Use and misuse of triptans in France: data from the GRIM2000 population survey

Update of French migraine epidemiology: A narrative review

This narrative review concerned the studies performed on representative samples of the French general population carried out over more than thirty years and aims to provide an update on the French migraine epidemiology. Eleven studies were selected (GRIM-1, MIG-ACCESS, GRIM-2, FRAMIG-2000, FRAMIG-3, GRIM-3, EUROLIGHT, IBMS, SNDS PACA/CORSICA, EGB FRANCE, CaMEO-I). The data extracted relates to four healings: prevalence and distribution, individual burden, recognition and care and societal burden.

Headache Attributed to a Substance or Its Withdrawal

Identification of substances that may cause or trigger headache is important to start effective treatment early to prevent unnecessary suffering, deterioration in quality of life, and the development of chronic pain. Treatment in case of medication overuse and other chronic headache should be decisive and effective. Drug withdrawal and introduction of effective prophylactic medication for the underlying headache disorder should be the primary treatment strategy. Typical headache-inducing substances are nitric oxide, phosphodiesterase, cocaine, alcohol, histamine, carbon oxide, and calcitonin gene-related peptide. The withdrawal of caffeine, estrogen, and opioids is most often associated with the development of headache.

Migraine burden and costs in France: a nationwide claims database analysis of triptan users

Objectives: To estimate the burden of migraine in the population of French patients identified as specific migraine acute treatment users compared to a control group. Methods: A cross-sectional retrospective analysis was performed on the Echantillon Généraliste des Bénéficiaires claims database, a 1/97 random sample of the French public insurance database. A representative sample of all adults with at least one delivery of triptans, ergot derivatives or acetylsalicylic acid/metoclopramide (all drugs with a specific label in migraine acute treatment - SMAT) in 2014 was selected with a control group matched on age, gender and geographic region. Among triptan users, a sub-group of over-users was defined according to their level of triptan uptake expressed in defined daily doses (DDD - a standard daily dose of treatment of acute migraine) per month over 3 months and more, was also compared with controls. The cost analysis was performed in a societal perspective for direct costs. Sick leave indirect costs were estimated using the human capital approach. Results: In total 8639 SMAT users (mean age: 44.6 years; 78.7% women) were selected representing a crude prevalence rate of 1.7%. The annual per capita total healthcare expenditures were higher by €280 in this group compared to controls (€2463 vs. €2183). Triptans contributed 47.8% to this extra cost. They used significantly (p < .0001) more frequently than controls antidepressants (20.8% vs. 11.0%), anxiolytics (29.4% vs. 18.8%) and analgesics (53.8% vs. 35.8%). The per capita annual productivity loss associated with sick leave was higher by €295 (€1712 vs. €1417). Among triptan users, there were 2.9% over-users. This last group was characterized by substantially higher per capita annual extra direct (+ €1805) and indirect costs (productivity loss +€706) compared to controls. Conclusions: Due to its high prevalence, migraine costs generate a significant societal burden. The group of over-users concentrates high per capita direct and indirect costs.

Epidemiology of migraine: French key descriptive data

France is a country for which the epidemiology of migraine is very well known. Based on the results of the main studies over the last 20 years, this brief review presents the key descriptive data for French migraine epidemiology, and considers its prevalence, individual impact, recognition and medical management, and social impact.

Triptans use and overuse: A pharmacoepidemiology study from the French health insurance system database covering 4.1 million people

Introduction

The objective of this study was to estimate and to characterize the actual patterns of triptan use and overuse in France using a drug reimbursement database.

Methods

We included all people covered by the French General Health Insurance System (GHIS) from the Provence-Alpes-Côte-d’Azur (PACA) and Corsica administrative areas who had at least one dispensed dose of triptans between May 2010 and December 2011. All dispensed doses of triptans, migraine prophylactic treatment and psychotropic medications were extracted from the GHIS database. Triptan overuse was defined as triptan use >20 defined daily doses (DDD) per month on a regular basis for more than three consecutive months. Risk of overuse was assessed using logistic regression adjusted for gender and age.

