Comorbid and co-occurring conditions in migraine and associated risk of increasing headache pain intensity and headache frequency: results of the migraine in America symptoms and treatment (MAST) study

Background

Migraine has many presumed comorbidities which have rarely been compared between samples with and without migraine. Examining the association between headache pain intensity and monthly headache day (MHD) frequency with migraine comorbidities is novel and adds to our understanding of migraine comorbidity.

Methods

The MAST Study is a prospective, web-based survey that identified US population samples of persons with migraine (using modified International Classification of Headache Disorders-3 beta criteria) and without migraine. Eligible migraine participants averaged ≥1 MHDs over the prior 3 months. Comorbidities “confirmed by a healthcare professional diagnosis” were endorsed by respondents from a list of 21 common cardiovascular, neurologic, psychiatric, sleep, respiratory, dermatologic, pain and medical comorbidities. Multivariable binary logistic regression calculated odds ratios (OR) and 95% confidence intervals for each condition between the two groups adjusting for sociodemographics. Modeling within the migraine cohort assessed rates of conditions as a function of headache pain intensity, MHD frequency, and their combination.

Results

Analyses included 15,133 people with migraine (73.0% women, 77.7% White, mean age 43 years) and 77,453 controls (46.4% women, 76.8% White, mean age 52 years). People with migraine were significantly (P < 0.001) more likely to report insomnia (OR 3.79 [3.6, 4.0]), depression (OR 3.18 [3.0, 3.3]), anxiety (OR 3.18 [3.0 3.3]), gastric ulcers/GI bleeding (OR 3.11 [2.8, 3.5]), angina (OR 2.64 [2.4, 3.0]) and epilepsy (OR 2.33 [2.0, 2.8]), among other conditions. Increasing headache pain intensity was associated with comorbidities related to inflammation (psoriasis, allergy), psychiatric disorders (depression, anxiety) and sleep conditions (insomnia). Increasing MHD frequency was associated with increased risk for nearly all conditions and most prominent among those with comorbid gastric ulcers/GI bleeding, diabetes, anxiety, depression, insomnia, asthma and allergies/hay fever.

Conclusions

In regression models controlled for sociodemographic variables, all conditions studied were reported more often by those with migraine. Whether entered into the models separately or together, headache pain intensity and MHD frequency were associated with increased risk for many conditions. Future work is required to understand the causal sequence of relationships (direct causality, reverse causality, shared underlying predisposition), the potential confounding role of healthcare professional consultation and treatment, and potential detection bias.

Patient-Reported Lupus Flare Symptoms Are Associated with Worsened Patient Outcomes and Increased Economic Burden

BACKGROUND

Lupus flares significantly contribute to health resource utilization and hospitalizations. Identification of flare activity may be hindered since validated assessment scales are rarely used in clinical practice and flare severity may fall below clinician-assessed thresholds. Therefore, patient-reported outcomes of lupus flare frequency are important assessment tools for lupus management.

OBJECTIVE

To better understand the relationship between lupus flares as reported by persons with lupus and specific direct and indirect costs, including hospital admission, unplanned urgent care (UC)/emergency department (ED) visits, work productivity loss, and nonwork activity impairment.

METHODS

In this cross-sectional analysis, persons with lupus were drawn from 2 enriched sampling sources. Data were collected via an online survey and included individuals with self-reported physician's diagnosis of systemic lupus erythematosus, skin or discoid lupus, or lupus nephritis. Respondents were asked the total number of hospitalizations and ED/UC visits for any reason and for lupus-related hospitalizations and ED/UC visits. Work productivity loss and nonwork activity impairment were measured via the Work Productivity and Activity Impairment - General Health scale. The sample was stratified into those with 0 flares, 1-3 flares, 4-6 flares, and 7 or more flares, with 0 flares used as the reference. Chi-square tests for trend and analyses of variance were used to evaluate differences among flare frequency groups. Multivariable regression modeling was conducted to evaluate the independent relationship of flare frequency to health care use and productivity loss.

RESULTS

We studied 1,288 survey respondents with known flare frequency in the past 12 months. Flare frequency increased with duration of illness. The mean number of lupus-related hospital admissions was significantly associated with increasing flare frequency for the total sample (F = 3.9; P < 0.009). Compared to patients with no flare, those who reported flare activities had 1.72-3.13 times higher rates of hospitalizations. The mean number of lupus-related ED/UC visits were also found to be significantly associated with increasing flare frequency for the total sample (F = 23.4; P < 0.001), and rates were increased by 6.98- to 16.12-fold for unplanned ED/UC visits depending on flare frequency. Rates of employment were significantly related to increasing flare frequency. With respect to work-related impairment, absenteeism increased with greater lupus flare frequency (F = 6.2; P < 0.001), as did presenteeism (F = 31.5; P < 0.001) and the combined value of total work productivity loss (F = 30.4; P < 0.001). Mean work-related activity impairment was 12%-32% more among patients who reported flare activities compared to those who reported no flares.

CONCLUSIONS

Increased lupus-related flare frequency is associated with worsened patient outcomes as measured by increased hospitalizations, visits to the ED/UC, work productivity loss, and activity impairment. This association may be an important indicator of disease severity and resource burden and therefore suggests an unmet need among patients experiencing lupus-related flares.

DISCLOSURES

This study was sponsored by Mallinckrodt Pharmaceuticals via grants to Vedanta Research and The Lupus Foundation of America. Katz received consulting fees from Vedanta Research, which received grant support from Mallinckrodt Pharmaceuticals to support data collection and analysis. Nelson and Connolly-Strong are employees of Mallinckrodt Pharmaceuticals and are stockholders in the company. Reed is an employee of Vedanta Research. Daly and Topf are employees of the Lupus Foundation of America, which received grant funding to support data collection. This study was a podium presentation at The American College of Rheumatology (ACR) Annual Meeting 2018; October 19-24, 2018; Chicago, IL.

Most Bothersome Symptom in Persons With Migraine: Results From the Migraine in America Symptoms and Treatment (MAST) Study

Objectives

The objectives of this study were to determine the rates of nausea, phonophobia, and photophobia reported overall and as the most bothersome symptom (MBS) in individuals with migraine and to identify individual characteristics associated with each of the 3 candidate MBSs.

