(1)	Adelman JU, Sharfman M. Impact of oral sumatriptan on workplace productivity, health related Quality-of-Life, Healthcare use and patient satisfaction with medication in nurses with migraine. Am J Manag Care 1996; December. Abstract: Although oral sumatriptan has previously been shown to be effective and well tolerated in the acute treatment of migraine, the effects of this drug on workplace productivity, ability to perform non-workplace activities, health related quality of life, healthcare use, patient satisfaction with medication, and clinical effectiveness have not been assessed concurrently within the context of one clinical trial. This study, conducted in 220 nurses with migraine, examined the effect of oral sumatriptan on these variables for 6 months after usual therapy had been used for 2 months. On average, total disability time (ie, lost workplace productivity + lost activity time) because of migraine was 31% lower with sumatriptan than with usual therapy (P <0.001). Patient scores on all dimensions of the Short Form-36 Health Survey improved after 6 months of sumatriptan treatment. The average number of migraine-related visits to a clinic or physician's office for migraine consultation was significantly lower (P<0.001) during the sumatriptan phase compared with the usual therapy phase. Mean patient satisfaction scores were significantly higher (P<0.05) for sumatriptan compared with usual therapy after both 3 months and 6 months of treatment. Headache relief 2 hours postdose was reported by 76% of patients across migraine days during the sumatriptan phase compared with 44% of patients during the usual therapy phase (P<0.001). Data from this study demonstrate that oral sumatriptan may reduce both the economic and social costs of migraine for patients and their employers.
(2)	Beers MH and Berkow R. The Merck Manual of Diagnosis and Therapy, 17th edition. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
(3)	Biddle AK, Shih YC, Kwong WJ. Cost-benefit analysis of sumatriptan tablets versus usual therapy for treatment of migraine. Pharmacotherapy 2000; 20(11):1356-1364. Abstract: We performed a systematic assessment of the costs and benefits of sumatriptan and usual therapy for migraine from society's perspective. A decision tree was constructed with probability estimates based on data from an open-label clinical trial assessing the economic and human impacts of sumatriptan and usual therapy on nursing personnel. Direct medical care costs including costs for drug, physician, and emergency room visits were considered. Benefits were estimated using the human capital approach based on the national average of weekly earnings and productivity loss estimated from a migraine clinical trial. The net benefits of sumatriptan and usual therapy for the treatment of a single migraine attack were estimated to be $50 and $20, respectively. The annual incremental net benefit of sumatriptan over usual therapy was estimated to be $114-540/patient. The price difference was offset by benefits of sumatriptan in reducing use of health care resources and productivity loss.
(4)	Cady RC, Ryan R, Jhingran P, O'Quinn S, Pait DG. Sumatriptan injection reduces productivity loss during a migraine attack: results of a double-blind, placebo-controlled trial. Arch Intern Med 1998; 158(9):1013-1018. Abstract: OBJECTIVE: To evaluate the impact of sumatriptan succinate injection compared with placebo on productivity loss during a migraine attack in the workplace. DESIGN: Randomized, double-blind, placebo-controlled, parallel-group clinical trial. SETTING: Fifteen clinical centers in the United States. PATIENTS: One hundred thirty-five patients 18 years and older diagnosed as having migraine according to International Headache Society criteria. INTERVENTIONS: Patients self-administered sumatriptan injection (6 mg) or matching placebo to treat a moderate or severe migraine occurring within the first 4 hours of a minimum 8-hour work shift. MAIN OUTCOME MEASURES: Mean productivity loss 2 hours after dosing and across the work shift; percentages of patients returning to normal work performance within 2 hours after dosing and across the work shift; percentages of patients experiencing headache relief (reduction of moderate or severe predose pain to mild or no pain) 1 and 2 hours after dosing. RESULTS: Mean productivity loss was significantly (P< or =.002) lower in the sumatriptan group compared with the placebo group both during the 2-hour postdose period (sumatriptan, 39 minutes; placebo, 54 minutes) and across the work shift (sumatriptan, 86 minutes; placebo, 168 minutes). Significantly (P<.001) greater percentages of patients in the sumatriptan group compared with the placebo group returned to normal work performance by 2 hours after dosing (sumatriptan, 52%; placebo, 9%) and across the work shift (sumatriptan, 66%; placebo, 18%). Significantly (P< or =.001) greater percentages of patients in the sumatriptan group compared with the placebo group experienced headache relief 1 hour after dosing (sumatriptan, 69%; placebo, 18%) and 2 hours after dosing (sumatriptan, 79%; placebo, 32%). CONCLUSION: Sumatriptan reduced migraine-associated productivity loss during a minimum 8-hour work shift by approximately 50% compared with placebo and alleviated headache in more than three fourths of patients.
