Recomendaciones de consenso para el tratamiento de la prevención de la migraña / Consensus recommendations for the treatment of migraine prevention

Objetivo los objetivos son conocer la opinión de neurólogos y farmacéuticos hospitalarios sobre aquellos aspectos aún en el debate respecto al papel de los anticuerpos monoclonales anti-CGRP en el tratamiento preventivo de la migraña. Identificar aquellas controversias aún existentes. Proponer recomendaciones consensuadas de mejora asistencial. Y promover el acceso de los clínicos y los pacientes a estos nuevos tratamientos en la prevención de la migraña con fármacos biológicos, a fin de mejorar la atención y seguimiento del paciente. Métodos se identificaron y valoraron recomendaciones para la utilización de fármacos biológicos en la prevención de la migraña a través de la metodología de consenso Delphi, proponiendo 88 aseveraciones agrupadas en 3 temas: un módulo de clínica que trata sobre el manejo de los tratamientos biológicos en la migraña, un módulo de pacientes que trata sobre las estrategias de educación al paciente y mejora de la adhesión y un módulo de coordinación que incluye las aseveraciones relacionadas con las estrategias para mejorar el trabajo conjunto entre los 2 colectivos. Se empleó la escala ordinal de Likert de 9 puntos para puntuar dichas recomendaciones y, posteriormente, los datos se analizaron estadísticamente a través de diferentes métricas. Resultados tras las 2 rondas de consulta, se alcanzó consenso en el acuerdo en 71 aseveraciones (80,7%) y consenso en el desacuerdo en una de ellas (1,1%), quedando como indeterminadas 16 aseveraciones (18,2%) de las 88 debatidas. Conclusiones el alto grado de consenso indica que la opinión de neurólogos y farmacéuticos hospitalarios sobre el papel de los anticuerpos monoclonales anti-CGRP en el tratamiento de la migraña es muy similar y permite identificar aquellas controversias aún existentes, para mejorar la atención y seguimiento del paciente con migraña. (AU)

Objective The objectives are to know the opinion of neurologists and hospital pharmacists on those aspects still under debate regarding the role of anti-CGRP monoclonal antibodies in the preventive treatment of migraine. To identify those controversies that still exist. To propose agreed recommendations for improvement of care. And to promote access of clinicians and patients to these new treatments in the prevention of migraine with biological drugs, in order to improve patient care and follow-up. Methodology Recommendations for the use of biological drugs in the prevention of migraine were identified and evaluated through the Delphi consensus methodology, proposing 88 statements grouped into three themes: a clinical module that deals with the management of biological treatments in migraine; a patient module that discusses patient education and adherence improvement strategies; and a coordination module that includes statements related to strategies to improve joint work between the two groups. The 9-point Likert ordinal scale was used to score these recommendations and, subsequently, the data was statistically analyzed through different metrics. Results After both rounds of voting, consensus was reached in agreement on 71 of the 88 statements (80.7%), leaving one statement (1.1%) with consensus in disagreement and 16 remaining as indeterminate (18.2%). Conclusions The high degree of consensus indicates that the opinion of neurologists and hospital pharmacists on the role of anti-CGRP monoclonal antibodies in the treatment of migraine is very similar and allows identifying those controversies that still exist, to improve the care and follow-up of patients with migraine. (AU)

[Translated article] Consensus recommendations on the preventive treatment of migraine.

OBJECTIVE: The objectives are to know the opinion of neurologists and hospital pharmacists on those aspects still under debate regarding the role of anti-Calcitonin Gene-related Peptide monoclonal antibodies in the preventive treatment of migraine. To identify those controversies that still exist. To propose agreed recommendations for improvement of care. And to promote access of clinicians and patients to these new treatments in the prevention of migraine with biological drugs, in order to improve patient care and follow-up. METHODOLOGY: Recommendations for the use of biological drugs in the prevention of migraine were identified and evaluated through the Delphi consensus methodology, proposing 88 statements grouped into 3 themes: a clinical module that deals with the management of biological treatments in migraine; a patient module that discusses patient education and adherence improvement strategies; and a coordination module that includes statements related to strategies to improve joint work between the two groups. The 9-point Likert ordinal scale was used to score these recommendations and, subsequently, the data was statistically analysed through different metrics. RESULTS: After both rounds of voting, consensus was reached in agreement on 71 of the 88 statements (80.7%), leaving 1 statement (1.1%) with consensus in disagreement and 16 remaining as indeterminate (18.2%). CONCLUSIONS: The high degree of consensus indicates that the opinion of neurologists and hospital pharmacists on the role of anti-Calcitonin Gene-related Peptide monoclonal antibodies in the preventive treatment of migraine is very similar and allows identifying those controversies that still exist, to improve the care and follow-up of patients with migraine.

