The ongoing fight to add to the epidemiologic understanding of migraine is explored in part 2 of this special 3-part multimedia series on the evolution of migraine care.
This is part 2 of a special 3-part multimedia series. For part 1, click here.
In the early days of migraine care, the major concern for physicians lay in the general lack of treatment options. This was driven, in part, by a less-than-spectacular amount of literature pointing to the biologic mechanisms and pathways at play in the disease, to the point that outside of few circles of migraine specialists, the belief in a neurologic basis of the disease was waning.
Now, some 30 years and a number of new approvals later, the field has been met with an inflection point. The challenge is no longer in the ability to treat patients (though access to certain medications remains an issue) but in the identification of them and the subsequent maximization of their care. Where physicians were once left with no choice but to dismiss patients for lack of options, now they stand able to help, but uncertain of what will provide the most benefit. Additionally, a better understanding of the biology of migraine and the utility of these medications has opened the window for increased identification and education of patients, as well as an improved familiarity with their needs.
For migraine specialists, it is certain that although the past was dark, the future is quite bright. But as physicians such as Richard B. Lipton, MD, know all too well, the patients of the present do not necessarily benefit from the advances of the future. In the meantime, the focus has shifted from simply developing options to demonstrating optimization—both for the future and for the now. This, in turn, has resulted in a blurring of the lines, so to say, between preventive and acute care.
“For many years, we drew a bright line distinguishing between acute treatment and preventive treatment, and we really thought of them as separate entirely,” Lipton, who is the Edwin S. Lowe Professor and vice-chair of neurology, a professor of epidemiology and population health, and a professor of psychiatry and behavioral sciences at the Albert Einstein College of Medicine, and director of the Montefiore Headache Center, told NeurologyLive. “When you're studying preventive treatment, you study the reduction in monthly headache days, and when you study acute treatments, you study relief of an ongoing attack 2 hours after taking drugs, in general. We viewed the differences between acute and preventive treatment as fundamental and biologically based.”
Lipton elucidated that specifically, 2 events caused this reconsideration of the bright line that was previously painted between acute and preventive treatments—the CGRP agents and the neuromodulation devices, which have shown to have both preventive and acute applications. This knowledge of the disease has improved, and now the understanding of the patients with it and their needs must improve as well. As such, over the last decade of this modern age of care, the gathering of epidemiologic data has certainly come to the forefront.
For example, the development of drugs targeting calcitonin gene-related peptide (CGRP) has led to effective and targeted treatments for the prevention of migraine for essentially the first time in history. A welcomed step forward, of course, but as studies have shown, not every patient derives benefit from these drugs. On top of this, patient prevalence is quite high. A 2018 systematic review suggested that 1 in 6 Americans suffers from the debilitating condition,1 and the Migraine Research Foundation estimated it as the third most prevalent disease in the world.2 In 2019, another study noted that the 1-year prevalence of incident migraine was 2.2% (1.5% in men and 3.1% in women), with close to 12% of patients found to have severe disability related to the condition.3 These findings add weight to the need to answer the burning questions of which patients need preventive or acute care options, or both.
“The reality is, not everyone with migraine needs a preventive at all. Our estimate is that a little under 40% of people with migraine are candidates for preventive therapy. For the vast majority, all they need is acute treatment,” Lipton said.
“There are people who appropriately self-treat with over-the-counter medications [OTCs] and have no unmet needs. But there are also people who are using OTCs only who've never seen a doctor,” he explained. “There are barriers at the level of seeking care, there are barriers at the level of diagnosis, and then if you seek care and get a diagnosis, are you getting minimally effective treatment?”
As well, each additional approval has come with its own challenges in incorporation into care. Lipton explained that the triptans, as well as opioids and barbiturate combination agents, can actually worsen severity and cause patients to develop medication overuse headache (MOH) if not taken carefully, adding to patient education as a priority. Epidemiologic data suggest that the prevalence of MOH is highest among adults aged 30 to 50 years, with a preponderance of cases in female patients versus male patients (the ratio ranging from 3:1 to 4:1). Furthermore, between 21% and 52% of pediatric patients with chronic headache meet the diagnostic criteria for MOH.4
Also, as access to new agents increases, so does the patient awareness about the disease; more treatment options means more patients willing to try treatment. But as the number of patients increases, the ability of migraine specialists to see every individual decreases similarly.
Studies have also revealed challenges in patient education about the disease, in spite of increasing awareness. Many patients, it seems, are still seeking care either unsuccessfully, or in the wrong places. In the MAST study, only approximately 21% of persons with migraine had reported a diagnosis by a health care provider, despite the lifetime rate of medical consultation for headache being 79.8%.3 Additionally, the OVERCOME study revealed that migraine is most often seen by primary care providers, with just about 15% of individuals with migraine visiting headache specialists, and another 15% seeking care from pain specialists.5
This leads to concerns not only about patients possibly getting inappropriate treatments but about the education around migraine care for physicians who do not specialize in headache disorders. Particularly, there is a glaring need in primary care. Additional data from OVERCOME revealed that these physicians prescribe triptans to 33% of patients with migraine and opioids, which many headache specialists do not recommend, to 27%.6
“I think a huge gap is, first of all, giving primary care doctors the time that they need to manage migraine, and getting them up to speed on emerging therapies,” Lipton said. “The majority of [non-specialist-treated] patients are seen by pediatricians, internists, family doctors, and gynecologists. It's a little outrageous for me to say that primary care doctors should do a better job in migraine management, but I do think headache is part of the remit of primary care doctors. I'm very interested in improving migraine care in primary care settings, and I think there's a huge opportunity there.”
Lipton also noted that patients tend to fall off from treatment quite rapidly due to lack of efficacy or lack of diagnosis, as well, even if they are among those who have sought care for their migraines. He estimated that of those with migraine and disability on their current treatment, perhaps 60% are currently seeking care, and of those, perhaps 70% have gotten an actual diagnosis of migraine from a healthcare professional.
“At the end of the day, there are a lot of people with migraine and disability who are not reversing all 3 of those barriers to effective treatment,” Lipton explained.
Although migraine care has definitively taken great leaps forward in the pharmacologic sense, there is certainly more to glean about the use of these drugs, and a number of pressing issues remain unaddressed. Increasing patient awareness and improving their personal disease management is still a priority and cultivating the non-headache physician's understanding of migraine is paramount.
Though for Lipton, even in light of these challenges, the coming years are ripe with opportunity. “We never know what we're going to learn in the future,” he said.