Epidemiology studies are useful to clinicians because they highlight diagnosis and prescribing patterns, common trends within a disease, and unmet needs.
Migraine is a common neurological disorder that affects both children and adults in the United States. It is a known cause of significant disability, ranked sixth by the World Health Organization for years lost to disability.1
This year, at the Annual Scientific Meeting of the American Headache Society (AHS), several abstracts were presented that discussed the epidemiology and treatment patterns of migraine in the United States. These studies highlighted the discrepancy between the high prevalence of migraine and the use of non-specific medications to treat acute migraine attacks in the outpatient, emergency, and hospital settings.
Prevalence of migraine
The prevalence of migraine in the Observational Survey of the Epidemiology, Treatment and Care of Migraine (OVERCOME) study was similar to that seen in the American Migraine Prevalence and Prevention studies completed in the early 2000s.2 The 1-year prevalence of incident migraine was 2.2% (1.5% in men and 3.1% in women) and declined with age.3 Approximately 21% of persons with migraine had reported a diagnosis by a health care provider, and close to 12% were found to have severe disability related to migraine.3 Migraine is most often seen by primary care providers (PCPs), with only about 15% of persons with migraine visiting a headache specialist, and another 15% seeking care from a pain specialist.2
Use of non-specific medications
Several studies presented at the AHS Annual Scientific Meeting highlight that migraine continues to be treated with non-specific acute medications. Opioids were the most commonly prescribed medication for acute migraine. The majority of persons with migraine (63.7%) used over-the-counter drugs.3-5
Bickel and colleagues6 found that opioids were frequently used in the emergency department (ED) for adolescents with migraine; they were ordered for 23.1% of patients seen the ED for migraine within the first 12 hours. In these ED cases in which opioids were ordered, 58% of the time they were used as first-line treatment. Opioids were also more likely to be prescribed for older children.
In the Migraine in America Symptoms and Treatment (MAST) study, 8.5% of respondents reported seeking medical attention at an ED or urgent care (UC) center during the previous 6 months.7 Factors associated with ED or UC center use were management of migraine with opioids, ergots, or triptans and very poor/poor acute treatment optimization.
Use of non-specific medications for migraine continues in patients who are admitted to the hospital. At the AHS Annual Scientific Meeting, Katherina Platzbecker highlighted the readmission rates in patients with migraine.8 Those who were admitted for unrelated surgery and treated for migraine during their inpatient stay were more likely to receive non-specific acute therapies. If given migraine-specific treatment, these patients were less likely to be re-admitted for any cause.
In studies of adults, opioid use for migraine is high. In the Chronic Migraine Epidemiology and Outcomes (CAMEO) study, 36.3% of respondents were using opioids for migraine.4 Schwedt and colleagues4 described several factors associated with opioid use in the CAMEO respondents:
• Male sex
• Increasing body mass index
• Increasing monthly headache day frequency
• Increasing trigger points outside of the head, face, and neck
• Depression, anxiety, and cardiovascular comorbidity
• Emergency facility use during the past 6 months
For patients who were given a diagnosis of migraine or chronic migraine, there was a decreased likelihood of opioid use.4
The OVERCOME study evaluated the treatment of migraine in patients with 4 or more migraine headache days per month. The study concluded that a majority of people with 4 or more migraine headache days per month have seen a health care professional for headache; most have seen their PCP. PCPs prescribe triptans to 33% of these patients and opioids to 27%.9 Patients with migraine in this study who were seen by a neurologist or headache specialist received triptans at a lower rate (26% to 27%) than those seen by PCPs and received fewer opioids (11% to 12%).9 Patients seen by neurologists and headache specialists were more likely to be prescribed preventive medications.
Implications for clinicians
Epidemiology studies are useful to clinicians when treating patients because they highlight diagnosis and prescribing patterns, common trends within a disease, and unmet needs. For migraine, these studies all highlight that further education targeting primary care, hospitalists, and emergency physicians is needed to improve the quality of care provided to persons with migraine and help reduce the burden of opioid use. Opioids are well known to worsen migraine frequency and severity, causing opioid hyperalgesia and potentially contributing to central sensitization, both risk factors for transformation of migraine to chronic migraine.10,11 Targeted education on early diagnosis of migraine and appropriate acute treatment options for both outpatient and inpatient use may help reduce disability related to migraine.
1. World Health Organization. Headache disorders. 2016. https://www.who.int/news-room/fact-sheets/detail/headache-disorders. Accessed July 22, 2019.
2. Lipton RB. Patterns of diagnosis, consultation, and treatment of migraine in the US: results of the OVERCOME study. Presented at: American Headache Society 61st Annual Scientific Meeting; July 11-14, 2019; Philadelphia, PA.
3. Lipton RB, Reed ML, Munjal S, et al. One-year incidence of migraine in the US population: results from the Migraine in America Symptoms and Treatment (MAST) study. Headache. 2019;59:9.
4. Schwedt TJ, Lipton RB, Friedman BW, et al. Demographics, headache characteristics, and other factors associated with opioid use in people with migraine: results from the Chronic Migraine Epidemiology and Outcomes Study. Headache. 2019;59:6.
5. Ashina S, Foster SA, Nicholson RA, et al. Opioid use among people with migraine: results of the OVERCOME study. Headache. 2019;59:6.
6. Bickel J, Connelly M, Glynn EF, et al. Rates and predictors of using opioids in the emergency department to treat migraine in the adolescents and young adults. Headache. 2019;59:12.
7. Schwedt T, Munjal S, Reed ML, et al. Headache treatment patterns and co-morbid health burden associated with emergency department and urgent care use in people with migraine: survey results from Migraine in America Symptoms and Treatment study. Headache. 2019;59:17.
8. Platzbecker K. Incidence, consequences, and prevention of postoperative, pain-related hospital readmission in migraineurs. Presented at: American Headache Society 61st Annual Scientific Meeting; July 11-14, 2019; Philadelphia, PA.
9. Buse DC, Nicholson RA, Araujo AB, et al. Migraine care across the healthcare landscape in the United States among those with 4 or greater migraine headache days per month: results of the OVERCOME study. Headache. 2019;59:16.
10. Mitra S. Opioid induced hyperalgesia: pathophysiology and clinical implications. J Opioid Manag. 2018;4:123-130.
11. Bigal ME, Lipton RB. Excessive opioid use and the development of chronic migraine. Pain. 2009;142:179-182.