Shortcomings and missed potentials in the management of migraine patients - experiences from a specialized tertiary care center

Real-world treatment patterns and healthcare resource utilization among migraine patients: A German claims database analysis

AIMS

Despite migraine being one of the most common neurological diseases, affected patients are often not effectively treated. This analysis describes the burden of migraine in Germany and assesses real-world treatment patterns and healthcare resource utilization (HCRU) of preventive-treated migraine patients from the perspective of the Statutory Health Insurance.

METHODS

A retrospective analysis was conducted using InGef Research Database claims data from 2018-2019. Migraine patients were stratified into cohorts by acute and preventive treatment status. Patients on preventive treatment were further stratified according to type of prophylaxis received. Disease burden in preventively treated migraine patients was reported via treatment patterns, pathways, and comorbidities. HCRU was assessed through outpatient provider visits, hospitalizations, and sick leave.

RESULTS

160,164 adult migraine patients were identified, of which 55,378 (34.6%) were prescribed preventive treatment with conventional (n = 25,984, 46.9%), calcitonin gene-related peptide monoclonal antibody (CGRP mAb) (n = 613, 1.1%), or off-label therapies (n = 28,781, 52.0%). 936 (1.7%) patients received Botulinum Neurotoxin Type A (BoNTA). CGRP mAb-treated patients had a high rate of triptan prescriptions (2018: 95.5%; 2019: 88.9%), migraine-related hospitalizations (2018: 33.0%; 2019: 21.0%), and sick leave (2018: 26.8%; 2019: 22.5%). A high proportion of CGRP mAb- and BoNTA-treated patients was diagnosed with abdominal and pelvic pain (34.3% and 36.2%) and low back pain (34.1% and 35.3%). These patients also showed a high prevalence of depressive episodes (49.1% and 50.1%) and chronic pain disorders (37.5% and 32.9%).

LIMITATIONS

This study focused on descriptive analyses which do not allow for assessment of causality when comparing treatment groups.

CONCLUSIONS

Disease burden was high in patients receiving CGRP mAbs suggesting that patients treated preventively with CGRP mAbs shortly after product launch in Germany were severely affected chronic migraine patients. The same may be true for patients receiving BoNTA who also showed an increased disease burden.

Efficacy of the Digital Therapeutic sinCephalea in the prophylaxis of migraine in patients with episodic migraine: study protocol for a digital, randomized, open-label, standard treatment controlled trial

BACKGROUND

The German government implemented the Digital Healthcare Act in order to bring Digital Therapeutics into standard medical care. This is one of the first regulatory pathways to reimbursement for Digital Therapeutics (DTx). The Digital Therapeutic sinCephalea is intended to act as a prophylactic treatment of migraine by reducing the migraine days. For this, sinCephalea determines personalized nutritional recommendations using continuous glucose monitoring (CGM) data and enables the patients to follow a personalized low-glycemic nutrition. Migraine is a headache disorder with the highest socioeconomic burden. Emerging evidence shows that CGM-based personalized nutritional recommendations are of prophylactic use in episodic migraine. However, prospective data are yet missing to demonstrate clinical effectiveness. This study is designed to fill this gap.

METHODS

Patients between 18 and 65 years of age with proven migraine and a minimal disease severity of 3 migraine days per month are included. After a 4-week baseline phase as a pre-study, patients are randomized to the DTx intervention or a waiting-list control. The objective of the study is to show differences between the intervention and control groups regarding the change of migraine symptoms and of effects of migraine on daily life.

DISCUSSION

To our knowledge, this is the first systematic clinical trial with a fully digital program to enable patients with migraine to follow a personalized low-glycemic nutrition in order to reduce their number of migraine days and the migraine-induced impact on daily life. Designing a clinical study using a digital intervention includes some obstacles, which are addressed in this study approach.

TRIAL REGISTRATION

German Registry of Clinical Studies (Deutsches Register Klinischer Studien) DRKS-ID DRKS00024657. Registered on March 8, 2021.

