Association between migraine and exclusive breastfeeding: A cross-sectional study.

BACKGROUND: Medical conditions may preclude a mother from exclusively breastfeeding her infant; however, the association between migraine and the duration of exclusive breastfeeding is not well known. OBJECTIVE: To evaluate the association between migraine and the duration of exclusive breastfeeding in a representative sample of Canadian females. METHODS: We used the Canadian Community Health Survey, a cross-sectional survey, to identify females aged 20-49 years who delivered a baby in the previous 5 years. History of migraine was self-reported. Females reported if they breastfed their baby, and among those who did, they further reported the duration of exclusive breastfeeding. We evaluated the association between migraine and the rate of breastfeeding, and the duration of exclusive breastfeeding adjusting for selected covariates. RESULTS: We included 5282 females, of whom 862 (16.3%) had migraine. Compared to females without migraine, females with migraine were less likely to have high income (annual income >$80,000: 362 [42.0] vs. 2276 [51.6]), and more likely to have comorbid mood (176 [20.5] vs. 378 [8.6%]) and anxiety (196 [22.8%] vs. 406 [9.2%]) disorders. Migraine was not associated with breastfeeding (proportion of females who did not breastfeed, migraine vs. no migraine: 114/862 [13.2%] vs. 498/4420 [11.3%]; adjusted odds ratio 1.03; 0.74-1.27); however, females with migraine had lower odds (≥6 months of exclusive breastfeeding: 216/688 [31.4%] vs. 1325/3561 [37.2%]; adjusted odds ratio from ordinal shift analyses 0.84; 0.71-0.99) of longer duration of exclusive breastfeeding than females without migraine. CONCLUSION: Females with migraine exclusively breastfeed their infants for a shorter duration compared to females without migraine, suggesting the need to better support this population through education on the safety and benefits of exclusive breastfeeding and better access to safe and effective treatment of migraine in lactating females.

Understanding the gaps in headache and migraine treatment with psychological and behavioral interventions: A narrative review.

OBJECTIVE: In this narrative review, we summarize relevant literature pertaining to psychosocial risk factors for headache and migraine progression, current behavioral and psychological treatments, and consider promising treatments. BACKGROUND: Headache and migraine are common and associated with significant burden and disability. Current treatments targeting psychosocial risk factors show modest outcomes and do not directly address the impact of early life adversity, including the development of maladaptive emotional processing. An intervention that could address these factors and include components of current evidence-based interventions may lead to improved outcomes. METHODS: We searched PubMed and Google Scholar for articles through December 2022. Search terms included headache, migraine, psychological interventions, behavioral interventions, cognitive-behavioral therapy, mindfulness, psychiatric comorbidities, adverse childhood experiences, trauma, and emotional processing. RESULTS: Trauma and childhood adversity show a correlation with headache and migraine progression. Developmental adversity and trauma interfere with adaptive emotional processing, which may worsen headache and migraine symptoms, while adaptive ways of experiencing emotions are shown to improve symptoms. Current behavioral and psychological interventions, such as cognitive-behavioral and mindfulness therapies, are effective treatments for headache, but they produce small to medium effect sizes and do not directly address the impact of trauma and emotional conflicts-common factors that contribute to chronicity and disability, especially among certain subpopulations of headache patients such as those with migraine. Thus, there exists a gap in current treatment. CONCLUSION: There is a gap in headache and migraine treatment for those patients who have a history of trauma, childhood adversity, and maladaptive emotional processing. We suggest that an integrated psychological treatment that includes components of current evidence-based interventions and addresses gaps by focusing on processing trauma-related emotions may improve chronic and debilitating symptoms.

Migraine and air pollution: A systematic review.

