Abstract
To assess the prevalence of migraine and the attitudes and practice patterns of Taiwanese neurologists regarding migraine management, we mailed the survey questionnaire to all of the actively practicing board-certified neurologists from the membership list of the Taiwan Neurological Association. Of the targeted 531 neurologists, 123 (23.2%) participated in this study. Thirty of the participants (27.6%) reported having migraine. Most neurologists (88.5%) felt that headache was an important part of their practice. Many neurologists (65.0%) used neuroim- aging to evaluate patients with severe headache and 44.7% used electroencephalography for headache evaluation. Many participants knew that combination analgesic was a common cause of medication-overuse headache, but did not know that ergotamine, acetaminophen and triptans were possible aetiologies of medication-overuse headache. Our study suggests that awareness of medication- overuse headache and the indications of neuroimaging should be stressed in Taiwan, and headache guidelines should be modified according to local factors.
Migraine is not uncommon in Asians. Previous studies in Asia using the International Headache Society (IHS) criteria (1) have shown that the prevalence of migraine ranged from 8.4% to 12.7% (2). In Taiwan, approximately 14.4% of women and 4.5% of men suffered from migraine in 1 year (3), and 3.2–3.9% in the population had chronic daily headache (4, 5). These data are similar to, though in the lower range of, those reported in western countries (6).
In contrast to the high prevalence of migraine in all ethnic groups, the treatment may differ country-wise owing to the diversity of healthcare systems, clinicians’ attitudes and practice patterns. For instance, since 1990 triptans have become one of the most efficacious treatments of choice for acute severe migraine (7). However, they were not introduced to Taiwan's healthcare system until 1997. In Taiwan, the National Health Insurance (NHI) programme was launched in 1995. It is a government-run, single-payer system with a low copayment for out-patient and in-patient services, enrolling more than 96% of Taiwan's population with more than 90% of healthcare providers included (8). Unlike the USA, UK or Canada, the mandated physician referral system is absent in Taiwan, and patients have complete freedom to access the tertiary care institutions for primary care. As a result, NHI is characterized with a high out-patient clinic visiting rate: 14 visits per capita in 2001, compared with 11 visits in 1999 (8). The reimbursement allowance for oral sumatriptan (50 mg, tablet) was two tablets per month from 1999 to 2004 and was expanded to eight tablets in August 2004. At present, no parenteral triptans are in the market here.
For better management of migraine, many countries have developed their own guidelines for both abortive and preventive therapy of migraine. Such a guideline has not been established in Taiwan. It is important to understand the clinicians’ attitudes to migraine and their consensus on migraine management; factors such as practice setting and healthcare system should also be considered. Otherwise, the guideline may not be practical. For this reason, the neurologist is becoming a new and important target of migraine research.
The purpose of this study was to investigate the practice pattern and attitudes of migraine management of Taiwan's neurologists. Such a survey has not been conducted in Asia before.
Methods
We invited all the actively practising board-certified neurologists based on the membership list of the Taiwan Neurological Association to participate in this survey. A self-administered questionnaire was mailed to each of them, with self-addressed stamped envelopes and return fax numbers. The 59-item questionnaire collected data on: (i) the demographic and practice characteristics (age, sex, years in practice, location of practice, and practice settings) (n = 10); (ii) their attitudes about migraine and its management [this section consisted of 12 yes/no questions (Table 1), which were modified from the Migraine Knowledge, Attitude, and Practice Patterns (MKAPP) Survey (9)]; (iii) the prescription patterns of migraine preventive medications (n = 6); (iv) the prescription patterns of triptans and other acute treatments for migraine (n = 16); (v) approaches to diagnosis, evaluation, and education of headache patients (n = 8); (vi) self-reporting of their headaches (n = 1); (vii) headache continuing education within the past 2 years (n = 6).
