Health equity, care access and quality in headache - part 2

Menopause, Perimenopause, and Migraine: Understanding the Intersections and Implications for Treatment

Migraine affects women three times more often than it does men, and various mechanisms may explain this incidence, including the key role of female sex hormones. Fluctuations in the levels of these hormones and their feedback control regulate the menstrual cycle, pregnancy, puerperium, perimenopause, and menopause. They can influence the occurrence and severity of migraine throughout the reproductive period. Of particular importance seems to be the perimenopausal period, which is associated with an increase in migraine, especially menstrual migraine, which is considered more disabling and less amenable to treatment than non-menstrual attacks. This article reviews the available evidence documenting the relationship between perimenopause, menopause, and migraine and diagnostic considerations in an attempt to determine the management of these periods of a woman's life. Special considerations, future directions, and unmet needs for perimenopausal and menopausal migraine are also discussed.

Monthly Headaches and Severity in Patients on Galcanezumab or Traditional Preventive Migraine Medication: A 24-Month Claims and Electronic Health Records Study

INTRODUCTION

Migraine, affecting millions globally, imposes a significant burden on patients and healthcare systems. Calcitonin gene-related peptide monoclonal antibodies are recommended as first-line preventive treatments by international guidelines, yet real-world prospective studies comparing their year-long effectiveness to standard of care (SOC) treatments are time-consuming, resource-intense and therefore limited. This study aimed to test the utility of claims data and electronic health records (EHR) by evaluating changes in monthly headache days (MHDs) and disease severity among US patients with migraine receiving galcanezumab versus traditional standard-of-care preventive migraine medications.

METHODS

A real-world study was conducted using Optum data from US administrative claims and EHR of patients diagnosed with migraine and receiving galcanezumab or SOC. Changes in MHDs over a 24-month follow-up were converted from changes in acute medication using the Pharmacy Quality Alliance (PQA) measure for Migraine Preventive Therapy, and migraine severity was assessed using EHR free text. Data were analyzed using two-sample t-test, chi-square and Fisher exact tests.

RESULTS

Of 63,939 patients with eligible claims, 28,264 (44.2%) had notes in EHR; of those, 227 and 65 patients had information for migraine severity and headache days, respectively. Patients receiving galcanezumab showed significant improvement in MHDs compared to the SOC cohort when assessed using PQA measures (mean [SD] change from baseline to follow-up, - 0.18 [4.76] vs 0.15 [3.85]; p < 0.001). A significantly greater proportion of patients treated with galcanezumab exhibited a 50% reduction (25.9% vs 16.7%; p < 0.001) and 75% reduction (15.7% vs 11.6%; p < 0.001) in MHDs than the standard-of-care cohort. Mean change in migraine severity and MHDs was not determined by EHR because of low sample sizes.

CONCLUSION

In this exploration of multiple data sources and methodologies, changes in MHDs over 24 months were small in patients treated with galcanezumab or SOC. While real-world data from administrative claims and EHR provided insights, limitations such as small sample sizes for migraine severity data and challenges in extracting clinical outcomes underscore the need for further research.

Neurological Advocacy

Advocacy is an important part of the practice of neurology integral to optimal patient care and research. Opportunities exist for neurologists to further their engagement in advocacy outside of the office, and neurologists are well-positioned to share their knowledge and expertise as advocates. Many barriers to care, such as the cost of and access to prescription drugs, have an outsized impact on patients with neurological conditions, which underscores the importance of neurological advocacy. Advocacy opportunities span many different forms and range from local to global in scale. The benefits to a neurology career can be vast, from improved knowledge of health care systems to leadership opportunities, to networking among colleagues and community leaders, and enhanced academic profiles. Numerous resources are available for neurologists seeking further engagement in advocacy for their patients and profession.

Consulting, diagnosis and treatment patterns in migraine: results from the Migraine in Poland cross-sectional survey

Background

The Migraine in Poland study is a cross-sectional survey that assesses symptomatology, consulting, diagnosis, treatment and impact of migraine in Poland.

Objectives

The purpose of this article is to define patterns of care for migraine in Polish patients.

Methods

The survey was conducted from August 2021 to June 2022. Participants were recruited through various channels, targeting mostly persons suffering from headaches. The web survey included questions allowing for diagnosis according to the International Classification of Headache Disorders. A detailed questionnaire evaluated healthcare system utilization, history of diagnosis, as well as the use of acute or preventive treatment, including non-pharmacological methods.

Results

In total, 3225 individuals aged 13-80 (mean age 38.9) responded to the questionnaire (87.1% were women). Migraine without aura (MwoA) diagnosis was confirmed in 1679 (52.7%) of subjects, and 1571 (93.6%) of them consulted a medical professional for their headaches in the past. Among those who consulted for headache, 91% reported having received a medical diagnosis of migraine. 92.5% of MwoA participants declared the current use of some form of treatment. Non-steroidal anti-inflammatory drugs and acetaminophen were the most frequently used acute medications (n = 1318, 78.5%) followed by combination analgesics, especially those containing codeine (n = 991, 59%). Triptans/ergots were used by 57.1%. A total of 22.8% of subjects used acute treatment with a frequency indicating medication-overuse. Prophylactic treatment was at some point used by 35.68%, while 11.49% were currently on preventive medications. The most frequently prescribed preventives were iprazochrome (8.99%), followed by flunarizine (8.10%) and topiramate (5.90%). A total of 23.28% subjects used nutraceuticals for migraine prevention (most frequently magnesium).

Conclusion

Despite high consultation and diagnosis rates among Polish patients with migraine, there is a need for improving standards of care, especially in regard to choice of treatment. There is also a need to raise public awareness of the dangers of codeine-based medications (available over-the-counter in Poland).