Consensus recommendations for the treatment of migraine prevention. / Recomendaciones de consenso para el tratamiento de la prevención de la migraña.

OBJECTIVE: The objectives are to know the opinion of neurologists and hospital pharmacists on those aspects still under debate regarding the role of anti-CGRP monoclonal antibodies in the preventive treatment of migraine. To identify those controversies that still exist. To propose agreed recommendations for improvement of care. And to promote access of clinicians and patients to these new treatments in the prevention of migraine with biological drugs, in order to improve patient care and follow-up. METHODOLOGY: Recommendations for the use of biological drugs in the prevention of migraine were identified and evaluated through the Delphi consensus methodology, proposing 88 statements grouped into three themes: a clinical module that deals with the management of biological treatments in migraine; a patient module that discusses patient education and adherence improvement strategies; and a coordination module that includes statements related to strategies to improve joint work between the two groups. The 9-point Likert ordinal scale was used to score these recommendations and, subsequently, the data was statistically analyzed through different metrics. RESULTS: After both rounds of voting, consensus was reached in agreement on 71 of the 88 statements (80.7%), leaving one statement (1.1%) with consensus in disagreement and 16 remaining as indeterminate (18.2%). CONCLUSIONS: The high degree of consensus indicates that the opinion of neurologists and hospital pharmacists on the role of anti-CGRP monoclonal antibodies in the treatment of migraine is very similar and allows identifying those controversies that still exist, to improve the care and follow-up of patients with migraine.

¿Va a cambiar la neurología tras la pandemia de Covid-19 en los próximos cinco años?. Estudio de enfoque mediante informadores clave / Will neurological care change over the next 5 years due to the COVID-19 pandemic?

INTRODUCCIÓN: La pandemia de Covid-19 va a conllevar cambios en la asistencia neurológica, que no se pueden prever fácilmente a largo plazo. MATERIAL Y MÉTODOS: A través de un modelo de informadores clave, se busca el consenso siendo los encuestados, jefes de servicio de Neurología con conocimiento amplio de la situación al haber actuado durante la pandemia, de cómo va a ser la especialidad en un plazo de cinco años. RESULTADOS: Aunque se obtiene un grado de acuerdo bajo entre encuestados, si se describen acuerdos por consenso a nivel mayor (85%) y menor (70%). Los principales acuerdos se refieren al incremento de precauciones, al uso de la telemedicina, al mantenimiento de las consultas telefónicas, a la reducción de asistencia a las consultas evitando que hayan salas de espera con un número alto de personas, al desarrollo de técnicas docentes no presenciales y a la adaptación en el desarrollo de ensayos clínicos en relación a la visita de los monitores. Sin embargo, no se acuerda que haya cambios en la indicación de exploraciones complementarias, ni en la propia exploración neurológica. CONCLUSIÓN: El método de informadores clave ha permitido conocer que cambios se pueden prever tras la pandemia

INTRODUCTION: The COVID-19 pandemic will give rise to long-term changes in neurological care, which are not easily predictable. MATERIAL AND METHODS: A key informant survey was used to enquire about the changes expected in the specialty over the next 5 years. The survey was completed by heads of neurology departments with broad knowledge of the situation, having been active during the pandemic. RESULTS: Despite a low level of consensus between participants, there was strong (85%) and moderate consensus (70%) about certain subjects, mainly the increase in precautions to be taken, the use of telemedicine and teleconsultations, the reduction of care provided in in-person consultations to avoid the presence of large numbers of people in waiting rooms, the development of remote training solutions, and the changes in monitoring visits during clinical trials. There was consensus that there would be no changes to the indication of complementary testing or neurological examination. CONCLUSION: The key informant survey identified the foreseeable changes in neurological care after the pandemic