Background

The MBS has emerged as an important coprimary efficacy endpoint in clinical trials of acute treatments for migraine, as recommended by the Food and Drug Administration. The current understanding of how persons with migraine designate an associated symptom as the most bothersome has been assessed primarily in the context of randomized trials.

Methods

Respondents (n = 95,821) in the cross‐sectional, observational Migraine in America Symptoms and Treatment (MAST) study were adults (aged ≥18 years) recruited from a US nationwide online research panel. A validated diagnostic screener identified 15,133 individuals who met modified International Classification of Headache Disorders (ICHD)‐3 beta criteria for migraine and reported at least 1 monthly headache day (MHD) over the previous 3 months. The survey ascertained sociodemographic variables, headache‐related disability, MHDs, cutaneous allodynia, medication overuse, a migraine symptom severity score, pain interference, noncephalic pain, anxiety and depression symptoms, visual aura over the previous year, and acute treatment optimization. The current analysis is based on respondents who also completed a 6‐month follow‐up assessment that included questions about their most bothersome headache symptom.

Results

A total of 7518 respondents completed the 6‐month follow‐up, and 6045 met inclusion criteria and were included in the analysis. The mean age of respondents was 47 (SD 13.4) years, 76.0% (4596/6045) were women, and 84.8% (5103/6017) were white. Among all respondents, 64.9% reported all 3 migraine symptoms. The MBS was photophobia in 49.1% (2967/6045), nausea in 28.1% (1697/6045), and phonophobia in 22.8% (1381/6045). Respondents reporting photophobia as the MBS were more likely to be men, to be obese, and to report visual aura. Those reporting nausea as the MBS were more likely to be women, to have lower incomes, and to report lower levels of treatment optimization. Respondents reporting phonophobia as the MBS were more likely to have cutaneous allodynia and less likely to have visual aura.

Conclusion

Most people with migraine in the MAST observational study reported all 3 cardinal symptoms of nausea, photophobia, and phonophobia. As in clinical trials, the most common MBS was photophobia. Patient profiles differed among the groups defined by their MBS.

Migraine progression in subgroups of migraine based on comorbidities: Results of the CaMEO Study

Objective

To test the hypothesis that statistically defined subgroups of migraine (based on constellations of comorbidities and concomitant conditions; henceforth comorbidities), previously identified using Chronic Migraine Epidemiology and Outcomes (CaMEO) Study data, differ in prognosis, as measured by rates of progression from episodic migraine (EM) to chronic migraine (CM).

Methods

The onset of CM was assessed up to 4 times over 12 months in individuals with EM and ≥1 comorbidity at baseline, based on constellations of comorbidities (comorbidity classes). The “fewest comorbidities” class served as reference. Individuals completing ≥1 follow-up survey from the web-based CaMEO Study were included. Covariates included sociodemographic variables and headache characteristics. Sex, income, cutaneous allodynia, and medication overuse were modeled as binary variables; age, body mass index, headache-related disability (Migraine Disability Assessment [MIDAS]), and Migraine Symptom Severity Scale as continuous variables. CM onset was assessed using discrete time analysis.

Results

In the final sociodemographic model, all comorbidity classes had significantly elevated hazard ratios (HRs) for risk of progression to CM from EM, relative to fewest comorbidities. HRs for CM onset ranged from 5.34 (95% confidence interval [CI] 3.89–7.33; p ≤ 0.001) for most comorbidities to 1.53 (95% CI 1.17–2.01; p < 0.05) for the respiratory class. After adjusting for headache covariates independently, each comorbidity class significantly predicted CM onset, although HRs were attenuated.

Conclusions

Subgroups of migraine identified by comorbidity classes at cross-section predicted progression from EM (with ≥1 comorbidity at baseline) to CM. The relationship of comorbidity group to CM onset remained after adjusting for indicators of migraine severity, such as MIDAS.

Clinicaltrials.gov identifier

NCT01648530.

Cryostorage tank failures: temperature and volume loss over time after induced failure by removal of insulative vacuum

PURPOSE

To determine liquid nitrogen evaporation rates of intact liquid nitrogen storage tanks and tanks with their vacuum removed.

METHODS

Donated storage tank performance (LN2 evaporation) was evaluated before and after induced vacuum failure. Vacuum of each tank was removed by drilling through the vacuum port. Temperature probes were placed 2 in. below the bottom of the styrofoam cap/plug, and tanks were weighed every 3 h. Evaporation rate and time from failure to the critical temperature was determined.

RESULT

Storage tanks with failed vacuum have a much higher evaporation rate than those with intact vacuum; evaporation rates increased dramatically within 3 to 6 h in the smaller tanks, and time to complete depletion varied according to starting LN2 volume. Tanks with storage racks/specimens may have altered evaporation profiles compared to tanks without. Locating temperature probes 2 in. below the styrofoam cap/plug suggests that for most applications, alarms would sound approximately 1 h prior to reaching the critical warming temperature, approximately - 130 °C. External signs of vacuum loss were dramatic: vapor, frost, and audible movement of air.

CONCLUSION

For the first time, we have data on how liquid nitrogen storage tanks behave when their vacuum is removed. These findings are conservative; each lab must consider starting volume, tank size/capacity, function (storage or shipping), age, and pre-existing evaporation behavior in order to develop an emergency response to critical tank failure. Times to complete failure/evaporation and critical warming temperature after vacuum loss are different; these data should be considered when evaluating tank alarm systems.

Discontinuation of Acute Prescription Medication for Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

Objective

This analysis assessed migraine‐related burden and treatment decisions in Chronic Migraine Epidemiology and Outcomes (CaMEO) Study survey respondents who stopped taking acute prescription medications for migraine.

Background

Migraine is a common yet underdiagnosed and undertreated neurological disease often associated with significant disability. Acute prescription medications are underused, in part because patients discontinue treatment. Rates and reasons for discontinuing acute prescription medications require exploration.

Methods

The CaMEO Study is a longitudinal, Internet‐based survey that identified and followed people who met modified ICHD‐3 migraine criteria. For this analysis, eligible respondents had used acute prescription medication for migraine in the past but no longer used or kept these treatments on hand (discontinued users). Respondents who reported discontinuing acute prescription treatment answered questions about length of time since last use and reasons for stopping. Reasons for discontinuing were thematically summarized. Monthly headache day frequency, Migraine Disability Assessment (MIDAS), Patient Health Questionnaire 9‐item depression screener, Generalized Anxiety Disorder 7‐item screener, and the 12‐item Allodynia Symptom Checklist were also assessed.