Neuromodulation in Chronic Migraine: Evidence and Recommendations from the GRADE Framework

Chronic migraine (CM) affects approximately 2% of the general population and is defined by the persistence of migraine symptoms for at least 15 days per month for at least 3 months. CM is often refractory to common drug treatments and is associated with a significant burden in functions of daily life during ictal phases, productivity loss, and direct costs. Modulation of pain is considered pivotal to reduce its impact and to improve the quality of life among patients with CM. In recent years, neuromodulation in CM has received growing attention; however, there remains no consensus regarding the effectiveness and safety of these procedures. Previous invasive methods such as occipital nerve neurolysis and interruption of the trigeminal dorsal root are not indicated due to high rates of relapsing pain and frequent procedural complications. Although emerging neuromodulation methods, both noninvasive, such as vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), remote electrical neuromodulation (REM), and invasive, such as deep brain stimulation (DBS), occipital nerve stimulation (ONS), and high-frequency 10-Hz spinal cord stimulation (HF-10 SNS) have demonstrated promising outcomes in early clinical trials, their use has yet to be integrated into routine clinical practice. In this review, study evidence and strength of recommendations are assessed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Other conditions such as therapeutic risk/benefit, direct and indirect costs, use of resources, and patient/clinician preferences are also evaluated.

Differences in pharmacological migraine treatment across different levels of clinical headache care - a cross-sectional study

BACKGROUND

Migraine significantly impairs quality of life, reduces workplace productivity, and imposes a substantial socio-economic burden. The severity of migraine correlates with its impact on quality of life and healthcare costs, emphasizing the need for adequate management. In the past, primary care services often faced issues of inadequate treatment. This study evaluates differences in pharmacological recommendations for acute and preventive migraine treatments across primary, secondary, and tertiary care settings.

METHODS

This cross-sectional study involves patients with confirmed migraine (with or without aura) visiting the tertiary headache center at Charité Berlin between 12/2015 and 01/2023 for the first time. Data on headache characteristics and prior treatments for acute and prophylactic treatments at primary/secondary and recommendations from tertiary level of care were retrieved from medical letters written after first consultation.

RESULTS

Among 1,047 migraine patients (42 years, 84% women), 99% had received treatment for acute migraine attacks by primary/secondary care facilities, and 96% were using it at their first consultation, with 63% advised to use a triptan. The average number of triptans tested prior to referral was 1 ± 0.99. Prophylactic treatment was prescribed to 52% of patients by primary/secondary care facilities, with an average of 1.2 ± 1.6 prior prophylactic attempts per patient, and 44% were actively using it at the time of consultation. More than two thirds of patients with over four monthly migraine days were not using prophylactic treatment at referral. Tricyclic antidepressants, beta-blocker and, anticonvulsants were prescribed significantly more often in primary/secondary care settings while Onabotulinumtoxin-A and Calcitonin Gene-Related Peptide(-receptor) antibodies were more commonly initiated in tertiary care. Treatment recommendations from primary/secondary settings were revised in 77% of patients following consultation at the tertiary headache clinic.

CONCLUSION

Compared to previous studies, the overall prescription of acute and prophylactic therapies in primary and secondary care facilities has improved. Further progress is needed in expanding the range of triptans and prophylactic treatments tested before referring patients to specialized centers. However, given the selected study population, the findings may not be fully applicable to all patients treated in primary/secondary care, especially those already receiving adequate care without being referred to specialized settings.

Mobile App-Based Interactive Care Plan for Migraine: Survey Study of Usability and Improvement Opportunities

Background

We implemented a novel mobile app-based Migraine Interactive Care Plan (MICP) integrated with our electronic health records (EHRs). The MICP facilitates remote assessment of adult patients with migraine, educational content delivery, and care team communication. Feasibility of the MICP was demonstrated in a pilot implementation study.

Objective

We aimed to assess the preferences and satisfaction of patients with migraine users of a mobile app-based care plan integrated with the EHR.

Methods

An electronic survey was administered to a single cohort of MICP users between December 6, 2021, and December 30, 2021. The survey assessed patient preferences for which data to track, frequency of tracking, and satisfaction with the MICP. Survey responses were compared between subsets determined by patient-reported headache frequency and treatment with and without botulinum toxin and calcitonin gene-related peptide (CGRP) antagonist therapy. The Wilcoxon rank-sum test was used for continuous variables and the χ2 test or Fisher exact test for categorical variables.

Results

The total sample size was 184 and the survey response rate was 30.4% (56/184). No significant differences in age (P=.26) or sex (P=.19) between respondents and nonrespondents were observed. Respondent median age was 42 (range 20-72) years and 94.6% (53/56) were female. Headache frequency was (1) 0 to 8 days (26/56, 46.4%), (2) 9 to 14 days (12/56, 21.4%), and (3) 15 or more days (18/56, 32.1%). No difference was observed in any survey responses based on headache frequency or treatment. The majority of respondents preferred to track headache days weekly (30/56, 53.6%) or daily (15/56, 26.8%) and preferred to change the frequency of headache tracking reminders (42/56, 75%). Respondents were somewhat or very interested in daily tracking personal observations in free text (41/52, 78.8%), medication treatment (43/52, 82.7%) and treatment response (39/56, 69.6%), class of medication treatment (36/52, 69.2%), severity of functional impairment (39/56, 69.6%), type of functional impairment (35/53, 66%), headache day (40/54, 74.1%), and headache pain level on a scale of 1 to 10 (38/53, 71.7%). Respondents agreed or strongly agreed that the education content was useful (31/51, 60.8%) but lacked personalization (25/51, 49%). Most respondents agreed or strongly agreed that they were satisfied with the MICP (38/50, 76%) and that it helped them communicate with their care team (38/53, 71.7%).