(5)	Clouse JC, Osterhaus JT. Healthcare resource use and costs associated with migraine in a managed healthcare setting. Ann Pharmacother 1994; 28(5):659-664. Abstract: OBJECTIVE: To compare healthcare use and associated costs in patients with migraine and patients without migraine headache. DESIGN: Retrospective review of a managed care organization's medical and pharmacy claims databases for claims filed between January 1, 1989 and June 30, 1990. PATIENTS: Patients between 18 and 64 years old with a 12-month minimum enrollment in the health plan, including enrollment for the prescription drug benefit. Migraine group (n = 1336) inclusion required a medical claim with the diagnosis of migraine headache and a pharmacy claim for a medication potentially used for migraine treatment. Comparison group (n = 1336) inclusion required at least one medical claim with no diagnosis of migraine; a pharmacy claim was not required. Comparison group patients were matched to migraine group patients by age, gender, enrollment status, and subscriber or dependent enrollment status. OUTCOME MEASURES: Total health services use, diagnosis-specific use of services, diagnostic procedures performed, comorbid conditions, medication use, and associated costs were tallied. RESULTS: Migraineurs generated nearly twice as many medical claims as comparison group patients, and nearly 2.5 times as many pharmacy claims. Number of claims generated and numbers of patients who generated claims within each of 19 diagnostic categories indicated greater comorbidity in the migraine group. Migraineurs used emergency services more than did patients in the comparison group. Total medical and pharmacy claims costs were $3.4 million for the migraine group and $2.1 million for the comparison group. The average amount paid per member-month of enrollment was significantly greater in the migraine group than in the comparison group. Comorbid conditions were responsible for a significant portion of costs in the migraine group. The migraine group incurred $83,537 for diagnostic procedures compared with $13,140 incurred by the comparison group. CONCLUSIONS: Patients with migraine had greater morbidity in general and incurred 64 percent greater costs in healthcare resource use compared with patients without migraine
(6)	Cohen JA, Beall D, Beck A et al. Sumatriptan treatment for migraine in a health maintenance organization: economic, humanistic, and clinical outcomes. Clin Ther 1999; 21(1):190-204. Abstract: This study was undertaken to assess the impact of 12 months of sumatriptan therapy (6 mg subcutaneously) for migraine on health care use, health-related quality of life, productivity, patient satisfaction with the medication, and clinical efficacy in a health maintenance organization (HMO). One hundred forty-eight patients received open-label sumatriptan for 12 months for the treatment of migraine. Medical records were reviewed to obtain information on the frequency of migraine-related health care use during the 12 months before and during sumatriptan treatment. Patients completed questionnaires on their productivity at work, health-related quality of life, and satisfaction with medication at baseline and after 3, 6, and 12 months of sumatriptan treatment. For each migraine, patients recorded pain severity scores before and after taking sumatriptan and the time between dosing and onset of meaningful relief. Sumatriptan was associated with significant reductions in migraine-related use of general outpatient services, telephone calls, urgent care services, and emergency department visits (P < 0.05); a significant increase in the use of pharmacy services (P < 0.05); and significant and sustained improvements in health-related quality-of-life scores compared with baseline (P < 0.001). Patients lost significantly less time from work and were significantly more satisfied with sumatriptan compared with their usual therapy (P < 0.05). Two hours after dosing, 81% of patients experienced reduction of moderate or severe pain to mild or no pain, and 90% of all patients experienced meaningful relief of pain. The use of sumatriptan for 12 months in an HMO was associated with reductions in health care use and improved health-related quality of life, productivity, and patient satisfaction with medication.
