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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
– Development of new instruments
• Strategies for managing migraine using
impact measures
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
•
•
•
•
•
•
Ancient civilizations
Classical times
Medieval
18th–19th Century
19th Century
20th–21st Century
Ancient treatments for migraine
Classical times
Medieval
18th – 19th Century
19th Century
20th Century
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
60
51
Sufferers (%)
50
40
36
30
20
12
10
1
0
None
Mild
Stewart WF et al. Neurology 1994;44(suppl 4):24–39.
Moderate/
severe
Don’t know
Sufferers (%)
Migraine-related disability in Canada
50
45
40
35
30
25
20
15
10
5
0
47
22
17
14
None
Mild
Edmeads J et al. Can J Neurol Sci 1993;20:131–7.
Moderate
Severe
Sufferers (%)
Migraine-related disability in Japan
45
40
35
30
25
20
15
10
5
0
40
34
21
5
None
Mild
Sakai F, Igarashi H. Cephalalgia 1997;17:15–22.
Moderate
Severe
Migraine-related disability in Europe
%
Always have to lie down
Postpone household chores
Relations with family and friends
affected
Not in control of life
Disruption of life
Clarke CE et al. Q J Med 1996;89:77–84
76
90
54
34
67
Impact in the workplace – USA
Cumulative percent of total lost
workday equivalents
Females
100
80
60
40
20
0
0
20
40
60
Sufferers (%)
Stewart WF et al. Cephalalgia 1996;16:231–8
80
100
Impact in the workplace – Europe
%
Usually miss work
Difficulty performing work
Cancel appointments/meetings
Rely on other people
Perceived effect on promotion
Clarke CE et al. Q J Med 1996;89:77–84
50
72
67
45
15
Impact on education
• Total days per year of school missed
–
–
•
Children with migraine
Controls
7.8***
3.7
Days per year lost due to migraine
–
–
Children with migraine
Controls
*** p<0.0001
Abu-Arefeh I, Russell G. BMJ 1994;309:765–9
2.8
0
Impact on family and social
activities –1
• Impact on spouse
–
–
–
•
Activities cancelled
Tension between spouses
Sexual relations impaired
%
76
30
24
Impact on children
–
–
–
Interferes with activities
Attention-seeking behaviour
Hostile behaviour
Smith R. Headache 1996;36:278.
94
22
17
Impact on family and social
activities – 2
•
•
•
•
Affects relations with family
Affects relations with friends
Affects relations with other people
Social events cancelled
Kryst S, Scherl ER. Headache Classification and Epidemiology.
(Olesen J, ed) New York, Raven Press Ltd, 1994; p345–50
%
56
35
33
54
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 = $31 million
Ferrari MD. Pharmacoeconomics 1998;13:667–75
Burden of migraine to society:
Indirect costs
• Total annual indirect costs of migraine due to
lost productivity (adjusted to US$)
–
–
–
–
–
–
–
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
• 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
• 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
• 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
Yes
Migraine
patients in
need of
care
Consulting
No
Motivate
patient to
seek care
Yes
Diagnosed
No
Improve
diagnosis
Yes
Appropriately
treated
No
Improve
treatment
Yes
Ongoing
assessment
of control
No
Encourage
follow-up
Good
outcome
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
• 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
• 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
• Two studies
–
–
Von Korff et al
Washington County 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 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
• Four severity grades identified
Grade I:
Grade II:
Grade III:
Grade IV:
low pain intensity and low disability
high pain intensity and low
disability
high disability which was
moderately limiting
high disability which was severely
limiting
Von Korff M et al. Pain 1992;50:133–49
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

Pain Impact (activity limitations, depression and poor-to-fair self-rated QoL)
Extent of disability
60
40
20
Grade IV
Grade III
0
1 month
Grade II
Grade I
1 year
Von Korff MR, Stang PE. Headache Classification and Epidemiology (J Olesen
ed). New York: Raven Press, 1994;p367–71
2 years
Impact on society – Direct costs

Total cost of headache care per year per patient
Mean cost of headache care ($US)
1000
800
600
400
200
0
I
II
III
Migraine severity grade at baseline
Von Korff MR, Stang PE. Headache Classification and Epidemiology (J Olesen
ed). New York: Raven Press, 1994;p367–71
IV
Impact on society – Indirect costs

Unemployment rate
30
Severity grade at baseline
Unemployed (%)
Grade IV
Grade III
Grade II
Grade I
20
10
0
Baseline
Year 1
Von Korff MR, Stang PE. Headache Classification and Epidemiology (J Olesen
ed). New York: Raven Press, 1994;p367–71
Year 2
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 link
10
9
8
Pain rating
7
6
5
4
3
2
1
0
None
Partial
Disability
Stewart WF et al. Neurology 1994;44(suppl 4):24–39
All day
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
• Migraine Disability Assessment
Questionnaire (MIDAS)
• Headache Impact Test (HIT)
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 rational basis for treatment
decisions and follow-up
The MIDAS Questionnaire
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. Cephalalgia 1999;19:107–14
Scoring the MIDAS Questionnaire
Grade
Definition
MIDAS score
Medical
need
0–5
Low
6–10
11–20
21+
Moderate
High
High
Add up total scores from Questions 1–5
I
II
III
IV
Minimal or infrequent
disability
Mild or infrequent
disability
Moderate disability
Severe disability
Stewart WF et al. Cephalalgia 1999;19:107–14
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
Use of MIDAS to specify treatment
Disability
assessment
MIDAS
Grade I
ASA, NSAIDs
(Triptans)
MIDAS
Grade II
NSAIDs, DHE
(Triptans)
MIDAS
Grade III/IV
Triptans, DHE,
butorphanol
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 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)
• 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
• 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
Most
Severe
Least
Severe
Range (%)
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
10
10
10
10
HDI
HImQ
MIDAS
MSQ
49
96
35
46
‘HIT’ matches questions to
each patient’s severity level
80
Severe
70
60
50
Mild
40
30
20
10
Moderate
Distribution of DynHA headache severity scores:
Headache sufferers, US population (n=1016)
Most
Severe
70
Migraine
Averages
80
Moderate
Headache
Population
60
50
40
30
20
Least
Severe
10
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
• 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
Sample Patient Report:
Headache Impact Test (HIT)
• Your score
• Your progress
• What your score means
• What you should do
Sample Clinician
Report:
Headache Impact Test (HIT)
• Patient score
• Patient progress
• Interpretation
• About the test
Strategies for managing migraine
using impact measures
• US Headache Consortium Guidelines
• US Primary Care Network Guidelines
• UK MICPA Guidelines
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
• 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
•
•
•
•
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
• 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
• 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
• 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
• 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 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
• Oral triptan (nasal or sc if required)
• Alternative triptan
• Migraine: prophylaxis plus acute
treatments
• Frequent headaches: diagnosis of CDH
• Consider referral
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
• 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?