Results

Of 13,624 respondents with migraine, 4840 (35.5%) had ever used acute prescription medications and 1719 (35.5%) of those were discontinued users. Discontinued users had a mean (SD) age of 42.1 (14) years, and 1348/1719 (78.4%) were female. Monthly headache frequency of 0‐4 days was reported by 1073/1719 (62.4%) of respondents, 5‐9 days by 322/1719 (18.7%), 10‐14 days by 135/1719 (7.9%), and ≥15 days by 189/1719 (11.0%). Two‐thirds (1160/1719 [67.5%]) of discontinued users reported a receiving migraine (or chronic migraine) diagnosis from a doctor or other health professional in the past. Although all had spoken to a doctor about their headaches, 1504/1719 (87.5%) had stopped having their headaches managed or treated by a doctor for at least 12 months. Only 1 in 5 discontinued users reported being able to work or function normally with a headache, and 717/1719 (41.7%) had moderate to severe disability (MIDAS). Among the most commonly reported reasons for prescription medication discontinuation were switching to non‐prescription pain medication (782/1719 [45.5%]), as well as concerns about prescription medication efficacy (484/1719 [28.2%]) and tolerability (428/1719 [24.9%]). Nearly half of respondents who reported either efficacy or tolerability concerns had moderate to severe disability.

Conclusions

People with migraine who discontinue acute prescription medication have a high level of unmet treatment need. The majority cannot work or function normally with headaches, with 646/1719 (37.6%) of discontinued users reporting 5 or more headache days per month.

Unmet Acute Treatment Needs From the 2017 Migraine in America Symptoms and Treatment Study

Objectives

To characterize unmet treatment needs in a sample of Migraine in America Symptoms and Treatment (MAST) Study participants using oral, acute prescription migraine medications.

Background

The MAST Study is a 2017 study of US adults with migraine that profiles current treatment patterns and identifies and quantifies unmet treatment needs.

Methods

Cross‐sectional data from an online survey of US adults meeting ICHD‐3 beta criteria for migraine. For inclusion in this paper, respondents self‐reported a history of 3 or more monthly headache days (MHDs) in the past 3 months and at least 1 MHD in the past 30 days, and current use of orally administered acute prescription medication for headache. Three domains of unmet need were identified: inadequate treatment response (ie, inadequate 2‐hour pain freedom, recurrence within 24 hours of initial relief), demanding attack characteristics (rapid onset of attack, headache associated with sleep), and unique patient characteristics (opioid or barbiturate overuse, cardiovascular comorbidity). Sociodemographics, oral medication use, and coexisting conditions and symptoms (ie, level of treatment optimization, psychological symptoms, attack‐related cutaneous allodynia, and migraine symptom severity) were assessed for each domain and by the number of unmet need domains.

Results

Overall, 15,133 respondents met inclusion criteria, 26.0% (3930/15,133) reported current use of oral acute prescription medication to treat headache. Eligible participants had a mean age of 45.0 years, 73.6% [2892/3930] were women and 81.1% [3186/3930]) were White. A total of 95.8% (3765/3930) of respondents had at least 1 unmet acute treatment need; 89.5% (3516/3930) reported demanding attack characteristics, 74.1% (2912/3930) reported inadequate treatment response, and 16.1% (634/3930) presented with unique patient characteristics. Common areas of unmet need were rapid headache onset (65.3% [2567/3930]), moderate to severe disability (55.6% [2187/3930]), inadequate 2‐hours pain freedom (49.0% [1892/3930]), and headache recurrence within 24 hours (38.0% [1493/3930]). An increasing number of unmet treatment need domains was associated with worsening psychological symptoms, attack‐related cutaneous allodynia and migraine symptom severity.

Conclusion

Nearly all MAST Study respondents using acute oral prescription medications for migraine reported at least 1 unmet treatment need. As unmet needs increased, so did coexisting conditions and symptom severity.

Life With Migraine: Effects on Relationships, Career, and Finances From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

Objective

To assess the effects of migraine on important life domains and compare differences between respondents with episodic and chronic migraine and between sexes.

Background

Migraine is associated with a substantial personal and societal burden and can also affect the interpersonal dynamics, psychological health and well‐being, and financial stability of the entire family of the person with migraine.

Methods

The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study is a prospective, longitudinal, Web‐based survey study undertaken between September 2012 and November 2013 in a systematic U.S. sample of people meeting modified International Classification of Headache Disorders, 3rd edition migraine criteria: 19,891 respondents were invited to complete the Family Burden Module, which assessed the perceived impact of migraine on family relationships and life, career and finances, and overall health. Respondents were stratified by episodic migraine (<15 headache days/month) and chronic migraine (≥15 headache days/month) and sex for comparisons.

Results

A total of 13,064 respondents (episodic migraine: 11,944 [91.4%]; chronic migraine: 1120 [8.6%]) provided valid data. Approximately 16.8% of respondents not currently in a romantic relationship (n = 536 of 3189) and 17.8% of those in a relationship but not living together (n = 236 of 1323) indicated that headaches had contributed to relationship problems. Of those in a relationship and living together (n = 8154), 3.2% reported that they chose not to have children, delayed having children or had fewer children because of migraine (n = 260; episodic migraine: n = 193 of 7446 [2.6%]; chronic migraine: n = 67 of 708 [9.5%]; P < .001). Of individuals responding to career/finance items (n = 13,061/13,036), 32.7% indicated that headaches negatively affected ≥1 career area (n = 4271; episodic migraine: n = 3617 of 11,942 [30.3%]; chronic migraine: n = 654 of 1119 [58.4%]), and 32.1% endorsed worry about long‐term financial security due to migraine (n = 4180; episodic migraine: n = 3539 of 11,920 [29.7%]; chronic migraine: n = 641 of 1116 [57.4%]).

Conclusions

Migraine can negatively affect many important aspects of life including marital, parenting, romantic and family relationships, career/financial achievement and stability, and overall health. Reported burden was consistently greater among those with chronic migraine than among people with episodic migraine; however, few differences were seen between the sexes.

