A recently published study looking at patient preference for early onset of preventive migraine treatments showed that both patients with chronic (CM) and episodic migraine (EM) treated with eptinezumab (Vyepti; Lundbeck) consider the likelihood of reduction of migraine on day 1 post dose to be as important as their overall reductions in the first month of treatment.1
Primary investigator Jessica Ailani, MD, FAHS, FAAN, director, MedStar Georgetown Headache Center, and colleagues analyzed a cohort of 101 patients (CM: n = 55; EM: n = 46) who completed an online preference-elicitation thresholding exercise. To align with the end point used in PROMISE-1 and PROMISE-2 (NCT02559895; NCT02974153), the clinical trials that led to eptinezumab’s approval, the speed of onset of migraine-preventive efficacy was defined as the likelihood that a migraine would be experienced on the first day after treatment.
"Preferences of patients for early onset of migraine-preventive efficacy have been described but need to be better understood as treatments with the potential to improve it, like eptinezumab, become available,” the study authors wrote. "This finding has important implications for decisions about which migraine prevention treatment options to discuss with patients. In particular, a more rapid onset of migraine-preventive efficacy has the potential to decrease the burden of migraine for patients and may help them regain control in a way that is meaningful to them."
Before beginning the threshold exercises, participants completed 2 warm-up tasks intended to test comprehension of choice tasks. In the thresholding exercises, participants were presented with 2 choice frames. In each choice frame, they were asked to select between 2 hypothetical migraine prevention medications that were defined by the likelihood of experiencing a migraine on day 1 postdosing and the number of migraine days the first month postdosing (SIDEBAR).
STUDY EXERCISE
Each study participant was presented with 2 treatment scenarios (treatment A or treatment B), with a description of the features of each—defined as the likelihood of experiencing a migraine after the first day of treatment and the number of days with a migraine in the first month of treatment—and asked which they preferred. Based on responses, the probability of experiencing a migraine and number of days was varied.
Participants were randomized to which choice frame they were presented with first. Depending on the choice task, the subgroup population, and the participants’ answers, the choice task was repeated 2-6 times, each time changing the levels of performance of 1 attribute for 1 treatment. The changes were designed to move the participant toward being indifferent between the treatments and were made in accordance with predefined algorithms.
Exercise 1 varied the amount of reduction in the likelihood of migraine on day 1 with treatment B.
- If patients preferred treatment A, the likelihood of migraine after day 1 with treatment B was reduced in the next scenario.
- If they preferred treatment B, the likelihood of migraine after day 1 with treatment B was increased in the next scenario.
Exercise 2 varied the amount of reduction in the migraine days per month with treatment B.
- If they preferred treatment A, the number of migraine days per month with treatment B was reduced in the next scenario.
- If they preferred treatment B, the number of migraine days per month with treatment B was increased in the next scenario.
CHOICE FRAME 1
Treatment A
- Episodic migraine: Fixed reduction of 5 monthly migraine days, fixed 22% chance of migraine first day post dose
- Chronic migraine: Fixed reduction of 10 monthly migraine days, fixed 42% chance of migraine first day post dose
Treatment B
- Episodic migraine: Fixed reduction of 6 monthly migraine days, varied 0%-22% chance of migraine first day post dose
- Chronic migraine: Fixed reduction of 12 monthly migraine days, varied 10%-42% chance of migraine first day post dose
CHOICE FRAME 2
Treatment A
- Episodic migraine: Fixed reduction of 6 monthly migraine days, fixed 14% chance of migraine first day post dose
- Chronic migraine: Fixed reduction of 12 monthly migraine days, fixed 28% chance of migraine first day post dose
Treatment B
- Episodic migraine: Varied reduction of 0-6 monthly migraine days, fixed 22% chance of migraine first day post dose
- Chronic migraine: Varied reduction of 0-12 monthly migraine days, fixed 42% chance of migraine first day post dose
Demographically, those with CM had been experiencing migraine for an average of 25.1 years and had an average of 14.3 migraine days per month, whereas those with EM had been experiencing migraine for an average of 26.9 years and had an average of 7.1 migraine days per month.
Based on responses to choice frame 1, 58% of participants with CM considered a 14% point-reduction in the likelihood of having a migraine on day 1 postdosing to have equivalent or greater value as a reduction of 2 migraine days during the first month post-dosing. Furthermore, for these patients, a median reduction of 9.0% (IQR, 13.0%) in the chance of migraine on day 1 postdosing was also considered just as valuable as a reduction of 2 migraine days in the first month postdosing.
Based on choice frame 2, 74% of participants (95% CI, 61.8-86.2) with CM thought that a 14% point-reduction in the likelihood of a migraine on day 1 post-dosing had the same value as a reduction of greater than or equal to 2 migraine days during the first month of treatment. These participants continued to value median reductions of 5 migraine days (IQR, 5.0) the first month post-dosing the same as a 14% point-reduction in the likelihood of migraine on day 1.
In the EM group, 51% (95% CI, 34.9-68.0) of participants that responded to choice frame 1 considered an 8% point-reduction in the likelihood of migraine on day 1 postdosing to have equivalent or greater value than reductions of 1 monthly migraine day. They also reported that a median reduction of 6.5% (IQR, 18.0%) in the likelihood of a migraine on day 1 is equivalent to the reduction of greater than or equal to 1 migraine day in the first month postdosing.
Based on choice frame 2, 69% (95% CI, 53.2-84.0) of participants with EM felt as though an 8% reduction in the likelihood of migraine day 1 post-dosing had the same value as a reduction of at least 1 migraine day in their first month of treatment. Even if patients had a median reduction of 1.5 (IQR, 3.0) monthly migraine days, they considered that reduction to be as valuable as an 8% point-reduction in the likelihood of migraine on day 1 post-dosing.
"When faced with treatment options that offer faster or slower onset of migraine-preventive efficacy and different levels of reduction in the number of migraine days the first month postdosing, patients will have different views on the combination of these attributes that best meets their needs,” Ailani et al added. "This highlights the importance of shared decision making between clinicians and patients when selecting preventive treatments for migraine, which is part of a broader trend of focusing on the patient in regulatory, health technology, and clinical decisions."
REFERENCE
1. Ailani J, Winner P, Hartry A, et al. Patient preference for early onset of efficacy of preventive migraine treatments. Headache. Published online February 20, 2022. doi:10.1111/head.14255
