The Emerging Science of Prophylactic Therapies for Migraine. Final Outcomes Report. Lilly USA, LLC Grant ID: A 19557

Transcription

1 The Emerging Science of Prophylactic Therapies for Migraine Final Outcomes Report Lilly USA, LLC Grant ID: A 19557

2 Program Information Overview: This enduring webcast shared highlights from a live presentation, which took place in Scottsdale in November 2016 as part of the 46 th annual Scottsdale Headache Symposium, in conjunction with the American Headache Society. Featuring Dr. David Dodick, Dr. Deborah Friedman, and Dr. Stewart Tepper, this activity reviewed complicated patient cases and up to date information on targeted and specific therapies for the treatment of migraines. Intended Audience: This activity was designed for clinicians involved in the care and treatment of patients with migraine pain. Release/Expiration Date: December 29, 2016/December 29, 2017 Credit: 1.0 AMA PRA Category 1 Credit Sponsored By: The Academy for Continued Healthcare Learning (ACHL) Funding: Supported by an educational grant from Lilly USA, LLC

3 Executive Summary Impact 3276 Learners (2,000 Guaranteed guarantee exceeded) 1517 Certificates (350 Guaranteed guarantee exceeded) Professions Reached 32% Physicians 38% Physician Assistants 25% NP/Nurses 5% Other Patient Impact Changes will impact between 8,033 and 23,639 patients each month. Icon made by FreePik from

4 Executive Summary Satisfaction All faculty were very highly rated with an average rating of 3.55/4.0 Learning Objectives 99% of participants strongly agree that they are better able to meet the learning objectives after completing the activity Impact 67% of learners will change their practice based on this activity 50% of learners will seek to address barriers to patient access to therapies Patient Impact Patient outcomes will be positively impacted as a result of this activity according to 53% of learners Icon made by FreePik from

5 Executive Summary 77% The average post test score on questions regarding pharmacokinetics and MOA of CGRP mabs. Post activity, clinicians are aware of how these agents differ from currently approved therapies, and the advantages they offer specific patient subsets. 48% After participating in this activity, learners PLAN TO: More frequently assess their migraine patients for changes in disability Engage in patient education Discuss nonpharmacological strategies which patients can use to help control their pain These numbers demonstrate that clinicians not only received education on this new class of migraine drugs, but started to understand how to UTILIZE them in a clinical setting. More importantly, following the activity, many participants (67%) are instituting practice based changes to positively impact patient care and outcomes.

6 Executive Summary Future Educational Opportunities Improve management of side effects, comorbidities, and pain through a comparison of the adverse events associated with current and emerging therapies Provide educational tools to facilitate better communication with patients to increase shared decision making Educate clinicians on the science of approved and emerging therapies to increase personalized therapy Icon made by FreePik from

7 Faculty CHAIR David Dodick, MD, FAHS, FRCPC, FACP Professor of Neurology Mayo Clinic Phoenix, AZ FACULTY Deborah I. Friedman, MD, MPH, FAHS Professor, Neurology and Neurotherapeutics and Ophthalmology University of Texas Southwestern Medical Center Dallas, TX Stewart J. Tepper, MD, FAHS Geisel School of Medicine at Dartmouth Professor of Neurology Hanover, NH

8 Level 1: Participation Total Participants Certificates Awarded Practicing Type Physician 32% Physician Assistant 38% Nurse Practitioner 18% Nurse 7% Other HCP 5% 0% 5% 10% 15% 20% 25% 30% 35% 40% N=1517

9 Level 1: Specialty Specialty Family/General Practice 30% Surgery 13% Internal Medicine Neurology 10% 11% Emergency Medicine Psychiatry Pediatrics Pain Medicine 7% 6% 5% 4% Clinical (unspecified) 14% 0% 5% 10% 15% 20% 25% 30% 35% N=1517

10 Level 2: Learning Objectives Please rate the following objectives to indicate if you are better able to: Analysis of Respondents Rating Scale: 4 = Strongly Agree 1 = Strongly Disagree Illustrate how to factor multiple patient specific characteristics into the treatment plan when managing migraines 3.40 Examine and discuss the emerging science associated with calcitonin gene related peptide (CGRP) monoclonal antibodies (mabs) and their role in migraine prevention Highlight strategies and tools to assess the impact of migraine on daily functioning and quality of life in order to generate a more personalized and inclusive treatment plan % of learners strongly agree or agree that all learning objectives were met. N=1485

11 Level 2: Satisfaction Faculty Ratings Rating Scale: 4=Excellent, 1=Poor Ability to effectively convey the subject matter Expertise on the subject matter David Dodick, MD, FAHS, FRCPC, FAPC Deborah Friedman, MD, MPH, FAHS Stewart Tepper, MD, FAHS All faculty were highly rated across all areas, with an average rating of 3.55/4. Overall Evaluation Analysis of Respondents 4 = Excellent, 1 = Poor Quality of educational content 3.52 Level of instruction % of learners rated all aspects of the activity as excellent or good! N=1485