OBJECTIVE: To systematically synthesize evidence from a broad range of studies on the association between air pollution and migraine. BACKGROUND: Air pollution is a ubiquitous exposure that may trigger migraine attacks. There has been no systematic review of this possible association. METHODS: We searched for empirical studies assessing outdoor air pollution and any quantified migraine outcomes. We included short- and long-term studies with quantified air pollution exposures. We excluded studies of indoor air pollution, perfume, or tobacco smoke. We assessed the risk of bias with the World Health Organization's bias assessment instrument for air quality guidelines. RESULTS: The final review included 12 studies with over 4,000,000 participants. Designs included case-crossover, case-control, time series, and non-randomized pre-post intervention. Outcomes included migraine-related diagnoses, diary records, medical visits, and prescriptions. Rather than pooling the wide variety of exposures and outcomes into a meta-analysis, we tabulated the results. Point estimates above 1.00 reflected associations of increased risk. In single-pollutant models, the percent of point estimates above 1.00 were carbon monoxide 5/5 (100%), nitrogen dioxide 10/13 (78%), ozone 7/8 (88%), PM2.5 13/15 (87%), PM10 2/2 (100%), black carbon 0/1 (0%), methane 4/6 (75%), sulfur dioxide 3/5 (60%), industrial toxic waste 1/1 (100%), and proximity to oil and gas wells 6/13 (46%). In two-pollutant models, 16/17 (94%) of associations with nitrogen dioxide were above 1.00; however, more than 75% of the confidence intervals included the null value. Most studies had low to moderate risks of bias. Where differences were observed, stronger quality articles generally reported weaker associations. CONCLUSIONS: Balancing the generally strong methodologies with the small number of studies, point estimates were mainly above 1.00 for associations of carbon monoxide, nitrogen dioxide, ozone, and particulate matter with migraine. These results were most consistent for nitrogen dioxide.

Headache Education in Canadian Medical Schools.

This study aims to gain a better understanding of the current scope of headache education received in Canadian medical schools. The Women's College Hospital Centre for Headache at the University of Toronto, Canada, distributed a questionnaire to administrators and physicians involved in medical student education at Canadian medical schools and gathered information surrounding headache education. Overall, the degree of headache education varied between schools in regard to the hours of training that occurred and year the training took place. This survey provides an initial insight into the current standards of headache-specific education in Canadian medical schools.

Trainee Headache Education and Management Enhancement (THEME) Study.

We investigated the association between clinical rotation at a specialized headache center and headache knowledge of resident trainees. Using standardized pre- and post-questionnaires, change in self-reported knowledge of headache disorders and management in 31 participants undertaking clinical rotations were evaluated. There was a statistically significant improvement in self-reported measures of headache disorder knowledge post-rotation [mean score (SD), 3.19(0.543), p < 0.001] and significant improvement in overall knowledge measured using case-based questionnaires pre- vs. post-rotation [7.1(1.4) vs. 7.9(1.5), p = 0.003]. Rotation at a specialized headache center improved trainees' self-reported knowledge and test-based scores, suggesting that such rotation should be included in postgraduate curriculum.

Adverse Childhood Experiences and Medication Overuse Headache: Burden and Treatment Impact.

Adverse childhood experiences (ACEs) are a risk factor for progression from episodic to chronic migraine. Risk factors for medication overuse headache (MOH) are incompletely understood, but opioid overuse may carry a higher risk than overuse of other medication types. We performed a retrospective chart review investigating the frequency and impact of ACEs in patients with MOH. Of 68 included patients, 37 (54.4%) reported ACEs. There was no significant inter-group difference in baseline migraine disability assessment (MIDAS) or monthly headache days. Patients with ACEs reported more opioid overuse, and worse headache-related disability at follow-up, despite similar monthly headache days. Patients with ACEs require complex, multidisciplinary treatment.

Preventive Treatment of Migraine.

Migraine significantly impacts individuals from all walks of life and from all around the globe. Chronic or high-frequency episodic migraine has similar disability and burden on the healthcare system and can be challenging to manage. The focus of this article is to provide an outline of the available pharmacological and nonpharmacological evidence-based strategies that clinicians can employ to build a "toolbox" for their patients.

