Do racial/ethnic disparities exist in recommended migraine treatments in US ambulatory care?

Background Racial disparities in migraine have been reported in the US. Migraine in African Americans (AA) is more frequent, more severe, more likely to become chronic and associated with more depression and lower quality of life compared to non-Hispanic Whites (NHW). It is possible that racial differences in prescribing practices contribute to these differences, but little is known about the quality of migraine prescribing patterns in the US or whether racial differences exist. Objective To determine if racial differences in quality of migraine medical prescription care exist. Methods We used data from the National Ambulatory Medical Care Survey to estimate differences in the use of migraine prophylactic and abortive medications by race. Quality of migraine care was defined using the American Academy of Neurology Headache Quality Measure Set (AAN-HQMS). Patients were assigned to one of four categories representing the overall quality of evidence for their abortive and prophylactic medications using the AAN-HQMS. We hypothesized that there would be suboptimal migraine treatment in minority populations. Racial comparisons were made using descriptive statistics after applying NAMCS survey weights. Results Two thousand, eight hundred and sixty visits were included in the study, representing approximately 50 million migraine visits in the US from 2006-2013. In all, 41.3% of AA, 40.8% of NHW, and 41.2% of Hispanic (HI) patients received no prophylactic treatments ( p = 0.99). A total of 18.8% of AA patients, 11.9% of NHW patients, and 6.9% of HI patients received exclusively Level A prophylaxis ( p = 0.30). A total of 47.1% of AA patients, 38.2% of NHW patients, and 36.3% of HI patients received no abortive treatments ( p = 0.23). In total, 15.3% of AA patients, 19.4% of NHW patients, and 17.7% of HI patients received any Level A abortives (i.e. triptans or Dihydroergotamine; DHE, p = 0.64). A total of 15.2% of all patients had a prescription for opiates, but there were no racial differences. Conclusions Migraine may be undertreated with prophylactic medications. Level A acute analgesics may be underused and opiates overused. No major racial/ethnic differences in abortive or prophylactic treatment were identified.

Education and decision making at the time of triptan prescribing: patient expectations vs actual practice.

BACKGROUND: Optimizing patient satisfaction with their medical care and maximizing patient adherence with treatment plans requires an understanding of patient preferences regarding education and their role in decision making when treatments are prescribed. OBJECTIVE: To assess the congruence between patient expectations and actual practice regarding education and decision making at the time a triptan is prescribed. METHODS: This multicenter cross-sectional survey was performed by headache fellow members of the American Headache Society Headache Fellows Research Consortium at their respective tertiary care headache clinics. Migraine patients who were new patients to the headache clinic and who were current triptan users (use within prior 3 months and for ≥1 year) or past triptan users (no use within 6 months; prior use within 2 years) completed questionnaires that assessed the education they received and their role in decision making at the time a triptan was first prescribed as well as their desire for education and participation in decision making when a triptan is prescribed. RESULTS: Consistent with patient preference, most participants received the majority of their education about the triptan from the prescriber's office (70.2%). In descending rank order, participants most desired to be informed about how to decide if a triptan should be taken, when during the course of migraine a triptan should be taken, possible side effects, cost, and how to obtain refills. Regarding side effects, most participants preferred to receive education about the most common side effects of a triptan rather than addressing all possible side effects. Regarding triptan dosing, participants desired to be informed in descending order of importance about taking other medications with triptans, how many doses can be taken for each migraine, how many doses can be taken each week/month, what to do if the triptan does not work, and the triptan mechanism of action. The vast majority of participants (92%) preferred that the decision to prescribe a triptan be a joint decision between the patient and the provider. In actual practice, participants were not as involved in decision making as they would like to be, with patients reporting that the prescriber was the sole decision maker 55.1% of the time. Participants had confidence in their providers (87.7%) and generally felt they did a good job educating them about the triptan (71.1%). CONCLUSIONS: Based on this study, it is clear that patients prefer the shared model approach to medical decision making in regards to the prescription of triptans. The majority of patients received education that was generally consistent with their desires. Patients preferred that the prescribing provider be the primary source of information. The most desired educational topics included when/if a triptan should be taken, the number of times a triptan can be taken for a single migraine, co-administration with other acute medications, and the most common side effects. Focusing on these topics should enhance patient satisfaction and may improve compliance.