What should happen first with a new patient suspected of having migraine?


By the time someone diagnosed with migraine has seen a variety of doctors and specialists, diagnosis may have become clouded. It’s important that the diagnosis itself first be thoroughly explored with a new provider before moving on from there with management.


“The first thing I'd like to do is make sure they have migraine. That may sound, to some of the people listening who have probably very sophisticated histories, to be too over simplistic, but I would certainly argue that it is important, and imperative, for the doctor, physician, taking the history, to ensure the patient has a migraine. Now why would that be so? First instance, it's not difficult. If you're 19 years old, or 20 years old, a male or a female, and come to a physician's office or a neurologist, it's not difficult to get the history on the first occasion. The patient usually describes it in their own words, and you like to let them do that, and then you go through a category of characteristics to determine if that's the correct diagnosis or not. Over time, however, there's a real problem as patients see more and more doctors, more and more consultants, and more and more health professionals, what they tend to do is start to edit their own history. They start to add on things that they've learned through the process, learning about the disorder or disease. They make options that they think the doctors would like to hear. They do all sorts of things subconsciously, which they may not realize may affect the outcome of the diagnosis. By the time you arrive in middle age, and later life, you may have a very complicated and complex history of headache and multiple comorbidities. If someone didn't focus in on the original diagnosis, how can we be absolutely sure they have migraine? Because migraine can mimic, and be a chameleon for numerous other neurological disorders, so the first thing I do is sit down, and I go through it, and I go through it, and I go through it
until I think I've got it right.

“Once I know the patient has migraine with aura, I feel a little bit more comfortable. Why do I feel that way? Because it's very hard to find many other neurological disorders that can mimic that kind of stereotypical symptom. Therefore, I'm more convinced about what they have. If they simply are describing the headache, unilateral headache, nausea, vomiting, throbbing, moderately severe, worse with light, and sound, and movement, then what happens right away is you can say, ‘Oh yeah, that's probably migraine, but you can't be
sure.’ I have a little thing I tell the residents and some of the other doctors. I said, ‘Everything is a migraine until it isn't.’ Basically migraine can present many ways, many facets, and I try to get that key history because everything for the rest of their lives, and interaction with doctors, will depend on getting that original diagnosis. If it's wrong, I will predict that it will be handed on from doctor, to doctor, to healthcare professional. One thing doctors don't do very often, if you think about it, they don't go back and say, ‘Let's just go over the history again."

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Allan Purdy, MD

Professor of Neurology
Dalhousie University, Canada

Dr. Allan Purdy is a neurologist and a professor at Dalhousie University in Nova Scotia, Canada. Dr. Purdy is currently President of the American Headache Society. He has also served as president of the Canadian Headache Society and on the Board of Directors for the International Headache Society.

Dr. Purdy is regarded as one of the most gifted teachers in the field, developing educational programs for physicians around the world who care for patients with headache diseases. In addition to his research and education work, Dr. Purdy continues to see headache patients in his Canadian clinic on a part-time basis.