Risk Factors, Clinical Course, and Barriers to Care in Adults and Pediatrics. Rebecca R. Buttaccio, PA-C Dent Neurologic Institute

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2 Risk Factors, Clinical Course, and Barriers to Care in Adults and Pediatrics Rebecca R. Buttaccio, PA-C Dent Neurologic Institute

3 Speaker for Avanir Disclosures

4 Learning Objectives 1. Review the risk factors of headache transformation 2. Describe the clinical course and burden of episodic and chronic migraine headaches 3. Discuss various barriers of providing adequate care to headache patients

5 EPISODIC MIGRAINE (EM) 12% of population < 15 headache days/month CHRONIC MIGRAINE (CM) 1-2% of population 15 headache days/month 8 migraine days/month Duration 4 hours (CDH) ± Medication Overuse

6 Risk of Migraine & Transformation NONMODIFIABLE Family history/genetics Older age Female Caucasian Low socioeconomic Low education

7 MODIFIABLE Comorbidities Depression Anxiety Other pain disorders Obesity Asthma/Allergic rhinitis Snoring Head or neck injury Stress Headache and nausea frequency Allodynia (thermal) Medication overuse Caffeine Poor treatment efficacy

8 Medication Overuse Headaches (MOH) Overuse of acute medications for preexisting headaches Regular overuse of one or more agents for >3 months >15 days/month NSAIDS only >10 days/month Triptans, ergot alkaloids, combination analgesics, opioids > 5 days/month Butalbital compound <5 days/month lowers risk of MOH Prevalence = 1-2%

9 Female Midlife Low socioeconomic status Obesity Psychiatric comorbidities Sleep disturbance Smoking MOH Risk Factors

10 Treatment STOP MEDICATION MOH Treatment Butalbital abrupt taper requires phenobarbital Butalbiltal gradual taper, use steroids Triptans, ergots gradual taper, use steroids Opioid gradual taper NSAIDS abrupt or gradual Acute/preventive medications and other non-pharmacologic options

11 Migraines Over Time (% per year) Episodic Migraine 83% Persistent Episodic 2.5% Chronic Migraine 14.5% Other Outcomes

12 Migraine Burden 7 th most disabling disease worldwide 4 th most disabling disease among women

13 Migraine Disability Assessment Test (MIDAS) Rating Headache Disability within 3 months 1. Miss work or school 2. Productivity decreased by >50% at work or school 3. Avoid housework 4. Productivity decreased by >50% at home 5. Miss family, social or leisure activities

14 MIDAS Episodic vs. Chronic Migraines Days MIDAS Questions Episodic Chronic

15 Chronic Migraines & Employment CM disability 3.68 times greater than EM Less education Less full- or part-employment Less income

16 Chronic Migraines & Families If they didn t have CM 73% would be better spouses 69% would be better parents 67% avoided intimacy with partner 54% missed family time or vacation enjoyment 20% actually missed a vacation

17 $11 billion spent on inpatient and outpatient care, ED and prescriptions in 2008 $ CM $383 - EM 3 month cost in US in 2010 $13 billion per year Missed work and decreased productivity costs employers 112 million bedridden days/year

18 Barriers to Optimal Care 3 Steps for Adequate Care % Patients with all 3 Steps 1. Consultation with provider 2. Accurate diagnosis 3. Appropriate treatment 25% Episodic Migraines 5% Chronic Migraines

19 Episodic Migraine BARRIERS YES NO Consult with Provider 45.5% 54.5% Diagnosed Correctly 86.7% 12.3% Treatment is Appropriate 66.7% 33.3%

20 Chronic Migraine BARRIERS YES NO Consult with Provider 40.8% 59.2% é Diagnosed Correctly 24.6% 75.4% é Treatment is Appropriate 44.4% 55.6% é

21 Undertreatment Acute treatment Barriers to Treatment Fearful of cardiovascular side effects Preventive treatment < 30% in chronic migraine Only 13% in episodic migraine Should consider prophylactic therapy when migraines > 4-5 days/month

22 Side effects 2/3 of sufferers delay treatment 54% report at least 1 side effect with triptans 26-36% discontinued Compliance 34% took prescribed medication correctly 53% discontinued triptans because found OTC medications sufficient More likely to turn to alternatives with higher MIDAS

23 Cost % report concerns continuing medication due to cost Satisfaction 66% patients report satisfied or very satisfied with acute medications BUT 88% of patient sample willing to try new meds

24 Pediatric Patients Risk factors are similar to adults Concussions Neck pain text neck, heavy book bags, sports injuries Medication overuse (less common) Clinical Course Lower risk for CM transformation than adults 0.79 % (1.75% with medication overuse headaches) Report high disability similar to adults (PedMIDAS)

25 Barriers to Care Consulting with provider 60% report not seeing provider in over 1 year Diagnosis Delayed up to 20 months after first headache, 39 months if misdiagnosed Difficult to accurately diagnose due to variety of symptoms Appropriate treatment 1 in 5 CM patients use preventive medication Provider s and parents comfort levels Compliance, side effects, difficulty swallowing pills

26 Conclusion Rate of EM transformation to CM is 2.5% per year Many risk factors for CM transformation are treatable Large burden to healthcare and society Migraines are under diagnosed and medications are underutilized Treatment expectations must be discussed More education with patients, loved ones, and general population is needed