Peter Salgo, MD: If we take a look at the nation as a whole, what is the economic burden here of migraines on the United States, what do you think?
Wayne N. Burton, MD: Well, the economic burden is significant. And if you think about it from the employer standpoint, migraine affects people in their most productive years, [ages] 25 to 55. About 18% of women and about 6% of men have migraines. And if you look at the economic estimates, at least $11 billion in direct costs—in other words, medical and pharmacy costs—and at least $11 billion in what’s called indirect costs. Those are related to disability, to absenteeism, and to on-the-job productivity loss, which is termed presenteeism. And that on-the-job loss of productivity is really significant to employers.
Peter Salgo, MD: I’ll bet it is. I mean, you’re there but you’re not there.
Wayne N. Burton, MD: That’s correct.
Peter Salgo, MD: You’re in so much pain, you’re not working, [and] you’re distracted. And if you’re doing something critical, that could be critical for the whole enterprise, right? What’s your experience with the number of patients misdiagnosed or underdiagnosed? Do they come to your blog to talk to you about it?
Shoshana Lipson: They absolutely do. I would tend to say respectfully that the concept that 9 of 10 people are controlled is not incorrect, but it’s much, much more complex than that.
Peter Salgo, MD: Well, wait, that’s not quite what he said. Let me help you with this. I don’t know why I’m defending you. He said that if you get to somebody and make the correct diagnosis, then of those, 90% can get treatment.
Shoshana Lipson: Right. I would still tend to think that that’s generous, but again, it’s partly because it’s a complex situation. So as you said, 1 person’s idea of control could be that they have no more pain. Another person’s idea of control could be they go from 30 migraine days a month down to 15 or 14, and they become episodic. Another person’s concept of control could be they no longer have to take acute medication, whereas someone else just wants to be able to work at least part time. So the concept of control is somewhat subjective, not objective.
Peter Salgo, MD: Well, let me ask. Is there a technical definition of control?
Stephen Silberstein, MD: There are many different definitions.
Peter Salgo, MD: I knew you were going to say that.
Stephen Silberstein, MD: One different definition, a commonly used one, which is used by insurance companies, is a greater than 50% reduction in migraine days, defined as migraine [that] lasts at least 4 hours of moderate intensity. And that’s the term I was using. I wasn’t using patient-related data.
Peter Salgo, MD: I got it.
Shoshana Lipson: Right.
Peter Salgo, MD: Now, in terms other than therapeutic implications, other than I need my medicine, other than maybe I can’t get my medicine—we’re going to cover all that—what are the other aspects of migraine that affect patients’ lives?
Shoshana Lipson: Sure. Well, there are a lot of aspects. It obviously affects your ability to work, so you have not only absenteeism but also presenteeism, where people are at work and they’re not able to function up the normal standard of work. You have a lack of social life. A lot of people with severe chronic migraine become completely isolated. And then comorbid conditions seem to increase as well as you turn into having chronic migraine in especially things like depression [and] anxiety. [In] some autoimmune conditions, you see them more frequently. And the whole process of actually getting better seems to get more complex and challenging as you get more severe.
Peter Salgo, MD: Let’s talk about clinical guidelines for a minute. Now, it just so happens [that] we have you because you wrote them.
Stephen Silberstein, MD: I wrote the guidelines. That is correct.
Peter Salgo, MD: What do they recommend in terms of migraines, diagnosis, [and] therapy?
Stephen Silberstein, MD: The caveat would be that guidelines are based on studies, and if the studies have not been done, it doesn’t prove that the drug doesn’t work. So basically, the original guidelines defaulted to the International Headache Society criteria for diagnosis. And we spend our time looking at diagnostic testing and acute and [preventive] and nonpharmacologic treatment. And basically, over the course of the years for acute treatment, the drugs that we found to be effective are all the triptans, many of the nonsteroidals, and some of the combination products. And basically, we create a conclusion stating that if you have a mild attack, you can start with a nonspecific medication. But if your attack is more severe, it doesn’t respond to nonspecific medication; you should have triptans or DHE [dihydroergotamine]. The other thing we suggested strongly is [that] you should have a rescue medication, so if your treatment doesn’t work, you don’t have to wind up going to the emergency department.