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The Emerging Science of Prophylactic Therapies for
Migraine
Interim Outcomes Report
Lilly USA, LLC Grant ID: A‐19557
Program Information
Overview: This enduring webcast shares highlights from a live presentation, which took place in Scottsdale in November 2016 as part of the 46th annual Scottsdale Headache Symposium, in conjunction with the American Headache Society. Featuring Dr. David Dodick, Dr. Deborah Friedman, and Dr. Stewart Tepper, this activity reviews complicated patient cases and up‐to‐date information on targeted and specific therapies for the treatment of migraines.
Intended Audience:This activity was designed for clinicians involved in the care and treatment of patients with migraine pain.
Release/Expiration Date: December 29, 2016/December 29, 2017
Credit: 1.0 AMA PRA Category 1 Credit™
Sponsored By: The Academy for Continued Healthcare Learning (ACHL)
Funding: Supported by an educational grant from Lilly USA, LLC
Executive Summary
Impact1565 Learners (2,000 Guaranteed by activity expiration)661 Certificates (350 Guaranteed – guarantee exceeded)
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Patient ImpactUp to 16,508 patients will be impacted per month
Professions Reached33% Physicians
32% Physician Assistants30% NP/Nurses
5% Other
Executive Summary
SatisfactionAll faculty were very highly rated with an average rating of 3.58/4.0
Learning Objectives99% of participants strongly agree that they are better able to meet
the learning objectives after completing the activity
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Patient ImpactPatient outcomes will be positively impacted as a result of this
activity according to 88% of learners
Impact96% of learners will change their practice based on this activity
51% of learners will seek to address barriers topatient access to therapies
Executive Summary
49%
57%
75%
These numbers demonstrate that clinicians not only received education on this new class of migraine drugs, but started to understand how to UTILIZE them in a clinical setting.
More importantly, following the activity, nearly all participants (96%) are institutingpractice‐based changes to positively impact patient care and outcomes.
After participating in this activity, Learners PLAN TO:
• More frequently assess their migraine patients forchanges in disability
• Engage in patient education
• Discuss nonpharmacological strategies which patientscan use to help control their pain
Clinicians, post‐activity, are more open to using quantifiablescales (ie, HIT‐6, MIDAS) to assess
the impact of migraine on patients’ lives
The average post‐test score on questions regardingpharmacokinetics and MOA of CGRP mAbs. Post‐activity, clinicians are aware of how these agents differ from currently approved therapies,
and the advantages they offer specific patient subsets.
96%
Executive Summary
Improve management of side effects, comorbidities, and pain through a
comparison of the adverse events associated with current and emerging therapies
Provide educational tools to facilitate better communication with patients to
increase shared‐decision making
Educate clinicians on the science of approved and emerging therapies to
increase personalized therapy
Future Educational Opportunities
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Faculty
CHAIRDavid Dodick, MD, FAHS, FRCPC, FACPProfessor of NeurologyMayo ClinicPhoenix, AZ
FACULTYDeborah I. Friedman, MD, MPH, FAHSProfessor, Neurology and Neurotherapeutics and OphthalmologyUniversity of Texas Southwestern Medical CenterDallas, TX
Stewart J. Tepper, MD, FAHSGeisel School of Medicine at DartmouthProfessor of NeurologyHanover, NH
5%
8%
22%
32%
33%
Other HCP
Nurse
Nurse Practitioner
Physician Assistant
Physician
0% 5% 10% 15% 20% 25% 30% 35% 40%
Practicing Type
Level 1: Participation
Total Participants CertificatesAwarded
1565 661
N=661
17%
5%
6%
6%
9%
9%
12%
37%
Clinical (unspecified)
Psychiatry
Surgery
Pediatrics
Neurology
Emergency Medicine
Internal Medicine
Family/General Practice
0% 5% 10% 15% 20% 25% 30% 35% 40%
Specialty
Level 1: Specialty
N=661
Level 2: Learning Objectives
Please rate the following objectives to indicate if you are better able to:
Analysis of Respondents
Rating Scale: 4 = Strongly Agree
1 = Strongly Disagree
Illustrate how to factor multiple patient‐specific characteristics into the treatment plan when managing migraines
3.40
Examine and discuss the emerging science associated with calcitoningene related peptide (CGRP) monoclonal antibodies (mAbs) and theirrole in migraine prevention.
