{"id":2666,"date":"2018-03-28T06:26:18","date_gmt":"2018-03-28T06:26:18","guid":{"rendered":"https:\/\/www.touchneurology.com\/2018\/03\/28\/expert-perspectives-migraine-prevention-for-highly-impacted-patients\/"},"modified":"2019-10-01T11:27:41","modified_gmt":"2019-10-01T10:27:41","slug":"expert-perspectives-migraine-prevention-for-highly-impacted-patients","status":"publish","type":"post","link":"https:\/\/touchneurology.com\/headache-disorders\/journal-articles\/expert-perspectives-migraine-prevention-for-highly-impacted-patients\/","title":{"rendered":"Expert Perspectives\u2014Migraine Prevention for Highly Impacted Patients"},"content":{"rendered":"
Presented by: Richard B Lipton<\/b><\/p>\n
Albert Einstein College of Medicine, Bronx, NY, US<\/p>\n
Current guidelines recommend preventive treatments for people who experience frequent and disabling migraine headaches, specifically those suffering headaches on 4 or more days\/month.1<\/span> However, only one-third of people eligible for preventive treatments actually receive them, and of these, over three-quarters discontinue the treatment over the course of 1 year due to efficacy and safety limitations.1\u20133<\/span> Here we discuss the burden of migraine, barriers to the use of preventive treatments, and current and emerging approaches to treating migraine in highly impacted patients.<\/p>\n Scope and burden of the migraine problem<\/p>\n Migraine is a global problem that affects more than 10% of the population worldwide \u2014 an estimated 1.04 billion people.4<\/span> Of these, many experience at least 4 days\/month of migraine and should therefore be considered potential candidates for preventive treatment.5<\/span><\/p>\n Several studies have assessed the impact of migraine. The American Migraine Prevalence and Prevention (AMPP) study used a validated, self-administered questionnaire to assess disease burden in over 18,000 individuals with migraine.1<\/span> Migraine episodes resulted in severe impairment or necessitated bed rest in 53.7% of cases and caused some impairment in 39.1% of cases, with normal function reported in only 7.2% of cases.1<\/span> As a result of this impairment, migraine headaches caused substantially reduced participation in everyday activities as assessed by the Migraine Disability Assessment (MIDAS) questionnaire: in 3 months, more than a quarter of patients missed at least a day of work\/school, nearly half were unable to do housework or chores for a day or more and nearly one third missed at least a day of family or social activity.1<\/span><\/p>\n The Global Burden of Disease study assessed the burden of over 300 diseases and injuries between 1990 and 2016 based on the number of years of healthy life lost as a result of a disability (years lived with disability [YLD]).4<\/span> In 2016, migraine was found to be the second leading cause of YLD worldwide with 45.1 million YLD, ahead of conditions such as major depression, diabetes, and anxiety disorders.4<\/span><\/p>\n Presented by: Richard B Lipton<\/b><\/p>\n Albert Einstein College of Medicine, Bronx, NY, US<\/p>\n Who needs preventive treatment?<\/p>\n Several factors should be taken into account when considering preventive treatment for a patient with migraine. These include the frequency of headaches, interference with routine activities, migraine subtype, issues with acute medications, elevated risk for headache progression or other adverse neurological outcomes, and patient preference. That said, traditional criteria for preventive treatment focus, in part, on the frequency of headaches.5,6 <\/span>The frequency of headaches in patients with migraine varies over time and exists on a dynamic spectrum. Emerging evidence shows that patients transition from episodic migraine (less than 15 headache days\/month) to chronic migraine (15 or more headache days\/month; a process termed \u201cchronification\u201d7,8<\/span>) and vice versa<\/span> (Figure\u00a01<\/span>).9\u201311<\/span> Highly impacted patients can include those with high-frequency episodic migraine, chronic migraine, or medication-overuse headache. Highly impacted patients typically have 4 or more migraine days\/month associated with significant interference in routine activities despite the use of acute treatment.5<\/span> In these patients, acute medications may be ineffective, overused, poorly optimized, or associated with troublesome adverse events (AEs), and in some patients triptans or non-steroidal anti-inflammatory agents may be contraindicated. Highly impacted patients may also present with uncommon subtypes of migraine, for example, hemiplegic migraine, migraine with brainstem aura, migraine with prolonged or persistent aura, or migrainous infarction.