Abstract
BackgroundA synthesis of real-world discontinuation and switching patterns among triptan users and rates of acute medication use among patients with medication overuse headache (MOH) is needed to better understand the burden among patients with migraine. The study objectives were to: (1) synthesize rates of switching and discontinuation from triptans; (2) characterize acute medication use among patients with MOH; and (3) describe the associated burden.MethodsA systematic literature review was conducted, under the Preferred Reporting Items for Systematic Review guidelines, using MEDLINE/EMBASE from database inception to July 2019. The search strategy targeted studies of adults with migraine, and included terms related to migraine and its treatment. Continuous variables were summarized using means, standard deviations, and ranges. Dichotomous and categorical variables were summarized using the number and proportion of individuals.ResultsTwenty studies were included; seven describing patterns of switching and discontinuation among triptan users, and 13 characterizing triptan overuse among patients with MOH. High rates of switching to non-specific acute medications and low two-year retention rates were reported; among US samples switching to opioids at the first refill (18.2%) or after 1-year (15.5%) was frequent. Compared to persistent use of triptans, switchers experienced greater headache related impact and either no improvement or increased headache-related disability. Rates of medication overuse by agent among patients with MOH varied greatly across the included studies, and only one study described factors associated with the risk of MOH (e.g. duration of medication overuse). Medication agent, increased headache frequency (p = .008), and increased disability (p = .045) were associated with unsuccessful withdrawal; patients overusing triptans were more successful at withdrawal than those overusing opioids or combination analgesics (P < .0001).ConclusionsThe evidence summarized here highlights that rates of WCS are low and many patients turn to other acute medication at their first refill. Patients may experience no improvement in disability when switching from one triptan agent to another, or experience increasing disability and/or increasing migraine frequency when turning to traditional acute treatment for migraine. Variability in health care settings, patient severity, and study design contributed to heterogeneity across the synthesis.
Highlights
Migraine is the most debilitating of all health conditions among those younger than 50 years [1]
In the identified studies describing treatment patterns, rates of withinclass switching (WCS) were low, and many new triptan users switched from their index triptan to another class of medication at their first refill; most notably high rates of between-class switching (BCS) to opioids were observed among United States (US) populations compared to non-US/other populations [38, 39]
Strengths of this review include the use of rigorous systematic literature review methods to identify studies of real-world triptan use among patients with migraine and acute medication use among patients with medication overuse headache (MOH); including those that focused on precisely estimating treatment patterns among incident triptan users as well as studies reporting on various outcomes among patients with MOH
Summary
Migraine is the most debilitating of all health conditions among those younger than 50 years [1]. When an initially prescribed triptan becomes ineffective, it is recommended that a patient try another agent or switch to a combination triptan/analgesic, such as sumatriptan/naproxen, for future attacks [9] This process of trying another triptan is called withinclass switching (WCS), while the process of adding on or switching to a new class of migraine medication is called between-class switching (BCS). A more problematic form of BCS may occur when patients switch to opioids or barbiturates Their use may be needed to abort severe attacks, they should generally be avoided as they may reduce patients tolerability to SoC therapies and increase the risk of migraine chronification [9, 10]. The study objectives were to: (1) synthesize rates of switching and discontinuation from triptans; (2) characterize acute medication use among patients with MOH; and (3) describe the associated burden
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