(7)	Dasbach EJ, Carides GW, Gerth WC, Santanello NC, Pigeon JG, Kramer. Work and productivity loss in the rizatriptan multiple attack study. Cephalalgia 2000; 20(9):830-834. Abstract: The objective of this study was to measure the self-reported effect of acute migraine and its treatment on paid work and productivity loss. Patients self-administered a questionnaire in which the impact of a recent migraine on paid work and productivity activities was assessed. We included the questionnaire in a randomized, double-blind, placebo-controlled, crossover, out-patient study designed to examine the safety and efficacy of rizatriptan (5-HT1B/1D receptor agonist) 10 mg p.o. in patients treating four separate migraine attacks. A total of 407 patients, aged 18-65 years, suffering from moderate to severe migrainous headaches was studied. Patients receiving rizatriptan compared with placebo reported 0.7 fewer hours (P < 0.01) of paid worked missed due to absenteeism, 0.4 fewer hours (P < 0.05) of productive time lost on the job, and 1.1 fewer total hours (P < 0.01) of work loss per migraine attack. Rizatriptan compared with placebo significantly reduced migraine-related work loss associated with absenteeism and decreased effectiveness on the job.
(8)	Davies GM, Santanello N, Gerth W, Lerner D, Block GA. Validation of a migraine work and productivity loss questionnaire for use in migraine studies. Cephalalgia 1999; 19(5):497-502. Abstract: Migraine symptoms and therapy side effects cause significant functional disability that can result in work and productivity losses. Effective, well-tolerated migraine therapy with rapid onset of relief could decrease work and productivity losses. The Migraine Work and Productivity Loss Questionnaire (MWPLQ) evaluates the impact of migraine and migraine therapy on paid work. Data from a randomized, open-label extension study were collected over 3 months. Migraineurs were randomized to either rizatriptan (5HT1B/1D receptor agonist) or their usual migraine therapy. Data were analyzed from 164 patients who experienced at least one work-related migraine. Internal consistency (Cronbach's alpha) for the work difficulty domains ranged from 0.80 to 0.95. Work loss and work difficulty were moderately correlated (r = 0.39-0.58) with migraine severity and functional ability. Differences were found favoring rizatriptan for absenteeism (1.3 vs 2.4 h), effectiveness at work (62% vs 49%), and difficulty with work-related tasks (p < 0.01). The MWPLQ demonstrated favorable measurement characteristics in this study and could be an important research tool for future evaluations of migraine-related work disability
(9)	Dodick DW. Epidemiology and acute care of migraine headache. Manag Care Interface 2004; 17 Suppl D: 6-10, discussion 11-13. Abstract: It is well known that migraine is a common medical disorder with a prevalence of about 12% in the United States. This article reviews the cost burden of migraine, its acute treatment, the benefits of early treatment, and menstrual migraines.
(10)	Eastern Research Group, Inc. (February 2001). Profile of the prescription drug wholesaling industry: Examination of entities defining supply and demand in drug distribution (Task order N. 13, Contract No. 223-98-8002). Lexington, MA. Prepared for the Department of Health and Human Services. This report details several aspects of the prescription drug industry, starting with current federal and state regulations. A review of major categories of wholesalers is presented, along with models of drug distribution. Information about pharmaceutical purchasing organizations and typical industry discounts is also provided.
