Differences in pharmacological migraine treatment across different levels of clinical headache care - a cross-sectional study.

backgroundMigraine significantly impairs quality of life, reduces workplace productivity, and imposes a substantial socio-economic burden. The severity of migraine correlates with its impact on quality of life and healthcare costs, emphasizing the need for adequate management. In the past, primary care services often faced issues of inadequate treatment. This study evaluates differences in pharmacological recommendations for acute and preventive migraine treatments across primary, secondary, and tertiary care settings.

methodsThis cross-sectional study involves patients with confirmed migraine (with or without aura) visiting the tertiary headache center at Charité Berlin between 12/2015 and 01/2023 for the first time. Data on headache characteristics and prior treatments for acute and prophylactic treatments at primary/secondary and recommendations from tertiary level of care were retrieved from medical letters written after first consultation.

resultsAmong 1,047 migraine patients (42 years, 84% women), 99% had received treatment for acute migraine attacks by primary/secondary care facilities, and 96% were using it at their first consultation, with 63% advised to use a triptan. The average number of triptans tested prior to referral was 1 ± 0.99. Prophylactic treatment was prescribed to 52% of patients by primary/secondary care facilities, with an average of 1.2 ± 1.6 prior prophylactic attempts per patient, and 44% were actively using it at the time of consultation. More than two thirds of patients with over four monthly migraine days were not using prophylactic treatment at referral. Tricyclic antidepressants, beta-blocker and, anticonvulsants were prescribed significantly more often in primary/secondary care settings while Onabotulinumtoxin-A and Calcitonin Gene-Related Peptide(-receptor) antibodies were more commonly initiated in tertiary care. Treatment recommendations from primary/secondary settings were revised in 77% of patients following consultation at the tertiary headache clinic.

conclusionCompared to previous studies, the overall prescription of acute and prophylactic therapies in primary and secondary care facilities has improved. Further progress is needed in expanding the range of triptans and prophylactic treatments tested before referring patients to specialized centers. However, given the selected study population, the findings may not be fully applicable to all patients treated in primary/secondary care, especially those already receiving adequate care without being referred to specialized settings.