Los triptanes en la práctica clínica: eficacia, tolerancia y satisfacción del paciente con los fármacos (estudio TRIPRACLI) / Triptans in clinical practice: effectiveness, tolerance and patient’s satisfaction with medication (TRIPRACLI study)

Introducción y objetivos. Conocer en nuestro medio la eficacia, tolerabilidad y satisfacción del paciente migrañoso con diferentes triptanes en función de las características de sus crisis e intentar establecer un modelo predictivo para recomendar uno u otro en función de dichas características. Pacientes y métodos. Estudio retrospectivo observacional multicéntrico en unidades de cefalea. Se incluyen pacientes con migraña que utilizan un mismo triptán para el tratamiento de sus crisis. Se analizan datos de preferencia, eficacia, rapidez y tolerancia. Resultados. Se analizan 160 pacientes (88 mujeres), con una edad media de 42,92 años. Los triptanes más utilizados fueron eletriptán, almotriptán y rizatriptán. Tanto pacientes como médicos mostraron un alto grado de satisfacción (88% y 65%, respectivamente) con el triptán utilizado. En las encuestas de preferencia, los pacientes preferían el triptán actual sobre el previo (83%) o fármacos no específicos (93%). La valoración global en una escala analógica visual estuvo por encima de 7 para todos los triptanes, sin diferencias entre ellos. Al analizar la utilización de un determinado triptán en función de las características de las crisis, no se encontraron diferencias estadísticamente significativas. Conclusiones. En este grupo seleccionado de pacientes, los triptanes son un tratamiento por el que los pacientes muestran un alto grado de satisfacción. Aunque no existen diferencias globales en las puntuaciones entre los diferentes triptanes, el hecho de que determinados triptanes sean más utilizados por los pacientes después de experiencias previas con otros sugiere una mayor eficacia por su parte. No hemos encontrado ningún parámetro que prediga la utilización de un determinado triptán(AU)

Introduction and aims. This study was aimed determining the effectiveness, tolerance and satisfaction of patients with migraine as regards different triptans, according to the characteristics of their attacks. At the same time it sought to establish a predictive model that can be used to recommend one or another, depending on those characteristics. Patients and methods. Retrospective observation-based study conducted in headache units in a number of different centres. Patients included in the study were those with migraine who used the same triptan to treat their attacks. Data concerning preference, effectiveness, speed and tolerance were analysed. Results. The analysis included 160 patients (88 females), with a mean age of 42.92 years. The most commonly used triptans were eletriptan, almotriptan and rizatriptan. Both patients and doctors reported a high degree of satisfaction (88% and 65%) with the triptan that was used. In the surveys on preference, patients preferred their current triptan to the previous one (83%) or to non-specific drugs. The overall score on a visual analogue scale was above 7 for all the triptans, without any differences from one to another. On analysing the use of a particular triptan depending on the characteristics of the attacks, no statistically significant differences were found. Conclusions. In this selected group of patients, triptans are a treatment that patients claim to be very satisfied with. Although there are no overall differences in the scores among different triptans, the fact that certain triptans are used more by patients after previous experiences with others suggests that they are more effective. We did not find any parameter that predicts the use of a particular triptan(AU)

[Chronic migraine as seen by neurologists and patients: results of the CIEN-mig project (III)]. / La migraña crónica vista por el neurologo y el paciente: resultados del proyecto CIEN-mig (III).

