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Original Research (Original Article) 


Yasamiyan Rabah Salem Al-Harbi et al, 2020;4(3):746–752.

International Journal of Medicine in Developing Countries

The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia

Yasamiyan Rabah Salem Al-Harbi1*, Manal Abdel Hakim Selim2

Correspondence to: Yasamiyan Rabah Salem Al-Harbi

*Pharmacy College, Qassim University, Qassim, Saudi Arabia.

Email: yas.mino [at] hotmail.com

Full list of author information is available at the end of the article.

Received: 14 January 2020 | Accepted: 23 January 2020


ABSTRACT

Background:

The most common cause of chronic recurrent headaches without alarming symptoms is migraine. Potential triggers could precipitate acute attacks, and these include stress, specific foods, dehydration, missed meals, or disturbed sleep. Thereby, this study aimed to find the pattern of use, effectiveness, and the satisfaction of patients in Saudi Arabia regarding the abortive and prophylactic treatment of migraine.


Methodology:

The study included two steps: the first step was a pre-designed online questionnaire, which included a series of questions about the Saudi patient demographics, migraine history, type, symptoms, severity and triggers, as well as types of medications used as abortive therapy during the episodes, and the prophylactic treatment. The second step was a retrospective cross-sectional study on records of patients admitted to the Headache Clinic of the Neurology Department in King Fahd Specialist Hospital and diagnosed with migraine.


Results:

Total 209 participants responded to the online questionnaire in this study. Males had significantly higher satisfaction as compared to the females (p-value = 0.01). Patients aging between 20 and 40 years showed the highest appreciation of medication (p-value = 0.049). Patients who were on beta-blockers or Tricyclic antidepressants showed a higher level of satisfaction (p-value = 0.001), while patients who used prophylactic treatment for more than 12 months were more satisfied with their response as compared to other groups (p-value = 0.002).


Conclusion:

Pharmacologic management is still primitive. The preventive approach was also under-utilized. Under-treatment of migraine would affect patients' satisfaction and compliance, and most importantly patients' suffering.


Keywords:

Migraine, headache, treatment.


Introduction

Migraine is a moderate-to-severe headache that has specific characteristics, including being pounding, nauseating, unilateral and disabling of routine daily activities [1]. It lasts more than 30 minutes and usually between 4 and 72 hours, and often leads to avoidance of visual and auditory stimuli [2].

The acute attack could occur with and without the aura of transient scintillating scotomas or pins and needles [3]. Migraine is subtyped into episodic or chronic migraine based on the frequency of the attacks, with chronic migraine occurring on 15 or more days per month for more than 3 months, which for at least eight days per month has the typical features of migraine [4].

In general, migraine tends to improve with increasing age and pregnancy, and tend to respond to the medical treatment with a minority of cases requiring hospitalization [5]. Medical therapy of migraine encompasses both abortive and preventive medicine strategies [6].

The abortive strategy aims at terminating acute attacks of headache using oral paracetamol, Non-steroidal Anti-inflammatory Drugs, triptans, and prokinetics with avoidance of aggravating visual and auditory triggers [7]. In severe cases, parenteral administration is considered with the additive use of sedatives and narcotic analgesics [8].

The preventive strategy aims at reducing the frequency, severity, and duration of the attacks and avoiding medication-overuse headache [9]. A successful preventive strategy should lead to a more than 50% reduction in the attacks of migraine within three months [10].

Prevention of migraine involves pharmacologic therapy, such as beta-blockers, e.g., propranolol, anticonvulsants (topiramate), antidepressants (amitriptyline), combined with non-pharmacologic interventions including avoidance of the potential triggers, behavior, and medications adjustments [11,12].

A vital role in the management of migraines is to understand patients' perception of the disease, knowledge, behavioral and environmental circumstances, expectations, and concerns related to the different treatment options, including patients' satisfaction [13,14]. Since such information is lacking in Saudi Arabia, a surveillance study was conducted to understand the pattern of use and the effectiveness of the abortive and prophylactic treatment of migraine and patients' knowledge, awareness, and satisfaction with the treatment plans.


Subjects and Methods

This was an observational, cross-sectional study carried out in Saudi Arabia, using an online questionnaire and retrospective data review. The study population was Saudi patients over 18-year old, who met the International Headache Society criteria for migraine with or without aura and take at least one abortive medication for migraine with or without prophylactic therapy. All patients who completed the questionnaire were included in this study. Patients experiencing other forms of headaches were excluded. An online questionnaire was distributed among patients who met the inclusion criteria. Two hundred and nine responses were collected and described patients' socio-demographics, migraine symptoms and triggers, and the abortive and prophylactic medications used with particular attention to the frequency of use of abortive treatments, the perceived effectiveness, and the patient's satisfaction.

