Shortcomings and missed potentials in the management of migraine patients—experiences from a specialized tertiary care center

DOI: https://doi.org/10.1186/s10194- 019- 1034- 8

Abstract-Summary Despite the availability of evidence-based national and international guidelines, the management of migraine patients often remains poor, which is often attributed to a low availability of headache specialists.

The aim of this study was to investigate the adherence to national guidelines and to assess the possible potential of optimized therapy regimens in migraine patients. We collected data of migraine patients presenting to our out-patient clinic via standardized questionnaires regarding headache, diagnostics and experience with previous treatments.

1935 migraine patients were included between 2010 and 2018. In the 12 months before consulting our headache clinic 89.5% of the patients had consulted a general practitioner and 74.9% had consulted a neurologist because of their migraine.

Out of 1031 patients who had not been prescribed a preventative treatment 627 (60.8%) had in average 3 or more migraine attacks per month and thus qualified for a preventative treatment.

Our data suggest, that many migraine patients to this day do not receive state-of-

the-art therapy.

Adherence to national and international European guidelines could improve the

outcome in migraine patients.

Extended: Despite the availability of evidence-based national [524] and interna- tional [183] guidelines, the management and care provided to migraine patients is far from ideal [261].

The aim of the current study is therefore to investigate the adherence to national migraine guidelines for diagnosis and medical treatment in a sample of nearly 2000 patients consulting a third referee center for headache.

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Introduction Migraine patients still experience significant time delays in the diagnosis of their headache disorder [525] and the majority of migraine patients seem to not receive adequate acute [261] and preventative treatment [526].

Since the headache syndromes of these patients are per definition recognized by the patient and by the medical community, the question arises whether these patients were treated correctly or not, i.e. whether these patients suffer from particularly severe headache disorders and therefore are medically intractable or whether they have not been treated properly despite recognition of the disease.

The aim of the current study is therefore to investigate the adherence to national migraine guidelines for diagnosis and medical treatment in a sample of nearly 2000 patients consulting a third referee center for headache.

Methods The headache and facial pain outpatient clinic is a specialized tertiary care center within the University Medical Center Hamburg-Eppendorf with approximately 1000 to 1200 annual registered patient contacts.

These contacts reflect all combined consultations by migraine patients, patients with other primary or secondary headaches as well as patients suffering from pri- mary and secondary facial pain syndromes.

Due to German data protection law, data from patients not willing to participate in this study was not saved and we are therefore not able to provide a complete overview over all patients who consulted us.

Since migraine comprises the largest group of patients, providing meaningful

data, we focused on migraine according to ICHD-3 criteria [527] in the following.

For all our parameters that we report we focused on the first contact with the patients to get a clear picture what type of patients consult a university outpatient specialist clinic.

Results Patients with no prior preventative treatment missed in the 3 months prior to their first consultation on average 5.1 ± 10.9 (SD) work or school days (MIDAS, Item 1), could not do household work on 8.2 ± 11.1 days (MIDAS, Item 3) and missed on an average of 7.3 ± 11.0 days family or leisure activities (MIDAS, Item 5) because of their migraine headaches.

Patients with no prior preventative treatment and more than 3 migraine attacks per month had consulted a genral practitioner in 87.9% (551/627) of the casesand a neurologist in 67.5% (423/627) of the cases.

Of 904 patients who used preventative medications prior to their consultation, 45.8% had one, 21.2% had two and 10.3% reported three unsuccessful treatment attempts.

These patients were highly affected by their migraine headaches and previous

preventative treatment had been unsuccessful or never tried.

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Governance

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Discussion Most patients improve clinically, when we treated pharmacologically according to guidelines, the low adherence to evidence-based treatment strategies has consider- able, and more importantly, avoidable personal as well as socio-economic consequences.

This study is not powered or designed to reflect the amount of patients who are treated properly by primary or secondary care specialists, however as mentioned the experience of many headache specialists and literature suggests that many migraine patients are treated poorly [261].

Half of the patients, presenting to a specialized tertiary care headache clinic, had

never been prescribed a preventative treatment.

The rates of the improved outcome in patients that had previously not been pre- scribed a preventative treatment should therefore be seen as an indication that adherence to guideline therapy possibly improves the outcome, as expected.

Acknowledgement A machine generated summary based on the work of Ziegeler, Christian; Brauns, Greta; Jürgens, Tim P.; May, Arne. 2019 in The Journal of Headache and Pain.

Prevalence and burden of headache disorders in Lithuania and their public- health and policy implications: a population-based study within the Eurolight project