Nearly one-third of persons with four or more migraine headache days per month have not received a diagnosis.
A large percentage of the US population is contending with undiagnosed migraine and suboptimal care, according to results from the Observational Survey of the Epidemiology, Treatment and Care of Migraine (OVERCOME).1 The findings were presented at the 61st Annual Scientific Meeting of the American Headache Society, held July 11 to 14 in Philadelphia. The survey results also determined that 30% of patients with migraine may qualify for novel medications for acute migraine relief regardless of how many migraine headache days (MHD) they have per month.2
OVERCOME is a web-based survey that was conducted in a representative US sample of 21,143 persons with migraine. A migraine diagnosis was identified based on The International Classification of Headache Disorders 3rd edition (ICHD-3) criteria. The data were presented by Richard B. Lipton, MD, the Edwin S. Lowe Professor and Vice Chair of Neurology, Professor of Epidemiology and Population Health, and Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine in The Bronx, New York.
Here, we report on two assessments of OVERCOME data presented by Dr Lipton at the AHS meeting. The purpose of the first assessment was to update understanding of migraine diagnosis, consultation, and treatment in the United States. The second was to estimate the percentage of patients who meet American Headache Society (AHS) consensus criteria for acute treatment with novel therapies either because triptan therapy is contraindicated or because of failure to respond to or tolerate at least two oral triptans.3 The assessment stratified participants into those who experienced three or fewer MHD per month (n=12,299; 58%) and those who experienced four or more (n=8844; 42%).
First assessment of OVERCOME data
Persons who experienced three or fewer MHD per month but met ICHD-3 criteria for migraine were particularly vulnerable to going without a diagnosis, although the percentage of those with four or more MHD per month who had not received a diagnosis was considerable.1 Thirty-one percent of those with four or more MHD per month had not received a diagnosis and 45% of those with three or fewer MHD had not. Meanwhile, 73% of those with three or fewer MHD and 86% with four or more reported ever seeking medical care for headache or migraine, largely consulting with a primary care physician or neurologist, or receiving care in the emergency department. Diagnostic testing was reported by 50% of those with three or fewer MHD and 68% of those with four or more. Twelve percent of survey participants in the three-or-fewer MHD-per-month group and 21% of those in the four-or-more group reported ever visiting a headache specialist.
The researchers alarmingly found that opioid use rivaled that of triptan use: 41% of the three-or-fewer MHD group and 55% of the four-or-more MHD group reported having ever used an opioid for migraine management. Thirty percent and 42%, respectively, reported ever using a triptan.
Dr Lipton stressed that migraine in a significant percentage of the population sample remained undiagnosed. He noted that although primary care is the main source of patient diagnosis and treatment, more than 30% of surveyed patients with four or more monthly MHD had sought emergency care for a migraine. Also, he called the preponderance of opioid use relative to triptan use and the low rate of preventive medication use among prevention-eligible patients concerning.
Second assessment of OVERCOME data
The second assessment employed the migraine Treatment Optimization Questionnaire (mTOQ), which measures the adequacy of acute therapy. The study population was divided into three groups:
• Persons not currently on an oral triptan but with a history of use and discontinuation of at least 2 of them
• Persons currently using an oral triptan with mTOQ sum score <6 (poor/very poor treatment efficacy) and history of failing at least one oral triptan
• Persons with potential contraindications to triptans (eg, cardiovascular conditions or procedures)
Overall, the researchers found that, irrespective of group designation, 27% of persons with three or fewer MHD per month and 33% of those with four or more appeared to be eligible for novel medications designed for acute treatment of migraine. A quarter of the eligible population with three or fewer monthly MHD were currently using an oral triptan despite it being either contraindicated or providing poor/very poor effectiveness. The same percentage reported using opioids.
A third of persons with four or more monthly MHD were using oral triptans and about 30% were using opioids. Barbiturates were used by 13% of those with three or fewer and 16% of those with four or more MHD.
1. Lipton RB, Araujo AB, Nicholson RA, et al. Patterns of diagnosis, consultation, and treatment of migraine in the US: results of the OVERCOME Study. (2017-229-001).
2. Lipton RB, Pohl GM, Araujo AB, et al. Who is eligible for novel medications designed for the acute treatment of migraine and what are their unmet needs? Results of the OVERCOME Study. (2017-6229-004).
3. American Headache Society. The American Headache Society Position Statement on Integrating New Migraine Treatments Into Clinical Practice. Headache. 2019;59:1-18.