Factors associated with triptan use in episodic migraine: results from the American Migraine Prevalence and Prevention Study

Background.— Though triptans are considered the standard of acute therapy for migraine attacks with headache‐related disability, they are used by the minority of potentially eligible persons. Understanding the socio‐demographic and headache features that predict triptan use may help to clarify barriers to optimal treatment. Objective.— To assess the sociodemographic and headache features associated with triptan use in a US population sample of persons with episodic migraine. Methods.— The American Migraine Prevalence and Prevention Study (AMPP) is a longitudinal study conducted in a representative sample of US headache sufferers. Episodic migraineurs (n = 11,388) who provided treatment data in 2005 were included in the current analyses. We assessed factors associated with triptan use through univariate and multivariate analyses. Multivariate analyses were adjusted for sociodemographic factors, headache‐related disability, cutaneous allodynia, depression, and preventive headache medication use. Results.— Among persons with episodic migraine, 18.31% reported current use of triptans for acute headache treatment. In univariate analyses, triptan use was most common in midlife (ages 30‐59), among females, and was more common in Caucasians than in African Americans. Triptan use increased with headache frequency, headache‐related disability and allodynia, but decreased among persons with depression. In multivariate analyses, female gender, Caucasian race, age 40‐49, higher levels of education (college or higher), annual household income of ≥$40,000, having health insurance, the presence of cutaneous allodynia, greater headache‐related disability, and preventive medication use for migraine were significantly associated with triptan use. Conclusions.— Less than 1 in 5 persons with migraine in the United States who were respondents to this survey used triptans for acute headache treatment over the course of a year. Several markers of severe headache, including disability and allodynia, were associated with increased triptan use. Groups less likely to get triptans included males, African Americans, older adults, and the uninsured. Predictors of use provide insight into groups with unmet treatment needs.     

Acute pharmacotherapy of migraine,tension-type headache,and cluster headache

Abstract In most migraine patients acute therapy is needed. Migraine can be treated either with specific drugs, the triptans and ergot alkaloids, or with NSAIDs. Triptans are a major step foreward in migraine therapy. The therapeutic gain for headache relief is 50% for subcutaneous sumatriptan whereas it is 30-40% for most oral triptans. After oral triptans sustained pain free is only 30%. There is thus still ample room for improvement of acute therapy in migraine. For tension-type headache there is no specific therapy and it is treated with NSAIDs. Only 17-32% become pain free after these drugs. For attacks of cluster headache oxygen and subcutaneous sumatriptan can be used. Intranasal triptans can be an alternative.     

Headache currents commentary

What Happens to the Old Headache Medicines? Rapoport AM, MD Old headache medicines never die; they either fade away or come back in disguise. The disguise is often a new route of administration, which may work better, faster, more completely, with fewer adverse events, and/or have certain other advantages. The clinical aspects of 3 of the oldest headache medicines (ergotamine tartrate, dihydroergotamine, and methysergide) will be discussed here. Sumatriptan will then be discussed as the prototype of the newest category of acute care therapy (triptans) for migraine. It will be compared with the older medications, and the new forms being developed will be briefly discussed. Diclofenac potassium for oral solution will be mentioned as the newest drug approved for migraine by the Food and Drug Administration and a possible alternative to triptans in patients with frequent headaches or those with contraindications to vasoconstrictors. Dihydroergotamine, Ergotamine, Methysergide and Sumatriptan – Basic Science in Relation to Migraine Treatment Dahlöf C, Maassen Van Den Brink A. The 5‐hydroxytryptamine (5‐HT) receptor family mediates the effects of several drugs highly effective in migraine primarily by activating 5‐HT_1B, 5‐HT_1D, and 5‐HT_1F receptors. Ergotamine, dihydroergotamine and methysergide, as well as the “triptan” sumatriptan, are all agonists for these receptors. The receptor profile and degree of selectivity of these 4 drugs differ, which is reflected by their side effects that limit their use in the acute and prophylactic treatment of migraine. The acute antimigraine efficacy of these remedies is very much dependent on the formulation used where, in general, parenteral formulations are more effective in relieving the symptoms of a migraine attack.     

