Demographics and Clinical Characteristics of Patients with Migraine

Of 451,983 patients, 203,222 were selected for the analysis and divided into five treatment cohorts: 105,158 (51.7%) patients with acute migraine; 8308 (4.1%) with preventive migraine; 30,314 (14.9%) with preventive + acute migraine; 98 (0.05%) patients undergoing non-pharmacological treatments; and 59,344 (29.2%) patients classified as others (having a migraine-related claim but having no related treatment defined in the medication list) (Table S3).

The mean age of the population of 65,982 (32.5%) patients with available demographic data was 40 years, and 45.6% were 35–44 years of age (Table 1). Overall, a higher proportion of males were affected (55.4%). Most patients (n = 47,775, 72.4%) opted for an enhanced insurance plan. Overall, patients were predominantly Indian (n = 27,303, 41.4%), Pakistani (n = 8174, 12.4%), or Filipino (n = 8003, 12.1%).

Table 1 Patient demographic and clinical characteristics for the overall and sub-cohort population (sub-cohort 1: preventive, sub-cohort 2: acute, sub-cohort 3: preventive + acute)Number and Percentage of New Visits and Repeat Visits Among Patients with Migraine

A decrease in the percentage of new visits was observed each year, from 0.9% in 2015 to 0.8% in 2020 (Fig. 2). The percentage of repeat visits was recorded to be 0.9% and 0.9% in 2015 and 2020, respectively.

Fig. 2

Comparison of number and percentage of new visits and repeat visits in patients with migraine

Cardiovascular Comorbidities in Patients with Migraine

Among 203,222 study patients, 27,148 (13.4%) had cardiovascular comorbidities during the study period. The ICD-10 codes used to define the different comorbidities have been elaborated in Table S4.

Increased prevalence of cardiovascular comorbidities in the preventive sub-cohort (22.1%; n = 1835/8304), followed by preventive + acute (18.5%; n = 5613/30,314), and acute (11.2%; n = 11,761/105,158) patients with migraine (Table S5). Overall, myocardial ischemia/infarction (n = 12,498, 6.1%), cerebrovascular disease (n = 8463, 4.2%), peripheral vascular disease (n = 5059, 2.5%), arrhythmias (n = 3498, 1.7%), and congestive heart failure (n = 2671, 1.3%) were the most frequently reported cardiovascular comorbidities during the study period (Tables S5 and S6). A similar trend was observed across individual sub-cohorts. It should be noted that patients were not mutually exclusive.

Treatment Patterns and Line of Treatment

During the 12-month post-index period, data relevant to treatment patterns were available for 141,447 (69.6%), 8177 (98.4%), 103,445 (98.4%), and 29,825 (98.4%) patients in the overall cohort, preventive migraine, acute migraine, and preventive + acute migraine sub-cohorts, respectively (Table 2). Overall, NSAIDs (n = 119,355, 84.4%), triptans (n = 42,138, 29.8%), and beta-blockers (n = 18,157, 12.8%) were the frequently prescribed drug classes. Patients in the acute migraine sub-cohort were primarily prescribed NSAIDs (n = 93,310, 90.2%) and triptans (n = 29,496, 28.5%), while beta-blockers (n = 3937, 48.1%) and anticonvulsants (n = 2878, 35.2%) were frequently prescribed for patients in the preventive migraine sub-cohort. In the preventive + acute migraine sub-cohort, the majority of the patients were prescribed NSAIDs (n = 26,045, 87.3%), beta-blockers (n = 14,218, 47.7%), triptans (n = 12,642, 42.4%), and anticonvulsants (n = 11,259, 37.8%).