Results

We included 99,540 patients who had at least one prescription of a triptan over the 20 months of the study. Among them, 2243 patients (2.3%) were identified as overusers and received 20.2% of the total DDD prescribed. Twelve percent of overusers and 6.9% of non-overusers were aged more than 65 years (OR: 1.81). Overusers did not have a greater number of prescribers and pharmacists than non-overusers. They were more frequently prescribed a prophylactic medication for migraine treatment (56.8% vs 35.9%, OR: 2.36), benzodiazepines (69.9% vs 54.7%, OR: 1.93) and antidepressants (49.4% vs 30.2%, OR: 2.33).

Conclusions

This work suggests that triptan overuse may be due to insufficient prescriber awareness of appropriate prescribing. The off-label prescription of triptans among the elderly necessitates investigating their cardiovascular risk profile in this sub-group.

Management of medication-overuse headache

Medication-overuse headache (MOH) has developed into the third most common type of headache after tension-type headache and migraine. The prevalence reaches approximately 1% of the world's population and shows an increasing trend. Many important studies on MOH have been published in the last year, some of which investigated the pathophysiology of headache chronicity, with others focusing on the evaluation of risk factors. The International Headache Society revised its classification criteria on MOH. Several large population-based longitudinal studies clearly demonstrated that overuse of any kind of acute headache medication is the main risk factor leading to the development of chronic headache. Management of MOH remains difficult; the only effective treatment concept is consequent withdrawal therapy.

Medication-overuse headache

PURPOSE OF REVIEW

Medication-overuse headache (MOH) is a well described clinical entity. There is a growing body of knowledge on the epidemiology of MOH, risk factors, and treatment strategies.

RECENT FINDINGS

The International Headache Society updated the classification criteria for MOH. Population-based studies provided an insight into the prevalence and peculiarities of MOH patients in eastern Europe and Asia. Large-scaled population-based longitudinal studies made it possible to analyze risk factors leading to the development of MOH. Imaging studies helped to better understand the pathophysiology of headache chronicity. New treatment strategies have been suggested.

SUMMARY

MOH is a common headache disorder and a serious public health problem all over the world. Although the treatment regimen for MOH patients is straightforward and the outcomes are favorable, it is time now to move forward and establish a predictive model for early recognition of patients at high risk, to intervene early and avoid development of chronic headache.

Medication Overuse Headache: The Reason of Headache That Common and Preventable

Medication overuse headache (MOH) is well-defined clinically and is one of the common reasons of chronic daily headache, but its pathophysiology has not been elucidated yet. MOH has varying clinical features in regard to regional, psychosocial, medical and economic factors. Even though, the studies have shown that many factors may play a role, MOH is likely to occur in patients who are prone to primary headaches. Mainstay of the treatment is to withdraw the excessively used analgesic drugs. The primary prevention with education of the patients as well as early diagnosis and treatment of MOH will reduce its increasing financial burden on both patients and countries. Meticulous and multifactorial evaluation of the disease besides the diagnosis and treatment of the comorbid diseases will reduce the risk of recurrences.

The prevalence of primary headache disorders in Russia: a countrywide survey

OBJECTIVE

To estimate the 1-year prevalences of primary headache disorders and identify their principal risk factors in the general population of Russia.

METHODS

A countrywide population-based random sample of 2725 biologically unrelated adults in 35 cities and nine rural areas were interviewed in a door-to-door survey using a previously validated diagnostic questionnaire.

