Prophylactic treatment of migraine; the patient's view, a qualitative study

A qualitative evidence synthesis of patient perspectives on migraine treatment features and outcomes

OBJECTIVES

We aimed to identify migraine treatment features preferred by patients and treatment outcomes most valued by patients.

BACKGROUND

The values and preferences of people living with migraine are critical for both the choice of acute therapy and management approach of migraine.

METHODS

We conducted a qualitative evidence synthesis. Two reviewers independently selected studies, appraised methodological quality, and undertook a framework synthesis. We developed summary of findings tables following the approach of Grading of Recommendations, Assessment, Development and Evaluations Confidence in the Evidence from Reviews of Qualitative Research to assess confidence in the findings.

RESULTS

Of 1691 candidate references, we included 19 studies (21 publications) involving 459 patients. The studies mostly recruited White women from North America (11 studies) and Europe (8 studies). We identified eight themes encompassing features preferred by patients in a migraine treatment process. Themes described a treatment process that included shared decision-making, a tailored approach, trust in health-care professionals, sharing of knowledge and diversity of treatment options, a holistic approach that does not just address the headache, ease of communication especially for complex treatments, a non-undermining approach, and reciprocity with mutual respect between patient and provider. In terms of the treatment itself, seven themes emerged including patients' preferences for nonpharmacologic treatment, high effectiveness, rapidity of action, long-lasting effect, lower cost and more accessibility, self-management/self-delivery option that increases autonomy, and a mixed preference for abortive versus prophylactic treatments. The treatment outcomes that have high value to patients included maintaining or improving function; avoiding side effects, potential for addiction to medications, and pain reoccurrence; and avoiding non-headache symptoms such as nausea, vomiting, and sensitivity to light or sounds.

CONCLUSION

Patient values and preferences were individually constructed, varied widely, and could be at odds with conventional medical perspectives and evidence of treatment effects. Considering the availability of numerous treatments for acute migraine, it is necessary that decision-making incorporates patient values and preferences identified in qualitative research. The findings of this qualitative synthesis can be used to facilitate an individually tailored approach, strengthen the patient-health-care system relationship, and guide choices and decisions in the context of a clinical encounter or a clinical practice guideline.

Real-world experience of OnabotulinumtoxinA treatment in female patients with chronic migraine: a qualitative study using in-depth interviews

BACKGROUND

Chronic migraine (CM) causes great disability and affects an individual's quality of life. OnabotulinumtoxinA (OBT-A, Botox®) was the first prophylactic treatment specifically indicated for CM. The aim of this study was to describe the experiences of women with CM treated with OBT-A.

MATERIALS AND METHODS

The study design is a qualitative descriptive study. A purposeful sampling of 30 women (mean age, 42.7; standard deviation, 10.6) who had received at least two administrations of OBT-A for CM (PREEMPT protocol) was performed. Data collection included in-depth interviews and researchers' field notes. A thematic analysis was carried out according to qualitative research guidelines.

RESULTS

Five themes were identified: (a) A long way to go before Botox®, (b) First time hearing about the treatment and its expectations, (c) The administration of Botox®, (d) Treatment effects, and (e) Follow-up. Patients described a long history of treatment failures prior to the start of OBT-A treatment. Information about this migraine treatment came from the neurologist; following the information, patients had high expectations, including unrealistic expectations regarding the onset and duration of effect. They acknowledged fear of the injections and some discomfort due to the procedure. With treatment, participants reported better migraine control and an improvement in their quality of life. Follow-up had some barriers, such as delayed appointments for subsequent doses, but also strengths, such as effectiveness and few side effects.

CONCLUSIONS

Qualitative research offers insight into how patients with CM experience treatment with OBT-A. Our results highlight some relevant aspects that should be considered when providing OBT-A treatment.

Erenumab versus topiramate: post hoc efficacy analysis from the HER-MES study

OBJECTIVE

HER-MES was the first head-to-head, phase 4 trial to assess the tolerability and effectiveness of erenumab against standard of care treatment (topiramate). This post hoc analysis compared the efficacy of erenumab with topiramate in patients who completed the trial on study medication.

METHODS

Post hoc sensitivity analysis was performed using the full analysis set. Outcomes assessed included the proportion of patients with a ≥50% reduction in monthly migraine days (MMD) from baseline (50% responder rate), over the last 3 months (months 4, 5, and 6) of the double-blind treatment phase (DBTP), the 50% responder rate during the first month of the DBTP, and change from baseline in MMD during the DBTP. Multiple imputation was done for efficacy values of patients who discontinued study treatment.