12 Level 2: Objectivity & Bias Did You Perceive Any Bias? 100% 99% 80% 60% 40% 20% 0% 1% Yes No Activity was perceived as objective, balanced, and non biased. N=1485

13 Levels 3 & 4: Pre/Post test Overview Overview of correct responses: 100% 75% 50% 25% 0% 88% 85% 65% 41% 50% 13% Topic Question Pre Post % Change Understanding PK of CGRP mabs 1 13% 65% 400% CGRP mabs MOA 2 41% 88% 114% Migraine triggers/patient education 3 50% 85% 70% 195% Average percent change from pre to post test Learner knowledge and competence increased regarding efficacy and metabolism of CGRP monoclonal antibodies and how they can be used to solve some of the existing issues seen with approved therapies as well as with respect to strategies for patient education and patient control of migraine triggers

14 Levels 3 & 4: Pre test vs. Post test Which of the following is true? Pre (N=1872) Post (N=1517) A. CGRP monoclonal antibodies (mabs) have an average half life of up to 24 hours 75% 65% 55% B. CGRP mabs are cleared by the reticuloendothelial system 50% C. CGRP small molecule antagonists have shown efficacy in reducing the frequency of headache days in episodic migraine D. CGRP mabs target CGRP, amylin, and their receptors 25% 0% 21% 11% 13% 15% 11% 9% A B C D The number of participants correctly answering the post test question increased by 400% over the pre test, demonstrating that participants were more knowledgeable regarding the pharmacokinetic properties of this drug class. Participant understanding of how this new, emerging class of migraine therapies is cleared from the body may be especially relevant when tailoring therapy for patients who have pre existing conditions such as renal or liver impairments.

15 Levels 3 & 4: Pre test vs. Post test Which of the following CGRP antagonists target the CGRP receptor? A. Fremenezumab (TEV 48125) B. Erenumab (AMG 334) C. ALD % 75% Pre (N=1872) 88% Post (N=1517) D. Galcanezumab (LY ) 50% 41% 25% 0% 26% 16% 17% 5% 4% 3% A B C D As a result of this activity, learners were more knowledgeable regarding the differences between the mabs and how they act to inhibit CGRP and eventually, to reduce the frequency of episodic/chronic migraines. These learnings support recently released preclinical data which have also highlighted differences among fremenezumab, ALD 403, and galcanezumab regarding their respective times to bind and dissociate from the ligand which may contribute to differences drug effect duration.

16 Levels 3 & 4: Pre test vs. Post test Linda M is a 38 year old female who suffers from episodic migraines about five times a month. She takes a triptan and uses OTC medication to relieve her pain. Because of a project at work, she has been getting less sleep, is stressed, and has noticed that the number of her migraines has increased. What is the best course of action for this patient? A. Prescribe a sleep aid and remind her not to take too many triptans (>2 a day) B. Remind the patient about the factors that she can control and which will allow her to feel less stressed(ie, exercise, meditation, small breaks, eating well, staying hydrated) C. Consider transitioning her to preventive therapy such as amitriptyline or a beta blocker D. Consider transitioning her to preventive therapy such as onabotulinumtoxina or topiramate. 100% 75% 50% 25% 0% Pre (N=1872) Post (N=1517) 85% 50% 24% 12% 14% 3% 7% 5% A B C D Learners selected the correct answer 70% more often on the post test compared to pre test. Certain factors such as sleep, specific foods, and caffeine can trigger a migraine; however, these are factors which patients can help to control. Patient education can increase awareness of how patients can modify and minimize migraine triggers.

17 Levels 3 & 4: Pre test vs. Post test There are several tools and strategies clinicians can use to better understand the impact of migraine on patients lives as well as aid in increasing the understanding of both parties of how to effectively control migraine. From the list below, please identify one tool or strategy which you CURRENTLY USE/PLAN TO USE in order to better understand how migraine impacts your patients: A. Patient headache diaries B. Assess disability via scale such as HIT 6 or MIDAS C. Discuss the management of existing comorbidities so as to minimize other factors complicating migraine treatment D. Review patients treatment plans with them; discuss goals of migraine treatment, frequently 60% 50% 40% 30% 20% 10% 0% Currently Use (N=1872) Plan to Use (N=1485) 46% 39% 23% 20% 21% 21% 17% 13% A B C D An increase of 77% was seen post activity in learners who were open to using HIT 6 or MIDAS scales. These scales are composed of 5 6 questions which can be quickly administered in an office setting and completed by the patient. Use of these scales may provide a compliance advantage over a patient diary and are a quick way for clinicians to gather information on migraine disability.