RESULTS

Of the 2725 eligible adults contacted, 2025 (74.3%) responded (females 52.6%, mean age 39.5 ± 13.4 years). Of these, 1273 (62.9%) reported headache 'not related to flu, hangover, cold, head injury' occurring at least once in the previous year. The gender- and age-standardized 1-year prevalence of migraine was 20.8%. Female gender (odds ratio (OR) = 3.8; 95% confidence interval (CI) 2.8-5.1) and obesity (OR = 1.5; 1.1-2.1) were positively associated with this type of headache. The gender- and age-standardized 1-year prevalence of tension-type headache (TTH) was 30.8%. TTH was more prevalent in urban than in rural areas (OR = 1.6; 1.3-2.0). Headache on ≥15 days/month was reported by 213 (10.5%) respondents (gender- and age-standardized prevalence 10.4%), and associated with low socioeconomic status (OR = 3.4; 2.4-4.9), obesity (OR = 3.0; 2.1-4.3), female gender (OR = 2.9; 2.1-4.1) and age over 40 years (OR = 2.6; 1.9-3.6). The majority of these respondents (68.1%) overused acute headache medications.

CONCLUSION

The study demonstrated a high prevalence of migraine and a very high prevalence of headache on  ≥15 days/month, and revealed unmet health-care needs of people with headache in Russia.

Long-term effects of a sensitisation campaign on migraine: the Casilino study

In 2003, we conducted a sensitisation campaign on migraine in the Casilino district of Rome, by sending a letter with the ID Migraine test to all the households and placing posters in the GPs’ waiting room. Out of 195 headache patients recruited, 92% had migraine while 73% had never consulted a physician for headache. The aim of this study was to evaluate the long-term impact of this campaign. The follow-up was performed by a telephone interview. The questionnaire considered the characteristics of headache, quality of life, preventive and acute treatments, drug efficacy, comorbidity and subjective usefulness of the campaign. Of the 179 migraineurs, 90.5% (mean age 40.7 ± 16.5, 139 females) were included in the follow-up. An improvement was observed in mean pain intensity (−13.9%; p < 0.0001) and mean HIT-6 score (−6.1%; p = 0.0003). The campaign was considered to be useful by 63.6% of cases, while 66.1% reported an improvement in their clinical status. Improved patients showed a decreased mean number of days with headache per month (−51.7%; p < 0.0001), pain intensity (−21.8%; p < 0.0001), headache duration (−18.1%; p = 0.0008) and HIT-6 score (−11.7%; p < 0.0001). Our data suggest that the effects of a “single shot” campaign are beneficial not only in a short-term perspective, but even in the long term. Moreover, the lack of benefit in more severe cases suggests that such patients should not be treated by GPs alone: patients in whom the HIT-6 score, frequency, severity or duration of headache worsen should be promptly referred to the headache clinic.

Treatment of migraine and tension-type headache in Croatia

The aim of this study was to assess the treatment patterns of migraine and tension-type headache in the Croatian population. Analysis included the proportion of patients who were taking specific antimigraine therapy and the number of tablets per attack per month, the proportion of patients who were taking prophylactic therapy or using alternative treatment methods and their satisfaction with the treatment. The design of the study was a cross-sectional survey. Self-completed questionnaires were randomly distributed to adults >18 years of age in the Croatian population. A total of 616 questionnaires were analyzed: 115 patients with migraine (M), 327 patients with tension-type headache (TTH), and 174 patients with probable migraine (PM) and TTH. Specific antimigraine therapy was taken by half of patients with migraine: 35.7% of patients used triptans and 21.7% ergotamines. Prophylactic treatment had been used by 13.9% of M, 1.2% of TTH, and 6.9% of PM patients. Alternative methods of treatment were tried by 27% of M and TTH patients. Only 16.8% of patients with M pay regular visits to physicians, while 36.3% never visited a physician. More than half of TTH patients have never visited a physician. The majority of patients are only partially satisfied with their current treatment, and almost one-third are not satisfied. Results of this study indicate that the treatment of primary headaches in Croatia should be improved.

