Common Migraine Interventions Ineffective in Reducing Disease Burden

Richard B. Lipton, MD

Data from a recent study suggest that prior to 2018 and the introduction of the novel calcitonin gene-related peptide (CGRP) antagonists, preventive treatments for migraine did not greatly reduce its burden on patients.

The majority (70.1%) of patients studied had not used preventive treatments despite having an average of 9.6 (standard deviation [SD], 5.0) headache days per month. Patients that did use preventive treatments reported a lack of efficacy, leading to poor adherence.

Senior author Richard B. Lipton, MD, director, Montefiore Headache Center, and colleagues wrote that “high discontinuation rates suggest that the preventive medications being offered during the period of the study did not meet the treatment needs of patients. In addition, the decisions by about half of patients to alter their prescribed treatment plan without consulting their provider can pose substantial health risks... These findings suggest the need for more effective and better tolerated preventive treatment options.”

Lipton and colleagues enrolled 234 patients with episodic (EM) or chronic migraine (CM) initiating or changing preventive treatment at 28 primary care of neurology clinics in the US as part of the real-world, 6-month observational, non-interventional, ATTAIN study (Assessment of TolerabiliTy and Effectiveness in migrAINe Patients using Preventive Treatment).

Of the patients enrolled, 118 had EM (50.4%) and 116 had CM (49.6%). The patients were a mean age of 41 years (SD, 12) at enrollment and 22 years (SD, 11) at diagnosis. The majority of patients were women (n = 204; 87.2%) and white (n = 178; 76.1%).

WATCH NOW: Richard B. Lipton, MD: Achieving Simultaneous Acute and Preventive Migraine Treatment

Lipton and colleagues found that 70.1% (115 of 164) of patients had not used preventive migraine treatment in the last 5 years (treatment naïve) despite having an average of 9.6 headache days per month (SD, 5.0). Treatment-experienced patients (n = 70) had a mean 12.4 headache days (SD, 7.0) per month.

Nonsteroidal anti-inflammatory agents (n = 124; 53.0%) were the most commonly used acute medications at baseline, followed by acetaminophen-based products (n = 112; 47.9%), and triptans (n = 105; 44.9%). Topiramate was the most common preventive treatment (n = 100; 42.7%), followed by tricyclic antidepressants (n = 39; 16.7%), beta-blockers (n = 26; 11.1%), and onabotulinumtoxinA (n = 24; 10.3%).

A majority of patients had a severe Migraine Disability Assessment (MIDAS) score, with 110 (67.1%) treatment-naïve patients and 54 (77.1%) treatment-experienced patients falling under this category. Similar results were seen in Headache Impact Test (HIT) scores, with scores indicating severe impairment seen in 145 (88.4%) treatment-naïve and 62 (88.6%) treatment-experienced patients. 

Lipton and colleagues also surveyed patients with the Work Productivity and Activity Impairment (WPAI) questionnaire and found that an average of 53.3% productivity loss was reported by employed patients. 

During the study period, 116 patients (49.6%) modified their treatments, either discontinuing preventive treatment (n = 88 modifications; 28.2%) or modifying their pattern of use (n = 224 modifications; 71.8%); often without consulting their doctors.

Avoiding adverse events (AEs) was the primary reason for modification, with 52 patients (59.1%) discontinuing, 37 (41.6%) decreasing frequency or dose, and 29 (33.7%) skipping doses due to AEs. Perceived lack of efficacy was also reported as a reason that 20 (22.7%) discontinued, 15 (16.9%) decreased frequency or dose, and 18 (20.9%) skipped doses.

"Recent regulatory approvals for CGRP biologics, a new class of migraine preventive drugs, provide an additional treatment option with favorable efficacy and side effect profile with substantially lower discontinuation rates in clinical trials compared to other available oral preventive therapies. The rapidity of onset and favorable tolerability of CGRP biologics are attributes that promise to address the considerable limitations of previously available oral preventive options for migraine,” Lipton and colleagues concluded.

NeurologyLive previously spoke with Lipton about the advantages of CGRP receptor targeting for the simultaneous acute and preventive treatment of migraine. Lipton and colleagues have shown that rimegepant (Nurtec ODT; Biohaven), approved for the treatment of acute migraine, is also effective in preventive treatment, and is better tolerated than current treatments. Watch what he had to say about CGRP below.

REFERENCE

Kawata AK, Shah N, Poon JL, et al. Understanding the migraine treatment landscape prior to the introduction of calcitonin gene‐related peptide inhibitors: Results from the Assessment of TolerabiliTy and Effectiveness in MigrAINe Patients using Preventive Treatment (ATTAIN) study. Headache. doi: 10.1111/head.14053