American Migraine Prevalence And Prevention Research Articles

A Comparison of Headache Assessment via Digital Platform in United States (HeAD-US) and American Migraine Prevalence and Prevention (AMPP) Studies: Baseline Demographics and Headache Characteristics (P1-12.002)

A Comparison of Headache Assessment via Digital Platform in United States (HeAD-US) and American Migraine Prevalence and Prevention (AMPP) Studies: Baseline Demographics and Headache Characteristics (P1-12.002)

Migraine symptoms, healthcare resources utilization and disease burden in a large Polish migraine cohort

BackgroundThe Migraine in Poland study is the first large scale nationwide cross-sectional online survey of symptoms, approaches to management, treatment patterns, quality of life, and sociodemographic characteristics of the Polish migraine patients’ cohort, conducted from August 2021 to June 2022.MethodsA cross-sectional online survey was designed based on the American Migraine Prevalence and Prevention (AMPP) Study. Participants were recruited through broad advertisement through various channels. The survey included questions allowing for the diagnosis of migraine without aura (MwoA) based on the third edition of the International Classification of Headache Disorders (ICHD-3). Moreover, the questionnaire assessed sociodemographic and headache features, comorbidities, consultation rates with medical professionals, as well as the use of abortive or preventive treatment, including non-pharmacological methods, psychological symptoms and the burden of migraine.ResultsA structured online questionnaire was submitted by 3225 respondents aged 13 to 80 (mean age 38.9, 87.1% women). In this group 1679 (52.7%) of participants fulfilled ICHD-3 diagnostic criteria for MwoA, which was in most cases (88.3%) confirmed by a medical professional in the past. In this group the average number of monthly headache days was 4.7, while 47.8% of participants had at least 4 migraine days per month. Mean Migraine Disability Assessment score was 42.65 (median 32).Among MwoA respondents, 1571 (93.6%) had consulted their headache with a medical professional in the past – mostly neurologists (n = 1450 (83.4%) and primary care physicians (n = 1393 (82.9%). In the MwoA cohort, 1553 (92.5%) of participants declared the current use of some form of treatment, although only 193 (11.5%) respondents were currently on preventive medications. The most prevalent comorbidities included: chronic rhinitis (37.1%), allergies (35.9%) and low blood pressure (26.9%). Anxiety (20.4%) and depression (21.3%) were highly prevalent among participants.ConclusionsPeople with migraine in Poland face similar difficulties as their peers in other countries. Despite relatively high access to neurologist consultations and good diagnosis accuracy, migraine still poses diagnostic and therapeutic difficulties. In this context, migraine undertreatment in Polish population must be underlined, especially in context of high disease burden.

Predictors of treatment-response to caffeine combination products, acetaminophen, acetylsalicylic acid (aspirin), and nonsteroidal anti-inflammatory drugs in acute treatment of episodic migraine.

To identify predictors of acute treatment optimization for migraine with "over-the-counter" (OTC) or prescription nonsteroidal anti-inflammatory drugs (NSAIDs) as well as other widely used OTCs including acetaminophen, caffeine combination products (CCP), and acetylsalicylic acid (ASA, aspirin) among people with episodic migraine and to develop models that predict treatment response to each class of OTCs. Efficacy of acute OTC medications for migraine varies greatly. Identifying predictors of treatment response to particular classes of medication is a step toward evidence-based personalized therapy. For this prediction model development study, we used data from 2224 participants from the American Migraine Prevalence and Prevention (AMPP) study who were aged ≥18 years, met criteria for migraine, had <15 monthly headache days, and reported being on monotherapy for acute migraine attacks with one of the following classes medications: CCP (N=711), acetaminophen (N=643), ASA (N=110), and prescription or OTC NSAIDs (N=760). The primary outcome measures of treatment optimization were adequate 2-h pain freedom (2hPF) and adequate 24-h pain relief (24hPR), which were defined by responses of half the time or more to the relevant items on the Migraine Treatment Optimization Questionnaire-6. The mean (SD) age of the participants was 46.2(13.1)years, 79.4% (1765/2224) were female, 43.7% (972/2224) reported adequate 2hPF, and 46.1% (1025/2224) reported adequate 24hPR. Those taking CCP had better 2hPF and 24PR outcomes. For those taking NSAIDs, better outcomes were associated with lower average pain intensity (2hPF: odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80-0.99; 24PR: OR 0.86, 95% CI 0.77-0.96), cutaneous allodynia (2hPF: OR 0.92, 95% CI 0.89-0.96; 24PR: OR 0.91, 95% CI 0.87-0.95), depressive symptoms (2hPF: OR 0.95, 95% CI 0.92-0.98; 24PR: OR 0.95, 95% CI 0.91-0.99), and Migraine Disability Assessment Scale (MIDAS) grade (2hPF: OR 0.76, 95% CI 0.64-0.90; 24PR: OR 0.79, 95% CI 0.65-0.95). Adequate 2hPF for those taking CCP was associated with male gender (OR 1.83, 95% CI 1.21-2.77), lower average pain intensity (OR 0.80, 95% CI 0.70-0.91), lower cutaneous allodynia (OR 0.94, 95% CI 0.90-0.97), and lower Migraine Symptom Severity Scale Score (MSSS; OR 0.91, 95% CI 0.86-0.97). Adequate 24hPR for those taking CCP was associated with lower average pain intensity (OR 0.85, 95% CI 0.75-0.96), lower cutaneous allodynia (OR 0.92, 95% CI 0.89-0.96), and lower MIDAS grade (OR 0.81, 95% CI 0.68-0.96). Participants who were married (OR 1.51, 95% CI 1.05-2.19), had lower average pain intensity (OR 0.79, 95% CI 0.70-0.89), lower MSSS (OR 0.93, 95% CI 0.88-0.99), less depression (OR 0.96, 95% CI 0.93-0.99), and lower MIDAS grade (OR 0.72, 95% CI 0.59-0.87) had adequate 2hPF after taking acetaminophen. Participants who were married (OR 1.50, 95% CI 1.02-2.21), had lower pain intensity (OR 0.78, 95% CI 0.69-0.88), less depression (OR 0.95, 95% CI 0.91-0.98) and lower MIDAS grade (OR 0.53, 95% CI 0.42-0.67) had higher 24hPR following use of acetaminophen. A lower MSSS was the only factor associated with higher 2hPF and 24PR after using ASA (OR 0.78, 95% CI 0.67-0.92 and OR 0.79, 95% CI 0.67-0.93). Predictive models had modest performance in identifying responders to each class of OTC. A large subgroup of people with migraine had an inadequate response to their usual acute OTC migraine treatment 2- and 24-h after dosing. These findings suggest a need to improve OTC treatment for some and to offer prescription acute medications for others. Predictive models identified several factors associated with better treatment-response in each OTC class. Selecting OTC treatment based on factors predictive of treatment optimization might improve patient outcomes.