Estimation of embryo transfer media viscosity and consideration of its effect on media and uterine fluid interactions

RESEARCH QUESTION

What are the viscosities of media used for human embryo transfer and what is the possible effect of viscosity as it relates to interactions between transfer media and uterine fluid.

DESIGN

Chamber slide filling times, in seconds, were used to calculate viscosity for each commercial and in-house modified medium, with 12 or 24 replicates per medium under standard operating procedure temperature and gas equilibration conditions used for embryo transfer. Means, standard deviations and coefficients of variation were calculated, and each viscosity was estimated using a regression equation; viscosities for each medium were presented for comparative purposes.

RESULTS

Complete culture media (G1-Plus, G2-Plus, G-TL, 1-Step, Global Total, Global Total HEPES, and Sperm Wash Medium) had viscosity estimates of 1.65 cP, 1.77 cP, 1.68 cP, 1.29cP, 1.18 cP, 1.15 cP, and 1.20 cP, respectively. Complete transfer media (EmbryoGlue, UTM), had viscosity estimates of 3.59 cP and 1.28 cP, respectively. Global HEPES medium with 10%, 20%, 30%, and 50% synthetic serum substitute (SSS) volume per volume had viscosity estimates 1.16 cP, 1.23 cP, 1.25 cP, and 1.34 cP, respectively. For reference, water had a viscosity estimate of 1.06 cP.

CONCLUSIONS

A relatively narrow distribution of viscosities was observed across several transfer media despite the various commercial or in-house modifications. These data demonstrate the vast difference between viscosities of embryo transfer media and the assumed viscosity of uterine fluid (1000 cP). Contemporary embryo transfer media may be well-suited for IVF, but evaluation of all variables, e.g. media viscosity in the context of embryo transfer, adds to the knowledge base that should be available to practitioners.

Development of a claims-based algorithm to identify potentially undiagnosed chronic migraine patients

OBJECTIVE

To develop a claims-based algorithm to identify undiagnosed chronic migraine among patients enrolled in a healthcare system.

METHODS

An observational study using claims and patient survey data was conducted in a large medical group. Eligible patients had an International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) migraine diagnosis, without a chronic migraine diagnosis, in the 12 months before screening and did not have a migraine-related onabotulinumtoxinA claim in the 12 months before enrollment. Trained clinicians administered a semi-structured diagnostic interview, which served as the gold standard to diagnose chronic migraine, to enrolled patients. Potential claims-based predictors of chronic migraine that differentiated semi-structured diagnostic interview-positive (chronic migraine) and semi-structured diagnostic interview-negative (non-chronic migraine) patients were identified in bivariate analyses for inclusion in a logistic regression model.

RESULTS

The final sample included 108 patients (chronic migraine = 64; non-chronic migraine = 44). Four significant predictors for chronic migraine were identified using claims in the 12 months before enrollment: ≥15 versus <15 claims for acute treatment of migraine, including opioids (odds ratio = 5.87 [95% confidence interval: 1.34-25.63]); ≥24 versus <24 healthcare visits (odds ratio = 2.80 [confidence interval: 1.08-7.25]); female versus male sex (odds ratio = 9.17 [confidence interval: 1.26-66.50); claims for ≥2 versus 0 unique migraine preventive classes (odds ratio = 4.39 [confidence interval: 1.19-16.22]). Model sensitivity was 78.1%; specificity was 72.7%.

CONCLUSIONS

The claims-based algorithm identified undiagnosed chronic migraine with sufficient sensitivity and specificity to have potential utility as a chronic migraine case-finding tool using health claims data. Research to further validate the algorithm is recommended.

Predictors of allodynia in persons with migraine: Results from the Migraine in America Symptoms and Treatment (MAST) study

Background

Cutaneous allodynia is a common clinical feature of migraine that has been associated with reduced efficacy of acute migraine treatments and an increased risk of disease progression.

Objective

Identify factors associated with allodynia in a sample of adults with migraine.

Methods

An online survey panel was used to identify adults with migraine who averaged at least 1 monthly headache day over the previous 3 months. Data on sociodemographics, headache frequency, headache pain intensity, migraine symptom severity, medication use, depression and anxiety, and cutaneous allodynia (via the Allodynia Symptom Checklist) were obtained. Binary logistic modeling predicted the presence of allodynia. Odds ratios and 95% confidence intervals (CI) were calculated.

Results

In total, 15,133 individuals with migraine met the eligibility criteria. Mean age was 43.1 years, 73.0% were female, and 81.0% were Caucasian. Allodynia was present in 39.9%. The fully adjusted model, controlling for sociodemographics and headache features, demonstrated that allodynia was significantly associated with a higher migraine symptom severity score (odds ratio 1.17, confidence interval 1.15, 1.19) and more severe pain intensity (odds ratio 1.11, confidence interval 1.08, 1.14); probable depression and/or anxiety (odds ratio 1.83, confidence interval 1.67, 2.00); and overuse of acute medication (odds ratio 1.23, confidence interval 1.09, 1.38). A higher number of monthly headache days increased the likelihood of allodynia, but the effect was attenuated in the fully adjusted model.

Conclusion

In a representative sample of US adults with migraine, there were significant associations between allodynia and headache frequency and intensity, anxiety and/or depression, symptom severity, and acute medication overuse.

Sleep Disorders Among People With Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

OBJECTIVES

We examined the cross-sectional association of sleep apnea and indices of sleep quality with both episodic migraine (EM) and chronic migraine (CM).

BACKGROUND

Sleep apnea and abnormal patterns of sleep, such as insomnia, were associated with migraine onset, severity, and progression in previous research.

METHODS

The Chronic Migraine Epidemiology & Outcomes Study, a longitudinal study, used a series of web-based surveys to assess migraine symptoms, burden, and patterns of health care utilization. Quota sampling was used from September 2012 to November 2013 to generate a representative sample of the US population. Persons who screened positive for sleep apnea on the Berlin Questionnaire are said to be at "high risk" for sleep apnea. Respondents indicated if they believed that they had sleep apnea, if a physician had diagnosed it, and if and how they were treated. Other aspects of sleep quality were assessed using the Medical Outcomes Study (MOS) Sleep Measures.