3.42
Highlight strategies and tools to assess the impact of migraine on daily functioning and quality of life in order to generate a more personalized and inclusive treatment plan.
3.43
99% of learners strongly agree or agree that all learning objectives were met.
N=645
Level 2: Satisfaction
Faculty RatingsRating Scale: 4=Excellent, 1=Poor
Ability toeffectively convey the
subject matter
Expertise on the subject matter
David Dodick, MD, FAHS, FRCPC, FAPC 3.56 3.61
Deborah Friedman, MD, MPH, FAHS 3.56 3.61
Stewart Tepper, MD, FAHS 3.55 3.60
N=645
Overall Evaluation Analysis of Respondents4 = Excellent, 1 = Poor
Quality of educational content 3.53
Level of instruction 3.50
All faculty were highly rated across all areas, with an average rating of 3.58/4.
97% of learners rated all aspects of the activity as excellent or good!
Level 2: Objectivity & Bias
10%
90%
0%
20%
40%
60%
80%
100%
Yes No
Did You Perceive Any Bias?
Activity was perceived as objective, balanced, and non‐biased.
N=645
12%
39%50%
64%86% 85%
0%
25%
50%
75%
100%
1 2 3
Topic Question Pre Post % Change
Understanding PK of CGRP mAbs 1 12% 64% 433%
CGRP mAbs MOA 2 39% 86% 121%
Migraine triggers/patient education 3 50% 85% 70%
Overview of correct responses:
Levels 3 & 4: Pre/Post‐test Overview
Learners knowledge and competence increased regarding efficacy and metabolism of CGRP monoclonal antibodies and how they can be used to solve some of the existing issues seen with approved therapies as well as with respect to strategies
for patient education and patient control of migraine triggers
Average percent change from pre to post‐test208%
Levels 3 & 4: Pre‐test vs. Post‐test
Which of the following is true?
A. CGRP monoclonal antibodies (mAbs) have an average half‐life of up to24 hours
B. CGRP mAbs are cleared by the reticuloendothelial system
C. CGRP small molecule antagonists have shown efficacy in reducing the frequency of headache days in episodic migraine
D. CGRP mAbs target CGRP, amylin, and their receptors
21%12%
57%
11%11%
64%
15%10%
0%
25%
50%
75%
A B C D
Pre (N=861) Post (N=661)
The number of participants correctly answering the post‐test question increased by 433% over the pre‐test, demonstrating that participants were more knowledgeable regarding the pharmacokinetic properties of this drug
class. Indicating that participants understand how this new, emerging class of migraine therapies is cleared from the body‐‐‐which may be especially relevant when tailoring therapy for patients who have pre‐existing conditions
such as renal or liver impairments.
Levels 3 & 4: Pre‐test vs. Post‐test
Which of the following CGRP antagonists target the CGRP receptor?
A. Fremenezumab (TEV‐48125)B. Erenumab (AMG 334)C. ALD‐403D. Galcanezumab (LY‐2951742)
25%
39%
17% 19%6%
86%
5% 3%0%
25%
50%
75%
100%
A B C D
Pre (N=861) Post (N=661)
As a result of this activity learners were more knowledgeable regarding the differences between the mAbs and how they act to inhibit CGRP and eventually, to reduce the frequency of episodic/chronic migraines.
These learnings support recently released preclinical data which have also highlighted differences among fremenezumab, ALD‐403, and galcanezumab regarding their respective times to bind and dissociate from the ligand
which may contribute to differences drug effect duration.
Levels 3 & 4: Pre‐test vs. Post‐testLinda M is a 38‐year old female who suffers from episodic migraines about five times a month. She takes a triptanand uses OTC medication to relieve her pain. Because of a project at work, she has been getting less sleep, is stressed, and has noticed that the number of her migraines has increased. What is the best course of action for this patient?
A. Prescribe a sleep aid and remind her not to take too many triptans(>2 a day)
B. Remind the patient about the factors that she can control and which will allow her to feel less stressed(ie, exercise, meditation, small breaks, eating well, staying hydrated)
C. Consider transitioning her to preventive therapy such as amitriptyline or a beta blocker
D. Consider transitioning her to preventive therapy such as onabotulinumtoxinA or topiramate.
12%
50%
24%14%
3%
85%
7% 5%0%
25%
50%
75%
100%
A B C D
Pre (N=861) Post (N=661)
Learners selected the correct answer 70% more often on the post‐test compared to pre‐test. Certain factors such as sleep, specific foods, and caffeine can trigger a migraine; however, these are factors which patients can help to control. Patient education can increase awareness of how patients can modify and minimize migraine triggers.
