Real world preventative drug management of migraine among Spanish neurologists

DOI: https://doi.org/10.1186/s10194-019-0971-6

Abstract-Summary Many different preventatives have showed efficacy in the treatment of migraine.

We analysed socio-demographic parameters and evaluated 43 questions consid- ering migraine management as well as therapeutic choices regarding migraine sub- types and finally, neurologists’ personal perception.

The first choice for preventive therapy in chronic migraine among participants was topiramate (57%) followed by amytriptiline (17.9%) and beta-blockers (14.6%).

In episodic migraine, the preferred options were beta-blockers (47.7%), topira-

mate (21.5%) and amytriptiline (13.4%).

Regarding perceived efficacy, topiramate was considered the best option in chronic migraine (42.7%) followed by onabotulinumtoxinA (25.5%) and amitrypti- line (22.4%).

Episodic migraine was concerned, surveyed neurologists perceived topiramate

(43.7%) and beta-blockers (30.3%) as the best options.

When we evaluated the duration of treatment use with a view to adequate thera- peutic response, 43.5% of neurologists preferred 3 months duration and 39.5% were in favour of 6 months duration in episodic migraine.

Considering the preferred duration of treatment use in chronic migraine, 20.4% recommended 3 months, 42.1% preferred 6 months and 12.5% and 22.4% opted for 9 and 12 months respectively.

When considering onabotulinumtoxinA therapy, the number of prior therapeutic failures was zero in 7.2% of neurologists, one in 5.9%, two in 44.1%, three in 30.9% and four or more in 11.9%.

The initial management of migraine among Spanish Neurologists is in line with

most guidelines, where first choice preventative drugs are concerned.

The Management of episodic migraine differed from chronic migraine, both in

terms of neurologist preference and in their perceived efficacy.

Extended: We did not analysed non-pharmacological therapies or comorbidities

management, which should be considered for future studies.

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Introduction The Spanish Society of Neurology periodically publishes guidelines on the main neurological conditions, in order to help clinicians in their daily practice.

The Spanish Headache Study Group guidelines [223] recommended topiramate and beta-blockers as the first choice of preventive therapy in Episodic Migraine, followed by flunarizine, Lisinopril and candesartan.

The first oral preventive option in Chronic Migraine is topiramate, followed by

amitriptyline and in a third level flunarizine and beta-blockers.

We aimed to evaluate the preferences in the management of migraine with pre- ventive therapies, the perceived efficacy and safety of the current therapies among Spanish Neurologists.

Material and Methods The studied population was the community of Spanish Neurologists ascribed to the Spanish Society of Neurology.

The study included an anonymous survey mailed three times to all neurologist

members of the Society.

The survey analysis considered if the neurologist was a member of the Spanish Headache Study Group (SHSG) and those in whom headache disorders were their main area of interest.

Eligibilty criteria of treatments included all those mentioned in the Official Guidelines of the Spanish Headache Study Group, namely: beta-blockers, amitrip- tiline, topiramate, valproic acid, zonisamide, lisinopril, candesartan, fluoxetine, venlafaxine, desvenlafaxine, lamotrigine, magnesium, flunarizine, riboflavine, pre- gabalin, onabotulinumtoxinA (onabotA) and anaesthetic blockade of greater occipi- tal nerves (GON) [223].

In the comparison of continuous variables with qualitative variables, the employed test was Student t test and Median test in case of non-normal distribution or <30 variables per group.

Results The most frequent second choice drug were beta-blockers (25.7%) followed by topiramate (23.2%), amitriptyline (20.5%), onabotA (10.6%) and flunarizine (9.3%). Management of CM seemed to be different among general neurologists when compared with those focused on headache disorders, particularly concerning the first choice selection of topiramate (49.5% vs. 71.2%, p:0.017), amitriptyline (23.2 vs. 7.7%, p:0.016) and flunarizine (9.1% vs. 0%, p:0.027).

Topiramate was considered the most effective drug in the treatment of CM by 42.7% of responders, followed by onabotA in 25.2%, amiptriptyline (22.4%), beta- blockers (3.5%) and flunarizine (2.1%).

The second most frequently considered drug was also topiramate in 34.3%, fol- lowed by amitriptyline (19.7%), beta-blockers (15.3%), onabotA (8%), venlafaxin (5.8%), valproic acid and zonisamide (5.1% each).

Discussion These findings follow the Spanish Headache Study Group recommendations [223], but differences were found in the second and third choice, as few responders

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considered valproic acid as a potential option and amitriptyline was selected before flunarizine in all three groups.

Concerning the tolerability profile, most of the responders preferred beta- blockers but the preferred drugs were flunarizine, OnabotA, amitriptyline and topiramate.

Despite the difference of administration, OnabotA was perceived as well toler- ated by a high percentage of neurologists, in line with long-term studies show [224], and it was selected before GON blockades.

Despite that Spanish Guidelines recommend to consider OnabotA after two ther- apeutic failures and Spanish Health Care System covers OnabotA costs all across the country, only 49.5% of general neurologists surveyed admitted to starting it after the failure of two preventatives.

Conclusion Our study states that the main criterion in the selection of treatments is the subjec- tive perceived efficacy, topiramate being the drug considered as the most effective and therefore the first choice drug in CM and EMWA.

Despite the availability of many novel therapies, most of the clinicians employed

the classical drugs.

Acknowledgement A machine generated summary based on the work of García-Azorin, D.; Santos- Lasaosa, S.; Gago-Veiga, A. B.; Viguera Romero, J.; Guerrero-Peral, A. L.2019 in The Journal of Headache and Pain.

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