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Managing migraine in underserved populations

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By: By Amy Perez, AGNP-BC; Roger P. Simon, MD; and Alexandria May, PharmD, BCPS

Collaboration addresses barriers to care.

Takeaways:

  • Managing migraine in underserved populations presents unique challenges in an urban outpatient neurology clinic.
  • Barriers to care include psychiatric comorbidities, sleep disorders, financial hardship, poor health literacy, lack of transportation, and homelessness
  • Interprofessional care, including physicians, nurse practitioners, and neuropharmacists, can help meet patient needs.

Migraine is a neurologic disorder that affects approximately 1 billion people worldwide, mostly females. The Global Burden of Disease Study 2016 identified migraine as the second leading cause of disability, accounting for more disability than all other neurologic disorders combined. The World Health Organization reports that 1.7% to 4% of the world’s adult population experiences 15 or more headache days per month. (See About migraine.)

About migraines

The International Classification of Headache Disorders 3rd Edition distinguishes migraine headaches as migraine with aura, migraine without aura, and chronic migraine. Differential diagnosis includes primary headache disorders with tension-type headache, which is the most common.

Patients meet the diagnostic criteria for migraine if they experience recurrent headaches, defined as four or more headache attacks lasting 4 to 72 hours. Migraine headaches are associated with at least two characteristic features (unilateral location, pulsating quality, moderate or severe pain, physical activity aggravation) and either nausea or vomiting or photophobia and phonophobia. Treatment goals include preventing episodic migraine (fewer than 15 headache days per month) from progressing to chronic (more than 15 headache days per month).

From 2009 to 2010, according to Burch and colleagues, headache or head pain was the fourth leading cause of visits to the emergency department, accounting for approximately 16.7% of visits. Healthy People 2010 reported that more than 50% of migraine headache visits take place in primary care and 23.2% in specialty outpatient settings.

The Chronic Migraine Epidemiology and Outcomes Study illustrated the various costs—careers, personal relationships, financial stability, and families—to people living with migraine. Saylor and colleagues estimated that migraine can have an annual economic impact of approximately $2,600 for episodic migraine and $8,000 for chronic migraine.

Barriers to care

Clinicians treating patients with migraine in medically underserved areas face several challenges, including psychiatric comorbidities, sleep disorders, financial hardship, poor health literacy, lack of transportation, and homelessness. A headache physician, nurse practitioner, and neuropharmacist in an urban outpatient clinic work collaboratively to provide the best treatment possible despite these barriers to care.

Psychiatric comorbidities

Baskin notes that psychiatric comorbidities such as depression, anxiety, bipolar disorder, schizoaffective disorder, and post-traumatic stress disorder contribute to the challenge of effective migraine treatment. Comorbidities and stress increase the chances of episodic migraine progressing to chronic migraine. They also may complicate differentiating true migraine from other headache disorders and interfere with pharmacologic and nonpharmacologic treatment adherence.

In a systematic review, Dresler and colleagues found that migraineurs are over 2.5 times more likely to suffer from depression compared with non-migraineurs. The relationship between depression and migraine appears to be bidirectional.

More than half of patients with migraine will meet the criteria for at least one anxiety disorder in their lifetime. Anxiety disorders are two to five times more prevalent in patients with migraine than in the general population, up to two times more common in patients with migraine than in patients with depression, and more common in patients with chronic migraine compared with episodic migraine. Treating and controlling anxiety in patients with migraine generally is associated with improved adherence to, and effectiveness of, treatment plans and improved quality of life.

We implement various interventions—including deep breathing exercises, relaxation techniques, pharmacologic treatment, and psychiatric referrals—to address anxiety and other psychiatric disorders during patient visits. However, time constraints during an outpatient neurology visit limit our ability to maximize these interventions, and outside resources are limited, especially for underserved populations. In addition, the stigma associated with mental health treatment prevents some patients from seeking treatment.

Sleep disorders

Sleep disorders (including sleep apnea, restless leg syndrome, and insomnia) and migraine have a bidirectional association. To determine if a patient’s migraines are associated with a sleep disorder, ask about the timing of migraines. For example, patients who wake with a migraine, snore, or report gasping for air should raise suspicion for sleep apnea. Sleep disturbances (including irregular sleep, lack of sleep, or too much sleep) can trigger a migraine. Conversely, having a migraine headache can interfere with good sleep.

