The GRIM2005 Study of Migraine Consultation in France II. Psychological Factors Associated with Treatment Response to Acute Headache Therapy and Satisfaction in Migraine
Abstract
The objective of this analysis was to identify variables associated with treatment response in subjects with migraine. Data were collected from a sample of 10 000 subjects. A battery of questionnaires assessing clinical and psychological variables was completed. Migraine diagnosis was attributed using an algorithm based on the IHS criteria and treatment response using the ANAES criteria. We identified 1534 subjects, of whom 1443 were treated. For 54.2%, at least one ANAES criterion for treatment response was unfulfilled. Non-response was associated with female gender, high HIT-6 impact scores and high HAD psychological distress scores. The strongest associations with non-response were identified for four psychological variables: elevated scores on the CSQ catastrophization subscale and the ‘Consequences’ and ‘Acceptance’ dimensions of the Brief COPE, and low scores on the ‘Positive Reinterpretation’ Brief COPE dimension. In conclusion, many individuals with migraine respond inadequately to treatment. Behavioural interventions aimed at modifying coping strategies may improve outcome.
Introduction
Migraine is a common neurological disorder characterized by episodic severe headaches, which are frequently incapacitating. These episodic headaches can evolve into chronic headaches in certain individuals. Two recent large epidemiological studies have reported overall prevalence rates for migraine in the French general population of 17% (1) and 21% (2), with prevalence being higher in women and in young adults.
In spite of the introduction of efficacious and well-tolerated antimigraine drugs over the last two decades, the treatment of migraine still remains unsatisfactory. Two recent studies have demonstrated that nearly half the individuals with migraine headaches in the French general population have never consulted a physician for their headaches: 43% in the GRIM 2000 study (3), performed in 1999, and 40% in the FRAMIG 3 study, performed in 2003 (2). Moreover, even for subjects who have consulted at some time, most do not receive regular long-term follow-up (2,4).
In order to improve the standards of care for migraine sufferers and thus to reduce the individual and collective impact of migraine headaches, the French national health observatory (Agence Nationale d'Accréditation et d'Évaluation en Santé; ANAES) mandated an expert taskforce to develop guidelines for the treatment of migraine. These guidelines, published in 2004 (5), provide recommendations to physicians on the diagnosis and treatment of migraine headaches. The guidelines recommend that physicians ask their patients about what relief they derive from their regular treatment using a structured four-item questionnaire. If the patient replies affirmatively to all four questions, it is recommended to continue with the current treatment. In contrast, if a negative reply is given to one or more questions, it is recommended to prescribe a non-steroidal anti-inflammatory drug and a triptan to be used in a stepwise manner. The four criteria for treatment response proposed by the ANAES guidelines are the following. Do you obtain significant headache relief 2 hours after taking medication? Do you require only a single intake of medication for headache relief? Is your treatment well tolerated? Does treatment allow a rapid return to normal social, family or professional activities?
We have recently performed a large observational epidemiological survey in the French general population in order to study the characteristics of subjects with migraine, particularly in relation to medical care and to psychological variables (6). This survey provided an opportunity to assess treatment responses to headache relief medications in terms of the ANAES criteria. We have also tried to identify determinants of treatment response amongst the different demographic, clinical and psychological variables collected during the study.
Methods
This was a descriptive epidemiological study performed in a representative sample of the French adult general population between March and May 2005. A national representative sample of the general population was screened in order to identify migraineurs, who were interviewed in extenso to collect data on impact of headache, psychological aspects, symptoms of comorbid anxiety or depression and healthcare resource utilization.
Constitution of the study sample
A representative sample of the French adult population reporting headache was constituted by face-to-face interview with a target population of 10 000 individuals aged 18 or over representative of the national population in terms of gender, age, employment status and place of residence (nine geographical regions and five community size classes), according to the most recent census data from the French National statistics Office (INSEE, 1999). A quota method was used to ensure uniform representation of each socio-economic category in the final sample.
Interviews
Face-to-face interviews were conducted in the subject's home by trained interviewers from Institut de Sondage Lavialle, an international polling institute, as part of an omnibus survey that asked specific health-related questions within a much wider multisubject questionnaire. This system is thought to provide greater motivation and more neutral responses to questions on medical subjects. The CAPI/POLLUX (Computer Assisted Personal Interview) system was used to ensure exhaustive, accurate and unambiguous data collection. Thirteen screening questions were asked during the interview in order to identify individuals with migraine. Replies to these questions allowed a diagnosis of migraine to be assigned.