Characteristics,impact and treatment of 6000 headache attacks: The PAMINA study

The aim of this study was to prospectively evaluate the characteristics of headache attacks, their impact on daily activities as well as the type and efficacy of acute medication in patients with migraine. We included 281 patients with episodic migraine (87% females, aged 41.2±12.1). All patients kept a headache diary for 3 months covering headache characteristics, therapy and questions adopted from the Headache Impact Test (HIT‐6) for rating the impact of each single headache attack (HIT‐6 s). For evaluating the efficacy of acute medication we compared triptans with other compounds using headache duration as outcome parameter. Of 6051 headache attacks 52.8% fulfilled the ICHD‐II criteria of migraine. The HIT‐6 s score was 2.4±2.2 (range 0–6). It was lowest in untreated headaches (2.0±2.1) and highest in those treated with a combination of triptans and other compounds (4.1±2.0, p <0.001). Patients used triptans on 8.0% of all headache days, other compounds on 33.1%, a combination of both on 1.5% and no medication on 57.3% of the headache days. Migraine attacks of moderate or severe intensity treated with triptans alone lasted significantly shorter than those treated with other compounds (5.1±3.6 vs. 6.9±5.3 h, p <0.001). In conclusion, almost 50% of the headaches occurring in patients with migraine do not fulfill migraine criteria. Use of triptans is associated with a shorter duration of moderate and severe migraine attacks compared to use of other compounds.     

An epidemiological study of headache in Florianopolis, Brazil

The aim of this study was to estimate the 1-year prevalence of headache, migraine, tension-type headache (TTH) and chronic daily headache (CDH), and the degree of association of migraine with some sociodemographic characteristics of the population of Florianopolis, Brazil. This is a cross-sectional, door-to-door, population-based study. In 300 randomly selected households, 625 subjects, aged 15-64 years, responded to a structured questionnaire. The 1-year prevalence of headache was 80.8%, of migraine 22.1%, of TTH 22.9%, and of CDH 6.4%. Migraine and CDH were significantly more prevalent in females than in males. Migraine was significantly associated with the following variables: low household income, low electricity consumption, and divorced or widowed marital status. We have shown high prevalences of migraine and CDH in Florianopolis, close to the higher rates of previous studies. There was a preponderance of migraine in females, divorced or widowed, with a low socioeconomic level.     

Analysis of the patients attending a specialist UK headache clinic over a 3-year period

OBJECTIVE: This study analyzed the profile of patients who attended a specialist UK headache clinic over a 3-year period. METHODS: An audit was conducted of the clinical records of patients attending the specialist headache clinic at King's College, London, between January 1997 and January 2000. Data were collected for diagnoses given, current medications taken, medications prescribed and recommended, and investigations conducted. Results were calculated as numbers and proportions of patients for the 3-year period and for the 3 separate 12-month periods. RESULTS: A total of 458 patients were included in the audit. Most patients were diagnosed as having chronic daily headache (CDH, 60%) or migraine (33%). Prior to the clinic visit, most patients with CDH and migraine treated their headaches with analgesics, and there was little use of prophylactic medication. In the clinic, 74% of patients with CDH and 85% of migraineurs were prescribed prophylactic medication, and 81% of migraineurs were given triptans for acute treatment. Diagnostic testing was performed in 12% of the patients, and all results were normal or negative. CONCLUSIONS: CDH and migraine were the most common headache types encountered in this UK secondary-care clinic. Review of treatment patterns used prior to the initial clinic evaluation suggests that management of CDH and migraine in UK primary care is suboptimal, and educational initiatives are needed to improve headache management.     