Headache attributed to a substance or its withdrawal

Medication overuse, and subsequent medication overuse headache (MOH), is a growing and still underestimated problem worldwide. A significant number of recent epidemiological studies suggest that up to 4% of the general population in Europe, North America, and Asia overuse analgesics and other drugs for the treatment of pain conditions such as migraine. These studies also provide convincing evidence that about 1% of the general population suffers from MOH. The condition can be caused by almost all antiheadache drugs, including analgesics, ergots, triptans, and combined preparations. The clinical symptoms of MOH are heterogeneous and may vary from just an increase in headache attack frequency to a constant holocranial pain over years. The International Headache Society (IHS) defined MOH in its first classification in 1988 but modified the diagnostic criteria in its second classification in 2004 to facilitate diagnosis and the conduct of clinical trials. The underlying pathophysiology of MOH is not well understood. The only therapy is withdrawal from the overused substances. The only strategy to reduce the prevalence of MOH is to prevent the development of MOH in the first place by clear restriction of monthly doses of antiheadache drugs and constant education of both patients and physicians prescribing or recommending antiheadache drugs.

From drug-induced headache to medication overuse headache. A short epidemiological review, with a focus on Latin American countries

Medication overuse headache (MOH) is a daily or almost-daily type of headache that results from the chronicization, usually migraine or tension-type headache, as a consequence of the progressive increase of intake of symptomatic drugs. MOH is now the third most frequent type of headache and affects a percentage of 1-1.4% of the general population. The currently available data on the impact of chronic headache associated with analgesic overuse in specialist headache centres confirm, beyond doubt, the existence of a serious health problem. Limited amount of data exists on the burden and impact of MOH in Latin American Countries. In this review, we summarise the reliable information from the literature on the epidemiological impact of MOH.

Use and overuse of antimigraine drugs by pharmacy personnel in France: COTA survey

BACKGROUND

Pharmacy personnel are supposed to be well informed of recommendations for proper migraine management, but their easy access to medicines may favor self-medication and promote medication overuse for those with frequent migraine attacks.

OBJECTIVE

The main objective of the COTA survey was to investigate migraine management by pharmacy personnel who considered themselves as migraineurs.

METHODS

Out of 22,000 pharmacies currently open in France, a questionnaire was proposed to a random sample of approximately 4000 pharmacies with at least 1 self-considered migraineur in the pharmacy staff who accepted to complete and return the questionnaire. The reality of migraine was assessed by the study questionnaire according to the International Classification of Headache Disorders, 2nd edition (ICHD-II) criteria. In addition, the study questionnaire inquired about subjects' demographics, headache characteristics, consumption of medications for headaches, subjects' satisfaction with the usual treatment of headaches and treatment effectiveness. Medication overuse was defined in terms of treatment days per month during the previous 3 months according to the ICHD-II criteria for medication overuse headache.

RESULTS

Some 74% of the 3326 participating pharmacies with a self-considered migraine subject among their staff actually returned the survey questionnaire. Using the ICHD-II criteria, migraine was confirmed in 85% of participating subjects, of whom 38% were under medical supervision and had asked for a prescription, and 27% used recommended medications. The treatment used was truly effective for only 31% of migraineurs. Medication overuse was observed in 21% of all participating subjects, mostly migraineurs. Most migraineurs with medication overuse (81%) used nonrecommended treatments.

CONCLUSIONS

Considering their pivotal role in advising migraine patients who seek their help with self-management, migraine education of pharmacy personnel about proper migraine management should be reinforced.

Triptans in the Italian population: a drug utilization study and a literature review

Previous studies performed in selected populations show a poor utilization of triptans for migraine. The objectives of our study were to establish patterns of triptans utilization in a large sample, covering 1/10 of Italian population (5.57 millions), and to perform a review of published studies on this topic. We investigated drug prescription database collected during 2006 from 33 health authorities distributed in 8 different regions. About 0.6% of the subjects received at least one prescription of triptans in 1 year: 77.7% were females and 22.3% males. Age distribution shows that 9.5% of patients were aged above 65, and received prescriptions for 8.2% of packages. The review of the literature suggests that these percentages of utilization are common to several countries, and shows that occasional triptan users who received only one prescription in 1 year are a large percentage (40-60%); moreover, a minor population of triptan users utilize a large amount of total triptans. Finally triptans are frequently prescribed in people aged above 65 years, a population in which triptans are contraindicated or not recommended. Our study and the analyzed ones indicate suboptimal treatment of migraine patients with triptans and also an incorrect use in some patients (triptan abusers, elderly).