18 Level 4: Impact of Activity This activity will improve my performance: Yes, how? Yes: 57% No: 13% Validated Practice: 30% Treat migraines more effectively and provide better patient education/counseling Improved knowledge base and expanded education Apply different approach to screening patients Increased understanding of pathophysiology and possible treatments Awareness of CGRP receptor antagonist and good review of beta blocker use Encourage lifestyle changes for patients and keeping headache diary New prescription medications/headache outcome resources to use (patient reported outcome tools) Better manage patients with migraines using tools provided i.e. MIDAS and HIT 6 Use scales for assessment and prescribe prophylaxis when indicated This activity will improve my patient outcomes: Yes, how? Yes: 53% No: 13% Validated Practice: 34% Better able to create more precise treatment plans; improve patient outcomes by more effective treatment Assist patients via lifestyle modification and other treatment options; refer patients to appropriate provider Aware of other management therapies for chronic and episodic migraines Increased research leading to increased prophylactic treatment So often refer patients to neuro; may now be more likely to counsel, try preventives. N=1485 This activity was highly effective, with 57% indicating it will impact performance and 53% indicating it will impact their patients outcomes.

19 Level 4: Impact of Activity Please identify how you will change your practice as a result of attending this activity (select all that apply): Change the management and/or treatment of my patients by more frequently assessing disability caused by headache, taking time for patient education, and/or discussing nonpharmacological strategies that patients can use to help control their pain. 48% Create/revise protocols, policies, and/or procedures. 25% Other changes. 4% This activity validated my current practice, no changes will be made. 33% 0% 20% 40% 60% N= % of learners will change their practice!

20 Level 4: Impact of Changes on Patient Care Number of patients with migraines you see each month: >21 7% 11 to 20 14% 1 to 10 65% 0 14% 0% 20% 40% 60% 80% N=1485 Changes will impact between 8,033 and 23,639 patients each month. This assumes the data above is representative of all participating healthcare professionals (3,276), who indicated they would change their practice as a result of this activity (67%).

21 Level 4: Confidence After participating in this activity, how confident are you in describing the emerging targets under investigation for the prevention of migraine? A. Extremely confident B. Very confident C. Somewhat confident 50% 35% 47% D. Not very confident E. Not at all confident 25% 0% 12% 6% 1% A B C D E 47% of participants described themselves as being extremely or very confident in their ability to describe some properties of emerging agents for migraine prevention. N=1485 Future Education Opportunity: 54% of participants categorized themselves as somewhat confident, not very confident, or not at all confident, which potentially represents an audience who would be receptive to further education in this area.

22 Pharmacotherapy Considerations Which of the following factors do you give the most consideration to when adopting a new to market pharmacotherapy? Ease of patient compliance 31% Cost to the patient 42% Science underlying the new therapy 25% Other 2% 0% 10% 20% 30% 40% 50% N=1485

23 Pharmacotherapy Considerations When these therapies are approved for use in the US, which factor will determine if you will use them in the appropriate patient populations? Cost 55% Frequency of administration 13% Duration of effect 15% Ease of side effect mangement 17% 0% 10% 20% 30% 40% 50% 60% N=1485 Cost was by far the largest determinant of use for clinicians. Whether this represents costs to the practice to acquire the drug or the cost to the patient even with insurance is unclear. However, both factors would potentially drive access and use.

24 Level 4: Barriers Select all that apply: Level A. Current 4: migraine Perceived therapies do not offer Barriers To Implementing 30% adequate pain relief 24% 25% Changes B. Patient reluctance to see HCP regarding 22% N=1485 Please indicate any barriers you perceive in implementing these changes: their headaches C. Lack of consensus or professional guidelines D. Lack of time to assess/counsel patients E. Cost F. Lack of administrative support G. Reimbursement/insurance issues H. Lack of opportunity (patients) I. Lack of resources (equipment) J. Patient compliance issues K. No barriers L. Other barriers 20% 10% 0% 10% 20% 5% 18% Participants indicated cost (25%) as the most common barrier to implementing change in their practice. Other barriers included patient compliance (22%) and patient reluctance to see HCPs regarding headaches (22%). 24% indicated current migraine therapies do not offer adequate pain relief. 8% 4% 22% 14% A B C D E F G H I J K L 2%

25 Barriers Will you attempt to address these barriers in order to implement changes in your performance, and/or patients outcomes? Yes: 50% No: 18% N/A No barriers identified: 32% Yes, how? Advocate for patients in need of new therapies Talk to pharmacy about adding treatment options to formulary Utilize prescription drug programs and insurance preauthorization Increase patient education and time discussing options Increased patient assessment, education and reevaluations Adjust logic of therapy and diagnostic paradigms Address efficacy at outset of treatment and give treatments more time before changes are made Discuss with patient the importance of compliance Encourage patients to make treatment changes to increase quality of life; Set collaborative goals with patient and find cost effective solutions No, why not? Inundated by administrative barriers on multiple levels; lack of time It is not the major part of my practice and not enough time for comprehensive migraine management Difficult to address patient reluctance Very difficult to overcome breakdown in medical care system; it is hard to get approval for these types of medications These barriers are not easily addressed in a resource poor country where I practice N= % of learners are interested in addressing barriers, primarily through patient education, increased patient assessment, and even by engaging with insurers to approve a drug for a patient. Additional strategies practitioners are open to using include: periodic re evaluations of disease status, severity, and impact, and employing personalized treatments at the outset.

