Migraine Patients Skip Triptans in 40% of Attacks

Patients with migraine do not take their prescribed triptan medications in more than two in every five attacks, a new study finds.

Results from the largest-ever study to track real-time adherence to triptans during an extended period were presented here at the American Headache Society (AHS) 57th Annual Scientific Meeting by Robert A. Nicholson, PhD, director of behavioral medicine at the Mercy Clinic Headache Center & Mercy Health Research in St Louis, Missouri.

On the bright side, patients were more likely to take triptans when their pain was less severe, suggesting they were taking them at the first sign of migraine symptoms, and reported less disability when triptans were taken.

“We know that triptans work really well for a majority of patients with migraine. In this study, we found that those patients who can recognize their symptoms are best positioned to take a triptan,” Dr Nicholson said.

“One of the things we want to do is encourage providers to work with their patients and make sure patients are engaged in their own care to be able to be their own best managers of their pain,” he added. “They should be trained to pay attention to their symptoms so they can give themselves the best chance for success in treating a migraine when it occurs.”

Asked to comment on these findings, Thomas N. Ward, MD, professor of neurology at the Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire, said, “It’s quite clear that they had less disability on the days they take their triptan, which then of course begs the question, why don’t they take their triptans on other days? It’s complicated, and this study doesn’t really address that,” he added. “This little bit of behavioral information is very interesting, and obviously needs more study.”

Taking Triptans — or Not

Dr Nicholson analyzed real-time daily Web-based and smart device–enabled headache diaries from 262 patients who used a triptan for at least one migraine attack and who kept the records for at least 10 days.

Of a total of 7520 days assessed in which the patient had a migraine, probable migraine, or presumed migraine, the patient took a triptan in 57% and did not take a triptan in 43%.

When the patients were divided into tertiles of adherence (<34% of attacks = low, 34% – 67% = medium, >67% = high), those in the low-adherence group were significantly less likely to be female (86% vs 95% of the top adherers) and less likely to be married (57% vs 76%).

The low-adherence group also had a higher number of headache days per month (11.71 vs 9.77; P < .05).

After controlling for demographic and psychological variables, triptan adherence was higher when pain severity was mild (59%) vs moderate (45%) or severe (41%; P < .001).

However, patients were more adherent when they had nausea (52% yes vs 45% no; P < .05), photophobia (53% yes vs 45% no; P < .01), pulsating (56% yes vs 42% no; P < .001), and unilateral pain (56% yes vs 42% no; P < .001).

Within-attack disability (via the Migraine Disability Index) was significantly lower when a triptan was used than when it was not (P < .001).

Why Aren’t They Taking Their Triptans?

Dr Ward said that although formulary restrictions and/or insurance coverage may be playing a role in the nonadherence, the situation now is not nearly as bad as before many triptans became generic, when insurers would limit the number of allowable pills per month.

“People would hoard their tablets and wait until they were sure it was a migraine,” Dr Ward explained. “Yet, data says if you wait you get a worse result, use more medication, and get more side effects. So, we tell people to treat early, but not every little headache, because if you take too many pills, you get medication overuse — what we used to call ‘angalesic rebound’ headache.”

The generic triptans do not work in all patients, however, so cost and coverage could still be a major factor for some patients. “Pharmacy benefits plans may make you jump through a whole host of hoops proving they haven’t responded to less expensive [medications],” Dr Ward noted.

Other possible reasons for nonadherence might relate to an effect of the migraine itself. “People will wake up at night with a screaming headache and, instead of getting out of the bed and taking their medication — which is what we tell them to do — will often lay there desperately trying to go to sleep for hours,” Dr Ward remarked. “I’ve often wondered if that isn’t some sort of confusional episode related to the migraine.”

Or, some patients might just be a bit too optimistic. “Sometimes a little migraine will look like a tension-type headache. Sometimes they don’t escalate, and sometimes they go away. But there comes a point for most of us with migraine where you suddenly know it’s not just a little headache — maybe it starts to pound, maybe the lights bother you a little more, or you get sick to your stomach — and most migraine people know that things are going to go south. But you’d be surprised at how many patients wait to see how bad it’s going to get before they do anything. It’s almost like they’re hoping it won’t do what it did the last 50 times.”

Others may be trying to avoid a condition known as a “post-drome,” Dr Ward said, in which taking a triptan at the first sign of a migraine can move the patient straight from pain to a feeling of sleepiness or unease. “It’s usually better than the pain, but some still find it hard to function with that. It’s a complicated issue and it has to be individualized. You have to find out why.”

Indeed, Dr Nicholson said, “When patients are able to recognize the symptoms that indicate they’re going to be having a migraine, they seem to do best…. We want educated, engaged, activated, motivated patients. That’s what we want to train our patients to be.”

This study was funded by a grant from the National Institute of Neurological Disorders and Stroke and an investigator-initiated grant from Merck & Co. Dr Nicholson and Dr Ward have disclosed no relevant financial relationships.