Levels 3 & 4: Pre‐test vs. Post‐testThere are several tools and strategies clinicians can use to better understand the impact of migraine on patients’ lives as well as aid in increasing the understanding of both parties of how to effectively control migraine. From the list below, please identify one tool or strategy which you CURRENTLY USE/PLAN TO USE in order to better understand how migraine impacts your patients:
A. Patient headache diariesB. Assess disability via scale such as HIT‐6 or
MIDASC. Discuss the management of existing
comorbidities so as to minimize other factors complicating migraine treatment
D. Review patients’ treatment plans with them; discuss goals of migraine treatment, frequently
47%
14%19% 20%
39%
22% 20% 18%
0%
10%
20%
30%
40%
50%
60%
A B C D
Currently Use (N=861) Plan to Use (N=645)
An increase of 57% was seen post‐activity in learners who were open to using HIT‐6 or MIDAS scales. These scales are composed of 5‐6 questions which can be quickly administered in an office setting and completed by the patient. Use of
these scales may provide a compliance advantage over a patient diary and are a quick way for clinicians togather information on migraine disability.
Level 4: Impact of Activity
N=645
This activity will improve my patient outcomes:
Yes: 52% No: 12% Validated Practice: 36%
This activity will improve my performance:
Yes: 58% No: 11% Validated Practice: 31%
This activity was highly effective, with 58% indicating it will impact performanceand 52% indicating it will impact their patients’ outcomes.
Yes, how?
• Awareness of CGRP receptor antagonist and good review of beta blocker use• Encourage lifestyle changes for patients and keeping headache diary• I now better understand the emerging therapies and am reassured on the state of existing therapies as it relates to my practice
experience• New prescription medications/headache outcome resources to use (patient reported outcome tools)• Better manage patients with migraines using tools provided i.e. MIDAS and HIT‐6• Use scales for assessment and prescribe prophylaxis when indicated• Utilize new tools to assess migraine headaches and current RXs in the TX of Migraine H/As• Will place more emphasis on patient disability for prophylaxis
Yes, how?
• I now know of other management therapies for chronic and episodic migraines• Increased research leading to increased prophylactic treatment• So often refer patients to neuro; may now be more likely to counsel, try preventives.• Will start prophylaxis sooner
Level 4: Impact of Activity
4%
31%
24%
49%
0% 20% 40% 60%
This activity validated my current practice, no changes will be made.
Other changes.
Create/revise protocols, policies, and/or procedures.
Change the management and/or treatment of my patients by morefrequently assessing disability caused by headache, taking time forpatient education, and/or discussing nonpharmacological strategies
that patients can use to help control their pain.
N=645
96% of learners will change their practice!
Please identify how you will change your practice as a result of attending this activity (select all that apply):
Level 4: Impact of Changes on Patient Care
N=645
Changes will impact between 5,710 and 16,508 patients each month.This assumes the data above is representative of all participating healthcare professionals (1,582), who
indicated they would change their practice as a result of this activity (96%).
Number of patients with migraines you see each month:
14%
64%
15%
7%
0
1‐10
11‐20
>21
0% 20% 40% 60% 80%
Level 4: Confidence
After participating in this activity, how confident are you in describing the emerging targets under investigation for the prevention of migraine?
A. Extremely confidentB. Very confidentC. Somewhat confidentD. Not very confidentE. Not at all confident
11%
35%
47%
7%0%
0%
25%
50%
A B C D E
46% of participants described themselves as being extremely or very confident in their ability to describe some properties of emerging agents for migraine prevention.
Future Education Opportunity: 47% of participants categorized themselves as only “somewhat confident” potentially representing an audience who would be receptive to further education in this area.
Pharmacotherapy Considerations
Which of the following factors do you give the most consideration to when adopting a new‐to‐market pharmacotherapy?
N=652
2%
24%
44%
30%
0% 10% 20% 30% 40% 50% 60%
Other
Science underlying the new therapy
Cost to the patient
Ease of patient compliance
Pharmacotherapy Considerations
When these therapies are approved for use in the US, which factor will determine if you will use them in the appropriate patient populations?
N=652
Cost was by far the largest determinant of use for clinicians. Whether this represents costs to thepractice to acquire the drug or the cost to the patient even with insurance is unclear.
