Preventive treatment patterns in the adult migraine population: an observational UK study over 7 years.

BACKGROUND: Calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) are recommended by the United Kingdom National Institute of Health and Care Excellence for the prevention of migraine as treatment beyond third line. We report migraine prevalence and preventive treatment patterns in the adult United Kingdom primary care population over a 7.5-year period, focusing on patients ceasing ≥ 3 oral preventive medication classes. METHODS: Study populations were retrieved from the Clinical Practice Research Datalink GOLD database (study period: 19 September 2012 to 1 January 2020; inclusion criteria: ≥12 months follow-up, current-in-dataset, adult on 1 January 2020). Patients who used ≥ 1 oral preventive medication with ≥ 3-year follow-up after first prescription were considered preventive treatment users; class cessation was defined as cessation without evidence of restart within 6 months from end-of-supply date. RESULTS: On 1 January 2020, 3.0% of the total study population were diagnosed with migraine (n = 81,190/2,664,306); of these, 42.4% were preventive treatment users (n = 34,448/81,190). The most frequently used oral migraine preventive medication classes were beta-blockers (n = 14,713), tricyclic antidepressants (n = 14,415) and antiepileptics (n = 6497). Among preventive treatment users, 7.7% (n = 2653/34,448) ceased ≥ 3 oral preventive medication classes; of these, 21.7% (n = 576/2653) had been referred to a neurologist. CONCLUSIONS: Compared to existing population-based estimates of migraine prevalence, our data further corroborates that a considerable proportion of patients with migraine do not seek treatment. Among those who sought primary care within a 7.5-year period, almost half received empirical oral preventive treatment. Importantly, nearly 1 of 10 preventive treatment users ceased ≥ 3 oral preventive medication classes, highlighting a need for additional therapeutic options. These patients may benefit from CGRP antagonists and/or injectable onabotulinumtoxinA; however, only a minority was referred to specialist care, where these options would be more available. TRIAL REGISTRATION: Not applicable.

Health economic evaluation of a serum-based blood test for brain tumour diagnosis: exploration of two clinical scenarios.

OBJECTIVES: To determine the potential costs and health benefits of a serum-based spectroscopic triage tool for brain tumours, which could be developed to reduce diagnostic delays in the current clinical pathway. DESIGN: A model-based health pre-trial economic assessment. Decision tree models were constructed based on simplified diagnostic pathways. Models were populated with parameters identified from rapid reviews of the literature and clinical expert opinion. SETTING: Explored as a test in both primary and secondary care (neuroimaging) in the UK health service, as well as application to the USA. PARTICIPANTS: Calculations based on an initial cohort of 10 000 patients. In primary care, it is estimated that the volume of tests would approach 75 000 per annum. The volume of tests in secondary care is estimated at 53 000 per annum. MAIN OUTCOME MEASURES: The primary outcome measure was quality-adjusted life-years (QALY), which were employed to derive incremental cost-effectiveness ratios (ICER) in a cost-effectiveness analysis. RESULTS: Results indicate that using a blood-based spectroscopic test in both scenarios has the potential to be highly cost-effective in a health technology assessment agency decision-making process, as ICERs were well below standard threshold values of £20 000-£30 000 per QALY. This test may be cost-effective in both scenarios with test sensitivities and specificities as low as 80%; however, the price of the test would need to be lower (less than approximately £40). CONCLUSION: Use of this test as triage tool in primary care has the potential to be both more effective and cost saving for the health service. In secondary care, this test would also be deemed more effective than the current diagnostic pathway.

Prophylactic treatment of migraine by GPs: a qualitative study.

BACKGROUND: Despite the considerable impact of migraine, the use of preventive medication in primary care is limited. Only about 5% of migraine patients who qualify for prophylaxis actually receive it, and adherence is far from optimal. AIM: To explore the opinions of GPs regarding preventive medication for migraine. DESIGN AND SETTING: A qualitative focus group study in Dutch general practice. METHOD: Four focus groups (six GPs each) were formed. GPs were purposively sampled to acquire a range of participants, reflecting the more general GP population. RESULTS: GPs perceived patients' concerns about the impact of migraine and the potential benefits of prophylaxis. However, some were hesitant to start prescribing prophylaxis due to doubts about effectiveness, potential side effects, and the risk of developing drug dependency. GPs' decisions were often based on considerations other than those presented in national guidelines, for example, the patient's need to control their own problem. Many GPs placed responsibility for initiating prophylaxis with the patient. CONCLUSION: Various considerations hamper GPs from managing migraine with preventive medication, and various patient-related concerns cause GPs to deviate from national headache guidelines.

Prophylactic treatment of migraine; the patient's view, a qualitative study.