Predictors of treatment-response to acute prescription medications in migraine: Results from the American Migraine Prevalence and Prevention (AMPP) Study

ObjectiveTo identify predictors of acute treatment optimization with prescription drugs among people with episodic migraine. MethodsA total of 2896 individuals from the American Migraine Prevalence and Prevention study were included in this study. The primary outcome measures of treatment optimization were 2-h pain freedom (2hPF) and 24-h pain relief (24hPR), which were defined by responses to the Migraine Treatment Optimization Questionnaire-6 (mTOQ-6). We identified predictors of 2hPF and 24hPR in response to triptans, butalbital combination medications (BCMs), and opioids. Results:Participantswere on average 47.3 years old (SD=12.0), 85.6 % were female, and 88.4 % were white, 46.9 % of participants reported 2hPF and 49.5 % reported 24hPR with their “usual acute treatment”. The odds of adequate 2hPF response were reduced in men and those with higher average headache pain intensity, higher migraine symptom severity scores, presence of cutaneous allodynia, and depression. Adequate 24hPR was associated with being married, but declined in those with higher-than-average average headache pain intensity and frequency, greater disability, presence of cutaneous allodynia, and depression. Among participants reporting acute monotherapy, individuals taking triptans were more likely to have adequate treatment response in comparison with those taking BCMs (2hPF: OR=1.86, 95 %CI 1.42–2.42; 24hPR: OR=2.26, 95 %CI 1.73–2.96) and opioids (2hPF: OR=2.39, 95 %CI 1.94–2.96; 24hPR: OR=2.78, 95 %CI 2.24–3.44). There was no significant difference in response to treatment between the subsample taking BCMs and opioid users. ConclusionAlmost half of study respondents were not optimized on their usual prescription acute migraine treatment(s). Predictive models identified several features associated with treatment optimization.

Demographics, Headache Features, and Comorbidity Profiles in Relation to Headache Frequency in People With Migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study.

Migraine is typically divided into 2 headache frequency denominated categories, episodic migraine (EM) and chronic migraine (CM). Characterizing more narrow headache day frequency groups may be of value for better understanding the broad range of migraine experience and making treatment decisions. To characterize the impact and burden of migraine in 4 monthly headache day (MHD) categories. Respondents to the American Migraine Prevalence and Prevention Study 2005 survey who met criteria for migraine were categorized into low frequency episodic migraine (LFEM) 0-3, moderate frequency episodic migraine (MFEM) 4-7, high frequency episodic migraine (HFEM) 8-14, and CM with ≥15 headache days per month. Data including sociodemographics, headache features and symptomology, comorbidities, cutaneous allodynia, and severe migraine-related disability were compared among groups. We combined the low- and medium-frequency EM groups (L/MFEM) and compared them with the HFEM group in 1 set of models and compared the HFEM and CM groups in a second set of models. Binary logistic regression, linear regression, and ordered logistic regression were used depending upon the variable type and adjusted for sociodemographics. Among 11,603 eligible respondents with migraine, 67.7% (7860/11,603) were categorized with LFEM, 17.7% (2051/11,603) with MFEM, 7.8% (898/11,603) with HFEM, and 6.8% (794/11,603) with CM. The mean age was 46 (SD 13.7), 80.2% (9301/11,603) were female, and 90.0% (10,187/11,323) were White, 6.9% were Black (784/11,323), and 3.1% (352/11,323) were identified as Other race(s). Individuals with HFEM differed from L/MFEM on a wide range of sociodemographic variables in the categories of headache features, disability, and comorbidities while few differences were found when modeling HFEM vs CM. In comparison with L/MFEM and HFEM, the HFEM group was more likely to have severe disability (P<.001 OR=1.74 [1.42, 2.15]), chronic pain (P≤.007 OR=1.35 [1.09, 1.69]), arthritis (P=.001 OR=1.44 [1.15, 1.80]), high cholesterol (P=.005, OR=1.37 [1.10, 1.70]), ulcers (P=.016, OR=1.44 [1.07, 1.93]), and depression (Patient Health Questionnaire [PHQ-9]) (P<.001 OR=1.50 [1.22, 1.84]). While rates of migraine symptoms, headache impact and disability, and comorbidities generally increased with increases in MHD frequency, respondents with HFEM and CM were remarkably similar on a broad range of variables including sociodemographics, disability/impact, and comorbidities. There were many more significant differences between the HFEM and L/MFEM groups on the same variables. Future work should use empirical strategies to identify naturally occurring groups and possibly reconsider the boundary between CM and HFEM.

