Navigating Effective Approaches to Migraine Treatment for the Underinsured

Despite the availability of new therapies, the vast majority of people with migraine headache receive inadequate treatment. A 2013 study by Lipton et al¹ proposed 3 steps to achieving minimally effective pharmacologic therapy for acute and chronic migraine, including

·consultation with a prescribing healthcare professional;

·diagnosis of migraine; and

·use of appropriate acute treatments.

In follow-up, the Chronic Migraine Epidemiology and Outcomes (CaMEO) study in 2016² reported that a stunning minority of people with chronic migraine,less than 5%, successfully navigated all 3 steps to achieve satisfactory migraine management. Poor or no health insurance coverage was an important predictor of whether a consultation for migraine would even be sought.^1,2

Factors Contributing to Nonoptimized Care

According to a 2018 review of challenges to migraine management, low socioeconomic status is a significant contributing factor to progression from episodic to chronic migraine, as well as outcomes and quality of life for patients with migraine.³ “Individuals who are underinsured or uninsured tend to have less access to care,” explained study coauthor,  Teshamae Monteith, MD, FAHS, chief of the Headache Division, Department of Neurology at the University of Miami, Miller School of Medicine, and a clinical neurologist at the University of Miami Hospital and Clinics-UHealth Tower in Miami, Florida in an interview with Neurology Advisor. “As a consequence, they may have untreated and more frequent migraine attacks, which in itself is a risk factor for progression to chronic migraine,” she said.

Dr Monteith noted that migraine in underinsured populations may contribute to downward social mobility. Frequent migraine is associated with both work loss and socioeconomic consequences, she noted, and conversely, low socioeconomic status is a risk factor for migraine. “Depression, anxiety, and insomnia, and poor quality of life are also special concerns for untreated migraine, especially those with higher rates of disability,” she added.

Risks to Undertreatment of Migraine

“Migraine is managed most commonly by primary care physicians and general neurologists, as headache specialists specifically are quite scarce,” Matthew Robbins, MD, a clinical neurologist at Weill Cornell Medicine and New York Presbyterian Hospital in New York City told Neurology Advisor. “Underserved populations may utilize the emergency department of hospitals for migraine disproportionately because of inadequate care, which in the long run is certainly more costly on our healthcare system. These encounters manage the acute crises, but are not able to focus on preventive treatment, contributing to an added risk of progression from low- or intermediate-frequency to full-blown chronic migraine,” Dr Robbins said, pointing out that “low socioeconomic status is also associated with this transition of episodic migraine progressing to chronic migraine.” The Lipton study reported an increased risk for new-onset chronic migraine was self-reported over the course of a year in a group of over 5000 patients with episodic migraine.¹

Dr Monteith pointed to troubling attempts at self-management that also contribute risks of developing a more chronic course of migraine. “Without adequate access to care, people who suffer from disabling migraine attacks may be more likely to treat with over-the-counter medications [OTCs]. When acute treatment occurs on more than 10 to 15 days per month, there may be a risk of migraine progression due to medication overuse of acute analgesics,” Dr Monteith said.

This article originally appeared on Neurology Advisor