Attribution of headache diagnosis
A diagnostic algorithm was used to attribute one of three headache diagnoses on the basis of replies to the screening questions and the revised IHS criteria for headache classification (7). These three headache types were migraine (IHS categories 1.1 or 1.2, referred to as ‘strict migraine’ henceforward), probable migraine (IHS category 1.6) or chronic daily headache with migrainous features (CDH-M). Given the difficulty in obtaining accurate information on aura from patent self-report without case ascertainment by a physician, no attempt was made to distinguish between typical aura with migraine headache (IHS category 1.2.1) and migraine without aura (IHS category 1.1) in this study. The diagnostic algorithm used for strict and probable migraine has been described in our previous national migraine prevalence survey (1). For the present analysis, these two groups were collapsed into a single ‘episodic migraine’ group. The definition of CDH-M diverged from that of the previous study to take into account the new IHS classification. However, in the absence of prospective data from headache diaries, which were not used, of data on headache history and on potential analgesic drug abuse, this definition should be considered as purely operational. In the present study, the chronicity criterion for CDH-M was headache on more than 15 days per month during more than 3 months (corresponding to IHS category 1.5.1, chronic headache). In our previous study, the corresponding definition for CDH-M was headache on 30 days a month. It should be noted that this information was obtained from general declarative data from the participants, namely positive replies to two questions ‘Do you suffer from headaches?’ and ‘Do these headaches occur on more than 15 days per month during more than 3 months?
Data collection
Individuals identified as having migraine headaches were further interrogated about their migraine headaches in a subsequent part of the same interview and a number of psychometric rating scales were completed. These were the six-item Headache Impact Test (HIT-6 8, 9), the Hospital Anxiety and Depression Scale (HAD (10, 11), the catastrophising subscore of the Coping Strategy Questionnaire (CSQ (12)), the Brief COPE Inventory (13, 14) and the Brief Illness Perception Questionnaire (BIPQ) (15), all used in their validated French translations.
Information was also collected on physician consultations for headaches. Subjects were asked if they had ever consulted for their headaches and, if so, whether they had consulted in the previous year. They were also asked whether they treated their headaches. For those that did treat, four questions were asked corresponding to the four treatment response criteria from the ANAES recommendations. On the basis of their response, treated subjects were divided into a ‘responder’ group, who fulfilled all four ANAES criteria, and a ‘non-responder’ group, who failed to fulfil at least one ANAES criterion. Treatment satisfaction was assessed on a four-point Likert scale, ranging from 0 (totally unsatisfied) to 3 (very satisfied).
Psychometric rating scales
HIT-6
The HIT-6 instrument is a six-item questionnaire that yields an impact score on a linear scale with minimum and maximum possible values of 36 and 78, respectively. On the basis of this score, subjects can be assigned to one of four impact grades. These are little or no impact (grade 1, score ≤ 49), moderate impact (grade 2, score = 50–55), substantial impact (grade 3, score = 56–59) and severe impact (grade 4, score ≥ 60).
HAD
The HAD is a 14-item questionnaire assessing severity of anxiety and depression, seven items relating to anxiety and seven to depression and each scored on a four-point Likert scale. Possible scores for each pathology dimension range from 0 to 21, with a higher score reflecting greater severity. A score over eight on either score corresponds to clinically relevant anxiety or depression.
CSQ
The CSQ was designed to evaluate cognitive and behavioural coping strategies in chronic pain syndromes, and contains several dimensions and subscores. The Catastrophization subscore of the CSQ was used in the present study. It contains four items each scored on a four-point Likert scale, yielding a total score ranging from 4 to 16, with higher scores indicating greater difficulty coping.