Ideally, patients should be screened for obstructive sleep apnea and insomnia and referred to a sleep specialist. However, a sleep study may have up-front costs that create a barrier to comprehensive migraine headache treatment. In our clinic, we review good sleep hygiene techniques with patients, but many underserved patients don’t have control over their sleep environments, particularly those who are homeless.

Financial hardship

Approximately 30% of our patients are insured by Medicaid and 30% by Medicare Part D; 25% are uninsured. Assistance programs for certain medications are available for patients whose income is 400% below the federal poverty level, but many face the possibility of running out of medication or have limited treatment options. Psychiatric co-morbidities can limit pharmacologic treatment options. Many first-line migraine treatments are psychiatric medications, which limit the ability to titrate and make changes. Behavioral interventions—such as bio-feedback, mindfulness training, and cognitive behavioral therapy—frequently are unavailable to this patient population due to lack of insurance and financial resources. Some insurance doesn’t cover neuromodulation devices, which are used alone or in conjunction with pharmacologic treatment to change the activity of nerve pathways in the brain to stop a migraine. In addition, patient assistance programs aren’t available for the uninsured.

Health literacy and computer access

Functioning within the complex healthcare environment requires certain skills, including health literacy (the ability to find, understand, and use information and services to make personal health decisions). For example, patients must be able to read medication bottles, understand how to implement pharmacologic and nonpharmacologic interventions, and provide documentation in a timely manner to receive approval for financial assistance. In many cases, receiving health information requires that patients have a working phone number, computer access to communicate with healthcare providers, and access to phone or computer apps to manage a headache diary.

Approximately 80 million American adults require assistance with health literacy. Our clinic witnesses the challenges that can arise in patients with low health literacy, especially with medications requiring titration such as topiramate and lamotrigine. Our neuropharmacist—who has their own schedule for patient visits in the neurology clinic—helps address poor health literacy by assisting with completing forms to receive free or reduced-fee medications, creating color-coded medication systems, reviewing the use of pill boxes, and performing medication reconciliation. We use the teach-back method to assess a patient’s ability to read instructions.

Lack of transportation

Getting to appointments can be difficult without a car. Patients may rely on others for transportation and may miss or be late to appointments. Even when patients have a car, they may not be able to afford the cost of parking. Although our clinic is located near train and bus lines, services can be unreliable and inaccessible for some. We’re providing telehealth to patients during the pandemic, and discussions are underway with hospital administration to continue these practices to ensure continuity of care.

Homelessness

Patients who lack safe and secure housing may lack access to electricity, which means they may not have appropriate lighting to read medication instructions or refrigerators for storage. They’re at risk of having medications stolen, a problem frequently reported by our patient population. Without a permanent address, these patients can’t take advantage of receiving medications through the mail. During the pandemic, this has been another barrier to patients receiving medications consistently. To overcome this hurdle, we sometimes request that medications be mailed to a liaison in the pharmacy department who then gives them to the patient or a family member who might be willing to receive the medication and pass it along to the patient. However, many of these patients hesitate to go to pharmacies and have limited community support to have others pick up medications for them.

Treatment strategies

Migraine treatment begins with a thorough patient history, including screening for comorbidities using tools such as the Patient Health Questionnaire for depression, the Generalized Anxiety Disorder Scale, and the Epworth Sleepiness Scale to evaluate for sleep apnea. Identifying comorbidities helps the provider choose an effective migraine treatment that also addresses the comorbidity.

Treatment options for migraine headaches include both preventive and abortive medications. Some are available over-the-counter, but most are prescribed. Routes of administration include oral tablets, oral dissolving tablets, intranasal sprays, intramuscular injections, subcutaneous injections with Botox or the new calcitonin gene-related peptide (CGRP) medications, and I.V. infusions. The full scale of treatment options exceeds the scope of this article.

Preventive medications

Preventive medications include tricyclic antidepressants (amitriptyline) and serotonin-norepinephrine reuptake inhibitors (venlafaxine). They can be prescribed for patients with psychiatric comorbidities such as anxiety and depression, as well as sleep disorders. A beta blocker such as propranolol, another preventive medication, may be appropriate for patients with hypertension, anxiety, and migraine. However, the provider should monitor for worsening depression. Providers may prescribe anticonvulsants for chronic migraine treatment, but they require caution in women of child-bearing age due to the risk of fetal anomalies.

