Do family physicians fail to provide triptans for patients with migraine?

,

Applied Evidence

Do family physicians fail to provide triptans for patients with migraine?

J Fam Pract. 2006 December;55(12):1057-1062

By

Anne Walling, MB, ChB, FFPHM

We think not. Though improved prescribing is always desirable, the real challenge is patient adherence to regimens.

PDF Download

References

1. Nutting PA, Baier M, Werner JJ, Cutter G, Reed FM, Orzano AJ. Practice patterns of family physicians in practice-based research networks: a report from ASPN. J Am Board Fam Pract 1999;12:278-284.

2. Gibbs TS, Fleischer AB, Feldman SR, Sam MC, O’Donovan CA. Health care utilization in patients with migraine: demographics and patterns of care in the ambulatory setting. Headache 2003;43:330-335.

3. Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American migraine study II. Headache 2001;41:646-657.

4. Lipton RB, Scher AI, Kolodner K, Liberman J, Steiner TJ, Stewart WF. Migraine in the United States: Epidemiology and patterns of health care use. Neurology 2002;58:885-894.

5. Lipton RB, Diamond S, Reed M, Diamond M, Stewart WF. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache 2001;41:638-645.

6. Maizels M. Model interventions to improve headache outcomes in health care systems. In Reducing the Burden of Headache, Olesen J, Steiner TJ, Lipton RB (eds). New York: Oxford University Press; 2003:290-301.

7. Bigal ME, Kolodner KB, Lafata JE, Leotta C, Lipton RB. Patterns of medical diagnosis and treatment of migraine and probable migraine in a health plan. Cephalalgia 2006;26:43-49.

8. Cady R, Dodrick DW. Diagnosis and treatment of migraine. Mayo Clin Proc 2002;77:255-261.

9. Lipton RB, Scher AI, Steiner TJ, et al. Patterns of health care utilization for migraine in England and in the United States Neurology 2003;60:441-448.

10. Loder EW, Lipton RB. Conclusion: how primary care physicians can help their patients with migraine. Am J Med 2005;118:45S-46S.

11. Loder EW, Sheftell F. The quality of headache treatment in the United States: review and analysis of recent data. Headache 2005;45:939-946.

12. Snow V, Weiss K, Wall EM, Mottur-Pilson C. Pharmacologic management of acute attacks of migraine and prevention of migraine headache. Ann Intern Med 2002;137:840-849.

13. Lipton RB, Cutrer FM, Goadsby PJ, et al. How treatment priorities influence triptan p in clinical practice: perspectives of migraine sufferers, neurologists, and primary care physicians. Curr Med Res Opin 2005;21:413-424.

14. Gallagher RM, Cutrer FM. Migraine: diagnosis, management, and new treatment options. Am J Man Care 2002;8:S58-S73.

15. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000;55:754-763.

16. Ferrari MD, Roon KI, Lipton RB, Goadsby PJ. Oral triptans (setotonin 5-HT1B/1D agonists) in acute migraine treatment: a meta-analysis of 53 trials. Lancet 2001;358:1668-1675.

17. Lohman JJHM, van der Kuy-de Ree MM. Patterns of specific antimigraine drug use—a study based on the records of 18 community pharmacies. Cephalalgia 2004;25:214-218.

18. Von Korff M, Black LK, Saunders K, Galer BS. Headache medication-use among primary care headache patients in a health maintenance organization. Cephalalgia 1999;19:575-580.

19. Available at: www.pozen.com/product/migraine.asppjbpubs.com/script_reports/migraine.htm.

20. Tepper SJ, Dahlof CG, Dowson A, et al. Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of a headache: data from the Landmark Study. Headache 2004;44:856-864.

21. Stewart WF, Lipton RB, Kolodner K, Liberman J, Sawyer J. Reliability of the migraine disability assessment score in a population-based sample of headache sufferers. Cephalalgia 1000;19:107-114.

22. Stewart WF, Lipton RB, Kolodner KB, Sawyer J, Lee C, Liberman JN. Validity of the Migraine Disability Assessment Score in (MIDAS) n comparison to a diary-based measure in a population sample of migraine sufferers. Pain 2000;88:41-52.

23. Andrasik F, Lipchik GL, McCroy DC, Wittrock DA. Outcome measurement in behavioral headache research: headache parameters and psychosocial outcomes. Headache 2005;45:429-437.

24. Welch KMS, Mathew NT, Rosamond W, et al. Tolerability of sumatriptan: clinical trials and post-marketing experience. Cephalalgia 2000;20:687-695.

25. Robbins L. Triptans versus analgesics. Headache 2002;42:903-907.

26. Savini N, Martin A, Browning D. Switching patients with migraine from sumatriptan to other triptans increases primary care costs. Int J Clin Prac 2004;58:758-763.

27. Visser WH, de Vriend RHM, Jaspers NMWH, Ferrari MD. Sumatriptan in clinical practice: a 2-year review of 453 migraine patients. Neurology 1996;47:46-51.

28. Powers C, Szeto S, Pangtay D, Bort T, Cervi M, Cady R. Evaluation of migraineurs’ p for naratriptan over conventional first-line agents. Arch Fam Med 2000;9:753-757.

