Migraine Remains Underdiagnosed and Undertreated in the US
This report was reviewed for medical and scientific accuracy by Robert W. Gilbert, MD , Peachtree Neurological Clinic, Atlanta, Georgia.
Eleven years ago, the American Migraine Study I showed that the majority of Americans who suffered from migraine did not consult a physician and were relying mainly on over-the-counter (OTC) drugs for treatment of their headache episodes. A decade later, results of the American Migraine Study II show that not much has changed, even though new, extremely effective migraine-specific drugs have become available (i.e., the "triptans"). In the year 2000, headache sufferers have a choice of sumatriptan (Imitrex®) in three formulations (injection, tablet, nasal spray), rizatriptan (Maxalt®) in a tablet and a dissolvable wafer formulation, zolmitriptan (Zomig®) tablets, and naratriptan (Amerge®) tablets. Despite this array of safe, effective drugs, only about one in six American migraine sufferers takes a triptan.
"Efforts to educate patients about management of migraine have not kept pace with advances in understanding migraine and with advances in treatment. In measuring our progress over the past decade, we can say that the glass is half full," said Richard B. Lipton, MD, lead author of both the American Migraine Study I and II. Dr. Lipton is Professor of Neurology, Psychiatry, Epidemiology, and Social Medicine at the Albert Einstein College of Medicine, Bronx, New York. The American Migraine Study II included 29,258 individuals over the age of 12 from a random sample of US households. The prevalence of migraine in this sample was 12.6 percent, which was virtually unchanged from the prevalence in the 1989 study (12.1 percent). Migraine sufferers were three times more likely to be female than male, which is a well-known fact.
Only 48 percent of people who had migraine received a diagnosis from a physician, which is nine percent more than the American Migraine Study I showed in 1989. Even though more people with migraine were diagnosed in 1999, 57 percent of respondents relied only on OTC drugs to treat their headaches. Only 41 percent used prescription drugs in 1999, representing an increase of only four percent over 1989.
This shows that most migraine sufferers still are not consulting doctors and receiving the correct diagnosis, and that they are still not taking the most effective medications for their headaches, emphasized Dr. Lipton.
Both the 1989 and 1999 studies showed that migraine headache is associated with a high level of disability. Thirty-nine percent of the migraine sufferers said that their headaches were so severe that they needed bed rest, sometimes for several days at a time. Fifty-one percent said that their functional capacity at work or school was reduced by at least 50 percent during migraine attacks, and 66 percent said their work capacity at home was reduced by at least 50 percent. Migraine disability and loss of productivity at home and in the workplace translates to a huge economic burden. Estimates of the total cost of migraine, including the indirect costs of disability, range from $13 billion to $17 billion annually, according to different studies.
"The economic implications of migraine-related disability are huge," noted Dr. Lipton. He continued that the results of this study show that better education about migraine and available treatments is needed for both physicians and patients. Physicians need to be able to diagnose migraine correctly, and physicians and patients need to be educated about effective treatments that can reduce the pain and disability associated with migraine.
Early Treatment is Better
Another presentation at the meeting focused on the wisdom of treating migraine early in the course of the headache, before it becomes severe and debilitating. Treatment during the early phase would restore patients to their functional level sooner and reduce the pain and disability associated with migraine.
"When we treat migraine is just as important as what drug we use. Treatment should be initiated early, during the mild phase of the headache for people who typically go on to experience moderate to severe pain," Roger Cady, MD, told listeners. Dr. Cady is affiliated with the Headache Care Center in Springfield, Missouri.
Several studies have proven that early treatment with a triptan is associated with increased rates of freedom from pain at two hours (the endpoint studies use to show how well a migraine drug works). Studies of zolmitriptan showed that if the headache was treated early during the mild phase, 80 percent of patients were pain-free at two hours; if the headache was treated during the moderate phase, 57 percent were pain-free at two hours; and if treatment was reserved until the headache was severe, only 35 percent of patients were free of pain at two hours. "We used to think that triptans should be used as rescue medications when the headache is severe. We were wrong. They should be used earlier in the course of the headache," stated Dr. Cady.
He presented additional evidence from other studies of triptans showing that treatment during the mild phase results in higher pain-free rates at two hours and lower rates of recurrence with fewer side effects, compared to treatment when the headache is moderate to severe. Other studies suggest that the benefit of earlier treatment appears to be confined to the triptans and does not extend to OTC medications. One study showed that 76 percent of patients treated with sumatriptan were pain-free at two hours compared to only 27 percent treated with aspirin/metoclopramide. A second study showed that 68 percent of patients treated with sumatriptan versus 32 percent treated with ergotamine were pain-free at two hours.
"These studies suggest that treating the headache during the mild phase may prevent the nervous system from 'winding up' when the headache becomes severe," he suggested.
"The potential benefits of early treatment with a triptan are increased pain-free efficacy and preventing people from becoming disabled due to their migraine," stated Dr. Cady.