Twenty-five years of triptans – a nationwide population study

Background The efficacy of triptans as the main acute treatment strategy for migraine headache at the population-wide level needs to be understood to inform clinical decision-making. We summarise key trends in triptan use using more than 25 years of Danish nationwide data. Methods We conducted a nationwide register-based cohort study based on all Danish residents with access to public healthcare between 1 January 1994 and 31 October 2019 and summarise informative trends of all purchases of triptans in Denmark in the same period. Complete purchase records of Sumatriptan, Naratriptan, Zolmitriptan, Rizatriptan, Almotriptan, Eletriptan, and Frovatriptan were used. Findings Over a 25-year period, triptan use increased from 345 to 945 defined daily doses (DDD) per 1000 inhabitants per year and the yearly prevalence of triptan use increased from 5.17 to 14.57 per 1000 inhabitants. Between 2014 and 2019, 12.3% of the Danish migraine population purchased a triptan. Following their initial purchase, 43% of patients had not repurchased triptans within 5 years. At most, 10% of patients indicating triptan discontinuation tried more than one triptan. The prevalence of triptan overuse, defined as having purchased at least 20 DDDs of triptans per month for 3 consecutive months, increased in parallel with the prevalence of triptan use, prevalent in 56 of every 1000 triptan users every year between 2014 and 2019. Interpretation In a cohort with access to free clinical consultations and low medication costs, we observed low rates of triptan adherence, likely due to disappointing efficacy and/or unpleasant side effects rather than economic considerations. Triptan success continues to be hindered by poor implementation of clinical guidelines and high rates of treatment discontinuance.

Triptans use and overuse: A pharmacoepidemiology study from the French health insurance system database covering 4.1 million people

Introduction The objective of this study was to estimate and to characterize the actual patterns of triptan use and overuse in France using a drug reimbursement database. Methods We included all people covered by the French General Health Insurance System (GHIS) from the Provence-Alpes-Côte-d’Azur (PACA) and Corsica administrative areas who had at least one dispensed dose of triptans between May 2010 and December 2011. All dispensed doses of triptans, migraine prophylactic treatment and psychotropic medications were extracted from the GHIS database. Triptan overuse was defined as triptan use >20 defined daily doses (DDD) per month on a regular basis for more than three consecutive months. Risk of overuse was assessed using logistic regression adjusted for gender and age. Results We included 99,540 patients who had at least one prescription of a triptan over the 20 months of the study. Among them, 2243 patients (2.3%) were identified as overusers and received 20.2% of the total DDD prescribed. Twelve percent of overusers and 6.9% of non-overusers were aged more than 65 years (OR: 1.81). Overusers did not have a greater number of prescribers and pharmacists than non-overusers. They were more frequently prescribed a prophylactic medication for migraine treatment (56.8% vs 35.9%, OR: 2.36), benzodiazepines (69.9% vs 54.7%, OR: 1.93) and antidepressants (49.4% vs 30.2%, OR: 2.33). Conclusions This work suggests that triptan overuse may be due to insufficient prescriber awareness of appropriate prescribing. The off-label prescription of triptans among the elderly necessitates investigating their cardiovascular risk profile in this sub-group.

Triptan overuse in the Dutch general population: A nationwide pharmaco-epidemiology database analysis in 6.7 million people

Introduction: A population-based observational study was used to assess the prevalence, demographics, risk factors, and costs of triptan overuse, defined as more than 30 (International Headache Society criteria) or 54 (stringent criteria) defined daily doses per 3 months. Methods: Analysis of the Dutch Health Care Insurance Board Database for 2005, which included prescriptions for 6.7 million people (46% of the total Dutch population). Results: Triptans were used by 85,172 (1.3%) people; of these, 8,844 (10.4%; 95% CI 10.2–10.6) were overusers by International Headache Society and 2,787 (3.3%; 95% CI 3.2–3.4) were overusers by stringent criteria. The triptan-specific odds ratios for the rate of International Headache Society overuse compared with sumatriptan were: 0.26 (95% CI 0.19–0.36) for frovatriptan; 0.34 (95% CI 0.32–0.37) for rizatriptan; 0.76 95% CI 0.68–0.85) for naratriptan; 0.86 (95% CI 0.72–1.02) for eletriptan; 0.97 (95% CI 0.88–1.06) for zolmitriptan; and 1.49 (95% CI 1.31–1.72) for almotriptan. Costs for overuse were 29.7 million euros; for the International Headache Society criteria this was 46% of total costs and for stringent criteria it was 23%. Discussion: In the Dutch general population, 1.3% used a triptan in 2005, of which 10.3% were overusers and accounted for half of the total costs of triptans. Users of frovatriptan, rizatriptan and naratriptan had a lower level of overuse.

Botulinum Toxin Type A and Acute Drug Costs in Migraine with Triptan Overuse

Background:Patients with chronic migraine and medication overuse are significant consumers of health care resources.Objective:To determine whether botulinum toxin type A prophylaxis reduces the cost of acute migraine medications in patients with chronic migraine and triptan overuse.Methods:In this multicenter, open-label study, patients with chronic migraine (≥15 headache days/month) who were triptan overusers (triptan intake ≥10 days/month for ≥3 months) received botulinum toxin type A (95-130 U) at baseline and month three. Headache (HA) frequency and medication use were assessed with patient diaries, and headache-related disability by means of the MIDAS and Headache Impact Test-6 questionnaires.Results:Of 53 patients enrolled (mean age ± standard deviation, 46.5 years ± 8.4; 47 [88.7%] females), 48 (90.6%) completed the study at month six. Based on headache diaries, significant (P≤0.0002) decreases from baseline were observed for days per month with headache/migraine, days with any acute headache medication use, days with triptan use, and triptan doses taken per month. A significant (P<0.0001) increase from baseline in headache-free days per month was also observed. Prescription medication costs for acute headache medications decreased significantly, including significant reductions in triptan costs (mean reduction of -C$106.32 ± 122.87/month during botulinum toxin type A prophylaxis; P<0.0001). At baseline, 78% of patients had severe disability (MIDAS score) and 86.8% had severe impact due to headache (HIT-6 scores); at month six, this decreased to 60% and 68%, respectively.Conclusions:Botulinum toxin type A prophylactic therapy markedly decreased costs related to acute headache medication use in patients with chronic migraine and triptan overuse.

Predictors of outcome of the treatment programme in a multidisciplinary headache centre

Introduction: Despite the high prevalence of headaches, multidisciplinary headache clinics are few and their efficacy still needs validation. The objective was to characterise patients and treatment results in a tertiary headache centre. Subjects and methods: A systematic review of all referred patients in the Danish Headache Centre in a 2-year period. Outcome results were analysed with respect to diagnoses and sociodemographics. Results: A total of 1326 patients with a mean age of 43.7 years and male : female ratio of 3 : 7 were included. In total, frequency and absence rate from work were reduced from 20 to 11 days ( P < 0.001) and 5 to 2 days/month ( P < 0.001), respectively. Predictors for good outcome were female gender, migraine, triptan overuse and a frequency of 10 days/month, whereas tension-type headache and overuse of simple analgesics predicted a poor outcome. Conclusions: The present analysis provided support for a multidisciplinary approach in a tertiary headache centre. Further evaluation of specific treatment strategies and outcome predictors are important for future planning.