LONDON—Compared with the general population, headache specialists—especially the men—have a higher prevalence of migraine. That's the conclusion of a survey that found lifetime prevalence of migraine among headache specialists to be 75% for men and 78% for women, compared with 6% for men and 18% for women in the general population.

At the Headache World 2000 conference, Randolph W. Evans, MD, of the University of Texas at Houston Medical School and Baylor College of Medicine, and Richard B. Lipton, MD, Albert Einstein College of Medicine, in New York City, outlined the results of their survey of 42 headache specialists who attended an April 2000 meeting, in New Orleans, for the faculty of the Neurology Ambassador Program.

SELF-SELECTED SPECIALITIES?

Of the 33 participants who responded, 24 were male. The mean age was 51 for men, 43 for women. The mean number of years in practice was 20 for men, 10 for women. Within the previous year, 50% of the men and 67% of the women had attacks that fit the International Headache Society definition of migraine.

"I was astonished that the prevalence of migraine was so high," commented Dr. Lipton. Two subsequent studies confirmed this high prevalence among neurologists specializing in headache. "To some extent, it may be that people self-select" in choosing their medical specialty, Dr. Lipton acknowledged. However, when neurologists were asked about their migraines, their responses indicated that half had migraine before deciding to specialize, and the remaining half developed migraine after choosing their specialty.

Final results of the two expanded studies of approximately 1,000 attendees of the Neurology Ambassador Program and a sample of American Academy of Neurology members are currently being analyzed.

RISK … AND MANAGEMENT

The original survey of headache specialists also examined the physicians' experience with migraine management, including overall effectiveness of the triptans, treatment concerns specific to basilar migraine, safety of oral contraceptives (OCs) for migraineurs, and factors affecting initial treatment decisions.

"Ninety-seven percent of those surveyed believe that triptans are significantly more effective when used early in the course of a headache than later," Drs. Evans and Lipton reported. When rated on a four-point scale that ranged from "extremely effective" to "not very effective," rizatriptan was judged to be the most effective of the oral triptans, followed by zolmitriptan, sumatriptan, and naratriptan. When asked to select their first-choice agent for migraine prevention, 43% chose tricyclic antidepressants. Other responses included ß-blockers (33%), verapamil (12%), divalproex (9%), and selective serotonin reuptake inhibitors (3%).

For preventive treatment of basilar migraine, the group rated several choices on a five-point scale, from "extremely effective" to "I'm not sure." Divalproex was judged to be the best choice, followed by verapamil, tricyclic antidepressants, and ß-blockers.

"Few of the headache specialists surveyed use ß-blockers for preventive therapy in patients who have prolonged aura or basilar migraine," the researchers reported. "Only 12% use them without hesitation, and 27% use them only after other treatment fails. Nearly half (45%) never use ß-blockers in this patient group."

NO CLEAR CONSENSUS

The benefits of other migraine management options remained controversial or unsettled among those physicians surveyed, Drs. Evans and Lipton found. "The group was divided on the safety of triptans for treatment of the headache in basilar migraine after resolution of neurologic signs and symptoms," they noted; 34% agreed that triptans are safe, 36% disagreed, and 30% were unsure or did not know.

Similarly, the group was divided on the issue of whether oral contraceptives significantly increase the risk of stroke in migraineurs: 48% agreed, 46% disagreed, and 6% were unsure or did not know. "There was more certainty regarding OC safety in migraine with an aura that lasts one hour or less, in the absence of other risk factors," they noted. "Sixty-eight percent agreed that OCs are safe in this situation, while 26% disagreed. All participants agreed that OCs are safe in migraine without aura, in the absence of other risk factors."

The participants were also asked to rate (on a scale from 0 to 10, with 10 signifying "vitally important") five factors that influenced selection of their initial treatment for migraine. The most important factor was headache-related disability (mean rating, 9.0), followed by average severity of the migraine pain (8.4), comorbidities (7.9), pattern of associated symptoms (7.3), and migraine subtype (5.7).

"The caveat is that this is a study of modest size and a sample of neurologists with a special interest in headache, so generalize beyond that group very cautiously," Dr. Lipton warned.

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