26 Topics of Interest What topic areas would you most like to see in future activities? Managing neuropsychiatric comorbidities and migraine 31% Managing side effects of multiple migraine medications 36% Differentially diagnosing headache subtypes 33% 0% 20% 40% Clinicians indicate interest in all three topics provided, however this outcomes report demonstrates clinicians are most in need of strategies to help manage side effects seen with current migraine treatments as well as managing comorbidities in migraine patients. N=1485

27 Key Takeaways What is one pearl you took away as a result of your participation? Always consider what changes in life occurred that could be causing increase in migraines or any other morbidity (seizures, HF) Always include patient in treatment planning Better understanding of pathophysiology of how medications work Candasartan use as: prophylaxil instead of beta blockers in the treatment of episodic migraines CGRP AB's have long half life; antibodies are promising Consider alternatives to triptans Consider HA effect in psychiatric disorders Current available treatments are poorly utilized and not highly effective with significant adverse effects Did not realize how poorly available treatments are Difficulty of compliance and efficacy for prophylaxis Emerging use of CNS stimulator devices Excited about CGRP and hope to use it one day! Frequency of migraine/poor success rates of treatment Gabapentin is essentially worthless for prevention Good information on new treatment modalities High discontinuation rate among those treated prophylactically How few chronic migraine sufferers receive effective treatment Identify and manage exacerbating factors w/ conservative methods Monoclonal antibodies can be effective in prevention; appear to be very promising as prevention of migraine Learning about receptors Level of disability and medication overuse Statistical significance is not same as clinical significance Newer migraine medications and biologics MABs Importance of assessing impact of migraine disability over time Importance of reducing stress and other triggers Importance of spending time evaluating/counseling Important to assess non pharmacological treatments Look at manageable lifestyle issues Managing comorbidities for migraine sufferers New therapies/medications can be helpful for patients who don't generally respond to triptan/ergots Vast amount of pts untreated for migraine headache Use assessment tools to measure nature and effects of migraine Multiple treatment modalities must be investigated with new and advancing treatment strategies underway New medication for acute headaches without vasoconstriction New research coming out on the physiology and treatment Metoprolol, propranolol, timolol are effective and should be offered for prevention if patient physiology can tolerate Multifactorial nature of migraines & relationship to other conditions No consensus on best mgmt. of medication overuse headache Non invasive devices showing promise, awaiting FDA Non pharmacological management has an important role in pt care Patient compliance of prevention medication is poor Patients are not adequately assessed, diagnosed or treated Progression of prophylactic failure in correlation to increased changes Start prophylaxis sooner post 8+ headaches/month There are many options for treatment and patients should receive individualized care/treatment Use of evaluation tools other than headache diary

28 Appendix All text based responses

29 Level 4: Activity Impact If you indicated this activity will improve your performance, please specify: Ability to explore other treatment options for episodic versus chronic migraines Able to describe the emerging therapies to my patients Able to discuss emerging tx Able to give better information Able to make different decisions Addressing lifestyle changes as well as medication therapy Alternative treatment options As psychiatrists often have patients with migraine like or cluster headaches with their mood disorders or depressions. It is great to know there are meds coming that allow us to use something other than meds which currently have such side effects Assess patterns degree of disability Assessing the actual quality of their life affected awaiting CGRP therapies Aware of current offered therapies and assessment tools. Awareness of CGRP receptor antagonist. Good review of beta blocker use Awareness of new options/newer drugs Because i can determine better understanding, knowledge and dealing towards migraine Being able to better educate patient on various options that are available for management/treatments of chronic migraines Better able to communicate new information and improve on referral patterns Better able to determine impact on patient's quality if life and disability caused by migraines Better able to educate my patients Better assess migraine impact on quality of life Better assessment of disability Better assessment of HAs in patients Better discussion with patients Better educated on subject Better evaluation of migraine pt adherence/benefit to therapy Better evaluation of monthly headache patterns, potential for overuse Better HA management Better in the decision making available to the motor spectrum of nucleo peptide fractionize Better insight to plan of care Better knowledge in headache management, overall Better knowledge of newer therapies/prevention Better management and more prevention Better patient education Better strategies in management with medication and lifestyle changes for migraine patients Better understanding of pathophysiology/treatments Better understanding emerging therapies Better understanding of current treatments and new treatments on the horizon Better understanding of effective treatment modalities. Better understanding of first line therapies and contraindications Better understanding of new migraine therapies Broaden how I treat migraine pts and understanding emerging treatments that will be available to them in the future