The GRIM2005 study of migraine consultation in France I. Determinants of consultation for migraine headache in France

The aim of this study was to evaluate determinants of consultation for migraine in a representative sample of the French general adult population. We interviewed 10,032 subjects, of whom 1534 fulfilled the International Headache Society diagnostic criteria for migraine. These were categorized into migraine, probable migraine and chronic migraine. Information was collected on consultation experience; 436 subjects (28.4%) had never consulted for headache, 473 (30.8%) were in active consultation and 625 (40.7%) had previously consulted but lapsed. Subjects with chronic migraine showed the highest active consultation rates (51.8%). All subjects completed rating instruments for headache [Headache Impact Test (HIT)-6], psychiatric (Hospital Anxiety and Depression Scale scale) and psychological [Brief Illness Perception Questionnaire (BIPQ), Brief COPE Inventory and Coping Strategy Questionnaire] variables. The strongest determinants of active consultation were BIPQ scores, HIT-6 scores and migraine type. Consultation was associated with maladaptive coping strategies (social support, emotional expression and acceptance). Determinants of remaining in consultation were catastrophizing coping scores and previous consultation experience.

Medication-overuse headache: where are we now?

PURPOSE OF REVIEW

Many important studies on medication-overuse headache have been published in the last year. Some of them investigated the pathophysiology of headache chronicity, others focused on evaluation of risk factors. The International Headache Society revised the classification criteria. We provide a summary of the new findings and concepts.

RECENT FINDINGS

Medication-overuse headache was previously defined by the International Headache Society as a chronic headache which occurs following overuse of headache drugs and improves after withdrawal. Hence, the improvement of headache after withdrawal was mandatory for diagnosis. The new appendix criteria appeared last year and established a broader concept of medication-overuse headache no longer requiring improvement after discontinuation of medication overuse. Several large population-based longitudinal studies clearly demonstrated that overuse of any kind of acute headache medication is the main risk factor leading to development of chronic headache. Imaging studies provided new important insights into the pathophysiology of headache chronicity. New treatment strategies have been suggested.

SUMMARY

Recent data provide better insight into pathophysiology of medication-overuse headache. Epidemiological studies clearly demonstrate the necessity of establishing a predictive model for early recognition of patients at high risk to intervene early and avoid development of chronic headache.

Triptan use and risk of cardiovascular events: a nested-case-control study from the French health system database

BACKGROUND

The use of triptans (5-HT agonists) in the treatment of migraine is associated with a potential increasing risk of cardiovascular events and raises the question of the relationship between overuse and the occurrence of ischemic events.

OBJECTIVE

The aim of this study was to examine the association between the intensity of triptan use and occurrence of an cardiac event.

METHODS

Using the reimbursed drug prescription database of the National French Health Insurance System in the Midi-Pyrenees area, we identified subjects receiving at least one triptan in the second semester of 2002. From this population, we selected new users and retrieved all reimbursed care data up to 31 December 2003. We estimated the patterns of triptan exposure by calculating the number of defined daily doses (DDD) received per 30-day period. Another reimbursed health care database was used to identify as cases of cardiac outcomes those patients receiving care for the management of a possible heart ischemic event. Each case was randomly matched on age and gender with four controls free of any cardiovascular event before the index date. A conditional logistic regression was performed to assess the relationship between cardiac outcomes and exposure to triptans in the 30 days before the index date.