29. Boardman HF. Headaches in primary care: a pilot study. Cephalalgia 2000;20:364.-

30. Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002;324:1183-1193.

31. Chao J, Gillanders WG, Flocke SA, et al. Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract 1998;47:28-32.

32. Stange KC, Zyzanski SJ, Smith TF, et al. How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison of direct observation of patients visits. Med Care 1998;36:851-857.

33. Headache Classification Subcommittee of the International Headache Society The international classification of headache disorders 2nd ed. Cephalalgia 2004;24:S1-S150.

34. Scott A, Smith RD. Keeping the customer satisfied: issues in the interpretation and use of patient satisfaction surveys. Int J Qual Health Care 1994;6:353-359.

35. Linet MS, Celentano DC, Stewart WF. Headache characteristics associated with physician consultation: a population-based survey. Am J Prevent Med 1991;7:40-46.

36. Lafata JE, Moon C, Leotta C, Kolodner K, Poisson L, Lipton RB. The medical care utilization and costs associated with migraine headache. J Gen Intern Med 2004;19:1005-1012.

Practice recommendations

While continuing to improve recognition of migraine in your patient population, pay particular attention to the adherence rate among those for whom you have prescribed a triptan.
Ask patients who discontinue triptan therapy why they made that decision. Besides adverse effects from the agent, reasons may include medication cost, influence of comorbidities, or triptan interaction with medications you may not have known about.

Despite more than 5 million consultations annually, relatively little is known about the treatment of migraine in primary care. Much of the literature is projected from population surveys or reports concerning patients referred for specialist care or those entering treatment studies.

Our study is the largest reported to gather data directly from patients treated for migraine in family practice. The participating practices represent a spectrum of communities and practice types. As minimal differences exist in practice patterns between family physicians who participate in research networks and all family physicians¹, these findings may more accurately reflect the current status in family practice than other studies.

We believe that this study indicates family physicians offer triptans to most patients consulting specifically for migraine and that adherence issues contribute significantly to the perceived low rates of use of these medications in primary care. In recent years, considerable effort has gone into increasing the diagnosis of migraine and promoting the more extensive use of triptans in primary care patients (see article on page 1038 in this issue). Family physicians must certainly continue to improve the recognition of migraine; but attention to patient concerns about triptans and efforts to enhance adherence and appropriate use of these medications is obviously essential. We must continue efforts to better understand why some 30% or more of migraine patients in primary care practice discontinue a therapy that has been found to be highly effective and well accepted by patients in clinical studies.

Migraine-specific prescribing in primary care is better than commonly reported

Between 1990 and 1998, the number of physician office visits for migraine doubled to more than 5 million per year.² Of the more than 28 million US adults with migraine, approximately 70% of women and 50% of men are now believed to have consulted a physician at least once,³ and two thirds of these patients have made 5 or more physician visits for migraine.⁴ More than 72% of migraine-related physician visits are to primary care physicians, the most to family physicians.¹

Nevertheless, the headache literature routinely describes migraine as “undertreated” in primary care.^5-7 In particular, primary care physicians are perceived to under-prescribe triptans,^7-11 the most effective migraine-specific medications available, widely regarded as “the gold standard” for acute migraine therapy of all but mild attacks.^12-16 Population surveys estimate that only some 13% to 20% of migraine sufferers have been prescribed triptans.^4,5,9,17 A 1995 study of migraine patients enrolled in a health maintenance organization reported that 11.4% used subcutaneous sumatriptan; however, oral triptans were not included in the study.¹⁸ Ten years later, another study of health plan enrollees estimated that only 11% of those meeting strict criteria for migraine were prescribed triptans or ergots.⁷

FAST TRACK

Expect about one third of patients to discontinue triptan therapy

These low percentages do not correlate with our experience of primary care practice nor with data indicating substantial sales of triptans in the US.¹⁹ As we have not identified any studies that directly address prescribing by primary care physicians for migraine, we conducted a survey of patients who consulted family physicians for migraine during 2002.

Some of the differences between our findings and those based on prescription data could be attributed to the use of samples (reported to be particularly common in migraine treatment during this period), or difficulties in patient recall of medications.

Diagnosis of migraine not always coded. A more significant source of difference between our findings and those of population-based surveys is in the diagnosis of migraine. Most surveys use patient-reported symptoms for diagnosis, and hence the population of migraine sufferers includes those who have not had a physician visit coded for migraine. Our interest is in the primary care consultation specifically for migraine.

If a physician concludes a patient has migraine, this diagnosis is highly likely to be correct,²⁰ and our findings indicate that a migraine-specific medication is commonly offered. We strongly support ongoing efforts to improve the recognition of migraine by all physicians and emphasize that our results are based only on patients identified by migraine-coded primary care visits.

Why do patients discontinue triptans?

The finding that about one third of patients discontinued triptan use may be surprising in view of the widely reported efficacy¹⁶ and tolerability²⁴ of these medications, but this is almost identical to the results of a study of 663 patients of a US headache clinic.²⁵ Significant rates of triptan discontinuation have been reported by other studies.