Patients with chronic migraine (CM) and patients with medication overuse headache (MOH) tend to overutilize acute pain medications and underutilize preventive medications, compared with patients with episodic migraine (EM), data suggest.
In a retrospective observational study that included nearly 200,000 patients in three migraine cohorts, fewer than half of participants were given preventive medications such as anticonvulsants or antidepressants. Opioids were the most frequently dispensed acute medication in all cohorts.
“There are likely a number of reasons for the overprescribing of opioids and the underutilization of appropriate acute therapies and preventive agents,” study author Farnaz Amoozegar, MD, clinical assistant professor of neurology at the University of Calgary in Alberta, told Medscape Medical News. “Some of the reasons may include lack of education of primary care physicians on the appropriate treatment of migraine, insufficient time for primary care physicians to manage patients with pain conditions such as migraine, and long wait times to see specialists such as neurologists or headache specialists.”
The study was published October 16 in the Canadian Journal of Neurological Sciences.
Opioid Use Common
The findings highlight “an unmet need to more effectively manage migraine,” write the researchers. Without early and effective treatment, EM may progress to CM, and subsequently to MOH, a severe secondary headache disorder, they add. “There is an opportunity to improve the management of migraine by targeting newly diagnosed or recurrent patients with migraine to identify opportunities to improve treatment approaches as early as possible to improve patient outcomes.”
The researchers examined population-based administrative data from Alberta Health and Alberta Health Services and identified newly diagnosed or recurrent patients with migraine from 2012 to 2018. Patients were classified into the following three cohorts: EM (144,574), CM (27,283), and MOH (11,485). Mean age was 38.6, 42.3, and 46.4 years, respectively. Nearly all patients in the CM (> 99.9%) and MOH (96.2%) cohorts were female, compared with 67.2% of the EM cohort.
The researchers identified treatment patterns and calculated total healthcare costs for each patient over a median follow-up time of 2.9 years. Treatment patterns were summarized as the total number of acute and preventive medications dispensed, the rate of medication dispenses per person per year, the number and proportion of patients with at least one medication dispense, and the rate of medication dispenses per person per year among patients with at least one dispense.
Acute medications included NSAIDs, triptans, antiemetics, and opioids, while preventive medications included antihypertensives, anticonvulsants, antidepressants, neurotoxins, monoclonal antibodies, and antamines.
Healthcare costs were calculated for each patient as the sum of all migraine-related medications, hospitalizations, physician visits, diagnostic imaging (ie, MRI and CT), and ambulatory care, including emergency department visits.
Opioids were the most frequently dispensed medications in all cohorts. About 90% of the MOH cohort, 50.4% of the CM cohort, and 31.7% of the EM cohort received them. Among all patients, the mean rate of opioid prescription dispenses per patient per year was more than 15 times higher for the MOH cohort than for the CM cohort (15.7 vs 0.9) and more than 30 times higher than for the EM cohort (0.4).
The most dispensed preventive medication was antidepressants for the EM and CM cohorts (13.7% and 31.2%, respectively) and anticonvulsants for the MOH cohort (50.2%).
Higher all-cause mean healthcare cost per patient per year were observed for MOH ($16,611.5) and CM ($12,693), compared with EM ($4251).
“For clinicians, the overuse of acute medication — defined as the use of triptans, ergots, combination analgesics, or opioid-containing medications for ≥ 10 days per month, or the use of acetaminophen or NSAIDs ≥ 15 days per month — is an indicator for a poorly controlled headache,” the authors write.
They add that in this study, “acute medication utilization in the MOH cohort generally exceeded the Canadian guideline recommendations, which include patient education, abrupt withdrawal (or gradual for opioids and opioid-containing analgesics), use of preventive medications, effective acute medications to treat severe attacks with limitations on frequency of use, and patient follow-up and support.”
Solutions to this problem should include “education of physicians, starting in medical school and residency through to practicing physicians, providing primary care physicians with more time to assess patients and reducing wait times to see specialists,” said Amoozegar. She added that “migraine has a significant socioeconomic and personal burden. Improving management of migraine will not only benefit the patients affected, but also reduce its major socioeconomic impact. We need to continue educating physicians and improving access to care at all levels.”
“Critically Important Publication”
Commenting on the study for Medscape, Christine Lay, MD, a director of the Canadian Headache Society, called it “a critically important publication,” because it gives “a very clear picture of how EM, CM, and MOH remain ineffectively managed, resulting in high healthcare utilization costs and significant burden.” Lay, who was not involved with the study, is a professor of neurology at the University of Toronto and director of the Centre for Headache at Women’s College Hospital in Toronto.
Dr Christine Lay
“Despite effective migraine-specific acute medications (that is, triptans) being available for decades now, opioids continue to be prescribed at very high rates…yet their use in migraine is not recommended,” said Lay. “These data should empower healthcare providers to follow recommended guidelines to prescribe preventative therapy more often and to utilize migraine-targeted acute therapy, while avoiding the use of opioids.”
The study was sponsored by Lundbeck Canada. Amoozegar reported research support from Eli Lilly, Allergan/AbbVie, Biohaven, Novartis, and TEVA; consulting fees from TEVA, Eli Lilly, Novartis, Lundbeck, ICEBM, and Pfizer; and speaker’s honoraria from TEVA, Eli Lilly, Novartis, Allergan, Aralez, and ICEBM. Other authors are employed by Lundbeck Canada or Medlior Health Outcomes Research, which received funding for the study from Lundbeck Canada. Lay has disclosed no relevant financial relationships.
Can J Neurol Sci. Published October 16, 2023. Abstract
Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.
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