Supplementary data of the pattern of pharmacologic treatment were retrospectively collected from 50 randomly selected prescriptions for patients diagnosed with migraine and admitted to the Headache Clinic of Neurology Department in King Fahad Specialist Hospital, Buraida, Al-Qassim, Saudi Arabia.

All the data was recorded in a pre-designed and validated excel sheet. The data were represented in terms of frequencies and valid percentages for categorical variables. Correlations were done using the chi-square test for categorical variables at a level of significance p-value < 0.05. The data was further analyzed using IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY) version 24 for Microsoft Windows to perform all statistical calculations.


Results

Out of 209 participants, age was subcategorized into three groups on a scale of 20 years, starting with less than 20-year old and ending with more than 40-year old. Most of the respondents (63.1 %) belonged to the age group between 20 and 40 years old. On the other hand, the age group who were more than 40-year old had the least number of responses, with only 12.1% of responses. When gender was observed it was found that 68.7% were males, while females were 29%. The educational level was also evaluated. Approximately, 60.7% had a university degree or higher, while only 5.1% were illiterate (Table 1).

Table 1. Socio-demographic characters of the participants.

Socio-demographic characters Frequency (n) Percentage (%)
Gender Female 62 29.0
Male 147 68.7
Age group Less than 20 51 23.8
20 to 40 135 63.1
More than 40 26 12.1
Marital status Single 140 65.4
Married 72 33.6
Educational level Illiterate 11 5.1
Secondary 72 33.6
University degree or higher 130 60.7
Employment status Employed 61 28.5
Unemployed 152 71.0

Moreover, patients were asked about their history of cardio and cerebrovascular disease, which could be related to migraines. Approximately, 45.9% of the participants mentioned that they had hypertension, while 9.7% showed that they had heart failure (Figure 1).

Also, patients were asked about the characters of migraines that they had. Almost, 56.56% of the patients had a migraine at the age of less than 20 years, while 41.87% had five or fewer migraine attacks per month. Additionally, patients were asked about the degree of pain that they were experiencing. More than half of the participants (60.7%) described their migraine as moderate. When asked about the Migraine medications, 45% of the patients mentioned that the duration of migraine was more than 12 hours before using medications, while 65.2% of patients had pain relief after using medications for less than 2 hours (Table 2).

Figure 1. History of cardiovascular or cerebrovascular diseases that may be linked to migraines.

Table 2. Characteristics of migraine headaches.

Characteristics of migraine headaches Frequency Percentage (%)
Age of onset <20 112 56.56
20–40 79 39.89
>40 7 3.53
Number of migraine attacks experienced /month <2 85 41.66
2–5 85 41.66
5–15 24 5.82
More than 15 9 4.43
Degree of pain during the attack Mild 48 22.4
Moderate 130 60.7
Severe 26 12.1
Duration of migraine attack without taking medication <2 hours 75 37.5
2–5 hours 12 6
6–12 hours 23 11.5
>12 hours 90 45
Do you use any preventive medicine Never 134 62.6
Yes, I used it before 22 10.3
Yes, I am using now 46 21.5
Pain relief after abortive medications >2 hours 135 65.2%
2–5 hours 59 28.5%
>5 hours 13 6.3%

Also, patients were asked about the common symptoms of migraines that they had. Intolerance to sound and light came on the top of the list, with 39.7% participants suffering from this symptom (Figure 2).

Furthermore, the treatment used to treat migraines was evaluated among the recruited patients. Acetaminophen was the most prevalent medication used by 65.4% (Figure 3).

The use of prophylactic medications was also evaluated. Almost, 64.3% of the patients have not used these medications before. Approximately, 41.7% of the patients who used prophylactic medications previously mentioned that they stopped using it due to treatment failure, where 38% of the patients did not know exactly the type of medication that they used. Also, half of the patients used them for only 6 to 12 months, with 46% of the participants had migraine attacks between two to five attacks per month (Table 3).

Figure 2. Common symptoms of migraine.

Figure 3. Medications used to treat migraines.