New paradigms in the recognition and acute treatment of migraine

It would be ideal if clinical decisions regarding acute migraine treatment could be made on the basis of three parameters: a critical appraisal of available scientific evidence, clinical experience (including knowledge of the individual patient and his/her attack characteristics), and, of course, patient preferences. Patients are likely to prefer agents that offer rapid relief, pain-free status within 2 hours, no recurrence or need for rescue medication, extended time to recurrence (if present), consistency of therapeutic effect over multiple attacks, oral administration. good tolerability, safety, and minimal drug interactions. Fortunately, a number of specific therapies now are available which place these objectives within the patient's reach. Ongoing barriers to optimal migraine care include underrecognition, underconsultation, undertreatment, restrictions imposed by insurance companies, and exaggerated concerns regarding the safety of the triptans. Overcoming these barriers is likely to prove a more important contribution to patient care than endeavoring to establish the relative merits of one triptan over another. We have described in detail a number of strategies for improving recognition and treatment of migraine. Many headache specialists now believe that recurrent episodes of disabling headache, with a stable pattern over years, should be viewed as migraine until proven otherwise. In the end, this may represent the most useful paradigm in the primary care setting, where time is of the essence. Studies to validate this approach are needed. Acute treatment intervention that is based on scientific evidence, clinical experience, and patients' needs and desires will provide better outcomes than those presently obtained. Preliminary evidence favors early intervention with oral triptans, and randomized, prospective, double-blind, placebo-controlled studies, ideally employing a crossover design, are required to confirm this. The US Consortium's evidence-based guidelines, the National Headache Foundation's standards of care, and the Canadian guidelines have applied the standards of scientific inquiry to the field of headache management and "translation" of these guidelines into practical instruments for clinicians through vehicles such as the Primary Care Network's Patient-Centered Strategies for Effective Management of Migraine should raise the general standard of care for patients with migraine. Last, but far from least, initiatives undertaken by the World Health Organization (WHO) will add credibility to the many layfolk and professionals who have struggled to present headache as a disabling disorder worthy of scientific investigation and aggressive medical management. The WHO states: "These common complaints impose a significant health burden ... Despite this, both the public and the majority of healthcare professionals tend to perceive headache as a minor or trivial complaint. As a result, the physical, emotional, social and economic burdens of headache are poorly acknowledged in comparison with those of other, less prevalent, neurologic disorders." Migraine is finally out of the closet.     

MIGRAINE REVIEWS

Migraine is a very common neurobiological headache disorder that is caused by increased excitability of the CNS. It ranks among the world's most disabling medical illnesses. Diagnosis is based on the headache's characteristics and associated symptoms. The economic and societal effect of migraine is substantial: it affects the patients' quality of life and impairs work, social activities, and family life. There are many acute and preventive migraine treatments. Acute treatment is either specific (triptans and ergots) or non-specific (analgesics). Disabling migraine should be treated with triptans. Increased headache frequency is an indication for preventive treatment. Preventive treatment decreases migraine frequency, and improves the quality of life. More treatments are being developed, which provide hope to the many patients whose migraines remain uncontrolled.
Comment: Laudable aims for the clinician, yet we are more than 10 years post-sumatriptan launch and have still not convinced health care providers that triptans make sound economic sense from both a healthcare provider and societal perspective. We need the AHS and other professional groups to push home the messages developed by the WHO showing migraine headache amongst the top 20 disabling conditions. —David S. Millson     

Clinical and descriptive analysis of chronic daily headaches

With an ad hoc, previously validated clinical record, we analysed the headache characteristics in 245 patients (F, 78.4%, M, 21,6%; mean age, 43.1±12.9 years) affected by chronic daily headache (CDH) attending 9 Italian headache centers. Migraine without aura was the episodic headache preceding CDH in 72.3% of the cases. We divided CDH into 3 categories: chronic tension-type headache (CTTH), chronic coexisting migraine and tension-type headache (CCMTTH), and chronic migraine (CM). CCMTTH accounted for 46.5% of the cases, followed by CM (30.2%) and CTTH (23.3%). Female prevalence was more marked in CCMTTH and CM groups, in which episodic headache started earlier. Migraine without aura was the episodic headache preceding CDH not only in most cases of CCMTTH (83.0%) and CM (91.9%), but also in 25% of CTTH patients.Analgesics misuse (abuse of weak analgesics and/or combination drugs in almost all the cases) prevailed among CCMTTH (61%) and CM (89%) patients with respect to CTTH patients (37%).     

