Barriers to the Diagnosis and Treatment of Migraine: Effects of Sex, Income, and Headache Features
Barriers to the Diagnosis and Treatment of Migraine: Effects of Sex, Income, and Headache Features
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DOI：
10.1111/j.1526-4610.2012.02265.x
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发表时间：
2013-01-01
期刊：
影响因子：
5
通讯作者：
Buse, Dawn C.
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文献类型：
--
作者：
Lipton, Richard B.;Serrano, Daniel;Buse, Dawn C.
背景美国头痛协会指南指出，患有头痛相关残疾的偏头痛患者应接受某些急性治疗，包括偏头痛特异性药物和其他药物。然而，许多符合条件的人没有接受这些治疗。偏头痛患者可能会遇到接受最低限度适当护理的障碍。我们的目的是确定障碍，以照顾在人口样本的个人发作性偏头痛。我们评估了3个层面的障碍：医疗咨询、诊断和急性药物治疗的使用，并评估了社会经济学、人口统计学和头痛特异性变量对这些障碍的贡献。方法.我们确定了实现指南定义的适当急性药物治疗所需的最低限度的3个步骤：（1）咨询处方医疗保健专业人员;（2）接受偏头痛诊断;（3）使用偏头痛特异性或其他适当的急性治疗。我们使用2009年美国偏头痛患病率和预防研究样本的数据，以确定未满足治疗需求的发作性偏头痛患者，根据偏头痛残疾评估量表（MIDAS）评分，对应于II级（轻度），III级（中度）或IV级（重度）头痛相关残疾。我们确定这些人是否在过去的一年里咨询过医疗保健专业人士的头痛，如果他们曾经从医疗保健专业人士那里得到过偏头痛的医学诊断，以及他们目前是否正在使用适当的偏头痛急性治疗（即，曲坦，处方非甾体抗炎药，或含异美汀的药物）。我们分析了几个社会经济学，人口统计学和头痛特异性变量，以确定它们是否与3个定义步骤中的任何一个障碍有关。结果在775名符合条件的发作性偏头痛和头痛相关残疾的参与者中，45.5%（n = 353/775）在前一年曾因头痛咨询过医疗保健专业人士。在这些人中，86.7%（n = 306/353）报告接受了偏头痛的医学诊断。在确诊的咨询者中，66.7%（204/306）目前使用急性偏头痛特异性治疗。只有204人（26.3%）成功完成了所有3个步骤。多变量逻辑回归模型显示，目前头痛咨询的最强预测因素是有健康保险{优势比（OR）= 1.73（95%置信区间[CI]，1.07-2.79）}，头痛相关残疾率高（MIDAS评分变化10分的OR = 1.06 [95%CI，1.0-1.14]），偏头痛综合症状严重程度评分较高（OR = 1.19 [95%CI，1.05-1.36]）。在咨询者中，女性比男性更有可能被诊断（OR = 4.25 [95%CI，1.61-11.2]），并且随着平均头痛严重程度（OR = 1.44 [95%CI，1.12-1.87]）和偏头痛症状严重程度评分的增加而增加。在确诊的患者中，家庭年收入是目前使用指南定义的适当急性治疗的最强预测因素（OR = 1.44 [95%CI，1.07-1.93]），其次是MIDAS评分的10分变化（OR 1.16 [95%CI，1.02-1.35]）。结论.在需要医疗护理的偏头痛患者（MIDAS II级或更高）中，只有四分之一的人经历了我们提出的实现最低限度适当护理所需的3个步骤（咨询，诊断和治疗/药物使用）。健康保险状况是一个重要的预测咨询。在咨询，女性更容易被诊断比男性，这表明性别偏见的诊断可能是男性的一个重要障碍。在使用适当的处方药方面存在经济障碍。公共卫生工作应侧重于提高咨询率，特别是在无保险和诊断率，特别是在男性偏头痛。
Background. US Headache Consortium Guidelines state that persons with migraine with headache-related disability should receive certain acute treatments including migraine-specific and other medications. However, many eligible individuals do not receive these therapies. Individuals with migraine may experience barriers to receiving minimal appropriate care. We aimed to identify barriers to care in a population sample of individuals with episodic migraine. We assessed barriers at 3 levels: medical consultation, diagnosis, and acute pharmacologic therapy use and assessed the contribution of socioeconomic, demographic, and headache-specific variables to these barriers. Methods. We identified 3 steps that were minimally necessary to achieve guideline-defined appropriate acute pharmacologic therapy as: (1) consulting a prescribing health care professional; (2) receiving a migraine diagnosis; and (3) using migraine-specific or other appropriate acute treatments. We used data from the 2009 American Migraine Prevalence and Prevention study sample to identify persons with episodic migraine with unmet treatment needs, defined by a Migraine Disability Assessment Scale (MIDAS) score corresponding to Grade II (mild), III (moderate), or IV (severe) headache-related disability. We determined whether these individuals had consulted a health care professional for headache over the previous year, if they ever received a medical diagnosis of migraine from a health care professional, and whether they were currently using appropriate acute treatment for migraine (ie, a triptan, prescription non-steroidal anti-inflammatory drug, or an isometheptene-containing agent). We analyzed several socioeconomic, demographic, and headache-specific variables to determine if they were related to barriers in any of the 3 defined steps. Results. Of 775 eligible participants with episodic migraine and headache-related disability, 45.5% (n = 353/775) had consulted health care professional for headache in the preceding year. Among those individuals, 86.7% (n = 306/353) reported receiving a medical diagnosis of migraine. Among the diagnosed consulters, 66.7% (204/306) currently used acute migraine-specific treatments. Only 204 (26.3%) individuals successfully completed all 3 steps. Multivariate logistic regression models revealed that the strongest predictors of current consulting for headache were having health insurance {odds ratio (OR) = 1.73 (95% confidence interval [CI], 1.07-2.79)}, high headache-related disability (OR = 1.06 [95% CI, 1.0-1.14] for a 10-point change in MIDAS score), and a high composite migraine symptom severity score (OR = 1.19 [95% CI, 1.05-1.36]). Among consulters, diagnosis was much more likely in women than men (OR = 4.25 [95% CI, 1.61-11.2]) and became increasingly likely with increasing average headache pain severity (OR = 1.44 [95% CI, 1.12-1.87]) and migraine symptom severity score. Among those who were diagnosed, annual household income was the strongest predictor of currently using guideline-defined appropriate acute treatment (OR = 1.44 [95% CI, 1.07-1.93]) followed by a 10-point change in MIDAS score (OR 1.16 [95% CI, 1.02-1.35]). Conclusions. Among persons with migraine in need of medical care (MIDAS Grade II or greater), only one quarter traversed the 3 steps we proposed to be necessary to achieving minimally appropriate care (consulting, diagnosis, and treatment/medication use). Health insurance status was an important predictor of consulting.Among consulters, women were far more likely to be diagnosed than men, suggesting that gender bias in diagnosis may be an important barrier for men. There were economic barriers related to use of appropriate prescription medications. Public health efforts should focus on improving consultation rates, particularly in the uninsured and diagnostic rates particularly in males with migraine.