The nurse practitioner performs Botox injections every 12 weeks in our clinic. After training by the neuropharmacist, patients can administer monthly CGRP injections at home. This relatively new medication class was developed specifically to provide preventive and abortive treatment. It’s a good option for patients who prefer an alternative to daily medication, for those who’ve had treatment failures, or those who are already taking several other medications. Some patients receive a combination of daily oral preventive treatment as well as injections. (See Preventive treatment options.)

Preventive treatment options

The following list of preventive treatment options for migraine isn’t all-inclusive. It cites the most commonly used prescription-only medications.

Medication Formulation Cost*
Angiotensin converting enzyme Inhibitor
Lisinopril 5, 10, 20, or 40 mg tablets $4 ($12) for 30 tablets
Angiotensin receptor blocker
Candesartan 4, 8, 16, or 32 mg tablets $111 ($350) for 30 tablets
Antidepressants
Amitriptyline 25, 50, 75, or 100 mg tablets $13 ($35) for 30 tablets
Venlafaxine ER 37.5, 75, or 150 mg tablets $73 ($650) for 30 tablets
Antiepileptics
Divalproex ER 250 or 500 mg tablets $132 ($255) for 60 tablets
Topiramate 25, 50, or 100 mg tablets $31 ($254) for 60 tablets
Beta Blockers
Propranolol ER 80, 120, or 160 mg tablets $66 ($3,043) for 30 tablets
Metoprolol ER 25, 50, 100, or 200 mg tablets $22 ($65) for 30 tablets
Calcitonin gene-related peptide receptor antagonists
Erenumab (Aimovig) 70 or 140 mg/mL autoinjector Generic not available

($782 for 1 dose)

Fremanezumab (Ajovy) 225 mg/1.5 mL autoinjector Generic not available

($807 for 1 dose)

Galcanezumab (Emgality) 120 mg/mL pen Generic not available

($757 for 1 dose)

Calcium channel blocker
Verapamil ER 120, 180, or 240 mg tablets $24 ($214) for 30 tablets

ER/XR/XL = extended release, LA = long acting, SR = sustained release

*Estimated average retail cost at press time based on information obtained at http://www.goodrx.com. Generic price listed first; brand price in parentheses.

Abortive medications

Abortive migraine medications, such as triptans, can be used for episodic or chronic migraine treatment. Limitations include comorbidities such as uncontrolled hypertension and stroke history. Some patients can’t tolerate triptans and report chest pain. The potential for a medication overuse headache limits the amount of abortive medication a patient can take. Patient education, addressed at each visit, can help prevent this adverse reaction. (See Abortive treatment options.)

Abortive treatment options

The following list of abortive treatment options for migraine cites the most commonly used prescription-only medications and is not all-inclusive.

Medication Formulation Cost*
Serotonin receptor agonists
Almotriptan 6.25- or 12.5-mg tablets $258 for 6 tablets
Eletriptan 20- or 40-mg tablets $289 ($499) for 6 tablets
Frovatriptan 2.5-mg tablets $603 ($1,205) for 9 tablets
Lasmiditan 50-, 100-, or 200-mg tablet $670 ($793) for 8 tablets
Naratriptan 1- or 2.5-mg tablets $130 ($652) for 9 tablets
Rizatriptan 5- or 10-mg tablets $170 ($412) for 9 tablets
Sumatriptan 25-, 50-, or 100-mg tablets

6-mg injection

5- or 20-mg nasal spray

$146 ($350) for 9 tablets

$200 ($540) for 1 kit

$373 ($665) for 6 doses

Zolmitriptan 2.5- or 5- mg tablets $188 ($940) for 6 tablets
Ergot Derivative
Dihydroergotamine (D.H.E. 45) 1 mg/mL ampule $1,488 ($11,410) for 10 ampules (1 dose pack)
CGRP Inhibitors
Ubrogepant 50- or 100-mg tablets $1,070 for 10 tablets
Rimegepant 75-mg oral disintegrating tablet $1,078 for 8 tablets

*Estimated average retail cost at press time based on information obtained at http://www.goodrx.com. Generic price listed first; brand prices in parentheses.

