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

Validation of a survey tool assessing effectiveness of an educational intervention on the caring behaviors and referral activities of community pharmacists for migraineurs

BACKGROUND

Community pharmacists are in an ideal position to ameliorate migraineur under-consulting, under-diagnosis, and under-treatment. Contemporary education/training on developing therapeutic alliances with patients and in advanced pharmacotherapy may further motivate pharmacists to impact the care of migraineurs.

OBJECTIVES

The objectives of this study were to assess pharmacists' perceptions of a migraine training program and their self-assessment of subsequent impact on patient care and to develop and assess a tool evaluating the impact of the training program from the patients' perspectives: (1) for patients diagnosed with migraines - identify perceptions of care by pharmacists who have undergone specialty training in migraine vs. pharmacists who have not; and (2) for patients with recurrent headaches and not diagnosed with migraines - identify perceptions of pharmacist effectiveness and thoroughness, after specialty training, to identify a potential migraine diagnosis and referral for advanced care vs. pharmacists that have not undergone specialty training.

METHODS

This study employed a mixed method survey design using community pharmacies from the Tulsa, Oklahoma and Pittsburgh, Pennsylvania greater metropolitan areas. Pharmacists from intervention pharmacies received specialty training on migraine and were surveyed on their current practices and about the education program. Approximately 1 month after the training, control and intervention pharmacists were surveyed on current practices. Additionally, patients from both pharmacies were surveyed to assess Migraine Disability Assessment (MIDAS) and pharmacists' delivery of care derived from the Pharmacists' Care of Migraineurs Scale (PCMS). Surveys were handed out for a period of 3-months.

RESULTS

There were 16 pharmacists and 61 patients recruited. There was no difference in patient perceptions of pharmacists' care or in patient self-perceptions between migraineurs and recurrent headache sufferers. Ninety-two percent of pharmacists agreed that the program could be transferred to an internet-based educational program. The 14-item patient survey, however, demonstrated good internal consistency reliability, with each question having a Cronbach's alpha 0.80 or higher.

CONCLUSIONS

There are few studies evaluating the role and potential impact community pharmacists can have on patients suffering from migraines or recurrent headaches. While no difference was found between the groups, the internal reliability of the survey questions and the need to address needs of migraineurs warrants tool dissemination and a larger-scale study.

Economic impact of a triptan Rx-to-OTC switch in six EU countries

INTRODUCTION

Triptans have been safely and effectively used in the management of migraine for more than fifteen years, and it seems reasonable to wonder what would be the economic impact of moving a specific triptan to OTC availability. The objective of this study was then to examine the economic impact of payer policies of a triptan Rx-to-OTC switch in six EU countries (France, UK, Spain, Italy, Germany and Poland).

METHODS

A decision model was used to model the budgetary impact of a triptan Rx-to-OTC switch from the third-party payer (TPP) and the societal perspectives, using a one-year timeframe.

RESULTS

From the TPP perspective, it is estimated that the current overall direct spending on the management of migraine attacks across the 6 EU Member States is €582 million annually, and that the savings would reach €75 million (13% of the overall direct economic burden of migraine). From the societal perspective, €86 million annually would be added.

CONCLUSIONS

Given evidence of effectiveness and safety, and given the potential savings, a triptan Rx-to-OTC switch is a reasonable public policy decision.

Intranasal zolmitriptan for the treatment of acute migraine

OBJECTIVE

To review the pharmacokinetics, efficacy, tolerability, and patient acceptance of zolmitriptan nasal spray (NS).

BACKGROUND

Gastroparesis may delay or diminish the absorption of oral triptans, and nausea or vomiting may do the same and/or make it difficult to take a tablet. Some migraineurs require or prefer faster relief than oral medications provide. Injectable triptans provide the fastest drug delivery into the bloodstream, but many patients are reluctant to use them. Nasal sprays may address some of the problems with tablets and injectables while still providing rapid absorption of drug.

METHODS

Non-systematic review.