Conclusions

Most MICP users were motivated to track headache frequency, medication treatment with response, functional impairment, and pain intensity. Opportunities to improve the MICP include (1) allowing patients to change the frequency of assessments and notifications; (2) recording personal observations or comments through free text, which may include headache triggers; (3) assessment of headache severity using a 1 to 10 pain scale; and (4) tailoring headache education based on frequency and severity (episodic vs chronic migraine). These observations may be useful to improve the usability of the MICP and similar EHR-integrated migraine care platforms that others may develop.

Calcitonin gene-related peptide-targeted therapy in migraine: current role and future perspectives

Almost 40 years ago, the discovery of the vasoactive neuropeptide calcitonin gene-related peptide (CGRP) and its role in migraine pathophysiology ushered in a new era in migraine treatment. Since 2018, monoclonal antibodies (mAbs) targeting the CGRP pathway are available for migraine prevention. The approval of these drugs marks a pioneering development, as they are the first pharmacological agents specifically tailored for migraine prevention. Introduction of these agents contrasts the historical reliance on traditional preventive medications initially formulated for other indications and later repurposed for migraine therapy. Although the emergence of evidence on the efficacy and safety of CGRP-targeted mAbs has raised the bar for treatment success in migraine, their efficacy in other headache entities, such as cluster headache, is low to moderate. Small-molecule CGRP receptor antagonists called gepants have also been proven to be effective both as acute and preventive migraine treatments. Furthermore, these agents have bridged the traditional categories of acute and preventive treatment strategies. Short-term prevention and treatment during the prodromal phase of migraine represent emerging strategies enabling clinicians to develop treatment approaches designed to meet changing patient needs; however, these strategies still require more formal evidence. Although solid data have been gathered, further research concerning the efficacy and long-term safety of drugs targeting the CGRP pathway and robust pharmacoeconomic evaluations are needed. Finally, randomised withdrawal and switching studies would facilitate the formulation of evidence-based guidance for the discontinuation of and switching between drugs targeting the CGRP pathway.

Trends in migraine and tension-type headaches in South Asia: findings from the Global Burden of Disease Study 2021 (1990-2021)

Background

Headache disorders, including migraines and tension-type headaches (TTH), are major contributors to global disability. In South Asia, where these conditions are often underdiagnosed, their burden has grown substantially. This study evaluates trends in headache disorders across eight South Asian countries from 1990 to 2021, using data from the Global Burden of Disease (GBD) Study 2021.

Methods

Data from the GBD study were analysed to evaluate incidence, prevalence, and years lived with disability (YLDs) for headache disorders and their subtypes. Trends were assessed using absolute numbers and age-standardized rates, with demographic patterns by age and gender examined to identify vulnerable populations. Joinpoint regression analysis was employed to detect significant temporal shifts.

Results

From 1990 to 2021, headache disorders in South Asia rose from 114.2 million to 206.8 million in incidence, and from 367.4 million to 698.5 million in prevalence, with YLDs nearly doubling from 6.0 million to 11.6 million. Migraines accounted for 294.4 million cases, while TTH contributed 495.4 million cases, with YLDs increasing by 92.88 and 99.35%, respectively. Afghanistan saw the highest relative growth, while India contributed the largest absolute burden. Women and middle-aged adults were disproportionately affected, with the highest prevalence observed in females aged 30-34 years. The Maldives showed dramatic increases in TTH-related YLDs, highlighting disparities in smaller nations.

Conclusion

The rising burden of headache disorders in South Asia highlights the need for region-specific strategies targeting high-burden subtypes, countries, and vulnerable populations to mitigate their disabling impacts.

Evaluating headache referral trends and practices across different settings in neurology clinics: insights from an international cross-sectional multicenter study

BACKGROUND

Misdiagnoses often lead to suboptimal therapeutic approaches, making early and accurate diagnoses by experts crucial for effective headache management. This study primarily aims to investigate the referred patient profiles with headaches to optimize diagnostic and referral approaches.

METHODS

In this cross-sectional multicenter international study, sixty-nine neurologists from 13 countries evaluated headache patients referred to neurology clinics (NCs). Researchers recruited patients on different weekdays selected by the research randomizer program for five consecutive weeks in April and May 2022. The clinicians collected data on various factors such as age, sex, headache characteristics and accompanying symptoms using the Head-MENAA study questionnaire and the International Classification of Headache Disorders-3 (ICHD-3) criteria. Patients were grouped according to the settings as emergency services (ESs), other specialty clinics (OSCs) and private offices (POs) in which they were evaluated.

RESULTS

A total of 3722 individuals out of 12043 evaluated in NCs had headache complaints. Among them, 15.07% consisted of patients referred to neurology by these three different settings. 14.8% of them were referred from ESs, 16.58% from OSCs, and 68.64% were applied to POs. While there was not a significant difference between groups regarding the mean age, the proportion of male patients in the ESs (49.4%) was higher than those in OSCs (26.9%) and POs (23.1%) (p < 0.001). Headache severity was higher in the ESs and POs than in the OSCs and Neurology Outpatient Clinics (NOCs) (p < 0.001). Primary headaches were the reason for consultation in 89.2% of patients in the ESs, 90.3% of patients in OSCs and 93.5% of patients in POs, migraine without aura being the most common headache type in all groups.

CONCLUSIONS

This study suggests that preferences for admission and referral may vary based on demographic characteristics, types and severity of the headache, as well as accessibility and availability of different settings.