RESULTS

Of 12,810 eligible respondents with migraine and data on sleep, 11,699 with EM (91.3%) and 1111 with CM (8.7%) provided valid data for this analyses. According to the Berlin Questionnaire, 4739/12,810 (37.0%) were at "high risk" for sleep apnea, particularly persons with CM vs EM (575/1111 [51.8%] vs 4164/11,699 [35.6%]), men vs women (1431/3220 [44.4%] vs 3308/9590 [34.5%]), people with higher body mass index, and older people (all P < .001). Among respondents to the MOS Sleep Measures, persons with CM were more likely to report poor sleep quality than those with EM, including sleep disturbance (mean [SD] values: 53.2 [26.9] vs 37.9 [24.3]), snoring (38.0 [33.9] vs 31.0 [32.1]), shortness of breath (34.9 [29.8] vs 15.3 [20.6]), somnolence (44.1 [23.4] vs 32.2 [21.2]), and less likely to report sleep adequacy (34.0 [24.2] vs 39.2 [22.1]).

CONCLUSIONS

Compared with respondents with EM, a larger proportion of those with CM were at "high risk" for sleep apnea and reported poor sleep quality. This reflects an association between CM vs EM and sleep apnea and poor sleep quality; the potential relationships are discussed.

Migraine in America Symptoms and Treatment (MAST) Study: Baseline Study Methods, Treatment Patterns, and Gender Differences

OBJECTIVES

To summarize the baseline methods for the Migraine in America Symptoms and Treatment (MAST) Study and evaluate gender differences in sociodemographics and headache features; consultation and diagnosis patterns; and patterns of acute and preventive treatment use for migraine among study participants.

BACKGROUND

The MAST Study is a longitudinal, internet-based panel study of symptoms, approaches to management, and unmet treatment needs among US adults with migraine. This analysis focuses on the initial cross-sectional survey, conducted beginning in 2016, and is intended to update results from earlier national epidemiologic surveys of people with migraine in the United States.

METHODS

Respondents to the MAST Study were recruited from a US nationwide online research panel. Stratified random sampling identified a representative cohort of adults (aged ≥18 years). We administered a validated diagnostic screener based on modified ICHD-3 beta criteria to identify individuals with migraine averaging at least 1 monthly headache day (MHD) over the previous 3 months. A baseline assessment evaluated sociodemographic and headache features, patterns of consultation and diagnosis, and use of acute and preventive medications for migraine. Frequency data and chi-square contrasts (P < .05) were used to compare respondents based on gender.

RESULTS

Baseline survey data (N = 95,821) identified 18,353 respondents who met criteria for migraine, including 15,133 (women n = 11,049, men n = 4084) reporting at least 1 MHD for the preceding 3 months. The mean age of the sample was 43.1 (13.6) years; 73.0% of respondents were women, and 81.0% were Caucasian. Compared with men, women were younger (46.1 vs 42.0 years; P < .001); had more MHDs (5.6 vs 5.3; P < .001); and were more likely to report moderate or severe headache-related disability (45.9% vs 35.8%; P < .001) and cutaneous allodynia (43.7% vs 29.5%; P < .001). The lifetime rate of medical consultation for headache was 79.8% overall and slightly higher in women than in men. Women were more likely than men to have been diagnosed with migraine (48.3% vs 38.8%, P < .001). While 95.1% of people with migraine currently used acute treatment, the majority (58.9%) used over-the-counter (OTC) drugs to the exclusion of prescription drugs, while 11.3% used exclusively prescription drugs, and 20.5% used both. Among acute prescription medication users, women were more likely than men to take triptans (17.7% vs 14.3%, P < .001), while men were more likely than women to take opioids (14.5% vs 9.2%, P < .001). Oral formulations were used predominately (92.7% of the medication users), but men were more likely to use nasal sprays (13.6% vs 9.4%, P < .001) and injectables (7.9% vs 3.4%, P <  .001). Men (14.5%) were also significantly more likely than women (10.4%) to be taking daily oral preventive medication (P < .001).

CONCLUSIONS

The MAST Study identified a large sample of women and men with migraine from a sampling frame that broadly resembles the US population. Low participation rate increases the risk of response bias, however, comparisons with Census data and prior population studies for the demographic and headache characteristics of the current sample suggest that findings are generalizable to the population of people with migraine. Women had more MHDs than men, and they were more likely to report migraine-related disability and cutaneous allodynia. The lifetime consultation rate for headache was relatively high, but many with migraine symptoms reported never having received a diagnosis of migraine from a healthcare professional. Acute prescription and preventive migraine treatments are underused. Migraine persists as an underdiagnosed and undertreated public health problem in 2018, and there are many opportunities to improve the diagnosis and treatment of people with this painful, disabling condition.

Factors associated with acute medication overuse in people with migraine: results from the 2017 migraine in America symptoms and treatment (MAST) study

Background

The MAST Study is a longitudinal, cross-sectional survey study of US adults with migraine. These analyses were conducted to estimate rates of acute medication overuse (AMO) and determine associations of AMO with individual and headache characteristics.

Methods

Eligible respondents had ICHD-3-beta migraine, reported ≥3 monthly headache days (MHDs) in the past 3 months, ≥1 MHD in the past 30 days, and currently took acute headache medication. AMO was defined according to ICHD-3-beta thresholds for monthly days of medication taking when diagnosing medication overuse headache.

Results

Eligible respondents (N = 13,649) had a mean age of 43.4 ± 13.6 years; most were female (72.9%) and Caucasian (81.9%). Altogether, 15.4% of respondents met criteria for AMO. Compared with those not overusing medications, respondents with AMO were significantly more likely to be taking triptans (31.3% vs 14.2%), opioids (23.8% vs 8.0%), barbiturates (7.8% vs 2.7%), and ergot alkaloids (3.1% vs 0.6%) and significantly less likely to be taking NSAIDs (63.3% vs 69.8%) (p < 0.001 for all comparisons). Respondents with AMO had significantly more MHDs (12.9 ± 8.6 vs 4.3 ± 4.3, p  <  0.001); higher migraine symptom severity (17.8 ± 2.7 vs 16.4 ± 3.0, p  <  0.001), higher pain intensity scores (7.4 vs 6.5, p  <  0.001); and higher rates of cutaneous allodynia (53.7% vs 37.5%, p  <  0.001). Adjusted for MHDs, the odds of AMO were increased by each additional year of age (OR 1.02, 95% CI 1.02, 1.03); being married (OR 1.19, 95% CI 1.06, 1.34); smoking (OR 1.54, 95% CI 1.31, 1.81); having psychological symptoms (OR 1.62, 95% CI 1.43, 1.83) or cutaneous allodynia (OR 1.22, 95% CI 1.08, 1.37); and greater migraine symptom severity (OR 1.06, 95% CI 1.04, 1.09) and pain intensity (OR 1.27, 95% CI 1.22, 1.32). Cutaneous allodynia increased the risk of AMO by 61% in males (OR 1.61, 95% CI 1.28, 2.03) but did not increase risk in females (OR 1.08, 95% CI 0.94, 1.25).

