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Migraine in the 21st Century: Lessons from Epidemiologic Studies Marcelo E. Bigal, M.D.; Ph.D. Global Director for Scientific Affairs ─Neuroscience Merck.

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Presentation on theme: "Migraine in the 21st Century: Lessons from Epidemiologic Studies Marcelo E. Bigal, M.D.; Ph.D. Global Director for Scientific Affairs ─Neuroscience Merck."— Presentation transcript:

1 Migraine in the 21st Century: Lessons from Epidemiologic Studies Marcelo E. Bigal, M.D.; Ph.D. Global Director for Scientific Affairs ─Neuroscience Merck Research Laboratories Dept of Neurology, Albert Einstein College of Medicine

2 2 Overview  To review the epidemiology of migraine. Is migraine worth attention?  To review the burden of migraine on the individual, family and society. Is migraine worth recognition?  To estimate patterns of diagnosis and treatment for migraine, as well as barriers for care  To discuss the prognosis of migraine

3 3 Epidemiology Lesson 1 Migraine peaks with incidents in the teens and early twenties Accordingly, first migraine attacks often happen in childhood or puberty

4 4 Incidents per 1000 person-years Age at Onset Stewart et al: Am J Epidemiol 1991 Female Male Migraine, Incidence

5 5 Epidemiology Lesson 2 Migraine is Very Prevalent

6 Prevalence in adults worldwide: 1-year prevalence Population or community-based surveys of >500 participants covering ages y, using IHS or modified IHS criteria Africa4.0 (2 studies) Asia10.6 (6 studies) Australia Europe13.8 (9 studies) N. America12.6 (8 studies) S. America9.6 (10 studies) Tekle Haimanot Dent Sakai Takeshima Roh Alders Deleu Wang Lampl Zivadinov Rasmussen Bank Launer Hagen Dahlof Steiner Kryst Schwartz O’Brien Stewart Lipton Jaillard Morillo Wiehe Morillo Miranda Lavados 15.5 Lyngberg 14.7 Patel Mean: 11.2 Median: 10.2 Steiner TJ. Lifting the burden: The global campaign against headache. Lancet Neurol 2004;3(4):

7 7 Epidemiology Lesson 3  In the US migraine affects over 12% of the adults  Migraine is the most common neurological disease in men (6%)  Migraine is 3 times more common in women (18%) P  Prelavence peaks in adulthood, coinciding with the peak of work productivity

8 8 Migraine is very common in US. Results of 3 large studies conducted 15 years apart Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007;68(5):

9 9 Migraine is Most Common in Women and During Peak Productive Years Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache 2001;41(7):

10 10 Epidemiology Lesson 4 The Burden of Migraine is Severe and Complex

11 11 pain and suffering Burdens of One Person’s Migraine anxiety patienthood personal financial costs employer & work colleagues lifestyle compromise societal burden family burden co-morbidity

12 The burden of migraine is severe and affects:  Burden on Individual: –Health-related quality of life –Disability –Interictal burden of migraine  Burden on the family: –Migraine affects relationships Burden on society: –Costs The Several Burdens of Migraine

13 13 Burden on the Individual - Leading Causes of Years of Life Lost to Disability (YLDs) – WHO Report Steiner TJ. Lifting the burden: The global campaign against headache. Lancet Neurol 2004;3(4):

14 14 The Burden of Migraine is Not Restricted to the Attack – The Interictal Burden Symptom Burdens  During attacks –pain and suffering, leading to –reduced functional ability  Beyond the attack –fear of the next attack, leading to –avoidance behaviour and lifestyle compromise

15 15 The Family Impact of Migraine – Migraine Damages Relationships With Sufferer’s Partner 36% 20% From their partners’ perspective56%35% 29% USA and UK populations (245 migraine sufferers, 100 partners) From the sufferers’ perspective 56% Spend less time with partner 50% More likely to argue 47% Be a better partner without headaches 60% Less involved with partner at home % Sufferers affected % Less able to communicate 100 Lipton et al. Cephalalgia 2003;23:

16 16 The Economic Burden of Migraine - Migraine is Costly to Society Annual Cost in the US  $14.5 Billion Annually (1998) Hu H et al. Arch Intern Med. 1999;159: $7.9B $5.4B $1.2B 10% 30% 60% Emergency Room, Other Rx Office Visits Missed Work Direct Medical Cost Reduced Productivity

17 17 Epidemiology Lesson 5: There Are Several Barriers Preventing Good Outcomes in Migraine Treatment

18 18 Encourage Follow-Up Improve Treatment Improve Diagnosis Barriers to Successful Outcomes Lipton RB et al. Neurology Motivate Patients to Seek Care

19 19 Although Progresses Were Made, a Significant Proportion of Migraineurs are Unaware of Their Diagnosis AMS-IAMS-IIAMPPChange of 15 years Migraine Diagnosis38%48%56.20%47.9% Sinus Diagnosis43.10%42%39%-9.5% Tension Headache44%32.30%31%-29.5% "Sick" headaches13.10%7.80%7.50%-42.7% Cluster headache17.90%6.50%9.90%-44.7% Lipton RB, Bigal ME. Ten lessons on the epidemiology of migraine. Headache 2007;47 Suppl 1:S2-9.