Predictors of Adherence to Triptans: Factors of Sustained vs Lapsed Users

Objective.— The present study was conducted to identify factors that predict adherence to triptans by migraine patients. Background.— Triptans have demonstrated efficacy for acute migraine yet many migraine sufferers discontinue their use. Design and Methods.— A survey study was conducted using 785 subjects (390 health maintenance organizations [HMO] and 395 non‐HMO). Of those, 586 were sustained users of triptans (defined by at least 1 refill within the past year), and 199 were classified as lapsed users (ie, individuals who had 0 refills in the past year). Groups were compared on a variety of measures including a comprehensive Migraine Survey that included items related to efficacy and adverse events associated with the patient's current medication, as well as the Headache Impact Test (HIT)‐6 and Migraine Disability Assessment Score (MIDAS) questionnaires. Data were analyzed with multivariate analysis of variance and stepwise multiple regression. Results.— Sustained users of triptans were significantly more satisfied with their medication, confident in the medication's ability to control headache, and reported control of migraine with fewer doses of medication. Sustained users also switched triptans products significantly less often than lapsed users, and reported greater benefit from triptan intervention in restoring normal daily functions, including improved cognitive ability, compared with lapsed users' ratings of their nontriptan medication. More lapsed users than sustained users reported adverse events associated with past triptan use. Results from multiple and logistic regression analyses correctly classified 95% of sustained users and identified the most significant predictors for sustained use as: satisfaction and belief in medication, reliability of response, effectiveness in rapidly restoring normal levels of productivity, and fewer doses of medication for resolving an attack. The HIT‐6 and MIDAS distinguished between sustained and lapsed triptan users on days unable to do household work and missed family and social events. Conclusions.— Predictors of adherence to triptans included satisfaction and confidence in triptans' ability to stop the migraine and associated symptoms and to return the individual to normal functioning. The findings suggest that lapsed users may not be receiving optimal treatment, and that if their past response to triptans was a consequence of inadequate education, they may benefit from additional education on proper use of triptans.     

Quantitative Assessment of the Tension-Type Headache and Migraine Severity Continuum

Two quantitative measures for Waters'¹ tension-type head ache and migraine severity continuum are proposed. To ensure face validity, symptoms and precipitants of this disorder were compiled from the literature as a basis for the Auckland Migraine and Headache Inventory. This inventory was completed by 84 participants (mean age ± SD, 26.0 ± 9.7 years; range, 18 to 59 years) who complied with the criteria of the International Headache Society, for migraine of tension-type headache. The migraine headache index and the number of precipitants were derived from the Auckland Migraine and Headache Inventory. These scores yielded significant internal reliability ( r _s =.77 and .84), test-retest reliability ( r _s =.86 and .74), and concurrent validity ( r _s =.57) coefficients. The data, therefore, support the notion that the migraine headache index and the number of precipitants are reliable and valid indices of tension-type headache and migraine severity, suitable for participant selection and assessment of treatment. This study offers support for Waters'1 suggestion that tension-type headache and migraine are extremes of a severity continuum.     

