Abstract
Objective: Migraine is a common, disabling condition typically characterized by severe headache, nausea, and/or light and sound sensitivity. This study assessed migraine-related health resource utilization (HRU) occurring in the emergency room/accident & emergency department (ER/A&E) setting among European patients with 4 or more migraine days per month.
Methods: Patient-level clinical and HRU data were collected via chart extraction by ER/A&E physicians in France, Germany, Italy, and Spain. Eligible patients had 4 or more migraine days in the month prior to a migraine-related ER/A&E visit and a history of migraine, among other criteria. The index date for each patient was defined as the date of an ER/A&E visit for migraine on or after January 1, 2013. Physician and ER/A&E characteristics, patient and disease characteristics, treatment history, migraine-medication used, and migraine-related HRU (i.e. procedures) during the ER/A&E visit were assessed. Descriptive analyses were conducted in the pooled population, and a sensitivity analysis was performed by country.
Results: A total of 467 eligible patient’s charts (120 in France, 120 in Germany, 107 in Italy, and 120 in Spain) were provided by 136 physicians (36 in France, 36 in Germany, 28 in Italy, and 36 in Spain). On average, patients spent nearly 8 hours in the ER/A&E. Approximately 82% of patients received a blood test, 62% received an electrocardiography, and 46% received a cranial computerized tomography scan. Despite the majority of patients already using acute or prophylactic treatment upon visiting the ER/A&E, almost all patients were administered or prescribed migraine treatment during the visit. Approximately 21% of patients were admitted to the hospital, and over half of patients were referred to a neurologist or headache specialist.
Conclusions: European patients who had four or more migraine days in the month prior to a migraine-related ER/A&E visit had high HRU associated with the visit.
Introduction
Migraine is a neurological disorder typically characterized by recurrent moderate-to-severe headache, and accompanied by at least one sensory and autonomic symptom, such as pain, nausea, and/or light and sound sensitivityCitation1,Citation2. It is a common and often disabling condition, ranking among the top causes of disability globallyCitation3. Migraine is more prevalent among women than menCitation4,Citation5, and more common among adults under the age of 60 yearsCitation6. It is estimated to affect 11–16% of people worldwideCitation7,Citation8, with a prevalence in Europe of ∼15%Citation9. In 2008, the cost of migraine in Europe was estimated at €27 billion annuallyCitation10, resulting in a substantial impact on both patients and health systemsCitation11,Citation12.
Management of migraine symptoms depends on the type and frequency of headache, but may include behavioral modification (i.e. coping with triggers) as well as pharmaceuticals for acute or prophylactic treatmentCitation13. Epidemiologic studies have suggested that, while ∼38% of patients with migraine need preventive treatment, only 3–13% currently use itCitation14. Consequently, severe migraine symptoms may prompt visits to the emergency room/accident & emergency department (ER/A&E), resulting in costly outpatient procedures or hospitalization.
The majority of studies on migraine-related health resource utilization (HRU) in the ER/A&E setting have focused on patients in the US. According to a study by Lipton and SilbersteinCitation15 in 2015, headache patients accounted for 2.4% of all emergency patients in the US, 34.6% of whom were diagnosed with migraine. Additionally, the results from a prospective cohort study in the US found that, on average, patients with migraine visited the ER/A&E at least once every 6 monthsCitation16. A US study reported in 2008 that close to 20% of patients with migraine were admitted to a hospital, many of whom received neurological scans, and the most common acute medications prescribed were narcotics, antiemetic, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophenCitation17.
However, management of migraine in the ER/A&E may differ substantially across countries, and findings from the US may not generalize to other nations and health systems. Two separate findings of a literature review of the treatment of migraine in ER/A&E globally were that cranial imaging practices across ERs vary widely and that migraine patients are often prescribed opioids instead of migraine-specific medicationsCitation18. A prospective study of specialized neurological ER/A&Es in Germany reported that 13% of admissions were due to headache disorders, and this was the second most common reasonCitation19. In Europe, a 2018 study as part of the Eurolight project reported that migraine was often under-treated; too few individuals with migraine were found to consult physicians, and, of patients who did, migraine-specific medications were used inadequatelyCitation20. Thus, insufficient treatment or preventive care may contribute to the migraine-related burden on European ER/A&E departments, although this burden has not yet been quantified.
To address this gap in the literature, this chart review study aimed to assess migraine-related HRU that occurred in the ER/A&E setting among patients with 4 or more migraine days per month in France, Germany, Italy, and Spain. Unlike prior studies that focused on a single hospital or health system, the present study analyzed detailed information about the procedures and treatments received during a migraine-related ER/A&E visit in many different hospitals within those four European countries.