RESULTS

Patients (N = 777) were randomly assigned (1:1) to either 70 or 140 mg/month erenumab (N = 389) or 50-100 mg/day topiramate (N = 388). Of these, 334 patients (85.9%) receiving erenumab, and 231 patients (59.5%) receiving topiramate completed the DBTP on study medication. Patients on study medication until the end of the DBTP received a mean dose of 119 mg/month for erenumab and 92 mg/day for topiramate. At month 1, a significantly greater proportion of patients receiving erenumab (39.2%) reported ≥50% reduction in MMD from baseline compared with those receiving topiramate (24.0%; p < 0.001). In the last 3 months, a significantly larger proportion of patients receiving erenumab (60.3%) achieved ≥50% reduction in MMD from baseline compared with those receiving topiramate (43.3%; p < 0.001). Patients receiving erenumab demonstrated significantly greater reductions in MMD during the last 3 months from baseline versus those receiving topiramate (- 6.13 vs - 4.90; 95% CI: - 1.87 to - 0.61; p < 0.001).

CONCLUSIONS

This post hoc analysis demonstrated significantly superior efficacy of erenumab versus topiramate in achieving a ≥50% reduction in MMD with an early onset of efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03828539 .

A Qualitative Study to Explore Patient Perspectives of Prophylactic Treatment with OnabotulinumtoxinA for Chronic Migraine

INTRODUCTION

OnabotulinumtoxinA (OBT-A) is one of the most studied prophylactic treatments for chronic migraine. Large clinical trials, and now real-world studies, continue to provide evidence to support the use of OBT-A as an effective treatment to manage chronic migraine. The objective of this study was to explore patient experience and perception of prophylactic treatment with OBT-A for chronic migraine.

METHODS

Data were collected using semi-structured interviews using open-ended questions to uncover rich descriptive data on patient experiences. Interviews were transcribed and analysed using NVivo data analysis software to code and identify themes across the dataset. Three patient groups were included in the analysis: (1) patients who were receiving continued OBT-A treatment; (2) patients who discontinued OBT-A treatment; (3) patients who were recommended for OBT-A treatment but did not proceed.

RESULTS

For patients who received at least one OBT-A treatment, four main themes emerged, which described patients' expectations, experiences, and feelings towards their treatment decisions. Two main themes emerged that were common to patients, who had discontinued their treatment and those, who were recommended for OBT-A treatment but did not proceed, which were identified as potential barriers to initiate or continue prophylactic treatment with OBT-A.

CONCLUSION

Understanding patients' perspective is an important part of clinical practice and may impact on decision-making. Qualitative data can provide a more holistic view of patient care and treatment insights that may not be evaluated during a clinical trial. This study revealed potential barriers to treatment that can inform future policy and practice.

InterMiG: international differences in the therapeutic approach to migraine patients in specialized headache centers

Background

There is currently a wide therapeutic arsenal for migraine patients, without a single first-line preventive drug and we choose the different available alternatives taking into account comorbidities, national guidelines, previous treatments and personal experiences.

Our objective was to evaluate the differences in the use of migraine treatments between neurologists from different countries.

Methods

This is a multi-centre observational study carried out by neurologists from specialized headache units in seven countries, retrospective with consecutive inclusion of all patients presenting with a migraine diagnosis, over a period of three months.

Results

A total of 734 patients were recruited but only 600 were considered in the analysis in order to homogenize the patient cohorts from countries: 200 Spain (ES), 100 Italy (IT), 85 Russia (RUS), 80 Germany (DE), 60 Portugal (PT), 45 Poland (PL) and 30 Australia (AU). 85.4 % of patients were women with a mean age of 42.6 ± 11.8 years. Considering previous and current preventive treatment, the order of use was: antidepressants (69.3 %), antiepileptic drugs (54.7 %), beta-blockers and antihypertensive drugs (49.7 %), OnabotulinumtoxinA (44.0 %) and others (36.2 %).

Statistically significant differences were found between all pharmacological classes: antidepressants were commonly used in all countries, with the exception of Poland (AU: 76.7 %, IT: 71.0 %, DE: 60.0 %, PL: 31.1 %, PT: 71.7 %, RUS: 70.6 %, ES: 78.5 %; p < 0.0001); antiepileptic drugs were more frequently prescribed in Portugal, Australia and Spain (AU: 73.3 %, IT: 40.0 %, DE: 37.5 %, PL: 48.9 %, PT: 85.0 %, RUS: 29.4 % and ES: 69.0 %; p < 0.0001); beta-blockers and antihypertensive drugs were frequently used in all countries except Italy (AU: 60.0 %, IT: 14.0 %, DE: 53.8 %, PL: 48.9 %, PT: 68.3 %, RUS: 49.4 % and ES: 59.0 %; p < 0.0001); BTX-A were predominately used in Spain, Italy and Australia (AU:56.7 %, IT:58.0 %, DE:20.0 %, PL: 42.2 %, PT: 26.7 %, RUS: 24.7 % and ES: 58.5 %; p < 0.0001) and others were most frequently used in Poland (AU: 0.0 %, IT: 19.0 %, DE: 42.5 %, PL: 95.6 %, PT: 31.7 %, RUS: 3.5 % and ES: 49.5 %; p < 0.0001). If only patients without comorbidities are considered (200/600), statistically differences between countries persist in all preventive treatments.

