The Acute Treatment of Episodic and Chronic Migraine in the USA

Abstract

Understanding the patterns of acute treatment of migraine in the population is a necessary step in evaluating treatment in relation to guidelines, and in improving care. Herein we assess the specific medication used for the acute treatment of migraine and chronic migraine (CM) in the population. We identified 24 000 headache sufferers, drawn from over 165 000 individuals representative of the US population. This sample has been followed with annual surveys using validated questionnaires. As part of the survey, subjects were asked to report the specific medications currently used for their most severe headaches, dose, and number of days per month using medication. Complete responses were obtained from 14 540 individuals, including 9128 with episodic migraine and 503 with CM. For episodic migraine, specific treatment was used by 19.2% of subjects (triptans 18.7%; compounds with ergotamine 0.5%). A total of 11.1% routinely used opiates, whereas 6% used compounds with barbiturates. For CM, 22% used migraine-specific treatment, whereas 34.3% used opiates and barbiturates. Non-prescribed medications were frequently used in both groups. Opiates were more commonly used by those with CM [odds ratio (OR) 2.12, 95% confidence interval (CI) 1.69, 2.65], as were butalbital-containing compounds (OR 2.46, 95% CI 1.88, 3.22). The minority of migraineurs in the USA use specific medication, and one-fifth use opiates or barbiturates. For CM, > 34% use opiates or barbiturates. Accordingly, a sizable proportion use medications that are not firstline according to the US Headache Consortium Guidelines.

Controversies in migraine treatment: opioids should be avoided

“…Use of opioids for treatment of migraine is controversial. Despite evidence-based guidelines do not recommend opioids as first-line treatment of migraine attacks [2][3][4], and no randomized controlled trial has shown any significant effect of opioids on migraine attacks when pain-free was the primary end-point of the study [5], their use in clinical practice [6][7][8] and, even more, in emergency departments (EDs) is very large, especially in USA and Canada [9,10]. Moreover, among studies about the efficacy of opioids as rescue medication for acute migraine in EDs recently revised, only one evidenced a superiority of meperidina 75 mg i.m.…”

“…Data from American Migraine Prevalence and Prevention study analyzing rates and reasons for discontinuation of triptans and opioids in episodic migraine from 2008 to 2009 showed that opioids use was associated with an increased risk of medication discontinuation compared to triptans. Reasons for medication discontinuation included return of migraine pain, concerns regarding drug interactions, and stomach upset, among others [6,7]. The good management of acute migraine attacks is one of the most important components of the plan that prevents the transformation of episodic primary headache patterns into chronic headache disorders.…”

Didactic Migraine Education in US Doctor of Pharmacy Programs

“…29 We believe that this prevalence of butalbital-containing product prescribing is difficult to justify given the lack of data demonstrating the efficacy of butalbital-containing products; the consortium's guidelines state: ''no randomized, placebo-controlled studies prove or refute efficacy for [butalbital-containing products] in the treatment of acute migraine headaches. .…”

Meeting Acute Migraine Treatment Needs through Novel Treatment Formulations

“…Despite the development and availability of migrainespecific medications, only 19% of migraineurs use triptans for acute therapy, 1 and triptan satisfaction is modest at best. 2 Although patients prefer oral administration, gastric stasis limits the usefulness of this route of administration.…”

“…The most used treatment was triptans, with ergots used by Ͻ1% of patients. 1 Migraine sufferers continue to rely on overthe-counter preparations (68%). Opioids are used by 11% of patients and butalbital by 6%.…”