The incremental burden and healthcare resource utilization among people with migraine in Europe: Insights from the 2020 European National Health and Wellness Survey

BACKGROUND

Despite the high prevalence of migraine in Europe, there is limited research on the burden among people with migraine.

METHODS

This cross-sectional survey used patient-reported data from the 2020 European National Health and Wellness Survey in France, Germany, Italy, Spain, and the United Kingdom. The study assessed the sociodemographic characteristics, health-related quality of life, depression, work productivity and activity impairment, and healthcare resource utilization among matched samples of people with diagnosed migraine (n = 3985) and compared to a matched cohort without migraine (n = 7970). The study also analyzed the burden across migraine subgroups stratified by the number of migraine headache days.

RESULTS

Lower health-related quality of life, higher depression, increased work productivity and activity impairment, and higher healthcare resource utilization were reported among people with migraine and ≥1 migraine headache days compared to matched people without migraine (all p < 0.001). Additionally, the incremental burden was also observed across migraine subgroups (1-3, 4-7, 8-14, and ≥15 migraine headache days) irrespective of the use of prescription medication compared to the matched controls without migraine.

CONCLUSION

Migraine sufferers with ≥1 migraine headache days experienced worse productivity, lower quality of life, depression, and increased healthcare resource utilization than those without migraine, emphasizing the need for effective management strategies.

Evaluation of rimegepant utilization patterns and patient characteristics among new users: a United States administrative claims-based study

OBJECTIVE

To assess tablet utilization patterns and describe pre-treatment characteristics among new users of rimegepant.

BACKGROUND

Rimegepant is the only oral calcitonin gene-related peptide antagonist approved in the United States for both the acute and preventive treatment of migraine.

METHODS

We conducted a retrospective cohort study of people with migraine who initiated treatment with rimegepant using two US commercial claims databases (MarketScan and Optum). Patients (≥18 years old) with migraine who newly initiated rimegepant were included. Patients were stratified into two groups representing acute (quantity = 8) and prevention (quantity = 15 or 16) use cohorts. Baseline characteristics and medication use history were assessed on index and during the 365-day pre-index period. Rimegepant utilization periods were calculated based on days supplied and varying approaches to define use periods. Tablet quantity per 30 days was reported separately for both acute and prevention cohorts.

RESULTS

In MarketScan, a total of 14,037 rimegepant users were identified; 11,195 (79.8%) in the acute group and 1,880 (13.4%) in the prevention group. Rimegepant utilization for acute use was 4.9 ± 2.1 tablets per 30 days and for preventive use was 13.1 ± 7.7 tablets per 30 days. There was high baseline prevalence of triptan contraindications, warnings, and high cardiovascular risk, with a combined 46.2% meeting one or more of these criteria. Acute medication overuse was also common (25.1%) prior to rimegepant initiation. Results were consistent in the Optum database.

CONCLUSION

Our analysis provides the first real-world data available on tablet utilization and characteristics of new users of rimegepant.

Worldwide availability of medications for migraine and tension-type headache: A survey of the International Headache Society

BACKGROUND

In this study, we aimed to evaluate the differing global access to acute and preventive medications for migraine and tension-type headache.

METHODS

A custom-built questionnaire created by members of the International Headache Society Juniors Group was sent to International Headache Society members worldwide, including a list of acute and preventive treatments for migraine and tension-type headache. This list was based on evidence-based medicine guidelines. For each treatment, participants were asked about availability, type of reimbursement and variability of access within their country.

RESULTS

Eighty-four members completed the questionnaire providing data for 84 countries. The majority were neurologists (88%) and worked at an academic/university hospital (62%). Of participants, 36% were located in high-income economy countries and 13% were located in low-income economies. Common preventive treatments such as propranolol and topiramate were available in most countries (respectively in 99% and 92% of responding countries). Sumatriptan was available in most countries (95%), whereas other triptan availability was lower. Novel migraine treatments such as rimegepant and erenumab were only available in 14% and 46% of the assessed countries, respectively.

CONCLUSIONS

Availability of headache medications, ranging from simple analgesics to novel therapies migraine-specific drugs, varied greatly across the world. Actions are needed to improve effective drug availability in many countries to ensure an adequate management of people living with headache.

Understanding the efficacy and tolerability of migraine treatment: a deep dive into CGRP antagonists

INTRODUCTION

The discovery of the role of the calcitonin gene-related peptide (CGPR) in migraine pathogenesis ushered in a new era in headache medicine. This evidence led to the development of small-molecule CGRP receptor antagonists and monoclonal antibodies targeting either CGRP or its receptor.

AREAS COVERED

We will present selected aspects of the role of CGRP in the pathogenesis of migraine, the efficacy of CGRP-targeted treatment, and the still-open questions regarding the practical application of CGRP antagonists in headache medicine.

EXPERT OPINION

CGRP-targeting drugs represent a transformative approach to migraine treatment, offering superior efficacy and tolerability compared to traditional therapies, they are a helpful addition to the treatment arsenal but also have their flaws and require further observation. Their availability provides new hope for migraine patients, particularly those who have not responded adequately to conventional treatments. Future directions for migraine care planning, especially for chronic migraine and medication-overuse headache, should include universal access to these specific and effective forms of therapy to prevent complications from the disease and its negative effects in many aspects of a patient's life.

