Patient Preferences for Preventive Migraine Treatments

A Discrete-Choice Experiment

Carol Mansfield, PhD; David J. Gebben, PhD; Jessie Sutphin, MA; Stewart J. Tepper, MD; Todd J. Schwedt, MD; Sandhya Sapra, PhD; Neel Shah, PhD


Headache. 2019;59(5):715-726. 

In This Article

Abstract and Introduction


Objective: To understand treatment preferences of people with migraine and the relative importance of improvements in efficacy and avoiding adverse events (AEs), such as cognition problems or weight gain.

Background: Current preventive migraine medicines are associated with poor adherence and tolerability. There is an unmet need for effective migraine-specific preventive treatments with fewer AEs.

Methods: In a web-based discrete-choice experiment survey, respondents who self-reported having ≥6 migraine days/month were offered choices between pairs of hypothetical preventive migraine medicines. Six attributes, each with 3 levels, defined the medicines: reduction in headache days per month (10%, 25%, or 50%), frequency of limitations with physical activities (none, 1-category improvement, or 2-category improvement), cognition problems (no problems, thinking problems, or memory problems), weight gain (none, 5% body weight gain, or 10% body weight gain), how the medicine is taken (daily oral pill, once-monthly injection, or twice-monthly injection), and monthly out-of-pocket cost ($5, $60, or $175). The attributes and levels were informed by clinician input, the clinical literature, and 2 focus groups. An experimental design was used to create the pairs of hypothetical medicines for the discrete-choice experiment questions. Random-parameters logit was used to estimate the relative importance of the medicine attributes, and the results were used to predict the percentage of respondents who would select one medicine profile over another and to calculate willingness to pay for changes in attribute levels.

Results: The sample included 300 respondents; 72% indicated that migraines make physical activities difficult all or most of the time, and 81% had taken a prescription medicine to prevent migraine in the last 6 months. Respondents reported having, on average, approximately 16 headache days per month. Among noncost attributes, respondents valued a change from a 10% reduction in migraine days to a 50% reduction more highly than avoiding the worst levels of AEs, but were willing to trade off efficacy for less-severe AEs. Avoiding memory problems was more important than avoiding thinking problems. Avoiding a 10% weight gain was more important than avoiding thinking and memory problems. Respondents preferred a once-monthly injection or daily pill to twice-monthly injection. Respondents, on average, were willing to pay $84 (95% confidence interval [CI], $64-$103) per month to avoid a 10% weight gain, $59 (95% CI, $42-$76) per month to avoid memory problems, $35 (95% CI, $20-$51) per month to avoid a 5% weight gain, and $32 (95% CI, $18-$46) per month to avoid thinking problems.

Conclusions: A preventive migraine medicine with improved efficacy and AE profile and a favorable mode of administration would be valuable to migraine sufferers. Patients may be willing to trade off efficacy for better AE profiles. Clinicians should work with patients to select treatments that meet each patient's needs.


Migraine is a highly disabling neurologic disease characterized by moderate to severe, typically unilateral headache, commonly accompanied by nausea, photophobia, and phonophobia.[1] Migraine is 1 of 2 leading causes of years lived with disabilities in developed countries and is among the top 5 such causes worldwide.[2] The economic burden of migraine is considerable. An estimated $11 billion in direct costs and $12 billion in indirect costs are attributable to migraine annually in the United States (US). In addition, a recent retrospective database analysis estimated that individuals with migraine incur, on average, $13,000 in direct health care costs annually.[3–5] Moreover, migraine is often undertreated, which may lead to an increase in the use of health care resources (eg, emergency department visits and opioid use).[6]

There are unmet needs with currently available treatment options for migraine. Migraine preventive therapies are recommended for people who experience 4 or more migraine attacks per month, are overusing or have failed on acute medication, or experience significant migraine-related impairment in daily functioning or quality of life.[7] However, most commonly used preventive medicines were first licensed for other indications (eg, antihypertensives, antidepressants, and antiepileptics) and were not specifically designed to alter the underlying physiology of migraine (Mayo Clinic, 2017).[8] Many preventive migraine medicines have significant side effects, including fatigue, memory problems and mental confusion, weight gain, and sexual dysfunction.[7,9] Adherence to and persistence with preventive treatments for migraine are poor, and adverse events (AEs) are a frequent cause of treatment discontinuation.[10–12]

With the advent of novel preventive therapies for migraine, including biologics, it is important to understand patient preferences for the attributes of new therapies relative to older therapies. Evaluating patient preferences for attributes relating to efficacy, safety, mode of administration, and cost can shed light on the factors that are most important to patients and can help determine whether new therapies are addressing a previously unmet need. To evaluate patient preferences, a discrete-choice experiment (DCE) was conducted. A DCE is an accepted methodology for gathering and analyzing quantitative data on patients' relative preferences for the attributes of medical interventions.[13] DCEs are based on the principle that treatments comprise a set of attributes and that the value of a treatment to an individual is a function of these attributes.[14] DCEs reveal individuals' willingness to accept tradeoffs between features of multi-attribute products, recognizing that individuals place different levels of importance on different product attributes.[15–20]

The objective of this study was to understand migraine preventive treatment preferences of US patients with migraine and the relative importance of improvements in efficacy and avoiding treatment-related AEs.