Geographic Variation in the Use of Triptans and Opioids for the Acute Treatment of Migraine Attacks

Abstract

BACKGROUND: Clinical guidelines and published literature suggest that opioids should be used sparingly or avoided in patients with acute migraine due to a lack of evidence of their effectiveness, association with disease progression, and risk of dependence. Triptans are the first line option for the acute treatment of moderate to severe migraine attacks. Despite recommendations, published research suggests that opioids are prescribed more frequently than triptans (53% vs 48%) among patients with migraine. Previous studies have been published for other chronic disease states showing that geographic variation plays a role in prescribing patterns in the United States (US). Moreover, 26 states have passed legislation that limit the prescribing or dispensing of opioids for acute pain. Every state in the Northeast has currently implemented these laws. In addition, the Northeast has the greatest number of headache subspecialists and primary care physicians per capita Yet, the level geographic differences in prescribing patterns, among triptan and opioid users for patients with migraine, has not been elucidated. OBJECTIVE: To assess the geographic variations in triptan and opioid prescribing patterns for patients with migraine. METHODS: We conducted a retrospective cohort analysis using claims data from the IBM® MarketScan® Commercial and Medicare Supplemental databases from January 1, 2016 to December 31, 2018. The target population was adults with migraine who had a migraine-related medical encounter in 2017 with a confirmatory encounter taking place between 31 to 365 days after the initial claim. Baseline characteristics were assessed during the 12-month pre-index period. The 12-month follow-up period was used to assess the outcomes of interest, triptan and opioid utilization, stratified by the four Census-Bureau designated regions: Northeast, Midwest, South, and West. State-level descriptive geographic heat maps were created to depict the patterns of triptan and opioid use in the US. Logistic regression models were used to estimate the binary outcomes of any triptan or opioid use in the follow-up period. Zero-truncated Negative binomial regression models were used to estimate the rate of triptan and opioid use among users in the form of incidence rate ratios (IRR). These analyses were adjusted for age, sex, health plan, presence of chronic migraine, and Elixhauser comorbidity scores. RESULTS: A total of 147,700 patients met the study inclusion criteria. The mean age was 45 and 84% of the patients were female. The prevalence of chronic migraine in the study population was 13% and the mean (SD) comorbidity score was 1.5 (1.7). In the follow-up period, the mean (SD) number of triptan claims for the Northeast, Midwest, South, and West regions were 2.36 (4.05), 2.50 (4.15), 2.60 (4.27), and 2.66 (4.32) respectively. The mean (SD) number of opioid claims for the same regions were 1.50 (4.34), 2.20 (5.00), 2.33 (5.13), and 2.35 (5.45), respectively. Compared to the Northeast, a patient with migraine was more likely to be a triptan user in the Midwest (OR: 1.16; 95% CI: 1.12, 1.20), South (OR: 1.17; 95% CI: 1.14, 1.21), and West (OR: 1.21; 95% CI: 1.16, 1.25). However, among triptan users, there were no significant differences in triptan use when compared to the Northeast for the Midwest (IRR: 0.99; 95% CI: 0.96, 1.02), South (IRR: 1.01; 95% CI: 0.98, 1.04), and West (IRR: 0.99; 95% CI: 0.96, 1.02). Compared to the Northeast, a patient with migraine was more likely to be an opioid user in the Midwest (OR: 1.71; 95% CI: 1.65, 1.78), South (OR: 1.91; 95% CI: 1.85, 1.97), and West (OR: 1.71; 95% CI: 1.64, 1.78). Among opioid users, there was also an increase in opioid use when compared to the Northeast for the Midwest (IRR: 1.21; 95% CI: 1.14, 1.29), South (IRR: 1.17; 95% CI: 1.11, 1.24), and West (IRR: 1.41; 95% CI: 1.32, 1.50). CONCLUSION: Results of our study suggest that compared to patients in the Northeast, patients from the other regions of the US were more likely to use triptans and opioids. Among triptan users, the rates of use were similar across all regions. However, among opioid users, the rates of use were lowest in the Northeast, followed by the South, Midwest, and West. Future work should formally evaluate the impact of headache subspecialists and opioid use policies on opioid use across regions.