<\/p>\n <\/p>\n <\/p>\n Numerous predictors of headache progression from episodic to chronic migraine have been identified. These include headache features, comorbidities, and treatment-related factors. Persons with higher headache frequencies and allodynia are at increased risk for progression.12\u201314<\/span> Comorbidities associated with worsening headache include obesity, sleep disorders, depression, anxiety, asthma, and other respiratory disorders.11,13,14<\/span> Poor response to acute treatment and medication overuse are associated with chronic migraine onset in persons with episodic migraine.12,14<\/span> Progression from episodic to chronic migraine is also associated with increasing disability, and disability increases with an increased frequency of headache days (Figure 2<\/span>).8<\/span> Reducing the frequency of headache days is therefore a key treatment goal that effective preventive treatments should address.<\/p>\n Factors associated with reversion from chronic to episodic migraine have also been identified. A multivariate analysis of data from the AMPP study showed that baseline headache frequency is a predictor of remission from chronic to episodic migraine, i.e. a lower frequency of headache days is associated with a higher transformation from chronic to episodic migraine (15\u201319 versus 25\u201331 headache days\/month; odds ratio: 0.29 [95% confidence interval: 0.11\u20130.75]).10<\/span><\/p>\n What are the barriers to preventive treatment?<\/p>\n Preventive treatments for migraine are currently underused. Indeed, results of the AMPP study showed that approximately two-thirds of individuals with migraine who would qualify for preventive treatment do not receive it.1,15 <\/span>Potential barriers to achieving optimal, or even satisfactory, migraine control occur at three levels: consultation, diagnosis, and treatment. Some people with migraine may never seek medical care or lapse from care, and many diagnosed patients may not get adequate treatment, either acute or preventive, at the time of diagnosis or with follow-up.16<\/span> Follow-up is important as the initial treatment may be suboptimal or a patient\u2019s condition may change over time, therefore treatments may need to be adjusted to account for changes in efficacy, tolerability, adherence and\/or persistence.<\/p>\n To quantify the impact of these barriers to effective migraine management, a retrospective analysis of data from the AMPP study and the Chronic Migraine Epidemiology and Outcomes (CaMEO) study was performed.17,18<\/span> For episodic migraine, only 26.3% of people with migraine traversed all three barriers and received minimally appropriate treatment. For chronic migraine, only 4.5% of people traversed these barriers (Figure 3<\/span>).17,18<\/span> Diagnosis and treatment rates are lower for chronic migraine because the diagnostic rates are lower in consulters and because preventive treatment is part of the start-of-care for chronic migraine (and underused). Overall, these findings highlight the substantial unmet medical need in patients with migraine.<\/p>\n <\/p>\n Who discontinues preventive treatment and why?<\/p>\n Current preventive treatments (both on- and off-label) include antiepileptics (e.g. topiramate, divalproex), antidepressants (e.g. amitriptyline, venlafaxine), beta-blockers (e.g. timolol, propranolol, metoprolol), angiotensin-converting enzyme inhibitors (e.g. lisinopril), and angiotensin receptor blockers (e.g. candesartan).5,19<\/span> However, adherence to these treatments is poor; a retrospective claims database analysis of 8,688 patients experiencing 15 or more headache days\/month found that only 17\u201320% of patients remained adherent (defined as prescription claims covering at least 80% of days) to preventive medication after 1 year.2<\/span><\/p>\nWhich patients are highly impacted by migraine?<\/h3>\n