Patient experience of telemedicine for headache care during the COVID-19 pandemic: An American Migraine Foundation survey study.

OBJECTIVE: We sought to investigate the patient experience of telemedicine for headache care during the coronavirus disease 2019 (COVID-19) pandemic. BACKGROUND: The use of telemedicine has rapidly expanded and evolved since the beginning of the COVID-19 pandemic. Telemedicine eliminates the physical and geographic barriers to health care, preserves personal protective equipment, and prevents the spread of COVID-19 by allowing encounters to happen in a socially distanced way. However, few studies have assessed the patient perspective of telemedicine for headache care. METHODS: The American Migraine Foundation (AMF) designed a standardized electronic questionnaire to assess the patient experience of telemedicine for headache care between March and September 2020 to help inform future quality improvement as part of its patient advocacy initiative. The date parameters were identified as the emergence of severe acute respiratory syndrome coronavirus 2 disease and the declaration of a national emergency in the United States. The questionnaire was distributed electronically to more than 100,000 members of the AMF community through social media platforms and the AMF email database. RESULTS: A total of 1172 patients responded to our electronic questionnaire, with 1098 complete responses. The majority, 1081/1153 (93.8%) patients, had a previous headache diagnosis prior to the telemedicine encounter. A total of 648/1127 (57.5%) patients reported that they had used telemedicine for headache care during the study period. Among those who participated in telehealth visits, 553/647 (85.5%) patients used it for follow-up visits; 94/647 (14.5%) patients used it for new patient visits. During the telemedicine encounters, 282/645 (43.7%) patients were evaluated by headache specialists, 222/645 (34.4%) patients by general neurologists, 198/645 (30.7%) patients by primary care providers, 73/645 (11.3%) patients by headache nurse practitioners, and 21/645 (3.2%) patients by headache nurses. Only 47/633 (7.4%) patients received a new headache diagnosis from telemedicine evaluation, whereas the other 586/633 (92.6%) patients did not have a change in their diagnoses. During these visits, a new treatment was prescribed for 358/636 (52.3%) patients, whereas 278/636 (43.7%) patients did not have changes made to their treatment plan. The number (%) of patients who rated the telemedicine headache care experience as "very good," "good," "fair," "poor," and "other" were 396/638 (62.1%), 132/638 (20.7%), 67/638 (10.5%), 23/638 (3.6%), and 20/638 (3.1%), respectively. Detailed reasons for "other" are listed in the manuscript. Most patients, 573/638 (89.8%), indicated that they would prefer to continue to use telemedicine for their headache care, 45/638 (7.1%) patients would not, and 20/638 (3.1%) patients were unsure. CONCLUSIONS: Our study evaluating the patient perspective demonstrated that telemedicine facilitated headache care for many patients during the COVID-19 pandemic, resulting in high patient satisfaction rates, and a desire to continue to use telemedicine for future headache care among those who completed the online survey.

Risk for ischemic stroke and coronary heart disease associated with migraine and migraine medication among older adults.

