Fifteen Minute Headache Evaluation
Ninety percent of the headache visits in America do not exceed fifteen minutes in a primary care office. This is the time available for routine revisits of any sort in this era of managed care. Headache specialists protest at this amount of limited time. A physician specializing in one medical issue in this case headache cant conceive of dealing with any medical problem in less than 40 minutes for a first visit and fifteen or twenty minutes per revisit. The problem is the collection of relevant data. Any way it is done requires more than fifteen minutes. Unfortunately, the primary care doctor is also being told the same thing by specialists and experts in the study of depression, high blood pressure, obesity, ADD, high cholesterol and a few hundred other common maladies of mankind. In the perfect world certainly not todays world of medicine physicians should all spend as much time as is required with every patient until enough data is gathered to find the best resolution for each problem.
Special Considerations in Headache Diagnoses
Considerable research has been done on the frustrating disorders in medicine today. In a classic article by Wayne Katon, MD, Medically Unexplained Symptoms in Primary Care,1 he defined fourteen physical symptoms accounting for over 40% of visits to primary care doctors, with only about 10-15% accountable to a specific organic disorder. These symptoms included chest pain, fatigue, dizziness, headache, edema, back pain, tinnitus, shortness of breath, insomnia, abdominal pain, and numbness. He further reported that unexplained symptoms were often associated with personality and psychosocial factors, as well as overt psychiatric disease. They were also associated with increased costs and increased perception by the doctor that the patient was difficult or frustrating. Other studies by Dr. Katon and other researchers have documented that chronic unexplained symptoms, like headache, are often associated with major psychological factors.1-7
About 20 years ago, headache patients had a high probability of having their problem classified as psychosomatic and deserving of the non-organic label. Dr. Katon comments that an increasing number of medically unexplained symptoms over a patients lifetime correlates linearly with the number of anxiety and depressive disorders experienced. Given this point of view, is there any difference between the headache patient and the patients with those other strange unexplained symptoms such as tinnitus? One characteristic that differentiates headache from that pack of common unexplained symptoms is that headache has become much more specific than it ever was before in the past decade, both in terms of diagnosis and treatment. Research in headache has definitely shown that it is an organic disorder. It is also underdiagnosed and undertreated,8-10 specifically that the most severe and common disorder migraine is certainly neglected. Migraine is the disorder that most patients present with since it is rare that anyone with a slight or minimal headache seeks medical care for that problem alone. In a study performed by Tepper et al, it was reported that 94% of the patients presenting to primary care offices were diagnosed by headache specialists as migraine or migrainous headaches.11 Numerous studies have demonstrated the over-diagnosis of the two old classics, sinus and muscle tension headache,12 instead of the correct diagnosis migraine. Further, the documented comorbidity of psychiatric conditions with severe headache has certainly led to over-diagnosis of headaches as psychiatric disorders in the past. Certain conditions shown to exist in greater than expected incidence with migraine (comorbid conditions) include depression, panic disorder, bipolar disease, mitral valve prolapse, inner ear disorders such as carsickness, irritable bowel syndrome, and epilepsy.
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