Brief COPE
The Brief COPE was developed to assess the different ways in which people respond to stress. It contains 14 scales of two items, each of which measure conceptually distinct aspects of coping, nine reflecting functional strategies and five reflecting dysfunctional strategies. Each item can be scored from on a four-point Likert scale. The total scores on each scale were normalized on a scale of zero to 100. As there are few data on the psychometric properties of the Brief COPE for the study of headache, an analysis was performed to determine the factorial structure of the Brief COPE data collected in the study. This used principal component analysis with varimax rotation of the correlation matrix of the 28 items in the Brief COPE, and identified six dimensions, which explained 50% of the total variance in the data. These were (i) social support seeking and emotional expression, (ii) problem-directed coping, (iii) positive reinterpretation, distraction and humour, (iv) avoidance, including behavioural withdrawal and denial, (v) religiosity and spirituality, and (vi) acceptance. The internal consistency of the resolved structure, as measured by Cronbach's á coefficient, was 0.83. Data on the factorial structure of the Brief COPE in the study sample will be presented elsewhere (16).
BIPQ
The BIPQ investigates cognitive perceptions of illness and contains eight items scored on a 10-point Likert scale and a ninth open-response item. The sum of the mean scores on the eight items is used to generate the total BIPQ score.
Locus of control
In order to explore the locus of control, subjects were asked to rank three statements about personal health in order of most agreement. These statements were: personal health depends principally on medical advances (personalized external locus of control), personal health depends principally on actions that I take to look after myself (internal locus of control), and personal health depends principally on chance (impersonal external locus of control).
Statistical analysis
Preliminary statistical power calculations were performed in order to determine the number of subjects to include. In order to identify a determinant of consultation present in at least 15% of subjects associated with an odds ratio of at least 1.5, and with an α level of 0.05 and a statistical power (β level) of 80%, it would be necessary to evaluate at least 1577 subjects with migraine. Given a prevalence of migraine in the general population of 17% (1) and a loss of 7% due to lack of exploitable data, it would be necessary to screen 10 000 individuals in the general population.
In the current analysis, the distribution of demographic, clinical and psychological variables was compared between the responder and non-responder groups. In a first step, each variable was assessed individually in a univariate analysis. Categorical variables were compared with the χ2 test or with Fisher's exact test in case of low (<5 in any group) sample size, ordinal variables by the Kruskal–Wallis test and quantitative variables by analysis of variance for normally distributed variables or by the Mann–Whitney U-test for variables departing from normality. Next, variables whose distribution varied between the two treatments response groups at a probability level of 0.10 were retained for an ascending stepwise multivariate logistic regression analysis. At each step of the analysis, the most significant remaining variable was retained and the analysis reiterated until no more significant variables could be identified. The univariate analysis was only performed as a preliminary to generate a list of variables that could be entered into the multivariate analysis. It is at the level of the logistic regression that the multiplicity of independent variables is controlled. For this reason, it was not necessary to control for multiple comparisons at the stage of the univariate analysis. Odds ratios with 95% confidence intervals were determined from the final model for each variable retained in the multivariate model at a probability level of 0.05.
Two-sided statistical tests were used throughout and a probability level of 0.05 was considered statistically significant. All data were analysed centrally using software from SAS (Cary, USA; version 8.2).
Ethics
The study was performed according to international and French regulatory guidelines and current codes of Good Epidemiological Practice. As patient care was not altered by inclusion in the study, ethics committee approval was not necessary. With respect to data confidentiality, the study was declared to the Commission Nationale d'Informatique et Libertés.
Results
During the screening phase, 10 032 subjects were interviewed. Of these, 2740 reported suffering from headaches, 1534 of whom fulfilled diagnostic criteria for migraine, namely 1127 subjects in the episodic migraine group and 407 in the CDH-M group. The sociodemographic characteristics of the study sample are presented in Table 1. The majority of subjects were female (77.8%) and young adults (mean age 40.5 years).
