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Assessing the impact of migraine. Dr Andrew Dowson. Kings Headache Service Kings College Hospital London, UK. Overview. Definition of impact (disability) History of migraine impact Recent research into migraine impact Assessing migraine impact Rationale for using instruments

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Dr andrew dowson

Assessing the impact of migraine

Dr Andrew Dowson

Kings Headache Service

Kings College Hospital

London, UK


Overview

Overview

  • Definition of impact (disability)

  • History of migraine impact

  • Recent research into migraine impact

  • Assessing migraine impact

    • Rationale for using instruments

    • Development of new instruments

  • Strategies for managing migraine using impact measures


Definition of impact disability

Definition of impact (disability)

  • WHO definition–‘In the context of health experience, a disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being'

World Health Organization, 1980.


History of migraine impact

History of migraine impact

  • Ancient civilizations

  • Classical times

  • Medieval

  • 18th–19th Century

  • 19th Century

  • 20th–21st Century


Ancient treatments for migraine

Ancient treatments for migraine


Classical times

Classical times


Medieval

Medieval


18th 19th century

18th – 19th Century


19th century

19th Century


20th century

20th Century


Recent research into migraine impact

Recent research into migraine impact

  • USA

  • Canada

  • Japan

  • Europe

  • Impact in the workplace and in education

  • Impact on family and social activities


Migraine related disability in the usa

Migraine-related disability in the USA

51

36

Sufferers (%)

12

1

None

Mild

Moderate/severe

Don’tknow

Stewart WF et al. Neurology 1994;44(suppl 4):24–39.


Migraine related disability in canada

Migraine-related disability in Canada

47

Sufferers (%)

22

17

14

Edmeads J et al. Can J Neurol Sci 1993;20:131–7.


Migraine related disability in japan

Migraine-related disability in Japan

40

34

21

Sufferers (%)

5

Sakai F, Igarashi H. Cephalalgia 1997;17:15–22.


Migraine related disability in europe

Migraine-related disability in Europe

%

Always have to lie down 76

Postpone household chores 90

Relations with family and friends

affected 54

Not in control of life 34

Disruption of life 67

Clarke CE et al. Q J Med 1996;89:77–84


Impact in the workplace usa

Impact in the workplace – USA

Females

100

80

60

Cumulative percent of total lost workday equivalents

40

20

0

0

20

40

60

80

100

Sufferers (%)

Stewart WF et al. Cephalalgia 1996;16:231–8


Impact in the workplace europe

Impact in the workplace – Europe

%

Usually miss work 50

Difficulty performing work 72

Cancel appointments/meetings 67

Rely on other people 45

Perceived effect on promotion 15

Clarke CE et al. Q J Med 1996;89:77–84


Impact on education

Impact on education

  • Total days per year of school missed–Children with migraine 7.8***–Controls 3.7

  • Days per year lost due to migraine–Children with migraine 2.8–Controls 0

*** p<0.0001Abu-Arefeh I, Russell G. BMJ 1994;309:765–9


Impact on family and social activities 1

Impact on family and social activities –1

  • Impact on spouse %–Activities cancelled 76–Tension between spouses 30–Sexual relations impaired 24

  • Impact on children–Interferes with activities 94–Attention-seeking behaviour 22–Hostile behaviour 17

Smith R. Headache 1996;36:278.


Impact on family and social activities 2

Impact on family and social activities – 2

%

  • Affects relations with family 56

  • Affects relations with friends 35

  • Affects relations with other people 33

  • Social events cancelled 54

Kryst S, Scherl ER. Headache Classification and Epidemiology. (Olesen J, ed) New York, Raven Press Ltd, 1994; p345–50


Burden of migraine to society direct costs

Burden of migraine to society: Direct costs

  • Total annual costs of medical care (adjusted to $US)

    • USA = $1 billion

    • Canada = $1.9 billion

    • Sweden = $13 million

    • UK = $45 million

    • Netherlands = $300 million

    • Australia = $31 million

Ferrari MD. Pharmacoeconomics 1998;13:667–75


Burden of migraine to society indirect costs

Burden of migraine to society: Indirect costs

  • Total annual indirect costs of migraine due to lost productivity (adjusted to US$)

    • USA = $13 billion

    • Canada = $732 million

    • Sweden = $1.6 billion

    • UK = $1.1–1.3 billion

    • Netherlands = $1.2 billion

    • Spain = $1.1 billion

    • Australia = $568 million

Ferrari MD. Pharmacoeconomics 1998;13:667–75


Conclusions

Conclusions

  • The characteristic features of migraine and its accompanying impact have been described consistently over the past 2000 years