RESULTS

The cohort of new users of triptans included 8625 subjects, 4414 (51.18%) of whom received only one dispensation for triptans during the follow-up period (median duration: 427 days). For the remaining subjects, the peak of triptans delivery was </=8 DDD for 14.68% of the cohort, between 9 and 14 DDD for 22.17%, between 15 and 29 for 10.04% and >/=30 DDD for 1.92%. Fifty-seven users (0.66%) presented a cardiac history and 1388 patients (16.09%) had cardiovascular risk factors. We identified 155 incident cases of cardiac outcomes during the follow-up and compared these to 620 matched controls. Cases were older and presented more frequently with cardiac history or cardiovascular risk factors than the other users of triptans. The distribution exposure to triptans did not significantly differ between cases and controls with an odds ratio for an exposure </=8 DDD in the last 30 days of 0.74 [95% CI (0.31-1.77)] and that for an exposure >8 DDD equal to 1.14 [95% CI (0.58-2.27)].

CONCLUSION

The proportion of patients showing an overuse of triptans (more than 15 DDD for 30 days) reached 12% in this cohort of new users of triptans. However, we did not find any relationship between the overuse of triptans and cardiac outcomes. This study also shows that some patients with cardiovascular risk factors are actually treated by triptans. These patients are more likely to present a cardiac outcome potentially related to an ischemic event after the introduction of triptan.

Evaluation of Efficacy, Tolerability, and Treatment Satisfaction with Almotriptan in 3 Consecutive Migraine Attacks

The objective of the open-label, multicenter Migraine--Satisfaction with Treatment: Reality with Almogran study was to assess efficacy, tolerability, and satisfaction with almotriptan 12.5 mg among migraineurs who were not achieving adequate results with their current acute therapy. Data from 434 patients (342 evaluable), were obtained for 929 attacks by 154 neurologists in France. Using a questionnaire developed by the National Agency for Accreditation and Evaluation in Health (ANAES), almotriptan was associated with an increased proportion of patients experiencing significant relief at 2 h (69.3 vs. 26.6%), tolerating the medication well (91.2 vs. 76.0%), able to resume activities (70.5 vs. 24.9%), and taking only 1 dose (59.4 vs. 28.1%) compared with previous therapies. At 2 h, headache pain had disappeared in 33.4% of attacks and was mild in 26.9%. Recurrence rate was 28.4% and rescue analgesics were used in 20.9% of attacks. The rate of adverse event-related discontinuations was 2.6%. The proportion of patients who were very satisfied/satisfied overall with almotriptan treatment was 69%. Almotriptan 12.5 mg was effective, well-tolerated and associated with a high rate of treatment satisfaction in patients whose previous acute migraine therapy was inadequate according to the ANAES recommendations.

Modes de prescription et de consommation des triptans en Alsace : un mésusage fréquent mais évitable

AIMS

To analyze use of triptans in the Alsace region of France: patients, disorders motivating, doses, analgesics and migraine prophylactics associated treatments, contra-indications. To study major consumers (more than 144 intakes per year) and to determine among them the proportion who suffering from chronic headache.

METHOD

Data concerning all prescriptions of triptans and analgesics as well as migraine prophylaxis prescriptions were obtained from the computer databases of five of the French National Health's local health agencies in Alsace, recorded between April 1, 2003 and March 31, 2004. Data about motivating disorders and the clinical context were obtained using a questionnaire sent to prescribers. Data about patients with more than 144 intakes per year were provided by medical advisors of French Health insurance.

RESULTS

We founded 20686 users: 92.1 percent used between 0 and 6 intakes per month. 11.5 percent of disorders motivating the prescription that were mentioned by prescribers were for off-label use: tension-type headache 2.7 percent, mixed headache, 8.8 percent. Prescribers declared at least one contra-indication for triptan use for 7.8 percent of patients. Over all, prescriptions were off-label for 16.1 percent of patients. Patients who used more than 144 intakes per year accounted for 1.9 percent of the total number and self-medication accounted for 19.2 percent of all triptan intakes. Half of the patients were suffering from daily chronic headache (chronic migraine in 66 percent). 15.6 percent of these patients presented at least one contraindication (high blood pressure or ischemic disease). All in all we estimate that use of triptan is a misuse for 25 percent to 30 percent of the intakes. Quantities of other analgesics used increased simultaneously with triptan use: on average 65, 119 and 244 Defined Daily Doses (DDD)/person/year for patients who used between 1 and 72, 73 and 144 and more than 144 intakes respectively. On average 35.4 percent (in DDD) of analgesics used were opiates (dextropropoxyphene, codeine, tramadol). This proportion increased simultaneously with triptan use: 58.9 percent for major users. Prophylactic treatment for migraine was used by 27.9 percent of the patients: lack of prophylaxis was a prescriber's choice in 90 percent of the cases.

