Can Migraineurs Accurately Identify Their Headaches as "Migraine" at Attack
Can Migraineurs Accurately Identify Their Headaches as "Migraine" at Attack
Background: While treating migraine early when the headache is mild is believed to link to improved treatment outcomes, it is not clear whether patients can correctly self-identify a headache as a migraine at onset in real-world settings.
Objective: This study aims to assess the likelihood that patients can correctly self-identify a headache as a migraine at onset, and to evaluate cues that patients use to correctly identify migraine attacks.
Methods: Adult migraineurs were recruited from 14 headache clinics across the United States. Patients recorded their headache experiences via an electronic diary daily over a period of 30 days. On days when they experienced headaches, patients were asked to recall the types of headache they experienced at both onset and peak. Patients also identified cues for deciding whether the headache was a migraine or not. Using identification of migraine at headache peak as the criterion, we examined the sensitivity and specificity of migraine identification at onset. We employed generalized estimating equation (GEE) to evaluate factors identified at headache onset that predicted migraine identified at headache peak.
Results: Of the 192 enrolled patients, 182 patients recorded a total of 1197 headache episodes over 30 days. At headache onset, 888 episodes were deemed by patients as migraine and 309 episodes not migraine; a majority (92%) of these early migraine identifications were confirmed at headache peak. Sensitivity and specificity of self-identification of migraine at onset were 91% and 97%, respectively. A number of factors at headache onset were predictive of a migraine identified at peak: sensitivity to light (OR = 3.1, 95% CI: 1.9-5.0), headache severity (OR = 2.0, 95% CI: 1.4-2.8), nausea symptoms (OR = 2.6, 95% CI: 1.5-4.5), and visual disturbance (OR = 2.3, 95% CI: 1.1-4.9). Patients who ruled out tension-type headache at onset were twice (OR = 2.0, 95% CI: 1.5-2.8) as likely to conclude a migraine at peak.
Conclusions: Most migraineurs in tertiary care settings can correctly self-identify a headache as a migraine at onset. Factors such as headache severity, presence of nausea, visual disturbance, sensitivity to light, and no tension-type headache, appeared to augment the correct identification.
Controlled clinical trials testing treatment of migraine attacks early with triptans while the pain is mild have consistently demonstrated improved treatment outcomes. However, before advocating treating migraine while headache is still mild, it is important to understand whether migraine patients can recognize a headache as a migraine during the early phase of a migraine attack in real-world settings. If they can, what criteria do migraine patients use to conclude that their headache is indeed a migraine? Since migraine attacks are generally treated in an outpatient setting, identification of migraine is ultimately the critical step for patients in determining treatment needs.
While the literature of premonitory symptoms on prediction of migraine attack is scant, it points to the possibility that migraine patients can recognize migraine during the early phase of headache or possibly by utilizing migraine symptoms that emerge prior to onset of migraine. "Prodromes" or premonitory symptoms include fatigue, depressive symptoms, lack of concentration, stiff neck, and craving for certain food. Some patients experience these premonitory symptoms as early as 2-48 hours before the onset of a migraine attack. About 33% of headache clinic patients reported premonitory symptoms. Among headache episodes reporting premonitory symptoms, 72% were concluded as migraine. Nevertheless, the potential to intervene at the early phase of migraine is underscored.
The notion of treat early with triptans for acute migraine while the headache is mild was first suggested by Cady et al. In a retrospective analysis of protocol violators of a large, randomized, placebo-controlled study, compared with placebo, patients taking sumatriptan 50 mg without waiting for headache pain progressing to moderate or severe intensity had a significantly higher pain-free rate at 4 hours after dosing. Subsequent ad-hoc analyses of large trials provided additional evidence for improved treatment efficacy in which patients treated their migraine at the onset of headache when pain was mild, as compared with moderate/severe pain.
Randomized placebo-controlled studies provided additional evidence for improved drug efficacy when patients treated their migraine at the first sign of pain while it was mild. Stratified analyses showed a greater proportion of pain free at 2 hours after treatment for mild attacks than for moderate or severe attacks. A recent randomized, double-blind, placebo-controlled study showed that pain intensity was relatively more important than timing in achieving pain free at 2 hours after dosing.
Apart from clinical trial evidence, a prospective observational study lends support for better treatment effectiveness when the pain is mild. Reporting treatment outcomes via an interactive voice response system within 24 hours of migraine resolution, patients treated with rizatriptan 10-mg tablet or orally disintegrating tablet as soon as they experienced headache were significantly more likely to achieve pain relief after treatment, as compared with those who delayed treatment until headache became severe.
As a whole, an increasing body of literature shows that treating early with triptans while the pain is mild may confer better treatment outcomes. However, alternative study designs have been proposed to further support this recommendation.
While the extant literature suggests that treating early while the headache is mild enhances treatment outcomes, the potential benefits should be balanced against the potential risks of medication overuse and/or misuse. Migraine patients should treat early only if they are capable of reliably self-identifying a headache as a migraine at onset. The aims of this study are 2-fold: (1) to evaluate the extent to which self-identification of a headache as a migraine at onset is consistent with self-identification of a headache as a migraine at peak; and (2) to assess headache cues/factors that are used by migraine patients to identify a headache as a migraine.
