Migraine assessment- screening instruments & scales

Overview• Migraine is the most common headache disorder• Diagnosis is by ICHD-2 criteria• However, less than half of patients with migraine are properly

diagnosed• Out of these, only one-third are properly treated, leading to

headache-related disability & health-related quality-of-life(HRQoL)

• Migraine is often associated with psychiatric disorders, including depression and anxiety

• Thus, proper treatment of comorbid psychiatric disorders is crucial to the adequate treatment of migraines.

Impact of migraine• Thus, migraine adversely affects daily functioning

• Not only does it affect the family life and relationships but also has certain indirect costs

• These indirect costs can be enormous

• It is estimated that in the US, the indirect cost of migraine to employers is approximately $12 billion annually

Screening items & tools• These help us to:Facilitate diagnosis

Identify comorbid diseases

Evaluate disability & HRQoL

Assessment treatment response

Migraine diagnostic tools

ID Migraine• Three-item migraine screener• If the answer to any 2 questions is yes, then:Sensitivity = 0.82Specificity = 0.75• Test reliability comparable to that of other screening

tools• Sensitivity and specificity not influenced by gender ,

age, presence of comorbid headaches, or previous diagnostic status

• However, the global application of ID Migraine needs further validation due to the different prevalences of migraine symptoms in different regions and racial groups

• Eg. Asian populations show lesser prevalence of photophobia compared to Western populations but have a higher rate of Osmophobia

• Hence, validation or modification might be necessary when applying a screening instrument in different regions.

PCN screener• It assess a combination of treatment and

diagnosis

• It is efficient in a primary care setting

• Has 4 questions which give good insight

Brief headache screen

Disease impact assessment tools

• Migraine attacks vary in severity from moderate to severe pain with prolonged incapacitation

• Assessing pain and disability is important in determining the impact of disease

• Managing headache-related disability is a challenge

MIDAS• Migraine Disability Assessment Questionnaire• It is a 5-item questionnaire designed to evaluate disability

within the most recent 3 months• The patient needs to score the reduction in the performance,

in days, of work/school, household work, and family/social activities.

• A score 0-270 is used to indicate the overall level of disability• Due to its high internal consistency, validity, and good

correlation with clinical diagnoses and treatment, MIDAS has been widely validated across countries and translated into several languages

• In addition to disability assessment, MIDAS also serves as a powerful instrument for the stratified care of patients with migraine

Headache Impact Test(HIT-6)• Widely validated instrument

• The HIT-6 comprises six items to evaluate the frequency of severe headache

• Each of the six items is scored according to frequency, generating an overall score of 36-78

• The impact scores can be classified as Little or no impact (grade 1: score 36-49), Moderate impact (grade 2: score 50-55), Substantial impact (grade 3: score 56-59), or Severe impact (grade 4: score 60e78)

• The HIT-6 score is obtained at baseline and at every 4 weeks of treatment and could be used as a good surrogate marker of the response to treatment.

• A reduction of 2.3 points on the HIT-6 score following treatment indicates a clinically significant improvement in patients with chronic daily headache

• Furthermore, in a recent study, HIT-6 was found to be useful for understanding the specific burden of chronic daily headache compared with episodic headache (i.e., chronic migraine vs. episodic migraine)*

*Buse D, Manack A, Serrano D, Reed M, Varon S, Turkel C, et al. Headache impact of chronic and episodic migraine: results from the american migraine prevalence and prevention study. Headache 2012;52(1):3e17.

Evaluation of comorbid psychiatric disorders

• Migraine is known to be associated with a variety of psychiatric disorders.

• Certain personality traits are associated with a higher prevalence of migraine, especially chronic migraine and medication overuse

• Patients with primary headache disorders are prone to have a higher incidence of the neurotic triad of hypochondriasis, depression, and hysteria, but are still within two standard deviations compared with the control group

MMPI• Minnesota Multiphasic Personality Inventory

• Was originally designed to identify personality structure and psychopathology

• Consists of ten different scales that are used to identify nine major different personality traits

• MMPI (original edition) and MMPI-2 (revised in 1989)44 are commonly used in headache studies

Hospital Anxiety and Depression Scale (HADS)

• Designed for screening patients with potential anxiety and depression rather than grading the severity of the anxiety and depression.

• There are 14 items on the HADS questionnaire, seven of which measure anxiety (HADS-A) and seven of which measure depression (HADS-D).

• Each item is scored in a scale of 0e3, resulting in an overall score of 0e21 for both HADS-A and HADS-D

• A subscale of 3-9 on HADS-A yields a sensitivity of 0.66-0.86 and a specificity of 0.83-0.93 for anxiety,

• Whereas a subscale of 7-9 on HADS-D yields a sensitivity of 0.66-0.91 and a specificity of 0.87-0.97 for depression

Beck Depression Inventory (BDI)• BDI is commonly used as a tool to grade depression. • BDI consists of 21 questions, each scored on a scale of 0-3. • The questions covers most of the diagnostic criteria of the

major depressive disorders in(DSM IV) including hypochondriasis, perception of body image, and changes in sleep, appetite, etc

A score of 0-9 indicates minimal depression, 10-18 indicates mild depression, Score of 19-29 indicates moderate depression, and Score of >30 indicates severe depression

Patient Health Questionnaire (PHQ-9)• PHQ-9, a 9-item questionnaire with each item

corresponding to one criterion of the DSM-IV diagnostic criteria of major depressive disorder, serves as both a screening tool and a grading instrument for depression

• Each of the nine items is scored on a scale of 0e3 depending on the frequency of symptoms. An overall score 10 provides a sensitivity of 88% and specificity of 88%

• PHQ-4, a simplified edition of PHQ-9, has been developed to rapidly screen depression and anxiety

Assessing HRQoL

Migraine-Specific Quality of Life Questionnaire version 2.1 (MSQ v2.1)

• A 14-item questionnaire used to assess the limitations in daily performance due to migraine

• MSQ v2.1 is composed of three domains: role function-restrictive (RR), role function-preventive (RP), and emotional function (EF).

• The first two of these domains are used to access the reduction and prevention of daily social- and work-related activities

• The last domain is used to evaluate emotions associated with migraine.

European Quality of Life-5 Dimensions (EQ-5D)

• A self-reported health status that covers five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and general health status

• EQ-5D is widely used to evaluate the HRQoL of different diseases, including psychiatric diseases, medical diseases, surgical outcomes, etc.73

• In addition, in patients with migraines, EQ-5D scores are even worse during frequent attacks compared with the baseline condition of the patient

Short-form 36 (SF-36)• A multidimensional questionnaire used to assess the impact of

disease on eight health domains, such as: Physical functioning, Role limitations due to physical problems, Bodily pain, General health perceptions, Vitality, Social functioning, Role limitations due to emotional problems, and Mental health

• A score of 0-100 on each subscale is generated, with higher scores indicating better HRQoL

References• Peng KP, Wang SJ. Migraine diagnosis: screening

items, instruments, and scales. Acta Anaesthesiol Taiwan. 2012 Jun;50(2):69-73

• Buse DC, Rupnow MF, Lipton RB. Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clin Proc. 2009 May;84(5):422-35

• http://www.medscape.org/viewarticle/552933

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