Patient Drawings of Migraine Pain- Key to Success in Patient Selection?
Marek A. Hansdorfer, M.D.1,2, Lisa Gfrerer, M.D., Ph.D.3, Ricardo Ortiz, B.Sc.3, Kassandra P. Nealon, B.Sc.3 and William G., Jr. Austen, MD3, (1)Plastic & Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, (2)Rush University Medical Center, Chicago, IL, (3)Massachusetts General Hospital, Harvard Medical School, Boston, MA
Purpose: Patient selection for migraine surgery is the most important variable to ensure successful outcomes. From verbal and written descriptions alone it can be difficult to understand patients pain/trigger patterns. In our experience, a superior method to visualize pain is to ask patients to draw where the pain originates and where it radiates. We have found that there are pathognomonic pain patterns for all trigger sites that should be considered in patient selection. We typically do not operate on patients with atypical pain diagrams, as we believe they are poor candidates. There is a small subset of these atypical patients that undergo surgery based on other strong clinical findings. In this study we attempt to quantify this clinical experience.
Methods: One- hundred and six patients were prospectively enrolled in this study and asked to complete pain diagrams at screening. Diagrams were analyzed and categorized: 1) Typical- Pain over the distribution of a nerve with expected radiation 2) Intermediate- Pain over the distribution of the nerve with atypical radiation 3) Atypical- Pain outside of normal nerve distribution and atypical radiation. Surgical outcomes were documented using pre and postoperative Migraine Headache Index calculation. MHI between sub- categories was compared using unpaired T -tests.
Results: 74 patients demonstrated typical pain patterns, whereas 21 patients had intermediate and 11 patients had atypical pain patterns. Mean follow up was 14.12 months. MHI improved by 69.5% ± 38.7 in the typical pain pattern group compared to 69.35% ± 32.6 in the intermediate group and 39.04 ± 35.3 in the atypical group. There was no significant difference between the typical and intermediate group. However, there was a significant difference in MHI between the typical and atypical (p= 0.012), as well as the intermediate and atypical group (p= 0.017).
Conclusion: Patient self-created pain diagrams have become an important screening tool in our practice. We believe they represent a clear and easily interpreted test to screen candidates for surgery. This study suggests that surgical outcomes for patients with atypical pain patterns are significantly inferior when compared to normal or close to normal patterns. This tool and these findings should be taken into consideration when evaluating patients for migraine surgery.
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