Primary care clinicians’ perspectives on migraine management in Aotearoa New Zealand: a qualitative study

Interviewees acknowledged that a foundation of trust in the healthcare system did not always exist for marginalised groups, especially Māori and Pasifika, owing to past experiences of discrimination or culturally inappropriate care, which could discourage these patients from seeking health care. Taking time to build relationships was needed, but couldn’t happen unless patients chose to attend the healthcare service.

Language and communication differences could also make it difficult for patients to describe their experience of pain or other symptoms without appropriate translation or knowledge of the cultural context.

Key barriers to seeking help were affordability and registration with a practice. The cost barrier could be mitigated by offering services with low-cost appointments, although even when funding did exist to subsidise care for Māori, Pasifika and low-income patients, this was perceived to not be readily accessible. Lack of registration affected itinerant workers, people living in areas with closed practices and men, who tended to be less well connected with primary care, unlike women who were brought in through screening programmes.

Another barrier to seeking health care was patients having to find time to attend appointments around work and other obligations and cover costs of transport. This could be particularly difficult for those working shifts or full-time jobs where the employer did not allow time off during the day.

Interviewees agreed that a scarcity of primary care clinicians had resulted in fewer appointments and long wait times, with some patients waiting weeks for an appointment. These barriers contributed to patients ‘saving up’ their medical concerns and coming to their primary care provider with a long list, often with too many items to attend to in one consultation. This meant that perceived ‘non-urgent’ concerns, such as headache or migraine, went unaddressed.

Interviewees believed there could be a significant number of people with migraine in the community who may not know they have migraine disease and that prescription medication and other treatments are available that could reduce their attacks. As such, they ‘just put up with it’ (GP5), manage with over-the-counter or pharmacy medication or traditional medicine and approaches. On the other hand, interviewees noted that most patients did not request an explanation of migraine itself and already had some understanding. This could reflect a difference between those who sought help due to knowing about the condition and those who were not yet aware of having migraine or did not perceive a need to seek help.

Interviewees were well-informed on the process of diagnosing migraine and found the available diagnostic resources to be generally useful and sufficient, particularly HealthPathways, although these needed to be adapted to local areas. Few difficulties with making a diagnosis were reported, with respondents relying on the distinctive features of aura, severe throbbing, often one-sided pain, photo/phonophobia and nausea, as well as family history of migraine, although the variety of symptoms could mean that people presented in many different ways. The presence of any red flags, suspected atypical migraine (abdominal migraine, hemiplegic migraine and vestibular migraine) or new-onset migraine in older people prompted referrals to secondary care. The presence of comorbidities and polypharmacy could complicate diagnosis, particularly with analgesia overuse.

Interviewees reported good coverage of migraine disease management in GP training and postgraduate education, but recalled less teaching during undergraduate medical school and the NP training programme, noting the potential for recall bias for events some years in the past.

Interviewees noted that most patients with migraine should be managed in primary care, and information in HealthPathways and advice from neurologists were usually sufficient to support this, but a small proportion of more challenging migraine cases could struggle to get specialist care. When referral to neurology was required (in cases of diagnostic uncertainty, atypical migraine or treatment-resistant disease), clinicians reported long wait times. Referrals were sometimes declined, and even when accepted, patients would typically wait many months to be seen. Referral acceptance varied between regions. Private clinics were more likely to accept referrals for migraine, but had similarly long waiting times.

However, the facility for asking for written or phone advice from neurologists and the advice received was universally highly valued by clinicians, although some had concerns about long-term viability given pressure on neurology services. The utility of a specialist consult was sometimes to reinforce and validate the diagnosis, advice and treatment plans given by the primary care clinician.

The capacity and pathways for GPs and NPs to order CT head scans in the community also varied according to region. Imaging was used when history or examination red flags were identified.

Interviewees noted that the diagnosis of migraine could sometimes be obscured or overlooked due to patient comorbidities. In these cases, migraine could go undiagnosed and untreated due to being attributed to another condition. In particular, patients with psychiatric comorbidities, substance use, functional neurological disorders or even multimorbidity with multiple medications could be at risk of such overshadowing.