Migraine comorbidity and cognitive performance in patients with focal epilepsy

BackgroundMigraine and epilepsy are comorbid conditions. While it is well known that epilepsy can have an impact on cognitive abilities, there is conflicting evidence in the literature on the relationship between migraine and cognitive function. The aim of this study was to assess whether migraine comorbidity in patients with newly diagnosed focal epilepsy is associated with cognitive dysfunction. MethodsThis is a post hoc analysis of data prospectively collected for the Human Epilepsy Project (HEP). There were 349 participants screened for migraine with the 13 questions used in the American Migraine Prevalence and Prevention (AMPP) study. Participants were also screened for depression using the Neurological Disorder Depression Inventory for Epilepsy (NDDI-E) and the Center for Epidemiologic Studies Depression Scale (CES-D) and for anxiety using the Generalized Anxiety Disorder-7 (GAD-7) scale. Cognitive performance was assessed with the Cogstate Brief Battery and Aldenkamp–Baker Neuropsychological Assessment Schedule (ABNAS). ResultsAbout a fifth (21.2%) of patients with a new diagnosis of focal epilepsy screened positive for migraine. There were more women and less participants employed full time among the participants with comorbid migraine. They reported slightly more depressive and anxious symptoms than the participants without migraine. Migraine comorbidity was associated with ABNAS memory score (median: 2, range: 0–12, Mann Whitney U p-value: 0.015). However, migraine comorbidity was not associated with Cogstate scores nor ABNAS total scores or other ABNAS domain scores. In linear regressions, depression and anxiety scores were associated with the ABNAS memory score. ConclusionIn this study, there was no association between migraine comorbidity and objective cognitive scores in patients with newly diagnosed focal epilepsy. The relationship between migraine comorbidity and subjective memory deficits seemed to be mediated by the higher prevalence of depression and anxiety symptoms in patients with epilepsy with comorbid migraine.

PDG90 OPIOID USE AMONG MIGRAINE PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT (ED) OF A LARGE TERTIARY CARE INTEGRATED DELIVERY NETWORK IN TEXAS

To describe and compare opioid and non-opioid medication use in migraine patients presenting to the emergency department (ED). This was a retrospective analysis using electronic medical records (EMRs) from Baylor Scott & White Health Plan, obtained via ReachNet, from 2010 to 2017. Records were extracted for patients aged ≥ 18 with ≥ 1 ED visit coded for migraine [ICD-9 ‘346.xx’ or ICD-10 ‘G43.xx’] with continuous records 6 months before and after their index ED visit. Descriptive statistics of patient demographics, opioid and non-opioid medication use were summarized and analyzed using SAS 9.4. The study cohort included 3,187 ED visits for 1,429 migraine patients, with an average age of 42.7 (±13.9) years, 86.8% female, 74.5% Whites, and 18.4% African-Americans. Among 1,429 patients, 712 (49.8%) patients received ≥ 1 medication during the index ED visit, 308 (21.6%) received opioids, and 492 (34.4%) received non-opioid abortive medications. For those who received opioids (n=308), the most common medications administered (frequency of patients) were morphine [n=108 (35.1%)], hydromorphone [n=106 (34.4%)], fentanyl [n=71 (23.1%)], hydrocodone [n=46 (14.9%)], and butorphanol [n=14 (4.5%)]. Of the 1,429 patients, 371 (26.0%) had opioid or abortive prescriptions written to be filled at a pharmacy after their ED visits. About one-fourth [n=374 (26.2%)] of patients had ≥ 1 prescriptions of prophylactic filled during the 6-month post-index period. Despite guidelines discouraging the use of opioids for migraine, opioids were administered for more than one-fifth of the patients during the index ED visits. The American Migraine Prevalence and Prevention (AMPP) study suggests that about 38.8% of migraine patients should use prophylactic medications, but only about one-fourth of the ED patients in the current study were prescribed prophylactic medications after their index migraine ED visit. Future research should focus on exploring factors related to opioid use and barriers to migraine prophylaxis.

Framingham-Based Cardiovascular Risk Estimates Among People With Episodic Migraine in the US Population: Results from the American Migraine Prevalence and Prevention (AMPP) Study.