Hallmarks of primary headache: part 1 - migraine

BACKGROUND AND AIM

Migraine is a common disabling conditions which, globally, affects 15.2% of the population. It is the second cause of health loss in terms of years lived with disability, the first among women. Despite being so common, it is poorly recognised and too often undertreated. Specialty centres and neurologists with specific expertise on headache disorders have the knowledge to provide specific care: however, those who do not regularly treat patients with migraine will benefit from a synopsis on the most relevant and updated information about this condition. This paper presents a comprehensive view on the hallmarks of migraine, from genetics and diagnostic markers, up to treatments and societal impact, and reports the elements that identify migraine specific features.

MAIN RESULTS

The most relevant hallmark of migraine is that it has common and individual features together. Besides the known clinical manifestations, migraine presentation is heterogeneous with regard to frequency of attacks, presence of aura, response to therapy, associated comorbidities or other symptoms, which likely reflect migraine heterogeneous genetic and molecular basis. The amount of therapies for acute and for prophylactic treatment is really wide, and one of the difficulties is with finding the best treatment for the single patient. In addition to this, patients carry out different daily life activities, and might show lifestyle habits which are not entirely adequate to manage migraine day by day. Education will be more and more important as a strategy of brain health promotion, because this will enable reducing the amount of subjects needing specialty care, thus leaving it to those who require it in reason of refractory condition or presence of comorbidities.

CONCLUSIONS

Recognizing the hallmarks of migraine and the features of single patients enables prescribing specific pharmacological and non-pharmacological treatments. Medical research on headaches today particularly suffers from the syndrome of single-disease approach, but it is important to have a cross-sectional and joint vision with other close specialties, in order to treat our patients with a comprehensive approach that a heterogeneous condition like migraine requires.

Headache disorders: a persistent public health challenge for the under 50s

Introduction

Currently, neurological diseases has surpassed cardiovascular diseases as the primary cause of global disease burden. Among these, headache disorders are the most prevalent and have emerged as the main cause of disability in people under 50 years old in recent years. Since the release of GBD 2021, there has been no comprehensive systematic exposition on the burden of headache among individuals under 50 years old and a forecast for future burdens. This study aims to quantify the global, regional, and national burden of headache disorders among people under 50 from 1992 to 2021 and to predict future trends in order to provide policy makers with precise and effective epidemiological evidence.

Methods

This study extracted the incidence, prevalence, and DALYs data related to headache disorders in the 5-50 age group from the GBD 2021. After age-standardizing the data, we used joinpoint regression analysis and health inequity analysis to analyze the burden and temporal trend of headache disorders and predicted the future disease burden and changes based on the age-period-cohort model.

Results

By 2021, the case number of global incidence, prevalence and DALYs have increased by 35, 39, and 41%, respectively, over the past 30 years. The incidence and prevalence of tension-type headache (TTH) are significantly higher than those of migraine, but migraine causes greater health burdens. The burden is higher for female than for male. In terms of age, youth aged 25-29 years had the highest incidence in 2021, with an age-standardized rate (ASR) of 13,454.64 (95%CI, 9,546.96-18,361.36) per 100,000 population. Nationally, the highest ASR of incidence and prevalence are found in Norway, and the most damaging to health is found in Belgium. Among the five sociodemographic index (SDI) categories, the middle SDI has the highest number of cases (190 million in 2021). It is worth noting that the forecast shows that by 2046 the three indicators will reach 680 million, 2.33 billion, and 41 million, respectively, indicating that the burden of headache disorders in this age group will continue to persist.

Conclusion

Globally, the burden of headache disorders in people under 50 years of age remains significant and has not improved over the past 30 years, especially in regions with high SDI. Headache problems will continue to pose a serious public health challenge for this age group for some time to come. This study reveals the burden and distribution of headache disorders in this age group, providing important basis for governments and policymakers to accurately and effectively allocate health care resources, strengthen prevention and management strategies, and respond to this global health problem.

Improvement in diagnostic-therapeutic care pathways for women with migraine: an Italian Delphi panel

Background

Migraine is a highly underestimated and burdensome disease. Real-world studies evidence that migraine is more frequent and severe in women than men. However, to this day, no diagnostic-therapeutic pathways exist to satisfy the specific needs of female patients.

Methods

In this study, migraine experts, specialists in women's health, patient, and decision makers, analyzed the diagnostic and therapeutic options for women with migraine across various ages and health conditions within the Italian healthcare system. A Delphi approach was used to formulate statements and achieve a consensus.

Results

Gaps in clinical practice were identified, and strategies to accommodate women's needs were proposed. The experts agreed that a socio-behavioral intervention should be planned before any pharmacological treatment in pediatric/adolescent female patients and that the assessment of migraine with aura is considered crucial for adult women requiring contraceptive therapy. Acupuncture emerged as an effective treatment for pregnant and breastfeeding women, and hormone-replacement therapy selection in menopausal patients requires careful consideration to mitigate safety risks. The experts highlighted the absence of literature and guidelines for the management of migraine in women undergoing assisted reproductive procedures or oncological treatment. In light of these observations, the experts advocated the establishment of multidisciplinary collaborations between neurologists/headache specialists and other healthcare professionals, including general practitioners, pediatricians, gynecologists, and oncologists. Comprehensive migraine education for all healthcare professionals potentially involved in managing the disease, including pharmacists, was emphasized. Efforts to increase migraine awareness among women should be prioritized.

Conclusion

The insights gained from this Italian consensus study should serve to develop an improved, female-specific pathway to diagnose and treat migraine.

Characterizing barriers to care in migraine: multicountry results from the Chronic Migraine Epidemiology and Outcomes - International (CaMEO-I) study

OBJECTIVE

To assess rates of traversing barriers to care to access optimal clinical outcomes in people with migraine internationally.

BACKGROUND

People in need of medical care for migraine should consult a health care professional knowledgeable in migraine management, obtain an accurate diagnosis, and receive an individualized treatment plan, which includes scientific society guideline-recommended treatments where appropriate.