BACKGROUND: Prophylactic treatment is an important but under-utilised option for the management of migraine. Patients and physicians appear to have reservations about initiating this treatment option. This paper explores the opinions, motives and expectations of patients regarding prophylactic migraine therapy. METHODS: A qualitative focus group study in general practice in the Netherlands with twenty patients recruited from urban and rural general practices. Three focus group meetings were held with 6-7 migraine patients per group (2 female and 1 male group). All participants were migraine patients according to the IHS (International Headache Society); 9 had experience with prophylactic medication. The focus group meetings were analysed using a general thematic analysis. RESULTS: For patients several distinguished factors count when making a decision on prophylactic treatment. The decision of a patient on prophylactic medication is depending on experience and perspectives, grouped into five categories, namely the context of being active or passive in taking the initiative to start prophylaxis; assessing the advantages and disadvantages of prophylaxis; satisfaction with current migraine treatment; the relationship with the physician and the feeling to be heard; and previous steps taken to prevent migraine. CONCLUSION: In addition to the functional impact of migraine, the decision to start prophylaxis is based on a complex of considerations from the patient's perspective (e.g. perceived burden of migraine, expected benefits or disadvantages, interaction with relatives, colleagues and physician). Therefore, when advising migraine patients about prophylaxis, their opinions should be taken into account. Patients need to be open to advice and information and intervention have to be offered at an appropriate moment in the course of migraine.

Why do GPs with a special interest in headache investigate headache presentations with neuroradiology and what do they find?

The general practitioner with a special interest in headache offers an important contribution to the management of headache in primary care where the majority of presentations take place. A number of guidelines have been developed for neuroradiological investigation of headache, but their clinical utility and relevance is not known. Fourteen general practitioners with a special interest in headache recorded consecutive headache consultations over a 3-month period, whether patients were investigated with neuroradiology and if so the reason for investigation and outcome. Reason for investigation was compared to the guidelines published for the use in primary care. 895 patients were seen, of whom 270 (30.1%) were investigated. 47% of indications were outside the guidance framework used, the most common reason for investigation being reassurance. Of those investigated, 5.6% showed positive findings but only 1.9% of findings were felt to be of clinical significance. General practitioners with a special interest investigated with neuroradiology a greater level than general practitioners, but less than neurologists. However, yields of significant findings are broadly comparative across all groups. This report confirms other studies that suggest that even when there is a high level of clinical suspicion, yields of significant findings are very low.

Guidance for the management of headache in sport on behalf of The Royal College of General Practitioners and The British Association for the Study of Headache.

Headache is prevalent within the community and can have an impact on sport in both the amateur and elite player, either coincidentally or as a direct result of participation. Against a background of a limited evidence base, this paper suggests how headache can be classified within this context and offers guidance for treating both the amateur and elite athlete. The impact of headache in sport may be unrecognised and undertreated, and further research is needed in this area.

Working with lay people in health service research: a model of co-evolution based on complexity theory.

Involving lay researchers is an important part of Government policy in the United Kingdom within the context of the National Health Service. Here we draw upon insights from complexity theory to suggest a model that we call consensual qualitative research where lay researchers and professionals are co-producers of knowledge. The focus of attention is on understanding and facilitating the patterns that emerge from non-linear interaction at a local level. We describe some core principles that can facilitate the development of such a model and conclude that the resources in terms of time and effort that such an approach requires, should not be underestimated.

Impact of headache on young people in a school population.

BACKGROUND: Headache is the most frequent neurological symptom and the most common manifestation of pain in childhood. Estimates of the prevalence of headache in children and adolescents vary widely (depending on the setting, methodology, and diagnostic criteria applied) and the impact is not well understood. AIM: To quantify the impact of headache in a school population. DESIGN OF STUDY: A questionnaire survey. SETTING: Exeter schools. METHOD: A total of 1037 school children between the ages of 12 and 15 years were surveyed, of whom 49% were female. Main outcome measures were headache frequency, disease-specific impact using the Pediatric Migraine Disability Assessment Score (PedMIDAS), and generic quality of life impact using the Pediatric Quality of Life Inventory (PedsQL4). RESULTS: Twenty per cent of the study population had headache one or more times a week, with an average PedMIDAS score of over 12.1 (and an impact on over 12 days in a 3-month period). Ten per cent of the population had a PedMIDAS score of 16.8 and a PedsQL4 generic quality of life score of 70.1, indicating a poorer quality of life than that of children with asthma, diabetes, or cancer. An average of 0.6 days of school was lost in a 3-month period across all school children. CONCLUSION: There is a significant impact of headache on the quality of life of children. This impact is both unrecognised and unmet. GPs have an important role in identification and management of this problem.