30 Level 4: Activity Impact If you indicated this activity will improve your performance, please specify: By offering evidence based treatments By providing me with the knowledge to better diagnosed migraine sufferers. Can help me treat my patients better Change in monitoring and prescribing Change my treatment strategies. Understand and describe emerging treatments. Consider new treatments and continue to watch for new FDA approved options Consider newer treatment modalities Consider short comings of some preventatives Consideration for discharge after acute migraine Consideration of over use HAs more often Counsel patients better Did not realize how poor the tryptans were as treatment. Will give them less consideration. Different strategies addressing migraine pain Discuss migraine modalities with pt Discussing impact and frequency of migraines Educate patients on availability of new treatment strategies education of new therapies Emerging therapy knowledge Empowering the patient Enhanced knowledge regarding management of migraines Evaluate and assess migraines better with the different tools Evaluating many of the migraine treatments out there gives me a nice breadth of knowledge concerning those treatments Excellent information to share to patients Follow the guidelines in patient management Greater understanding of the treatment options for migraine Greater understanding of upcoming migraine treatment options Help direct appropriate and effective migraine care Help me to better understand treatment modalities Highlighted the importance and impact of migraine headaches and new therapies being explored I am a psychiatrist, and these speakers provided adequate background information so I could understand all material. I feel more confident collaborating in multidisciplinary care for my headache patients. This was an exemplary CME activity. I am aware now of new drugs and procedures available for management or migraines I am aware of new treatment options available to patients. I will try to use questionnaires mentioned in this activity to assess how my patients are doing. I am just beginning my career as a PA in neurology. I appreciate the more in depth discussion on headache treatments I am more aware of options and effects on patients compliance I better understand the use of preventive medications I can now add new medication management strategies and lifestyle modifications for the treatment of migraines. I do not treat migraines, but am better equipped if required to. I experience chronic migraine myself and if I can decrease my frequency of migraines I will be better able to assist patients/veterans who I treat/serve

31 Level 4: Activity Impact If you indicated this activity will improve your performance, please specify: I have to delve deeper into the type of headaches and their impact on functioning I know which medications are first line and second line. Know efficacy of and patient compliance challenges. I learned more about CGRP antagonist therapies I understand emerging therapies and am reassured on state of existing therapies as it relates to my practice experience I see migraine patients who need support I understand various med. side effects of newer & future drugs I was unaware of the new and emerging treatments for episodic and chronic migraine treatment I was unaware of this new drug class I will better tailored regimens for patients I will better understand and use newest treatment of migraine I will encourage patients to keep headache diaries to help ID possible helpful lifestyle changes. I will implement preventative treatment more readily. I will look into new drugs I will look more for emerging therapies I will use the validated evidence in treatment decisions as well as the tools in assessing disability. I will use this in practice. I work in a state prison where the formulary is limited. I work in pain management, and am often skeptical about initiating prophylactic tx of HAs Identify new options Identify pt that need more than tripans or ergots. Identify recommendations for chronic migraine management. Improve assessment and measure of treatment response Improve medication options for pts with CGRP Improve monitoring of headaches and when to refer Improve treatment and prophylaxis Increased awareness on the current research Increased knowledge of prophylactic meds for migraines. Increased knowledge on new available treatment options Increased patient education Inquire more thoroughly about current tx & symptoms It has increased my knowledge as far as family/friends who consult me for what they should do next about migraines Know more about the subject Know which long term medications are effective/preferable Knowing new treatments Knowledge about medication and management Knowledge of what is currently available and what is in trials to treat Migraines Learned new information about available tx in migraine Learning about pharmacology Learning more about Migraine pathophysiology Less reliance on triptans and more interest in newer treatments Made me more aware of treatment options which always is helpful to a nurse Make better clinical decisions Make patients more involved in making their treatments plans Managing migraines headache to look at diet and exercise May help to use medicines more wisely and according to guidelines and evidence based

