SNOOP Criteria for Headache Red Flags or Warning Signs

Headaches that should flag further attention

SNOOP Criteria for Headache Red Flags or Warning Signs

When is a headache not a migraine? When it's waving a red flag that it might be secondary to some other condition, according to Amaal J. Starling, MD.

Dr. Starling, an assistant professor of neurology at Mayo Clinic in Scottsdale, reviewed these red flags and some urgent causes of headache during the Mayo Clinic Hospital Medicine 2017 conference, held in Tucson, Ariz., in November.

“Your first responsibility when you see that patient with a headache is to rule out secondary causes,” said Dr. Starling. “Every headache patient that you see, you need to have a systematic approach.”

Subarachnoid hemorrhage is the first condition to consider when a patient describes a thunderclap headache. Image by iStock

She recommends an approach called SNOOP4. “I love mnemonics, and SNOOP4 is one of my favorite ones, developed by my mentor, Dr. David Dodick. I've adapted it a little bit,” she said.

As Dr. Starling explained, S is for systemic symptoms, such as fevers, chills, and weight loss or gain.

N is for neurologic symptoms and signs, “specifically focal ones, such as unilateral weakness, paralysis, numbness, visual loss, difficulty with thinking skills such as making mistakes at work,” she said.

The first O is for older age at onset (over 50 is a red flag), and the second is for sudden onset of this specific headache attack.

“A headache that reaches peak intensity, 10 10 pain, in less than a minute—that is a neurologic emergency and definitely something we need to elicit in history,” said Dr. Starling. Then there are the four P's: precipitation with Valsalva maneuver or exertion, postural or positional, pattern change or progressive, and pregnancy.

Causes of secondary headaches

Dr. Starling offered examples of headache causes that could be identified, or at least suspected, using the SNOOP4 mnemonic, including giant-cell arteritis (GCA). “This occurs typically in older individuals, in white females,” she said. “This is high on my differential for anyone with a new-onset headache greater than the age of 50.”

Headaches caused by GCA can also be red-flagged by the presence of systemic symptoms. About half of the time, patients with GCA have polymyalgia rheumatica or jaw and tongue claudication. Scalp tenderness is another symptom.

“People might have an abnormal temporal artery exam, where there's some nodularity, it's tender to the touch, or there may actually be absent temporal pulsations,” added Dr. Starling.

Visual symptoms can include double, blurred, or darkened vision and “of course the irreversible complication of ischemic optic neuropathy, which presents with vision loss, and that's what we're trying to prevent,” she said.

If a patient presents with these symptoms, the first step is not diagnosis, it's treatment. “Because we are trying to prevent that feared complication of visual loss, when you suspect it, treat it.

Do not allow for diagnostic workup and confirmation to delay your initiation of high-dose corticosteroids,” said Dr. Starling. She recommended a dose of 1 mg/kg of prednisone with an upper limit of 60 mg/d.

Some studies have also found benefit from low-dose aspirin (81 mg) to prevent cranial ischemic complications, she noted.

Once steroids are prescribed, the workup for GCA should include an erythrocyte sedimentation rate (ESR), complete blood count (CBC), and C-reactive protein (CRP) level.

“It's important to include a CBC and specifically a CRP because up to a quarter of individuals with biopsy-confirmed GCA may actually have a normal ESR, so the CRP is actually a more sensitive inflammatory marker for GCA,” said Dr. Starling.

Patients with suspected GCA should also undergo a temporal artery biopsy within seven days of initiating steroids, she advised. “And remember, even though they start with the symptomatic side, make sure that whoever performs the biopsy also performs bilateral biopsies if the symptomatic side is negative. Due to skip lesions, the vasculitis isn't continuous.”

Because patients with GCA frequently also have large vascular involvement, angiography of the chest by magnetic resonance or CT or positron emission tomography is needed.

“This is important, specifically for follow-up, because individuals that have that large-vessel involvement, they need an annual screening chest X-ray or a transthoracic echocardiogram, because one five individuals with large-vessel involvement in GCA end up with an aortic aneurysm, and one 16 end up with a dissection,” said Dr. Starling.

Thunderclap headache

If the headache red flag is sudden onset, a different diagnostic algorithm is in order. “What are 10 things that cause thunderclap headache?” Dr. Starling asked. “Subarachnoid hemorrhage. Great! Next? Subarachnoid hemorrhage. … That is the first thing that you should think about; that is all the way down to the tenth thing that you should think about.”

