Liam Davenport

June 21, 2016

SAN DIEGO — More than 40% of women with both obesity and migraine leave their headaches untreated, whereas the majority of those who do treat the pain rely on nonsteroidal anti-inflammatory drugs (NSAIDs) either alone or in combination with another medication, rather than migraine-specific treatments, a new study indicates.

Using smartphone technology to gather near-real-time data, the researchers found that obese women were treating just 58% of their headache days with at least one acute medication, delegates here at the American Headache Society (AHS) 58th Annual Scientific Meeting heard.

Of those women who did use a medication to ease their headaches, more than a quarter took an NSAID as a monotherapy, whereas almost 30% used the drugs in combination with another medication.

"We were surprised to find that almost half of the headache days were not treated, and we, at this point, do not know why," Jelena Pavlovic, MD, PhD, assistant professor of neurology at the Albert Einstein College of Medicine, New York, New York, told Medscape Medical News.

"One can speculate that people may choose not to treat because the current pharmacological options do not work well for them," she added, noting that some women may be using nonpharmacologic approaches, such as sleep and relaxation exercises.

Dr Pavlovic said that clinicians "need to recognize that patient often may not actually take medication though they are in pain," adding, "Once clinicians recognize this, teaching patients to treat acute headaches promptly and with adequate dosing is vital."

She described the optimization of therapy as a "two-way street" and highlighted that clinicians "should specifically ask patients why they don't treat certain headaches and try to address the potential needs/issues that may arise."

Emphasizing the need to obtain accurate information, Dr Pavlovic said, "This is particularly important for obese women who are at increased risk of going on to develop chronic migraine, since obesity is a well-known risk factor of chronic migraine."

Rashmi B. Halker Singh, MD, assistant professor of neurology at the Mayo Clinic, Scottsdale, Arizona, agreed that that the findings were "a bit of a surprise."

"I think many of us were not expecting to find that these women were using acute medications less often," she told Medscape Medical News. "It's kind of counterintuitive."

Dr Halker Singh continued: "The basic assumption before reading this study would have been that individuals who have more frequent headaches are more likely to take acute medication, because we know that a significant proportion of individuals with chronic migraine and often daily headaches overuse acute medications."

She added, "I think this is a group of patients we need to look at in more detail, and see what we can do in terms of migraine education and making sure they have access to appropriate treatment, both in terms of acute treatment and also knowing what the other options are."

Acute Medication Use

Previous studies on acute medication use patterns in individuals with migraine have typically been limited by their retrospective nature and issues around bias and ecological validity. To overcome these problems, the researchers used an Ecological Momentary Assessment, delivered via a smartphone, to determine medication use patterns on a per headache basis during a 28-day period.

They studied 136 women with neurologist-diagnosed migraine and obesity enrolled in the Women's Health and Migraine trial, who were an average age of 38.7 years and a mean body mass index of 34.9 kg/m2.

The women reported an average of 11.1 headache days per month. The pain intensity, on a scale of 0 to 10, was 5.6, while the mean migraine disability, as measured using the Headache Impact Test 6 total score, was 65.4.

Patients treated an average of 57.5% of headache days with at least one acute medication. Acute medications were divided into non-migraine-specific medications, such as NSAIDs, Excedrin (Novartis Consumer Health, Inc), opioids, and/or butalbital, and migraine-specific drugs, such as triptans.

The most commonly used drugs were NSAIDs, which were taken at least once by 79.4% of participants, with 27.9% of individuals using them as monotherapy. Triptans were used at least once by 34% of participants, with 4% using them as monotherapy.

Twenty-five percent of individuals used Excedrin at least once, with 5% using it as a monotherapy. Opioids and/or butalbital were taken at least once by 27% of patients, and they were used as a monotherapy by 1.5%.

The most frequent acute medication combination was NSAIDs and triptans, which was taken by 16.9% of participants. NSAIDs plus opioids/butalbital was used by 5.1% of individuals, with the same proportion taking NSAIDs and Excedrin. Just 1.5% of patients used three medications in combination.

Opioid/butalbital users had the highest average number of headache days per month, at 13.7 days vs 11.3 days for NSAID users, 11.6 days for triptan users, and 11.6 days for individuals who used Excedrin.

Dr Pavlovic explained that, as most of the current data on acute migraine treatment are derived from retrospective studies, it is not possible to compare directly medication rates in obese and nonobese migraine sufferers.

Dr Pavlovic said, however, that the results are "likely apply to nonobese women, as our sample was representative in terms of age and headache frequency."

"Furthermore, 40.4% of American women are obese...supporting the notion that these women are representative of the general population of women," she added.

For Dr Halker Singh, there remain a number of unanswered questions that could be addressed in further studies, particularly given that the researchers followed the women for only 28 days.

"It would be interesting to see if there's a difference in individuals who have chronic migraines vs episodic migraine, and you'd need more than 28 days' worth of data to clarify that question," she said.

"It would also be interesting to see if there's a difference in women who were not obese vs obese, as well as for the difference between obese men vs obese women."

No funding was declared. The researchers have disclosed no relevant financial relationships.

American Headache Society (AHS) 58th Annual Scientific Meeting: Abstract 158797. Presented June 9, 2016.

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