RESULTS

Significant levels of zolmitriptan NS are detectable in plasma within 2-5 minutes, and the rapid absorption is due to early uptake through the nasal mucosa. In 2 randomized trials, users of zolmitriptan NS were significantly more likely than placebo recipients to be pain-free at 15 minutes post-dose, the first time point measured, and about half of patients had sustained response at 24 hours. Studies in which patients could treat a migraine of any severity have documented significant headache response or relief with zolmitriptan NS at 10 minutes. In one trial, the rate of total symptom relief was significantly better with the NS than with placebo from 30 minutes post-dose. The most common side effect of zolmitriptan NS is unusual taste. Patient satisfaction studies indicate that zolmitriptan NS is appreciated for its speed of onset, ease of use, reliability, and overall efficacy.

CONCLUSIONS

Zolmitriptan NS provides onset of headache relief within 10 minutes for some patients and quickly abolishes some of the major migraine symptoms. Good candidates are migraineurs whose episodes rapidly escalate to moderate-to-severe pain and those who have morning migraine, have a quick time to vomiting, or have failed oral triptans.

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.

Migraineurs' perceptions of and interactions with pharmacists: a qualitative study

Aims and objectives

Migraine is an underdiagnosed and undertreated condition. Diagnosed and undiagnosed migraineurs come into frequent contact with pharmacists, who are in a unique position to intervene and potentially improve the therapeutic outcomes of migraineurs; however, little is known about migraineurs' attitudes towards pharmacists' roles and the experiences they have shared with pharmacists. The purpose of this study was to evaluate migraineurs' perceptions of the roles that pharmacists may play in helping them manage their disease.

Setting

Duquesne University, Pittsburgh, Pennsylvania, USA.

Method

The study employed the use of two focus groups of migraineurs from a university population, approached from a phenomenologic perspective. Focus-group sessions were conducted using a flexible interview guide. Focus-group content was digitally recorded, then transcribed, verified for accuracy and content analysed according to established criteria, employing the use of a formal coding procedure. Inductive analysis was performed to establish patterns, themes and categories in the data.

Key findings

Six principal themes emerged. Among the most important findings were that (1) migraineurs were concerned about managing their headaches and the impact migraine has on their lives and their families' lives, (2) migraineurs did not discuss their headaches or migraine therapy with pharmacists and (3) migraineurs believe that many communication barriers exist in their pharmacistpatient relationship.

Conclusion

Community pharmacists have an opportunity to impact the level of care provided to migraine sufferers. As such, community pharmacists should strive to remove communication barriers and be more proactive during interactions with these patients. Further study may examine how pharmacists can elicit more social support for migraineurs and to help migraineurs cope with their condition.

Development and construct validation of the pharmacists' care of migraineurs scale

OBJECTIVES

To develop the pharmacists' care of migraineurs scale (PCMS) and to evaluate its psychometric properties.

BACKGROUND

Migraine is often managed suboptimally in primary care. Migraineurs frequently come into contact with community pharmacists, who have the opportunity to make a positive impact on migraineur treatment outcomes. A valid and reliable tool that measures and documents the care provided by pharmacists to migraineurs is critical to the development and evaluation of educational programs and interventions.

METHODS

Relevant domains of pharmacist care and their respective composite items (behaviors) were identified through an extensive literature search and the use of 2 pharmacist and 2 migraineur focus groups sessions. The resultant 45 PCMS items composed a survey questionnaire mailed to a nationwide random sample of 6000 pharmacists. Data were subjected to an exploratory principal axis factoring procedure to discern the factor structure, and as such describe the latent domains composing the pharmacist caring behaviors constructs.

RESULTS

A total of 580 usable responses were returned, with an additional 60 returned as undeliverable, thus yielding a response rate of 9.7%. Exploratory factor analysis using principal axis factoring yielded 9 factors. However, upon examining the scree plot, communalities, and factor loadings, a reanalysis forcing a 7-factor solution yielded a more interpretable and plausible factor structure. The 7-factor solution included the following domains: (1) empathy; (2) prospective drug utilization review for newly diagnosed migraineurs; (3) medication counseling; (4) nonpharmacologic treatment plan; (5) headache sufferer triage; (6) dissemination of public health information; (7) maintenance of knowledge on migraine. Following the application of scale purification procedures, the final instrument is composed of 41 items and demonstrated a Cronbach's alpha reliability of 0.947. Cronbach's alpha reliabilities for the 7 domains ranged from 0.67 to 0.91, indicative of good to excellent internal consistency reliabilities for all the domains.