METHODS

The Chronic Migraine Epidemiology and Outcomes-International (CaMEO-I) Study was a cross-sectional, web-based survey conducted from July 2021 through March 2022 in Canada, France, Germany, Japan, the United Kingdom, and the United States (US). Respondents who met modified International Classification of Headache Disorders, 3rd edition, criteria for migraine and had Migraine Disability Assessment Scale (MIDAS) scores of ≥ 6 (i.e., mild, moderate, or severe disability) were deemed to need medical care and were included in this analysis. Minimally effective treatment required that participants were currently consulting a health care professional for headache (barrier 1), reported an accurate diagnosis (barrier 2), and reported use of minimally appropriate pharmacologic treatment (barrier 3; based on American Headache Society 2021 Consensus Statement recommendations). Proportions of respondents who successfully traversed each barrier were calculated, and chi-square tests were used to assess overall difference among countries.

RESULTS

Among 14,492 respondents with migraine, 8,330 had MIDAS scores of ≥ 6, were deemed in need of medical care, and were included in this analysis. Current headache consultation was reported by 35.1% (2926/8330) of respondents. Compared with the US, consultation rates and diagnosis rates were statistically significantly lower in all other countries except France where they were statistically significantly higher. Total appropriate treatment rates were also statistically significantly lower in all other countries compared with the US except France, which did not differ from the US. All 3 barriers were traversed by only 11.5% (955/8330) of respondents, with differences among countries (P < 0.001).

CONCLUSIONS

Of people with migraine in need of medical care for migraine, less than 15% traverse all 3 barriers to care. Although rates of consultation, diagnosis, and treatment differed among countries, improvements are needed in all countries studied to reduce the global burden of migraine.

TRIAL REGISTRATION

NA.

Treatment patterns of patients with migraine eligible for anti-CGRP pathway monoclonal antibodies

Introduction

Migraine is a debilitating neurological disorder, with a wide range of symptoms and disease burden, underscoring the heterogeneity of patients' disease characteristics and treatment needs. To characterize the profile of migraine patients in the US who may be eligible for preventive treatment with an anti-CGRP pathway mAb and to better understand treatment patterns and real-world use of acute and preventive medications for migraine, we conducted a retrospective cohort study of adult patients.

Methods

These patients were identified as having migraine using diagnosis codes or migraine-specific medication use (first = index) in the IQVIA PharMetrics® Plus database. Patients were required to have ≥ 12 months of continuous enrollment in medical and pharmacy benefits prior to index (baseline) and after index (follow-up). Patients were stratified into chronic migraine (CM) and non-chronic migraine (non-CM) by diagnosis codes. Based on acute migraine-specific medication dispensing data in the follow-up period, non-CM patients were divided into 3 cohorts: highest, middle, and lowest tertile of total units of dispensed acute migraine-specific medication (gepants, ditans, ergot derivatives, and triptans). Migraine medication use was captured in the baseline and follow-up periods.

Results

A total of 22,584 CM and 216,807 non-CM patients (72,269 patients in each tertile) were identified and included in the study. Over the follow-up, CM patients had a mean of 70 units of acute migraine-specific medications dispensed, while the highest, middle, and lowest tertile of non-CM patients had a mean of 92, 29, and 10 units, respectively. Anti-calcitonin gene-related peptide pathway mAbs were dispensed for 28.9% of CM patients, and for 6.9%, 4.1%, and 2.9% of non-CM patients in the highest, middle, and lowest tertiles, respectively.

Conclusion

A lower proportion of non-CM patients had use of anti-calcitonin gene-related peptide pathway mAbs compared to CM patients, confirming the unmet need with appropriate preventive medication. There appears to be a persistent gap in management of patients without a diagnosis of CM who are dispensed high quantities of acute migraine-specific medications.

Cost Effectiveness of Fremanezumab in Episodic and Chronic Migraine Patients from a Japanese Healthcare Perspective

BACKGROUND AND OBJECTIVES

Fremanezumab is an effective treatment for episodic (EM) and chronic migraine (CM) patients in Japan, but its cost effectiveness remains unknown. The objective of this study was to determine the cost effectiveness of fremanezumab compared with standard of care (SOC) in previously treated EM and CM patients from a Japanese healthcare perspective.

METHODS

Estimated regression models were implemented in a probabilistic Markov model to inform effectiveness and health-related quality-of-life data for fremanezumab and SOC. The model was further populated with data from the literature. The adjusted Japanese healthcare perspective included productivity losses. The main model outcomes were quality-adjusted life-years (QALYs), costs (2022 Japanese Yen [¥]), and incremental outcomes including the incremental cost-effectiveness ratio (ICER). Analyses were performed separately for the EM and CM patients and combined. Costs and effects were discounted at an annual rate of 2.0%.

RESULTS

The mean QALYs over a 25-year time horizon for the EM and CM populations combined were 13.03 for SOC and 13.15 for fremanezumab. The associated costs were ¥27,550,292 for SOC and ¥28,371,048 for fremanezumab. QALYs were higher and costs lower for EM patients compared with CM patients for both fremanezumab and SOC. The deterministic ICERs of fremanezumab versus SOC were ¥6,334,861 for EM, ¥7,393,824 for CM, and ¥6,530,398 for EM and CM combined. Indirect costs and choice of mean migraine days model distribution had a substantial impact on the ICER.

CONCLUSION

Using fremanezumab in a heterogeneous mixture of Japanese EM and CM patients resulted in a reduction of monthly migraine days and thus more QALYs compared with SOC. The cost effectiveness of fremanezumab versus SOC in EM and CM patients resulted in an ICER of ¥6,530,398, from an adjusted Japanese public healthcare perspective.