A Digital Therapeutic Allowing a Personalized Low-Glycemic Nutrition for the Prophylaxis of Migraine: Real World Data from Two Prospective Studies

Migraine is a headache disorder associated with a high socioeconomic burden. The digital therapeutic sinCephalea provides an individualized low-glycemic diet based on continuous glucose measurement and is intended to provide a non-pharmacological migraine prophylaxis. We performed two prospective studies with migraine patients who used sinCephalea over a period of 16 weeks. The patients used a headache diary and recorded their migraine-related daily life impairments using the assessment tools HIT-6 and MIDAS for a pre versus post comparison. In addition, continuous glucose data of patients were compared to healthy controls. In both studies, patients reported a reduction of headache and migraine days as well as reductions in HIT-6 and MIDAS scores. More specifically, migraine days decreased by 2.40 days (95% CI [−3.37; −1.42]), HIT-6 improved by 3.17 points (95% CI [−4.63; −1.70]) and MIDAS by 13.45 points (95% CI [−22.01; −4.89]). Glucose data suggest that migraine patients have slightly increased mean glucose values compared to healthy controls, but drop into a glucose range that is below one’s individual standard range before a migraine attack. In conclusion, sinCephalea is a non-pharmacological, digital migraine prophylaxis that induces a therapeutic effect within the range of pharmacological interventions.

Characteristics and natural disease history of persistent idiopathic facial pain, trigeminal neuralgia, and neuropathic facial pain

OBJECTIVE

This study aimed to characterize key features, and to assess the clinical development of common nondental facial pain syndromes such as persistent idiopathic facial pain (PIFP), trigeminal neuralgia (TN), and neuropathic facial pain (NEUROP).

METHODS

This is a longitudinal study in which prospective questionnaire data of patients presenting to a specialized outpatient clinic were collected from 2009 to 2019. A telephone interview was conducted with the same patients in 2020 to assess the natural disease history.

RESULTS

n = 411 data sets of patients with chronic facial pain were compiled. Among these were n = 150 patients with PIFP, n = 111 patients with TN, and n = 86 patients with NEUROP. Guideline therapy had not been initiated in 38.7% (58/150; PIFP), 19.8% (22/111; TN), and 33.7% (29/86; NEUROP) patients. Of the patients with PIFP, 99.3% (149/150) had primarily consulted a dentist due to their pain syndrome. The additional telephone interview was completed by 236 out of the 411 patients (57.4%). Dental interventions in healthy teeth had been performed with the intention to treat the pain in many patients (78/94 [83.0%] PIFP; 34/62 [54.8%] TN; 19/43 [44.2%] NEUROP), including dental extractions. 11.3% (7/43) of the patients with TN had never profited from any therapy. In contrast, 29.8% (28/94) of the patients with PIFP had never profited from any therapy. Furthermore, the primary pharmaceutical therapy options suggested by national guidelines were, depending on the substance class, only considered to be effective by 13.8% (13/94; antidepressants) and 14.9% (14/94; anticonvulsants) of the patients with PIFP.

CONCLUSIONS

Facial pain syndromes pose a considerable disease burden. Although treatment of TN seems to be effective in most patients, patients with PIFP and NEUROP report poor effectiveness even when following guideline therapy suggestions. In addition, unwarranted dental interventions are common in facial pain syndromes.

[Sumatriptan 3 mg subcutaneous : Clinical relevance of acute treatment of migraine despite dose reduction]

BACKGROUND

Triptans are a highly effective substance class in the acute treatment of migraine attacks. They contribute to a substantial improvement in the quality of life and help to reduce the socioeconomic burden of the disease.

RESULTS

Sumatriptan is the only triptan that is available for subcutaneous administration. It is primarily indicated in patients with the need for rapid relief or insufficient enteral resorption due to nausea and vomiting. In the treatment of migraine attacks with 6 mg subcutaneous sumatriptan the number needed to treat (NNT) is 2.3 for freedom from pain within 2 h and the NNT is 2.1 for pain relief within 2 h; however, the fast resorption of sumatriptan after subcutaneous administration induces more side effects than the oral route, for example dizziness, paresthesia or chest pressure sensation.

CONCLUSION

Clinical studies showed that reducing the subcutaneous dose to 3 mg in migraine treatment has significantly better tolerability with high response rates and freedom from pain within 2 h with 66.7% (3 mg) or 50% (6 mg).