Abstract and Introduction
Abstract
Background: While treating migraine early when the headache is mild is believed to link to improved treatment outcomes, it is not clear whether patients can correctly self-identify a headache as a migraine at onset in real-world settings.
Objective: This study aims to assess the likelihood that patients can correctly self-identify a headache as a migraine at onset, and to evaluate cues that patients use to correctly identify migraine attacks.
Methods: Adult migraineurs were recruited from 14 headache clinics across the United States. Patients recorded their headache experiences via an electronic diary daily over a period of 30 days. On days when they experienced headaches, patients were asked to recall the types of headache they experienced at both onset and peak. Patients also identified cues for deciding whether the headache was a migraine or not. Using identification of migraine at headache peak as the criterion, we examined the sensitivity and specificity of migraine identification at onset. We employed generalized estimating equation (GEE) to evaluate factors identified at headache onset that predicted migraine identified at headache peak.
Results: Of the 192 enrolled patients, 182 patients recorded a total of 1197 headache episodes over 30 days. At headache onset, 888 episodes were deemed by patients as migraine and 309 episodes not migraine; a majority (92%) of these early migraine identifications were confirmed at headache peak. Sensitivity and specificity of self-identification of migraine at onset were 91% and 97%, respectively. A number of factors at headache onset were predictive of a migraine identified at peak: sensitivity to light (OR = 3.1, 95% CI: 1.9-5.0), headache severity (OR = 2.0, 95% CI: 1.4-2.8), nausea symptoms (OR = 2.6, 95% CI: 1.5-4.5), and visual disturbance (OR = 2.3, 95% CI: 1.1-4.9). Patients who ruled out tension-type headache at onset were twice (OR = 2.0, 95% CI: 1.5-2.8) as likely to conclude a migraine at peak.
Conclusions: Most migraineurs in tertiary care settings can correctly self-identify a headache as a migraine at onset. Factors such as headache severity, presence of nausea, visual disturbance, sensitivity to light, and no tension-type headache, appeared to augment the correct identification.
Introduction
Controlled clinical trials testing treatment of migraine attacks early with triptans while the pain is mild have consistently demonstrated improved treatment outcomes. However, before advocating treating migraine while headache is still mild, it is important to understand whether migraine patients can recognize a headache as a migraine during the early phase of a migraine attack in real-world settings. If they can, what criteria do migraine patients use to conclude that their headache is indeed a migraine? Since migraine attacks are generally treated in an outpatient setting, identification of migraine is ultimately the critical step for patients in determining treatment needs.
While the literature of premonitory symptoms on prediction of migraine attack is scant, it points to the possibility that migraine patients can recognize migraine during the early phase of headache or possibly by utilizing migraine symptoms that emerge prior to onset of migraine. "Prodromes" or premonitory symptoms include fatigue, depressive symptoms, lack of concentration, stiff neck, and craving for certain food. Some patients experience these premonitory symptoms as early as 2-48 hours before the onset of a migraine attack. About 33% of headache clinic patients reported premonitory symptoms. Among headache episodes reporting premonitory symptoms, 72% were concluded as migraine. Nevertheless, the potential to intervene at the early phase of migraine is underscored.
The notion of treat early with triptans for acute migraine while the headache is mild was first suggested by Cady et al. In a retrospective analysis of protocol violators of a large, randomized, placebo-controlled study, compared with placebo, patients taking sumatriptan 50 mg without waiting for headache pain progressing to moderate or severe intensity had a significantly higher pain-free rate at 4 hours after dosing. Subsequent ad-hoc analyses of large trials provided additional evidence for improved treatment efficacy in which patients treated their migraine at the onset of headache when pain was mild, as compared with moderate/severe pain.
Randomized placebo-controlled studies provided additional evidence for improved drug efficacy when patients treated their migraine at the first sign of pain while it was mild. Stratified analyses showed a greater proportion of pain free at 2 hours after treatment for mild attacks than for moderate or severe attacks. A recent randomized, double-blind, placebo-controlled study showed that pain intensity was relatively more important than timing in achieving pain free at 2 hours after dosing.
Apart from clinical trial evidence, a prospective observational study lends support for better treatment effectiveness when the pain is mild. Reporting treatment outcomes via an interactive voice response system within 24 hours of migraine resolution, patients treated with rizatriptan 10-mg tablet or orally disintegrating tablet as soon as they experienced headache were significantly more likely to achieve pain relief after treatment, as compared with those who delayed treatment until headache became severe.
As a whole, an increasing body of literature shows that treating early with triptans while the pain is mild may confer better treatment outcomes. However, alternative study designs have been proposed to further support this recommendation.
While the extant literature suggests that treating early while the headache is mild enhances treatment outcomes, the potential benefits should be balanced against the potential risks of medication overuse and/or misuse. Migraine patients should treat early only if they are capable of reliably self-identifying a headache as a migraine at onset. The aims of this study are 2-fold: (1) to evaluate the extent to which self-identification of a headache as a migraine at onset is consistent with self-identification of a headache as a migraine at peak; and (2) to assess headache cues/factors that are used by migraine patients to identify a headache as a migraine.
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