LOS ANGELES—Outpatient, community-based parenteral treatment of migraine is feasible and very well accepted by patients when their usual acute care therapy has not worked, according to a study presented at the 56th Annual Scientific Meeting of the American Headache Society.
In this setting, patients have their therapy customized depending on their baseline acute and prophylactic therapy, comorbid medical conditions, and prior experience. “This is readily accomplished and happily accepted by patients in a comfortable environment without the problems often seen in emergency department (ED) settings,” reported Ira M. Turner, MD. “In addition, there are significant cost savings to both the patient and third-party payers.”
Ira M. Turner, MD
An Unmet Need
Migraine patients who experience occasional attacks when their usual acute therapy fails often seek treatment in a hospital ED. “The overwhelming majority of these patients, in our experience, express extreme dissatisfaction with how they are treated in the ED settings,” said Dr. Turner, who is a staff neurologist at the Center for Headache Care and Research at Island Neurological Associates in Plainview, New York. The reasons for patient dissatisfaction with ED treatment include long waiting times, bright lights, noise, being treated like “drug seekers,” use of nonspecific remedies (especially opiates), and lack of use of more specific or evidence-based therapies such as triptans, ergots, antiemetics, steroids, and parenteral NSAIDs. In contrast, the infusion center at Island Neurological Associates offers seven reclining chairs and a relaxed atmosphere. In addition, the facility is operated by a nursing staff overseen by neurologists.
Satisfaction Survey
To quantify patient satisfaction, Dr. Turner and colleagues performed a retrospective review of routinely collected pretreatment and post-treatment patient questionnaires from patients seen in their community-based infusion suite. All patients were treated with parenteral therapy for acute migraine attacks unresponsive to their usual therapy. Data were collected on headache severity, nausea, photophobia, phonophobia, and osmophobia. An overall patient impression of treatment satisfaction was also recorded. During the 60-day study period, data were available on 30 consecutively treated patients. Medications used included any combination of the following: ketorolac, diphenhydramine, metoclopramide, prochlorperazine, ondansetron, magnesium sulfate, methylprednisolone, dexamethasone, dihydroergotamine, or subcutaneous sumatriptan. “The treating physician determined the actual combination of drugs for each patient,” Dr. Turner said. No opiates or barbiturates were used.
Patients Endorse the Infusion Experience
Using the Patients’ Global Impression of Change, 27 of 30 patients (91%) felt overall satisfied and clinically improved. Two believed that there was no benefit, and one reported feeling worse. The average pretreatment pain intensity score was 2.4 on a 0-to-3 scale (0 = no pain; 1 = mild pain; 2 = moderate pain; and 3 = severe pain). Post-treatment average pain intensity decreased to 1.2. Similar reductions in symptom intensity were found for the other parameters measured. The average pretreatment nausea score of 2 decreased to 0.6 post-treatment; the average pretreatment photophobia score of 2.3 decreased to 1.2 post-treatment; the average pretreatment phonophobia score of 1.9 declined to 0.9 post-treatment; and the average pretreatment osmophobia score of 1.8 decreased to 0.8 post-treatment.
Generally Dr. Turner’s group is reimbursed between $250 to $400 for an average hour and a half treatment by a registered nurse. A neurologist is present in the office should problems arise, which is rare. In contrast, “In the ED, charges often range in the thousands,” Dr. Turner said.
—Glenn S. Williams