Quality of Treatment for Migraine Doesn’t Seem To Differ By Race, But Opioid Prescribing for Migraines is Still Too High

Headaches are one of the main reasons patients seek health care advice, and racial and ethnic differences exist. For example, migraine in African Americans is more frequent, more severe, more likely to become chronic, and associated with more depression and lower quality of life versus non-Hispanic whites. Given these disparities, researchers at the University of Michigan set out to determine whether there are also racial differences in the quality of migraine treatment.

In a study published in Cephalalgia, researchers reported that approximately 40% of patients received no preventive medications – prophylactic treatments – though that is the recommended approach for most patients. Further, “among patients that receive a prophylactic agent, it is almost twice as likely that they will receive exclusively agents with low-quality evidence as it is that they will receive agents with only high-quality evidence.”

As for race or ethnic differences in prophylactic treatment, however, patients were treated similarly: 41.3% of African Americans (AA) received no prophylactic treatments from 2006 to 2013, compared to 40.8% of non-Hispanic whites (NHW), and 41.2% of Hispanic (HI) patients.

For patients who needed first-line treatment (also called “abortive treatment”), as with preventive medication, the University of Michigan researchers did not find relevant differences across ethnicities or races, but they did find nearly 40% of patients did not receive a first-line treatment when it was indicated. And similar to the prescribing pattern for preventive medications, when a first-line treatment was prescribed, it was more likely to be one with low-quality evidence.

“This shows an underuse of medications with high-quality evidence,” first author Larry Charleston IV, M.D., M.Sc., an assistant professor of neurology at the University of Michigan Medical School said. “Even for patients being prescribed an abortive medication, we found 27 percent of them were given at least one low-quality abortive medication. Better options do exist.”

The data “suggest that there are major opportunities to improve the quality of headache medication prescribing in the United States, as less than a quarter of migraine patients received all high-quality abortive or prophylactic medications.”

Perhaps most disturbingly, migraine patients “receive prescriptions for opioids about as commonly as they receive prescriptions for medications with high-quality evidence for migraine treatment,” the researchers found.

Looking at the use of opiates, 15.2% of all patients had a prescription for opiates, but there were no racial differences, Larry Charleston and James Burke, University of Michigan, say. In other words, the “investigation into racial disparities in migraine treatment came up empty, but instead it found a different concern that reaches across populations” – opioid overuse, as noted in an article in Lab Report.

The findings on opioid overuse come at a time when opiate-related mortality is “rapidly increasing in the United States,” the study authors note.

“The argument against opiate use for migraine is strengthened by the observation that it is associated with more severe headache-related disability, symptomology, comorbidities (depression, anxiety, and cardiovascular disease and events), greater need to see health care providers and high risk for medication overuse headache. Moreover, most evidence suggests that opiates are, if anything, less effective than non-opiate alternatives,” according to the researchers.

“Given the considerable risks of opiates and the lack of evidence of increased efficacy, opiates should be used rarely, if ever, for migraine,” they conclude. “Interventions to reduce opiate use in the migraine population are urgently needed.”

This overuse of opiates and underuse of less risky, more effective therapies is another example of practitioners ignoring evidence-based medicine. What’s different about this particular example is that it involves opioids, at a time when the opioid abuse crisis has become so critical that the President recently declared it a national emergency. This seems to be an area ripe for educating physicians or for health plans to provide appropriate parameters for prescribing of migraine therapies, to ensure opioids are prescribed only for patients who truly need them.