32 Level 4: Activity Impact If you indicated this activity will improve your performance, please specify: Methods in assessing pt headaches and responses to tx Migraine diagnosis and treatment with better outcomes More aggressive diagnosis and treatment of migraines More aware of treatment options More evaluation of lifestyle factors affecting migraines More detail to migraine management More education on treatment strategies More effective medication management More focus on patient care and preventative measures More knowledge of prospective therapies and assessment tools More knowledgeable about new treatments for migraines More prepared for the new agents (CGRP) when they come out More selective in choosing treatment for migraine headache More tools to assist patients More treatment option knowledge New prescription medications to consider and headache outcome resources (patient reported outcome tools) Newer emerging therapies need to be considered more often Numerous patients that are under managed. I am constantly starting new treatment therapy for people that have not been addressed for migraine management in the past Offer patient more choice for prevention Patient care/education Preventing headache with appropriate medication Pt assessment tools Midas or Hit 6 to be introduced and used in clinical evaluations Pts in hospital environments can have exacerbations of migraines and often need special interventions to self manage Put into consideration the efficacy and side effects of current treatment Refer more patients to HA specialists. I am disappointed that no single definition of migraine was proposed. e.g. Are cluster headaches now migraines Regarding assessment of QOL related to migraine Specific, current knowledge gained on migraine prevention and treatment Spend more time on preventative measures instead of drug administration Take care of migraine patients daily Take more thorough hi ask for diary Tell patients of new medications coming in the future The newly learned about therapies will help me effectively examine my patient. The outcomes of efficacy to control pt's Migraine headache will improve and also will improve adherence to therapy if patient is agreeable with injection type of medications. This activity has increased my awareness of the under treatment of migraine headaches and has broadened my knowledge of current and future treatments. This activity will help me manage patients with migraine better using the tools provided I.e MIDAS and HIT 6. To better assess patient holistically in regards to migraine in setting of other comorbidities Treating migraines more effectively Understanding emerging therapies is helpful and hopeful Understanding meds for proper usage.

33 Level 4: Activity Impact If you indicated this activity will improve your performance, please specify: Understanding of non pharmacologic and emerging medication treatments for migranes Understanding options beyond the basics, when the basics fail Up to date treatment approaches Updated EBP Updated therapies Use of newer agents in the treatment of migraine type diseases Use of newer therapies when available Use scales for assessment and prescribe prophylaxis when indicated Using measures such as Midas to evaluate outcome treatments and need for neuro referrals Utilize new tools to assess migraine headaches and current RXs in the TX of Migraine H/As Validate caregivers technique We don't currently have any patients on prophylactic therapy for chronic migraines, but I believe some of my patients would benefit from it We have lots of headache patients coming to ENT for perceived sinusitis. Hopefully I am better able to diagnose them and refer to neuro Wider variety of treatment options Will improve my history taking skills with regard headache treatment Will place more emphasis on patient disability for prophylaxis Will try to treat my patients better Will use current guidelines in practice when appropriate Will use different medications Will use Midas and hits headache evaluation tools. Also feel more comfortable prescribing topiranate for migraine prophylaxis now Will use validated rating scales With updated knowledge Work in Residential treatment Centers where headaches are among the most common complaints Yes, will consider using other tools and approaches when managing chronic migraine patients

34 Patient Impact If you indicated this activity will improve your patients outcomes, please specify: Able to evaluate and manage, give more advice According to presentation new approach to preventive therapy Addressing morbidities will enlighten burdens After learning about emerging modalities, I will know which new treatments to recommend to my patients As a provider in chronic pain medication, I will be able to better assist my patients via lifestyle modifications and other treatment options. I will be able to assess and refer patients with chronic migraines to the appropriate provider Awaiting CGRP therapies Aware of treatments available Based on use and data of newer meds Be up to date with emerging therapies Begin use of diaries Being able to discuss emerging medications for the treatment of migraines Better treatment and education Better assessment practices will promote better pt outcomes Better care delivery Better care provided Better choice of agents will help them avoid more days of migraine per month Better clinical response Better control with prophylactic meds Better discharge planning Better evaluation and treatment Better insight to plan of care Better management an prevention Better management of migraines with hopefully no new onset of new conditions Better outcomes with newer, more effective therapies Better patient education Better prescription choices Better referral to specialist Better results from medicines Better screening Better serve patient needs Better tools to help assess patient Better treatment choices should improve outcomes Better treatment options Better treatment outcomes Better treatment regimen and communication to patients Better treatments (maybe) for headache sufferers Better under of pathophysiology and possible treatments Better understanding of management of migraine Better understanding of migraines management Better ways to assess tx plus medication update was helpful By evaluating after the implementations of the strategy to manage migraine to a client By giving them more treatment choices By improving approach to the problem By prescribing better tx, enhanced outcomes are expected By starting preventative treatment, I will improve patient QOL Can help target treatment and behaviors Can use new approaches when available and appropriate Choose medications appropriately

