The presenting and prescribing patterns of migraine in an Australian emergency department: A descriptive exploratory study

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.

Epidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study

OBJECTIVE

To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs).

BACKGROUND

Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally.

METHODS

An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome.

RESULTS

We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526).

CONCLUSION

Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.

Analysis of treatment cost and persistence among migraineurs: A two-year retrospective cohort study in Pakistan

Objectives

The persistence pattern of anti-migraine drugs’ use among migraineurs is very low in the United States and different European countries. However, the cost and persistence of antimigraine drugs in Asian countries have not been well-studied. Hence, the present study aimed to evaluate the treatment cost and persistence among migraineurs in Pakistan.

Methods

Data from prescriptions collected from migraineurs who visited the Outpatient Department (OPD) of different public and private sector tertiary-care hospitals of Karachi, Pakistan were used to conduct this retrospective cohort study from 2017 to 2019. The minimum follow up period for each migraineur was about 12 months for persistence analysis while dropped-out patients data were also included in survival analysis as right censored data. Pairwise comparisons from Cox regression/hazards ratio were used to assess the predictors of persistence with the reference category of non-binary variables i.e. hazard ratio = 1 for low frequency migraineurs and NSAIDs users. Persistence with anti-migraine drugs was estimated using the Kaplan-Meier curve along with the Log Rank test.

Results

A total of 1597 patients were included in this study, 729 (45.6%) were male and 868 (54.3%) were female. Non-steroidal anti-inflammatory drugs (NSAIDs) were the most prescribed class of drug initially for all classes of migraineurs (26.1%). Of them, 57.3% of migraineurs discontinued their treatment, 28.5% continued while 14.8% were switched to other treatment approaches. Persistence with initial treatment was more profound in female (58.8%) patients compared to males while the median age of continuers was 31 years. The total cost of migraine treatment in the entire study cohort was 297532.5 Pakistani Rupees ($1901.1). By estimating the hazard ratios (HR) using the Cox regression analysis, it can be observed that patients with high frequency (HR, 1.628; 95%CI, 1.221–2.179; p<0.0001) migraine, depression (HR, 1.268; 95%CI, 1.084–1.458; p<0.0001), increasing age (HR, 1.293; 95%CI, 1.092–1.458; p<0.0001), combination analgesics (HR, 1.817; 95%CI, 0.841–2.725; p = 0.0004) and prophylaxis drugs (HR, 1.314; 95%CI, 0.958–1.424; p<0.0001) users were at a higher risk of treatment discontinuation. However, patients with chronic migraine (HR, 0.881; 95%CI, 0.762–0.912; p = 0.0002), epileptic seizure (HR, 0.922; 95%CI, 0.654–1.206; p = 0.0002), other comorbidities (HR, 0.671; 95%CI, 0.352–1.011; p = 0.0003) and users of triptan(s) (HR, 0.701; 95%CI, 0.182–1.414; p = 0.0005) and triptan(s) with NSAIDs (HR, 0.758; 95%CI, 0.501–1.289; p<0.0001) had more chances to continue their initial therapy.

Conclusion

Similar to western countries, the majority of migraineurs exhibited poor persistence to migraine treatments. Various factors of improved persistence were identified in this study.

An Evaluation of Medication Prescribing Patterns for Acute Migraine in the Emergency Department: A Scoping Review

Migraine is one of the leading causes of disability worldwide and patients with acute migraine frequently present to emergency departments (ED). The current literature suggests that ED treatment of migraine headache varies across institutions. Considering this, we conducted a scoping review to summarize trends in medication prescribing patterns for acute migraine treatment in the ED setting. Trends were evaluated for factors influencing treatment choices, with particular attention placed on opioids and migraine specific therapy. This scoping review was based on the Arksey and O’Malley methodological framework and included studies published between 1 January 2000 and 31 May 2020. 14 publications met the inclusion criteria. The most common classes of medication prescribed were anti-emetics or Non-steroidal anti-inflammatory drugs (NSAID), but rates varied between studies. There was a concerning trend towards an underutilization of triptans and overutilization of opiates. The use of specific clinical treatment goals (e.g., two-hour pain free freedom response) was also not evident. Additionally, 88% (n = 8) of the nine studies commenting on adherence to hospital or evidence-based guidelines stated that practices were non-adherent. Overall, the reviewed literature reveals treatment practices for acute migraine in the ED are heterogeneous and deviate from established international recommendations.

Overuse of opioids for acute migraine in an Australian emergency department

OBJECTIVE

Acute migraine is associated with significant personal, economic and work-related disability. Management guidelines advise the use of simple analgesia, triptans, chlorpromazine and anti-emetics based on severity, with avoidance of opioids. We aimed to determine consistency of prescribing patterns in our ED with national guidelines.

METHODS

We performed a retrospective cohort analysis of migraine presentations (ICD-10-AM G439) between 2012 and 2016. Exclusion criteria included migraine without headache, other primary headaches and secondary headaches. Demographic and prescribing data were extracted from medical records. Results have been reported as proportions.