Finally, responses to treatment satisfaction were compared over different variables using the chi-square test at a level of significance p-value <0.05. Satisfaction was evaluated through a scale of “Excellent, Good, Fair, and Poor.” It was revealed that males had significantly higher satisfaction compared to females (p-value = 0.01). Also, patients aging between 20 and 40 years old showed the highest satisfaction to medication (p-value = 0.049).

Moreover, patients who were on beta-blockers or TCAs showed a higher level of satisfaction compared to those on anticonvulsants (p-value = 0.001). While patients who used prophylactic treatment for more than 12 months were more satisfied with their response compared to other groups (p-value = 0.002) (Table 4).


Discussion

Migraine is regarded as one of the most common neurological presentations that could dramatically affect patient’s productivity and quality of life [8,11]. Its prevalence was reported to be 26.97% in a large Saudi cohort, with 1:2.9 male-to-female predominance [6]. The treatment of migraine is a multidisciplinary approach that includes both pharmacologic and non-pharmacologic abortive and preventive interventions [3,5].

Table 3. Prophylactic treatment for migraine headaches.

Parameters Frequency Percent
Using prophylactic treatment for migraine Use it now 50 24.2
Use it before 24 11.6
Never use it 133 64.3
Reasons for stopping the use of medication Migraine is not severe 7 29.2
Treatment failed 10 41.7
Adverse effect 2 8.3
Cost 1 4.2
Other 4 16.7
Type of medication Beta-blocker (Propranolol etc.) 9 18.0
Anticonvulsant (valproic acid, topiramate, gabapentin) 16 32.0
Tricyclic antidepressants (TCAs) (Amitriptyline) 6 12.0
The patient doesn't know 19 38.0
Duration of using medication <6 months 16 32.0
6-12 months 25 50.0
more than 12 months 9 18.0
Approximate migraine attacks/month after starting the prophylactic treatment <2 22 44.0
2 to 5 23 46.0
>5 times 5 10.0
Degree of pain after starting prophylactic therapy Sharp 9 18.0
Medium 26 52.0
Slight 15 30.0
The general response to prophylactic medication Excellent 7 14.0
Good 32 64.0
Fair 6 12.0
Poor 5 10.0

Table 4. Comparison between satisfactions toward prophylactic treatment over different variables using the chi-square test.

Variables Excellent Good Fair Poor p-value
Gender Male 13 37 17 8 0.01*
Female 4 25 12 6
Age Group Less than 20 years 2 10 4 2 0.049*
20 to 40 years 14 44 21 9
More than 40 years 2 10 4 3
Type of medication Beta-blocker 5 3 9 1 0.001*
Anticonvulsant 2 19 3 0
TCAs 5 4 5 2
Do not know 27 67 28 27
Duration of use <6 months 20 43 19 12 0.002*
6-12 months 7 34 12 2
more than 12 months 12 16 14 16

*p-value at a level of significance <0.05.

The present work aimed at exploring the pattern of use of the abortive and preventive treatment of migraine, the perceived effectiveness, and patients' satisfaction in Saudi patients. It was revealed that the general satisfaction of Saudi patients towards their prophylactic migraine regimen was considered low. However, this should be correlated with a short duration of using prophylactic regimens. Additionally, males had significantly higher satisfaction (p-value = 0.01). Also, patients aging between 20 and 40 years old showed the highest satisfaction rates (p-value = 0.049).

When the type of medication used was considered, patients who were on beta-blockers or TCAs showed a higher level of satisfaction compared to those on anticonvulsants (p-value = 0.001). While patients who used prophylactic treatment for more than 12 months were more satisfied with their response compared to other groups (p-value = 0.002), this could show the importance of compliance to long use of prophylactic duration.

The satisfaction of migraine patients had been evaluated in different settings. Lantéri-Minet et al. [15] compared the satisfaction of patients with migraine toward the effectiveness of the treatment in order to develop a tool for acute management of migraine. Lantéri-Minet et al. [15] included 11,274 from 2,108 general practitioner clinics and evaluated satisfaction using a four-point scale. It was shown that patients who had poor treatment or poor compliance with treatment were dissatisfied with their management.

The findings of Lantéri-Minet et al. [15] were compliant with the present work, where the overall satisfaction rate was considered as poor. Additionally, the present study analyzed other aspects that could reveal the reasons behind this poor satisfaction, such as characteristics of migraine headaches and figures of using prophylactic treatment.