INTRODUCTION: Data on the reality of chronic migraine in our clinics are scarce. AIM. To know the frequency of consultation and attitude of the neurologist regarding chronic migraine, and the opinion of patients with this condition. SUBJECTS AND METHODS: A total of 145 neurologists consulted electronically two questionnaires. The first tested the impact of chronic migraine and their approach in the daily practice. The second was filled in by the consecutive patients. RESULTS: A total of 4.1% of patients consulted due to chronic migraine, mostly women in their forties. The average time for diagnosis was 28.7 months. All neurologists recommended preventive treatment from the beginning. More than a quarter kept this treatment for more than a year and used drug combinations. Only half thought that overuse was the reason for chronic migraine and the majority allowed non-steroidal anti-inflammatories and triptans at restricted doses. Only half of the patients knew they had chronic migraine. In their opinion, heredity and the absence of an early and serious treatment could contribute for chronic migraine development. CONCLUSIONS: Almost one patient per day consults due to chronic migraine, which gives an idea of its impact. A better feed-back with primary care level is necessary, if we consider that the delay in the diagnosis is longer than two years. The majority of neurologists follows the current recommendations of the Headache Group of the Spanish Society of Neurology.

[Satisfaction of the migraine patient attending neurology clinics: results of CIEN-mig project (II)]. / Satisfacción del paciente con migraña que acude a consultas de neurología: resultados del proyecto CIEN-mig (II).

INTRODUCTION: Migraine is the most common neurological consultation in our country. AIM. To analyse the satisfaction level of the patient with migraine attending our clinics. PATIENTS AND METHODS: A total of 160 neurologists asked 10 consecutive migraine patients to fill in a satisfaction questionnaire. RESULTS: The questionnaire was answered by 1330 patients. The most important factors they considered for their neurologists were professional experience and kindness. Patients thought neurologist should improve in time to explain treatment and accessibility. Almost 90% of patients considered that treatments for migraine had improved, but almost half of them were not satisfied with the management in primary care setting. Patients were more satisfied with symptomatic treatment (69.1%) than with preventatives (50.4%). More than half had a neuroimaging study due to their headaches. Only half thought that such an study would improve their satisfaction. CONCLUSIONS: The level of satisfaction of the migraine patient attending our clinics has improved in the last years. In patients' opinion the aspects which should be improved are the time to explain migraine and its treatment, accessibility and preventive treatment.

La migraña crónica vista por el neurólogo y el paciente: resultados del proyecto CIEN-mig (III) / Chronic migraine as seen by neurologists and patients: results of the CIEN-mig project (III)

Introducción. Existen pocos datos acerca de la realidad de la migraña crónica en nuestras consultas. Objetivo. Conocer la carga asistencial y la actitud del neurólogo frente a la migraña crónica y la opinión del paciente con esta patología. Sujetos y métodos. Un total de 145 neurólogos contestaron por vía electrónica dos cuestionarios. El primero iba encaminado a caracterizar el impacto de la migraña crónica y su actitud en la práctica habitual. El segundo había de ser respondido por tres pacientes consecutivos. Resultados. Un 4,1% consultó por migraña crónica, mayoritariamente mujeres en la quinta década. El tiempo medio hasta el diagnóstico fue de 28,7 meses. Todos los neurólogos recomendaron tratamiento preventivo desde el inicio. Más de una cuarta parte lo mantenía más de un año y utilizaba combinaciones de fármacos. Sólo la mitad pensaba que el abuso de analgésicos era la causa de la migraña crónica y la mayoría se decantó por permitir antiinflamatorios no esteroideos y triptanes de forma restringida. Sólo la mitad de los pacientes sabía que tenía migraña crónica. En su opinión, la herencia y la ausencia de un tratamiento reglado y precoz podrían contribuir al desarrollo de migraña crónica. Conclusiones. Casi un paciente al día consulta por migraña crónica, lo que da idea de su impacto asistencial. La coordinación con atención primaria es necesaria, si tenemos en cuenta que el retraso en el diagnóstico es de más de dos años. La mayoría de los neurólogos sigue las recomendaciones de tratamiento del Grupo de Cefaleas de la Sociedad Española de Neurología (AU)