Methods
Data source
This retrospective, non-interventional, panel-based chart review study used anonymized patient-level clinical and HRU data collected via chart extraction. Physicians who treated at least one patient with migraine in the ER/A&E setting in 2017 in France, Germany, Italy, or Spain were screened during April to June 2018. Eligible physicians’ ER/A&E departments must have treated ≥5 patients with migraine in 2017.
Physicians followed a random patient selection process in which a random letter was generated by the survey and physicians were instructed to pull all charts for patients with a last name starting with that letter. Physicians were then told to identify the first of these charts that met all of the eligibility criteria described below. Each eligible physician was invited to randomly select up to 5 patient charts in this method.
De-identified data were collected through an electronic case report form developed by the study investigators that had been pilot-tested by one physician from each country. Each chart extraction took ∼15–20 min for the contributing physicians to complete. All data came from previously recorded information found in patient charts.
This study was granted an exemption from full institutional board review by the Western Institutional Review Board on March 14, 2018.
Study population and selection criteria
Eligible patients were treated for migraine in the ER/A&E on or after January 1, 2013 (the index date), had a history of migraine and 4 or more migraine days in the month prior to the ER/A&E visit, and were ≥18 years old at the ER/A&E visit.
Study measures
Patient and disease characteristics collected included demographics (age and sex), age at first migraine, time from first migraine to the ER/A&E visit, history of menstrual-related migraines (yes/no), medical conditions at the time of the ER/A&E visit (e.g. anxiety, depression, hypertension, obesity, etc.), and previous hospitalization for migraine (yes/no). In addition, the number of non-migraine headache days in the month prior to the index date, average duration of a non-migraine headache in the month prior to the index date (in hours), number of migraine days in the month prior to the index date, average duration of a migraine episode in the month prior to the index date (in hours), and the number of prophylactic migraine treatments discontinued due to lack of efficacy or tolerability at any time prior to the index date were assessed. Data requested on patients’ treatment history included the prophylactic migraine treatments and classes of acute medication used when the patient came into the ER/A&E.
Migraine-related HRU assessed included the length of ER/A&E visit, the type of procedures used for migraine at the visit, hospital admission (yes/no), and number of days the patient spent in the hospital due to migraine, referral to neurologist/headache specialist (yes/no), and type of migraine-related pharmacologic treatments administered during and/or upon discharge from the ER/A&E visit (both prophylactic and acute). Migraine-related procedures included blood tests, cranial computerized tomography (CT) scan, electrocardiogram (EKG), electroencephalogram (EEG), fundoscopy, lumbar puncture/spinal tap, cranial and/or cranio-cervical magnetic resonance imaging (MRI) scan, urinalysis, x-ray, and others.
Statistical analyses
A descriptive analysis was conducted in the pooled patient population across all four countries. Categorical variables were summarized using counts and percentages, and continuous variables were summarized using means and standard deviations (SD). Only observed data were used and missing variables were not imputed. Sensitivity analysis stratified by country were also conducted.
Results
Physician characteristics
The study included 136 physicians from France (n = 36), Germany (n = 36), Italy (n = 28), and Spain (n = 36). Each physician treated an average of 305 patients with headache and 146 patients with migraine in the ER/A&E in 2017 ( and Supplementary Table S1). Slightly over half of the physicians (53.68%) practiced in an academic, teaching, or tertiary hospital. About 62% of the ER/A&E departments saw over 200 migraine patients in 2017, and the majority of the departments had 1–25 physicians (72%) and 1–50 available beds (74%).
Table 1. Physician characteristics.
Patient and disease characteristics
The physicians contributed 467 eligible charts of patients (120 in France, 120 in Germany, 107 in Italy, and 120 in Spain) who were treated in the ER/A&E for migraine on or after January 1, 2013 ( and Supplementary Table S2). Patient and disease characteristics were largely similar across countries (data not shown). On average, patients were 39 years old at the ER/A&E visit. Approximately 64% were female, 40% had been previously hospitalized for migraine, and the average migraine disease duration was 6.7 years. Approximately 32% of patients had no comorbidities at the time of the ER/A&E visit, while 24% had anxiety, 18% had hypertension, 17% had obesity, and 15% had depression. Of the female patients, 52% had a history of menstrual-related migraines.
Table 2. Patient characteristics and disease history.
In the month prior to the ER/A&E visit, patients had experienced an average of 7 migraine days, with an average duration of 16 h per migraine episode. On average, patients had failed 1.5 prophylactic migraine treatments due to lack of efficacy or tolerability.
Patients’ treatment history
Approximately 75% of patients were using an acute migraine treatment and 51% were using a prophylactic migraine treatment when they presented at the ER/A&E. The distribution of patients’ migraine related treatments is presented in (treatments by country are presented in Supplementary Tables S3–6). The most commonly used acute treatments at the time of the ER/A&E visit included COX inhibitors/NSAIDs (45%), triptans (22%), “other” (e.g. acetaminophen, paracetamol; 19%), ergotamines (8%), and opioids (7%). The most common prophylactic treatments were amitriptyline (15%) and propranolol (10%).