Acute Migraine Treatment in Adults

There are many options for acute migraine attack treatment, but none is ideal for all patients. This study aims to review current medical office‐based acute migraine therapy in adults and provides readers with an organized approach to this important facet of migraine treatment. A general literature review includes a review of several recent published guidelines. Acetaminophen, 4 nonsteroidal anti‐inflammatory drugs (NSAIDs) (ibuprofen, acetylsalicylic acid [ASA], naproxen sodium, and diclofenac potassium), and 7 triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) have good evidence for efficacy and form the core of acute migraine treatment. NSAID–triptan combinations, dihydroergotamine, non‐opioid combination analgesics (acetaminophen, ASA, and caffeine), and several anti‐emetics (metoclopramide, domperidone, and prochlorperazine) are additional evidence‐based options. Opioid containing combination analgesics may be helpful in specific patients, but should not be used routinely. Clinical features to be considered when choosing an acute migraine medication include usual headache intensity, usual rapidity of pain intensity increase, nausea, vomiting, degree of disability, patient response to previously used medications, history of headache recurrence with previous attacks, and the presence of contraindications to specific acute medications. Available acute medications can be organized into 4 treatment strategies, including a strategy for attacks of mild to moderate severity (strategy one: acetaminophen and/or NSAIDs), a triptan strategy for patients with severe attacks and for attacks not responding to strategy one, a refractory attack strategy, and a strategy for patients with contraindications to vasoconstricting drugs. Acute treatment of migraine attacks during pregnancy, lactation, and for patients with chronic migraine is also discussed. In chronic migraine, it is particularly important that medication overuse is eliminated or avoided. Migraine treatment is complex, and treatment must be individualized and tailored to the patient's clinical features. Clinicians should make full use of available medications and formulations in an organized approach.     

Analgesic/abortive overuse and misuse in chronic daily headache

The frequent use (> 15 times/month) of medication for the treatment of acute migraine attacks may cause medication overuse headache. This kind of headache can be caused by the intake of combination analgesics, opioids, ergot alkaloids, and triptans. The delay between first intake and daily headache is shortest for triptans (1 to 2 years), longer for ergots (3 years), and longest for analgesics (5 years). Treatment includes drug withdrawal followed by structured acute therapy and initiation of migraine prophylactic treatment.     

Somatic symptoms in headache patients: the influence of headache diagnosis, frequency, and comorbidity

BACKGROUND: Mood disorders of anxiety and depression are well known to be comorbid with primary headache disorders. Less is known of the comorbidity of other somatic symptoms with headache. METHODS: Headache Clinic patients were screened with the Primary Care Evaluation of Mental Disorders (PRIME-MD), a multidimensional psychiatric screening tool. The prevalence of somatic symptoms was compared by headache diagnosis, frequency of severe headache, and psychiatric diagnosis. Follow-up data were obtained 6 months after consultation. RESULTS: Clinical diagnoses and PRIME-MD data were available for 289 patients. Associated somatic symptoms were more frequent in patients with chronic migraine (mean 5.5, P<.001) and chronic daily headache (CDH) (6.3, P=.008) compared to episodic migraine (4.0); in patients with severe headache >2 days per week compared to 2 days per week had significantly higher somatic counts (P=.01). Six-month follow-up data were available for 140 patients. Associated symptoms decreased both for patients with and without decrease in severe headache frequency (mean reduction of 1.0, P=.01 and 0.8, P=.003, respectively). CONCLUSION: Associated somatic symptoms are more common in patients with chronic migraine and CDH, with more frequent severe headaches, and with associated anxiety or depression. Patients with episodic migraine have similar somatic prevalence as a previously studied primary care population. The spectrum of headache disorders may be characterized as showing increasing somatic prevalence as headaches, particularly severe headaches, become more frequent.     