Conclusions

AMO was present in 15% of respondents with migraine. AMO was associated with higher symptom severity scores, pain intensity, and rates of cutaneous allodynia. AMO was more likely in triptan, opioid, and barbiturate users but less likely in NSAID users. Cutaneous allodynia was associated with AMO in men but not women. This gender difference merits additional exploration.

The headache under-response to treatment (HURT) questionnaire, an outcome measure to guide follow-up in primary care: development, psychometric evaluation and assessment of utility

Background

Headache disorders are both common and burdensome but, given the many people affected, provision of health care to all is challenging. Structured headache services based in primary care are the most efficient, equitable and cost-effective solution but place responsibility for managing most patients on health-care providers with limited training in headache care. The development of practical management aids for primary care is therefore a purpose of the Global Campaign against Headache. This manuscript presents an outcome measure, the Headache Under-Response to Treatment (HURT) questionnaire, describing its purpose, development, psychometric evaluation and assessment for clinical utility. The objective was a simple-to-use instrument that would both assess outcome and provide guidance to improving outcome, having utility across the range of headache disorders, across clinical settings and across countries and cultures.

Methods

After literature review, an expert consensus group drawn from all six world regions formulated HURT through item development and item reduction using item-response theory. Using the American Migraine Prevalence and Prevention Study’s general-population respondent panel, two mailed surveys assessed the psychometric properties of HURT, comparing it with other instruments as external validators. Reliability was assessed in patients in two culturally-contrasting clinical settings: headache specialist centres in Europe (n = 159) and primary-care centres in Saudi Arabia (n = 40). Clinical utility was assessed in similar settings (Europe n = 201; Saudi Arabia n = 342).

Results

The final instrument, an 8-item self-administered questionnaire, addressed headache frequency, disability, medication use and effect, patients’ perceptions of headache “control” and their understanding of their diagnoses. Psychometric evaluation revealed a two-factor model (headache frequency, disability and medication use; and medication efficacy and headache control), with scale properties apparently stable across disorders and correlating well and in the expected directions with external validators. The literature review found few instruments linking assessment to clinical advice or suggested actions: HURT appeared to fill this gap. In European specialist care, it showed utility as an outcome measure across headache disorders. In Saudi Arabian primary care, HURT (translated into Arabic) was reliable and responsive to clinical change.

Conclusions

With demonstrated validity and clinical utility across disorders, cultures and settings, HURT is available for clinical and research purposes.

Electronic supplementary material

The online version of this article (10.1186/s10194-018-0842-6) contains supplementary material, which is available to authorized users.

Framingham-Based Cardiovascular Risk Estimates Among People With Episodic Migraine in the US Population: Results from the American Migraine Prevalence and Prevention (AMPP) Study

BACKGROUND

Cardiovascular (CV) events, conditions, and procedures (ECPs) are common in persons with migraine and are a contraindication to triptan and ergot use. In a prior study, we estimated that there are 2.6 million American adults with episodic migraine (EM) who have had CV ECPs. However, the prior analysis did not assess persons with migraine without CV ECPs who are at high risk for a first cardiovascular disease (CVD) event.

OBJECTIVES

To use the Framingham nonlaboratory CVD events risk equation to estimate the number of individuals with EM who are at elevated risk for a first CVD event in the next 10 years using data from the American Migraine Prevalence and Prevention Study, and then to extrapolate the findings to the US population to estimate the scope of people with EM for whom triptan and ergot therapies may be problematic.

METHODS

Data from respondents to the 2009 American Migraine Prevalence and Prevention (AMPP) Study questionnaire aged ≥22 who met criteria and headache day frequency for EM were included in this cross-sectional analysis. Ten-year, first CVD event risk was calculated using the nonlaboratory Framingham CV disease risk score (FRS). Variables were collected via respondent self-report and included sex, age, height, and weight to calculate body mass index (BMI), smoking status, and the presence of hypertension and diabetes among other variables. Standard FRS cut scores of ≥21 for women and ≥16 for men were used, which indicate a 30% or greater risk of a first CVD event in the next 10 years. History of CV ECPs was collected via self-report of ever having the ECP and for events and conditions that were diagnosed by a physician. We applied rates of positive ECPs and rates of high FRS to age and sex stratified estimates of the number of people with EM in the US derived from 2015 US Census data to estimate rates of both in the population.

RESULTS

The AMPP Study analysis sample included 5227 women and 1496 men with EM. Results showed that 69.5% of women and 73.4% of men had at least one CV risk factor from the FRS, 38.9% of women and 41.6% of men had ≥2 risk factors, and 18.6% of women and 19.1% of men had ≥3 risk factors. The proportion of women with high FRS was 0% for those aged 22-39, 0.8% (95%CI: 0.5-1.2%) among 40- to 59-year-olds and 15.2% (95% CI: 13.3-17.4%) among the ≥60 age group. For men, the corresponding proportions were 0, 7.3% (95% CI: 5.7-9.4%), and 53.0% (95% CI: 4.7-58.1%). Projecting to a national US sample, the number of persons with EM and high FRS was 403,000 for women and 510,000 for men. The proportion of women and men at high risk for future CV events based on a prior CV ECP, a high FRS or both increased with age from 20-39 (women 4.5%, men 4.2%), 40-59 (women 11.8%, men 18.6%), and ≥60 (women 31.2%, men 61.8%). An estimated 141,000 men aged 40-59 and 187,000 aged ≥60 and 34,000 women aged 40-59 and 181,000 women aged ≥60 in the US population with EM have not had a CV ECP but are at increased risk for a future CV event within the next 10 years based upon their FRS alone.