| Total sample (n = 1534) | Treated subjects (n = 1443) | ANAES responders (n = 661) | ANAES non-responders (n = 782) | P | |
|---|---|---|---|---|---|
| Age | 0.913 | ||||
| Mean ± s.d. | 40.5 ± 14.6 | 40.6 ± 14.5 | 40.7 ± 15.2 | 40.5 ± 14.0 | |
| Median (range) | 38 (18–88) | 38 (18–88) | 38 (18–81) | 48 (18–88) | |
| Interquartile range | 29–49 | 27–49 | 29.0–51.0 | 30.0–48.0 | |
| Gender | 0.028 | ||||
| Men (%) | 340 (22.2%) | 309 (21.4%) | 159 (24.1%) | 150 (19.2%) | |
| Women (%) | 1194 (77.8%) | 1134 (78.6%) | 502 (76.0%) | 632 (80.8%) | |
| Headache diagnosis | <0.001 | ||||
| Episodic migraine | 1127 (73.5%) | 1065 (73.8%) | 529 (80.0%) | 836 (68.6%) | |
| CDH-M | 407 (26.5%) | 378 (26.2%) | 132 (20.0%) | 246 (31.5%) |
Most of the study sample (n = 1443, 94.1%) were taking some sort of treatment for their headaches. However, for the majority of these treated subjects (n = 782, 54.2%), at least one of the four ANAES criteria was not fulfilled, and these were thus classified as treatment non-responders. Women were significantly over-represented in the ANAES non-responder group, as were subjects with chronic headaches (Table 1). No significant association between treatment response and any sociodemographic variable other than gender was observed, including age, education level, employment status, marital status and place of residence (data not shown).
The ANAES criterion that was most frequently unfulfilled was the need for only one intake of medication to obtain headache relief, reported by 81.2% of non-responders (Fig. 1). In contrast, only 9% of treated subjects considered their treatment to be poorly tolerated. Treatment satisfaction was significantly lower (P < 0.001) in treatment non-responders than in responders (Fig. 2).
Possible associations between treatment response according to the ANAES criteria on the one hand and indicators of headache impact, psychological variables and illness perception on the other were assessed. Mean scores on the HIT-6 scale of headache impact, as well as the proportion of subjects scoring 55 or more on the HIT-6 scale, corresponding to severe or very severe impact, were significantly higher in the non-responder group (Table 2). Similarly, mean scores on the HAD emotional distress scale and its anxiety and depression dimension subscales were significantly higher in the non-responder group, as were the proportion of subjects scoring over eight on the anxiety dimension and over 16 on the total score.
| Responders (n = 661) | Non-responders (n = 782) | Treated subjects (n = 1443) | P | |
|---|---|---|---|---|
| HIT-6 score | ||||
| Mean ± s.d. | 54.3 ± 8.8 | 59.2 ± 8.7 | 57.0 ± 9.1 | <0.001 |
| % HIT-6 > 55 | 294 (44.5%) | 522 (66.8%) | 816 (56.6%) | <0.001 |
| HAD anxiety dimension score | ||||
| Mean ± s.d. | 8.6 ± 4.0 | 9.6 ± 4.3 | 9.1 ± 4.2 | <0.001 |
| Score > 8 | 312 (47.2%) | 448 (57.3%) | 760 (52.7%) | <0.001 |
| HAD depression dimension score | ||||
| Mean ± s.d. | 4.7 ± 3.5 | 5.2 ± 3.6 | 4.9 ± 3.6 | 0.007 |
| Score > 8 | 103 (15.6%) | 143 (18.3%) | 246 (17.1%) | 0.182 |
| HAD emotional distress score | ||||
| Mean ± s.d. | 13.2 ± 6.2 | 14.7 ± 6.5 | 14.0 ± 6.4 | <0.001 |
| Score > 16 | 203 (30.7%) | 305 (39.0%) | 508 (35.2%) | 0.001 |
For the psychological variables, we observed significantly higher scores on the CSQ catastrophization dimension score and on the Brief COPE ‘Avoidance’ and ‘Acceptance’ scores in the non-responder group (Table 3). On the other hand, mean ‘Positive Reinterpretation’ dimension scores were higher in the responder group. There were significant differences in mean total scores and in mean scores on each of the eight dimensions of the BIPQ between the responder and non-responder groups (P < 0.001). These were higher in the non-responder group for the total score and the ‘Consequences’, ‘Timelines’, ‘Identity’, ‘Concern’ and ‘Emotional Response’ dimensions and higher in the responder group for the ‘Personal control’, ‘Treatment control’ and ‘Understanding’ dimensions (Table 3). The distribution of locus of control categories was similar in the two groups (Table 3).