Table 3. Pharmacologic migraine treatments.Table Footnotea
HRU during migraine-related ER/A&E visits
On average, patients presenting in the ER/A&E for migraine spent about 8 h in the ER/A&E prior to discharge ( and Supplementary Table S7). During the visit, 82% of patients received blood tests, 62% received an EKG, 46% received a cranial CT scan, and 38% received a urinalysis. Approximately 21% of patients were subsequently admitted to the hospital, and these patients spent an average of 3 days in the inpatient setting due to migraine. Over half (58%) of patients were referred to a neurologist or a headache specialist. Approximately 97% of patients were administered migraine treatment during the ER/A&E visit and 92% were prescribed migraine treatment upon discharge. Acute treatments were more commonly administered or prescribed than prophylactic treatments. The most frequently used acute medication classes during the ER/A&E visit and upon discharge were COX inhibitors/NSAIDs (54% and 32%, respectively) and triptans (32% and 44%) ().
Table 4. Resource use during the migraine-related ER/A&E visits.
In the sensitivity analysis by country, the longest migraine-related ER/A&E visits occurred in Italy, where patients spent an average of 10 h (France: 9 h, Germany: 5 h, Spain: 8 h). Patients in Germany had the highest use of procedures, with 90% receiving blood tests, 79% receiving an EKG, and 52% receiving a urinalysis. The country with the highest proportion of patients admitted to the hospital was France (38%).
Discussion
This study assessed migraine-related HRU that occurred in the ER/A&E setting among European patients with 4 or more migraine days per month. On average, these patients had suffered from migraine for ∼7 years, and 40% of patients had previously been hospitalized due to migraine. The average patient had already failed one prophylactic migraine treatment and was using acute and/or prophylactic treatment at the time of the visit.
To our knowledge, this is the first analysis of migraine-related HRU in the European ER/A&E setting, as most studies have focused on US patients or single hospitalsCitation15–17. A further strength of the present analysis is the inclusion of patients across France, Germany, Italy, and Spain in a variety of ER/A&E settings (i.e. private practice to academic hospitals), potentially providing a more comprehensive patient sample. Unlike many previous studies of practices in one ER/A&E, for the present study patients were drawn from numerous ER/A&Es in the four countries, making the results more generalizable. In addition, this study collected detailed information about the procedures and treatments used during the ER/A&E visits, contributing a valuable perspective on the real world treatment landscape of migraine in Europe.
Most patients included in this study were not newly diagnosed with migraine, yet still imposed a major HRU burden in the ER/A&E setting. In fact, most patients were using acute and/or prophylactic treatment for migraine at the time of the ER/A&E visit. Despite these treatments, the burden to both patients and society remains significant. The average patient spent nearly 8 h in the ER/A&E, during which the majority received a diagnostic test (most commonly blood tests, EKGs, cranial CT scans, and urinalysis). In addition, most patients received additional acute and/or prophylactic migraine treatment during the visit. This high ER/A&E burden aligns with a 2008 study of headache management in one US ER department, which observed that 51% of patients received CT scans and 9% of patients received a lumbar puncture (compared to 46% and 9% in the present study), usage much higher than reported national ratesCitation17. The burden on the medical system due to migraine also extended past the ER/A&E visit; more than one-fifth of patients were hospitalized and close to 60% were referred to a neurologist or headache specialist after the visit.
Together, these findings suggest that the treatment regimens of the patient populations were inadequate or ineffective in preventing ER/A&E visits, despite these patients having lived with migraine for an average of ∼7 years. This perspective aligns with a few prior studies of the treatment of migraine in the ER/A&E globallyCitation18. These prior studies have reported the lack of standardization in prescribing practices which could contribute to disorganized symptom management. A 2018 study of migraine in Europe also reported that migraine was often under-treated, that patients did not consult physicians often enough, and that migraine-specific medications were inadequately prescribedCitation20. Studies such as the current one can help to improve both our understanding of how to better manage migraine symptoms as well as reduce the substantial HRU burden on healthcare systems. Suggestions for future research include examining differences among patients with a first migraine-related visit to the ER/A&E compared with those with a history of visits, as well as differences in the use of procedures in academic hospitals compared with community hospitals.