Cardiovascular (CV) events, conditions, and procedures (ECPs) are common in persons with migraine and are a contraindication to triptan and ergot use. In a prior study, we estimated that there are 2.6 million American adults with episodic migraine (EM) who have had CV ECPs. However, the prior analysis did not assess persons with migraine without CV ECPs who are at high risk for a first cardiovascular disease (CVD) event. To use the Framingham nonlaboratory CVD events risk equation to estimate the number of individuals with EM who are at elevated risk for a first CVD event in the next 10 years using data from the American Migraine Prevalence and Prevention Study, and then to extrapolate the findings to the US population to estimate the scope of people with EM for whom triptan and ergot therapies may be problematic. Data from respondents to the 2009 American Migraine Prevalence and Prevention (AMPP) Study questionnaire aged ≥22 who met criteria and headache day frequency for EM were included in this cross-sectional analysis. Ten-year, first CVD event risk was calculated using the nonlaboratory Framingham CV disease risk score (FRS). Variables were collected via respondent self-report and included sex, age, height, and weight to calculate body mass index (BMI), smoking status, and the presence of hypertension and diabetes among other variables. Standard FRS cut scores of ≥21 for women and ≥16 for men were used, which indicate a 30% or greater risk of a first CVD event in the next 10 years. History of CV ECPs was collected via self-report of ever having the ECP and for events and conditions that were diagnosed by a physician. We applied rates of positive ECPs and rates of high FRS to age and sex stratified estimates of the number of people with EM in the US derived from 2015 US Census data to estimate rates of both in the population. The AMPP Study analysis sample included 5227 women and 1496 men with EM. Results showed that 69.5% of women and 73.4% of men had at least one CV risk factor from the FRS, 38.9% of women and 41.6% of men had ≥2 risk factors, and 18.6% of women and 19.1% of men had ≥3 risk factors. The proportion of women with high FRS was 0% for those aged 22-39, 0.8% (95%CI: 0.5-1.2%) among 40- to 59-year-olds and 15.2% (95% CI: 13.3-17.4%) among the ≥60 age group. For men, the corresponding proportions were 0, 7.3% (95% CI: 5.7-9.4%), and 53.0% (95% CI: 4.7-58.1%). Projecting to a national US sample, the number of persons with EM and high FRS was 403,000 for women and 510,000 for men. The proportion of women and men at high risk for future CV events based on a prior CV ECP, a high FRS or both increased with age from 20-39 (women 4.5%, men 4.2%), 40-59 (women 11.8%, men 18.6%), and ≥60 (women 31.2%, men 61.8%). An estimated 141,000 men aged 40-59 and 187,000 aged ≥60 and 34,000 women aged 40-59 and 181,000 women aged ≥60 in the US population with EM have not had a CV ECP but are at increased risk for a future CV event within the next 10 years based upon their FRS alone. Among people with EM in the US population, the number of women and men with relative contraindications to triptans and ergots based on a high FRS includes over 900,000 women and men. This includes more than half a million individuals with EM who have not had a prior CV ECP.

Allodynia Is Associated With Initial and Sustained Response to Acute Migraine Treatment: Results from the American Migraine Prevalence and Prevention Study.

In a population sample of persons with migraine treating with a single category of acute migraine medication, to identify rates and factors associated with acute treatment outcomes, including 2-hour pain freedom (2hPF), 24-hour pain response (24hPR), and 24-hour sustained pain response (24hSPR). Key predictors include acute treatment type (triptans and other medication categories), the influence of allodynia on response to medication, and the interaction between medication category and presence of allodynia in response to treatment among people with migraine. Cutaneous allodynia was previously associated with inadequate 2hPF, 24hPR, and 24hSPR (sustained response at 24 hours among those with adequate 2hPF) among people with migraine in the American Migraine Prevalence and Prevention (AMPP) Study. The AMPP Study obtained data from a representative US sample of persons with migraine by mailed questionnaire. The 2006 survey included 8233 people with migraine aged 18 or over who completed the Migraine Treatment Optimization Questionnaire (mTOQ). mTOQ was used to assess acute treatment outcomes including 2hPF, 24hPR, and 24hSPR. Eligible individuals used only a single category of acute prescription migraine treatments (n = 5236, 63.6%). This sample was stratified into 5 categories of type of acute prescription headache medication used (triptans, nonsteroidal anti-inflammatory drugs, barbiturate-combinations, opioids, and opioid combinations and ergot alkaloids). Separate binary logistic regression models evaluated: (1) triptans vs other medication types; (2) presence of allodynia vs no allodynia; and (3) the interaction of medication category with allodynia. Sociodemographic variables, health insurance status, over-the-counter and preventive medication use were included as covariates. Odds ratios (OR) and 95% confidence intervals (CI) were generated for each acute treatment outcome. Among eligible participants, the mean age was 46 years, and 82.5% were women. The triptan use group had better outcomes than other medication groups for 2hPF (OR range: 2.00-2.63, all significant except ergot alkaloids) and 24hPR (OR range: 2.10-6.22, all significant). No significant medication effects were found for the 24hSPR outcome. The presence of allodynia was associated with significantly worse outcomes for both 2hPF (OR range: 1.42-1.55, all significant) and 24hPR (OR range: 1.30-1.32, all significant, except for ergot alkaloids, P = .051). Allodynia effects were not significant for the 24hSPR. The interaction between medication and allodynia was also not significant (OR range for 2hPF: .68-2.02; OR range for 2hPR: .35-1.34; OR range for 24hSPR: 1.21-2.72) in any of the models, suggesting allodynia is an important predictor of treatment response regardless of the medication group prescribed. The use of triptan medication was associated with significantly better 2hPF (except vs ergot alkaloids) and significantly better 24hPR outcomes compared with other acute medication categories. The presence of allodynia significantly increased the likelihood of an inadequate treatment response for both of these outcomes. Triptan use was generally associated with the best outcomes. Because allodynia was associated with inadequate outcomes for all medication groups, we suggest that allodynia is an area of unmet treatment need.

Cardiovascular Events, Conditions, and Procedures Among People With Episodic Migraine in the US Population: Results from the American Migraine Prevalence and Prevention (AMPP) Study.