BACKGROUND: Migraine has been associated with cardiovascular disease (CVD) events among middle-aged adults. The objective of this study was to determine the risk for ischemic stroke and coronary heart disease (CHD) events among older adults with versus without migraine. METHODS: This retrospective cohort study was conducted using data from US adults ≥66 years of age with Medicare health insurance between 2008 and 2017. After stratification by history of CVD, patients with a history of migraine were matched 1:4 to those without a history of migraine, based on calendar year, age, and sex. Patients were followed through December 31, 2017 for ischemic stroke and CHD events including myocardial infarction or coronary revascularization. All analyses were done separately for patients with and without a history of CVD. RESULTS: Among patients without a history of CVD (n = 109,950 including n = 21,990 with migraine and n = 87,960 without migraine), 1789 had an ischemic stroke and 3552 had a CHD event. The adjusted hazard ratio (HR) among patients with versus without migraine was 1.20 (95% confidence interval [95%CI], 1.07-1.35) for ischemic stroke and 1.02 (95%CI, 0.93-1.11) for CHD events. Compared to patients without migraine, those with migraine who were taking an opioid medication had a higher risk for ischemic stroke (adjusted HR 1.43 [95%CI, 1.20-1.69]), while those taking a triptan had a lower risk for CHD events (adjusted HR 0.79 [95%CI, 0.67-0.93]). Among patients with a history of CVD (n = 79,515 including n = 15,903 with migraine and n = 63,612 without migraine), 2960 had an ischemic stroke and 7981 had a CHD event. The adjusted HRs (95%CI) for ischemic stroke and CHD events associated with migraine were 1.27 (1.17-1.39) and 0.99 (0.93-1.05), respectively. Patients with migraine taking an opioid medication had a higher risk for ischemic stroke (adjusted HR 1.21 [95%CI, 1.07-1.36]), while those taking a triptan had a lower risk for CHD events (adjusted HR 0.83 [95%CI, 0.72-0.95]), each versus those without migraine. CONCLUSIONS: Older adults with migraine are at increased risk for ischemic stroke. The risk for ischemic stroke among older adults with migraine may differ by migraine medication classes.

Post-Traumatic Headache in Children and Adolescents: a Narrative Review with a Focus on Management.

PURPOSE OF REVIEW: Although common, post-traumatic headache (PTH) in the pediatric population is a niche group with a paucity of published evidence on the diagnosis, most appropriate acute and preventative management, and prognosis. This article aims to review pediatric PTH, its epidemiology and pathophysiology with a focus on management and future directions. RECENT FINDINGS: Using MEDLINE, EMBASE, 52 articles on PTH in children and adolescents from 2016 to 2020 were identified. Over the last 4 years, our understanding of traumatic brain injury pathophysiology has grown, expanding the potential for more therapeutic targets. Despite this achievement, and recently published consensus guidelines, the review demonstrated a lack of published controlled trials to help guide management of pediatric PTH. The last 4 years have provided new insights into the potential pathophysiological mechanisms through laboratory research and advanced MR imaging; however, there continues to be a translational gap to clinical practice.

Management of Menstrual Migraine.

PURPOSE OF REVIEW: Migraine disease is a neurological brain disorder that has been associated with significant disability and socioeconomic burden affecting women three times more commonly than men. Menstrual migraine is a subclass of migraine disease affecting 42-61% of females living with migraine disease. Menstrual migraine is often far more disabling, of longer duration, and more resistant to treatment. It is crucial to gain a deeper understanding of the ongoing biological changes and have a current awareness of the management of this debilitating form of migraine disease to improve the quality of life of these females living with migraine disease. RECENT FINDINGS: In new treatment options such as devices and with large-scale genome-wide association studies in migraine, genes related to migraine are being identified. This article will review the current literature regarding the pathophysiology, epidemiology, and treatment of menstrual migraine.

Physicians' knowledge and practices regarding screening adult patients for adverse childhood experiences: a survey.

BACKGROUND: Adverse Childhood Experiences (ACEs) are common and associated with many illnesses. Most physicians do not routinely screen for ACEs. We aimed to determine if screening is related to knowledge or medical specialty, and to assess perceived barriers. METHODS: Physicians in Ontario, Canada completed an online survey in 2018-2019. Data were analyzed in 2019. RESULTS: Participants were 89 family physicians, 46 psychiatrists and 48 other specialists. Participants screened for ACEs "never or not usually" (N = 58, 31.7%), "when indicated" (N = 67, 36.6%), "routinely" (N = 50, 27.3%) or "other" (N = 5, 2.7%). Screening was strongly associated with specialty (Chi2 = 181.0, p < .001). The modal responses were: family physicians - "when indicated" (66.3%), psychiatrists - "routinely" (91.3%), and other specialists - "never or not usually" (77.1%). Screening was not related to knowledge of prevalence of ACEs, or of the link between ACEs and mental health, but was significantly associated with knowing that ACEs are associated with physical health. Knowing that ACEs are linked to stroke, ischemic heart disease, COPD, and diabetes predicted greater screening (Chi2 15.0-17.7, each p ≤ .001). The most prevalent perceived barriers to screening were lack of mental health resources (59.0%), lack of time (59.0%), concern about causing distress (49.7%) and lack of confidence (43.7%). CONCLUSIONS: Enhancing knowledge about ACEs' negative influence on physical illness may increase screening. Efforts to promote screening should address concerns that screening is time-consuming and will increase referrals to mental health resources. Education should focus on increasing confidence with screening and with managing patient distress.