Conclusions

There is heterogeneity in the choice of preventive treatment between different countries. Prospective comparative studies of the different oral and subcutaneous alternatives would help to create a global therapeutic algorithm that would guarantee the best option for our patients.

Efficacy and safety of eptinezumab in patients with chronic migraine: PROMISE-2

Objective

To evaluate the efficacy and safety of eptinezumab, a humanized anti–calcitonin gene-related peptide monoclonal antibody, in the preventive treatment of chronic migraine (CM).

Methods

The Prevention of Migraine via Intravenous ALD403 Safety and Efficacy–2 (PROMISE-2) study was a phase 3, multicenter, randomized, double-blind, placebo-controlled, parallel-group study. Adults with CM were randomly assigned to receive IV eptinezumab 100 mg, eptinezumab 300 mg, or placebo administered on day 0 and week 12. The primary endpoint was change from baseline in mean monthly migraine days (MMDs) over weeks 1 to 12.

Results

Among treated participants (n = 1,072), baseline mean number of MMDs was ≈16.1 across groups. Treatment with eptinezumab 100 and 300 mg was associated with significant reductions in MMDs across weeks 1 to 12 compared with placebo (placebo −5.6, 100 mg −7.7, p < 0.0001 vs placebo; 300 mg −8.2, p < 0.0001 vs placebo). Treatment-emergent adverse events (TEAEs) were reported by 43.5% (100 mg), 52.0% (300 mg), and 46.7% (placebo) of patients. Nasopharyngitis was the only TEAE reported for >2% of eptinezumab-treated patients at an incidence of >2% over placebo; it occurred in the 300 mg eptinezumab arm (eptinezumab 9.4%, placebo 6.0%).

Conclusion

In patients with CM, eptinezumab 100 and 300 mg was associated with a significant reduction in MMDs from the day after IV administration through week 12, was well tolerated, and demonstrated an acceptable safety profile.

Classification of evidence

This study provides Class I evidence that for patients with CM, a single dose of eptinezumab reduces MMDs over 12 weeks of treatment.

ClinicalTrials.gov identifier

NCT02974153.

Real-world treatment patterns and patient-reported outcomes in episodic and chronic migraine in Japan: analysis of data from the Adelphi migraine disease specific programme

Background

In Japan, detailed information on the characteristics, disease burden, and treatment patterns of people living with migraine is limited. The aim of this study was to compare clinical characteristics, disease burden, and treatment patterns in people with episodic migraine (EM) or chronic migraine (CM) using real-world data from clinical practice in Japan.

Methods

This was an analysis of data collected in 2014 by the Adelphi Migraine Disease Specific Programme, a cross-sectional survey of physicians and their consulting adult patients in Japan, using physician and patient questionnaires. We report patient demographics, prescribed treatment, work productivity, and quality-of-life data for people with CM (≥15 headache days/month) or EM (not fulfilling CM criteria). In descriptive analyses, continuous and categorical measures were assessed using t-tests and Chi-squared tests, respectively.

Results

Physicians provided data for 977 patients (mean age 44.5 years; 77.2% female; 94.5% with EM, 5.5% with CM). A total of 634/977 (64.9%) invited patients (600 with EM; 34 with CM) also provided data. Acute therapy was currently being prescribed in 93.7% and 100% of patients with EM and CM, respectively (p = 0.069); corresponding percentages for current preventive therapy prescriptions were 40.5% and 68.5% (p < 0.001). According to physicians who provided data, preventive therapy was used at least once by significantly fewer patients with EM than with CM (42.3% vs. 68.5%, respectively; p < 0.001). Among patients who provided physicians with information on issues with their current therapy (acute therapy: n = 668 with EM, n = 38 with CM; preventive therapy: n = 295 with EM, n = 21 with CM), lack of efficacy was the most frequently identified problem (acute therapy: EM 35.3%, CM 39.5% [p = 0.833]; preventive therapy: EM 35.3%, CM 52.4% [p = 0.131]). Moderate-to-severe headache-related disability (Migraine Disability Assessment total score ≥ 11) was reported by significantly fewer patients with EM than with CM (21.0% vs. 60.0%, respectively; p < 0.001) among patients who provided data.