RESULTS

Of 4769 headache presentations, the application of exclusion criteria led to a total of 744 patients who received a migraine diagnosis (G439). Most were female (558/744, 75%), young (mean age 36.4 years) and had a self-reported migraine history (558/744, 75%). There were 54 different medications prescribed. Paracetamol was more frequently prescribed (385/744, 52%) than aspirin (134/744, 18%). Opioid prescription occurred in nearly half of all presentations (345/744, 46%). Similar opioid prescriptions were also observed in those with a documented history of migraines (253/558, 45%). A minority of patients received triptans (51/744, 7%). Overall, a quarter of patients (189/744, 25%) received no guideline-recommended medications.

CONCLUSION

We observed considerable polypharmacy in ED migraine management with inconsistent prescribing patterns. Recommended medications were infrequently used and opioid use was common. Factors influencing prescribing patterns require further investigation in order to improve rates of guideline recommended treatment.

An Updated List of Neuromedicinal Plants of Pakistan, Their Uses, and Phytochemistry

BACKGROUND

Almost every region of Pakistan is stacked with a large number of medicinal plants. Due to high cost and unavailability of allopathic medicines for the neurological diseases, especially in rural areas, traditional healers prescribe phytotherapy for various neurological diseases like epilepsy, depression, anxiety, insomnia, Alzheimer, and migraine. Such treatments are considered to be most effective by the native people.

METHODS

The data was collected from articles published on medicinal plants of various districts of Pakistan, using article search engines like Medline, Pubmed, Web of Science, Science Direct, and Google Scholar. Also, information regarding various neurological uses and mode of applications of medicinal plants was obtained from traditional healers, folk medicine users, and local elderly people having knowledge of medicinal plants.

RESULTS

A total of 54 families were found to be used in various neurological diseases, of which the highest use was of Solanaceae (22.22%), Asteraceae (12.96%), Lamiaceae, Papaveraceae, and Poaceae, 9% each, and Caprifoliaceae, Cucurbitaceae, Rhamnaceae, and Rosaceae, 5.5% each. According to districts, 15% of plants that were effective in neurological affections were found in Bahawalpur, 11% in Swat, 8% in Muzaffarabad, 7% in Malakand, and 6% in Bahawalnagar, Dir, Gilgat, and Sarghoda each, with 5% in Dera ghazi khan and Jhelum each. According to the plant's habit, out of total of 103 plants, 61.15% were found to be herbs, 22.33% trees, 11.65% shrubs, and 4.85% climbers. According to the part used of plant, whole plant, leaves, fruits, roots, seeds, and flowers were found to be used 32.03%, 24.27%, 20.38%, 16.50%, 13.59%, and 11.65%, respectively. According to disease's types, 45.63% were found to be effective in insomnia, 31.06% in epilepsy 12.62% in depression, 6.80% in anxiety, 7.77% in hysteria, and 5.88% in migraine.

CONCLUSION

Taking into consideration this useful knowledge on medicinal properties of the plants for curing neurologic diseases, it is believed that research in areas of ethnomedicine and ethnopharmacology can bring auspicious results that have potential of adding value to the very rich natural resources of Pakistan. This study will help all the researchers from diverse backgrounds working on plants based medicine for neurological diseases.

Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury

BACKGROUND

Rapid and effective pain relief in acute traumatic limb injuries (ATLI) is one of the most important roles of emergency physicians. In these situations, opioid addiction is an important concern because of the dependency on opioids. The study aims to compare the effectiveness of intravenous (IV) fentanyl versus morphine in reducing pain in patients with opioid addiction who suffered from ATLI.

METHODS

In this double-blind randomized clinical trial, 307 patients with ATLI, who presented to the emergency department (ED) from February 2016 to April 2016, were randomly divided into two groups. One group (152 patients) received 0.1 mg/kg IV morphine. The other group (155 patients) received 1 mcg/kg IV fentanyl. Patients' demographic data, pain score at specific intervals, vital signs, side effects, satisfaction and the need for rescue analgesia were recorded.

RESULTS

Eight patients in the morphine group and five patients in the fentanyl group were excluded. Pain score in the fentanyl group had a significant decrease at 5-minute follow-up (P value=0.00). However, at 10, 30, and 60-minute follow-ups no significant differences were observed between the two groups in terms of pain score reduction. The rescue analgesia was required in 12 (7.7%) patients in the fentanyl group and in 48 (31.6%) patients in the morphine group (P value=0.00). No significant difference was observed regarding side effects, vital signs and patients' satisfaction between the two groups.

CONCLUSION

Fentanyl might be an effective and safe drug in opioid addicts suffering from ATLI.

The Role of Genetic Polymorphisms in Chronic Pain Patients

It is estimated that the total annual financial cost for pain management in the U.S. exceeds 100 billion dollars. However, when indirect costs are included, such as functional disability and reduction in working hours, the cost can reach more than 300 billion dollars. In chronic pain patients, the role of pharmacogenetics is determined by genetic effects on various pain types, as well as the genetic effect on drug safety and efficacy. In this review article, we discuss genetic polymorphisms present in different types of chronic pain, such as fibromyalgia, low back pain, migraine, painful peripheral diabetic neuropathy and trigeminal neuralgia. Furthermore, we discuss the role of CYP450 enzymes involved in metabolism of drugs, which have been used for treatment of chronic pain (amitriptyline, duloxetine, opioids, etc.). We also discuss how pharmacogenetics can be applied towards improving drug efficacy, shortening the time required to achieve therapeutic outcomes, reducing risks of side effects, and reducing medical costs and reliance upon polypharmacy.