Migraine prescription density and recommendations. Results of the PCAOM Study

Shortcomings and missed potentials in the management of migraine patients - experiences from a specialized tertiary care center

Background

Migraine is a common and severely disabling neurological disorder affecting millions of patients in Europe. Despite the availability of evidence-based national and international guidelines, the management of migraine patients often remains poor, which is often attributed to a low availability of headache specialists. The aim of this study was to investigate the adherence to national guidelines and to assess the possible potential of optimized therapy regimens in migraine patients.

Methods

We collected data of migraine patients presenting to our out-patient clinic via standardized questionnaires regarding headache, diagnostics and experience with previous treatments. We also assessed the efficacy of treatment started by our center.

Results

1,935 migraine patients were included between 2010 and 2018. In the 12 months before consulting our headache clinic 89.5% of the patients had consulted a general practitioner and 74.9% had consulted a neurologist because of their migraine. Nevertheless, 50% of the patients underwent unnecessary diagnostics and 34.2% had not been treated according to evidence-based treatment guidelines. Out of 1,031 patients who had not been prescribed a preventative treatment 627 (60.8%) had in average 3 or more migraine attacks per month and thus qualified for a preventative treatment. These patients missed in the 3 months prior to consultation on average 5 work or school days. Initiating a preventative treatment was effective in 71.2% of the patients, that provided follow-up data.

Conclusions

Our data suggest, that many migraine patients to this day do not receive state-of-the-art therapy. Adherence to national and international European guidelines could improve the outcome in migraine patients. Future research should try to answer why guidelines are not followed.

Prescription patterns in preventive and abortive migraine medication

BACKGROUND

Migraine is considered a common but under-diagnosed and untreated condition. Treatment patterns have pointed at frequent over-the-counter medication use and low use of preventive therapies. Studies exploring migraine prescription practice among doctors are few.

METHODS

A population-based study was carried out to examine the prescription practice in the use of acute and preventive migraine medications. The data covered 4864 working-age people reporting they have been diagnosed with migraine. Data on reimbursed prescription medicines from 1 January 1998 to 31 December 2006 were drawn from the registers of the Social Insurance Institute of Finland and compared with age- and sex-matched controls.

RESULTS

Anti-inflammatory analgesics were prescribed for 71% of female and 62% of male migraine patients vs. 56% and 50% of controls. Triptans were prescribed for 21% of female and 10% of male patients. Combinations of analgesics and muscle relaxants were offered to 37% of female and 29% of male patients vs. 26% and 21% of controls, and antidepressants to 19% of women and 14% of men vs. 13% and 9% of controls.

CONCLUSION

Although use of preventive medication among migraineurs was high, the prescription patterns in acute treatments showed that NSAIDS were used more often than triptans. Assimilation of national guidelines to treat migraine published in 2002 in Finland was not reflected in the prescription patterns up to 2006.

[Predisposing factors of the migraine syndrome in children]

INTRODUCTION

The aim of this paper was to define characteristics which could be used to recognize groups of children at risk for migraine syndrome.

MATERIAL AND METHODS

Predisposing factors of migraine syndrome were investigated by conducting a poll among 24.828 children aged 3-16, in Vojvodina, during the period between 1988-2004.

RESULTS

For the purpose of defining recognizable characteristics of children with migraine syndrome, a comparison of children with migraine headaches, non-migraine headaches, and those without headaches was done among 24.828 children. Apart from direct heredity, the following factors should be accepted as predisposing factors of migraine syndrome: child's order of birth (second child), length of breast-feeding, age at which the ready-made industrial food was introduced, as well as the age at which the child started the whole-day stay (which is in inverse proportion to the risk of migraine attacks and the age of the first symptoms), particularities in behaviour pattern, family social status, atmosphere in the family, previous paroxysmal torticollis, episodic vertigo of unknown etiology, recurrent abdominal pain, and lack of cerebral hemisphere dominance.

CONCLUSION

Children with migraine headaches have particularities, not clear enough for the time being, but recognition of which is necessary for early prevention of migraine syndrome in childhood.

Doctors' prescription behaviour regarding dosage recommendations for preparations of kava extracts

BACKGROUND

There are many publications on the use of kava extracts as a treatment alternative to tricyclic antidepressants and benzodiazepines, but little has been done to investigate the potential adverse effects that may be associated with prolonged or high-dose usage.

OBJECTIVES

To investigate the extent to which physicians comply with the recommended daily dose (RDD) of an antidepressant such as kava and the consequences of this behaviour with regard to the safety and efficacy of frequently prescribed kava extracts (Trade names: Antares, Laitan and Kavasporal forte).

METHOD

The analysis was carried out using the patient database MediPlus, which provides anonymous access to a representative and valid panel of physicians and patients in Germany.

RESULTS

Prescriptions for Antares showed that the RDD of 1 tablet per day was exceeded in 58.2% of the cases, while those for Laitan showed that the RDD of 1 capsule per day was significantly exceeded in 75.6% of the cases; a one-off prescription was issued in 66% of the cases. As a result, the required effect diminished very quickly. Prescriptions for Kavasporal forte showed that the daily dosage of 2 capsules per day complied with the recommendations in only 49.1% of the cases; in 38.8% of the cases, the dosage dropped below the respective recommendation. As a consequence, the lower-dosed Kavasporal forte was prescribed for longer periods than the higher-dosed Antares and Laitan.

CONCLUSIONS

In the case of a low-dosage recommendation, we saw a trend to over-dose in prescribing behaviour, which increases the risk of undesirable adverse reactions. On the other hand, we saw a trend to under-dose in the case of a higher dosage recommendation. This fact may explain the unexpected inefficacy of the therapy. These trends affected the duration of therapy, whereby a dosage lower than the RDD was prescribed for a longer period than a dosage higher than the RDD.

Migraine consultation patterns in primary care. Results from the PCAOM study 1994-96

In order to establish a basis for the planning of improved medical care of migraine in Germany, we report on the proportion of migraine patients under primary care and the continuity of consultations for migraine as determined by age, gender, and history of migraine and nonmigraine practice contact (Primary Care of Migraine, PCAOM Study). A primary-care-physician-based migraineurs' sample of 16,573 women and 4,636 men (MediPlus, IMS Health) was placed in relation to cases expected according to International Headache Society criteria in the base population, and was followed for up to 3 years for repeat consultations. Overall, no more than 51% and 37%, respectively, of female and male statutory health-insured migraine headache sufferers had a migraine diagnosis mentioned at least once a year in primary care. At younger ages, substantially less advantage was taken of available primary healthcare for migraine; 79% of the women and 74% of the men were estimated to present again to the same primary-care physician within 3 years because of migraine, the corresponding figures for patients with no history of migraine in the practice concerned being 41% and 31%, respectively. Following first migraine contacts, time to recontact and quarterly recontact prevalences for migraine did not differ, whether on the basis of an established nonmigraine primary care relationship or a first encounter with a medical practice. Trust evidenced by an existing nonmigraine doctor-patient relationship apparently did not carry over to migraine. Results indicate that one of the greatest challenges in relation to the care of migraine patients in Germany is to establish and maintain solid doctor-patient relationships.