Introduction. Data on the reality of chronic migraine in our clinics are scarce. Aim. To know the frequency of consultation and attitude of the neurologist regarding chronic migraine, and the opinion of patients with this condition. Subjects and methods. A total of 145 neurologists consulted electronically two questionnaires. The first tested the impact of chronic migraine and their approach in the daily practice. The second was filled in by the consecutive patients. Results. A total of 4.1% of patients consulted due to chronic migraine, mostly women in their forties. The average time for diagnosis was 28.7 months. All neurologists recommended preventive treatment from the beginning. More than a quarter kept this treatment for more than a year and used drug combinations. Only half thought that overuse was the reason for chronic migraine and the majority allowed non-steroidal anti-inflammatories and triptans at restricted doses. Only half of the patients knew they had chronic migraine. In their opinion, heredity and the absence of an early and serious treatment could contribute for chronic migraine development. Conclusions. Almost one patient per day consults due to chronic migraine, which gives an idea of its impact. A better feedback with primary care level is necessary, if we consider that the delay in the diagnosis is longer than two years. The majority of neurologists follows the current recommendations of the Headache Group of the Spanish Society of Neurology (AU)

Satisfacción del paciente con migraña que acude a consultas de neurología: resultados del proyecto CIEN-mig (II) / Satisfaction of the migraine patient attending neurology clinics: results of CIEN-mig project (II)

Introducción. La migraña es el motivo neurológico más frecuente de consulta en nuestro país. Objetivo. Analizar el grado de satisfacción del paciente migrañoso que acude a consultas de neurología de nuestro país. Pacientes y métodos. Un total de 160 neurólogos españoles pasó un cuestionario de satisfacción a 10 pacientes consecutivos con migraña que acudieron a consulta. Resultados. Un total de 1.330 pacientes contestaron el cuestionario. Los factores que los pacientes consideraban más importantes por parte de neurólogo fueron la experiencia profesional y la amabilidad. Los pacientes pensaban que deberíamos mejorar sobre todo en el tiempo en explicar el tratamiento y en la facilidad de acceso a la consulta. Casi el 90% de los pacientes pensaba que los tratamientos frente a la migraña habían mejorado, pero casi la mitad de los pacientes no estaba satisfecha con la atención en la atención primaria. Los pacientes se mostraban más satisfechos con el tratamiento sintomático (69,1%) que con el tratamiento preventivo (50,4%). A algo más de la mitad de los pacientes se les había realizado un estudio de neuroimagen para analizar sus cefaleas. Sólo la mitad pensaba que llevar a cabo un estudio de neuroimagen mejoraría su satisfacción. Conclusiones. La satisfacción de los pacientes con migraña que acuden a consultas de neurología ha mejorado los últimos años. En su opinión, los aspectos susceptibles de mejora serían la explicación de esta afección y su tratamiento, la facilidad de acceso a la consulta y el tratamiento preventivo (AU)

Introduction. Migraine is the most common neurological consultation in our country. Aim. To analyse the satisfaction level of the patient with migraine attending our clinics. Patients and methods. A total of 160 neurologists asked 10 consecutive migraine patients to fill in a satisfaction questionnaire. Results. The questionnaire was answered by 1330 patients. The most important factors they considered for their neurologists were professional experience and kindness. Patients thought neurologist should improve in time to explain treatment and accessibility. Almost 90% of patients considered that treatments for migraine had improved, but almost half of them were not satisfied with the management in primary care setting. Patients were more satisfied with symptomatic treatment (69.1%) than with preventatives (50.4%). More than half had a neuroimaging study due to their headaches. Only half thought that such an study would improve their satisfaction. Conclusions. The level of satisfaction of the migraine patient attending our clinics has improved in the last years. In patients’ opinion the aspects which should be improved are the time to explain migraine and its treatment, accessibility and preventive treatment (AU)

La migraña crónica vista por el neurólogo y el paciente: resultados del proyecto CIEN-mig (III) / Chronic migraine as seen by neurologists and patients: results of the CIEN-mig project (III)

