Failure of preventive treatments in migraine: an observational retrospective study in a tertiary headache center

Abstract

Background: Although the criteria for acute migraine treatment and prevention have been well described, there are still unmet needs, general underuse and low benefits of preventive drugs. The aim of the present study was to retrospectively observe the short-term effect of preventive treatment in a cohort of migraine patients attending a tertiary headache center, using data from electronic medical records. Methods: This was an observational retrospective cohort study based on data collected in a tertiary headache center. Data were extracted from an electronic dataset collected from January 2009 to December 2019. The main selection criteria were as follows: age of 18-75 years; diagnosis of migraine without aura (MO), migraine with aura (MA) or chronic migraine (CM); a control visit 3 months after the first access; and prescription of preventive treatment with level of evidence 1 as reported by Italian guidelines. As the primary outcome, we considered the change in the frequency of headache at the follow-up visit. Then, as secondary outcome measures, we used disability scores, intensity of headache, and allodynia. As predictive factors, we considered age, migraine duration, sex, headache frequency, allodynia, anxiety and depression at baseline, and comorbidity with fibromyalgia. Results: Among the 6430 patients screened, 2800 met the selection criteria, 1800 returned to the follow-up visit, 550 withdrew because of adverse events, and 1100 were included the analysis. One hundred thirty-four patients had a frequency reduction of 50% or more. Flunarizine was used for less severe migraine, with a better effect compared to those of other drugs (odds ratio: 1.48; p: 0.022). Low headache frequency and absent or mild allodynia predicted a better outcome. Conclusions: The mild effect of preventive drugs on migraine features and even the number of patients who were lost to follow-up or dropped out because of adverse events confirm that in severe and chronic patients, the first line of prevention can only delay a more focused therapeutic approach.

Osmophobia in primary headache patients: associated symptoms and response to preventive treatments

“…In regard to the migraine cohort evaluated after 3 months preventive treatment, it is not a primary aim of the study to give comments about the effect of therapies. Briefly, present study confirmed what recently reported by our group, a high percentage of patients below the threshold of 50% headache frequency reduction, though in the present evaluation we found more responders [ 12 ]. There was also a general mild improvement of main migraine clinical aspects, while flunarizine confirmed a better effect on frequency and amitriptyline on mood.…”

“…They were visited after 3 months follow up. Some of the patients were also included in the previous evaluation, and we followed the same therapeutic options detailed in Delussi and de Tommaso [ 12 ]. Patients were considered responders if they reported a 50% reduction of headache frequency at follow up.…”

“…Patients underwent the clinical assessment that we described in previous studies [ 12 ]. At the moment of visit booking, patients are generally requested to fill a headache diary [ 12 – 14 ]. The same chart, is recommended to be completed during the follow up period.…”

Pathophysiological Bases of Comorbidity in Migraine

“…The correct therapeutic approach to single causes of comorbidity in such complicated patients could improve their global clinical picture (Affaitati et al, 2020 ). A recent observational study on the effects of preventive treatments after 3 months of therapy showed that patients with FM have a profile of resistance to first-line preventive drugs (Delussi et al, 2020 ). Tricyclic antidepressant amitriptyline was actually the most frequently prescribed drug for the treatment of migraine patients comorbid with FM (Delussi et al, 2020 ).…”

“…A recent observational study on the effects of preventive treatments after 3 months of therapy showed that patients with FM have a profile of resistance to first-line preventive drugs (Delussi et al, 2020 ). Tricyclic antidepressant amitriptyline was actually the most frequently prescribed drug for the treatment of migraine patients comorbid with FM (Delussi et al, 2020 ). However, researchers did not report the possible effect of amitriptyline on specific symptoms of FM and how the mild improvement of migraine could impact the disability linked to diffuse pain (Affaitati et al, 2020 ).…”