Transcript: Urvish Patel, MD, on Status Migrainosus Triggers and Impact on Morbidity

Dr Patel: My name is Urvish Patel, and I’m a research associate affiliated with Icahn School of Medicine at Mount Sinai, and I’ll be presenting today the work on triggers of status migrainosus and its impact associated with higher morbidity among migraineurs.

Why this study is important is because, though it's just less than 1% of migraineurs having status migrainosus, which is more than 72 hours of headache or migraine episode, but that is resistant to medicine, and the hospitalization associated with that is longer, expensive and has higher hospital burden in terms of cost, as well as disability–patients’ disability. That is why this topic is very important, and that is why the triggers and risk factors are very important to evaluate.

Neurology Consultant: What prompted you and your colleagues perform the study of triggers of status migrainosus and the impact on morbidity?

Dr Patel: Migraine is a common disorder among women. Status migrainosus is a sub-section, su-part of migraine, when a migraine has longer duration, especially more than 72 hours, or it is resistant to multiple medicines, or it is so severe that it requires hospitalization. Now, why we think about this, status migrainosus, is because it is associated with very high cost and higher chance of disability, or I can say the morbidity, associated with patients who are having migraine. Those patients, if particularly risk factors are there, then the likelihood of converting for those patient into status [migrainosus] is very common. So, we try to identify those risk factors first, and then we try to identify those triggers. That was the study.

Neurology Consultant: Could you discuss the key findings from your study?

Dr Patel: Let me tell you a little bit briefly about the data and the population on which this study is based. So, we used basically a nationwide impatient sample. It's 90% representative of US database of 2003 to 2014, and among those samples, we took the adult hospitalization with the migraineurs, and from those migraineurs, we identified patients having status migrainosus and intractable migraine, the severe migraine requiring hospitalization. And after that, from those patients having status migranosus, we separated those patients having higher morbidity. Now, we defined morbidity as hospitalization for more than 5 days. We consider 5 days as more than 90% of the mean migraine hospitalization. So, more than 5 days, and their discharge is not home–their discharge is somewhere other than home like short-term hospitalization skilled nursing home, or intermediate care facilities. And then, we tried to see what factors are associated with the triggers of status migrainosus, and what are the factors associated with morbidity, status migrainosus-related morbidity?

And, the key findings of our study–number one, in our database, we were having approximately 4.4 million patients having a migraine primary diagnosis. Out of 4.4 million, we are having 29.32% having status migrainosus. So, that's a huge number. The trend of status migrainosus increased as the years passed by from 2003 to 2014. That could be due to multiple reasons. The most common reason is medication overuse, and we will talk about later on that in the advanced direction, what we are thinking about. So that is increasing, number one.

The second–the characteristics of the status migrainosus patients are younger, they are more commonly female, they are white, and on weighted analysis, we found that drug abusers are having a higher risk of having status migrainosus. Similarly, the patient who is having vitamin D deficiency, the long-term vitamin D deficiency among migraineurs–then they're prone towards converting to status migrainosus. Similarly, opioid abuse, especially among drug abusers, some of the organic sleep disorders, medication overuse, some of the depression and anxiety type of disorders, so psychiatric disorders and PTSD, depression, and generalized anxiety. So, 3 types of psychiatric disorders were highly associated with the risk factors of status migrainosus–or, I can say the triggers of status migrainosus among the patients who were hospitalized with migraine. So that was the key finding–that these are the risk factors.

Now, out of that, which patients are associated with higher morbidity? That was another key finding. So, the patient who is having concurrent ischemic stroke, history of stroke, or hemorrhagic stroke–I mean, of course, that is one of the important findings, which is associated with higher morbidity. That is nothing much new, but comorbidities, especially obesity number one, atrial fibrillation number two, renal failure, epilepsy and psychiatric illnesses, concurrent psychiatric illness, are associated with higher morbidity among the patient with status migrainosus.

So, an important thing is that psychiatric disorders are not only associated with converting migraine into status migrainosus–so, they are the risk factors or triggers for status migrainosus–but also associated with higher morbidity among them. So, that is one of the important points thatwe want to emphasize in a future study.

And the second thing we would like to emphasize: so, what should be the important interpretation of this finding? Number one, we would like to emphasize more on medication overuse. Overuse headache, which is one of the primary headache disorders, we would like to see that trend and the weighted analysis, whether the increasing trend in status migrainosus is big because of that medication, or what is headache or not. And what is the role of psychiatric disorders after treating them? What are the risk factors? Those are the main risk factors. After treating those disorders, whether we can reduce the burden or we can mitigate the risk or not. That is the goal of this study.

Neurology Consultant: What direction should future research take now after this study?

Dr Patel: As I mentioned before that the study–in the beginning, we didn't know the risk factors, but the majority of risk factors belong to psychiatric disorders. So now, the future direction to emphasize on as we identify the linkage between psychiatric disorders and status migrainosus–we would like to emphasize more on whether treating psychiatric risk or psychiatric disorders can mitigate the risk of status migrainosus or not, number one. That could be possible only in the prospective type of cohort studies, and in the future, more studies need to be done in order to evaluate that.

And second, that whether the increasing the trend of status migrainosus–is the important reason medication overuse headache or not? That is the second thing, and our team is already working in some of the medication overuse headache, including opioids and other medicines. So, let's see what the results will in the last 10 to 15 years of data–which and whether the medicines are related to status migrainosus, converting migraine to migrainosus or not. So those are the 2 important directions we are aiming for.

Neurology Consultant: What are the key takeaways neurologists should keep in mind about this topic?

Dr Patel: That's a very important thing here in this study. What we think is that every migraineur patient should be evaluated for number one, psychiatric risk factors because that is–and of course, the medication overuse headache. That is one of the most important findings because we have not proven yet whether treating those factors could mitigate risk or not. That is a secondary thing, but that is one of the common findings we found–that it’s associated with also converting migraine to status migrainosus, as well is associated with higher morbidity. So, one thing every migraineur must be evaluated for psychiatric disorders, number one.

And, the second take-home message is some of the small things are common in, let's say, vitamin D deficiency. It's a very small thing, but still, it increases the risk by 1.28 hours. So, that is easily treatable. If the patient is admitted in the hospital, it's easy to identify and easy to treat. So, why not to emphasize this more? And, it's nothing new. For many years, we’ve known the association and linkage between vitamin D and headache, so it's good to identify early and to treat on time. So, that is the second key point that we want to emphasize as a take-home message.