Though migraine, particularly migraine with aura, is a cardiovascular (CV) risk factor, the scope and distribution of cardiovascular disease in representative samples of people with migraine are not known. This is important because many widely used acute migraine treatments, including triptans, ergot alkaloids, and nonsteroidal anti-inflammatory drugs, carry precautions, warnings, or contraindications for use in persons with CV disease. To assess the scope and distribution of cardiovascular events, conditions, and procedures in persons with episodic migraine in a representative sample of the US population, using data from the American Migraine Prevalence and Prevention (AMPP) Study. Eligible subjects completed the 2009 AMPP survey, met ICHD-3beta criteria for migraine, and had a headache frequency of less than 15 days per month (episodic migraine). A survey on cardiovascular events (ie, myocardial infarction), conditions (ie, angina), and procedures (ie, carotid endarterectomy) was adopted from the Women's Health Study and the Physician's Health Studies. Cardiovascular events and conditions were defined by participant reports of having both experienced and received a physician diagnosis for a particular event or condition. The distribution of CV events, conditions, and procedures was summarized for the entire migraine sample and in groups defined by gender and age (22-39, 40-59, and ≥60). To assess the numbers of persons with episodic migraine in the US, we applied age and gender stratified estimates of migraine prevalence to the 2015 Census data. To estimate the number of cardiovascular events, conditions, and procedures in the US migraine population, we applied age and gender stratified event rates to the number of persons with episodic migraine in each stratum. The 2009 AMPP Study survey was returned by 11,792 study participants out of 16,983 (64.9% response rate), including 6723 individuals who met study criteria for episodic migraine (5227 women and 1496 men). Among 22-39 year olds with episodic migraine, 3.4% reported having received a physician diagnosis of CV events or conditions and 1.1% reported undergoing CV related procedures. Among 40-59 year olds, 10.2% reported having received a physician diagnosis of CV events or conditions and 3.5% reported CV related procedures. For those age 60 or older, 22.3% reported CV events or conditions and 8.8% reported CV procedures. Prevalence of events, conditions, and procedures was higher in men than women and also in older age groups. However, the absolute number of CV events, procedures, and conditions was greater for women than men due to the higher population prevalence of episodic migraine in women. We projected that 2.0 million women and 665,000 men in the US had episodic migraine and a history of one or more CV event, condition, or procedure. By age group, it is estimated that 579,000 among those aged 22-39, 1.37 million of those aged 40-59, and 696,000 of those 60 and older with episodic migraine have ever had at least one CV event, procedure, or condition. Based on these analyses, we estimate that there are roughly 2.6 million people with episodic migraine aged 22 and older in the US with one or more prior CV event, condition, or procedure. For this group, cardiovascular contraindications to many migraine-specific acute migraine therapies may make treatment challenging.

A Comparison of the Chronic Migraine Epidemiology &amp; Outcomes (CaMEO) Study and American Migraine Prevalence and Prevention (AMPP) Study: Demographics and Headache-Related Disability (P1.167)

A Comparison of the Chronic Migraine Epidemiology &amp; Outcomes (CaMEO) Study and American Migraine Prevalence and Prevention (AMPP) Study: Demographics and Headache-Related Disability (P1.167)

Direct and Indirect Costs of Chronic and Episodic Migraine in the United States: A Web-Based Survey.

The objective of this study was to compare the societal direct and indirect costs of chronic and episodic migraine in the United States. Episodic and chronic migraine are distinguished by the frequency of headache-days. Chronic migraine has a greater overall impact on quality of life than does episodic migraine. Individuals with chronic migraine also use more healthcare resources (resulting in higher direct costs) and experience greater decreases in productivity (resulting in higher indirect costs) than those with episodic migraine as shown in the American Migraine Prevalence and Prevention (AMPP) Study. The International Burden of Migraine Study utilized a web-based questionnaire to elicit data on several topics related to the burden of migraine illness, including health resource utilization and productivity losses. Potential survey participants were identified by Synovate Healthcare (Chicago, IL, USA) from a pool of registered panelists from various countries. The panelists were screened online to determine eligibility and to identify individuals with migraine (episodic or chronic), based on reported symptoms. Participants from the United States were divided into episodic and chronic migraine groups, based on reported headache-day per month frequency. Direct and indirect costs were estimated by applying estimated unit costs to reported headache-related productivity losses and resource use. Costs were compared between participants with episodic and chronic migraine. Mean [standard deviation] total annual cost of headache among people with chronic migraine ($8243 [$10,646]) was over three times that of episodic migraine ($2649 [$4634], P < .001). Participants with chronic migraine had significantly greater direct medical costs ($4943 [$6382]) and indirect (lost productivity) costs ($3300 [$6907]) than did participants with episodic migraine (direct, $1705 [$3591]; indirect, $943 [$2084]) (P < .001 for each). Unlike previous findings, direct medical costs constituted the majority of total headache-related costs for both chronic migraine (60.0%, $4943 of $8243) and episodic migraine (64.3%, $1705 of $2649) participants. A large portion of direct medical costs are attributable to pharmaceutical utilization among both chronic migraine (80%, $3925 of 4943) and episodic migraine (70%, $1196 of $1705) participants. The results of this study build on previous results of the AMPP Study, demonstrating that headache-related direct, indirect, and total costs are significantly greater among individuals with chronic migraine than with episodic migraine in the United States.

Adding Additional Acute Medications to a Triptan Regimen for Migraine and Observed Changes in Headache‐Related Disability: Results From the American Migraine Prevalence and Prevention (AMPP) Study