The Traffic Light of Headache: Simplifying Acute Migraine Management for Physicians and Patients Using the Canadian Headache Society Guidelines.

Migraine is a disabling neurological condition and it is well described that early treatment is more effective and less likely to lead to headache recurrence. While it would seem intuitive for a migraine sufferer to treat early, despite well-established guidelines by the Canadian Headache Society, many sufferers continue to treat late. As a result, acute therapy is less effective, resulting in higher associated disability and a longer lasting attack. Pain scales can help patients determine how to treat; however, we propose a simple, easily recalled traffic light system to help patients determine which drug to use based upon how they feel. The traffic light system is based on the associated disability of the migraine attack, with green being a "I can still go" headache, a yellow being a "I have to slow down" headache, and a red being a "I have to stop" headache. The traffic light system leads to earlier more effective treatment with a reduction in migraine-associated disability.

The Impact of Shift Work on Migraine: A Case Series and Narrative Review.

OBJECTIVE: We present a case report of 2 migraine patients engaged in shift work, followed by a narrative review, to assess whether shift work influences headache-related disability and chronification of migraine. BACKGROUND: Numerous modifiable factors can lead to chronification of migraine and to higher headache-related disability. These include, among others, obesity, depression, overuse of acute medications, ineffective acute treatments, and stressful life events. Sleep disruptions and disorders are also felt to increase the risk of transitioning from episodic to chronic migraine. We hypothesize that shift work, which by definition leads to atypical or irregular sleep cycles, along with poor quality sleep, is a risk factor for chronification of migraine. METHODS: We present the case histories of 2 shift workers with migraine as per International Classification of Headache Disorders 3 criteria, seen at a large, busy academic headache center, followed by a narrative review of the literature. RESULTS: Previous literature regarding the relationship between shift work and migraine is sparse and conflicting, with more recent studies suggesting that shift work may be a risk factor for migraine-related disability. In our case series, both patients initially reported severe migraine headache-related disability and both patients had noted a worsening of their headaches after beginning night shift work. Both improved when switched back to day shifts, then worsened upon being put back on night shifts. Their headache patterns finally reverted from chronic to episodic migraine after eliminating night shifts completely and maintaining a good sleep routine. CONCLUSIONS: In the 2 cases presented, shift work appeared to be associated with chronification of migraine and higher headache-related disability despite optimal headache management and good patient adherence. A switch to only day shifts promoted transition to an episodic, less disabling pattern of migraine. It is clinically important to take a detailed sleep history in headache patients, and when appropriate, provide support for workplace accommodations. Further larger-scale, rigorous studies are needed to more clearly delineate the relationship between shift work and migraine.

Secondary Headaches During Pregnancy: When to Worry.