The findings of this study should be interpreted in light of several limitations, some of which are common to all retrospective analyses. First, the study included patients treated for migraine in the ER/A&E in France, Germany, Italy, and Spain who had 4 or more migraine days in the month prior to the ER/A&E visit. Thus, the results of this study may not be representative of patients in other countries or to the whole of Europe, or patients who had less frequent migraine episodes per month. There may exist large variability among other European countries in regards to migraine-related healthcare utilization, and future studies of other nations are suggested. Second, there is the possibility for errors introduced during chart extraction and data entry. However, logic checks in the questionnaire and in analysis programs were implemented to minimize the errors. Similarly, this study may be affected by inaccurate data recorded in the primary charts, recall bias (e.g. “unknown/not sure” response options), and non-random missing data (e.g. specifically omitting a particular answer option across questions). Finally, the history of migraine may be self-reported by the patient instead of diagnosed by a physician. However, over half the patients included in this study were receiving prophylactic medication for migraine at the time of the ER/A&E visit, which would have required a diagnosis. Additionally, as the average duration of migraine was 6.7 years among patients overall, it is likely that most patients in this study had a previous diagnosis of migraine.
Conclusions
This study demonstrated a high burden of migraine-related HRU in the ER/A&E setting among European patients with 4 or more migraine days per month. The average visit lasted several hours and often included migraine-related diagnostic tests and treatments. Many patients were referred to a neurologist or headache specialist and some were hospitalized following the visit. Future studies are recommended to confirm these findings and quantify the cost burden associated with migraine-related HRU in the ER/A&E setting.
Transparency
Declaration of funding
This research was sponsored by Novartis Pharmaceuticals Corp., and the sponsors were involved in all stages of the work and in the manuscript preparation.
Declaration of financial/other interests
ES, WG, MLZ, EF, and EF are employees of Analysis Group, Inc., which has received consulting fees from Novartis. PV MAV, TT, NM, MMP, SR, MN, and DR are employees of Novartis. The peer reviewers on this manuscript have received an honorarium from JME for their review work. In addition, a reviewer on this manuscript has disclosed receiving compensation form Novartis for consulting services and/or speaking activities. The reviewers have no other relevant financial relationships or otherwise to disclose.
Supplemental Material
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Medical writing assistance was provided by Shelley Batts, an employee of Analysis Group, Inc. and funded by the sponsor.
Related Research Data
References
- Persico AM, Verdecchia M, Pinzone V, et al. Migraine genetics: current findings and future lines of research. Neurogenetics. 2015;16:77–95.
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (Beta version). 2013. Available from: https://www.ichd-3.org/.
- Steiner TJ, Stovner LJ, Vos T, et al. Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain. 2018;19:17.
- Lipton RB, Bigal ME, Diamond M, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343–349.
- Hazard E, Munakata J, Bigal ME, et al. The burden of migraine in the United States: current and emerging perspectives on disease management and economic analysis. Value Health. 2009;12:55–64.
- Fillingim RB, King CD, Ribeiro-Dasilva MC, et al. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10:447–485.
- Vos T, Allen C, Arora M, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–1602.
- Woldeamanuel YW, Cowan RP. Migraine affects 1 in 10 people worldwide featuring recent rise: a systematic review and meta-analysis of community-based studies involving 6 million participants. J Neurol Sci. 2017;372:307–315.
- Stovner LJ, Andree C. Prevalence of headache in Europe: a review for the Eurolight project. J Headache Pain. 2010;11:289–299.
- Stovner LJ, Andree C, Eurolight Steering C. Impact of headache in Europe: a review for the Eurolight project. J Headache Pain. 2008;9:139–146.
- Steiner TJ, Stovner LJ, Katsarava Z, et al. The impact of headache in Europe: principal results of the Eurolight project. J Headache Pain. 2014;15:31.
- Vo P, Paris N, Bilitou A, et al. Burden of migraine in Europe using self-reported digital diary data from the migraine buddy(c) application. Neurol Ther. 2018;7:321.
- Martin PR, MacLeod C. Behavioral management of headache triggers: avoidance of triggers is an inadequate strategy. Clin Psychol Rev. 2009;29:483–495.
- Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78:1337–1345.
- Lipton RB, Silberstein SD. Episodic and chronic migraine headache: breaking down barriers to optimal treatment and prevention. Headache. 2015;55(Suppl 2):103–122; quiz 23–26.
- Freitag FG, Lyss H, Nissan GR. Migraine disability, healthcare utilization, and expenditures following treatment in a tertiary headache center. Proc (Bayl Univ Med Cent). 2013;26:363–367.
- Sahai-Srivastava S, Desai P, Zheng L. Analysis of headache management in a busy emergency room in the United States. Headache. 2008;48:931–938.
- Minen MT, Tanev K, Friedman BW. Evaluation and treatment of migraine in the emergency department: a review. Headache. 2014;54:1131–1145.
- Rizos T, Juttler E, Sykora M, et al. Common disorders in the neurological emergency room–experience at a tertiary care hospital. Europ J Neurol. 2011;18:430–435.
- Katsarava Z, Mania M, Lampl C, et al. Poor medical care for people with migraine in Europe - evidence from the Eurolight study. J Headache Pain. 2018;19:10.