To diagnose a subarachnoid hemorrhage, order a CT scan of the head without contrast and a lumbar puncture.

“The reason that you want to do both is because there is this inverse timing relationship between the CT head and the lumbar puncture, depending on when the subarachnoid hemorrhage occurred and when the person presented,” she said.

“Within the first 24 hours, a CT head is highly sensitive, after which it loses sensitivity. … In the intial six hours after the thunderclap headache, the lumbar puncture is not as sensitive; however, the lumbar puncture beyond 12 hours and at one week and two weeks is really 100% sensitive.”

If the results of both tests are normal, the good news is the patient probably doesn't have a subarachnoid hemorrhage. Unfortunately, there are a lot of other etiologies of a thunderclap headache. “And they are neurologic emergencies,” said Dr. Starling, who divided the potential headache causes into vascular and nonvascular.

“In the vascular column, the one that we very commonly see and is oftentimes missed is reversible cerebral vasoconstriction syndrome and then also hypertensive crisis, cervical artery dissection, as well as cerebral venous thrombosis and stroke,” she said. Potential nonvascular causes include meningitis, sinusitis (especially sphenoid), and spontaneous intracranial hypotension.

“You need to do neurovascular imaging so that you can rule out all the different vascular and nonvascular causes,” Dr. Starling said. This can include MRI, magnetic resonance angiography (MRA), magnetic resonance venography (MRV), or CT angiography or venography scans if the other tests are not immediately available.

Those scans can reveal vascular patterns such as “beads on a string,” which indicate reversible cerebral vasoconstriction syndrome (RCVS). The first step in treatment of RCVS is to withdraw any serotonergic medications, Dr. Starling advised. “Also elicit a history of any drug abuse, because marijuana and cocaine can be associated with RCVS,” she said.

Patients should be treated with a calcium-channel blocker. “Borrowing from the subarachnoid hemorrhage literature and evidence, we use nimodipine, which isn't actually FDA-approved for the treatment of RCVS, but we haven't actually performed any [randomized controlled trials] in the treatment of RCVS,” she said.

The tricky part is making sure that patients don't become hypotensive. “So you want to run IV fluids at the same time you're also giving them the IV calcium-channel blocker,” said Dr. Starling. Another pitfall to avoid is steroid treatment, which has been associated with worse outcomes from RCVS.

“There is another entity that has this exact same imaging and that's CNS [central nervous system] vasculitis. … In CNS vasculitis, the treatment initially is with corticosteroids,” said Dr. Starling.

To differentiate the two, pay attention to patients' reported symptoms. “RCVS—thunderclap-onset headache for clinical presentation.

CNS vasculitis—the headache is going to be diffuse, subacute, insidious, progressive headache.”

The two conditions can also be distinguished by the results of a lumbar puncture. “If you perform a lumbar puncture in RCVS, 90% of the time it will be completely normal. In CNS vasculitis, it will be an inflammatory picture, 90% of the time,” she said.

When not to puncture

A lumbar puncture is a good diagnostic tool for some causes of headache, but for others, it can make the situation worse. Dr. Starling offered the case of one patient who had a progressive daily headache that got worse throughout the day and with coughing, yelling, or stress.

The patient turned out to have spontaneous intracranial hypotension, so ordering a lumbar puncture would not have been good. “They already have less spinal fluid than they should, and then you're going to puncture their thecal sac and take out more spinal fluid and that actually makes the whole situation worse. Sometimes patients can actually decompensate if that does occur,” she said.

Instead, the best diagnostic tools would be an MRI of the brain with and without contrast and an MRI of the spine without contrast. She also recommended seeking a consult with a neurologist due to the complicated diagnostic and treatment algorithm.

Her final red-flag headache example also highlighted the importance of collaboration between the specialties. Pregnancy is associated with secondary headaches, especially in women with a history of migraine.

“Migraine patients who become pregnant are actually at higher risk for things eclampsia or cerebral sinus venous thrombosis, ly related to endothelial dysfunction that occurs in people with migraine,” Dr. Starling said.

Diagnosis of course requires testing, but some standard modalities, including contrast, are contraindicated in pregnant women.

“Fortunately, there are some studies that we can do, especially in the second and third trimester of pregnancy, that are safe, including a noncontrast MRI of the brain, an MRA of the head, an MRV of the head, and a lumbar puncture,” said Dr. Starling. “The radiologist will just use time-of-flight imaging to see the blood vessels. … It can still be done, if you just talk to your radiologist.”