| Responders (n = 661) | Non-responders (n = 782) | Treated subjects (n = 1443) | P | |
|---|---|---|---|---|
| CSQ catastrophization score | ||||
| Mean score ± s.d. | 7.2 ± 3.1 | 9.0 ± 3.6 | 8.1 ± 3.5 | <0.001 |
| Brief COPE (mean score ± s.d.) | ||||
| SSEE | 40.2 ± 13.2 | 40.6 ± 13.2 | 40.4 ± 13.2 | 0.639 |
| Problem-directed coping | 47.4 ± 12.4 | 47.0 ± 12.6 | 47.2 ± 12.5 | 0.511 |
| Positive reinterpretation | 41.5 ± 12.2 | 38.3 ± 11.0 | 39.8 ± 11.7 | <0.001 |
| Avoidance | 29.8 ± 8.7 | 32.4 ± 10.2 | 31.2 ± 9.6 | <0.001 |
| Religiosity and spirituality | 34.9 ± 9.4 | 35.5 ± 11.0 | 35.2 ± 10.3 | 0.897 |
| Acceptance | 57.5 ± 11.5 | 59.8 ± 11.1 | 58.7 ± 11.3 | <0.001 |
| BIPQ – 10 questions | ||||
| Mean score ± s.d. | 5.8 ± 1.7 | 6.3 ± 1.5 | 6.0 ± 1.6 | <0.001 |
| Locus of control | 0.362 | |||
| Medical advances | 165 (25.0%) | 171 (21.9%) | 336 (23.3%) | |
| Looking after oneself | 359 (54.3%) | 429 (54.9%) | 788 (54.6%) | |
| Chance | 131 (19.8%) | 170 (21.7%) | 301 (20.9%) | |
A higher proportion of responders were currently actively consulting a physician for their headaches compared with the non-responder group (Fig. 3), and a lower proportion had never consulted.
Variables whose distribution differed between the two groups at a probability level of 0.10 were entered into a multivariate logistic regression analysis to variables independently associated with treatment response. Data from 1377 patients for whom no source data were missing were included in the model. The analysis retained seven variables (Table 4). The strongest associations were observed for four psychological variables. Elevated scores on the CSQ catastrophization subscale, on the ‘Consequences’ dimension of the BIPQ and on the ‘Acceptance’ dimension of the Brief COPE were associated with failure to fulfil at least one of the four ANAES criteria for treatment response, as were a low score on the ‘Positive Reinterpretation’ dimension on the Brief COPE and on the ‘Personal Control’ dimension of the BIPQ.
| Variable | Odds ratio (95% CI) | P |
|---|---|---|
| CSQ catastrophization score | 1.106 (1.064–1.150) | <0.0001 |
| BIPQ (‘Consequences’ dimension) | 1.089 (1.040–1.140) | 0.0003 |
| BIPQ (‘Personal control’ dimension) | 0.939 (0.906–0.974) | 0.0006 |
| Brief COPE (‘Acceptance’ dimension) | 1.018 (1.008–1.028) | 0.0004 |
| Headache consultation | 0.0056 | |
| Never (reference) | 1.00 | |
| At least once | 1.430 (1.110–1.842) | |
| HAD anxiety dimension score | 0.0199 | |
| ≤8 (reference) | 1.00 | |
| >8 | 1.306 (1.043–1.636) | |
| Brief COPE (‘Positive reinterpretation’ dimension) | 0.989 (0.980–0.999) | 0.0319 |
Goodness of fit of the final model was assessed using the Hosmer-Lemeshow test, which showed that the hypothesis of a perfect fit was not rejected (P = 0.3601). In addition the receiver operating characteristic curve showed that the predictive ability of the model to explain treatment response was reasonably good (area under the curve = 0.697).
The ability of the model to predict response on the individual criteria of the ANAES was also assessed (Table 5). Elevated scores on the CSQ catastrophization subscale and low scores on the ‘Personal Control’ dimension of the BIPQ were associated with non-response on all four ANAES criteria. Elevated scores on the ‘Consequences’ dimension of the BIPQ were associated with non-response only for criteria 1 (headache relief after 2 hours), although probability levels were close to significance for the other two ANAES criteria as well. On the other hand, high scores on the ‘Acceptance’ dimension of the Brief COPE were only associated with non-response for criterion 2 (need for a single intake of medication) and a score over eight on the HAD anxiety score only with non-response for criterion 3 (tolerability). A low score on the ‘Positive Reinterpretation’ dimension on the Brief COPE was associated with non-response for criteria 2 and 4 (rapid return to normal activity) and consultation was associated with non-response for criteria 2 and 3.