Revolutionizing migraine management: advances and challenges in CGRP-targeted therapies and their clinical implications

Migraine, a prevalent neurological disorder, affects approximately 14.1% of the global population and disproportionately impacts females. This debilitating condition significantly compromises quality of life, productivity, and incurs high healthcare costs, presenting a challenge not only to individuals but to societal structures as a whole. Despite advances in our understanding of migraine pathophysiology, treatment options remain limited, necessitating ongoing research into effective therapies. This review delves into the complexity of migraine management, examining the roles of genetic predisposition, environmental influences, personalized treatment approaches, comorbidities, efficacy and safety of existing acute and preventive treatments. It further explores the continuum between migraine and tension-type headaches and discusses the intricacies of treating various migraine subtypes, including those with and without aura. We emphasize the recent paradigm shift toward trigeminovascular activation and the release of vasoactive substances, such as calcitonin gene-related peptide (CGRP), which offer novel therapeutic targets. We assess groundbreaking clinical trials, pharmacokinetic and pharmacodynamic perspectives, safety, tolerability, and the real-world application of CGRP monoclonal antibodies and gepants. In the face of persisting treatment barriers such as misdiagnosis, medication overuse headaches, and limited access to specialist care, we discuss innovative CGRP-targeted strategies, the high cost and scarcity of long-term efficacy data, and suggest comprehensive solutions tailored to Turkiye and developing countries. The review offers strategic recommendations including the formulation of primary care guidelines, establishment of specialized outpatient clinics, updating physicians on novel treatments, enhancing global accessibility to advanced therapies, and fostering patient education. Emphasizing the importance of lifestyle modifications and holistic approaches, the review underscores the potential of mass media and patient groups in disseminating critical health information and shaping the future of migraine management.

The influence of factors associated with past reproductive histories on migraines in middle-aged premenopausal women: a nationwide population-based study in Republic of Korea

Introduction

Women can experience various reproductive events, such as pregnancy, childbirth, lactation, and contraception, which cause long-term changes in female hormones. In middle-aged women, the prevalence of migraine is high, and a clear gender difference is evident. This study investigated the effects of factors associated with past reproductive events on the risk of new migraine in middle-aged premenopausal women.

Methods

The influence of reproductive factors on migraine in middle-aged women was investigated using the Korean National Health Insurance Service (KNHIS) and Korean Health Examination (KHE) databases. The reproductive factors of interest were parity, breastfeeding, and oral contraceptive (OC) use. The study included 949,704 middle-aged premenopausal women 40-60 years of age. The study population was divided into two groups based on new diagnosis of migraine during the follow-up period (2009-2018).

Results

The risk of new migraine tended to increase in the primiparous (hazard ratio, HR: 1.179; 95% confidence interval, CI: 1.137-1.221) and multiparous groups (HR: 1.181; 95% CI: 1.142-1.221) compared with the nulliparous group. The breastfeeding ≥12 months group (HR: 1.071; 95% CI: 1.052-1.091) showed a significantly increased risk of new migraine compared with the non-breastfeeding group. All women in the OC groups (< 1 year, HR: 1.048; 95% CI: 1.028-1.069 and ≥ 1 year, HR: 1.100; 95% CI: 1.067-1.134) showed a higher risk of new migraine than those in the non-OC group.

Conclusion

The results of the current study indicate that childbirth, longer breastfeeding, and OC use may be associated with a higher risk of new migraine in middle-aged premenopausal women.

Global, regional, and national burden and trends of migraine among women of childbearing age from 1990 to 2021: insights from the Global Burden of Disease Study 2021

BACKGROUND

Migraine, a neurological disorder with a significant female predilection, is the leading cause of disability-adjusted life years (DALYs) in women of childbearing age (WCBA). There is currently a lack of comprehensive literature analysis on the overall global burden and changing trends of migraines in WCBA.

METHODS

This study extracted three main indicators, including prevalence, incidence, and DALYs, related to migraine in WCBA from the Global Burden of Disease(GBD) database from 1990 to 2021. Our study presented point estimates with 95% uncertainty intervals (UIs). It evaluated the changing trends in the burden of migraine in WCBA using the estimated annual percentage change (EAPC) and percentage change.

RESULTS

In 2021, the global prevalence, incidence, and DALYs cases of migraine among WCBA were 493.94 million, 33.33 million, and 18.25 million, respectively, with percentage changes of 48%, 43%, and 47% compared to 1990. Over the past 32 years, global prevalence rates and DALYs rates globally have increased, with an EAPC of 0.03 (95% UI: 0.02 to 0.05) and 0.04 (95% UI: 0.03 to 0.05), while incidence rates have decreased with an EAPC of -0.07 (95% UI: -0.08 to -0.05). Among the 5 Socio-Demographic Index (SDI) regions, in 2021, the middle SDI region recorded the highest cases of prevalence, incidence, and DALYs of migraine among WCBA, estimated at 157.1 million, 10.56 million, and 5.81 million, respectively, approximately one-third of the global total. In terms of age, in 2021, the global incidence cases for the age group 15-19 years were 5942.5 thousand, with an incidence rate per 100,000 population of 1957.02, the highest among all age groups. The total number of migraine cases and incidence rate among WCBA show an increasing trend with age, particularly in the 45-49 age group.

CONCLUSIONS

Overall, the burden of migraine among WCBA has significantly increased globally over the past 32 years, particularly within the middle SDI and the 45-49 age group. Research findings emphasize the importance of customized interventions aimed at addressing the issue of migraines in WCBA, thus contributing to the attainment of Sustainable Development Goal 3 set by the World Health Organization.

