Rates and reasons for discontinuation of triptans and opioids in episodic migraine: results from the American Migraine Prevalence and Prevention (AMPP) study.

BACKGROUND: Persons with migraine use acute medications to manage headache pain and associated symptoms. Several studies have reported reasons why patients select specific medications; however, little is known about why patients discontinue acute medications. This study assesses reasons for discontinuation of two commonly used classes of medication-triptans and opioids.

METHODS: This study uses data from the 2008 and 2009 AMPP surveys. Eligible subjects had episodic migraine in both 2008 and 2009 and provided data on acute treatment use in both years. The AMPP survey also assessed reasons for discontinuing migraine medications.

RESULTS: Of 3,334 eligible migraineurs, 714 triptan users in 2008, 247 (34.6%) had discontinued triptans by 2009. In 2008 there were 417 opioid users, of whom 246 (59.0%) had discontinued the drug by the 2009 survey. Ordinal regression comparing the pattern of headache-related disability (MIDAS scores) revealed a decrease in headache-related disability among triptan discontinuers (21.4% moderate to severe disability) compared to opioid discontinuers (33.0% moderate to severe disability [p=.004]). Triptan discontinuers were 48% less likely to discontinue because of pain recurrence than those discontinuing opioids (p=.006), 51% less likely to discontinue due to chest pain (p=.018), and 57% less likely to discontinue due to neck pain (p=.004) compared to opioid discontinuers. Triptan discontinuers were 47% less likely to discontinue headache medication because of concern about interactions with other medications (p=.013) and 42% less likely due to concern about effects to the stomach compared to opioid users (p=.029). No differences in reasons for discontinuation were noted for efficacy of pain relief or side effects.

DISCUSSION: This study shows that opioid use is associated with an increased risk of medication discontinuation compared to triptans. Reasons for medication discontinuation included return of migraine pain, concerns regarding drug interactions, and stomach upset, among others. Physicians managing patients using opioids may need to frequently assess the patient's risk of discontinuing their treatment plan, or physicians may need to be proactive and modify the treatment plan to better suite the patient's needs, which may change over time. Further studies are warranted that evaluate rates and reasons of discontinuation of other classes of acute migraine medications.