Other interviewees noted that both patients and clinicians may minimise menstrual migraine, with women believing this was a normal part of having a menstrual cycle or seen as something to put up with, rather than something for which treatment was available.

Interviewees generally had an excellent level of knowledge on the treatment of migraine disease and the need to tailor it to each patient, describing the analgesic ladder for treating acute attacks (from simple analgesia and anti-nausea medication to triptans) and instigating preventive treatment for frequent attacks. A key feature was finding ‘what works for them’ (NP2) and individualising treatment. Interviewees had a similar approach to acute management, advising patients to act quickly at the beginning of a migraine and take a combination of medications if needed.

Preventive medications were discussed for patients who were missing work and having frequent or severe attacks. Usual migraine prophylaxis options were beta-blockers, tricyclic antidepressants (particularly nortriptyline), ovulation-inhibiting contraception for menstrual migraine and less often, topiramate or pizotifen.

As with diagnosis, HealthPathways was the key source of treatment information and could be used to reassure patients about the range of treatment options and reinforce advice given. It was also useful to cite when making a specialist referral, to demonstrate that recommended treatment had been exhausted.

Other sources of useful information mentioned by respondents included Best Practice Advocacy Centre (BPAC^NZ),²⁸ Goodfellow Unit,²⁹ the Royal New Zealand College of General Practitioners, peer groups and colleagues (from primary care and neurology), Up to Date, NZ Doctor, UK guidelines and education activities (webinars, podcasts, in-person events and articles).

One area of treatment with low clinician awareness was the new class of migraine-specific medications blocking the action of calcitonin gene-related peptide (CGRP), a neuropeptide involved in inducing migraine attacks. Although three of these new medications were available in NZ at the time of the interviews, none were funded and all cost upward of $300 a month. Some interviewees had heard of these but none regularly prescribed them. Reasons given for this were that the medications were not affordable for their patient groups or they would prefer neurologists to initiate unfamiliar medications.

All interviewees placed significant emphasis on communication with patients. This included exploration and explanation of the role of migraine triggers (especially caffeine, menstruation and iron deficiency), lifestyle factors (sleep, healthy eating, stress and exercise), the efficacy and side effects of any medication prescribed and titration plans for starting preventives. There had to be a balance between setting realistic expectations about the efficacy (and timeframe for response) of preventives and encouraging people to persevere. Several interviewees mentioned referring patients to Healthify, a patient web resource with NZ-specific, up-to-date information about health conditions, including migraine.

Interviewees noted that many people who present to primary care with headache want reassurance that they do not have a life-threatening condition, such as a brain tumour. Identifying and addressing these concerns was particularly important for those who expected a head scan, including explanation of why this was not needed.

Managing migraine as a chronic condition came with the known barriers to ongoing care, especially financial cost. Oral preventive medications needed to be trialled for at least several months with slow dose changes to minimise adverse effects, requiring repeat visits or contact. The cost of trying and monitoring use of preventive medications could add up to hundreds of dollars, so some patients did not return for follow-up.

There was also the barrier of appointment times. It could take longer than 15 min to develop and implement treatment plans for both managing and preventing attacks, and talk about keeping a headache diary to monitor progress and potential precipitating and lifestyle factors.

Working with other healthcare professionals to manage limited access to primary care clinicians was seen as a way to optimise patient care. Patients could be referred to practice pharmacists, health improvement practitioners (HIPs), health coaches (HCs) and nurses for support in use of medications or making lifestyle changes as part of migraine treatment.

Physiotherapists were seen as a useful resource for patients experiencing a musculoskeletal component to their migraine presentations, eg head and neck pain, and for addressing vestibular symptoms, but the perceived cost of physiotherapy was a barrier. Interviewees reported some positive patient experiences from other complementary therapies such as acupuncture, osteopathy, massage, nutrition and supplements, but were cautious about therapies with limited evidence, especially when these were expensive and patients were expected to continue therapy indefinitely. The main foci for primary care clinicians were lifestyle changes and pharmaceutical treatment.

Interviewees described how some patients experienced stigma in relation to their migraine disease, especially in the workplace and education environment. They cited a lack of public understanding of the potential severity of migraine, as well as the difficulty of dealing with a chronic invisible illness. Several interviewees reported having to advocate for their patients to get allowances for missing work/school.