  • Most migraine sufferers report significant impact (disability) associated with their attacks

  • Disability occurs in paid work, education, household tasks and family and leisure activities


Assessing migraine impact

Assessing migraine impact

  • Migraine attacks vary in severity from:–Moderate pain with no activity limitations

    to–Severe pain and prolonged incapacitation


The need for tools to assess migraine impact

The need for tools to assess migraine impact

  • No objective method to assess medical need

  • Poor communication between patients and physicians

  • Inefficient treatment strategies

    • Trial and error

    • Stepped care


Barriers to migraine care

Barriers to migraine care

Yes

Yes

Yes

Yes

Migrainepatients inneed of care

Ongoingassessmentof control

Goodoutcome

Appropriatelytreated

Diagnosed

Consulting

No

No

No

No

Motivate patient to seek care

Improve diagnosis

Improve treatment

Encourage follow-up


Measuring the impact of migraine

Measuring the impact of migraine

  • Define parameters for assessing impact of migraine to the sufferer and to society

  • Develop a simple to use tool which captures this information in a reliable and valid manner


Migraine impact to the sufferer

Migraine impact to the sufferer

  • Pain intensity is the most important aspect–Reported more frequently than other symptoms–Usually severe

  • Sufferers consulting a physician do so mostly for pain relief

Edmeads J et al. Can J Neurol Sci 1993;20:131–7


Migraine impact on society

Migraine impact on society

  • Headache-related disability is the most important determinant of migraine’s societal impact measured in economic terms

de Lissovoy G, Lazarus SS. Neurology 1994;44(suppl 4):56–62


Grading migraine severity

Grading migraine severity

  • Two studies–Von Korff et al–Washington County Study


Von korff study

Von Korff study

  • Graded severity of primary care patients with back pain, headache and jaw pain–Pain intensity–Disability–Persistence–Recency of onset

Von Korff M et al. Pain 1992;50:133–49


Pain disability link

Pain–disability link

  • Pain intensity and disability measures formed a reliable hierarchical scale–Pain intensity scaled lower range of severity–Disability scaled upper range of severity

  • Persistence and recency of onset did not scale with pain intensity or disability

Von Korff M et al. Pain 1992;50:133–49


Pain impact grades

Pain impact grades

  • Four severity grades identifiedGrade I:low pain intensity and low disabilityGrade II:high pain intensity and low disabilityGrade III:high disability which was moderately limitingGrade IV:high disability which was severely limiting

Von Korff M et al. Pain 1992;50:133–49


Primary care headache patients

Primary care headache patients

  • Grading system tested on 740 headache patients over 2-year period

  • Individual sufferer–Pain impact increased as severity grade increased

  • Society–Direct and indirect costs increased as severity grade increased

Von Korff MR, Stang PE. Headache Classification and Epidemiology (J Olesen ed). New York: Raven Press, 1994;pp367–71


Impact on the individual

Impact on the individual

  • Pain Impact (activity limitations, depression and poor-to-fair self-rated QoL)

60

40

Extent of disability

20

Grade II

Grade I

Grade IV

Grade III

0

1 month

1 year

2 years

Von Korff MR, Stang PE. Headache Classification and Epidemiology (J Olesen ed). New York: Raven Press, 1994;p367–71


Impact on society direct costs

Impact on society – Direct costs

  • Total cost of headache care per year per patient

1000

800

600

Mean cost of headache care ($US)

400

200

0

I

II

III

IV

Migraine severity grade at baseline

Von Korff MR, Stang PE. Headache Classification and Epidemiology (J Olesen ed). New York: Raven Press, 1994;p367–71


Impact on society indirect costs

Impact on society – Indirect costs

  • Unemployment rate

30

Severity grade at baseline

Grade II

Grade I

Grade IV

Grade III

20

Unemployed (%)

10

0

Baseline

Year 1

Year 2

Von Korff MR, Stang PE. Headache Classification and Epidemiology (J Olesen ed). New York: Raven Press, 1994;p367–71


Washington county study

Washington County Study

  • Telephone interview identified migraine sufferers in the general population

  • Sufferers rated most recent headache in previous 5 days

  • Pain intensity rated from 0–10

  • Disability rated as none, partial or all day

Stewart WF et al. Neurology 1994;44(suppl 4):24–39.