Source: https://acpinternist.org/archives/2018/01/headaches-that-should-flag-further-attention.htm

Side-locked headaches: an algorithm-based approach

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Red flag symptoms: Headaches

SNOOP Criteria for Headache Red Flags or Warning Signs

  • Onset of headaches >50 years
  • Thunderclap headache – subarachnoid haemorrhage
  • Neurological symptoms or signs
  • Meningism
  • Immunosuppression or malignancy
  • Red eye and haloes around lights – acute angle closure glaucoma
  • Worsening symptoms
  • Symptoms of temporal arteritis

Headache is a common neurological presentation in primary care and may be primary or secondary.

Primary headache includes tension-type headaches, cluster headaches and migraine. Secondary headache may be caused by glaucoma, sinusitis, intracranial malignancy, haemorrhage, idiopathic intracranial hypertension and infection.1

Headaches may cause significant morbidity and can result in absence from work or school. The most common types are tension-type headaches and migraines.

Red flag symptoms should be excluded to rule out more serious causes of headache. It is of note that intracranial masses do not usually cause headache.1

Clinical assessment

History taking involves assessing the location of the headache, its onset, severity, duration, and exacerbating and relieving factors.

Possible triggers may include coughing, sneezing, exercising, changes in posture and onset of menses. It is helpful to assess whether there have been previous episodes and if so, whether there has been a change in the pattern or severity of the headache.

The nature of the pain, as well as how debilitating the headache is, should be assessed. It is useful to find out what treatments have been tried and any response to them.

New headaches presenting in a patient over the age of 50 years may indicate temporal arteritis.1

Other relevant features may include nausea and vomiting, fever, and visual symptoms including red eye, visual field defects, blurring and diplopia. The presence of lacrimation and facial flushing may be suggestive of cluster headaches.1

Carbon monoxide poisoning may present with headaches, vomiting, muscle weakness and diplopia.1 There may be a history of an aura in migraine and pulsatile tinnitus may be suggestive of idiopathic intracranial hypertension. If clinically appropriate, asking the patient to keep a headache diary may be helpful.

Focal neurology may indicate intracerebral pathology, a bleed or infection. Neurological signs may include impaired level of consciousness, weakness, new onset seizures or papilloedema. Headache associated with vomiting, drowsiness or changes in posture may be caused by raised intracranial pressure.1

A thunderclap headache refers to a severe headache of sudden onset – this may indicate subarachnoid haemorrhage. It is helpful to exclude head trauma occurring within the past three months of the headache.1

Red eye and haloes around lights may indicate acute angle closure glaucoma. Risk factors include a family history and hypermetropia.1

A rare cause of headache, found more commonly in young obese women, is idiopathic intracranial hypertension.1 The history may suggest features of raised intracranial pressure and papilloedema may be found on clinical examination.

Physical examination should include vital signs and a full neurological examination. Eye examination should include pupillary reflexes, extraocular movements, fundoscopy and visual field assessment. It may be necessary to exclude meningism.

If temporal arteritis is suspected, the scalp should be examined for swelling and tenderness, and there may be a history of jaw claudication.

Causes of secondary headache

  • Intracranial malignancy
  • Haemorrhage
  • Idiopathic intracranial hypertension
  • Infection – encephalitis, meningitis
  • Giant cell artteritis
  • Analgesic overuse
  • Carbon monoxide poisoning

Management

Depending on the clinical cause, it may be appropriate to arrange blood tests. The presentation may warrant immediate referral to hospital, for example, in suspected subarachnoid haemorrhage.

In cases of suspected temporal arteritis, immediate management with high-dose steroids is required to prevent blindness.

If a patient presents with recent headaches associated with signs of raised intracranial pressure, urgent referral should be made via the two-week wait pathway.2

If a patient presents with headaches associated with focal or non-focal neurology, urgent referral should be made, if appropriate.2

Non-focal neurology may refer to cognitive changes and altered mental status. Urgent referral is recommended by NICE if there is a change in the usual pattern of headache, with increasing severity.2

If there is a history of malignancy in a patient with new onset seizures, neurological deficit or signs, persistent headaches and/or altered mental status or cognitive changes, urgent referral is recommended.2

A history of new onset headache in patients who are immunocompromised, for example, in relation to HIV or immunosuppressive therapy, a history of malignancy known to cause cerebral metastases and vomiting in the absence of other causes may warrant referral for further investigation.2

  • Dr Kochhar is a GP in Bexhill, East Sussex

Click here to take a test on this article and claim a certificate on MIMS Learning

  • Click here to browse our resource of Red Flag alert symptoms

This is an updated version of an article that was first published in August 2015.