The New National Headache Management System is an easy solution to provide more efficient and evidence-based headache services

Headaches make up 30% of all Neurology outpatient consultations.1 There is distinct variability in the management of headaches by Neurologists, leading to unnecessary disparities in the standard of care and likelihood of response between patients. A significant proportion of patients with headache diagnoses do not receive the evidence-based treatments recommended in national or international guidelines,2 and substantial numbers of patients are not receiving preventive therapies.3  Ziegeler et al. found that a third of patients reporting to a tertiary headache centre had not received preventive therapy in line with guidelines, and half had never been prescribed a preventive treatment.2 Considering that 46% of the global adult population are estimated to have a headache disorder,4 this lack of a consistent, evidence-based approach is somewhat incongruent with the patient socio-economic impact. It is probable that lack of adherence to current headache guidelines is a multi-faceted issue. This variation in treatment (and therefore patient outcome), although unexplored,2 is not likely to be a simple educational issue. To add to this, an educational approach, in the form of seminars and workshops, does not have entirely positive evidence to support its use in implementing changes to patient care.5  It seems more probable that there are also structural issues within the health service that in some way preclude patients with headache disorders from gaining appropriate care.  For example, using only doctors to care for patients with such a common condition may cause bottle-necking in access, and may not be an appropriate use of clinical resource.  The current context of a global pandemic has shown us the importance of using the skillsets of all NHS staff working together for patient care.  For headache care this could involve greater use of nursing colleagues or allied health professionals such as Pharmacists. To facilitate such an aim, an easily used and standardised approach is essential. We believe that the guidelines from the British Association for the Study of Headache (BASH),6 could facilitate such an approach.

Treatment Realities of Headache Disorders in Rural Germany by the Example of the Region of Western Pomerania

(1) Background: Headache disorders are among the most disabling medical conditions but the supply with experienced providers is outpaced by the demand for service. It is unclear to what extent particularly patients in rural regions are affected by limited access to comprehensive care. Furthermore, it is unknown what role general practitioners (GPs) play in headache care. (2) Methods: First-time consultations to a specialised headache clinic at a tertiary care centre were asked to participate. Their socio-demographic background, general and headache-specific medical history, disability and quality of life (QoL) were assessed. Additionally, 176 GPs in neighbouring districts were contacted regarding headache management. (3) Results: We assessed 162 patients with first-time consultations (age 46.1 ± 17.0 years, 78.1% female), who suffered from migraine (72%), tension type, cluster and secondary headaches (each 5-10%). About 50% of patients received a new headache-diagnosis and 60% had treatment inconsistent with national guidelines. QoL was significantly worse in all domains compared to the general population. About 75% of GPs see headache patients at least several times per week, and mostly treat them by themself. (4) Conclusions: More than every second headache patient was neither correctly diagnosed nor received guideline adherent treatment. Headache-related disability is inferior to what is expected from previous studies. Access to specialised health care is more limited in rural than in urban regions in Germany and GPs request more training.

Facial pain beyond trigeminal neuralgia

PURPOSE OF REVIEW

Trigeminal neuralgia is a well-known facial pain syndrome with several treatment options. In contrast, non-neuralgiform idiopathic facial pain syndromes are relatively rare, reflected by the fact that, until 2020, no internationally accepted diagnostic classification existed. Like trigeminal neuralgia, these non-dental facial pain syndromes need to be managed by neurologists and pain specialists, but the lack of pathophysiological understanding has resulted in an underrepresented and undertreated patient group.

RECENT FINDINGS

This work provides a brief overview of the most common primary facial pain syndromes, namely, the facial attack-like facial pain, which corresponds to attack-like headache, the persistent idiopathic facial pain (formerly 'atypical facial pain'), and trigeminal neuropathy. What these disorders have in common is that they should all be treated conservatively.

SUMMARY

On the basis of pragmatic classifications, permanent and attack-like primary facial pain can be relatively easily differentiated from one another. The introduction of the new International Classification of Orofacial Pain offers the opportunity to better coordinate and concentrate scientific efforts, so that in the future the therapy strategies that are still inadequate, can be optimized.

