Even though African Americans are more likely than whites to experience debilitating migraine headaches, there are no racially based treatment disparities, new research shows.
However, investigators did find across-the-board overuse of opioids for migraine and overall suboptimal treatment of the disorder.
Dr Larry Charleston IV
“We saw that patients are being prescribed the wrong medications, like opioids, just about as much as they’re getting the right medications,” first author, Larry Charleston IV, MD, assistant professor, Department of Neurology, University of Michigan, Ann Arbor, told Medscape Medical News.
The study was published online in Cephalagia.
Low Preventive Care
The investigators’ original hypothesis — that African Americans receive relatively poor care with regard to migraine medications — was not borne out.
Previous research has uncovered marked racial differences in some aspects of migraine care. African Americans, for example, use healthcare services for migraine less frequently than white Americans, and they terminate appointments and receive inaccurate diagnoses more often.
The investigators analyzed all headache visits for adult patients participating in the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2013. The NAMCS is a nationally representative survey that focuses on outpatient, office-based care.
The analysis included 2860 NAMCS visits, which represent over 50 million outpatient visits in the United States during the years of the study. Of the total sample, 76% were non-Hispanic white, 10% were African American, and 10% were Hispanic.
Researchers classified migraine-related medications — both prophylactic and abortive — according to evidence-based categories determined by the American Academy of Neurology’s Headache Quality Measurement Set.
For both abortive and prophylactic agents, researchers put patients into one of four categories. The first three of these were “no agent” prescribed, “all high-quality” agents, and “some low-quality” agents. The fourth category was “any opiate” for abortive agents and “all low-quality” for prophylactic agents.
The authors expected to find that lower-quality abortive and prophylactic medications were prescribed more often to African-American patients than other patients.
Instead, they found that many patients of all races received low-quality migraine preventive medications (28.0% among whites, 22.0% among African Americans, and 26.4% among Hispanics).
In addition, a greater percentage of African-American patients (18.8%) received “all high-quality” prophylactics compared with 11.9% of white patients and 6.9% of Hispanic patients.
Overall quality of preventive medications did not significantly differ by race (P = .26).
There were also no major racial differences for abortive medications. The study showed that 15.3% of African-American patients, 19.4% of non-Hispanic white patients, and 17.7% of Hispanic patients received exclusively high-quality drugs, such as triptans or dihydroergotamine.
A total of 47.1% of African American, 38.2% of white, and 36.3% of Hispanic patients received no abortive treatments.
About 15.2% of all patients received a prescription for an opiate (16.0% of African Americans, 15.7% of whites, and 9.3% of Hispanics).
Room for Improvement
Opiates, said Dr Charleston, are not a first-line treatment for migraine. “They are associated with more headache-related disability; more need to see healthcare providers; and more anxiety, depression, and cardiovascular events.”
These drugs also contribute to medication overuse headaches, said Dr Charleston. “Opioids are not a substitute for a comprehensive pain plan, which is what we need.”
Clinicians prescribe opiates to treat migraine for several reasons, said Dr Charleston. For example, they may be pressured by time constraints in the clinic or by patients wishing to continue receiving an opiate that has already proven effective in controlling their pain.
Dr Charleston noted that opiate prescribing habits may have changed since 2013, the last year of the study.
The quality of abortive medications did not significantly differ by race (P = .44).
Although the researchers tried to control for other pain conditions, such as musculoskeletal disorders, it’s possible that opioids were prescribed for these other syndromes and not migraine.
Because many antihypertensive medications are considered high-quality migraine prevention agents, researchers repeated the primary analysis after excluding patients with hypertension. The results did not change significantly.
Because office-based prescribing patterns for migraine medications don’t explain the greater burden of migraine among African Americans, it’s possible, said Dr Charleston, that these patients seek migraine treatment at hospital emergency departments rather than doctors’ offices.
He noted that in the study, African-American visits represented only 10% of the total migraine visits to doctor offices, which is much less than the percentage of African Americans in the general US population.
It’s also possible that African Americans are prescribed migraine-related drugs but don’t take them because of their cost. That, too, may help explain the relatively high migraine burden in this group.
African Americans may get a general headache diagnosis rather than a migraine diagnose, which may also skew some of the results.
Dr Charleston stressed that the study provided no details on headache severity or the reasons medications were prescribed.
The study results highlight the importance of “prescribing migraine-specific medications wherever possible,” said Dr Charleston.
They also underline the need for more training in headache management for medical students, “particularly in neurology and primary care fields,” he said.
Dr Charleston considers the new study a “baseline” from which to broaden awareness of available medications to treat migraines.
“We do have room for improvement in our quality of care.”
Limitations
Commenting on the findings for Medscape Medical News, Charles Argoff, MD, professor of neurology at Albany Medical College and director of the Comprehensive Pain Center at Albany Medical Center, New York, said the study has several limitations.
When using the terms “high” and “low” quality of evidence for migraine medications, the authors “do not provide context to what this means when taking care of a real person,” said Dr Argoff.
“This is a huge weakness — no ‘high’ quality evidence treatment is effective for all patients, and in fact, it’s well known that many patients do not respond to those treatments that have a high level of evidence associated with their use.”
He pointed out that many patients don’t benefit from even Food and Drug Administration–approved migraine abortive agents.
As for opioids, Dr Argoff said not much can be concluded from this study with regard to the percentage of patients who received a prescription for this type of drug.
“This study does not describe why opioids were used — or whether other treatments were used first and were unsuccessful or whether opioids were used as initial agents.”
As with all other medical treatments, “opioids are neither absolutely good nor bad, appropriate nor inappropriate, in any setting,” said Dr Argoff.
Dr Charleston and Dr Argoff have disclosed no relevant financial relationships.
Cephalalgia. Published online June 26, 2017. Abstract
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