(11)	Edmeads J, Mackell JA. The economic impact of migraine: an analysis of direct and indirect costs. Headache 2002; 42(6):501-509. Abstract: OBJECTIVE: This study examined whether individuals with migraine incurred greater direct and indirect costs than a matched group free of migraines. METHODS: Using population-based survey data, we matched individuals with migraine (n = 1087) and a migraine-free control group one-to-one for age, sex, employment status, and number of comorbidities. We assessed the prior six months' direct medical care in terms of self-reported hospital days and emergency department and physician visits. Costs were computed by multiplying utilization by unit costs and summing across categories. Indirect costs were calculated based on the number of days missed from employment or household activities. RESULTS: The sample was 80% female and had an average of 39 years and 0.4 comorbid conditions. Two-thirds were employed. Migraineurs had higher direct medical costs over the prior six months (522 dollars versus 415 dollars, P =.039), primarily due to a greater frequency of physician and emergency department visits. The cost of lost productivity for the migraine group was also higher, by more than 200 dollars (P =.014). The combined total for direct and indirect costs was 1,242 dollars for migraineurs and 929 dollars for the comparison group (P =.006). Additional analyses comparing those with moderate versus severe migraine demonstrated that more severe migraineurs had higher costs for lost productivity (1,021 dollars versus 251 dollars, P<.001) and higher costs when direct and indirect costs were combined (1,656 dollars versus 685 dollars, P<.001). CONCLUSION: Migraine is an expensive illness and two-thirds of the financial burden is linked to indirect costs. Consequently, individuals with migraine, employers, and insurance companies all have an economic stake in reducing the migraine burden.
(12)	Gerth WC, Carides GW, Dasbach EJ, Visser WH, Santanello NC. The multinational impact of migraine symptoms on healthcare utilisation and work loss. Pharmacoeconomics 2001; 19(2):197-206. Abstract: OBJECTIVE: To compare self-reported healthcare resource utilisation, paid work loss, unpaid work loss and loss of effectiveness at work due to migraine in a clinic-based adult migraine population. METHODS: The Migraine Background Questionnaire (MBQ) was translated and pilot-tested for use in 25 countries. The questionnaire was then self-administered by patients at a screening visit for 3 phase III clinical trials of rizatriptan [a selective serotonin (5-hydroxytryptamine) 5-HT1B/1D receptor agonist] in 23 US and 78 non-US sites. PARTICIPANTS: Persons 18 to 65 years of age with at least a 6-month history of moderate to severe migraines prior to the screening visit were surveyed. RESULTS: A total of 2670 persons (54.7% Europe, 16.5% Latin America, 23.1% North America, 5.5% other countries) completed the MBQ and had responses which could be analysed. On average, each patient reported 2.78 doctor visits, 0.53 emergency room visits and 0.06 hospitalisations related to migraine per year. Patients self-reported being only 46% effective while on the job with migraine symptoms. Extrapolation of patient self-reported work and productivity loss for the last 4 weeks to an annual basis suggested that clinic-based patients with migraine lose 19.5 workday equivalents (8.3 days due to absenteeism, 11.2 days due to reduced workday equivalents) due to migraine per year. In the US, the annual employer cost of this total migraine-related work loss is estimated to be $US3309 (2000 values) per patient with migraine. The levels of self-reported healthcare resources utilised for migraine and work loss were generally consistent across geographic regions. CONCLUSIONS: The impact of migraine symptoms on healthcare resource utilisation and work loss was similar across most measures in Europe, Latin America, North America and other countries. Total migraine-related work loss due to absenteeism and reduced workday equivalents accounts for most of the economic burden of migraine, regardless of country, in a clinic-based migraine population.
