The use of triptans and other acute treatments for the management of migraine in routine clinical practice in England: a retrospective cohort study using the Clinical Practice Research Datalink (CPRD)

Migraine is a common and disabling neurological condition affecting around 10 million people in the UK. Optimal management has been indicated as a priority for improving migraine care in the UK, supported by clinical guidelines to provide clinicians with pathways for using acute and preventative treatments. There is a paucity of evidence on the real-world management of migraine, particularly with acute treatments. A retrospective cohort study using linked primary and secondary healthcare data in England (Clinical Practice Research Datalink [CPRD] Aurum and Hospital Episode Statistics [HES]). Adults with their first diagnosis of migraine between 1st January 2017 and 31st March 2019 were identified. Acute treatment patterns (prescribing rates, sequencing) and triptan use were described during a variable 12-month minimum follow-up period, up to 31st March 2020. A total of 62,205 patients met all eligibility criteria, of which 76.2% (n = 47,420) were female and the mean (SD) age at index was 39.8 (15.5) years. Almost 60% (n = 36,849; 59.2%) of the cohort received no prescription for acute treatment during follow-up, 23.1% (n = 14, 379) received acute treatment only and 17.6% (n = 10,977) received acute and preventative treatments. Triptans (25.7%; n = 15,971) and non-steroidal anti-inflammatory drugs (15.1%; n = 9,368) were the most frequently prescribed acute treatments during follow-up. Opioids were prescribed to 28.5% (n = 3,130) of the acute and preventative subgroup, and 15.8% (n = 2,267) of the acute only subgroup during follow-up. Only 1.8% (n = 1,127) were prescribed two different triptans with the median (IQR) time to second triptan of 7.8 (2.2–15.8) months. Of these, 17.2% (n = 198/1,149) subsequently cycled back to a previously prescribed triptan. A large proportion of patients with migraine received no prescribed acute treatments, potentially indicating over-the-counter management or treatment with preventatives administered in secondary care. The most prescribed acute treatments were triptans. Very few were tried on more than one triptan, with some returning to earlier triptans. A significant proportion of our cohort were prescribed an opioid regimen, counter to UK clinical guidance. These observations suggest some variability to local guidance and international best practices in the treatment in migraine, highlighting a need for further guidance on the use of acute treatments.