However, both factors would potentially drive access and use.
15%
15%
11%
58%
0% 10% 20% 30% 40% 50% 60%
Ease of side effect mangement
Duration of effect
Frequency of administration
Cost
Level 4: Perceived Barriers To Implementing Changes
Select all that apply:
Participants indicated cost (27%) as the most common barrier to implementing change in their practice. Other barriers included patient
compliance (24%) and patient reluctance to see HCPs regarding headaches (24%). Also, 23% indicated current migraine therapies do not
offer adequate pain relief.
N=645
23% 24%
11%
19%
27%
5%
18%
7% 5%
24% 24%
2%
0%
10%
20%
30%
A B C D E F G H I J K L
Level 4: Barriers
A. Current migraine therapies do not offer adequate pain relief
B. Patient reluctance to see HCP regarding their headaches
C. Lack of consensus or professional guidelines
D. Lack of time to assess/counsel patients
E. Cost
F. Lack of administrative support
G. Reimbursement/insurance issues
H. Lack of opportunity (patients)
I. Lack of resources (equipment)
J. Patient compliance issues
K. No barriers
L. Other barriers
Please indicate any barriers you perceive in implementing these changes:
Level 4: Barriers
N=591
Will you attempt to address these barriers in order to implement changes in your performance, and/or patients’ outcomes?
Yes: 51% No: 18% N/A – No barriers identified: 31%
Yes, how?
Assist my patients and contact pharmaceutical companies when insurance will not pay for the drug prescribed. Address efficacy at outset of treatment and give treatments more time before changes are made Cost vs benefit will be discussed Discuss with patient the importance of compliance Encourage patients to be an active participant in their healthcare Follow the changing guidelines Increased patient assessment, education and reevaluations Set collaborative goals with patient and find cost‐effective solutions
No, why not?
Very difficult to overcome breakdown in medical care system It is hard to get approval for these types of medications Because I can't prescribe anything more than a triptan and toradol in an urgent care setting. This was informative for me to educate
people about what is out there. These barriers are not easily addressed in a resource‐poor country where I practice
51% of learners are interested in addressing barriers, primarily through patient education,liaising with pharmaceutical companies to obtain lower patient medication costs,
and even by engaging with insurers to approve a drug for a patient.
Additional strategies that practitioners are open to using include: periodic re‐evaluations of disease status,severity, and impact, and employing personalized treatments at the outset.
Topics of Interest
What topic areas would you most like to see in future activities?
N=645
Clinicians indicate interest in all three topics provided, however this outcomes report demonstrates clinicians are most in need of strategies to help manage the side effects seen with current migraine treatments as well as
managing comorbidities in migraine patients.
33%
36%
31%
0% 20% 40%
Differentially diagnosing headache subtypes
Managing side effects of multiple migrainemedications
Managing neuropsychiatric comorbidities andmigraine
Key Takeaways
What is one pearl you took away as a result of your participation?
Always consider what changes in life occurred that could be causing increase in migraines or any other morbidity (seizures, HF)
I was surprised by how few chronic migraine sufferers receive effective treatment
Better understanding of pathophysiology of how some migraine medications work
Candasartan use as: prophylaxil instead of beta blockers in the treatment of episodic migraines
CGRP AB's have long half life; antibodies are promising Consider alternatives to triptans Consider HA effect in psychiatric disorders Current available treatments are poorly utilized and not highly
effective with significant adverse effects Did not realize how poorly available treatments are and how
patients do not take them Emerging use of CNS stimulator devices Frequency of migraine/poor success rates of tx Gabapentin is essentially worthless for migraine prevention;
ineffective for migraine prophylaxis High discontinuation rate among those treated prophylactically Monoclonal antibodies can be effective in prevention; appear to be
very promising as prevention of migraine Level of disability and medication overuse Statistical significance is not same as clinical significance Use migraine assessment tools to measure nature and effects of
migraine Newer migraine medications and biologics MABs
How much testing is done on the emerging drugs I am excited about CGRP and hope to use it one day! Importance of reducing stress and other triggers Importance of spending time evaluating/counseling Important to assess non‐pharmacological treatments Managing comorbidities for migraine sufferers New therapies/medications can be helpful for patients who suffer
from migraines that don't generally respond to triptan/ergots Vast amount of pts untreated for migraine headache Use migraine assessment tools to measure nature and effects of
migraine Multiple treatment modalities must be investigated; new and
