Slow but Steady Improvement Observed in Migraine Diagnosis Rates, Use of Preventatives

Richard B. Lipton, MD

Data from the longitudinal OVERCOME study’s 2018 migraine cohort showed that relative to previous population-based findings, consultation for migraine may now be more likely to include ambulatory clinics, diagnosis rates have shown slow and consistent improvement over time, and the use of preventive medication may be slowly improving.¹ Notably, though, the subgroups of patients with the highest disability reported some of the lowest use of preventative medications.

Led by Richard B. Lipton, MD, director, Montefiore Headache Center, the data also suggest that episodic migraine (EM) is a condition with substantial heterogeneity and should not be approached with the same mentality for each individual. In the analysis, Lipton and colleagues identified several opportunities for optimizing migraine care, including patients seeking care in primary care, more people getting diagnosed with migraine and being prescribed potentially beneficial acute and preventive medication.

The findings provided a “snapshot” of the migraine landscape and how it has changed over the years. Establishing the migraine cohort involved 3 phases: creating a demographically representative sample of US adults (n = 97,478), identifying those with active migraine (n = 24,272), and characterizing symptomatology, consultation, treatment, and impact of migraine (n = 21,143). Among those in the final migraine cohort, monthly headache day frequency distribution was broken into 4 categories: low-frequency EM (LFEM; n = 12,299 [58.2%]), medium frequency EM (MFEM; n = 4070 [19.2%]), high frequency EM (HFEM: n = 2291 [10.8%]), and chronic migraine (CM: n = 2483 [11.7%]).

READ MORE: Nerivio Shows Effectiveness as Acute Migraine Treatment in Large-Scale, Real-World Analyses

Most patients (78.9%) reported having at least 1 lifetime medical consultation for headache/migraine, with consultation in primary care being the most common (70.3%), followed by consultation in neurology (28.1%) or headache specialist (15.6%). In total, 31% of the cohort had consulted at an emergency department or urgent care center at least once.

For the 51% of the population that had consulted for headache/migraine in the past 12 months, each patient had an average of 2.9 visits (standard deviation [SD], 7.8). The median number of consultations for migraine during this time were low (0 for LFEM, 1 for MFEM/HFEM, and 2 for CM). “Given that the majority of individuals with MFEM/HFEM/CM experienced moderate or severe migraine-related disability (MFEM, 57.5%; HFEM, 68.8%; and CM, 79.7%), these consulting numbers are concerning,” the study authors wrote.

Among the migraine cohort (n = 21,143), 19,888 (94.1%) individuals met the International Classification of Headache Disorders, 3rd edition-based case definition of migraine and 12,905 (61.0%) self-reported a medical diagnosis (SR-MD) of migraine. The average age of diagnosis for those with an SR-MD of migraine was 23.7 years (standard deviation [SD], 11.8), and the average number of years between migraine onset and diagnosis was 3.3 years (SD, 6.5). Notably, the averages for both age at diagnosis and years between onset and diagnosis varied by half a year or less across monthly headache day categories.

When observing treatment patterns, investigators found that 97.1% of the cohort had used an acute treatment for migraine in their lifetime. Although 76.8% reported having used a prescription medication in their lifetime, only 40.0% currently used prescription medication. Lifetime use of triptans was reported by 35.0% whereas 22.7% reported current use.

Preventive medications were used by only 26.1% of the cohort during their lifetimes, even though 40.4% of respondents met eligibility criteria for migraine prevention. Of these, 16.8% were currently using a preventive, with an increase in these medications observed based on higher monthly headache day frequency (LFEM, 13.2%; MFEM, 18.4%; HFEM, 20.4%; and CM, 28.9%). Notably, as alluded to by Lipton, et al, of those who were eligible for preventative medications, a majority were not taking them—with a particularly disparate ratio in the groups with the highest reported severity. Of those in the MFEM group, 81.5% (n = 3317) were eligible but only 18.4% (n = 749) were on a preventative currently; in the HFEM and CM groups, 100% were eligible (HFEM, n = 2219; CM, n = 2483), but only 20.4% (n = 467) and 28.9% (n = 718) were currently on a preventative, respectively. Migraine Disability Assessment (MIDAS) scores of III or IV (moderate or severe disability) were reported for 23.9% and 33.6% of the MFEM group, respectively; 29.0% and 49.8% of the HFEM group, respectively; and 12.8% and 66.9% of the CM group, respectively (FIGURE).

FIGURE. Migraine Preventative Eligibility Among Subgroups

Lipton and colleagues compared the outcomes observed with previous notable studies, including the American Migraine Studies (AMS-I/AMS-II), completed in 1989 and 1999, and the 2004 American Migraine Prevalence and Prevention study (AMPP). Over the past 30 years, data has shown that SR-MD rates, among those who screened positive for migraine, have risen from 38% in AMS to 48% in AMS-II to 56% in AMPP and now 58.6% in 2018. Lifetime consultation for migraine at an emergency department was 24%, which was larger than the 5%-6% observed in AMS-I and AMPP.^2-4

Although low, the overall rate of 16.8% for use of migraine prevention medication was higher than the 12%-13% rate responded in AMPP and suggests potentially model improvement in preventive medication use. The proportion of people with migraine was also similar to the findings from the AMPP study, but the overall rates of use have increased by 25%.

"This baseline OVERCOME (US) 2018 cohort study will be followed by other unique cohorts followed longitudinally to assess changes in the migraine care landscape concurrent with the introduction of novel therapeutic classes for preventing or treating migraine,” Lipton et al concluded.¹

REFERENCES
1. Lipton RB, Nicholson RA, Reed M, et al. Diagnosis, consultation, treatment, and impact of migraine in the US: results of the OVERCOME (US) study. Headache. Published online January 25, 2022. doi:10.1111/head.14259

2. Lipton RB, Stewart WF, Simon D. Medical consultation for migraine: results from the American Migraine Study. Headache. 1998;38(2):87-96. doi:10.1046/j.1526-4610.1998.3802087.x

3. Stewart WF, Lipton RB, Dowson AJ, Sawyer J. Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability. Neurology. 2001;56(suppl 1):S20-S28. doi:10.1212/wnl.56.suppl_1.s20

4. Diamond S, Bigal ME, Silberstein S, Loder E, Reed M, Lipton RB. Patterns of diagnosis and acute and preventive treatment for migraine in the United States: results from the American Migraine Prevalence and Prevention study. Headache. 2007;47(3):355-363. doi:10.1111/j.1526-4610.2006.00631.x