CONCLUSIONS

The high rate of triptan misuse emphasizes the importance of improving prescription of these drugs.

Patients' Management of Migraine and Chronic Daily Headache: A Study of the Members of the Migraine Action Association (United Kingdom)

BACKGROUND

Many strategies are available to treat and prevent migraine and chronic daily headache (CDH). Broadly these strategies can be divided into four groups, including (i) health care consultations, (ii) medication and alternative remedies, (iii) general (acute and prophylactic) strategies, and (iv) social support.

OBJECTIVE

This study aimed to compare headache management between migraine (MO), migraine with aura (MA), and those with CDH over the last 12 months.

DESIGN

A postal questionnaire was sent to 887 members of the Migraine Action Association (MAA). The response rate was 60.5% (n=537), and 438 questionnaires were included in the analysis. Migraine (n=117) and MA (n=239) patients were classed according to the International Headache Society (IHS). CDH (n=82) was diagnosed when respondents had 15 or more headache days per month. Descriptive tests, analysis of variances (ANOVAs), chi2, and Kruskal-Wallis tests were used for statistical analysis (P<.05).

RESULTS

The three groups did not differ in age, gender, ethnicity, level of education, and employment status. Significant differences in management strategies between the groups were found in the number of respondents who had consulted headache specialists (P=.002) and neurologists (P=.004), the number and types of acute medications (eg, triptans, P=.002), the use of antidepressants (P=.004), and some acute and prophylactic avoidance techniques. Although, no significant differences between the groups were found in the use of other health professionals (eg, GP), alternative health professionals, general acute management, and the use of social support, they all actively used these strategies.

CONCLUSIONS

The respondents of this study were active users of management strategies that are based on a combination of health care consultations, medication and alternative remedies, general management, and social support. In comparison to previous findings, the respondents in this study frequently reported higher use of management strategies (such as the use of triptans), which may be related to this group of patients being better informed about headache management than those with headache within the general population. Thus, the findings may not be representative for the general population, but they give an indication of the influence and importance of headache-related education carried out by patient organizations such as the MAA.

What Do Patients Want from Their Acute Migraine Therapy?

A minority of migraine sufferers are diagnosed and treated and medical consultation rates are low even among those aware of their condition. Despite guidelines recommending the use of triptans, there are high rates of usage of nonspecific treatments, mainly simple analgesics, coupled with low prevalence of triptan use. Consequently, many individuals with migraine are not receiving the kind of treatment that would meet their expectations and leave them satisfied. For patients, the most important attributes of acute migraine treatment are complete freedom from pain, rapid onset of action, no recurrence and absence of side effects. More widespread use of triptans would have the potential to improve outcomes and increase patient satisfaction, leading to a better migraine-related quality of life. In choosing among triptans, physicians need to match individual patients' needs and wants with the attributes of the particular triptans, taking into account a medication's complete profile of efficacy, consistency and tolerability, and using information from meta-analyses and modelling to ensure evidenced-based, patient-oriented decision-making.

Adverse reactions related to drugs for headache treatment: clinical impact

OBJECTIVE

To assess the clinical impact of adverse reactions related to drugs for primary headache treatment.

METHODS

We examined the adverse reactions to 360 medications prescribed by the specialists of the Headache Centre of the University of Modena and Reggio Emilia to 256 consecutive outpatients (214 female, 42 male; mean age: 38.88 +/- 14.06 years; range 10-72 years). Adverse reactions were reported by patients during scheduled follow-up visits, classified by specialists and reassessed by a clinical pharmacologist.