Trends and prescribing patterns of antimigraine medicines in nine major cities in China from 2018 to 2022: a retrospective prescription analysis

BACKGROUND

The objective of this study was to investigate the trends and prescribing patterns of antimigraine medicines in China.

METHODS

The prescription data of outpatients diagnosed with migraine between 2018 and 2022 were extracted from the Hospital Prescription Analysis Cooperative Project of China. The demographic characteristics of migraine patients, prescription trends, and corresponding expenditures on antimigraine medicines were analyzed. We also investigated prescribing patterns of combination therapy and medicine overuse.

RESULTS

A total of 32,246 outpatients who were diagnosed with migraine at 103 hospitals were included in this study. There were no significant trend changes in total outpatient visits, migraine prescriptions, or corresponding expenditures during the study period. Of the patients who were prescribed therapeutic medicines, 70.23% received analgesics, and 26.41% received migraine-specific agents. Nonsteroidal anti-inflammatory drugs (NSAIDs; 28.03%), caffeine-containing agents (22.15%), and opioids (16.00%) were the most commonly prescribed analgesics, with corresponding cost proportions of 11.35%, 4.08%, and 19.61%, respectively. Oral triptans (26.12%) were the most commonly prescribed migraine-specific agents and accounted for 62.21% of the total therapeutic expenditures. The proportion of patients receiving analgesic prescriptions increased from 65.25% in 2018 to 75.68% in 2022, and the proportion of patients receiving concomitant triptans decreased from 29.54% in 2018 to 21.55% in 2022 (both P <  0.001). The most frequently prescribed preventive medication classes were calcium channel blockers (CCBs; 51.59%), followed by antidepressants (20.59%) and anticonvulsants (15.82%), which accounted for 21.90%, 34.18%, and 24.15%, respectively, of the total preventive expenditures. Flunarizine (51.41%) was the most commonly prescribed preventive drug. Flupentixol/melitracen (7.53%) was the most commonly prescribed antidepressant. The most commonly prescribed anticonvulsant was topiramate (9.33%), which increased from 6.26% to 12.75% (both P <  0.001). A total of 3.88% of the patients received combined therapy for acute migraine treatment, and 18.63% received combined therapy for prevention. The prescriptions for 69.21% of opioids, 38.53% of caffeine-containing agents, 26.61% of NSAIDs, 13.97% of acetaminophen, and 6.03% of triptans were considered written medicine overuse.

CONCLUSIONS

Migraine treatment gradually converges toward evidence-based and guideline-recommended treatment. Attention should be given to opioid prescribing, weak evidence-based antidepressant use, and medication overuse in migraine treatment.

Rimegepant orally disintegrating tablet 75 mg for acute treatment of migraine in adults from China: a subgroup analysis of a double-blind, randomized, placebo-controlled, phase 3 clinical trial

BACKGROUND

Rimegepant orally disintegrating tablet (ODT), an oral small-molecule calcitonin gene-related peptide receptor antagonist, is indicated for acute and preventive treatment of migraine in the United States and other countries. Previously, a large clinical trial assessed the efficacy and safety of rimegepant ODT 75 mg for the acute treatment of migraine in adults living in China or South Korea. A post hoc subgroup analysis of this trial was performed to evaluate the efficacy and safety of rimegepant for acute treatment of migraine in adults living in China.

METHODS

Eligible participants were ≥ 18 years of age and had a ≥ 1-year history of migraine, with 2 to 8 attacks of moderate or severe pain intensity per month and < 15 headache days per month during the 3 months before screening. Participants self-administered rimegepant ODT 75 mg or matching placebo to treat a single migraine attack of moderate or severe pain intensity. The co-primary endpoints were pain freedom and freedom from the most bothersome symptom (MBS) at 2 h post-dose. Key secondary endpoints included pain relief at 2 h post-dose, ability to function normally at 2 h post-dose, use of rescue medication within 24 h post-dose, and sustained pain freedom from 2 to 24 h and 2 to 48 h post-dose. All p values were nominal. Safety was assessed via treatment-emergent adverse events (TEAEs), electrocardiograms, vital signs, and routine laboratory tests.

RESULTS

Overall, 1075 participants (rimegepant, n = 538; placebo, n = 537) were included in the subgroup analysis. Rimegepant was more effective than placebo for the co-primary endpoints of pain freedom (18.2% vs. 10.6%, p = 0.0004) and freedom from the MBS (48.0% vs. 31.8%, p <  0.0001), as well as all key secondary endpoints. The incidence of TEAEs was comparable between the rimegepant (15.2%) and placebo (16.4%) groups. No signal of drug-induced liver injury was observed, and no study drug-related serious TEAEs were reported in the rimegepant group.

CONCLUSIONS

A single dose of rimegepant 75 mg rimegepant was effective for the acute treatment of migraine in adults living in China, with safety and tolerability similar to placebo.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04574362 Date registered: 2020-10-05.

Health equity, care access and quality in headache - part 1

Current definitions of migraine that are based mainly on clinical characteristics do not account for other patient's features such as those related to an impaired quality of life, due to loss of social life and productivity, and the differences related to the geographical distribution of the disease and cultural misconceptions which tend to underestimate migraine as a psychosocial rather than neurobiological disorder.Global differences definition, care access, and health equity for headache disorders, especially migraine are reported in this paper from a collaborative group of the editorial board members of the Journal of Headache and Pain. Other components that affect patients with migraine, in addition to the impact promoted by the migraine symptoms such as stigma and social determinants, are also reported.