Conclusions

Preventive treatment patterns in people with EM versus CM differ in Japan, with both types of migraine posing notable disease burdens. Our findings demonstrate that more effective migraine therapies are required to reduce the burden of the disease.

Electronic supplementary material

The online version of this article (10.1186/s10194-019-1012-1) contains supplementary material, which is available to authorized users.

Once-monthly galcanezumab for the prevention of migraine in adults: an evidence-based descriptive review and potential place in therapy

In the last 15 years relevant efforts have been made to demonstrate that calcitonin gene-related peptide (CGRP) antagonism is a valuable and druggable mechanism for treatment or prevention of migraine. Galcanezumab is one of the antibodies developed and studied to prevent migraine by targeting CGRP. The scope of this review is to report data currently available on galcanezumab. According to available data, galcanezumab is safe and efficacious in preventing migraine in episodic migraine patients, also reducing disability and functional impairment due to the disorder. In September 2018, galcanezumab was approved in the USA for the prevention of migraine in adults. The placement of galcanezumab into the current therapeutic scenario will be a revolution for migraine patients, and probably in a less near future also for patients affected by other primary headaches.

Migraine-preventive prescription patterns by physician specialty in ambulatory care settings in the United States

Many adults with migraine who require preventive therapy are often not prescribed the proper medications. The most likely reason is that primary care physicians are unacquainted with preventive medications for migraine. The present study assessed the migraine-preventive prescription patterns in office visits using data from the National Ambulatory Medical Care Survey from 2006 to 2009 in the United States. Patients who were 18 years or older and diagnosed with migraine were included in the analysis. In accordance with the recommendations of the headache guidelines, we included beta-blockers, antidepressants, triptans for short-term prevention of menstrual migraine, and other triptans for acute treatment. Weighted visits of adults with migraine prescribed with preventive medication ranged from 32.8% in 2006 to 38.6% in 2009. Visits to primary care physicians accounted for 72.6% of the analyzed adult migraine visits. Anticonvulsants (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.14–0.57, p < 0.001) and triptans for menstrual migraine (OR 0.50, 95% CI 0.28–0.91, p = 0.025) were less frequently prescribed by primary care physicians compared with specialty care physicians, such as neurologists and psychiatrists. There were no significant differences in the prescription patterns of antidepressants and beta-blockers between primary and specialty care physicians. Beta-blockers were prescribed to patients with comorbidity of hypertension, and antidepressants were used by patients with comorbidity of depression. There are differences in the prescription patterns of certain type of preventive medications between primary care physicians and specialty care physicians.

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Anticonvulsants were less used by primary care physicians than specialty care physicians.

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Triptans for prevention were also less used by primary care physicians.

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No differences were found in patterns of antidepressants and beta-blockers.

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Beta-blockers were used for patients with comorbidity of hypertension.

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Antidepressants were used for patients with comorbidity of depression.

Organising medication discontinuation: a qualitative study exploring the views of general practitioners toward discontinuing statins

BACKGROUND

Discontinuing medications is a complex decision making process and an important medical practice. It is a tool in reducing polypharmacy, reducing health system expenditure and improving patient quality of life. Few studies have looked at how general practitioners (GPs) discontinue a medication, in agreement with the patients, from a professional perspective. Three research questions were examined in this study: when does medication discontinuation occur in general practice, how is discontinuing medication handled in the GP's practice and how do GPs make decisions about discontinuing medication?

METHODS

Twenty four GPs were interviewed using a maximum variation sample strategy. Participant observations were done in three general practices, for one day each, totalling approximately 30 consultations.

RESULTS

The results show that different discontinuation cues (related to the type of consultation, medical records and the patient) create situations of dissonance that can lead to the GP considering the option of discontinuation. We also show that there is a lot of ambiguity in situations of discontinuing and that some GPs trialled discontinuing as means of generating more information that could be used to deal with the ambiguity.

CONCLUSIONS

We conclude that the practice of discontinuation should be conceptualised as a continually evaluative process and one that requires sustained reflection through a culture of systematically scheduled check-ups, routinely eliciting the patient's experience of taking drugs and trialling discontinuation. Some policy recommendations are offered including supporting GPs with lists or handbooks that directly address discontinuation and by developing more person centred clinical guidelines that discuss discontinuation more explicitly.