Picture: iStock

References

1. NICE. Headaches: Diagnosis and management of headaches in young people and adults. CG150. London, NICE, September 2012.

2. NICE. Referral guidelines for suspected cancer. CG27. Quick Reference Guide. London, NICE, June

Source: https://www.gponline.com/red-flag-symptoms-headaches/neurology/neurology/article/1332134

SNOOP: Red Flags for Headache

SNOOP Criteria for Headache Red Flags or Warning Signs

Get MRI with contrast if you need to get imaging for HA. 

“Red flag signs and symptoms include focal neurologic signs, papilledema, neck stiffness, an immunocompromised state, sudden onset of the worst headache in the patient’s life, personality changes, headache after trauma, and headache that is worse with exercise.”

Stands forDDx Tests to consider
 SSystemic s/s with HA (Fever, rash, fatigue, weight loss, neck stiffness, personality changes Arteritis, CVD, encephalitis, inflammation, meningitisBlood tests, LP, neuroimaging, skin biopsy
Secondary risk factors: New HA in pt with HIV, cancer, immunocompromised state, Lyme disease, trauma (HA after trauma)-CA: Metastasis-HIV: Opportunistic infection; tumor-Lyme: MeningoencephalitisLP, Neuroimaging
NNeurologic signs/symptoms: HA with AMS / ALOC, change in personality, focal neurologic deficits (not typical aura)CNS infection / Encephalitis; mass lesion; stroke; AVM; CVD; intracerebral bleed,Blood tests, LP, neuroimaging
OOnset is sudden/abrupt: Sudden onset of the worst HA in the patient’s life.Maximal intensity occurs within seconds to minutes, thunderclap HABleeding into AVM, mass lesion (esp. posterior fossa), Subarachnoid hemorrhage; LP, neuroimaging
OOlder than 50 yo: New HA after age 50Temporal arteritis, Mass lesionTenderness over temporal artery indicates temporal arteritis, PMRESR, temporal artery biopsy, neuroimaging
PPositional HA changes upright vs lying HA 2/2 spontaneous Intracranial hypotension; Cervicogenic HA; herniation of a posterior fossa arachnoid cyst; posterior fossa pathology; Neuroimaging
Prior HA now different in quality or progressive/ worsening Hx of med overuse, mass lesion, subdural hematoma Neuroimaging
Papilledema: Visual problemsEncephalitis, mass lesion, meningitis, pseudotumor cerebri LP, neuroimaging

SNOOP-PAPS is an alternative.

A postural headache (worse in the upright position) is the hallmark of spontaneous intracranial hypotension.

Idiopathic intracranial hypertension (benign intracranial hypertension, pseudotumor cerebri) is characterized by increased pressure within the skull (intracranial pressure).

HA=Headache; CA= Cancer, AVM = Arteriovenous malformation; LP = Lumbar puncture; PMR = Polymyalgia rheumatica; CVD = Collagen vascular disease
AMS: Altered Mental Status; ALOC: Altered level of consciousness

I learned the SNOOP mnemonic from neurologist Dr. Padram Navab in California. It covers the red flags listed in the following AAFP articles.

More Red Flag Signs and Symptoms in the Evaluation of Acute Headache (From AAFP 2013)

DANGER SIGN OR SYMPTOMPOSSIBLE DIAGNOSESTESTS
First or worst headache of the patient’s lifeCentral nervous system infection, intracranial hemorrhageNeuroimaging
Headache triggered by cough or exertion, or while engaged in sexual intercourseMass lesion, subarachnoid hemorrhageLumbar puncture, neuroimaging
New onset of severe headache in pregnancy or postpartumCortical vein/cranial sinus thrombosis, carotid artery dissection, pituitary apoplexyNeuroimaging
Rapid onset with strenuous exerciseCarotid artery dissection, intracranial bleedNeuroimaging

http://www.aafp.org/afp/2013/0515/p682.html

http://www.aafp.org/afp/2001/0215/p685.html

https://www.ncbi.nlm.nih.gov/m/pubmed/18272121/ – A differential diagnosis in postural headache: herniation of a giant posterior fossa arachnoid cyst. Lu KC, et al. Am J Emerg Med. 2008.

