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ACP does not support QPP measure 435: "Quality of Life Assessment for Patients with Primary Headache Disorders." While this measure represents an important clinical concept and evidence supports the benefit of shared decision-making around prophylactic treatment options for chronic migraines on improved patient outcomes, we cannot estimate the measure impact on improved clinical outcomes. Furthermore, we note several issues with the measure specifications. First, denominator specifications include exclusion criteria for patients without insurance to cover assessment costs, reinforcing uncertainty surrounding the intervention’s ability to improve quality outcomes. Second, the numerator specifies an assessment tool that is specific to migraine headaches. Therefore, clinicians would have to rely on general quality of life assessment tools for all other headache disorders and results may influence other treatment decision areas. Third, as currently specified, clinicians are required to perform quality of life assessments on all patients with primary headache disorders, regardless of clinical relevance to the patient’s primary complaints. Developers should consider revising the specifications to include a principle diagnosis of primary headache. Incentivizing clinicians to perform routine assessments in patients without a principle diagnosis of headache may result in underuse of more meaningful, evidence-based interventions. If quality programs used this measure as a tracking tool, the results would likely encourage appropriate discussions surrounding prophylactic treatment and ultimately result in improved patient outcomes.