| Variable | Full model | ANAES criteria | Consulting in last 12 months | |||
|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | |||
| CSQ catastrophization score | <0.001 | <0.001 | <0.001 | 0.0145 | <0.001 | 0.0287 |
| BIPQ (‘Consequences’ dimension) | <0.001 | <0.001 | 0.0677 | 0.0515 | <0.001 | 0.7108 |
| BIPQ (‘Personal control’ dimension) | <0.001 | <0.001 | 0.0383 | 0.0192 | <0.001 | 0.0332 |
| Brief COPE (‘Acceptance’ dimension) | <0.001 | 0.1169 | <0.001 | 0.3614 | 0.3163 | 0.3708 |
| Headache consultation | 0.0056 | 0.3732 | <0.001 | 0.0026 | 0.8098 | NA |
| HAD anxiety dimension score | 0.0199 | 0.4221 | 0.0730 | 0.0164 | 0.3519 | 0.7818 |
| Brief COPE (‘Positive reinterpretation’ dimension) | 0.0319 | 0.1251 | 0.0383 | 0.6350 | 0.0381 | 0.0802 |
Finally, the model was reiterated in the subgroup of 453 patients who had consulted for their headaches in the previous year in order to control for persistence in seeking medical help (Table 5). Although the sample size is lower, three of the same variables (elevated scores on the CSQ catastrophization subscale, and low scores on the ‘Positive Reinterpretation’ dimension of the Brief COPE and on the ‘Personal Control’ dimension of the BIPQ) were retained as predictors of treatment response. On the other hand, scores on the ‘Acceptance’ dimension of the Brief COPE, the ‘Consequences’ dimension of the BIPQ and the HAD anxiety scale were no longer associated with treatment response.
Discussion
In this general population study, we observed that treatment response failed to fulfil at least one of the ANAES criteria for an adequate treatment response in over half (54.2%) of subjects with migraine who used medication to treat their headaches. This criterion was chosen for the current analysis because it is the one specified in French treatment guidelines for considering switching headache medication. Most commonly, for 81.2% of non-responders, this corresponded to insufficient relief with a single medication intake, necessitating a second treatment subsequently. In contrast, the treatment was considered poorly tolerated by 9% of subjects only. This finding is consistent with the good overall tolerability of antimigraine drugs.
Treatment response according to the ANAES criteria was well correlated with overall subjective treatment satisfaction, with 98.4% of responders being satisfied with treatment. This observation supports the good external validity of the ANAES criteria. However, around one-third of non-responders were in active consultation for their headaches, which suggests that physicians do not use the ANAES criteria systematically to monitor treatment responses and, if necessary, to modify the headache relief medication used by their patients. This situation is unnecessarily unsatisfactory given the fact that a substantial proportion of non-responders will gain adequate headache relief when switched to a triptan in accordance with the ANAES guidelines (16).
No demographic variable was associated with the likelihood of treatment response. Even though the overall level of treatment response is unsatisfactory, this does not seem to vary between different demographic groups, arguing for a relatively uniform approach to migraine treatment in France. Headache impact scores were associated with poor treatment response, but this association may be spurious because the HIT-6 instrument and the ANAES criteria (notably criterion 4 concerning rapid return to normal activities) overlap to some extent. Concerning the HAD, high emotional distress scores and, more particularly, anxiety dimension subscores were associated with a lower probability of treatment response. This may be related to poorer treatment adherence, as the presence of symptoms of anxiety or depression has been widely reported to be associated with poor adherence in many fields of medicine (17, 18). It should be noted that information on anxiety and depression was obtained with the HAD, which collects data on the subject's feelings at the time of completion, and high scores do not necessarily reflect a diagnosis of anxiety or mood disorder assigned by, for example, the DSM-IV criteria, which would require persistence of symptoms over time.