20 20 Most People With Migraine Still Use OTC Medications 6 in 10 Sufferers Still Rely on OTCs Alone or No Medication to Manage Headache Pain Lipton RB et al. Headache. 2001;41:

21 21 Among Individuals Who Receive Therapy, Maintanaince is Low DeterminantRelevancePotential Modifiable Factors (hypotheses) Potential Actions Disease's DrivenThis determinant works as an "umbrella" factor. If the disease is seen as trivial, patients may be less motivated to use meds. Accordingly, understanding this component will drive all the other determinants. Neutralizing concepts such as: 1) Migraine is not lethal 2) Migraine is another annoying part of life that I have to deal with. 3) Migraine has nothing to do with the brain. 4) Migraine may be treated with OTCs and analgesics (see link with medication overuse project). Awareness campaigns focusing on: 1) Nobody should live with pain. 2) There are consequences of poor management (e.g migraine progression) 3) Migraine is a disorder of the brain 4a) There are medications that target the very biology of migraine 4b) Medication overuse is a consequence of migraine mismanagement. Medication's driven Understanding factors associated with satisfaction/dissatisfaction after using specific meds over the long haul increase maintenance of therapy strategies. Why are the determinants of low maintenance to therapy? 1)Adverse events? 2)Formulary restrictions? 3)Fear (perception of safety)? Based on findings, to build awareness campaigns accounting for the fear factor, limited formulary and limited knowledge of disease Physician's DrivenSome doctors are more efficient than others in engaging patients. Why? 1) Do they request follow up visits? 2) Do they explain more about the disease? 3) Are they less focused on rare side effects? 1 )Education activities that focus on health provider's actions that are associated with satisfaction and adherence. Patient's drivenWhat factors are associated with the decision making process about using meds? And being actively engaged with the plan? 1) Lack of disease-specific knowledge may be associated with poor adherence and MDs have little time to educate patients. 2) Comorbidities (anxiety, depression) may interfere in adherence. Unrealistic expectations may impact adherence Patient-centered education activities (tapes, web-based, short education activities) may increase adherence in a cost effective way.

22 22 Epidemiology Lesson 6: Comorbidities are Frequent in Migraine and Complicate Diagnosis and Treatment

23 23 Migraine is Comorbid With:  Neurologic disorders –Epilepsy –Ischemic stroke –Tourette’s  Psychiatric disorders –Depression –Bipolar disease –Anxiety/panic disorder  Other disorders –Raynaud’s –Snoring/sleep apnea –Asthma/allergy –Noncephalic pain –GI disorders –Arthritis –Low back pain

24 24 Comorbidities Increase With Increased Headache Frequency OR=2.1 (1.7 – 2.5)* % % % % * ORs and 95% confidence intervals adjusted for age, gender and SES (income) % % % % % % OR=1.8 (1.5 – 2.2)* OR=1.6 (1.1 – 2.4)* OR=1.7 (1.4 – 2.1)* OR=2.5 (2.1 – 3.02)*

25 25 Epidemiology Lesson 7 Although the Prognosis of Migraine is Variable, in a Subgroup Migraine Progresses Into Chronic Migraine

26 Migraine Remission Evolution to symptom free over prolonged period of time Persistence Relative clinical stability and no markers of progression Progression Clinical - Evolution to chronic migraine Functional - Changes in the PAG - Central sensitization Anatomical - Lesions in the brain - Lesions outside the brain Bigal ME, Lipton RB. The prognosis of migraine. Curr Opin Neurol 2008;21(3):

27 27 Evidence from Epidemiology Baseline1-year follow-up 798 Migraineurs Stable controls (2 to 104 headache days/year) Intermediate (105 to 179 headache days/year) New-onset CDH (180+ headache days/year) 23 (3%) 49 (6%) 726 (91%) Scher AI et al. Pain. 2003;16:81-89.

28 28 Risk Factors for Migraine Progression Bigal and Lipton, Headache 2006 Not modifiable by health interventions FemaleSex Low Socioeconomic Status Head Trauma Modifiable by health interventions Attack Frequency Obesity Medication Overuse Caffeine Overuse Stressful life events Snoring Other Allodynia Other pain syndromes Pro-Inflammatory Status Pro-Thrombotic Status

29 29 Probability of Chronic Migraine as a Function of Barbiturate Exposure Bigal ME, Serrano D, Buse D, Scher A, Stewart WF, Lipton RB. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8):

30 30 Probability of Chronic Migraine as a Function of Opioid Exposure Bigal ME, Serrano D, Buse D, Scher A, Stewart WF, Lipton RB. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8):

31 31 Summary  Migraine is a frequent and disabling chronic disease with recurrent attacks  Migraine is common in men and 3 times more common in women  The burden of migraine is higher in the years of peak productivity  The burden of migraine affects the individual, family and society

32 32 Summary  Despite improvements, several barriers to good migraine outcomes still exist  Several disorders are comorbid to migraine. They complicate diagnosis and treatment  In a subgroup, migraine progresses. Risk factors for progression have been identified and should be screened and treated.


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