Source: https://www.timeofcare.com/snoop-red-flags-for-headache/

Epidemiology, Assessment, and Diagnosis of Migraine

SNOOP Criteria for Headache Red Flags or Warning Signs

DR. LIPTON: My name is Richard Lipton. I’m a neurologist and epidemiologist at the Albert Einstein College of Medicine. I also direct the Montefiore Headache Center. This is a medical roundtable on the epidemiology, assessment, and diagnosis of migraine.

Joining me is an outstanding faculty. Dr. Stephen Silberstein is a neurologist who directs the Jefferson Headache Center and is a Professor of Neurology at Thomas Jefferson University.

DR. KURTH: I am Tobias Kurth, Director of Research at INSERM, the French National Institute of Health and Medical Research. I am also affiliated with the University of Bordeaux, and I am Adjunct Associate Professor of Epidemiology at the Harvard School of Public Health.

DR. BUSE: I am Dawn Buse, an Associate Professor of Neurology at the Albert Einstein College of Medicine, Assistant Professor in the Clinical Health Psychology Doctoral Program at the Ferkauf Graduate School of Psychology of Yeshiva University, and Director of Behavioral Medicine at the Montefiore Headache Center in Bronx, NY.

DR. LIPTON: Today, we will be discussing issues in epidemiology, assessment, and diagnosis of migraine.

Migraine and headache disorders, in general, are one of the most common reasons that people seek help for, in primary care settings; therefore, this is a topic of great importance for primary care doctors.

The first section of this talk will focus on the diagnosis of migraine. Dr. Silberstein, how do you approach diagnosing a patient with headaches?

DR. SILBERSTEIN: If a patient comes to a physician’s office complaining of recurrent moderate-to-severe headaches, his/her condition should be considered as migraine until proven otherwise.

Clearly, there are certain features, but the criteria are that if the patient has a moderate headache associated with features such as one-sided, throbbing, headache aggravated by movement, nausea, vomiting, or sensitivity to light and sound, then it is clearly a migraine.

The number of attacks can be used to differentiate migraine from a migraine mimic. In general, I consider it a migraine unless there’s a reason to think otherwise or unless you see so-called warning signs.

DR. LIPTON: Can you tell us about the situations where secondary headaches may be a problem?

DR. SILBERSTEIN: We, as a group, have developed something called the SNOOP. This is our mnemonic for worrisome headaches. First, the “S” refers to systemic symptoms such as fever or weight loss.

The secondary risk factor is a new headache in a person with HIV or systemic cancer. The “N” stands for neurological symptoms or signs that cannot be explained by the aura of migraine such as confusion or alteration of consciousness. The “O” stands for a sudden onset.

A sudden onset of headache should be taken as a serious neurological event until proven otherwise.

The second “O” stands for older. If there is a progressive onset of headache in an older patient, particularly a middle-aged one, one should always be concerned about a secondary headache. The “P” stands for previous headaches. Change in the attack frequency is a clinical feature that we worry about. These conditions indicate that an underlying condition may possibly be serious.

DR. LIPTON: Can you tell us about some signs that might reassure you that there is no serious cause of headache?

DR. SILBERSTEIN: The more the current headache is similar to a prior headache, the more ly that it is not serious. If a headache predictably occurs around menstruation or ovulation, it’s a sign that it is not serious.

Other additional features of migraine that make us think it’s a benign headache disorder and not something else, include hunger or anger; alcohol consumption; insufficient sleep; family history of headaches; or so-called childhood precursors of migraine, particularly motion sickness or vertigo.

DR. LIPTON: Dr. Kurth, do you believe that everyone who presents with headache needs a neuroimaging procedure to exclude brain tumors or other secondary disorders?

DR. KURTH: The quick answer is no, but of course, it’s more complex as you go into the details—there are several aspects that need to be considered. Most importantly, not everybody in the population with a migraine needs neuroimaging, but that depends on detailed clinical symptoms, i.e.

, whether there’s any indication that the migraine is caused by another illness or there’s a clear change in the aura symptoms or recurrence of migraine with atypical features.