advancing treatment strategies for control of migraines are underway
New medication for acute headaches that doesn't cause vasoconstriction
New research coming out on the physiology and treatment of migraine
Metoprolol, propranolol, and timolol are established as effective and should be offered for migraine prevention if patients physiology can tolerate it
Start prophylaxis sooner post 8+ headaches/month Patient compliance of prevention medication is poor Patients with migraines are not adequately assessed, diagnosed or
treated Non‐invasive devices showing promise, awaiting FDA Non‐pharmacological management has an important role in pt care
Next Steps
Final outcomes report to be provided 90 days post‐activity expiration (March 2018)
For questions, please contact:Brittany PusterDirector, Education DevelopmentAcademy for Continued Healthcare Learning (ACHL)
E: [email protected]: 773‐714‐0705 ext. 134
Appendix
All text‐based responses
Level 4: Activity Impact
If you indicated this activity will improve your performance, please specify: Addressing lifestyle changes as well as medication therapy Advances in migraine tx Assess patterns degree of disability Aware of current offered therapies and assessment tools. Awareness of CGRP receptor antagonist. Good review of beta
blocker use. Better and more tx options Better assessment of HAs in patients Better evaluation of monthly headache patterns, potential for
overuse. Better insight to plan of care Better knowledge of newer therapies/prevention. Better management of migraine Better patient education Better under of pathophysiology and possible treatments. Better understanding of current treatments and new
treatments on the horizon Better understanding of effective treatment modalities. Broaden how I treat my patient's with migraines and
understanding emerging treatments that will be available to them in the future.
Change in monitoring and prescribing Change my treatment strategies. Understand and describe
emerging treatments.
Consider new treatments and continue to watch for new FDA approved options
Consider short comings of some preventatives Consideration of over use HAv more often Discuss migraine modalities with pt Discussing impact and frequency of migraines Educate patients on availability of new treatment strategies Encourage lifestyle changes for patients and keeping
headache diary Evaluate and assess migraines better with the different tools. Exposed me to latest therapeutic strategies on how to TX and
how to best monitory therapeutic goals. Help me to better understand treatment modalities How is screen patients I am aware of new treatment options available to patients. I
will try to use questionnaires mentioned in this activity to assess how my patients are doing.
I experience chronic migraine myself and if I can decrease my frequency of migraines I will be better able to assist patients/Veterans who I treat/serve
I know which medications are first line and then second line. Know efficacy of various drugs and patient compliance challenges.
I now better understand the emerging therapies and am reassured on the state of existing therapies as it relates to my practice experience
Level 4: Activity Impact
If you indicated this activity will improve your performance, please specify: I understand the various meds, side effects of the newer &
future drugs. I was unaware of this new drug class I will encourage patients to keep headache diaries to help ID
possible helpful lifestyle changes. identify pts that need more than Tripans or Ergots. Inquire more thoroughly about current treatment & symptoms Know which long term medications are effective/preferable learning about pharmacology Made me more aware of treatment options which always is
helpful to a nurse Make patients more involved in making their treatments plans May help to use medicines more wisely and according to
guidelines and evidence based More aggressive diagnosis and treatment of migraines More focus on preventative measures More prepared for the new agents (CGRP) when they come out. More selective in choosing treatment for migraine headache New prescription medications to consider and headache
outcome resources (patient reported outcome tools). Offer patients more choice for prevention
Prior to this lecture, I was unaware of all the treatment options in development for migraines
Pts in hospital environments can have exacerbations of migraines and often need special interventions to self‐manage
Put into consideration the efficacy and side effects of current treatment
Specific, current knowledge gained on migraine prevention and treatment
This activity will help me manage patients with migraine better using the tools provided I.e. MIDAS and HIT‐6.
To better assess patient holistically in regards to migraine in setting of other comorbidities
Understanding meds for proper usage. Use of newer therapies when available Use scales for assessment and prescribe prophylaxis when
indicated Utilize new tools to assess migraine headaches and current
RXs in the TX of Migraine H/As We don't currently have any patients on prophylactic therapy
for chronic migraines, but I believe some of my patients would benefit from it.