Other treatment options

Migraine treatment goals include decreasing headache frequency, intensity, and duration. This can be accomplished with a combination of preventive and abortive medications, lifestyle changes, and comorbidity management. Other treatment options include vitamins (such as magnesium and riboflavin), essential oils, and over-the-counter medications.

Identifying migraine triggers—such as certain foods, alcohol, dehydration, and stress—can help prevent headaches. However, patients without housing may not be able to avoid triggers, and the stress of food and shelter insecurity may prompt a migraine.

Nursing implications

Our clinic’s nursing team interacts with patients in various ways. Certified nursing assistants perform the initial clinic triage and vital sign assessment. They provide reports of patient headache pain and other concerns. The nurse practitioner completes the evaluation and assessment and develops treatment strategies. Although the patient may be coming to a clinic visit because of migraine headaches, the holistic nursing model allows for the complete assessment of other issues (sleep disorders, mental health issues, health literacy) that may impact successful treatment. Clinic nurses check out patients at the end of the visit and are instrumental in ensuring prescriptions have been sent to the correct pharmacy, educating patients about the treatment plan, and scheduling follow-up visits.

A collaborative approach

Headache management in underserved populations is a global and local healthcare burden. Our headache clinic works to provide migraine treatment with a combined approach of provider treatment, neuropharmacist education, and referrals to specialists. This collaborative approach allows us to better meet the needs of this unique patient population. Additional questions for future research include examining differences in migraine prevalence between urban and rural populations.

Amy Perez is an adult nurse practitioner in the outpatient neurology clinic at Grady Health System in Atlanta, Georgia. Roger P. Simon, MD, is a neurologist at Grady Neurology Clinic in Atlanta, Georgia. Alexandria May, PharmD, BCPS, is a clinical pharmacist specialist at Grady Health System in Atlanta, Georgia. 

References

Baskin SM. Behavioral approaches in headache medicine. Virtual Scottsdale Headache Symposium. November 2020.

Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the United States: Updated statistics from government health surveillance studies. Headache. 2015;55(1):21-34. doi:10.1111/head.12482

Buse DC, Fanning KM, Reed ML, et al. Life with migraine: Effects on relationships, career, and finances from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. Headache. 2019;59(8):1286-99. doi:10.1111/head.13613

Centers for Disease Control and Prevention. Healthy People 2010. November 6, 2015. cdc.gov/nchs/healthy_people/hp2010.htm#:~:text=Healthy%20People%202010%20builds%20on,be%20used%20to%20measure%20progress.

Davies A, Wood LJ. Homeless health care: Meeting the challenges of providing primary care. Med J Aust. 2018;209(5):230-4. doi: 10.5694/mja17.01264

Dresler T, Caratozzolo S, Guldolf K, et al. Understanding the nature of psychiatric comorbidity in migraine: A systematic review focused on interactions and treatment implications. J Headache Pain. 2019;20(1):51. doi: 10.1186/s10194-019-0988-x

Health Resources & Services Administration. Health literacy. August 2019. hrsa.gov/about/organization/bureaus/ohe/health-literacy/index.html

Hickey KT, Masterson Creber RM, Reading M, et al. Low health literacy: Implications for managing cardiac patients in practice. Nurse Pract. 2018;43(8):49-55. doi:10.1097/01.NPR.0000541468.54290.49

International Headache Society. The International Classification of Heachache Disorders. 3rd ed. ichd-3.org

Minen MT, Begasse De Dhaem O, Kroon Van Diest A, et al. Migraine and its psychiatric co-morbidities. J Neurol Neurosurg Psychiatry. 2016;87(7):741-9. doi:10.1136/jnnp-2015-312233

Saylor D, Steiner TJ. The global burden of headache. Semin Neurol. 2018;38(2):182-90. doi:10.1055/s-0038-1646946

Stovner LJ, Nichols E, Steiner TJ, et al. Global, regional and national burden of migraine and tension-type headache, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17(11):954-76. doi:10.1016/S1474-4422(18)30322-3

Vos T, Abajobir AA, Abate KH, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 disease and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211-59. doi:10.1016/S0140-6736(17)32154-2

World Health Organization. Headache disorders. April 8, 2016. who.int/news-room/fact-sheets/detail/headache-disorders 

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