Medical attendance
Worldwide population-based epidemiologic surveys have consistently demonstrated that the majority of M sufferers are not currently consulting their physicians about their problem and that many have never even consulted a physician [
10‐
18].
Studies in Canada, Denmark, The Netherlands, and USA have shown that 55–70% of M patients sought initial treatment from primary care physicians [
10,
12,
15]. A UK study showed that 20% of M sufferers never visited a doctor and among those who did almost 50% felt that the physician did not help [
13]. In Sweden, 27% of patients with M visited a doctor (6% regularly and 21% occasionally) with 60% being satisfied with their treatment [
16]. In Austria, 39.6% never visited a doctor, 30.8% once, 16.8% occasionally, and 12.8% regularly [
18]. Two studies from France indicated that 59% had visited a doctor; in one study 70% were not satisfied with initial treatment after their first visit, with 48% being satisfied in the other study. Among those who had never visited a doctor 87% were from MIDAS I group and even 68% were from MIDAS IV group [
3,
19]. A study that encompassed data from six South American countries stated that 59% of patients had never visited a doctor [
20]. In Europe, patients usually need to be referred to a specialist by their primary care physician, and about 5–15% will visit a specialist [
15,
21,
22].
Many M sufferers who do consult physicians for M relief do not receive a correct diagnosis. In a US study, 40% of M sufferers stated that they had not been diagnosed as having M even after consultation with a physician [
12]. Only 45% of migraineurs who sought medical treatment for their migraines were correctly diagnosed [
23].
Results of our study are similar to studies from other countries regarding physician visit. Due to a M headache, 63.7% of M patients have visited a physician at least once, but only 16.8% pay regular visits. One quarter of M and PM patients have visited a physician several times, but have not been satisfied with treatment. For M, 4–5% of patients have seen an internal medicine doctor, and nearly 10% of headache sufferers have visited other specialists.
In our study, 43–50% of patients had visited a GP, among those 44.4% with M had also visited a neurologist and only 16.2% with TTH (P < 0.0001). The reason for the high percentage of patients visiting a neurologist is probably because in Croatia, a prescription for triptans requires a neurologist’s approval. This is probably a major obstacle for a proportion of patients who cannot find the time to visit a specialist, or have difficulties with making an appointment. In Croatia, 96% of the population has “basic health insurance” covering visits to GPs and a minor part of costs for medical examinations or medications. The “additional health insurance” costs between 130 and 214 Euros per year (depending on the amount of the salary or pension), and covers the majority of cost for medical examinations and drugs. A patient who is not paying the “additional insurance” will pay 16.5 Euros for a visit to a neurologist. There is a so-called “list A” for medications which are fully covered and a “list B” which are partially covered by the health insurance. The three available triptans in Croatia (sumatriptan, zolmitriptan, and rizatriptan) are reimbursed by health insurance: sumatriptan tablets 50 mg are fully reimbursed (“list A”) and for others (sumatriptan nasal spray, zolmitriptan, and rizatriptan melting disks or tablets- “list B”) there is an additional surcharge of approximately 3–8 Euros per package. A prescription for triptans, however, is not necessary, but at a cost of between 9 and 31 Euros per package, the costs for triptans are high. The average salary in Croatia is approximately 730 Euros, and the unemployment rate is now 14%. Therefore, if the patient does not have the “additional health insurance” the costs for visits to a neurologist and for triptans are rather high.
Satisfaction with treatment
One study showed that the main reasons were dissatisfaction with treatment or feeling that the physician was ignorant about, or not interested in solving the problem [
10]. In a population-based study in the United States, only 29% of M sufferers reported that they were “very satisfied” with their usual acute treatment [
24].
Our study showed that when specifically asked for satisfaction with treatment so far, the results of the proportion of patients in each group was similar: one-fifth to one quarter of patients being completely satisfied, nearly half of patients stated that they were partially satisfied, and approximately 30% were mostly or completely unsatisfied. Patients attending headache clinics were more satisfied with treatments provided than patients visiting community care physicians [
25].
These data should be analyzed for use in future studies to show subgroups of patients and their reasons for dissatisfaction with current therapies. Targeting untreated groups will help establish better health care plans in Croatia. Our study has shown that the main information source are mass media (journals 55.4% and TV or radio 47.4%), whereas information from the internet and from medical books is still restricted to a smaller number of health seekers.