CONCLUSION

Among people with EM in the US population, the number of women and men with relative contraindications to triptans and ergots based on a high FRS includes over 900,000 women and men. This includes more than half a million individuals with EM who have not had a prior CV ECP.

Fluctuations in episodic and chronic migraine status over the course of 1 year: implications for diagnosis, treatment and clinical trial design

Background

Relatively little is known about the stability of a diagnosis of episodic migraine (EM) or chronic migraine (CM) over time. This study examines natural fluctuations in self-reported headache frequency as well as the stability and variation in migraine type among individuals meeting criteria for EM and CM at baseline.

Methods

The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study was a longitudinal survey of US adults with EM and CM identified by a web-questionnaire. A validated questionnaire was used to classify respondents with EM (<15 headache days/month) or CM (≥15 headache days/month) every three months for a total of five assessments. We described longitudinal persistence of baseline EM and CM classifications. In addition, we modelled longitudinal variation in headache day frequency per month using negative binomial repeated measures regression models (NBRMR).

Results

Among the 5464 respondents with EM at baseline providing four or five waves of data, 5048 (92.4%) had EM in all waves and 416 (7.6%) had CM in at least one wave. Among 526 respondents with CM at baseline providing four or five waves of data, 140 (26.6%) had CM in every wave and 386 (73.4%) had EM for at least one wave. Individual plots revealed striking within-person variations in headache days per month. The NBRMR model revealed that the rate of headache days increased across waves of observation 19% more per wave for CM compared to EM (rate ratio [RR], 1.19; 95% CI, 1.13–1.26). After adjustment for covariates, the relative difference changed to a 26% increase per wave (RR, 1.26; 95% CI, 1.2–1.33).

Conclusions

Follow-up at three-month intervals reveals a high level of short-term variability in headache days per month. As a consequence, many individuals cross the CM diagnostic boundary of ≥15 headache days per month.Nearly three quarters of persons with CM at baseline drop below this diagnostic boundary at least once over the course of a year. These findings are of interest in the consideration of headache classification and diagnosis, the design and interpretation of epidemiologic and clinical studies, and clinical management.

Electronic supplementary material

The online version of this article (doi:10.1186/s10194-017-0787-1) contains supplementary material, which is available to authorized users.

Allodynia Is Associated With Initial and Sustained Response to Acute Migraine Treatment: Results from the American Migraine Prevalence and Prevention Study

OBJECTIVE

In a population sample of persons with migraine treating with a single category of acute migraine medication, to identify rates and factors associated with acute treatment outcomes, including 2-hour pain freedom (2hPF), 24-hour pain response (24hPR), and 24-hour sustained pain response (24hSPR). Key predictors include acute treatment type (triptans and other medication categories), the influence of allodynia on response to medication, and the interaction between medication category and presence of allodynia in response to treatment among people with migraine.

BACKGROUND

Cutaneous allodynia was previously associated with inadequate 2hPF, 24hPR, and 24hSPR (sustained response at 24 hours among those with adequate 2hPF) among people with migraine in the American Migraine Prevalence and Prevention (AMPP) Study.

METHODS

The AMPP Study obtained data from a representative US sample of persons with migraine by mailed questionnaire. The 2006 survey included 8233 people with migraine aged 18 or over who completed the Migraine Treatment Optimization Questionnaire (mTOQ). mTOQ was used to assess acute treatment outcomes including 2hPF, 24hPR, and 24hSPR. Eligible individuals used only a single category of acute prescription migraine treatments (n  =  5236, 63.6%). This sample was stratified into 5 categories of type of acute prescription headache medication used (triptans, nonsteroidal anti-inflammatory drugs, barbiturate-combinations, opioids, and opioid combinations and ergot alkaloids). Separate binary logistic regression models evaluated: (1) triptans vs other medication types; (2) presence of allodynia vs no allodynia; and (3) the interaction of medication category with allodynia. Sociodemographic variables, health insurance status, over-the-counter and preventive medication use were included as covariates. Odds ratios (OR) and 95% confidence intervals (CI) were generated for each acute treatment outcome.

RESULTS

Among eligible participants, the mean age was 46 years, and 82.5% were women. The triptan use group had better outcomes than other medication groups for 2hPF (OR range: 2.00-2.63, all significant except ergot alkaloids) and 24hPR (OR range: 2.10-6.22, all significant). No significant medication effects were found for the 24hSPR outcome. The presence of allodynia was associated with significantly worse outcomes for both 2hPF (OR range: 1.42-1.55, all significant) and 24hPR (OR range: 1.30-1.32, all significant, except for ergot alkaloids, P  =  .051). Allodynia effects were not significant for the 24hSPR. The interaction between medication and allodynia was also not significant (OR range for 2hPF: .68-2.02; OR range for 2hPR: .35-1.34; OR range for 24hSPR: 1.21-2.72) in any of the models, suggesting allodynia is an important predictor of treatment response regardless of the medication group prescribed.

CONCLUSIONS

The use of triptan medication was associated with significantly better 2hPF (except vs ergot alkaloids) and significantly better 24hPR outcomes compared with other acute medication categories. The presence of allodynia significantly increased the likelihood of an inadequate treatment response for both of these outcomes. Triptan use was generally associated with the best outcomes. Because allodynia was associated with inadequate outcomes for all medication groups, we suggest that allodynia is an area of unmet treatment need.

Family Impact of Migraine: Development of the Impact of Migraine on Partners and Adolescent Children (IMPAC) Scale

Objective

To describe the development of the Impact of Migraine on Partners and Adolescent Children (IMPAC) scale.

Background

Although existing data and clinical experience suggest that the impact of migraine is pervasive and extends beyond the individual with migraine, no validated tools exist for assessing the impact of migraine on the family.

Methods

The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study is a longitudinal study of people with migraine in the United States. The Family Burden Module (FBM) of the CaMEO Study contained an item pool of 53 questions derived through literature review, clinician input, and patient focus groups pertaining to the following concepts: impact of migraine on family interpersonal relationships, activities, well‐being, finances, and health‐related quality of life. Respondents with migraine (ie, probands) were categorized into 4 groups based on household composition: migraine probands with partners/spouses and children (M‐PC), migraine probands with partners/spouses only (M‐P), migraine probands with child(ren) only (M‐C), and migraine probands without a partner/spouse or child(ren) (M‐O). The IMPAC scale was developed in 3 steps: (1) exploratory factor analysis and item reduction, (2) bifactor analysis, confirmatory factor analysis, and scoring, and (3) reliability and construct validity analyses.

