Mark Percifield, PharmD: Hello and welcome to this Pharmacy Times® Peer Exchange entitled “The Migraine Treatment Landscape and the Role of the Pharmacist”. My name is Mark Percifield. I’m the manager of a specialty pharmacy in Largo, Florida. Also taking part in this discussion is Amy Dunleavy, community pharmacist at Osterhaus Pharmacy in Maquoketa, Iowa; Jennifer Mazan, associate professor at Midwestern University College of Pharmacy, Downers Grove, Illinois; and Dr. Timothy Smith, President and Chief Executive Officer of StudyMetrix Research in St. Peters, Missouri. Today we are talking about a topic that is very close to my heart because I suffer from migraines. We’ll talk about a variety of topics related to migraines, including discussions of acute and preventive treatment options, and the role of the pharmacist. Without further ado, let’s get started.
Jennifer, I’ll start with you. How do you explain the differences between migraines and other types of headache to a patient who comes to the public pharmacy?
Jennifer L. Mazan, PharmD: It is important to educate the patient that migraines are more than just a headache. Unlike other types of headaches, migraines are complex. They often present themselves differently. They include many symptoms and can seriously affect the patient’s quality of life. Migraineurs may experience nausea, vomiting, difficulty concentrating, or sensitivity to light or noise. Some may even experience an aura preceding the headache. Once they are painless, the patient may find that they are tired, exhausted, or even irritable. It’s a lot more than the pain of a headache.
Mark Percifield, PharmD: Those are some great points. Timothy, there is a lot of discussion about the underdiagnosis and under-treatment of migraines. What can you tell us about that?
Timothy Smith, MD, RPh, FACP, AQH: When we think of migraines, adequate treatment takes just a few steps. The patient must first consult, obtain an accurate diagnosis, and then be prescribed the necessary effective treatment. Studies have shown that we as a health system cannot cope with this very well. There’s a study called the American Migraine Prevalence and Prevention Study – we’ll call it the AMPP study – and that study looked at patients with episodic migraines. These are patients with migraines who have headaches for less than 15 days per month. This study showed that only 26% of patients who actually suffer from episodic migraines were actually consulted, accurately diagnosed, and receiving evidence-based treatment. If we look at the patients with chronic migraines – these are the patients with more severe illness with 15 or more migraine or headache days per month – as we did in the Chronic Migraine and Epidemiology and Outcomes Study (CaMEO), only 4 , 5% of these patients had successfully climbed this path to be seen, get an accurate diagnosis, and be prescribed appropriate treatment. When we look at these numbers, it’s pretty obvious that as a healthcare system in this country we are not doing as well as we should.
Mark Percifield, PharmD: It looks like underdiagnosis and under treatment are a problem from reading these statistics. What are the signs and symptoms of an episodic migraine and how are they different from a chronic migraine?
Timothy Smith, MD, RPh, FACP, AQH: The new international diagnostic criteria of the International Headache Society have dropped the nickname “episodic migraine”. We speak of migraines as an overall diagnosis, and these are patients with recurring, intermittent headaches. Jennifer mentioned many of the symptoms; Basically, these are headache attacks that last from 4 to 72 hours if not treated or inadequately treated. They are of moderate to severe intensity and are – generally, though not always – unilaterally distributed or have a unilateral component that is more pronounced on one side of the head than in the holocephalic or bilateral distribution. For many, the pain has a throbbing or pulsating quality. This is combined with nausea with or without vomiting and sensitivity to light and noise. This describes a migraine pattern. The old term episodic migraines meant that this was the rarer case – less than 15 days per month. Chronic migraines have basically the same characteristics as headache attacks, except for chronic migraines it occurs 15 days per month or more and at least 8 of these days must have the full migraine characteristics that we just described.
Mark Percifield, PharmD: Thanks for sharing this. That seems like many days that someone can have a migraine headache. This is very effective, but that leads me to my next question. Amy, how does migraine affect patient quality of life?
Amy R. Dunleavy, PharmD: As you heard from Tim and Jennifer, these symptoms – throbbing pain, nausea and vomiting, sensitivity to photos and noise – can really affect the person, preventing them from performing normal activities during their daily life and preventing them from being with their loved ones . Migraines can keep them from working. For migraineurs, this can take hours or even days. Response to therapy is really important; A faster response to therapy can improve the patient’s quality of life. In migraineurs, headaches can significantly increase the time spent in the doctor’s office or in the emergency room. We tend to find that our migraineurs are the ones who use these services frequently just because the pain and discomfort become quite unbearable.
Mark Percifield, PharmD: Many Thanks. I remember a consultation with a patient where she was unable to attend her daughter’s graduation ceremony because she woke up with a migraine. These moments have a major impact on the patient’s quality of life. Thanks for sharing this.
Transcript edited for clarity.