Migraine consultation patterns in primary care. Results from the PCAOM study 1994-96

Prescription patterns in preventive and abortive migraine medication

BACKGROUND

Migraine is considered a common but under-diagnosed and untreated condition. Treatment patterns have pointed at frequent over-the-counter medication use and low use of preventive therapies. Studies exploring migraine prescription practice among doctors are few.

METHODS

A population-based study was carried out to examine the prescription practice in the use of acute and preventive migraine medications. The data covered 4864 working-age people reporting they have been diagnosed with migraine. Data on reimbursed prescription medicines from 1 January 1998 to 31 December 2006 were drawn from the registers of the Social Insurance Institute of Finland and compared with age- and sex-matched controls.

RESULTS

Anti-inflammatory analgesics were prescribed for 71% of female and 62% of male migraine patients vs. 56% and 50% of controls. Triptans were prescribed for 21% of female and 10% of male patients. Combinations of analgesics and muscle relaxants were offered to 37% of female and 29% of male patients vs. 26% and 21% of controls, and antidepressants to 19% of women and 14% of men vs. 13% and 9% of controls.

CONCLUSION

Although use of preventive medication among migraineurs was high, the prescription patterns in acute treatments showed that NSAIDS were used more often than triptans. Assimilation of national guidelines to treat migraine published in 2002 in Finland was not reflected in the prescription patterns up to 2006.

Efficacy of almotriptan in early intervention for treatment of acute migraine in a primary care setting: the START study

AIMS

The benefits of taking almotriptan early for acute migraine when pain is mild have clearly been demonstrated in the neurology setting. The aim of this study was to determine whether similar benefits with early intervention of almotriptan can be achieved in everyday general practice, where most migraineurs are managed.

METHODS

In this European, prospective, observational study, patients were asked to treat up to three migraine attacks over a 2-month period with almotriptan 12.5 mg administered within 1 h of pain onset and when pain was mild (early + mild intervention group).

RESULTS

A total of 501 patients were enrolled in primary care centres across Spain, France and Italy. The intention-to-treat analysis involved 454 patients who reported 1174 migraine attacks, with early intervention being used in 138 of these attacks. A greater proportion of patients who took almotriptan early + mild for their first migraine attack (n = 42) were pain free at 2 h compared with those in the non-early + mild intervention group (n = 410) (62% vs. 35%; p < 0.001). Similar results were obtained for all migraine attacks comparison [65% (n = 138) vs. 38% (n = 1036); p < 0.001]. Other secondary end-points were also significantly in favour of early + mild treatment, including sustained pain free (SPF), SPF with no adverse events (SNAE), and time lost because of migraine (all p < 0.001). Almotriptan was well tolerated with no serious adverse events reported.

CONCLUSIONS

In the primary care setting, early intervention with almotriptan for treatment of migraine provides significant clinical benefits compared with delaying treatment and/or waiting until pain intensity has progressed beyond mild.

The cycle of migraine: Patients' quality of life during and between migraine attacks

BACKGROUND

Despite advances in therapy, the prevalence of migraine has remained constant over the past 17 years. The current diagnostic procedure for migraine does not take into account the entire cycle of migraine, which includes both the pain of the acute attack and the worry between attacks.

OBJECTIVES

This review discusses the effects of migraine on health-related quality of life. The focus is on the impact of migraine between attacks and more successful clinical management of the complete cycle of migraine in both the neurology and primary care settings.

METHODS

A search of MEDLINE (January 1997-January 2007) was conducted to determine the impact of migraine on quality of life and the need for and use of migraine preventive treatment. The search terms were migraine prevention, migraine prophylaxis, bead-ache and quality of life, migraine disability, and head-ache disability. The inclusion of specific studies was based on subjective, comparative evaluation and standard levels of evidence. Older publications were included to provide a historical perspective.

RESULTS

Worry in expectation of the next migraine attack can have negative effects on the family and social lives and work productivity of patients with migraine. The benefits of preventive pharmacotherapy for migraine may be measured over time in terms of changes in the frequency of acute attacks, impact of acute treatment on headache recurrence within the next 24 hours, and reduction in overall functional impairment. Optimizing the acute treatment outcome and reducing the frequency of episodes may help alleviate the cycle of migraine. The clinical assessment of migraine should include multiple dimensions. Several questionnaires, such as the Migraine Disability Assessment and the 6-item Headache Impact Test, have been developed to help clinicians assess the dimensions of migraine. These questionnaires should be used in conjunction with open communication techniques that elicit any underlying worry associated with migraines. Preventive therapies that have been approved by the US Food and Drug Administration include the neurostabilizers divalproex sodium and topiramate, and the beta-blockers timolol and propranolol. Despite not being approved for this indication, the antidepressant amitriptyline has shown levels of evidence of efficacy in preventing migraine in controlled trials similar to those for the approved medications.

CONCLUSION

The assessment of whether patients with migraine may benefit from preventive therapy should include the use of open communication techniques to uncover possible impairment between attacks.

