Treatment Patterns, Discontinuation, and Switching of Acute Medications for Migraine: A Cross-Sectional Survey

Thesis (Master's)--University of Washington, 2018BACKGROUND: Migraine is an episodic neurological disorder that poses significant burden on patients and the physicians who manage their therapy. Treatment patterns for acute medications for migraine are not well characterized using claims databases alone. A variety of treatment approaches are taken by physicians and patients to find the optimal acute migraine medication. Only a few studies have evaluated the role of cardiovascular risk in migraine treatment selection. Generally, there is some understanding that cardiovascular disease risk may play a role in acute medication selection but few studies have explored this subgroup of patients in depth. Using Adelphi survey data, our research attempts to fill these gaps. The objective of this study was to characterize treatment patterns of discontinuation, switching, and satisfaction with acute medications for migraine using cross-sectional survey data from patients and physicians. METHODS: Adelphi administered three surveys, the Physician Workload Questionnaire (PWQ), Patient Record Form (PRF), and Patient Self-Completion Questionnaire (PSC). We analyzed data from all three surveys. Survey respondents were migraineurs regardless of treatment history. We characterized physician demographics and workload patterns as well as patient demographics and migraine specific characteristics. Additionally, we characterized treatment patterns for discontinuation or switching. We also assessed physician-reported reasons for discontinuation or switching as well as patient-reported side effects currently experienced. We calculated the level of satisfaction for both physicians and patients with current acute medications for migraine. We then explored characteristics of patients that were associated with triptan treatment failure, discontinuation in the past due to side effects, and discontinuation in the past due to lack of efficacy. In our secondary analyses, we focused on treatment patterns among patients with increased cardiovascular (CV) risk. RESULTS: Physicians (N=431) completed a Patient Record Form (PRF) on up to 10 patients each with migraine for whom they were making treatment decisions. A total of 4,254 PRFs were completed. Over 70% of the patients were female, 47% were on acute medications only, 39% were on acute and preventive medications, 4% were on preventive medications only, and 11% were on no current treatment. At completion of data collection, patients had spent an average of 1,023 days on their current acute medication, while an average of 81 days elapsed between the most recently discontinued or switched acute medication and the start of the current medication. Sumatriptan and Ibuprofen were the two medications with the highest proportion of patients experiencing prior use with 23% and 16%, respectively. Physicians reported lack of efficacy as the most common reason for discontinuation or switching acute medications for migraine. Tiredness/fatigue was the most commonly reported side effect patients experienced while taking acute medications for migraine. On a seven-point Likert scale, over 60% of physicians and over 60% of patients were satisfied or extremely satisfied with their prescribed acute medications for migraine. The adjusted odds of treatment failure on a triptan were significantly higher for obese versus patients with normal BMI (OR = 1.438, 95% CI 1.083 to 1.991), significantly higher for episodic versus chronic patients (OR = 2.535, 95% CI 1.873 to 3.431), and significantly higher for those with current severe migraine (OR = 2.346, 95% CI 1.079 to 3.219) or current moderate migraine (OR = 1.529, 95% CI 1.169 to 2.015), each compared to mild migraine. Twelve percent of patients cited their most common reason for discontinuation or switching their triptan medication was after asking their doctor. For our subgroup analysis, patients with CV risk followed similar trends as the entire patient sample in the PRF with regards to demographics, the proportion of patient experiencing prior use, physician reasons for discontinuation or switching, and physician-reported level of satisfaction. Out of 611 patients characterized as having CV risk, 163 patients (27%) failed to achieve pain freedom at two hours post-dose while on a triptan. CONCLUSION: Our findings show that patients had spent, on average, three months on their current acute medication for migraine while almost three months elapsed between the most recently discontinued or switched acute medication and the start of current medication. Triptans were the most common class of medications with the highest proportion of patients experiencing prior use which is consistent with current guidelines and their place in therapy. Lack of efficacy was cited most commonly by physicians as their reason for discontinuation or switching. Tiredness/fatigue was the most commonly reported side effect experienced by patients which may also be indicative of the triptan side effect profile. Physicians and patients were generally satisfied with current acute medications for migraine. Treatment failure while on a triptan was significantly associated with obesity, episodic migraine, and severe or moderate migraine. These migraine-specific characteristics may suggest patients with higher migraine burden in general. Finally, almost a third of patients with CV risk failed to achieve two-hour headache freedom on a triptan post-dose on more than half of occasions. Our study revealed that patients with CV risk may not be receiving adequate migraine relief from triptans