Translation and validation of an extended German version of ID Migraine™ as a migraine screening tool

Background and purpose:

Diagnosing a patient with headache as a migraineur is critical for state-of-the-art migraine management. Screening tools are imperative means to improve the diagnostic yield in the primary care settings and specialized clinics. This study aims to translate and assess the diagnostic accuracy of a German version of the ID Migraine™ as a widely used and efficient screening instrument.

Methods:

The Functional Assessment of Chronic Illness Therapy translation methodology was used to translate the original three-item ID Migraine™, including a fourth question for aura, from the English language into the German language. Diagnostic accuracy of the German ID Migraine™ and predictors of false screening results were assessed among patients presenting to a headache outpatient clinic of a tertiary care center in Germany over a 6-month period.

Results:

The translation procedure yielded a harmonized German ID Migraine™ and its diagnostic accuracy was assessed in 105 patients (80 female, 46.5 ± 17.2 years of age), including 79 patients (75.2%) with migraine. The three-item German ID Migraine™ provides a sensitivity of 99%, specificity of 68%, and positive and negative predictive values of 90% and 95%, respectively, using a cutoff of ≥2. Positive and negative predictive values in a general headache population are estimated to be 74% and 98%, respectively. The aura question identified 18 out of 20 migraineurs with aura.

Conclusions:

The German ID Migraine™ is an accurate screening tool for migraine even in a challenging population of a specialized outpatient clinic. Its diagnostic accuracy indicates a potential utility for screening in primary health care.

Estimating the savings associated with a migraine-free life: results from the Spanish Atlas

BACKGROUND AND PURPOSE

Migraine is a common and costly neurological disorder. The aims of this study were to quantify the costs of chronic (CM) and episodic migraine (EM) in Spain, evaluating the impact of psychiatric comorbidities and disability, and to estimate the economic savings associated with reducing the number of migraine-days by 50%.

METHODS

This was an observational, cross-sectional analysis of data from migraine patients who participated in the Spanish Migraine Atlas. The participants were invited to complete a structured questionnaire including the following scales: the Headache Needs Assessment, the Hospital Anxiety and Depression Scale, and the Migraine Disability Assessment Scale (MIDAS).

RESULTS

A total of 475 patients were included, of whom 187 had CM (39.4%). Total costs per patient/year were: €16 578.2 ± €34 568.1 for CM and €6227.8 ± €6515.7 for EM. A higher degree of disability, according to MIDAS, significantly increased the total cost of migraine, while the presence of psychiatric comorbidity increased costs for EM patients only. A reduction of 1 migraine-day per month decreased average total costs by €744.14 per patient/year for EM and €663.20 per patient/year for CM, while a reduction in the number of migraine-days by 50% would result in economic savings of €2232.44 per patient/year (R²  = 0.927) for EM and €6631.99 per patient/year (R²  = 0.886) for CM.

CONCLUSIONS

The costs associated with migraine were driven by migraine frequency and the degree of disability, whereas psychiatric comorbidity only influenced the cost of EM. These results highlight the need to optimize migraine management to reduce the economic migraine burden. Future studies are needed to confirm our results.

[Migraine in childhood and adolescence-neurostimulation as a future innovative approach in terms of a multimodal treatment regimen]

Although migraine is a relevant health issue in children and adolescents, clinical care and research are still underrepresented and underfunded in this field. Quality of life can be significantly reduced when living with frequent episodes of pain. Due to the high level of vulnerability of the developing brain during adolescence, the risk of chronification and persistence into adulthood is high. In this narrative review, we describe the corner stones of a patient-centered, multimodular treatment regimen. Further, an update on the pathophysiology of migraine is given considering the concept of a periodically oscillating functional state of the brain in migraine patients ("migraine is a brain state"). Besides central mechanisms, muscular structures with the symptoms of muscular pain, tenderness, or myofascial trigger points play an important role. Against this background, the currently available nonpharmacological and innovative neuromodulating approaches are presented focusing on the method of repetitive peripheral magnetic stimulation.