PURPOSE OF REVIEW: Headaches in pregnancy are a frequent cause of worry for both patients and healthcare providers. Physiological changes during this period increase the risk of a number of secondary headache disorders, and often also have an impact on primary headache disorders. This article reviews recent research into distinguishing worrisome vs non-worrisome headache presentations during pregnancy. RECENT FINDINGS: Recent research suggests that secondary causes of headache are highly prevalent during pregnancy, in between 25 and 42.4% of women seeking medical attention. Secondary causes of headache in pregnancy are most commonly homeostatic disturbances and hypertensive disorders of pregnancy, vascular problems, space-occupying lesions, and infections. Migraine itself also increases the risk of hypertensive disorders of pregnancy. Specific red flags for a secondary cause of headache in pregnancy include absence of any headache history, more severe pain, systemic features such as elevated blood pressure, and abnormal laboratory tests including thrombocytopenia or thrombocytosis, elevated liver function tests, elevated C-reactive protein, or proteinuria, in addition to traditional red flags, such as a change in headache pattern. Secondary causes of headache are common in women seeking medical attention during pregnancy. Red flags for secondary causes of headache during pregnancy may be remembered with the mnemonic PREGNANT HA (proteinuria, rapid onset, elevated blood pressure or temperature, gestational age in third trimester, neurological signs or symptoms, altered level of consciousness, no headache history or known history of a secondary headache disorder, thrombocytopenia or thrombocytosis, high liver function tests or CRP, or agonizingly severe pain). Increased education of patients and their providers may help improve selection of patients for workup of a secondary cause.

Headache Education Active-Waiting Directive: A Program to Enhance Well-Being During Long Referral Wait Times.

OBJECTIVE: The aim of this initiative was to evaluate the clinical impact, patient acceptability, and sustainability of implementing a newly developed evidence-guided migraine education program in an academic headache center. BACKGROUND: Headache is the fifth most common reason for emergency department (ED) visits and accounts for more than 10 million physician visits annually. Successful management of headaches presents a challenge to both primary care providers and neurologists. The catchment area for an academic headache specialty center in a large metropolitan area is over 6 million with an average wait time of over 15 months. This delays diagnosis and impacts patients, thus a Headache Education Active-Waiting Directive (HEAD) was developed to improve patient knowledge and self-care skills among migraine patients awaiting an initial appointment. METHODS: This was a prospective pre- and post-intervention study. English-speaking adults, aged 18-65 years, referred to the Center for Headache at the University of Toronto for headache consultation between May and December 2012, who had not previously been assessed by a headache specialist, were consented and enrolled. Data on Migraine Disability Assessment (MIDAS) with additional questions on emergency visits, lifestyle, and self-efficacy were collected premigraine and postmigraine education program session. RESULTS: Two hundred and forty-eight patients attended the HEAD program and 177 (71%) consented to the study. Detailed predata and postdata were available for 152 participants (mean age 42.5 ± 11.9 years, 86% females); 117/150 (78%) presented with depressive symptoms and 90/146 (62%) presented with anxiety symptoms. One hundred and thirty-seven of 143 (96%) were using headache treatment. Eighty of 137 (58%) were overusing over-the-counter medications and only 21/137 (15%) were on preventative treatment. There was a decrease in the MIDAS scores of participants at postsession testing prior to neurological consultation (pre-MIDAS mean 50.0 ± 64.6 vs post-MIDAS mean 43.2 ± 50.8, P = .046), as well as a decrease in the number of patients requiring ED visit (presession 33 [22%] vs postsession 17 [11%], P = .001). A significant decrease in medication and narcotic overuse after the HEAD program was also observed. Hydration (water intake), morning protein intake, and routine sleep frequency also significantly improved postsession. Controlling for pre-MIDAS score, poor outcome defined as higher post-MIDAS score was statistically associated with lower education level [F(2,149) = 10.88, P = .001]. The majority (144/167, 86%) of the participants found the HEAD program helpful, with 70/167 (42%) very satisfied and 74/167 (44%) somewhat satisfied. One hundred and thirty-two of 167 (79%) felt empowered after attending the education session, and 152/167 (91%) felt that other patients with headache would benefit from this program. CONCLUSIONS: The HEAD program, created to help manage lengthy appointment wait times, was associated with lowering migraine-associated disability, decreasing ED visits, reducing medication and narcotic use and overuse. Education empowers patients to take an active role in their care, especially in regards to improving treatment timing and modifiable lifestyle behaviors. This education program can potentially play a role in early intervention for headache patients especially with chronic migraine and medication overuse headache.

