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

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Applied Evidence

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

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

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References

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A study based on British general practice pharmacy records reported 55% of patients not renewing a triptan prescription during 1 year of follow-up,²⁶ and an older study of patients attending a Dutch neurology clinic found that 25% of sumatriptan users discontinued this drug over a 2-year period.²⁷ One US primary care treatment study found that on enrollment, 62% of 143 migraine patients had previously used triptans or ergotamines but had discontinued therapy.²⁸

As in our study, the principal stated reason for discontinuation in the Dutch study²⁷ was lack of efficacy. Conversely, in the US primary care study only 13% of patients gave lack of efficacy as the principal reason for discontinuation but 20% cited cost and 55% cited nonprescribing by physicians.²⁸

FAST TRACK

The principal reason patients give for discontinuing triptans is lack of efficacy

As shown in the TABLE, the most striking differences between patients who discontinued triptans and those who continued were in patient satisfaction with treatment and current use of narcotic medication for migraine, but the higher grades of MIDAS scores (FIGURE) were also significantly more common in the patients who discontinued.

This study was not designed to assess if these factors caused or resulted from triptan discontinuation, but the association of triptan “failure” with 3 other significant negative factors could indicate subgroups of patients with especially high morbidity from migraine or risk of poor response to migraine-specific treatment. Future studies are needed to better characterize patients who discontinue, especially to examine the roles of comorbidities, total medication use, and the role of subspecialty referral.

TABLE
Differences between patients who discontinued triptans and those who continued

	DISCONTINUERS	CONTINUERS	P VALUE
Disability (MIDAS score)
Grade I or II	34	98	.034
Grade III or IV	86	145
Medication coverage*
All or some	106	216	.904
None	14	28
Patient satisfaction
Satisfied	71	201	<.001
Dissatisfied	49	44
Gender
Female	103	216	.39
Male	18	27
Current narcotic use
Use	57	54	<.001
No use	64	191
* Payment by health insurance for migraine medications
Sample size calculated for alpha=0.05 and power=1–beta=0.80.

Limitations of this study

This study has several weaknesses, mainly the low response rate and potential biases in patient selection and participation. A headache survey mailed to 200 randomly selected patients in a single British general practice reported a response rate of 61%²⁹and the American Migraine II Survey reported response rates of 59% to 69% of households.⁴ Considerations of patient confidentiality, cost, and burdening busy practices limited our ability to use many of the strategies recommended to increase response rate.³⁰ The highest response rates were from those smaller practices where the office staff expressed most interest in the study.

FAST TRACK

The MIDAS questionnaire is a 5-item instrument designed to assess impact of migraine on daily activities

Although ICD coding has shortcomings as a technique of identifying a study population, it is reported to be very accurate for specific conditions such as migraine and for patients with insurance.^31,32 We did not include questions to verify that patients met International Headache Society (IHS) criteria for migraine³³ because of concerns about the length of the survey and because a positive diagnosis of migraine by a family physician is reported to be likely accurate 98% of the time.²⁰ Examining how the accuracy of diagnosis and the various subtypes of migraine impact treatment would be interesting additions to a future study.

Methods and Results

For this study, we used 10 community practices—5 rural and 5 urban, and all associated with the Kansas Practice Research Network—to conduct an observational, cross-sectional study of adult patients who consulted family physicians because of migraine during 2002. The 5 rural practices served communities ranging from 835 to 6313 in population and were selected to represent the different geographic regions of the state. Similarly, the 5 urban practices represented different demographic areas within the city of Wichita (population 344,284).

Patients were identified by use of migraine-specific ICD-9 codes (all subgroups of ICD 9-346) for the consultation. The only exclusion was of patients aged less than 18 years. The 15-item written survey (FIGURE W1) gathered demographic data and incorporated the standardized Migraine Disability Assessment Score (MIDAS) questionnaire (FIGURE),^21,22 as well as questions about migraine experience, medications, and satisfaction with treatment.

The MIDAS questionnaire is a simple 5-item written instrument (FIGURE) developed from more complex measures of headache and morbidity specifically to assess impact on daily activities. Its validity, reliability, and ease of use have been confirmed in population studies and busy clinical settings.^21-23 The survey asked patients to name all medications (prescription, nonprescription, or other, including herbal remedies) usually used for migraine. In addition, a specific question addressed current or previous use of the triptans available at the time of the study—ie, naratriptan (Amerge), sumatriptan (Imitrex—injection, oral, or nasal spray), rizatriptan (Maxalt), zolmitriptan (Zomig), almotriptan (Axert), and frovatriptan (Frova). This question used both generic and trade names for the medication. Patients who reported previous but not current use of any triptan were asked to describe their reasons for discontinuation in their own words.

Patients received the survey by mail, along with a cover letter from their personal physicians inviting them to participate in the study and instructions to return the anonymous survey directly to the primary investigator. Patients were assured that neither their personal physicians nor the researchers could identify participants and that their ongoing medical care would not be altered in any way by their participation in the survey or by the information provided. The study was approved by the University of Kansas School of Medicine Institutional Review Board.

Data were entered into a Microsoft Access 2000 file and 2 data entry personnel performed data editing to verify each entry. Data were analyzed using Microsoft Excel. Analysis was completed using the statistical program SPSS for Windows V.11.0 (SPSS Inc, Chicago, Ill). The principal modes of data analysis included chi-square, Kruskal-Wallis, independent samples t-tests, and analysis of variance (ANOVA). A probability value of less than 0.05 was considered statistically significant.

Results

The 10 participating practices identified 992 patients aged 18 or older who consulted at least once during 2002 primarily for a migraine-related diagnosis. After 3 mailings, 447 surveys suitable for analysis were returned (a response rate of 45%). For individual practices, the number of patients surveyed ranged from 9 to 540, and the response rates were from27.5% to 72%. Responders did not differ from nonresponders in age or gender distribution.

The respondents were predominantly female (83%) with a mean age of 44 years (range, 18–82). Two thirds of the respondents had experienced migraine for more than 10 years, and most reported that migraine significantly impacted their lives. Sixty percent of patients scored 10 or more on the MIDAS scale, indicating moderate-severe migraine-related disability.

Most respondents (85.5%) had private insurance. Only 14% reported having no assistance with payment for migraine medications, and 58% reported that “all” or “most” of their migraine medications were paid by insurance plans. Seventy-three percent of respondents were “satisfied” or “very satisfied” with medical treatment for migraine and only 5% “very dissatisfied.”

Participants reported using a wide range of prescription and nonprescription medications. Overall, 366 (82%) patients reported experience with triptans. Of these patients, 206 (56%) had used more than 1 triptan. Current triptan use was reported by 245 (55%) of all respondents. Among the 121 patients who reported discontinuation of triptans, the most common reason provided was lack of efficacy (57%), followed by adverse effects (24%).

Statistically significant differences were found between patients who continued triptan therapy and those who discontinued in migraine disability (MIDAS scores), satisfaction with migraine treatment, and reported use of narcotic medication for migraine (TABLE). Patients who discontinued triptan therapy did not differ significantly from those who continued in age, gender, number of years with migraine, insurance type, use of prophylactic migraine medication or reported use of analgesics, combination medications, ergots, “other,” or “no” medications to treat migraine attacks.