Though triptans are the most widely used acute treatments for migraine, response to treatment is sometimes suboptimal. Triptan therapy is often augmented by the addition of other acute treatments. The benefits of this practice have not been examined in large-scale, real-world observational studies. To assess changes in headache-related disability associated with adding additional acute treatments to a triptan regimen by category of added treatment including: a second triptan, nonsteroidal anti-inflammatory drugs (NSAID), opioids or barbiturates. Subjects were participants in the American Migraine Prevalence and Prevention study, a longitudinal, US population-based study of individuals with "severe" headache. Respondents who met International Classification of Headache Disorders 3 beta criteria for migraine were on triptan therapy per respondent self-report, used the same triptan, and provided headache-related disability data for at least 2 consecutive years. Subjects were divided based on headache days per month into 3 groups: low-frequency episodic migraine (LFEM, 0-4), moderate-frequency episodic migraine (MFEM, 5-9), and high-frequency episodic migraine/chronic migraine (HFEM/CM, ≥ 10 headache days per month). HFEM and CM were combined into a single group for analyses because of sample size limitations. Patterns of acute treatment for migraine were monitored from one year to the next over the following couplets of years (2005-2006, 2006-2007, 2007-2008, and 2008-2009). The first eligible couplet was analyzed for each respondent. Medication regimens studied included: (1) maintaining current triptan use (consistent group); (2) adding a different triptan; (3) adding an NSAID; or (4) adding a combination analgesic containing opioids or barbiturates. We assessed change in Migraine Disability Assessment (MIDAS) score from the first to the second year of a couplet, contrasting scores of participants with consistent use with those who added an acute treatment to their triptan regimen. The study sample (N = 2128) included 111 individuals who added another triptan, 118 who added an opioid or barbiturate, and 69 who added an NSAID, with referent groups of approximately 600 cases in each group who remained consistent. In general, MIDAS scores were higher among those who made changes from one year to the next compared with those who did not make changes in therapy. In fully adjusted models, adding triptans or NSAIDs was associated with increased disability for HFEM/CM cases at follow-up but decreased disability at follow-up for MFEM cases, resulting in significant interaction effects for both adding triptans and NSAIDs, respectively (15.88, 95% confidence interval [CI] 0.75, 31.01, 38.52, 95% CI 12.43, 64.61). While the effects of adding vs staying consistent on the outcome of headache-related disability varied by medication type added and headache frequency strata, in general, these results suggest that for individuals with migraine, adding acute therapies to current triptan use is generally not associated with reductions in headache-related disability. The results were strongest among persons with HFEM and CM. These results identify important unmet medical needs in current migraine management, especially among patients with high-frequency migraine, and suggest that alternative treatment strategies are needed to improve patient outcomes.

Acute treatment optimization in episodic and chronic migraine: results of the American Migraine Prevalence and Prevention (AMPP) Study.

The migraine Treatment Optimization Questionnaire (mTOQ) was developed to assess response to acute treatment in persons with migraine. The original validated form used yes or no response options. This study aims to (1) assess the psychometric properties of a 6-item version of the mTOQ (mTOQ-6) using ordinal response options; (2) compare treatment optimization using the revised mTOQ-6 for both episodic and chronic migraine (EM and CM, respectively); (3) identify demographic, headache, and treatment features associated with treatment optimization. The American Migraine Prevalence and Prevention (AMPP) Study is a longitudinal, US population-based study. Annual questionnaires were mailed to a sample of 24,000 severe headache sufferers identified by screening a panel constructed to be representative of the US population. The current study included respondents to the 2006 AMPP Study survey who met modified International Classification of Headache Disorders-3 beta criteria for migraine; persons with CM (≥15 HA days/month) or EM (<15 HA days/month) were included. Acute treatment optimization was measured with the mTOQ-6. A single factor latent variable model was used to assess item characteristics. This model was expanded through structural equation models (SEM) to incorporate a contrast between persons with CM and EM on the scaled treatment optimization scores. We estimated both an unadjusted SEM and a SEM adjusted for demographic features, headache characteristics, and acute treatment. Migraine criteria were met by 8612 persons (539 for CM and 8073 for EM) who completed the mTOQ-6 as part of the 2006 AMPP Study survey. When compared, those with CM exhibited worse treatment optimization across all domains of the mTOQ-6. For example, 35.1% of CM and 44.6% of EM respondents reported being pain free at 2 hours "half the time or more" with their usual migraine medication. Latent variable model parameters indicated excellent psychometric properties of the mTOQ-6. Scaled treatment optimization scores obtained from the unadjusted SEM were significantly lower (indicating worse treatment optimization) for persons with CM (3.25) compared to persons with EM (4.01), b = -0.76, P < .0001; scores remained significantly lower for CM after adjustment with a wide array of demographic and disease severity covariates. Poor treatment optimization was associated with cutaneous allodynia, major depression, and the use of nonsteroidal anti-inflammatory drugs. Better treatment optimization was associated with the use of triptans and preventive medications. Estimates of the latent variable scores for the mTOQ-6 revealed persistent low levels of treatment optimization for both EM and CM, though treatment optimization is worse for CM.

Burden of migraine related to menses: results from the AMPP study.

BackgroundStudies of the difference between menstrually associated and non-menstrually associated migraine are somewhat controversial. The majority of studies have focused on comparing menstrual to non-menstrual attacks rather than comparing study groups with different migraine diagnoses with respect to menstruation. As there is limited knowledge available on the overall impact and burden of migraine among groups of women with and without menstrually associated migraine our goal was to examine differences between these groups. We hypothesized that there would be greater burden of migraine related to menstruation and headache frequency in a population study across groups of women.MethodsWe analyzed data from the American Migraine Prevalence and Prevention (AMPP) Study, a longitudinal, US, population-based study. We included female respondents to the 2009 survey, aged 18 to 60, who met modified ICHD-2 criteria for migraine, were actively menstruating and fit one of three definitions based on the self-reported association of menses and migraine attacks: self-reported predominantly menstrual migraine (MM, attacks that only or predominantly occur at the time of menses), self-reported menstrually-associated migraine (MAM, attacks commonly associated with menses, but that also occur at other times of the month), and self-reported menstrually-unrelated migraine (MUM). These three groups were compared on characteristics and measures of headache impact and burden (Headache Impact Test– 6 item (HIT-6) and Migraine Disability Assessment Scale (MIDAS).ResultsThere were 1,697 eligible subjects for this study in the following categories: MM (5.5%), MAM (53.8%), or MUM (40.7%). Women with MM had an older age of migraine onset. Those with predominantly menstrually-related attacks (MM) had fewer headache-days but appeared to be more impaired by attacks. HIT-6 and MIDAS scores were significantly higher for both the MM and MAM groups compared with the MUM groups; however, effects were more robust for MM than MAM.ConclusionsNearly 60% of women with migraine reported an association between migraine and menses. These women reported greater headache impact and migraine-related burden on functioning than those in whom migraines were not related to menstruation. Women with MM were more impaired by attacks while women with MAM had overall highest burden, likely due to experiencing migraines on additional days.