Results

The analysis of data from 13,064 respondents to the FBM meeting criteria for migraine yielded a 12‐item IMPAC scale, with 4 items applying to all of the groups, 4 more items applying to the groups with partners (M‐P and M‐PC), and 4 additional items to the groups with children (M‐C and M‐PC). Item responses can be summed and converted into a scoring system assessing mild (<0.5 SD below mean; IMPAC scale Grade I), moderate (0.5 SD below to <0.5 SD above mean; Grade II), severe (0.5‐<1.5 SD above mean; Grade III), and very severe (≥0.5 SD above mean; Grade IV) family impact. Test information curves relating to the IMPAC scale for each household type indicated adequate reliability across a large range of family burden severity (from ∼1 SD below to ∼3 SD above mean) and IMPAC scores showed moderate‐to‐large correlations with other validated tools (range, ± 0.38‐0.52), providing support for construct validity.

Conclusions

We developed a questionnaire to assess family burden attributed to migraine that is brief, robust, and psychometrically sound, with a simple scoring algorithm that can be applied to various household compositions. This questionnaire may be valuable in research settings to provide quantifiable data on the impact of migraine on family dynamics and in clinical settings to facilitate conversations about family burden as a target and a motivation for better treatment.

Spinal devices in the United States-investigational device exemption trials and premarket approval of class III devices

BACKGROUND CONTEXT

Recently, there has been increased public awareness of regulatory actions by the United States Food and Drug Administration (FDA) on spinal devices. There has also been increased scrutiny of the pivotal clinical trials of these devices.

PURPOSE

To investigate the premarket approval (PMA) of class III spinal devices in the United States since the turn of the century. To explore clinically relevant issues that affect the interpretation of investigational device exemption trials.

STUDY DESIGN

Literature review.

METHODS

From 2000 to 2015, data on PMA applications for spinal devices were obtained from two sources. First, meetings of FDA's Orthopaedic and Rehabilitation Devices Panel were identified from the Federal Register. Second, the FDA database of approved PMA applications was queried. For each device, two authors reviewed all archival data. There was no external source of funding.

RESULTS

Twenty-one devices met the study criteria. There were 76.2% that received approval and 47.6% that went to panel. Arthroplasty devices were most common (52.4%), least likely to go to panel (3 of 11), and most likely to be approved after panel (3 of 3). Biologic devices were most likely to go to panel (3 of 3) and least likely to be approved after panel (1 of 3). Before and after 2009, there was no decrease in the number of spinal devices approved. All 21 devices were studied in a pivotal clinical trial. All trials except one were randomized controlled trials, and all trials except one were two-arm noninferiority designs.

CONCLUSIONS

There has been no decrease in the number of new FDA-approved class III spinal devices since the turn of the century. The majority of devices have been for cervical arthroplasty. By contrast, biologic devices were most likely to go to panel and least likely to be approved after panel. The pivotal trials for nearly all devices were randomized, two-arm, noninferiority trials.

Cardiovascular Events, Conditions, and Procedures Among People With Episodic Migraine in the US Population: Results from the American Migraine Prevalence and Prevention (AMPP) Study

BACKGROUND

Though migraine, particularly migraine with aura, is a cardiovascular (CV) risk factor, the scope and distribution of cardiovascular disease in representative samples of people with migraine are not known. This is important because many widely used acute migraine treatments, including triptans, ergot alkaloids, and nonsteroidal anti-inflammatory drugs, carry precautions, warnings, or contraindications for use in persons with CV disease.

OBJECTIVES

To assess the scope and distribution of cardiovascular events, conditions, and procedures in persons with episodic migraine in a representative sample of the US population, using data from the American Migraine Prevalence and Prevention (AMPP) Study.

METHODS

Eligible subjects completed the 2009 AMPP survey, met ICHD-3beta criteria for migraine, and had a headache frequency of less than 15 days per month (episodic migraine). A survey on cardiovascular events (ie, myocardial infarction), conditions (ie, angina), and procedures (ie, carotid endarterectomy) was adopted from the Women's Health Study and the Physician's Health Studies. Cardiovascular events and conditions were defined by participant reports of having both experienced and received a physician diagnosis for a particular event or condition. The distribution of CV events, conditions, and procedures was summarized for the entire migraine sample and in groups defined by gender and age (22-39, 40-59, and ≥60). To assess the numbers of persons with episodic migraine in the US, we applied age and gender stratified estimates of migraine prevalence to the 2015 Census data. To estimate the number of cardiovascular events, conditions, and procedures in the US migraine population, we applied age and gender stratified event rates to the number of persons with episodic migraine in each stratum.

RESULTS

The 2009 AMPP Study survey was returned by 11,792 study participants out of 16,983 (64.9% response rate), including 6723 individuals who met study criteria for episodic migraine (5227 women and 1496 men). Among 22-39 year olds with episodic migraine, 3.4% reported having received a physician diagnosis of CV events or conditions and 1.1% reported undergoing CV related procedures. Among 40-59 year olds, 10.2% reported having received a physician diagnosis of CV events or conditions and 3.5% reported CV related procedures. For those age 60 or older, 22.3% reported CV events or conditions and 8.8% reported CV procedures. Prevalence of events, conditions, and procedures was higher in men than women and also in older age groups. However, the absolute number of CV events, procedures, and conditions was greater for women than men due to the higher population prevalence of episodic migraine in women. We projected that 2.0 million women and 665,000 men in the US had episodic migraine and a history of one or more CV event, condition, or procedure. By age group, it is estimated that 579,000 among those aged 22-39, 1.37 million of those aged 40-59, and 696,000 of those 60 and older with episodic migraine have ever had at least one CV event, procedure, or condition.

CONCLUSION

Based on these analyses, we estimate that there are roughly 2.6 million people with episodic migraine aged 22 and older in the US with one or more prior CV event, condition, or procedure. For this group, cardiovascular contraindications to many migraine-specific acute migraine therapies may make treatment challenging.