The percentage of agreement for the questions about attitudes to migraine and its management among participating neurologists
Descriptive and analytic statistics were performed with the Statistical Products for the Social Sciences (SPSS) software for Windows, version 11.0 (SPSS Inc., Chicago, IL, USA). The participants were stratified according to sex, headache diagnoses (migraine or non-migraine), practice settings (university-based hospitals, clinical hospitals, or solo practices), and prescription patterns (prescribing triptans to their migraine patients, or not). The difference in mean values or the distribution among subgroups was compared by using Student's t-test or the χ2 test where appropriate. A P-value < 0.05 was regarded as statistically significant.
Results
Participants
Of the targeted 531 neurologists, 123 (23.2%) participated in this study. Participants of the study had a mean age of 42.2 ± 8.6 years and were predominantly men (87.0%). They had been in practice for a mean 10.0 ± 8.5 years. The female participants were significantly younger than the males (37.6 vs. 42.8 years, t = 2.33, P = 0.02). The practice settings were university-based hospitals (31.7%), clinical hospitals (59.4%) and solo practices (8.9%). The gender ratio and practice settings did not differ between the participants and non-participants (χ2 test, P > 0.05). Since rare physicians were headache specialists, only one participant ran a headache clinic. Most participants (79.9%) had never attended the headache continuing education programme in the past 2 years.
Overall, participants saw a median of 174 patients per week, 19.4% of whom were headache patients. The female participants saw significantly fewer patients per week (109 vs. 184, t = 2.57, P = 0.01) but a higher proportion of headache patients (25.0% vs. 18.6%, P = 0.047). Based on the answers, the majority of the headache patients were those with tension-type headache (49.1%), followed by those with migraine (31.7%) in the out-patient clinics.
Fifty-five participants (45.1%) did not have headache, while 30 (28 males and two females) had had migraine in their lifetime (27.6%). The participants with and without migraine did not differ in age (41.8 vs. 42.3 years, t = 0.28, P = 0.78).
Attitudes to migraine and its treatment
Table 1 shows the percentage of agreement in the statement of attitudes to migraine and its treatment among the participants. Although almost all participants were not headache specialists, 88.5% considered headache an important part of their practice, while 10.7% did not agree. Most of them (78.7%) also agreed that migraine was primarily a disease of the brain with a well-established neurobiological basis, and only 13.9% disagreed.
Use of preventive medications in migraine management
Eighty-six (69.9%) participants agreed that migraine preventive medications were indicated for patients having two or more attacks per week. Nevertheless, 15 (12.2%) participants prescribed the preventive medications only when the patients had 14 or more headache days per month, and one used them only in those with probable medication-overuse headache (MOH). The participants with and without migraine did not differ regarding their indication of migraine preventive medications (χ2 test, P = 0.75). β-Blocker was the most commonly (96.7%) prescribed, followed by flunarizine (87.0%), tricyclic antidepressants (80.5%) and valproic acid (54.5%). Sixty-six participants (53.7%) prescribed the preventive medications for only 3 months, and 36 (29.3%) for 6 months.
Use of triptans and other acute treatment in migraine management
Only 83 (67.5%) participants had ever prescribed triptans for their migraine patients. Forty participants had never prescribed triptans; the main reason was high cost of the triptans (n = 14, 35.0%). Participants who did or did not prescribe triptans were not different in age, sex or the proportion of self-reported migraine, but the latter was more likely to solo practice (χ2 test, P = 0.001). In fact, only 18.2% of solo practice participants prescribed triptans to their migraine patients.
Fifty-seven participants (46.3%) instructed their patients to take triptans in early stage of headache, while 28 (22.8%) participants instructed their patients not to take triptans until the headache became severe.
Almost all the participants (97.4%) in their practice had encountered headache suffers who chronically ingested ‘cold syrup’ for headache relief, i.e. the liquid-form over-the-counter medications with a combination of caffeine, acetaminophen and other components. Although most participating neurologists (90.2%) knew this kind of medication would cause MOH, 45.5% and 40.7% of the participants did not know acetaminophen and ergotamine could also cause MOH, respectively. Most (83.6%) participants did not know triptans would lead to MOH.