Pain disability link1

Pain–disability link

10

9

8

7

6

Pain rating

5

4

3

2

1

0

None

All day

Partial

Disability

Stewart WF et al. Neurology 1994;44(suppl 4):24–39


Conclusions1

Conclusions

  • An impact (disability) grading system has the potential to describe the burden of migraine both to the individual sufferer and to society

  • This provides a foundation for grading migraine severity


New instruments for assessing migraine impact

New instruments for assessing migraine impact

  • Migraine Disability Assessment Questionnaire (MIDAS)

  • Headache Impact Test (HIT)


Rationale for midas

Rationale for MIDAS

The MIDAS Questionnaire was developed as a tool to:

  • Improve physician–patient communication

  • Motivate disabled migraine sufferers to seek care

  • Identify patients with high treatment needs

  • Provide a rationalbasis for treatment decisions and follow-up


The midas questionnaire

The MIDAS Questionnaire


The midas questionnaire1

The MIDAS Questionnaire

  • Paper-based questionnaire, accessible at surgeries and pharmacists

  • 5 questions assessing the days lost due to migraine over a 3-month period:

    • Paid work

    • Household work

    • Family and social activities

  • Total lost days are summed and categorised into 4 severity grades

  • Two unscored questions assess headache frequency and pain intensity

Stewart WF et al. Cephalalgia1999;19:107–14


Scoring the midas questionnaire

Scoring the MIDAS Questionnaire

GradeDefinitionMIDAS score Medical need

IMinimal or infrequent

disability0–5Low

IIMild or infrequent

disability6–10Moderate

IIIModerate disability11–20High

IVSevere disability21+High

Add up total scores from Questions 1–5

Stewart WF et al. Cephalalgia1999;19:107–14


The midas questionnaire summary of research and clinical testing

The MIDAS Questionnaire: summary of research and clinical testing

  • Research criteria

    • Reliability

    • Content validity (accuracy)

    • Construct validity

    • External validity

  • Clinical practice criteria

    • Face validity

    • Easy to use

    • Easy to score

    • Intuitively meaningful

Lipton RB et al. Rev Contemp Pharmacother 2000;11:63–73


Dr andrew dowson

Use of MIDAS to specify treatment

  • ASA, NSAIDs

  • (Triptans)

MIDAS Grade I

  • NSAIDs, DHE

  • (Triptans)

MIDAS Grade II

Disability assessment

  • Triptans, DHE, butorphanol

MIDAS Grade III/IV


Midas strengths and weaknesses

MIDAS strengths and weaknesses

  • Strengths

    • Aid to communication between physicians and patients

      • Widely used by headache specialists and neurologists

    • Aid to referral for primary care physicians

    • Sensitive to change: can be used as an outcome measure following treatment


Midas strengths and weaknesses1

MIDAS strengths and weaknesses

  • Weaknesses

    • May not cover the full spectrum of headache due to its brevity

    • Grade scores may not indicate medical need

      • Many disabled patients score as Grade I

      • Weighting of questionnaire towards headache frequency

        • Patients with frequent headaches (e.g. CDH) tend to score as Grade IV

    • Not accepted as a stratification tool to aid choice of treatment


Headache impact test hit

Headache Impact Test (HIT)

  • Web-based test, accessible to all headache sufferers

  • Dynamic questionnaire covering the full headache range

  • In practice, 5 questions sufficient to grade the majority of headache sufferers


Features of dynamic assessments

Features of dynamic assessments

  • Questions are not printed on forms in advance

  • Items are sampled dynamically from all areas of headache impact

  • All levels of disability and impact are measured

  • Patients are questioned until clinical standards of score precision are met

  • Scores and interpretation guidelines are based on modern psychometric methods

  • Clinicians choose the amount of precision they need for their purpose


Ranges covered by four questionnaires

Ranges covered by four questionnaires

Most

Severe

80

80

80

80

70

70

70

70

60

60

60

60

50

50

50

50

40

40

40

40

30

30

30

30

20

20

20

20

20

20

Least

Severe

10

10

10

10

HDI

HImQ

MIDAS

MSQ

Range (%) 49 96 35 46


Dr andrew dowson

‘HIT’ matches questions to

each patient’s severity level

80

Severe

70

Moderate

60

50

Mild

40

40

30

20

10


Dr andrew dowson

Distribution of DynHA headache severity scores:

Headache sufferers, US population (n=1016)

Most

Severe

80

70

Migraine

Moderate

Headache

Averages

60

Population

50

40

30

20

Least

Severe

10


Dynamic hit is brief and accurate

Dynamic HIT is brief and accurate

  • Clinical standard of accuracy was achieved in 5 or fewer questions by:

    98% of those with migraine

    97% with severe headache

    87% with moderate headache

    61% with mild headache


Advantages of dynamic hit

Advantages of Dynamic HIT

  • Brevity of a short form

  • Accuracy required for measuring individual patients at all levels (mild to severe impact)

  • Comparability with widely-used questionnaires

  • Basis for an improved HIT static short form

  • Availability to all on the Internet


Dr andrew dowson

Sample Patient Report:

Headache Impact Test (HIT)

  • Your score

  • Your progress

  • What your score means

  • What you should do


Dr andrew dowson

Sample Clinician

Report:

Headache Impact Test (HIT)

  • Patient score

  • Patient progress

  • Interpretation

  • About the test


Strategies for managing migraine using impact measures

Strategies for managing migraine using impact measures

  • US Headache Consortium Guidelines

  • US Primary Care Network Guidelines

  • UK MICPA Guidelines


Dr andrew dowson

US Headache Consortium Guidelines: Schematic

Migraine

diagnosis

Disability

assessment

Patient

communication

and education

Individualised

management

Stratified care

IHS criteria

  • Attack frequency

  • Attack severity

  • Degree of disability

  • Non-headache symptoms

  • Patient participation

    • preference

    • prior response

    • co-existent conditions

IMPACT

Matchar DB et al. Neurology 2000;54:www.aan.com/public/practiceguidelines/03.pdf


Us headache consortium guidelines recommendations for treatment

US Headache Consortium Guidelines: Recommendations for treatment

  • Use migraine-specific agents (e.g. triptans, ergots, DHE)

    • as first-line treatment in patients with moderate or severe headache

    • in those who respond poorly to NSAIDs and combination medications

  • Non-oral route of administration if severe nausea or vomiting

  • Rescue medication for non-responsive migraine

  • Guard against medication-overuse headache

Matchar DB et al. Neurology 2000;54:www.aan.com/public/practiceguidelines/03.pdf


Us primary care network guidelines

US Primary Care Network Guidelines

  • Impact-based recognition of migraine

  • Acute treatment strategy

  • Preventive treatment strategy

  • Special considerations

    • Behavioural and physical treatments

    • Chronic headache disorders

    • Specific patient groups

    • System management


Impact based recognition of migraine

Impact-based recognition of migraine

  • How do headaches interfere with your life?

  • How frequently do you experience headaches of any type?

  • Has there been any change in your headache pattern over the last 6 months?

  • How often and how effectively do you use medication to treat headaches?


Acute treatment strategy

Acute treatment strategy

  • Identify components of migraine symptomatology that allow for early intervention

  • Select best treatment for each patient

  • Instruct patients on proper use of medications

  • Encourage use of a headache diary

  • Provide patient education

  • Tailor intervention to the individual’s needs to maintain or return the patient to full function


Preventive treatment strategy

Preventive treatment strategy

  • Reduce attack frequency, severity or duration

  • Improve responsiveness to treatment of acute attacks

  • Improve function and reduce disability

  • Prevent the evolution of episodic headaches to CDH

  • Treat co-morbid disorders


Uk mipca guidelines

UK MIPCA Guidelines

  • Individualised approach

  • Treatment is prescribed according to each patient’s needs

  • Patient’s needs assessed according to:

    • Nature of attacks

    • Impact of migraine on individual’s life

    • Demands of the patient’s lifestyle


Initial management strategy

Initial management strategy

  • Initial consultation

    • Diagnosis

    • Review previous treatments

    • Discuss pattern/frequency of attacks

  • Initiate acute treatments for sufferers experiencing 4 attacks per month

    • Simple analgesic  anti-emetic

    • Oral triptan if analgesic previously unsuccessful


Follow up management strategy

Follow-up management strategy

  • Oral triptan (nasal or sc if required)

  • Alternative triptan

  • Migraine: prophylaxis plus acute treatments

  • Frequent headaches: diagnosis of CDH

  • Consider referral


Overall conclusions

Overall conclusions

  • Migraine is a remarkably disabling condition

  • Measuring the impact (disability) of migraine aids the assessment of migraine severity

  • Tools that assess the impact of migraine are now available

  • US and UK management guidelines advocate the assessment of migraine impact


Topics for discussion

Topics for discussion

  • Does MIPCA endorse impact testing for migraine in primary care?

  • If so, which test should be used?

  • How should impact testing be used in primary care?

  • Should the change in impact measure be used as an outcome measure?


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