if these programs would influence
their confidence or perception of management difficulties. One exception was found neurologists and GPs
reported comparably high difficulties when managing
migraine complicated by comorbidities. The most frequent comorbid conditions of migraine are psychiatric
and cardiovascular disorders [31] that fall beyond the
routine neurological practice and neurological training,
lowering neurologists confidence levels.
The prevalence of self-reported migraine in our group
was 18%, a higher prevalence than that found in the general Portuguese population [32] and in other European
countries [33]. A higher frequency of migraine among
neurologists (ranging from 27.6 to 71%) has been consistently described by French [22], American, Canadian,
German, Taiwanese, English, Spanish and Italian physicians [34], and several possible explanations are proposed participation or professional orientation bias,
stressful and sleep deprivation-related factors or even
personality traits [34]. Our sample includes two specialties, although the prevalence was higher in neurologists
(30%) than in GPs (15%) and a difference was not significant. In previous studies the prevalence of migraine
among GPs was found to be similar to that of the general
population [3537]. The gender ratio in our sample was
1.5, which is lower than what could be expected for this
age group [38], suggesting a higher recognition of the diagnosis among male physicians, maybe influenced by the
male preponderance of the neurologist group.
The vast majority of physicians in our sample spontaneously reported that having migraine influences their
perception of the disease and the way they treat their patients. This subjective report was corroborated by the fact
that migraine-suffering physicians were more likely to
rate migraine as disabling or very disabling and also
more likely to report a high or very high interest in migraine. This interesting observation has been described
before [3941] and corroborates a common commentary
of migraine patients in medical interviews Nobody understands migraine unless they have it a statement
which often precedes the question Doctor, do you suffer
from migraine? . In our sample, 51% of physicians reported that, if asked, they share this personal information
with the patients. Only 21% discuss their own migraines
with the patient spontaneously. The sharing of their own
migraine experience with patients builds up confidence
and empathy, improving patients feelings and quality of
life [40]. This strategy, among others, could be included
Gil-Gouveia

in programs aimed at improving consultation skills in


headache.
When addressing treatment issues, the majority or
Portuguese physicians are satisfied or very satisfied with
available acute and preventive treatment options for migraine. This high satisfaction with preventives was not
found in the French study [22], the difference probably
relating to the fact that our physicians were mainly primary care physicians who are able to refer difficult migraine patients. Regarding acute treatment, the most important aspect they refer is the ability to obtain headache
relief within 2 h. Tolerability and rapid return to normal
function are rated almost equally in importance. When
analyzing the smaller sample of migraine-suffering physicians reporting on treatment of their own attacks, satisfaction with acute treatment was high. The vast majority of physicians obtain relief within 2 h and all reported
good tolerability yet only 29% reported being able to return to normal activity after treatment. Although physicians do not seem to value tolerability, none reported
tolerability issues when using the acute treatment. Despite considering return to normal function important,
most physicians do not with their current acute treatment option. In sum, when physicians are patients, they
favor lower efficacy over side effects, contrasting to literature data that reports rapid and complete headache
relief as the most important attributes for migraine attack treatment for both physicians and patients independently [42, 43].
The most used acute treatments were NSAIDs and analgesics (especially paracetamol), in line with reports by
the French, Spanish and German neurologists [22, 44,
45]. Only 21% of physicians reported using triptans as
their first choice for treating attacks, although 31% had
used triptans in the previous 3 months. It is very difficult
to determine if these values are within expectations for a
migraine population, as several variables influence triptan use by diagnosed migraineurs in different countries
it can vary between 16 and 47% [46]. A preference for
non-triptan drugs is evident in our sample, which can relate to cost the average out-of-pocket price of a triptan
tablet in Portugal is EUR 4.47 while EUR 0.17 is the average unit price of ibuprofen, naproxen and paracetamol
(values that already include partial reimbursement of the
Portuguese National Health System) [47]. Other possible
explanations may relate to the age of the sample, e.g. with
an average of 50 years and 25 years of medical experience,
these doctors were trained to use NSAIDs and analgesics
for migraine treatment. Furthermore, this is probably a
mildly disabled migraine population, as only 2% reported

having more than 15 migraine days per month and 42%


reported having less than 1 headache episode monthly,
suggesting that most physicians probably never needed to
escalate their treatments. All the acute and preventive
drugs our physicians use are included on the national
guidelines for migraine treatment [48] with level A or B
recommendations, reflecting a highly updated and realistic perception of migraine management.
To conclude, Portuguese doctors involved in migraine
management and who participated in this study have realistic perceptions of migraine management. Having migraine themselves influences their valorization of disability of migraine and their interest in migraine patients but
not their perception of the disease or of its management.
Training programs in headache and migraine should include valorization of disability involving migraine-suffering physicians could increase other physicians interest
in this condition. Although difficult to generalize, this
study suggests that physicians directly involved in treating headache patients experience management difficulties but are able to do a very conscientious and adequate
job.

Doctors Headache

Eur Neurol 2014;71:157164


DOI: 10.1159/000355278

Acknowledgements
The author acknowledges the assistance of Almirall Medical
Adviser, Ana Filipa Mendona, and Isabel Pavo Martins for critically reviewing the work. This study was supported by Almirall in
collaboration with the Portuguese Headache Society.

Disclosure Statement
The author has received personal compensation from Almirall for protocol review and adaptation and cooperation in study
design.

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