Prevalence and impact of headache and migraine among Pomeranians in Espirito Santo, Brazil

This is the first study to assess the prevalence of headache and migraine among Pomeranian descendents in Brazil. A high prevalence of headache in the last 6 months was found (53.2%). Most headache sufferers were diagnosed as having migraine (55%). More women reported to have headache than men (65% and 33.8%, respectively). Migraine was the most common headache found among women (62.2%). Among men migraine was responsible for only 37.8% of the cases of headache. A high impact of headache was found, especially among migraineurs. Most of the headache sufferers declared to seek medical assistance for headache (67%) and most of them used to take common analgesics for headache relief. None of them was under prophylactic therapy.

Company reference estimates for productivity loss due to migraine and productivity gains using rizatriptan 10 mg in Germany

The prevalence of migraine in Germany is up to 14% in the female and up to 8% in the male population and peaks between the age of 35 and 45. Few studies have investigated the productivity loss and resulting costs attributable to migraine in Germany or addressed the question whether these costs can be reduced by optimal treatment. In recent years, 5-HT(1B/D) agonists (so-called triptans), a generation of drugs highly specific for migraine treatment, have been introduced. Seven 5-HT(1B/D) agonists have been approved in Germany with more than 20 dosage forms. We present a model that enables employers to estimate the annual cost of migraine and the annual cost that could be saved by treatment of migraine with rizatriptan compared with the use of non-specific antimigraine medication. A representative German company with 10,000 employees is used for the reference case analysis. This company is predicted to have 580 female and 284 male employees with migraine. These employees are estimated to lose 6992 workdays or 31.8 person years of productive effort annually due to migraine, valued approximately 1,431,719 euros. The value of work loss that could be avoided by treating migraine with rizatriptan is estimated at 619,094 euros annually. These data indicate that costs arising from lost productivity can be reduced by treating migraine headaches with a triptan.

Use of a structured migraine diary improves patient and physician communication about migraine disability and treatment outcomes

Migraine is frequently undertreated, perhaps because impaired communication between patients and physicians underestimate the disability associated with migraine attacks. The purpose of this study was to evaluate the benefits of a structured migraine diary used during a prospective open-label study of triptan-naive patients in Spain for recording information on response to therapy for a pre-study migraine attack and three consecutive migraine attacks, the first and third treated with rizatriptan 10-mg wafer and the second with usual non-triptan therapy. Of 97 patients (83% women; mean age, 39 years) who completed the study, all reported moderate to severe pain, and two-thirds reported severe to total impairment during migraine attacks. At study end, 72% of patients reported that the migraine diary helped communication with their doctor about migraine, and 70% were more or much more satisfied than before the study with level of overall medical care provided by their doctor. Patients who reported the diary to be useful also reported higher overall satisfaction with medical care (p < 0.001). Most of the 22 physicians (91%) reported that the diary enabled them to better communicate with their patients about migraine, and all reported that it enabled them to assess differences in pain intensity and disability across patients. We conclude that a structured migraine diary can be a valuable aid for improving communication between physicians and patients regarding migraine disability and treatment outcomes.

Migraine prophylactic medication usage patterns in The Netherlands

This study aims to investigate usage patterns of specific migraine prophylactic medications in ergotamine and triptan patients commencing this treatment for the first time during 1 January 1992 until 31 December 1998. Usage patterns of specific migraine prophylactic drugs were evaluated for each patient by accessing data from a large prescription database and were characterized as continued, switch or stop use during the patient observation period. Several patient and medication-related factors were explored in order to identify a possible relationship with the specific usage pattern defined. Approximately 75% of the study population (n = 729) had terminated (stop or switch) prophylactic treatment after 1 year. Age < 40 years (relative risk (RR) 1.9; 95% confidence interval (CI) 1.2-3.2) and the concomitant use of non-steroidal anti-inflammatory drugs (RR 3.2; 95% CI 1.2-5.5) or specific abortive migraine drugs resulted in a faster onset of treatment modification (switch). Overall, migraine prophylactic treatment is used for a relatively short period, probably attributable to the common limitations associated with migraine prophylaxis, such as poor compliance and/or limited therapeutic efficacy. Patterns of use can be influenced by a variety of factors, including age, type of prescriber and certain co-medication. Patient interview studies are required to clarify these issues further.

Health care utilization in patients with migraine: demographics and patterns of care in the ambulatory setting

BACKGROUND

Migraine affects people of all races and both sexes. Migraineurs suffer both financial losses and impaired quality of life. Recent progress in the treatment of migraine has not been made readily available to all who suffer the condition.

OBJECTIVE

To assess outpatient health care delivery patterns for migraine sufferers in the United States.

METHODS

National Ambulatory Medical Care Survey data from 1990 to 1998 was used to assess the demographics of patients seen with a diagnosis of migraine, the types of physicians they saw, and the medications used to treat migraine.

RESULTS

Women accounted for 79% of visits for migraines and whites for 91% of the visits. There was a dramatic increase in the number of migraine visits during the study period, from 9.4 visits per 1000 people in 1990 to 18 visits per 1000 in 1998. Primary care physicians saw the majority of patients (72.2%). Butalbital/aspirin/caffeine was the drug most commonly prescribed for migraine treatment, followed by acetaminophen/dichloralphenazone/isometheptene mucate, propranolol, and sumatriptan.

CONCLUSION

Perhaps in part due to newer treatment options, the number of visits for the treatment of migraine doubled over the study interval. Even so, most patients with migraine continue to be treated with older and presumably less effective medications.