Table 2 Treatment pattern for the overall and sub-cohort population for the 12-month post-index period (sub-cohort 1: preventive, sub-cohort 2: acute, sub-cohort 3: preventive + acute)

The LOT analysis showed that the treatments prescribed as LOT1 to patients with migraine were either monotherapies or combination therapies of NSAIDs, triptans, anticonvulsants, beta-blockers, Botox, and CGRP antagonists. In the post-index period, the most commonly prescribed LOT1 was NSAIDs (n = 7642), followed by triptans (n = 3374), NSAIDs + triptans (n = 2182), beta-blockers + NSAIDs (n = 1243), and anticonvulsants (n = 1194). Few patients received LOT2 and LOT3, possibly due to continuation of LOT1. No patient received a true LOT3.

Specialty Analysis

In the overall population, general medicine (n = 104,714, 51.5%) was the most frequently visited specialty at the index date, followed by neurology (n = 41,466, 20.4%), and internal medicine (n = 28,625, 14.1%) (Table 3). At the index date, 64.2% of patients (n = 67,466) in the acute migraine sub-cohort had the first consultation with general medicine practitioners, while 58.1% of patients (n = 4828) in the preventive migraine sub-cohort and 50.8% of patients (n = 15,413) in the acute + preventive sub-cohort had their first specialty consultation with a neurologist.

Table 3 Specialty visited by overall population and sub-cohort population (sub-cohort 1: preventive, sub-cohort 2: acute, sub-cohort 3: preventive + acute)

The data pertinent to patients visiting other specialties prior to a neurologist in the 12-month post-index period were available for 3.9% of patients (n = 7910). The specialties visited prior to a neurologist consultation included general medicine (n = 4538, 57.4%), internal medicine (n = 1285, 16.2%), and ear, nose, throat (ENT) (n = 583, 7.4%). The average number of days taken to visit a neurologist was 65, and the number ranged from 1 to 364 days. More than half of the patients (n = 4428, 56.0%) visited a neurologist within a month (Table 3).

HCRU and Associated CostsOverall HCRU and Associated Costs

HCRU and associated cost data related to combined sub-cohorts of patients with migraine (acute, preventive, and acute + preventive) were available for 143,780 patients with migraine during the 12-month post-index period including the index date (Table S7). The median all-cause and migraine-specific claims during the post-index period were 10.0 (1.0–323.0) and 2.0 (1.0–71.0), respectively. The percentage contribution of migraine-specific median healthcare cost to all-cause median healthcare cost was 20.7%. Among the three sub-cohorts, all-cause and migraine-specific claims were highest in the preventive + acute sub-cohort (13.0 [1.0–309.0] and 3.0 [1.0–71.0], respectively) with the migraine-specific median cost to all-cause median cost being 26.0%.

Likewise, the overall median all-cause and migraine-specific healthcare gross costs were US $1252.6 (2.4–564,740.7) and US $198.1 (0–168,903.3), respectively, with the highest in the preventive + acute sub-cohort (US $2030.6 [8.6–564,740.7] and US $424.8 [1.4–9443.5], respectively) (Table S7). Migraine-specific costs contributed 19.9% of the all-cause cost during the post-index period. The highest disease burden among the cohorts in terms of gross cost was in the preventive + acute migraine sub-cohort (27.3%).

HCRU and Associated Cost Based on Visit Type

During the post-index period, the median all-cause claims were highest for outpatient visits (10.0 [1.0–323.0]), followed by ER visits (2.0 [1.0–84.0]) and inpatient visits (1.0 [1.0–14.0]) (Table 4). Migraine-specific claims showed a similar trend, with the highest median claims for outpatient visits (2.0 [1.0–69.0]) followed by ER and inpatient visits.

Table 4 Healthcare resource utilization and costs by visit type (12-month post-index period)

The associated median all-cause cost was highest for inpatient visits (US $10,445.5 [3.3–557,343.1]), followed by outpatient (US $1146.9 [1.0–251,832.5]), and ER visits (US $423.9 [0–22,016.7]) (Figure S1 and Table 4). Similarly, the associated median disease-specific cost was also highest for inpatient visits (US $4496.7 [20.0–168,903.3]). Study analysis showed that migraine-specific median inpatient cost contributed 75.9% of all-cause inpatient cost during the post-index period.