Economic Burden and Costs of Chronic Migraine

Chronic migraine (CM) is a subtype of migraine broadly defined by the presence of headache at least 15days per month. Emerging evidence suggests that CM and episodic migraine (EM) differ not only in headache frequency, but that they are distinct clinical entities. Because individuals with CM are more disabled, they demonstrate higher societal burden than those with EM. There have been three important surveys published within the last five years that have focused on the societal burden associated with CM. The first is the American Migraine Prevalence and Prevention (AMPP) study, a longitudinal population-based survey performed in the U.S. The second, the International Burden Migraine Study (IBMS), is a Web-based survey conducted in North America, Western Europe, Asia/Pacific, and Brazil. The third is a clinic-based survey performed in Taiwan. This review discusses results of these studies with regard to healthcare resource use (and related direct costs) and loss of productivity (and related indirect costs) from the perspective of cost-effectiveness of new therapeutic approaches to CM.

Chronic rhinitis and its association with headache frequency and disability in persons with migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study

Rhinitis is a comorbidity of migraine, but its relationship to migraine headache frequency and headache-related disability is unknown. To determine if rhinitis and its subtypes are associated with an increased frequency and associated disability of migraine. The AMPP Study is a longitudinal study of individuals with "severe" headache from the US population. Respondents meeting ICHD-2 criteria for migraine in 2008 were identified and the presence of rhinitis was determined using the European Community Respiratory Health Survey (ECRHS). Those with rhinitis were subtyped as allergic, non-allergic, mixed and unclassified based on a rhinitis questionnaire. The primary outcome measures were categories of headache-day frequency and headache-related disability as measured by the Migraine Disability Assessment Scale (MIDAS). Logistic regression for ordered categories was used for modeling each outcome separately, adjusted for sociodemographics profile, headache features, headache treatments and comorbidities. The AMPP Study questionnaire was mailed to 17,892 persons and returned by 60.1% of respondents. Among the migraine sample ( N = 5849), 66.8% had rhinitis with mixed rhinitis as the most common form. The presence of rhinitis of any type was associated with headache frequency after adjusting for sociodemographic variables only (OR 1.33; 95% CI 1.16, 1.53) and in the fully adjusted model (OR 1.25; 95% CI 1.05-1.49). Headache-related disability (MIDAS category) was associated with rhinitis after adjusting for sociodemographic features (OR 1.30; 95% CI 1.17-1.46), but lost significance in the fully adjusted model (OR 1.10; 95% CI 0.96-1.26). Mixed rhinitis was associated with an increased headache frequency category in the model adjusted for sociodemographics (OR 1.45; 95% CI 1.24-1.70) and in that adjusted for all covariates (OR 1.28; 95% CI 1.05-1.57). The odds ratio for MIDAS categories were similarly increased in both models for the mixed rhinitis group. The frequency and disability of migraine are higher in persons with rhinitis, particularly those with mixed rhinitis. These results, however, should be considered preliminary until confirmed in future studies because of the modest questionnaire response rate in this study.

Impact of NSAID and Triptan Use on Developing Chronic Migraine: Results From the American Migraine Prevalence and Prevention (AMPP) Study

To assess the influence of triptan or nonsteroidal anti-inflammatory drug (NSAID) use on the likelihood of developing chronic migraine (CM) among persons with episodic migraine (EM). CM is common in tertiary headache care, and relative to EM, CM is associated with a number of deleterious outcomes, including higher headache-related disability, reduced health-related quality of life, and increased direct and indirect costs. Symptomatic medication use has emerged as an important risk factor for the development of CM. Limited evidence based on a single year of follow up suggests that the association between NSAID and triptan use with the onset of CM varies in a dose-dependent manner that interacts with headache frequency. However, this interaction has never been explicitly studied. Herein, we evaluate results from a large-scale, 5-year, population-based observational study to characterize these relationships and test the hypothesis that NSAID use may modify the effect of triptan use on CM onset. In the American Migraine Prevalence and Prevention (AMPP) study, 11,249 participants had EM in 2005 and provided up to 5 years of annual follow-up data. We analyzed the characteristics of persons with EM 1 year that predicted new onset CM in the subsequent year, focusing on treatment with NSAIDs and triptans as exposures. These adjacent years of data provide the basis for analysis and are termed "couplets." Repeated measures logistic regression with a subject-specific random intercept was used to model the likelihood of transition from EM to CM as a function of NSAID or triptan dose while controlling for a number of covariates including headache features, use of other medications, and the number of couplets per individual. The analysis included 9031 individuals with EM contributing up to 5 years of data and up to 4 couplets each. Results indicated that on average, 55% of the participants used NSAIDs in any given year and 2% transitioned to CM over subsequent years. Among the 20% using triptans, 3% per year transitioned to CM. Among persons with less than 10 headache days per month, frequency of NSAID use was associated with dose-dependent reductions in risk of CM onset. Among those with 10-14 headache days per month, increasing days per month of NSAID use was associated with increasing risk of CM onset. Increasing days per month of triptan use was associated with increased risk of transitioning to CM. Combination use of NSAIDs and triptans was not protective against transition to CM, but was also not statistically significantly associated with increased risk of CM onset. Triptan use in EM is associated with an increased risk of CM onset that increases with days of medication use. For NSAIDs, effects depend on headache days per month. NSAIDs are protective in individuals with less than 10 headache days per month but associated with increased risk with 10 or more headache days per month. Combining a triptan and NSAID was not associated with a statistically significant increased risk of CM onset, whereas increased risk of CM onset was significantly associated with triptan monotherapy.