Will place more emphasis on patient disability for prophylaxis work in Residential Treatment Centers where headaches are
among the most common complaints
Level 4: Activity Impact
If you indicated this activity will improve your patients’ outcomes, please specify:
Addressing morbidities will enlighten burdens After learning about emerging modalities, I will know which
new treatments to recommend to my patients. As a provider in chronic pain medication, I will be able to
better assist my patients via lifestyle modifications and other treatment options. I will be able to assess and refer patients with chronic migraines to the appropriate provider
Being able to discuss emerging medications for the treatment of migraines.
Better choice of agents will help them avoid more days of migraine per month.
Better treatment choices should improve outcomes Better treatments (maybe) for headache sufferers Better under of pathophysiology and possible treatments. Can use new approaches when available and appropriate Different prevention methods of migraine and newer meds Due to the low patient adherence data, I will assess
compliance at each appt. hopefully to decrease patients’ headache days I now know of other management therapies for chronic and
episodic migraines Improved patient outcome from headache relief Improving patient outcomes by more effective treatment
Increased knowledge of appropriate assessment tools as well as in depth knowledge of treatment options
Increased research leading to increased prophylactic treatment
More patients treated for chronic migraines More precise treatment plans Multimodal approach for the management of pain study. New considerations for therapy that may better help patients. Planning care and referral to specialist in a more timely manner Put into consideration Neuromodulation Rapid and sustained response Recognize the need for therapy So often refer Pts to neuro; may now be more likely to counsel,
try preventives. Superb update on new medications and devices This will hopefully reduce overuse of abortive migraine
medications. To provide alternative treatments from my current practice understanding the mechanics Utilizing current TX protocol to improves my patient's condition. Will start prophylaxis sooner Will use Triptans more for debilitating migraines. Know what
alternatives exist.
Level 4: Activity Impact
If you plan to change the management and/or treatment of your patients by more frequently assessing disability caused by headache, taking time for patient education, and/or discussing nonpharmacological strategies which patients can use to help control their pain OR create/revise protocols, policies, and/or procedures, please specify the changes you will make:
Actively trying to prevent Ask for headache diaries, and discuss quality of life burden and
their goals Asking more questions about how headaches affect my patient
daily activities Better assessment with scales Better patient documentation of headaches By assessing the impact of migraines on patients' lives Getting involved in patient education Consider the MIDAS screening in addition to patient journals. Consider use of new drugs Diagnose and treat migraines more aggressively Diaries, lifestyle, to learn about new treatment options Disability assessment Discussing more ways to avoid triggers and non‐
pharmacological ways to control their migraines Discussing non‐pharm options Discussing nonpharmacological strategies which patients can
use to help control their pain Encourage documentation of headaches and associated
disabilities to help select more personalized treatment options
Ensuring pts are permitted to self‐manage their resting periods as much as possible in a hospital setting
Extend assessment time possibly with questionnaire Getting the HIT‐6 tool to use Headache diaries, life style, stress factors, diet, sleep. Headache diaries, strict monitoring of all medications and
supplements Headache diary I think both pharmacological and non‐pharmacological
strategies are just as important I will counsel patients more on non‐pharmacological means to
control migraines Implement more frequent use of assessment tools Include the tools mentioned in this program and the current
RXs included Increasing follow up visits Insist on headache diaries Make the correct diagnosis with subsequent referral MIDAS More frequent follow‐up More frequently assessing disability caused by headache
Level 4: Activity Impact
If you plan to change the management and/or treatment of your patients by more frequently assessing disability caused by headache, taking time for patient education, and/or discussing nonpharmacological strategies which patients can use to help control their pain OR create/revise protocols, policies, and/or procedures, please specify the changes you will make:
More headache diaries More patient protocols More preventive plans More pt. discussion More referrals to neurology and recommending considering
study participation More use of HA assessment tools. More use of HA diaries. Motivational interviewing to better understand patient desired
outcomes Push patient and family education; provide hope and
encouragement Revise protocols & instruct PA's. Take more time Taking time for patient Education That personal, mental and environmental factors have a great
impact headache; Exercise; CBT
Use MIDAS or HIT‐6 Use MIDAS or HIT‐6 to assess and monitor patients Use of diary Use rating scales Use the MIDAS
Use the questionnaires to assess Using checklists and HA diaries Using described tools to assess when needed. Utilize PROS in evaluating migraine treatment MIDAS and HIT‐6
scales Utilizing preventive medications in a more optimal fashion Will have support staff to meet with patients to reinforce use of
non‐medication issues they can control at each appointment Working with and educating patients