Treatment response is associated with several psychological variables, notably with coping strategies and with illness perception dimensions. The multivariate analysis shows that these psychological variables are independent covariates of response with respect to self-reported symptoms of anxiety and depression. Most of the psychological predictors of poor treatment outcome, psychological distress, catastrophization, low positive reinterpretation, and all of the subscales on the BIPQ, imply poor coping or psychological dysfunction. An exception to this pattern is that poor treatment outcome is also predicted by acceptance. Acceptance is not an equivocal coping strategy. Although this may reflect helplessness and unwillingness to take control over headaches, alternatively it might indicate a healthy shift from treatment-seeking to adaptation. Acceptance should not have the same value in coping with crisis as it does in coping with migraine as a chronic condition. The use of catastrophization, avoidance or acceptance strategies is associated with an inadequate treatment response, whereas the use of positive reinterpretation is associated with response. As the study is cross-sectional, it is unclear whether the factors associated with treatment response are the reason for or a consequence of treatment failure. Although it is not possible to attribute causality to these associations, or address other than speculatively what underlies them, it is useful to bring them to the attention of prescribers, because maladaptive coping strategies are associated with a poor treatment prognosis. The use of behavioural interventions aimed at modifying coping strategies may improve treatment outcome, particularly when associated with treatment by a triptan.
There are few data available concerning psychological variables or other patient-reported perceptions and response to drug treatment. One study reported that higher physical functioning scores on the SF-36 health-related quality of life profile before treatment with sumatriptan were associated with a higher probability of treatment response (19). Another study using cluster analysis to assess relationships between, inter alia, disease perceptions and treatment response found that low pain perceptions, less functional impairment and less depressive symptoms clustered with greater treatment response in terms of pain reduction (20). In the same study, no association was observed between psychological phenotype evaluated with the Multidimensional Pain Inventory and treatment response (21). In contrast, some, but not all (21), studies of cognitive behavioural therapy in migraine have identified psychological variables associated with treatment response (22). These include the perceived ‘changeability’ of illness (23) and emotional vulnerability (24). The former concept may be related to the BIPQ personal control, consequences and time-line dimensions used in the present study, whereas the latter may be related to the CSQ catastrophization measure. More information is available on determinants of treatment response in chronic pain conditions, where poor response has often been associated with maladaptive coping strategies (25), and the present results from patients with migraine are consistent with this.
Information on determinants of treatment response in migraine is extremely scant and merits further study. In particular, determinants of treatment adherence should be investigated, as this may be an area where motivational interventions could make a significant difference to final outcome. Variables that are related specifically to outcome of pharmacological or non-pharmacological treatment should be distinguished, as this may help to optimize matching of patients to treatment.
An important limitation of this study is that no information was collected on migraine treatments actually used, because treatment response varies with specific migraine treatments. This precludes evaluation of whether particular classes of medication are more efficacious than others in this general population, and in particular of whether individuals taking triptans do actually respond adequately. This limitation is due to the difficulty of collecting accurate information on medication use in the context of an omnibus survey in the general population. In addition, as many subjects in France use multiple medications to treat their headaches (4), and questions referred to headaches in general, rather than a given headache treated by a given medication, it would be difficult to assign accurately and exclusively headache responses to individual treatments. The determinants of treatment response identified in this study should not be considered exhaustive, as information on potentially important variables, for example medication abuse, was not accessible in a community-based survey of this type. In addition, other uncollected variables such as adherence to treatment may contribute to, or explain, the observed associations between psychological variables and treatment response.
In conclusion, a significant proportion of individuals with migraine in France fail to respond satisfactorily to their headache relief medication, even when their treatment is managed by a physician. Educational measures could prove useful in increasing physician awareness of the utility of the ANAES criteria for monitoring and adapting migraine treatment. Psychological variables may exert a modest influence on treatment response, and should be taken into account in optimizing treatment strategies and specific psychosocial interventions proposed if significant departures from population norms are observed.
Disclosure
The study was initiated and financed by GSK Laboratory, France. FNO and AEH are employees of GSK laboratory. MLM, HM, AP and FR received consultation fees from GSK Laboratory for their contribution to the design, implementation and interpretation of the study. FM received emoluments from GSK Laboratory for carrying out the analysis of the data.
References
1 Henry P, Auray JP, Gaudin AF, Dartigues JF, Duru G, Lantéri-Minet M et al. Prevalence and clinical characteristics of migraine in France. Neurology 2002; 59:232–7.
2 Lantéri-Minet M, Valade D, Geraud G, Chautard MH, Lucas C. Migraine and probable migraine – results of FRAMIG 3, a French nationwide survey carried out according to the 2004 IHS classification. Cephalalgia 2005; 25:1146–58.