HCRU and Associated Costs Based on Activity Type

The median all-cause claims were highest for medications (5.0 [1.0–262.0]), services (5.0 [1.0–145.0]), and procedures (4.0 [1.0–265.0]) during the post-index period (Table 5). Migraine-specific claims showed similar results, with the highest median claims for medications (1.0 [1.0–65.0]). Claims due to procedures (26.3%) and medications (26.2%) contributed maximally towards the average disease burden. However, the diagnosis-related group (DRG) contributed 89.5% towards the average disease burden.

Table 5 Healthcare resource utilization and costs by activity type (12-month post-index period)

The maximum median all-cause cost was incurred for procedures (US $484.7 [0.5–182,851.2]), followed by medications (US $319.6 [0–247,424.9]) and services (US $212.0 [0.2–225,702.9]). Migraine-specific findings suggested similar outcomes, with maximum cost associated with procedures (US $91.4 [0.3–59,396.7]). For DRG activity, the median all-cause claim was 1.0 (1.0–10.0), with the corresponding median cost being US $7052.2 [0–139,969.9]. DRG contributed around 64.9% towards all-cause cost. Study analysis showed that 32.0%, 24.5%, 24.5%, and 35.2% of all-cause HCRU cost of medications, procedures, services, and consumables, respectively, were related to migraine (Figure S2 and Table 5).

Overall HCRU and Associated Costs Among Combined Sub-Cohort of Patients with Migraine and Specific Cardiovascular Comorbidities

The disease-specific HCRU and associated costs among the combined sub-cohort of patients with migraine with specific cardiovascular comorbidities were analyzed for the 12-month post-index period. Most patients had myocardial ischemia/infarction (n = 5012), followed by cerebrovascular disease (n = 4119) and peripheral vascular disease (n = 1985).

The median migraine-specific cost was higher for patients with intestinal ischemia (US $1175.6 [43.1–12,613.9]), pulmonary embolism (US $1039.2 [8.6–126,246.9]), and cerebrovascular disease (US $647.8 [1.0–356,042.1]) than for patients with other specific cardiovascular comorbidities (Table S8).

HCRU and Associated Costs Based on Visit Type by Cardiovascular Comorbidity

The migraine-specific cost was analyzed among the combined sub-cohort of patients with migraine and specific cardiovascular comorbidities for inpatient, outpatient, and ER visits. For inpatient visits, the maximum median cost was observed for patients with arrhythmias (US $9698.6 [1300.0–89,921.5]) and congestive heart failure (US $9148.3 [1369.4–102,176.6]). The highest cost for outpatient visits was reported for patients with pulmonary embolism (US $804.8 [8.6–9903.3]) and venous thromboembolism (US $570.3 [4.8–19,845.9]). Similarly, migraine-specific costs due to pulmonary embolism (US $848.8 [130.1–6701.0]) and venous thromboembolism (US $747.8 [14.4–4915.8]) contributed the most towards ER visits (Table S9).

HCRU and Associated Costs Based on Activity Type by Cardiovascular Comorbidity

Analysis of migraine-specific costs among the combined sub-cohort of patients with specific cardiovascular comorbidities for activity type showed that the median net costs for medications and procedures were highest for patients with congestive heart failure (US $262.2 [0.5–14,233.5]) and intestinal ischemia (US $1255.5 [20.6–8687.6]) (Table S10). For consumables, the net cost was highest for patients with peripheral vascular disease (US $1987.6 [0.5–38,210.5]), while for services, patients with pulmonary embolism incurred the highest cost (US $31,389.7 [52.3–321,694.9]). For DRG-related activity, migraine-specific costs due to congestive heart failure (US $7599.0 [2049.8–89,921.5]) accounted for the maximum share in terms of net cost.