Documenting Physician-Patient Encounters Vital to Diagnose and Treat Chronic Migraine

Documenting Physician-Patient EncountersAccording to a new study presented at the 57th Annual Scientific Meeting of the American Headache Society, migraines may be underreported and under-treated in teen athletes. In most cases studied, it is unclear whether there occurred an exacerbation of primary headache disorder, new onset headache not related to trauma, or genuine concussive injury in the students. Proper communication and clinical documentation via accurate medical transcription can provide clear and reliable information about headaches and ensure effective treatment.

The study involved a cross-sectional survey that evaluated the characteristics and prevalence of headache in 74 competitive football players in the age group 14 to 18. The survey gathered data regarding personal and family history of headache as well as concussion history. The results of the survey are as follows.

  • A total of 33.8% participants reported they have a history of migraine while 37.5% reported history of previous concussion.
  • Around 29.6% reported a history of multiple concussions. Among them, 50% reported a personal history of migraine.
  • Of those participants that reported history of concussion, 40.7% reported a personal history of migraine.

Overall, the migraine prevalence among teen population in the study was 33.8%, considerably higher than the 16.2% estimated prevalence of migraine/probable migraine among the general population. However, it remains unclear whether this significant increase in prevalence is due to increased awareness of headache disorders, the result of contact exposure or a predisposition for migraine development post concussion.

Another study presented at the 57th Annual Scientific Meeting of the American Headache Society confirmed that migraine or probable migraine is the main phenotype found in concussed teen athletes. The study evaluated 25 sports-related concussion patients in the age group 12-19 and found predominant headache phenotype was migraine or probable migraine having average pain score of 6.3 out of 10. Concussions occurred in teen athletes while participating in football, basketball, softball, soccer, hockey, lacrosse or gymnastics. If 5% experienced loss of consciousness, 48% reported nausea, 52% reported phonophobia as a result of concussion, and 72% reported neurocognitive symptoms.

In the light of these two studies, we can conclude that though concussion-related migraines are common in teen athletes, they are possibly less reported and do not receive effective treatment. Effective communication between physicians and patients is very important for accurate diagnosis, optimizing treatment plans and facilitating patient adherence. Physicians should ask patients open-ended questions (such as asking patients about their headaches and how these affect their life), migraine frequency (headache attacks, headache days), and headache-related disability.

When it comes to diagnosing and treating chronic migraine, documenting physician-patient encounter is an effective way to evaluate the communication. Physicians should make use of a well-designed EHR to record each and every detail in a simple and quick manner. However, limitations to narrative descriptions, and errors from frequent copying and pasting information within the EHR fields can compromise the accuracy of documentation. A blended approach of EHR integration and transcription is advisable. In this approach, the physician’s recordings are transcribed, checked for quality and populated into the corresponding fields in the electronic record system. Professional transcription companies offer three-level quality checking for the data to ensure maximum accuracy.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.