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What patients want from migraine therapy

 

An interesting question this for any therapy area, and one that is so often missed or ignored. A large study [1] that asks useful questions of patients, and obtains interesting answers, cannot be ignored.

Study

Representative American households were identified by random digit survey in 1998. About 5100 were contacted by telephone using a computer assisted interview to identify people with migraine according to International Headache Society criteria.

Results

There were 688 individuals identified as having migraine in the past year, a prevalence of 18% in women and 6% in men. Their mean age was 43 years. Patients and their doctors About a third had never consulted a doctor. Half did not think their headaches that bad, and the other half had a treatment that worked for them. Underlying this was that significant minorities (40%) did not think that doctors had any useful remedies or was too inconvenient, and about a third thought that seeing a doctor was too expensive (this being the USA).

About a fifth had seen doctors previously, but had not done so in the past year. This was predominantly because treatments were working or the headaches had improved. But about half also thought that their doctor could do nothing for their migraine, could not help them, or was not interested in headache.

Satisfaction with present treatment

Patient satisfaction with their current treatment was predominantly positive (Figure 1). Of the 70% who were not very satisfied, the reasons for dissatisfaction (Figure 2) were generally to do with lack of efficacy of treatments rather than about adverse effects. When questioned, most people thought that satisfactory pain relief should be within one hour, and more than half thought it should be within 30 minutes.

Figure 1: Patients reporting satisfaction with current treatment

Figure 2: Reasons for dissatisfaction with current migraine treatment

What patients want from treatment

Bit of a no-brainer, this. Patients want the headache to go away now, completely, and not come back (Figure 3). They also want any associated symptoms, like nausea, to be relieved also. The bulk of them want a tablet or rapidly dissolving tablet, and are not impressed by subcutaneous or intranasal delivery systems.

Figure 3: What patients want from treatment

What patients want from their doctor

The responses to questions about what patients wanted from their doctors produced a constellation of answers, all of which demonstrate clearly that patients see their relationship with their doctor as a partnership (Figure 4). They want questions answered, and to be educated about controlling their migraines to prevent them happening and how to treat attacks.

Figure 4: What patients want from their doctor

Comment

This is an absolutely fascinating paper that takes us into the mind of the person with migraine. Put simply they are not interested in fancy methods of drug delivery. They are not wholly satisfied with their current treatment. They want the pain relieved quickly and completely, with a tablet. They want to talk to their doctor about their condition and how to make it easier to control.

Part of the fascination is that this turns issues about outcomes on its head. The idea of partial headache relief at two hours as being the main outcome of trials is a nonsense. Complete pain relief at one hour is what patients want. And not only that, they don't want it to come back, so the other outcome should be patients who are pain free at one hour and remain so for 24 hours. These are not outcomes easily found from clinical trials.

The other fascination comes from the fact that this study also asked 167 healthcare professionals similar questions. The professionals had different views to patients. Professionals were much more interested in fancy drug delivery systems: patients wanted a tablet. Professionals thought that patients would want their doctors to be clever-clogs and have bags of medical expertise: patients wanted to talk and build knowledge and trust.

Final thought

The study was supported by a pharmaceutical company (Merck, in the USA). IT is almost inconceivable that a study like this, fundamental in concept and importance, would have been supported by science foundations anywhere in the world.

Reference:

1 RB Lipton, WF Stewart. Acute migraine therapy: do doctors understand what patients with migraine want from therapy? Headache 1999 39: S20-S26.