Use of acute treatment
Triptans are widely recommended for M since studies have shown that their use increases productivity at work and improves the quality of life of M sufferers [
26]. However, studies worldwide show that the majority of M patients are using OTCs and the minority is using triptans [
2‐
6,
17,
27,
28]. This is largely influenced by the physician who is treating the patient. A study from Singapore showed that community care physicians treat patients with triptans far less than do physicians in headache clinics [
25].
In our study, 57.4% of M patients stated that they are currently using or have tried specific M treatment: 35.7% used triptans and 21.8% used ergotamines or dihydroergotamines. According to Croatian guidelines for headache treatment [
29], analgesics and triptans should be the first line for M treatment, while ergotamines can be recommended with some exceptions. However, our results show that a large number of patients are still using ergotamines. Reasons for this are probably due to the fact that these drugs were previously used as specific treatment, and patients have a lack of information regarding new drugs such as triptans. Another reason is that ergotamines are somewhat less expensive as compared to triptans: a price for 20 tablets of combined ergotamine with paracetamol and caffeine is 7 Euros; however, they are not available as OTC drugs and are not a prescription drug in Croatia (they can only be purchased abroad). The least expensive are NSAIDs; the price varies between 1 and 3 Euros for ten tablets.
In our study, 67.4% of M patients were satisfied with specific medications if taken on time and only 4.7% were not satisfied. Studies showed that intra-individual consistency to oral triptan response is 40–50% in 3/3 M attacks [
30]. Efficacy, adverse events, costs, and physician’s knowledge have a major influence on triptan consumption.
Results of our study showed that patients with M were taking significantly more tablets per month for M attacks as compared with TTH patients. In the group of patients who were taking one tablet per month, 71.1% of M patients were satisfied with their treatment and an additional 25% were partially satisfied, whereas the percentage of satisfied patients who must take two or three medications was 48 and 55.6% respectively. In the TTH group, approximately 70–80% of all patients (taking 1, 2 or 3 tablets per attack) were satisfied with treatment. These results indicate that the more medications the patients must take per headache attack, the less likely they are to be satisfied with their efficacy. This study was not designed to provide data on medication overuse in the general population; therefore, these data is not available. A study from the USA showed that half of the patients use OTC drugs for the acute M attack despite the fact that 73% of them require a second dose or product; patients using a triptan were less likely to require a second dose or product [
31]. A survey comparing the consumption of analgesics over the past 20 years in nine countries showed that in half of countries analyzed the consumption of analgesics has increased significantly, and it has remained constant or showed a minor increase in the others [
32].
Use of prophylactic treatment
In our study, 13.9% of patients have used prophylactic therapy for M. The details regarding the type and duration of prophylactic therapy were not obtained. A French study showed that only 6% of M patients are currently taking prophylaxis, among those 22% were in MIDAS III or IV group [
3]. Another population-based study in France showed that only 0.3% of M patients and 1.4% with PM are taking prophylactic treatment [
27]. A study from the USA showed that 12.4% of patients with M are taking prophylaxis [
8] and 7.9% of PM patients, even though this percentage should be higher based on patients’ characteristics [
33]. In Australia, 8.3% of patients were taking prophylactic medication [
34]. In a Canadian study, only 31% of patients with severe or chronic M were taking prophylactic treatment [
7]. More than half of patients on prophylaxis, especially <40 years of age, tend to discontinue the therapy within 3 months [
35].
Use of alternative treatment
Alternative methods of treatment in our study have been used by approximately one quarter of patients in all three groups of patients. Approximately 40% of patients with M and PM were satisfied with alternative methods, whereas in the TTH group this percentage was even higher, at 60%. Studies from other countries show that patients relatively frequently reach for alternative methods for headache treatment: approximately one-third of patients in Italy, Switzerland, and Singapore tried at least one method [
25,
36,
37]. Analysis of patients who visited a specialized headache clinic revealed that even 84% tried one or more alternative methods and 60% of those stated that these methods were efficient [
38]. American studies observed an increase in the proportion of patients seeking alternative methods for headache treatment [
39].
Study limitations
This study has several limitations. First, the data were collected by a questionnaire; it is possible that the data obtained from a face-to-face interview would, to some extent, be different. Second, the data regarding the number of specific acute M treatment and OTC drugs were provided as a total number of used medication and not in separate groups. Furthermore, details about types of prophylactic treatments were not provided due to the limited number of questions asked. Finally, due to a rather small sample size our results need to be further validated.