by Thomas N. Ward, MD

The ObserVational survey of the Epidemiology, tReatment and Care Of MigrainE (OVERCOME) study is a web-based survey of current United States migraine healthcare including over 20,000 adult patients with both episodic (< 15 migraine days per month) and chronic (≥ 15 migraine days per month). The presentation assessed barriers to effective treatment and the process patients and providers must navigate to try to achieve effective treatment. The study included those with moderate or severe migraine-associated disability (n=5,873), patients who had sought care in the past year, received a diagnosis of migraine by a health care provider and were grouped by monthly headache days (4-7, 8-14 and ≥15). Measurements included migraine disability, cutaneous allodynia, symptom severity, quality of life related to migraine, treatment optimization and pain severity.

The pathway to treatment for headache patients includes seeking care, receiving a correct diagnosis and being offered appropriate treatment/taking it. Overall, 69% of respondents sought care, 80% were diagnosed but only 28.3% received a recommended treatment (based on the 2012 AAN/AHS guidelines and/or the 2018 AHS position statement on new migraine treatments). Of note, only 15.4% of respondents with ≥4 monthly headache days and moderate or severe headache-related disability completed the pathway.

Seeking care was found to be associated with older age males, having health insurance and having severe headache-related disability. Receiving a migraine diagnosis was associated with being female and having severe headache-related disability. The group of respondents only receiving their care at emergency departments, urgent care or retail clinics was associated with a lack of diagnosis and were often not receiving recommended preventive treatments.

Headache specialists have known of barriers to appropriate care for patients with migraine for years. Despite aggressive educational efforts many patients even now do not receive a correct diagnosis and now there is evidence that not only should acute treatment be optimized/individualized but preventive options vary depending on whether the patient has episodic or chronic migraine. Lack of health insurance and paradoxically having health insurance are both barriers to appropriate treatment. Evidence-based medicine shows that while there are many preventive treatment options for episodic migraine, for chronic migraine the best evidence is for topiramate, monoclonal CGRP antibodies and onabotulinumtoxinA.

Education and advocacy seem to be the most promising ways forward. Patient support groups hold great promise. For-profit health insurance companies would seem to have an inherent conflict of interest and create what I view as an unethical situation. When a provider prescribes an appropriate treatment but the patient cannot afford it due to a lack of insurance or the insurer refuses to cover an appropriate treatment, instead sometimes insisting on treatments less likely to be effective and not following evidence-based medicine, frustration for both the patient and health care provider often ensues, not to mention poor headache-related outcomes.

 

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References

1. Shapiro RE. What Will it Take to Move the Needle for Headache Disorders? An Advocacy Perspective. Headache: e-pub ahead of print. https://doi.org/10.1111/head.13913. First published August 19, 2020.
2. Loder EL, Burch R, Rizzoli P. The 0212 AHS/AAN Guidelines for Prevention of Episodic Migraine: A Summary and Comparison with other Recent Clinical Practice Guidelines. Headache 2012; 52(6): 930-945.
3. American Headache Society. The American Headache Society Position Statement on Integrating New Migraine Treatments Into Clinical Practice. Headache 2019; 59(1): 1-18.
4. Buse D, Kovacik AJ, Nicholson RA et al. Acute Treatment Optimization Influences Disability and Quality of Life in Migraine: Results of the ObserVational survey of the Epidemiology, tReatment and Care of MinrainE (OVERCOME) Study. Neurology 2020; 94 (15 Supplement)