Migraine Treatment Landscape and the Role of the Pharmacist - Episode 1

Educating the Community About Migraine

A panel discussion regarding the underdiagnosis and burden of migraine attacks on patients and the rationale for educating the community about signs and symptoms.

Mark Percifield, PharmD: Hello, and welcome to this Pharmacy Times® Peer Exchange titled “The Migraine Treatment Landscape and the Role of the Pharmacist.” My name is Mark Percifield. I’m a specialty pharmacy manager in Largo, Florida. Joining me in this discussion are Amy Dunleavy, a community pharmacist at Osterhaus Pharmacy in Maquoketa, Iowa; Jennifer Mazan, an associate professor at Midwestern University College of Pharmacy in Downers Grove, Illinois; and Dr Timothy Smith, the president and chief executive officer of StudyMetrix Research in St. Peters, Missouri. Today we’re going to talk about a topic that’s very near and dear to my heart, because I suffer from migraines. We’re going to talk about several topics pertaining to migraine, including discussions around acute and preventive treatment options as well as the role of the pharmacist. Without further ado, let’s get started.

Jennifer, I’ll start with you. How do you explain to a patient coming into the community pharmacy the differences between a migraine vs other types of headaches?

Jennifer L. Mazan, PharmD: It’s important to educate the patient that a migraine is more than just a headache. Unlike other types of headaches, migraines are complex. They often present differently. They include numerous symptoms, and they can have a profound impact on the patient’s quality of life. Patients who suffer with migraines may experience nausea, vomiting, difficulty concentrating, or sensitivity to light or sound. Some may even experience an aura that precedes the headache. Once they’re pain-free, the patient may find that they’re tired, exhausted, or even irritable. It’s much more than the pain of a headache.

Mark Percifield, PharmD: Those are some great points. Timothy, there’s a lot of discussion about the underdiagnosis and undertreatment of migraine. What can you tell us about that?

Timothy Smith, MD, RPh, FACP, AQH: When we think about migraine, getting adequate treatment requires a few steps. The patient first must consult, be accurately diagnosed, and then get required, effective treatment prescribed. Studies have shown that, as a health system, we’re not doing very well with that. There’s a study called the American Migraine Prevalence and Prevention Study—the AMPP study, we call it—and this study looked at patients with episodic migraines. These are patients with migraines with less than 15 days of headache per month. This study showed that only 26% of the patients who actually suffer from episodic migraine have actually consulted, been accurately diagnosed, and received an evidence-based treatment. When we look at the chronic migraine patients—these are the patients with more severe conditions, with 15 or more migraine or headache days per month—as we did in the Chronic Migraine and Epidemiology and Outcome study (CaMEO), only 4.5% of those patients had successfully navigated that pathway to be seen, get an accurate diagnosis, and get appropriate treatment prescribed. When we look at those numbers, it’s pretty apparent we’re not doing as well as we should be as a health system in this country.

Mark Percifield, PharmD: It looks like underdiagnosis and undertreatment is an issue when you read those statistics. What are the signs and symptoms of episodic migraine, and how do they differ from a chronic migraine?

Timothy Smith, MD, RPh, FACP, AQH: The new international diagnostic criteria for the International Headache Society have dropped the “episodic migraine” moniker. We talk about migraine as a total diagnosis, and these are patients with recurrent, intermittent headaches. Jennifer mentioned many of the symptoms; basically, these are headache attacks that last from 4 to 72 hours if they’re inadequately treated or untreated. They’re moderate to severe in intensity, and they are—generally speaking, although not always—unilateral in distribution or have a unilateral component that’s more prominent on 1 side of the head as opposed to holocephalic or bilateral distribution. The pain has a throbbing or pulsatile quality for many. That’s combined with nausea with or without vomiting and light and noise sensitivity. This describes a migraine pattern. The old designation of episodic migraine stated that this was the less frequent case—less than 15 days per month. Chronic migraine has, basically, that same characteristic of the headache attacks, only with chronic migraine this occurs 15 days per month or more and at least 8 of those days have to have the full migraine characteristics that we just described.

Mark Percifield, PharmD: Thank you for sharing that. That seems like a lot days that someone can suffer from a migraine. That’s very impactful, but that leads me to my next question. Amy, how does migraine impact the quality of life of patients?

Amy R. Dunleavy, PharmD: As you’ve heard Tim and Jennifer mention, those symptoms—throbbing pain, nausea and vomiting, photo and sound sensitivity—really can affect the individual and prevent them from carrying out normal activities during their daily life, keeping them from being active with their loved ones. Migraines can be keeping them from work. For individuals suffering from migraines, this can last for hours or even days. The response to therapy is really important; having that quicker response to therapy can enhance a patient’s quality of life. For patients with migraine, headaches can really increase the amount of times the individual spends at the doctor’s office or in the emergency department. We tend to find our migraine sufferers being those individuals who frequently utilize those services just because that pain and discomfort does become quite intolerable.

Mark Percifield, PharmD: Thank you. I recall a consultation I had with a patient where she was not able to attend her daughter’s graduation because she woke up with a migraine. Those moments are impactful when it comes to the patient’s quality of life. Thank you for sharing that.

Transcript edited for clarity.