RESULTS

Adverse reactions with a causal relationship classified as definite/probable/possible were 202 (56%): 62% (80/129) were due to acute treatments and 53% (122/231) to prophylactic treatments (chi2 test, P = 0.115 ns). More than 90% of the adverse reactions were of limited intensity [mild (58%) or moderate (36%)]. Only 5% were severe, and two reactions (1%) were serious. The most affected apparatus was the nervous system (41%). Of these adverse reactions, 43% caused the discontinuance of the treatment, especially of prophylaxis (54%). Patients evaluated 70% of the medications as effective, but, at the same time, they considered most of the adverse reactions (69%) unacceptable.

CONCLUSION

Adverse reactions related to headache medications have a strong impact on patients' management, even if their real intensity and severity are usually very limited. Drugs for headache treatment are still far from being ideal drugs. To prevent the discontinuance of effective medications, the physician, prior to prescribing, should assess, together with the patient, the acceptability of the more common adverse drug reactions.

Migraine treatment strategies: the global Migraine And Zolmitriptan Evaluation (MAZE) survey--phase IV

OBJECTIVE

To determine which medications UK migraineurs have access to and assess the usage of these products in a 'real-life' setting.

RESEARCH DESIGN AND METHODS

Data were collected using an online questionnaire, which subjects were directed to by advertisements in pharmacies, a UK national newspaper, on the internet and information on the Migraine Action Association website and newsletters. Respondents were eligible for inclusion if attacks fulfilled International Headache Society criteria for migraine and/or if previously diagnosed by a physician as having migraine.

MAIN OUTCOME MEASURES

Respondents were asked to specify which products had been prescribed or purchased for migraine treatment. The pattern of use of these products was determined, including the reasons why respondents chose particular products to treat attacks.

RESULTS

Of 3072 eligible respondents, the majority had purchased a variety of over-the-counter (OTC) medicines for treatment of attacks. Eighty-seven per cent had been diagnosed by a physician and were prescribed multiple products (average 1.68); 45% received triptans, but 26% were still prescribed products that were also available OTC. Over half (52%) of respondents initially used an OTC medicine to treat the last migraine attack. However, 73% required a second dose/product, mainly as a result of lack of efficacy of the first dose/product. Respondents using triptans were less likely to require a second dose/product than those not using triptans (52% vs. 78%, respectively). The two main reasons for choosing a triptan to treat an attack were the need for quick control and the severity of the attack. Satisfaction with regard to migraine medication was higher among triptan-users than nontriptan users.

CONCLUSIONS

Medicines that are available OTC are often used as first-line therapy for migraine despite many migraineurs having access to prescription therapies such as triptans. Many migraineurs require a second dose/product, possibly indicating sub-optimal treatment efficacy. Physicians should consider the range of migraine-specific treatments available, including triptans, in order to develop a treatment plan that is based on the patient's needs and preferences.

Etude pharmacoépidémiologique française de l’utilisation des triptans en médecine générale

This French pharmacoepidemiological study describes triptan use in general practice for triptan 'naive' (never treated by a triptan before study inclusion) and 'non-naive' (already treated by a triptan) patients. Data from 1774 patients were analysed (81% women). The mean age of the patients was 41 years (+/-12.8). This study showed that 95% of the patients had a diagnosis of migraine according to the International Headache Society (IHS) criteria. This result confirmed the effective use of triptans by general practitioners. Migraines in patients treated with triptans in the present study were more severe than in subjects reporting migraine in the general population. 'Naive' and 'non-naive' patients had similar IHS diagnoses and severity profiles but, for 'non-naive' patients, the migraine history was longer and the disability (quality of life) reported was worse than for the 'naive' patients. The reasons for the treatment switch were the need for improved efficacy, a faster onset of action, fewer recurrences and better tolerability.