We often see migraine reoccurring in the elderly and are suspicious of an underlying disease such as a vascular condition or maybe a tumor, in very rare cases, that can trigger migraine reoccurrence. In such cases, we should perform neuroimaging to rule out underlying diseases.

However, if we’re talking about a patient with a typical migraine, typical aura, or typical age for a patient with migraine, neuroimaging studies are certainly not indicated.

There is an increasing number of studies showing that certain lesions in the brain, such as hyperintensities in the white matter, are more common in patients with migraine, but it remains unclear what these lesions mean for patients and what their consequences are. Therefore, there’s no need to perform an imaging study to potentially identify these brain lesions in patients with migraine.

DR. LIPTON: Dr. Silberstein, do you agree?

DR. SILBERSTEIN: I do.

DR. LIPTON: Dr. Silberstein, how do you diagnose migraine and its most important subsets?

DR. SILBERSTEIN: Migraine is more than a headache. When talking about migraine, we need to consider other aspects the premonitory features, the aura, and the headache itself. These aspects really help us with subtypes. For migraine headache, there are criteria for making a diagnosis.

To make the diagnosis of migraine without aura, 5 attacks have to have occurred and need to be associated with 2 of the following 4 features: one-sidedness, pulsating or throbbing, aggravation of the headache due to movement, or moderate-to-severe intensity.

To summarize, if you have a one-sided pulsating headache with nausea, that’s a migraine. Since the ICHD-II criteria1 require that the headache is not attributed to another disorder, we look at the absence of red flags to diagnose migraine. If a red flag is present, we need to investigate the patient’s headache further. That is the headache of migraine without aura.

There is another variety of migraine called migraine with aura. The aura refers to focal neurological symptoms that precede or accompany the headache of migraine. The most common aura is visual (flashing lights or loss of vision).

Some people can have problems with pins and needles or mild weakness. To make the diagnosis, a patient has to have unilateral symptoms that are often both positive and negative. What I mean by that is that there are both flashing lights and loss of vision.

They usually develop over 5 min, and they usually continue for 5 to 60 min. That helps differentiate the aura of migraine from a focal seizure or a transient ischemic attack. If the aura is followed by a headache, then it is classified as a migraine aura with headache.

The migraine aura can occur alone, particularly in the elderly.

The second type of distinction is between episodic and chronic migraine. When a person with migraine has multiple attacks with headaches for 14 or fewer total days per month, we call it episodic migraine. When a person with migraine has a headache for 15 or more days a month, we call it chronic migraine.1

The difference between episodic and chronic migraine is the frequency of the attack. Migraine with or without aura is the presence of the aura of migraine.

DR. LIPTON: Dr. Silberstein, what tools do you use in practice to support your diagnosis?

DR. SILBERSTEIN: When you see a patient for the first time, the more information you have, the better it is for diagnosis.

If a patient, for example, brought in a diary or calendar delineating their attacks or information from another physician where they filled out a questionnaire or even a specific migraine information questionnaire, you are more equipped to, first, support the diagnosis, and second, identify the triggers and find out what medications they may or may not have tried in the past. We can figure out what will work and what won’t work with them.

DR. LIPTON: Let’s move on to a discussion of assessment. Dr. Buse, having diagnosed migraine, what are the most important features to assess before formulating a treatment plan?

DR. BUSE: It is vital to consider the impact of headache on all aspects of a patient’s life, including occupational or academic functioning and family, social, and personal arenas.

These areas can be assessed by simply asking the patient, “How are your headaches affecting your life?” In addition, clinically validated instruments are available to assess headache-related disability, headache impact, and quality of life. It’s also useful to assess medical and psychiatric comorbidities.

Migraine is comorbid with many medical and psychiatric conditions, including depression and anxiety. In some cases, migraine may be more severe, chronic, and treatment-refractory when associated with certain conditions.

Inquire specifically about both pharmacologic treatments, which may be acute or preventive, and nonpharmacologic treatments, including behavioral/psychological; physical; lifestyle, such as asking about sleep habits and problems, exercise, and activity; and other nonpharmacologic therapies.

In addition, asking the patient specifically about nutraceuticals, vitamins, and herbs is vital because if healthcare providers (HCPs) do not ask these questions, patients may not voluntarily offer this information.

DR. LIPTON: Dr. Buse, why is it important for primary care clinicians to assess disability and life impact? Are there tools that you might recommend for this?

Source: https://themedicalroundtable.com/article/epidemiology-assessment-and-diagnosis-migraine