Women and Migraine: the Role of Hormones.

PURPOSE OF REVIEW: Migraine is a debilitating disease, that is encountered in countless medical offices every day and since it is highly prevalent in women, it is imperative to have a clear understanding of how to manage migraine. There is a growing body of evidence regarding the patterns we see in women throughout their life cycle and how we approach migraine diagnosis and treatment at those times. RECENT FINDINGS: New guidelines regarding safety of medication during pregnancy and lactation are being utilized to help guide management decisions in female migraineurs. There is also new data surrounding the risk of stroke in individuals who suffer from migraine with aura. This article seeks to provide an overview of a woman's migraine throughout her lifetime, the impact of hormones and an approach to management.

Unique CT Perfusion Imaging in a Case of HaNDL: New Insight into HaNDL Pathophysiology and Vasomotor Principles of Cortical Spreading Depression.

BACKGROUND: The etiology of HaNDL is not known. Recent neuroimaging studies have suggested that there may be altered cerebrovascular blood flow during acute episodes. However, what exactly these vascular changes represent and how they may relate to the overall pathogenesis of HaNDL is uncertain. CASE: A 42-year-old, right-handed male, presented with acute aphasia and right arm weakness. Urgent CT/CT-angiogram were normal except for an incidental hypoplastic right anterior cerebral artery (ACA) A1 segment. However, CT perfusion revealed global left hemisphere hypoperfusion in the range of oligemia. Also, the right ACA territory, supplied by the dominant left A1, shared the same pattern of hypoperfusion. Further investigations and clinical course were consistent with HaNDL. DISCUSSION/CONCLUSIONS: The pattern of global left hemispheric hypoperfusion seen in this case of HaNDL supports a hypothesis of secondary oligemia induced by a hemispheric wave of cortical spreading depression (CSD). However, the extension of hypoperfusion to the right ACA territory represents a phenomenon not previously reported in this field. We speculate that the direct spread of CSD-induced vasomotor changes across the anomalous vasculature could account for this finding. This case provides a valuable contribution toward understanding HaNDL pathophysiology and in doing so may also yield broader implications regarding neurophysiological principles of CSD.

Public Drug Coverage and Its Impact on Triptan Use Across Canada: A Population-Based Study.

BACKGROUND: Public drug coverage for triptan medications varies across jurisdictions in Canada, which may lead to differences in usage patterns and patient risk for medication overuse headache. METHODS: We conducted a population-based, cross-sectional analysis of publicly funded triptan use in seven provinces across Canada from January 1, 2012 to December 31, 2012. All patients who had filled at least one prescription for a triptan during the study period were included. We defined quantity limits of 6, 12, and 18 triptan units per month to assess the prevalence of high volumes of triptan use, which may place patients at risk for medication overuse headaches, and compared this prevalence between provinces with different funding restrictions. RESULTS: We identified 14,085 publicly funded users of triptans in 2012 in the seven provinces studied, 82.5% of whom were aged less than 65 years (N = 11,631). The prevalence of triptan use ranged substantially by province, from 0.04% in Ontario to a maximum of 1.0% in Manitoba (P < .001). Furthermore, the percentage of patients in each province using more than 6, 12, or 18 units per month differed significantly between provinces (P < .001). In particular, the percentage of patients treated with more than 6 units per month ranged from as low as 2.1% in Saskatchewan to 43.8% in Ontario. CONCLUSIONS: Differing public drug reimbursement criteria for triptans may be one contributing factor that has led to our observation of considerable variation in both prevalence of triptan prescribing and potential overuse of these medications. We offer that monthly quantity limits may be considered as a tool to decrease risks for medication overuse headache.