Chronic Migraine Is Underdiagnosed and Undertreated

Only half of all patients who report experiencing symptoms that would fulfill migraine diagnostic criteria have received a formal migraine diagnosis from a physician. At the 32nd Annual Scientific Meeting of the American Pain Society, Richard Wenzel, PharmD, said that so many patients go undiagnosed and undertreated in part because diseases of the brain do not have a biological marker of disease, and there are not many tools available to measure disease severity and impact of migraine.

Wenzel, from the Diamond Headache Clinic Inpatient Unit at St. Joseph Hospital in Chicago, IL, discussed the prevalence and impact of migraine, effective diagnostic and management strategies, and the strengths and limitations of various medications for migraine during “Update on Migraine Treatment” at the Pharmacotherapy Special Interest Group Wednesday, May 8, at the 2013 annual meeting of the American Pain Society.

Migraine is a pervasive and debilitating condition that affects 30 million people in the US, 22 million of whom are women. One in four US households has at least one migraine sufferer. Nine out of 10 patients with migraine report they cannot function normally during a migraine attack; three in 10 require bed rest. At least one in four migraine patients have missed at least one day of work over the last three months due to their illness.

Wenzel outlined several general goals for migraine treatment, as established by the US Headache Consortium. He said first and foremost, the physician should establish a diagnosis of migraine and create a formal management plan outlining a pharmacotherapy regimen and any non-pharmacologic measures the physician recommends.

The three-item ID Migraine™ validated screener is one useful diagnostic tool. It asks patients whether they felt nauseated or sick to their stomach when they have a headache, whether light bothers them during a headache attack, and if their headaches have limited their ability to work, study, or perform other activities of daily living for at least one day. Wenzel said studies have shown that a “yes” answer to two out of three of these questions accurately indicates a diagnosis of migraine (the screener has a sensitivity and specificity of 81% and 75%, respectively).

Wenzel said that patient education is also an important part of treatment. Patients should be educated on the purposes of acute and preventive drugs and devices, and the strengths and limitations of each. “It is also important to set realistic expectations regarding migraine treatment. We can’t cure migraine, we can only manage it,” said Wenzel.

Physicians should also discuss potential precipitating causes or migraine triggers and help the patient devise strategies for avoiding them.

Wenzel said that ideally physicians should adopt a stratified approach to care for migraine that starts with a diagnosis and assesses the aggregate burden of migraine on the patient’s life. He mentioned that the Migraine Disability Assessment Scale (MIDAS) and the Headache Impact Test (HIT) are useful tools for assessing and quantifying migraine headaches real-world impact on patients’ lives. After identifying the impact of the migraines, the patient can be stratified as low need (low migraine burden, can be treated with OTC medications), moderate need (can be treated with a combination of OTC and prescription medications), and high need (treated with migraine-specific prescription medications and preventive medications).

Physicians should promote early intervention in treatment. Patients should not wait until their migraine attack is severe before taking medications. Wenzel said, “they should take medication when they’re sure they’re having an attack.”

He noted that nearly all (95%) of patients with migraine take some form of medication. Nearly all of them treat their attacks with acute medication (which are intended to halt or significantly reduce an attack that is occurring or is about to occur). About half of all patients use only OTC medications for their migraine, self-treating with aspirin, Tylenol, etc. About one-fifth of patients use only prescription products, and the remaining 30% or so use a combination of OTC and prescription medications.

Wenzel noted that although migraine in general is undertreated, medication overuse is quite common among the patients who are actively managing their condition. This can have several negative effects, including the development of transformed migraine, which is a migraine condition that evolves from episodic attacks to daily or near daily chronic headache. The process can take months or years, during which patients experience an increase in migraine frequency, with generally less severe pain. Wenzel said that medication overuse is a factor in 8 out of 10 people with transformed migraine, but transformation may occur without overuse. He also noted that studies have shown compounds containing barbiturates and opiates are associated with a two-fold increased risk of transformed migraine.

When it comes to selecting medications for managing migraine, Wenzel said that triptans (oral, nasal, etc) are the treatment of choice of the US Headache Consortium for moderate and severe migraine and migraine associated with disability. There is also solid evidence supporting the effective use of dihydroergotamine intranasal. He said that triptans are not associated with development of chronic migraine and there is some evidence that NSAIDs protect against the transition to chronic migraine at low and moderate use.

Wenzel said that studies have shown “exposure to repeated attacks and sustained doses of analgesics appear to result in brainstem changes as patients progress from episodic migraine to chronic migraine. These changes will tend to increase attack frequency and hence analgesic consumption.”