35 Patient Impact If you indicated this activity will improve your patients outcomes, please specify: Chronic migraine requires multiple interventions Common difficult to treat patients Control headaches/symptoms Current updates are very helpful Diagnosis Diary Different prevention methods of migraine and newer meds Different treatment options Discussing with coworkers Due to I will be better informed Due to the low patient adherence data, I will assess compliance at each appt Excellent academic activity Expect a decrease in patient headache frequency Help in treating migraines help my performance Help with better treatments Help with refractory migraine patients Hopefully help provide other tx options to provide relief Hopefully improved communication Hopefully or will have decreased migraines Hopefully to decrease patients headache days Hopefully to improve quality of life Hopefully will improve their management and quality of life Hopefully, patients will do better I am more knowledgeable about migraine because of this I can only hope it will by being more complete I can provide state of the art therapy I have more tools now I hope my "Yes" answer to Q a will be true I hope so I hope to help relieve patients of migraines faster and help prevent them as well I know how to better treat my patients I learned about more effective medication and progress evaluation strategies did not know before I now know of other management therapies for chronic and episodic migraines I offer onabotulinum treatment but now will refer to neurology for consideration of alternative treatments I will be able to try alternative treatment with patients who have adverse reactions and contraindications to typical episodic and chronic migraines I will be better educated to deal with difficult to treat patients I will have better outcomes I will provide better care for treating migraine headache than before with multimodalities: new headache meds (CGRP antagonists) and combined the other alternative therapies I'm currently in school for my D.N.P. and not in practice, but it has opened my eyes to the upcoming treatments I am sure to have to be privy to when I start practicing. Improve outcomes with new strategies for prevention and tx Improve quality of life Improved accessibility to the appropriate specialists/centers for the management of chronic migraine improved knowledge of current and forthcoming treatments

36 Patient Impact If you indicated this activity will improve your patients outcomes, please specify: Improved patient outcome from headache relief Improving patient outcomes by more effective treatment In years to come utilize CGRP antibody drugs Increase knowledge of options Increase percentage of patients treated Increased knowledge of appropriate assessment tools as well as in depth knowledge of treatment options Increased research leading to increased prophylactic treatment Increased variety for treatment of headaches Learned new information about a common problem Less drugs Less headaches, improved quality of life Less migraine headaches Lower use of tryptans likely Med compliance Medication change from beta to arb Medication changes Medication options Migraine treatment option Monitoring patient symptoms More choices More compliance More effective pharmacotherapy More effective practitioner More individualized care and treatment More interactions More knowledge towards research and options for migraines More knowledge, tactics More options to discuss More patients treated for chronic migraines More precise treatment plans More referrals to specialist if not controlled and educate about newer options More time with patients More tools to assist patients Multimodel approach for the management of pain study My patients will have an educated provider My patients would get up to date treatment New considerations for therapy that may better help patients. new medication for migraine prevention New medications to consider for treatment New tools to target other mechanisms for migraines New treatments Now I have more options for patient treatment Optimize therapy Patient adherence Patient care Patient focused treatment for better outcomes Patient has more control Patients will appreciate being headache free Perhaps, if I can increase adherence Plan on using for education Planning care and referral to specialist in a more timely manner Possibly able to use the drugs that are in the horizon Prevention Pt education

37 Patient Impact If you indicated this activity will improve your patients outcomes, please specify: Put into consideration Neuromodulation Rapid and sustained response Recognize the need for therapy Refer to PCP with specific sx s Referral of pts to experts in use of So often refer Pts to neuro; may now be more likely to counsel, try preventives Strategies for prevention Superb update on new medications and devices Symptoms improved Targeting evidence based treatments The causes and triggers of migraines can explained to patients They need information and support This will hopefully reduce overuse of abortive migraine medications To provide alternative treatments from my current practice Treatment tailored to the patient Treatment with success Understand emerging therapies Understanding the mechanics Use new info for better outcomes Use self report outcomes Utilizing current TX protocol to improves my patient's condition Very few of my patients will have access to these newer options due to insurance coverage/costs. Will be more apt to alter treatment and tailor to each patient Will consider prophylaxis sooner Will improve management of headache patients Will pay closer attention especially us psychiatric pts Will start prophylaxis sooner Will use candesartan as a preventive instead of the Beta blockers due to efficacy and fewer side effects Will use triptans more for debilitating migraines. Know what alternatives exist Yes, hopefully the information learned can improve the healthcare my patients receive Yes, offer them more options

