Identifying Outcome Measures for Migraine Value-Based Contracting Using the Delphi Method

Pharmacologic Treatment of Acute Attacks of Episodic Migraine: A Systematic Review and Network Meta-analysis for the American College of Physicians

BACKGROUND

Migraine is common, affecting 15% of Americans.

PURPOSE

To compare benefits and harms of pharmacologic treatments for acute attacks of episodic migraine in adults and assess cost-effectiveness.

DATA SOURCES

Three electronic databases searched to October 2024, gray literature, and reference lists.

STUDY SELECTION

Two investigators independently selected English-language randomized trials.

DATA EXTRACTION

Single reviewer data extraction with second review. Dual independent risk of bias and certainty of evidence (COE) assessment.

DATA SYNTHESIS

Twenty-one head-to-head and 165 placebo-controlled trials were included in meta-analyses and network meta-analyses. Triptans were more effective than acetaminophen (low COE) and nonsteroidal anti-inflammatory drugs (NSAIDs) (high COE) for pain outcomes at 2 hours and pain freedom up to 48 hours. Triptan and acetaminophen combinations were more effective than acetaminophen alone (moderate COE) for pain outcomes at 2 hours and pain freedom up to 48 hours but not more than triptans alone (low COE). Triptan and NSAID combinations were more effective for pain outcomes at 2 hours and pain freedom up to 48 hours compared with acetaminophen (low COE), gepants (low COE), NSAIDs (high COE), and triptan monotherapy (moderate COE). Triptan regimens, however, often had a higher risk for adverse events. One study found triptans more cost-effective than ditans and gepants.

LIMITATIONS

Harms assessment was limited to randomized trials. Many comparisons lacked sufficient evidence to draw conclusions.

CONCLUSION

Triptans and combinations of triptans were more effective than NSAID and acetaminophen alone.

PRIMARY FUNDING SOURCE

American College of Physicians. (PROSPERO: CRD42023441146).

Patients' Values and Preferences Regarding the Pharmacologic Treatment of Acute Episodic Migraine : A Rapid Review

BACKGROUND

Understanding patients' values and preferences is essential for guideline development.

PURPOSE

To identify and synthesize evidence on patients' values and preferences for the American College of Physicians (ACP) clinical guideline on the pharmacologic treatment of acute attacks of episodic migraine.

DATA SOURCES

MEDLINE (Ovid) and CINAHL (EBSCO) were searched from inception to October 2024, and backward citation searches on pertinent publications were performed.

STUDY SELECTION

Reviewers dually screened abstracts and articles.

DATA EXTRACTION

One reviewer performed data extraction, and a second team member checked for accuracy. Risk of bias was assessed in the included studies dually.

DATA SYNTHESIS

The data were synthesized narratively and the certainty of evidence (COE) was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and GRADE-CERQual (GRADE-Confidence in the Evidence from Reviews of Qualitative Research) guidance. Of 2243 references screened, we included 16 quantitative studies and 1 qualitative study. Effectiveness for pain was rated as more important than avoiding harms (moderate COE) or treating accompanying symptoms (moderate COE). Both effectiveness for pain and avoiding harms were more important than other attributes such as convenience or route of administration (moderate COE). Relieving nausea and vomiting was more important than other accompanying symptoms, such as photophobia (moderate COE). Cost was not important (moderate COE).

LIMITATIONS

The choices in the included studies differed, making synthesis difficult and reducing certainty. Generalizability is limited because the included studies span 29 years and included patients of average age 35 to 47 years. Potential variation between patients was not captured.

CONCLUSIONS

Patients value effectiveness for pain foremost, and avoiding harm is more important than other treatment attributes.

PRIMARY FUNDING SOURCE

American College of Physicians. (PROSPERO: CRD42023464889).

Core Outcome Set Development for Tension-Type Headache Treatment Using Traditional Chinese Medicine: Protocol for a Delphi Consensus Study

BACKGROUND

Tension-type headache (TTH) is the most common type of headache and the second most common health-related complaint among children and adults. Traditional Chinese medicine (TCM) offers unique therapeutic benefits in treating TTH. However, the lack of standardized evidence-such as inconsistencies in outcome selection and reporting in clinical studies, a lack of consensus on outcomes and measures, high risks of selective reporting bias, and missing data-has limited the development of robust evidence supporting the efficacy of TCM in treating TTH. Therefore, establishing a core outcome set (COS) is crucial for standardizing TCM clinical studies for TTH, thereby enhancing the quality and comparability of research findings.

OBJECTIVE

This study aims to develop a COS for future clinical studies on the treatment of TTH with TCM.

METHODS

The COS will be developed through the following 3 stages. First, systematic reviews and semistructured interviews will be conducted to identify potential essential outcomes, which will be evaluated by the steering committee to finalize a preliminary list of outcomes. Data will be processed using thematic analysis to ensure comprehensive coverage of relevant outcomes. Second, a 2-round Delphi survey will be conducted, inviting stakeholders, including health care experts and patients with tension-type headaches, to determine the importance of each outcome. Statistical analysis will be used to assess the level of consensus and prioritize outcomes based on predefined criteria. Third, a face-to-face consensus meeting will be held to finalize the COS and recommend measurement times for each outcome. Key outcomes will be interpreted based on their clinical relevance and feasibility of measurement, ensuring the COS is comprehensive and applicable in clinical settings.

RESULTS

The protocol has been registered in PROSPERO, with the review commencing on October 1, 2024, and anticipated results by November 15, 2024. The systematic reviews will be finalized, followed by the Delphi survey and consensus conference in late 2024 and early 2025. The COS findings will be reported per COS-STAR (Core Outcome Set-STAndards for Reporting) guidelines, published in an international journal, presented at conferences, and disseminated to participants for clinical application.