Validity and reliability of the Bahasa Melayu version of the Migraine Disability Assessment questionnaire

BACKGROUND

The study was designed to determine the validity and reliability of the Bahasa Melayu version (MIDAS-M) of the Migraine Disability Assessment (MIDAS) questionnaire.

METHODS

Patients having migraine for more than six months attending the Neurology Clinic, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia, were recruited. Standard forward and back translation procedures were used to translate and adapt the MIDAS questionnaire to produce the Bahasa Melayu version. The translated Malay version was tested for face and content validity. Validity and reliability testing were further conducted with 100 migraine patients (1st administration) followed by a retesting session 21 days later (2nd administration).

RESULTS

A total of 100 patients between 15 and 60 years of age were recruited. The majority of the patients were single (66%) and students (46%). Cronbach's alpha values were 0.84 (1st administration) and 0.80 (2nd administration). The test-retest reliability for the total MIDAS score was 0.73, indicating that the MIDAS-M questionnaire is stable; for the five disability questions, the test-retest values ranged from 0.77 to 0.87.

CONCLUSION

The MIDAS-M questionnaire is comparable with the original English version in terms of validity and reliability and may be used for the assessment of migraine in clinical settings.

Preventive treatment for migraine in primary care, a population-based study in the Netherlands

Background

Preventive treatment of migraine contributes to reducing the impact of migraine but its extent of use in routine care is unknown.

Objective

The objective of this article is to assess current use, previous use, duration and course of preventive treatment of migraine in Dutch general practice.

Methods

We conducted a retrospective cohort study, for the period between 1997 and 2007, in the Interdisciplinary Processing of Clinical Information (IPCI) database, a GP research database in the Netherlands (source population of more than half a million subjects). All prevalent and incident migraine patients ( N = 7367) were included.

Results

About 13% of all migraine patients currently use preventive therapy and almost half of migraine patients have prior use. Of those starting with preventive treatment, 56% (95% CI: 54.3–64.7) still used it after nine months. There was a long delay between migraine diagnosis and preventive treatment start. Forty-four percent (95% CI 43.0–45.7) started preventive therapy in the study period.

Conclusion

This large primary-care database study shows that a limited number of patients are current users of preventive treatment, but many patients have prior use. After diagnosis there is often an extended time before preventive treatment is applied. Also there is often only one attempt. The continuation in time seems appropriate. Preventive therapy in migraine still deserves focus.

Acceptance of preventive treatment in migraine patients: results of a survey

BACKGROUND

The number of migraine patients eligible for preventive treatment is considerably higher than the number of patients actually using it. This study explores reasons for this discrepancy.

METHODS

An explorative survey among patients and their general practitioners (GPs) participating in a trial on preventive medication. Migraine patients who were eligible for preventive treatment (n = 75) attended an evaluation consultation with their GP to optimize migraine treatment. GPs and patients who did not start preventive treatment were asked if they had discussed the possibility of preventive treatment and, if so, why they decided not to start it.

RESULTS

Of the 32 GPs, 8 (25%) did not discuss the possibility of preventive treatment with their patients; in 4 because of perceived lack of effectiveness. Patients who did not start preventive treatment (n = 43) used less triptans and had less psychological distress compared to those who did start (n = 32). Main reasons for patients not starting were negative attitudes towards medication in general, fear of medication side-effects, previous unsuccessful attempts, attacks not being severe enough, and impact of migraine on daily life acceptable.

CONCLUSION

The decision of the individual patient and their GP to start preventive treatment is not only determined by attack frequency, but also depends on the impact of the headache attacks on their daily life and their negative attitude towards medication.

Prophylactic treatment of migraine by GPs: a qualitative study

BACKGROUND

Despite the considerable impact of migraine, the use of preventive medication in primary care is limited. Only about 5% of migraine patients who qualify for prophylaxis actually receive it, and adherence is far from optimal.

AIM

To explore the opinions of GPs regarding preventive medication for migraine.

DESIGN AND SETTING

A qualitative focus group study in Dutch general practice.

METHOD

Four focus groups (six GPs each) were formed. GPs were purposively sampled to acquire a range of participants, reflecting the more general GP population.

RESULTS

GPs perceived patients' concerns about the impact of migraine and the potential benefits of prophylaxis. However, some were hesitant to start prescribing prophylaxis due to doubts about effectiveness, potential side effects, and the risk of developing drug dependency. GPs' decisions were often based on considerations other than those presented in national guidelines, for example, the patient's need to control their own problem. Many GPs placed responsibility for initiating prophylaxis with the patient.

CONCLUSION

Various considerations hamper GPs from managing migraine with preventive medication, and various patient-related concerns cause GPs to deviate from national headache guidelines.