Effects of Switching Acute Treatment on Disability in Migraine Patients Using Triptans

To assess the influence of switching acute treatment on headache-related disability in a population sample of individuals with migraine using acute triptan therapy. Acute treatments for migraine are often modified in clinical practice. The effect of changes in treatment from one triptan to another or from a triptan to another medication class has rarely been studied. Patterns of acute treatment for migraine were monitored from 1 year to the next in the American Migraine Prevalence and Prevention (AMPP) Study for the following couplets (2005-2006, 2006-2007, 2007-2008, and 2008-2009). Changes in medication regimens were classified as follows: (1) switch within the triptan class; (2) switch to combination analgesics containing opioids or barbiturates; (3) switch to non-steroidal anti-inflammatory drug (NSAID) agents; (4) maintaining current therapy (consistent use, "control"). We assessed change in migraine disability assessment scale score from the first to the second year of a couplet contrasting those with consistent use with those who changed acute treatment. Each individual contributed only 1 couplet to the analysis. Persons who added an acute treatment are considered in a separate manuscript. We modeled change in migraine disability assessment scale score as a function of change in medication regimen with consistent users as the control group. We identified 81 individuals who switched to another triptan, with a referent of 619 who remained consistent, 31 cases who switched to an opioid or barbiturate with a referent of 666 who remained consistent, and 20 cases who switched to an NSAID with a referent of 667 cases who remained consistent. In cell-mean coded analyses of covariance (ANCOVA), switching from one triptan to another or switching from a triptan to an opioid/barbiturate was never associated with significant improvements in headache-related disability compared with consistent treatment. Switching from a triptan to an NSAID was associated with significant increases in headache-related disability among those with high-frequency episodic/chronic migraine (HFEM/CM) compared with those with low-frequency episodic migraine (LFEM) (interaction = 34.81, 95% confidence interval 10.61 to 59.00). The same was true comparing high-frequency episodic/chronic migraine with those with moderate-frequency episodic migraine (interaction = 48.73, 95% confidence interval 2.63 to 94.83). In this observational study, switching triptan regimens does not appear to be associated with improvements in headache-related disability and in some cases is associated with increased headache-related disability.

Global perspectives on the burden of episodic and chronic migraine

Recent studies have profiled chronic migraine (CM) and episodic migraine (EM) in many regions of the world using samples derived from various sources. In a previous issue of Cephalalgia, Wang and colleagues contrast patients with CM and EM recruited from two headache clinics in Taiwan (1). Their results add to the growing evidence indicating that, in comparison with EM, CM is less common but far more burdensome to individuals, as evidenced by measures of headacherelated disability, medical and psychiatric comorbidities, and health-related quality of life (HRQoL), and to society, as indexed by measures of lost productive time as well as direct medical costs. In 2011, the World Health Organization and Lifting the Burden Campaign against Headache published the ‘‘Atlas of Headache Disorders and Resources in the World 2011.’’ The authors of ‘‘The Atlas’’ stated, ‘‘Our view of the global burden attributable to headache disorders is incomplete. . .’’ (2). They urged researchers around the world to gather and publish data on the prevalence, burden, and other variables related to primary headaches in order to increase the understanding of the global status of headache prevalence, burden, costs, and care. They estimated the prevalence of headache on 15 days per month (an approximation of chronic daily headache (CDH)) in Southeast Asia to be 1.7% based on a compilation of data from epidemiological studies. CM is a form of CDH; however, ‘‘The Atlas’’ did not report rates of CM. In their recent systematic review of CDH and CM in the Asia-Pacific region, Stark and colleagues (3) identified two population studies, both from Taiwan, that reported the prevalence of CM as 1.7% (reported as transformed migraine (TM)) (4) and 1.0% (reported as CDH with migrainous features) (5). They also identified 19 clinic-based studies that reported rates and features of patients with CM. They concluded that Asia may have a lower prevalence of CM and CDH than the international average, although the rates of CM reported in the studies from Taiwan are similar to the prevalence of CM reported by the American Migraine Prevalence and Prevention (AMPP) study (6). Stark et al. also noted that CM was associated with significant headache-related disability, functional impairment, and psychiatric comorbidity in reports of clinic studies from Taiwan, Korea, and China. These findings from the Asia-Pacific region are similar to those reported by large international (7,8), North American (6), and European studies (9), which have also demonstrated that CM is associated with greater disease burden on multiple indices compared with EM. Making comparisons among studies and variations regions of the world is difficult because of variation in sources of study subjects and data collection methods among other factors. Fortunately, the AMPP study, the International Burden of Migraine Study (IBMS), and the study by Wang and colleagues collected and reported similar data, which allows for comparisons across studies. The AMPP study screened 120,000 United States (US) households selected to be representative of the US population and had a 64.9% response rate. Of 28,261 respondents who reported experiencing ‘‘severe headache’’ in the preceding year, 24,000 were followed annually from 2005 to 2009 with mailed, written questionnaires. The AMPP survey instrument was based on validated items from the American Migraine Studies 1 and 2 (10,11) along with validated questionnaires such as the Migraine Disability Assessment Scale (MIDAS) (12). The IBMS utilized a targeted, Webbased methodology to recruit and survey participants with EM and CM in 10 countries. Invitations were sent via email to 72,059 panelists. Of 23,312 respondents