3 Pradalier A, Auray JP, El Hasnaoui A, Alzahouri K, Dartigues JF, Duru G et al. Economic impact of migraine and other episodic headaches in France: data from the GRIM2000 study. Pharmacoeconomics 2004; 22:985–99.
4 Lucas C, Chaffaut C, Artaz MA, Lanteri-Minet M. FRAMIG2000: medical and therapeutic management of migraine in France. Cephalalgia 2005; 25:267–79.
5 Geraud G, Lanteri-Minet M, Lucas C, Valade D. French guidelines for the diagnosis and management of migraine in adults and children. Clin Ther 2004; 26:1305–18.
6 Lantéri-Minet M, Massiou H, Nachit-Ouinekh F, Lucas C, Pradalier A, Radat F, Mercier F, El Hasnaoui A. The GRIM2005 study of migraine consultation in France. I. Determinants of consultation for migraine headache in France. Cephalagia 2007; doi: 10.1111/j.1468-2982.2007.01426.x.
7 Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain, 2nd edn. Cephalalgia 2004; 24:1–160.
8 Gandek B, Alacoque J, Uzun V, Andrew-Hobbs M, Davis K. Translating the Short-Form Headache Impact Test (HIT-6) in 27 countries: methodological and conceptual issues. Qual Life Res 2003; 12:975–9.
9 Kosinski M, Bayliss MS, Bjorner JB, Ware JE Jr, Garber WH, Batenhorst A et al. A six-item short-form survey for measuring headache impact: the HIT-6. Qual Life Res 2003; 12:963–74.
10 Lépine JP. Echelle HAD (Hospital Anxiety and Depression scale): Traduction française 2000 [cited 1st February, 2007]; available from http://www.bossons-fute.com/Documents/echelleHAD.pdf.
11 Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67:361–70.
12 Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain 1983; 17:33–44.
13 Carver CS. You want to measure coping but your protocol's too long: consider the brief COPE. Int J Behav Med 1997; 4:92–100.
14 Muller L, Spitz E. Multidimensional assessment of coping: validation of the Brief COPE among French population. Encephale 2003; 29:507–18.
15 Broadbent E, Petrie KJ, Main J, Weinman J. The brief illness perception questionnaire. J Psychosom Res 2006; 60:631–7.
16 Massiou H, Pradalier A, Donnet A, Lanteri-Minet M, Allaf B. Evaluation of efficacy, tolerability, and treatment satisfaction with almotriptan in three consecutive migraine attacks. The migraine – satisfaction with treatment: reality with Almogran study. Eur Neurol 2006; 55:198–203.
17 DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004; 42:200–9.
18 Dunbar-Jacob J, Erlen JA, Schlenk EA, Ryan CM, Sereika SM, Doswell WM. Adherence in chronic disease. Annu Rev Nursing Res 2000; 18:48–90.
19 Litaker DG, Solomon GD, Genzen JR. Using pretreatment quality of life perceptions to predict response to sumatriptan in migraineurs. Headache 1997; 37:630–4.
20 Davis PJ, Reeves JL II, Graff-Radford SB, Hastie BA, Naliboff BD. Multidimensional subgroups in migraine: differential treatment outcome to a pain medicine program. Pain Med (Malden, Mass) 2003; 4:215–22.
21 Larsson B, Melin L. Follow-up on behavioral treatment of recurrent headache in adolescents. Headache 1989; 29:250–4.
22 Primavera JP III, Kaiser RS. Non-pharmacological treatment of headache: is less more? Headache 1992; 32:393–5.
23 Narduzzi KJ, Nolan RP, Reesor K, Jackson T, Spanos NP, Hayward AA et al. Preliminary investigation of associations of illness schemata and treatment-induced reduction in headaches. Psychol Reports 1998; 82:299–307.
24 Gatchel RJ, Deckel AW, Weinberg N, Smith JE. The utility of the Millon Behavioral Health Inventory in the study of chronic headaches. Headache 1985; 25:49–54.
25 Gatchel R, Epker J. Psychosocial Predictors of Chronic Pain and Response to Treatment. In: Gatchel R, Turk D editors. Psychosocial Factors in Pain. New York: Guilford Press, 1999;pp. 412–34.
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Article first published: December 2007
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