38 Patient Impact If you plan to change management and/or treatment of your patients by more frequently assessing disability caused by headache, taking time for patient education, and/or discussing nonpharmacological strategies which patients can use to help control pain OR create/revise protocols, policies, and/or procedures, please specify the changes you will make: Actively try to prevent Adding one or more of the headache scoring measures to our regular intake process and then using the information appropriately to adjudicate referrals to specialists Ask about other treatments patient tried Ask for headache diaries; discuss QOL burden and their goals Ask for more information Asking more questions about how headaches affect my patient daily activities Assess disability further Assess treatment effectiveness Assess with appropriate tools Better assessment with scales Better assessments Better education of avoidance to triggers and identifying Better instruction on nonpharmacological strategies. Better management provider to patient info Better migraine treatment plans Better patient documentation of headaches Better counseling By assessing the impact of migraines on patients' lives, Getting involved in patient education By speaking on the cause and effect Chronic migraine patients Closer follow ups Conduct MIDAS and HIT scale Consider new mgmt options Consider the MIDAS screening in addition to patient journals Consider use of new drugs Correct assess of patients and correct medication therapy Create/revise protocols, policies, and/or procedures Daily diet intake meditation times and medications Diagnose and treat migraines more aggressively Diaries, lifestyle, con't to learn about new tx options Diary and follow up Diary reviews will be more frequent and will use the HIT as well Disability assessment Discussing ways to avoid triggers and non pharmacological ways to control migraines Discussing nonpharmacological strategies which patients can use to help control their pain Education and logs of what's been done already Education with patients Emphasize to insurance companies to authorize prophylaxis Encourage documentation of headaches and associated disabilities to help select more personalized treatment options Ensuring I rate disability causes by headache Ensuring pts are permitted to manage rest periods in hospitals

39 Patient Impact If you plan to change management and/or treatment of your patients by more frequently assessing disability caused by headache, taking time for patient education, and/or discussing nonpharmacological strategies which patients can use to help control pain OR create/revise protocols, policies, and/or procedures, please specify the changes you will make: Evaluation measures, patient teaching re stress, sleep. Referrals for newer treatments such as CGRB Extend assessment time possibly with questionnaire Focus more on prevention Forms the patient completes Getting the Hit 6 tool HA patients Headache diaries, life style, stress factors, diet, sleep. Headache diaries, more stress management evaluation Headache diaries, stressors different treatment options Headache diaries, strict monitoring of meds/supplements I think both pharmacological and non pharmacological strategies are just as important I will counsel patients on non pharmacological means I will discuss at each visit the number of migraine days a month and will assess the disability caused by them I will focus more on the level of disability with pt headaches I will take more time with patients to gather accurate info and assess medication adherence and discussing s/e of meds, do necessary labs and provide comprehensive headache mgmt Implement more frequent use of assessment tools Implementing better care Improve assessment process Improve treatment Improved knowledge of available treatment options Include the tools mentioned in this program and the current RXs included Increased discussion/patient education Increasing follow up visits Insist on headache diaries Keep it at forefront of evals Keep up to date Lifestyle changes Make the correct diagnosis with subsequent referral Might try to see if can get some treatment with nonpharmacologic, but costs and other factors such as surgery or difficulty using vagal stimulation make much problematic More education More frequent assessment/follow up More frequently assessing disability caused by headache More objective monitoring More patient protocols More preventive plans More referrals to neurology and recommending considering study participation More requests for Neuro MD consultations More time for discussion of other ways to manage migraines More use of HA assessment tools. More use of HA diaries

40 Patient Impact If you plan to change management and/or treatment of your patients by more frequently assessing disability caused by headache, taking time for patient education, and/or discussing nonpharmacological strategies which patients can use to help control pain OR create/revise protocols, policies, and/or procedures, please specify the changes you will make: Mostly talking with the patient and implementing nonpharmacological strategies and devise a way to monitor there compliance and outcome Motivational interviewing to understand pt desired outcomes Need to evidence basis protocol for management Patient Education Provided more information Push patient and family education; provide hope and encouragement Refer to facilities that offer new therapies Regular patterns Reinforce the use of headache diary and non pharmacological management Revise protocols and instruct PA's Sleep, exercise, dietary, and hydration Switching to prophylaxis Take more time to speak with patient regarding effects of headache and strategies to prevent and ease the stress of what comes with headache responsibilities (children, work) Taking to pts more about their triggers That personal, mental and environmental factors have a great impact headaches; Exercise; CBT Tools Ultrasound Unsure but hope to be able to assess this better when I return to full time practice Up to date education for my patients Use available scales, questionnaires Use MIDAS or HIT 6 for longitudinal evaluation. Consider use of CGRP receptor agonists, use of non invasive nerve stimulation or transcranial magnetic stimulation Use MIDAS or HIT 6 to assess and monitor patients, consider new monoclonals as they become available Use formal assessment tools and discussion of tx options w/ pt Use of HIT 6 and other tools for discussing disability, sitting down at the end of the office visit to review the treatment plan in terms of the patient's lifestyle and understanding and ensure that the patient expresses interest and enthusiasm in the change (s). Investigate the use of devices as they are offered Use outcome measures Use rating scales Use MIDAS refer more attention to stressor control Use tools to project disability from migraine and assess patients that will benefit from the newer treatment options Utilize PROS in evaluating migraine tx MIDAS and Hit 6 scales Utilizing preventive medications in a more optimal fashion Will have support staff meet w/pts to reinforce use of nonmedication issues they can control at each appt