Administrative prevalence and incidence, characteristics and prescription patterns of patients with migraine in Germany: a retrospective claims data analysis

Background

Migraine is a frequent headache disorder with high disease burden. The aims of this study were to determine the administrative prevalence and incidence of migraine in Germany; and to elucidate disease characteristics, prescription patterns and the patient journey through the German healthcare system.

Methods

In this retrospective, observational study, adult patients with migraine (International Classification of Diseases, 10th revision, German modification G43) were identified in the anonymised German Company Sickness Fund database (CSFD) from 2008 through 2016. The administrative prevalence and incidence of migraine were calculated for the total CSFD study population and extrapolated to the German Statutory Health Insurance (SHI) population. Migraine subtypes, concurrent diagnoses, prescription patterns and visited healthcare professional groups were analysed.

Results

A total of 243,471 patients with migraine were identified in the CSFD (2008–2016); 78.0% were female and 45.3% were aged 35–54 years. The administrative prevalence of migraine, extrapolated to the SHI population, ranged between 2.89% in 2008 and 3.98% in 2016; administrative incidence ranged from 0.587% in 2009 to 0.267% in 2016, and varied between 0.399% and 0.442% during 2011 to 2015. Overall, 29.1% of patients received at least one prescription for any preventive medication listed in the German guideline. Only 7.9% received the same preventive medication for more than 1 year, with 82.9% of these patients discontinuing the medication before study end. Regarding acute medications, 74.2% of prescriptions were for analgesics/non-steroidal anti-inflammatory drugs and 21.2% were for triptans. General practitioners most commonly diagnosed and treated migraine in the CSFD population. Patients with prescriptions for two or more different preventive therapy classes had higher use of acute and emergency medications, and visited healthcare professionals and hospitals more frequently than patients with no prescriptions or prescriptions for only one preventive therapy class.

Conclusions

The administrative prevalence of migraine in this claims database suggests many patients with migraine did not seek medical care. Of those who did, fewer than one-third received preventive medication, with most patients having been prescribed only one such medication and few having continued treatment beyond 1 year. These outcomes suggest there is scope for improvement in migraine management in Germany.

Burden of migraine in Finland: multimorbidity and phenotypic disease networks in occupational healthcare

BACKGROUND

Migraine is a complex neurological disorder with high co-existing morbidity burden. The aim of our study was to examine the overall morbidity and phenotypic diseasome for migraine among people of working age using real world data collected as a part of routine clinical practice.

METHODS

Electronic medical records (EMR) of patients with migraine (n = 17,623) and age- and gender matched controls (n = 17,623) were included in this retrospective analysis. EMRs were assessed for the prevalence of ICD-10 codes, those with at least two significant phi correlations, and a prevalence >2.5% in migraine patients were included to phenotypic disease networks (PDN) for further analysis. An automatic subnetwork detection algorithm was applied in order to cluster the diagnoses within the PDNs. The diagnosis-wise connectivity based on the PDNs was compared between migraine patients and controls to assess differences in morbidity patterns.

RESULTS

The mean number of diagnoses per patient was increased 1.7-fold in migraine compared to controls. Altogether 1337 different ICD-10 codes were detected in EMRs of migraine patients. Monodiagnosis was present in 1% and 13%, and the median number of diagnoses was 12 and 6 in migraine patients and controls. The number of significant phi-correlations was 2.3-fold increased, and cluster analysis showed more clusters in those with migraine vs. controls (9 vs. 6). For migraine, the PDN was larger and denser and exhibited one large cluster containing fatigue, respiratory, sympathetic nervous system, gastrointestinal, infection, mental and mood disorder diagnoses. Migraine patients were more likely affected by multiple conditions compared to controls, even if no notable differences in morbidity patterns were identified through connectivity measures. Frequencies of ICD-10 codes on a three character and block level were increased across the whole diagnostic spectrum in migraine.

CONCLUSIONS

Migraine was associated with an increased multimorbidity, evidenced by multiple different approaches in the study. A systematic increase in the morbidity across the whole spectrum of ICD-10 coded diagnoses, and when interpreting PDNs, were detected in migraine patients. However, no specific diagnoses explained the morbidity. The results reflect clinical praxis, but also undoubtedly, the pathophysiological phenotypes related to migraine, and emphasize the importance of better understanding migraine-related morbidity.