Migraine and chronic daily headache management: a qualitative study of patients' perceptions

AIM: The aim of the study was to gain insight into the patients' perceptions of migraine and chronic daily headache (CDH) management. METHODS: Thirteen, semi-structured and individual interviews with seven migraine and five CDH patients were carried out and analysed in QSR NUD*IST5, using a grounded theory methodology. RESULTS: The participants described using five areas of management: 1) health care use; 2) medication use; 3) alternative therapies; 4) social support; and 5) lifestyle and self-help. The participants described their expectations, preferences, worries and (dis)satisfaction in relation to these five areas of management. The participants adapted headache management to suit their needs and preferences, making migraine and CDH management highly individual and giving the headache patient a central role within their own care. CONCLUSION: Health care is changing towards a greater involvement of the patients in their own care. Therefore, it is important to increase understanding of the patients' perspective of chronic diseases, including migraine and CDH. The results from this study inform health care professionals of the range of their patients' needs and preferences. This knowledge can be used to shape clinical practice, to develop patient education programmes and to further research efforts into issues that are important to the headache patient.     

Treatment of chronic daily headache

Patients with chronic daily headache (CDH) are difficult to treat. A combination of general measures and specific pharmacological treatments is necessary. When possible, pharmacological management should be planned on an outpatient basis. The general protocol should include abrupt discontinuation of the offending symptomatic medications, specific treatment for detoxification, daily nonsteroidal anti-inflammatory drugs (NSAIDs) for about 1 month, triptans only for moderate-severe headache, and prophylactic treatment. Either amitriptyline plus propranolol or valproic acid have been classically recommended for transformed migraine prophylaxis. Refractory patients can respond to a combination of a beta-blocker and valproic acid, possibly due to their complementary mechanisms of action. Recently, the new antiepileptic topiramate has been shown to be especially useful in this indication. At least one-third of patients, however, do not improve. Therefore, the best treatment of this incapacitating entity continues to be its prevention. Preventive measures should include: (1) public information concerning the risk of frequent self-treatment for headaches; (2) inform headache patients of the risk of analgesic overuse/rebound headache; (3) recommend NSAIDs and triptans as symptomatic medications; and (4) active use of preventive medications when headaches begin to increase in frequency.     

Assessment of migraine disability using the migraine disability assessment (MIDAS) questionnaire: a comparison of chronic migraine with episodic migraine

BACKGROUND: Chronic migraine is the most common type of chronic daily headache seen in headache tertiary care centers. Most patients with chronic migraine report their ability to function and feeling of well-being as severely impaired. OBJECTIVE: To measure the headache-related disability of patients with chronic migraine using the Migraine Disability Assessment (MIDAS) Questionnaire, comparing it with that obtained in a control group of patients with episodic migraine. METHODS: The clinical records of 703 patients with chronic daily headache treated in a headache specialty clinic were reviewed to identify 182 with chronic migraine who were evaluated using the MIDAS at their initial visit. Our control group consisted of 86 patients with episodic migraine. RESULTS: Of the 182 patients with chronic migraine, 127 (69.8%) were overusing acute-care medication. Patients were predominantly women (72.5%), with a mean age of 38.3 years. The group with episodic migraine consisted of 59 women (68.6%), with a mean age of 36.1 years. No statistically significant demographic differences were observed between the two groups. The group with chronic migraine had more total headache days over 3 months (66.7 versus 15.5, P<.001), missed more days of work or school (5.3 versus 2.3, P =.0007), had more reduced effectiveness days at work or school (11.9 versus 4.6, P =.0001), missed more days of housework (16.5 versus 3.3, P<.0001), and missed more days of family, social, or leisure activities (7.0 versus 5.5, P =.03). The group with chronic migraine was more likely to be in MIDAS grade IV (64.3% versus 43.2%, P =.001), reflecting the great likelihood of severe disability in this group. The average total MIDAS score was 34.9 in the group with chronic migraine versus 19.3 in the group with episodic migraine (P<.001). CONCLUSION: In subspecialty centers, patients with chronic migraine demonstrate remarkable impairment of their daily activities and are severely burdened by their headache syndrome, reflected by their high MIDAS scores. The chronicity and pervasiveness of migraine thus is associated with increased functional impairment as well as increase in headache frequency.