InterMiG: international differences in the therapeutic approach to migraine patients in specialized headache centers

DOI: https://doi.org/10.1186/s10194-021-01258-y

Abstract-Summary There is currently a wide therapeutic arsenal for migraine patients, without a single first-line preventive drug and we choose the different available alternatives taking into account comorbidities, national guidelines, previous treatments and personal experiences.

Statistically significant differences were found between all pharmacological classes: antidepressants were commonly used in all countries, with the exception of Poland (AU: 76.7%, IT: 71.0%, DE: 60.0%, PL: 31.1%, PT: 71.7%, RUS: 70.6%, ES: 78.5%; p < 0.0001); antiepileptic drugs were more frequently prescribed in Portugal, Australia and Spain (AU: 73.3%, IT: 40.0%, DE: 37.5%, PL: 48.9%, PT: 85.0%, RUS: 29.4% and ES: 69.0%; p < 0.0001); beta-blockers and antihyperten- sive drugs were frequently used in all countries except Italy (AU: 60.0%, IT: 14.0%, DE: 53.8%, PL: 48.9%, PT: 68.3%, RUS: 49.4% and ES: 59.0%; p < 0.0001); BTX-A were predominately used in Spain, Italy and Australia (AU:56.7%, IT:58.0%, DE:20.0%, PL: 42.2%, PT: 26.7%, RUS: 24.7% and ES: 58.5%; p < 0.0001) and others were most frequently used in Poland (AU: 0.0%, IT: 19.0%, DE: 42.5%, PL: 95.6%, PT: 31.7%, RUS: 3.5% and ES: 49.5%; p < 0.0001).

If only patients without comorbidities are considered (200/600), statistically dif-

ferences between countries persist in all preventive treatments.

Extended: Statistically significant differences were found in the global set of all patients in the use of preventive treatments considering the patient’s previous pathology.

Background More recent guidelines have summed up the real-life experience of general practi- tioners and headache centers and recommend that the choice of a migraine prophy- lactic drug should be based on the attack frequency (episodic vs. chronic), comorbid diseases and the patient’s individual needs [193, 194].

Whereas in some countries general practitioners successfully treat most patients with migraine, in others countries this is not the case, resulting in a large number of drug-naïve patients referred to third-level headache centers.

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Such differences in patient populations and proportions of refractory headaches

seen by specialized centers may also influence drug choice.

The objective of this study was to evaluate the differences of preferences of use of acute and preventive migraine treatments internationally across headache centers in several countries.

One-way ANOVA was used in order to study group mean differences between

countries and patient’s age and headache frequency.

Results Regarding medical referral, if we only selected patients referred by general neurolo- gists (38.8%, 233/600): triptans (73.4 %, 171/233) and NSAIDS (53.6%, 125/233) were also the standard treatments and non-statistically significant differences were found in triptan prescription between countries (AU: 66.7%, IT: 79.5 %, DE: 62.5%, PL: 80.0%, PT: 76.9%, RUS: 84.8%, ES: 74.0%; p = 0.178).

When we focus the analysis on patients referred by general practitioners (175/600, 29.2%), differences are observed between countries, both in the use of triptans (AU: 53.8%, IT: 51.0%, DE: 91.3%, PL: 80.0%, PT: 55.6%, RUS: 100.0%, ES: 36.4%; p = 0.012) and NSAIDs (AU: 34.6%, IT: 84.0%, DE: 73.9%, PL: 100.0%, PT: 55.6%, RUS: 0.0%, ES: 63.6%; p < 0.0001).

Discussion It can be seen that there is no single first-line drug of choice as preventive treatment, and significant differences can be observed between countries and there is a wide arsenal of drugs used, opting for one or the other according to the patient’s profile and their comorbidities, but there are also differences in relation to the nationality of the prescribing physician.

We have analyzed a total of 734 patients from seven different countries (Australia, Italy, Germany, Poland, Portugal, Russia and Spain), from specialized headache units, which implies a more complex patient profile, often with a long pharmaco- logical history.

The most widely used neuromodulator treatment was TPM, also in patients with- out comorbidities, however countries like Russia use it significantly less, approxi- mately in 1/4 patients, compared to others such as Portugal or Australia, where it has been prescribed in 3/4 or Spain in 2/3.

Conclusions Of choosing the most appropriate acute or preventive migraine treatment, comorbidities, the patient’s opinion [198], and of course, that of the neurologist must always be assessed, but as we have observed in this first international study, this may differ depending on the country where the treatment is prescribed.

This investigation shows the need for a larger multicentre study to verify these results and to continue with comparative clinical trials between the first line treat- ments, in order to create global international algorithms that guarantee the best therapeutic option for our patients.

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Acknowledgement A machine generated summary based on the work of Gago-Veiga, ; Huhn, J-I; Latysheva, N; Campos, A Vieira; Torres-Ferrus, M; Ruiz, A Alpuente; Sacco, S; Frattale, I; Ornello, R; Ruscheweyh, R; Marques, IB; Gryglas- Dworak, A; Stark, C; Gallardo, VJ; Pozo-Rosich, P. 2021 in The Journal of Headache and Pain.

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