CONCLUSIONS

This study is necessary as developing a COS for future TCM clinical studies in the treatment of TTH can maximize the value of data from individual trials and provide high-quality research evidence.

TRIAL REGISTRATION

Core Outcome Measures in Effectiveness Trials Initiative 1473; https://tinyurl.com/3ts62s2p.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/63481.

Priority acute and preventive migraine treatment benefits: Results of the Migraine Clinical Outcome Assessment System (MiCOAS) qualitative study of people living with migraine

BACKGROUND

There is renewed emphasis on including patients in determining, defining, and prioritizing outcomes for migraine treatment.

OBJECTIVES

To obtain insights directly from people living with migraine on their priorities for treatment.

METHODS

A total of 40 qualitative interviews were conducted as part of the Migraine Clinical Outcome Assessment System project, a United States Food and Drug Administration grant-funded program to develop a core set of patient-centered outcome measures for migraine clinical trials. Interviews included a structured exercise in which participants rank-ordered pre-defined lists of potential benefits for acute and preventive migraine therapy. The 40 study participants who reported being diagnosed with migraine by a clinician ranked the benefits and explained their rationale.

RESULTS

Study participants consistently ranked either pain relief or absence of pain as their top priority for acute treatment. Relief/absence of other migraine symptoms and improved functioning were also prioritized. For preventive treatment, participants prioritized reductions in migraine frequency, symptom severity, and attack duration. Few differences were found between participants with episodic migraine and those with chronic migraine. However, participants with chronic migraine ranked "increased predictability of attacks" much higher than those with episodic migraine. Participants' rankings were influenced by prior expectations and experiences of migraine treatments, which caused many participants to deprioritize desired benefits as unrealistic. Participants also identified several additional priorities, including limited side-effects and reliable treatment efficacy in both acute and preventive treatments.

CONCLUSION

The results showed the participants prioritized treatment benefits aligned with existing core clinical outcomes used in migraine research, but also valued benefits that are not typically assessed, such as predictability. Participants also deprioritized important benefits when they believed treatment was unlikely to deliver those outcomes.

Expert consensus established around flexible, individualized migraine treatment utilizing a modified Delphi panel

OBJECTIVE

To characterize treatment decision-making processes and formalize consensus regarding key factors headache specialists consider in treatment decisions for patients with migraine, considering novel therapies.

BACKGROUND

Migraine therapies have long been subject to binary classification, acute versus preventive, due to limitations of available drugs. The emergence of novel therapies that can be used more flexibly creates an opportunity to rethink this binary classification. To determine the role of these novel therapies in treatment, it is critical to understand whether existing guidelines reflect clinical practice and to establish consensus around factors driving management.

METHODS

A three-round modified Delphi process was conducted with migraine clinical experts. Round 1 consisted of an online questionnaire; Round 2 involved an online discussion of aggregated Round 1 results; and Round 3 allowed participants to revise Round 1 responses, incorporating Round 2 insights. Questions elicited likelihood ratings (0 = highly unlikely to 100 = highly likely), rankings, and estimates on treatment decision-making.

RESULTS

Nineteen experts completed three Delphi rounds. Experts strongly agreed on definitions for "acute" (median = 100, inter-quartile range [IQR] = 5) and "preventive" treatment (median = 90, IQR = 15), but noted a need for treatment customization for patients (median = 100, IQR = 6). Experts noted certain aspects of guidelines may no longer apply based on established tolerability and efficacy of newer acute and preventive agents (median = 91, IQR = 17). Further, experts agreed on a treatment category referred to as "situational prevention" (or "short-term prevention") for patients with reliable and predictable migraine triggers (median = 100, IQR = 10) or time-limited periods when headache avoidance is important (median = 100, IQR = 12).

CONCLUSIONS

Using the modified Delphi method, a panel of migraine experts identified the importance of customizing treatment for people with migraine and the utility of "situational prevention," given the ability of new treatment options to meet this need and the potential to clinically identify patients and time periods when this approach would add value.

Core outcome set for preventive intervention trials in chronic and episodic migraine (COSMIG): an international, consensus-derived and multistakeholder initiative

OBJECTIVE

Typically, migraine prevention trials focus on reducing migraine days. This narrow focus may not capture all that is important to people with migraine. Inconsistency in outcome selection across trials limits the potential for data pooling and evidence synthesis. In response, we describe the development of core outcome set for migraine (COSMIG).

DESIGN

A two-stage approach sought to achieve international, multistakeholder consensus on both the core domain set and core measurement set. Following construction of a comprehensive list of outcomes, expert panellists (patients, healthcare professionals and researchers) completed a three-round electronic-Delphi study to support a reduction and prioritisation of core domains and outcomes. Participants in a consensus meeting finalised the core domains and methods of assessment. All stages were overseen by an international core team, including patient research partners.

RESULTS

There was a good representation of patients (episodic migraine (n=34) and chronic migraine (n=42)) and healthcare professionals (n=33) with high response and retention rates. The initial list of domains and outcomes was reduced from >50 to 7 core domains for consideration in the consensus meeting, during which a 2-domain core outcome set was agreed.

CONCLUSION

International and multistakeholder consensus emerged to describe a two-domain core outcome set for reporting research on preventive interventions for chronic and episodic migraine: migraine-specific pain and migraine-specific quality of life. Intensity of migraine pain assessed with an 11-point Numerical Rating Scale and the frequency as the number of headache/migraine days over a specified time period. Migraine-specific quality of life assessed using the Migraine Functional Impact Questionnaire.