Additionally, Seng et al. [16] examined the satisfaction of patients towards migraine treatment for acute attacks using triptans. Seng et al. [16] recruited 337 patients with acute migraine episodes who used triptans to relieve their symptoms. It was shown that patients who used triptan had lower activity limitations with migraines and better satisfaction toward the use of medications.

On the other hand, the present study evaluated the satisfaction of patients toward prophylactic therapy use. Also, the present study showed that patients on beta-blockers or TCA had a significantly better satisfaction rate compared to anticonvulsants (p-value =0.001).

Moreover, Lantéri-Minet et al. [17], evaluated the patients' expectations and satisfaction toward their migraine treatment in France. Lantéri-Minet et al. [17] included 1,710 in their survey from 489 clinics in France. It was revealed that the satisfaction toward migraine treatment was correlated to compliance with medications and using specific medications. These findings were also supported by the present study.

Finally, the present study had some limitations; it was performed in only one city in Saudi Arabia, multicenter studies in the future are recommended. Furthermore, the small sample size could decrease the reliability of the results.


Conclusion

Migraine is a common disabling health burden in Saudi Arabia and worldwide. Management of migraine is challenging for patients and physicians. Non-pharmacological approaches, including lifestyle modification and avoidance of triggers, might, in fact, be a trade-off dissatisfaction because of migraine and dissatisfaction by life-style modifications, eventually affecting patients' compliance. In this study, pharmacologic management is still primitive. The use of simple analgesics as abortive treatment with less interest in the use of other classes and combinations may reflect the concerns of medication overuse headache. The preventive approach was also under-utilized. Under-treatment of migraine would affect patients' satisfaction and compliance, and most importantly patients' suffering. Health education and awareness programs should target both physicians and patients for accurate diagnosis and step-wise approach for the management of migraine with the escalation of treatment according to the patient's satisfaction.


List of Abbreviations

TCA Tricyclic antidepressant

Conflict of interest

The authors declared that there is no conflict of interest regarding the publication of this case report.


Funding

None.


Consent of publication

Informed consent was obtained from all participants.


Ethical approval

The College of Pharmacy, Qassim University research ethics board approval was acquired prior to conducting any study procedure.


Author details

Yasamiyan Rabah Salem Al-Harbi, Manal Abdel Hakim Selim

  1. Pharmacy College, Qassim University, Qassim, Saudi Arabia
  2. Lecturer, Pharmacy Practice Department, Pharmacy College, Qassim University, Qassim, Saudi Arabia

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How to Cite this Article
Pubmed Style

Al-Harbi YRS, Selim MAH. The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia. IJMDC. 2020; 4(3): 746-752. doi:10.24911/IJMDC.51-1579004848


Web Style

Al-Harbi YRS, Selim MAH. The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia. http://www.ijmdc.com/?mno=81986 [Access: March 29, 2020]. doi:10.24911/IJMDC.51-1579004848


AMA (American Medical Association) Style

Al-Harbi YRS, Selim MAH. The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia. IJMDC. 2020; 4(3): 746-752. doi:10.24911/IJMDC.51-1579004848



Vancouver/ICMJE Style

Al-Harbi YRS, Selim MAH. The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia. IJMDC. (2020), [cited March 29, 2020]; 4(3): 746-752. doi:10.24911/IJMDC.51-1579004848



Harvard Style

Al-Harbi, Y. R. S. & Selim, . M. A. H. (2020) The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia. IJMDC, 4 (3), 746-752. doi:10.24911/IJMDC.51-1579004848



Turabian Style

Al-Harbi, Yasamiyan Rabah Salem, and Manal Abdel Hakim Selim. 2020. The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (3), 746-752. doi:10.24911/IJMDC.51-1579004848



Chicago Style

Al-Harbi, Yasamiyan Rabah Salem, and Manal Abdel Hakim Selim. "The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia." International Journal of Medicine in Developing Countries 4 (2020), 746-752. doi:10.24911/IJMDC.51-1579004848



MLA (The Modern Language Association) Style

Al-Harbi, Yasamiyan Rabah Salem, and Manal Abdel Hakim Selim. "The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia." International Journal of Medicine in Developing Countries 4.3 (2020), 746-752. Print. doi:10.24911/IJMDC.51-1579004848



APA (American Psychological Association) Style

Al-Harbi, Y. R. S. & Selim, . M. A. H. (2020) The pattern of use, effectiveness, and satisfaction of patients regarding migraine treatment in Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (3), 746-752. doi:10.24911/IJMDC.51-1579004848