Persistence with Migraine Prophylactic Treatment and Acute Migraine Medication Utilization in the Managed Care Setting

• Published in: Clinical therapeutics Vol. 30; no. 12; pp. 2452 - 2460
• Main Authors: Yaldo, Avin Z., PhD, Wertz, Debra A., PharmD, Rupnow, Marcia F.T., PhD, Quimbo, Ralph M., MA
• Format: Journal Article
• Language: English
• Published: Bridgewater, NJ EM Inc USA 01.12.2008; Elsevier; Elsevier Limited
• Subjects: Adult; Age Factors; Amitriptyline - therapeutic use; Biological and medical sciences; Cohort Studies; Databases, Factual - statistics & numerical data; Dose-Response Relationship, Drug; Drug Prescriptions - statistics & numerical data; Drug Therapy, Combination; Drug Utilization Review - methods; Drug Utilization Review - statistics & numerical data; Female; Fructose - analogs & derivatives; Fructose - standards; Fructose - therapeutic use; headache; Headache. Facial pains. Syncopes. Epilepsia. Intracranial hypertension. Brain oedema. Cerebral palsy; Humans; Internal Medicine; Kaplan-Meier Estimate; Male; Managed Care Programs - organization & administration; Managed Care Programs - statistics & numerical data; Medical Education; Medical sciences; Medication Adherence - statistics & numerical data; Middle Aged; Migraine Disorders - drug therapy; Migraine Disorders - prevention & control; migraine prophylaxis; Nervous system (semeiology, syndromes); Neurology; Pharmacology. Drug treatments; Proportional Hazards Models; Propranolol - therapeutic use; resource use; Retrospective Studies; Sex Factors; Time Factors; Timolol - therapeutic use; topiramate; triptans; Valproic Acid - therapeutic use; Vascular diseases and vascular malformations of the nervous system; resource use; migraine prophylaxis; headache; triptans; topiramate; Drug; Headache; Topiramate; Nervous system diseases; Managed care; Acute; Migraine; Resource; Cardiovascular disease; Anticonvulsant; Cerebral disorder; Vascular disease; Persistence; Prevention; Pain; Treatment; Central nervous system disease; Triptan derivatives; Neurological disorder; Cerebrovascular disease
• ISSN: 0149-2918; 1879-114X
• DOI: 10.1016/j.clinthera.2008.12.010

Abstract Objective: The aim of this study was to describe persistence with migraine prophylactic treatment and acute migraine medication utilization in patients prescribed migraine prophylaxis. Methods: For this retrospective cohort study, the Health Core Integrated Research Database provided pharmacy/medical claims data from 5 commercial health insurance plans (ie, excluding Medicare and Medicaid) on adult patients with migraine. Eligible patients had ≥1 pharmacy claim for a migraine prophylactic medication between July 1, 2000, and May 31, 2005, and ≥12 U of any combination of acute treatment (serotonin receptor agonist [triptan], ergotamine, or ergotamine combination) dispensed during the 180-day period preceding a first pharmacy claim for a prophylactic medication ( index date ). The prophylactic medication identified at index date was used for categorizing patients into 1 of 4 cohorts: amitriptyline, propranolol/timolol, divalproex sodium, or topiramate (reference). Kaplan-Meier curves were used for evaluating unadjusted risk for discontinuation over time, and a multivariate Cox proportional hazards model was developed to analyze factors associated with discontinuation of prophylactic medication. Results: A total of 12,783 patients met the inclusion criteria and were included in the analysis (amitriptyline, 3749; propranolol/timolol, 2718; divalproex sodium, 1644; and topiramate, 4672). The mean (SD) ages were not significantly different across cohorts (43.9 [11.3], 42.0 [11.1], 43.1 [11.3], and 43.9 [10.6] years, respectively). The mean duration of treatment was significantly longer (131 [184] days) with topiramate compared with amitriptyline (94 [152] days), propranolol/ timolol (119 [180] days), and divalproex sodium (109 [158] days) ( P < 0.001, P = 0.005, and P<0.001,respectively). The risks for discontinuing prophylactic treatment were 23%, 6%, and 11% higher with amitriptyline, propranolol/timolol, and divalproex sodium, respectively, compared with topiramate ( P <0.001, P = 0.024, and P <0.001). Patients prescribed topiramate had a higher mean consumption rate of triptans preindex; postindex, decreases in triptan use were observed in all cohorts, although the magnitude of the decrease was greatest in patients prescribed topiramate compared with the other cohorts. Conclusions: In this study, prescription of topiramate was associated with greater persistence with prophylactic treatment than the other prophylactic drugs. Furthermore, greater reductions in acute treatment utilization, particularly triptans, were observed among patients prescribed topiramate compared with the other prophylactic cohorts.