Approaches to diagnosis and evaluation
Eighty respondents (65.0%) used brain magnetic resonance imaging or computed tomography for patients with severe headache, even in those without neurological deficit. Fifty-five (44.7%) participating neurologists still used electroencephalography (EEG) for headache survey. Of them, 23 (41.8%) chose EEG because it could provide information such as structural lesion, and it was cheaper than other neuroimaging studies.
Discussion
The present study shows that the neurologist's attitudes to migraine did not greatly differ between Taiwan and the USA (9). Most participating neurologists in Taiwan agreed that migraine was a brain disease with a neurobiological basis. Most agreed that headache patients were an important part of their practice. Though it is more time-consuming and emotionally draining, half of the neurologists were interested in seeing more headache patients in the future. A higher percentage of neurologists in Taiwan would like to devote themselves to the headache field in comparison with the USA data (9). This is probably because headache is a new and arising subspecialty in Taiwan.
In line with another survey in the USA (10), the prevalence of migraine was much higher among neurologists than in the general population. Possible explanations for this phenomenon include: participation bias (neurologists with migraine responded more willingly to headache surveys), selection bias (neurology may be an attractive subspecialty for doctors with migraine), and report bias (neurologists understand migraine better and remember more details of their headaches). Despite this, neurologists with or without migraine did not differ in terms of practice profile or their attitudes to migraine management from those in the USA (10).
There is no official headache management guideline in Taiwan, but many neurologists learned the USA or UK guidelines from journals and websites. Consistent with the MKAPP study (9), many neurologists in Taiwan would order neuroimaging studies for patients with severe headache, including those without focal signs. Although EEG was not recommended by most headache guidelines, some neurologists in Taiwan still used EEG as a screening tool of the intracranial structure lesion, mainly for economic reasons. This implied that neurologists both in the USA and Taiwan were concerned about misdiagnosis of secondary headaches.
In contrast to other developed countries, we found that sumatriptan was underutilized in Taiwan, and many neurologists had never prescribed it to their migraine patients. Higher cost and strict regulation from the NHI probably limited triptan usage and prompted physicians to choose the non-steroidal anti-inflammatory drug or ergotamine instead. As for prophylactic therapy, most neurologists in Taiwan agreed that it is indicated if migraine occurs more than twice per week. Since many prophylactic medications were inexpensive, price should be no barrier to prescription. Nonetheless, the prescription rate of prophylactic agents was not high in Taiwan. Most prophylactic treatment continued for only a relatively short period (<6 months), in line with a survey in the Netherlands (11). Whether this was due to poor compliance or lack of efficacy was uncertain and warranted a further investigation.
As in other countries, MOH is very common in the neurological clinics of Taiwan. Most neurologists in Taiwan understand that overuse of combination analgesics (‘cold syrup or capsule’) is a common cause of chronic daily headache and are familiar with this scenario. On the other hand, many neurologists participating in this study failed to recognize acetaminophen, ergotamine and triptans as the aetiological agents of MOH. This misconception may hinder effective care, since overuse of abortive drugs during prophylaxis is associated with an increased likelihood of treatment failure (11).
Based on the present study, we suggest that pharmacoeconomic studies are needed in Taiwan to demonstrate the cost-effectiveness of the triptans, and if utilization of expensive healthcare resources may be reduced after addition of prophylactic treatment. Factors affecting the prescribing patterns of neurologists should be explored. MOH should be highlighted for future continuing medical education on headache. The migraine guidelines should be modified, taking into consideration the restriction from the health system and treatment options available in Taiwan.
The limitation of our study was the low response rate, which is not uncommon in other physician-specific surveys (9, 12). It should be noted that the participants and non-participants of this study did not differ in their demographic profile. Generalization of our conclusions should be more cautious. The other limitation was that the diagnosis of migraine in the participating neurologists was self-reported. Since most neurologists were familiar with the diagnostic criteria of IHS migraine, the bias might be not significant.
Footnotes
Acknowledgements
This study was supported in part by grants from the Taipei Veterans General Hospital (VGH 94-296).