Introducción. Existen pocos datos acerca de la realidad de la migraña crónica en nuestras consultas. Objetivo. Conocer la carga asistencial y la actitud del neurólogo frente a la migraña crónica y la opinión del paciente con esta patología. Sujetos y métodos. Un total de 145 neurólogos contestaron por vía electrónica dos cuestionarios. El primero iba encaminado a caracterizar el impacto de la migraña crónica y su actitud en la práctica habitual. El segundo había de ser respondido por tres pacientes consecutivos. Resultados. Un 4,1% consultó por migraña crónica, mayoritariamente mujeres en la quinta década. El tiempo medio hasta el diagnóstico fue de 28,7 meses. Todos los neurólogos recomendaron tratamiento preventivo desde el inicio. Más de una cuarta parte lo mantenía más de un año y utilizaba combinaciones de fármacos. Sólo la mitad pensaba que el abuso de analgésicos era la causa de la migraña crónica y la mayoría se decantó por permitir antiinflamatorios no esteroideos y triptanes de forma restringida. Sólo la mitad de los pacientes sabía que tenía migraña crónica. En su opinión, la herencia y la ausencia de un tratamiento reglado y precoz podrían contribuir al desarrollo de migraña crónica. Conclusiones. Casi un paciente al día consulta por migraña crónica, lo que da idea de su impacto asistencial. La coordinación con atención primaria es necesaria, si tenemos en cuenta que el retraso en el diagnóstico es de más de dos años. La mayoría de los neurólogos sigue las recomendaciones de tratamiento del Grupo de Cefaleas de la Sociedad Española de Neurología (AU)

Introduction. Data on the reality of chronic migraine in our clinics are scarce. Aim. To know the frequency of consultation and attitude of the neurologist regarding chronic migraine, and the opinion of patients with this condition. Subjects and methods. A total of 145 neurologists consulted electronically two questionnaires. The first tested the impact of chronic migraine and their approach in the daily practice. The second was filled in by the consecutive patients. Results. A total of 4.1% of patients consulted due to chronic migraine, mostly women in their forties. The average time for diagnosis was 28.7 months. All neurologists recommended preventive treatment from the beginning. More than a quarter kept this treatment for more than a year and used drug combinations. Only half thought that overuse was the reason for chronic migraine and the majority allowed non-steroidal anti-inflammatories and triptans at restricted doses. Only half of the patients knew they had chronic migraine. In their opinion, heredity and the absence of an early and serious treatment could contribute for chronic migraine development. Conclusions. Almost one patient per day consults due to chronic migraine, which gives an idea of its impact. A better feedback with primary care level is necessary, if we consider that the delay in the diagnosis is longer than two years. The majority of neurologists follows the current recommendations of the Headache Group of the Spanish Society of Neurology (AU)

[Approach of neurologists in Spain to migraine: results of the CIEN-mig project (I)]. / Actitud del neurólogo español frente a la migraña: resultados del proyecto CIEN-mig (I).

INTRODUCTION: Headache is the most frequent neurological reason for consultation in our country. AIM: To obtain descriptive data on the approach and satisfaction of the neurologist regarding the diagnosis, burden and management of headaches, and migraine in particular, together with the relationship with primary care physicians (PCP). SUBJECTS AND METHODS: A total of 160 neurologists participated and answered electronically five questionnaires during one year. The results for patients were obtained in a standard clinic day and for the first 10 patients. RESULTS: The mean number of patients/day was 20.7. Thirty-six percent consulted due to headache, most under 50 and women. Half had migraine; in 70% daily activities were moderate-severely affected. Almost half had missed at least one work day due to migraine in the previous month. Neurologist considered that headache background of PCP should improve, mainly regarding preventive treatment. Complementary studies were asked in a rather low proportion of patients; CT (35%) being the most frequent. The majority indicated triptans, and in the mild phase of pain, and neuromodulators or beta-blockers for the preventive treatment. CONCLUSIONS: Migraine is the first reason for consultation in the Neurology Services of our country and impacts negatively in the quality of life of our patients, usually women below 50. Its management should be improved with a better feedback with PCP and the use of the most efficacious treatments.

Cefaleas

Guía de actuación clínica en Atención Primaria que contiene los siguientes apartados : introducción, definición y clasificación, criterios diagnósticos, valoración inicial y seguimiento, tratamiento, criterios de interconsulta y/o derivación al especialista correspondiente, criterios de buen control y actuación frente a posibles complicaciones, puntos clave, algoritmos, cuadros de resumen y anexos como información complementaria. También incluye una guía de consulta rápida.