CONCLUSIONS

The PCMS demonstrated very good construct validity and reliability. While additional validity testing is warranted, the PCMS should allow for benchmarking in the evaluation of interventions designed to improve pharmacists' care to migraineurs and for identifying correlates to effective community pharmacist migraineur care.

Triptans--why once?

OBJECTIVE

To evaluate triptan use patterns in a large Israeli HMO district.

BACKGROUND

Triptans, 5HT(1B/1D) agonists, provide an effective and safe relief of headache and accompanying symptoms during an acute migraine attack.

METHOD

We retrospectively reviewed the computerized prescription filling data of 1498 patients who filled a first triptan prescription between July 2003 and June 2004.

RESULTS

During a 1-year follow-up period, 841 patients (56.1%) purchased triptans only once. Single-time users were significantly more prevalent among men and in patients younger than 30 or older than 70 years.

CONCLUSIONS

It seems that many migraine patients choose not to use triptans after their first experience with the drug.

Effectiveness and Satisfaction with Zolmitriptan 5mg Nasal Spray for??Treatment of Migraine in??Real-Life Practice

OBJECTIVE

Addressing the needs of migraineurs by actively seeking patient feedback on disease-related disability and treatment satisfaction may lead to improved management and treatment outcomes. Patient feedback can be collected in postmarketing surveillance (PMS) studies. The objective of this PMS study was to evaluate the efficacy and tolerability of zolmitriptan 5 mg nasal spray in the acute treatment of migraine attacks.

PATIENTS AND METHODS

Patients received zolmitriptan 5 mg nasal spray to treat migraine attacks of any severity and were followed up after a maximum of 4 months. Patients evaluated the efficacy and tolerability of zolmitriptan nasal spray, and were asked whether they wished to continue using zolmitriptan nasal spray and their preference compared with previous treatments. Physicians also assessed the efficacy and tolerability of zolmitriptan nasal spray.

RESULTS

A total of 1838 patients (84.8% females) participated in the study. Within 30 minutes of administration of zolmitriptan nasal spray, 85.0% of patients reported improvements in headache pain, with 25.1% reporting an improvement within 10 minutes. At 1 hour post-dose, 57.9% of patients were pain free and 61.7% were able to resume usual daily activities. Most patients (72.9%) rated zolmitriptan nasal spray as 'better' than previous therapy. The majority (88.8%) expressed a wish to continue using zolmitriptan nasal spray. Physicians evaluated the efficacy of zolmitriptan nasal spray as 'excellent' or 'good' in 89.4% of patients. Tolerability was evaluated as 'excellent' or 'good' in 91.6% of patients.

CONCLUSIONS

Zolmitriptan 5 mg nasal spray provides favourable efficacy and tolerability in the acute treatment of migraine attacks. Most patients assessed zolmitriptan nasal spray as 'better' than previous treatment, with nearly all wishing to continue using it.

Improved migraine management in primary care: results of a patient treatment experience study using zolmitriptan orally disintegrating tablet

The 'Zomig Appropriate for Primary care' programme was developed to address the needs of primary care physicians (PCPs) to improve migraine management. As part of the programme, an international, open-label, 6-month clinical study was performed. The study included new and tangible outcome variables relevant to PCPs and recruited patients presenting in primary care with an established migraine diagnosis. Patients treated up to three migraine attacks per month with zolmitriptan orally disintegrating tablet (ODT) 2.5 mg. All other migraine attacks occurring during the study period were treated with the patient's usual migraine medication (including other triptans). Questionnaires were used to record patient treatment experiences at the study end. The primary end-point was the proportion of patients wanting to continue using zolmitriptan ODT. Some 595 patients treated 7171 migraine attacks with zolmitriptan ODT. Of the 504 patients who completed the 6-month questionnaire, 380 (75.4%) wished to continue using zolmitriptan ODT. The results of the study indicate that patient-orientated end-points are more motivational and meaningful to physicians than traditional end-points used in controlled clinical trials, allowing them to make informed decisions regarding migraine management.