(13)	Gerth WC, Sarma S, Hu XH, Silberstein SD. Productivity cost benefit to employers of treating migraine with rizatriptan: a specific worksite analysis and model. J Occup Environ Med 2004; 46(1):48-54. Abstract: Employers in the United States might not be aware of the productivity costs of migraine or the extent to which those costs can be reduced by optimal treatment. An economic model was developed to enable employers to estimate the productivity costs of migraine to their company and the savings that will accrue if those patients who suffer from migraine are treated with rizatriptan. Analyses were run for both a major financial services corporation and a representative U.S. company. The major financial services corporation, with 87,821 employees, is projected to lose 538 person-years annually, at an estimated cost of 23.8 million dollars. A representative U.S. company with 10,000 employees is projected to lose 46.0 person-years of productive effort annually as a result of migraine, valued at approximately 1.94 million dollars. The value of the annual work loss avoided if migraine is treated with rizatriptan is projected at 10.3 million dollars for the financial services corporation and 841,000 dollars for the representative U.S. company. There is a substantial productivity cost burden of migraine from a U.S. employer perspective. These productivity costs can be reduced significantly by treating migraine headaches with rizatriptan
(14)	Greiner DL, Addy SN. Sumatriptan use in a large group-model health maintenance organization. Am J Health Syst Pharm 1996; 53(6):633-638. Abstract: The outcomes of sumatriptan use at a health maintenance organization (HMO) were studied. The study was conducted during one year beginning immediately after sumatriptan was added to the formulary of a large group-model HMO. Subjects were included on the basis of drug-use evaluation criteria, a positive response to the first dose of sumatriptan (administered at the HMO by a nurse), and ability to participate in a telephone survey. Responders to the first dose were eligible to receive up to six doses of sumatriptan for home use. The telephone survey was designed to assess sumatriptan's effects on migraine headache and to capture data on quality of life, perceived problems with sumatriptan, and patient satisfaction. Patients who received sumatriptan between April and September 1993 were interviewed in late September 1993; patients who received sumatriptan between September and April 1994 were interviewed in late April 1994. Of 180 patients surveyed, 160 (89%) had evaluable responses. Migraine headache improved in two thirds of the patients. Sumatriptan was more effective than previously used agents in three fourths. The mean number of migraine headaches per patient per month decreased from 7.4 to 4.2. Quality-of-life indicators, such as time spent with friends, improved in three fourths. Eighty-three percent reported missing fewer days from work. Ninety percent said they would continue to take the drug, despite a 44% incidence of drug-related problems. There were no unexpected problems. A retrospective review showed that utilization of the HMO's resources was reduced with sumatriptan. Placing sumatriptan on an HMO's formulary led to favorable effects on the frequency and severity of migraine headache, patient quality-of-life indicators and productivity, and resource utilization by the organization
(15)	Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: disability and economic costs. Arch Intern Med 1999; 159(8):813-818. Abstract: BACKGROUND: Migraine is a common disabling disease but its economic burden has not been adequately quantified. OBJECTIVE: To estimate the burden of migraine in the United States with respect to disability and economic costs. METHODS: The following data sources were used: published data, the Baltimore County Migraine Study, MEDSTAT's MarketScan medical claims data set, and statistics from the Census Bureau and the Bureau of Labor Statistics. Disability was expressed as bedridden days. Charges for migraine-related treatment were used as direct cost inputs. The human capital approach was used in the estimation of indirect costs. RESULTS: Migraineurs required 3.8 bed rest days for men and 5.6 days for women each year, resulting in a total of 112 million bedridden days. Migraine costs American employers about $13 billion a year because of missed workdays and impaired work function; close to $8 billion was directly due to missed workdays. Patients of both sexes aged 30 to 49 years incurred higher indirect costs compared with younger or older employed patients. Annual direct medical costs for migraine care were about $1 billion and about $100 was spent per diagnosed patient. Physician office visits accounted for about 60% of all costs; in contrast, emergency department visits contributed less than 1% of the direct costs. CONCLUSIONS: The economic burden of migraine predominantly falls on patients and their employers in the form of bedridden days and lost productivity. Various screening and treatment regimens should be evaluated to identify opportunities to reduce the disease burden
(16)	IMS Consulting. Longitudinal Analysis of the Migraine Market. February 2005. IMS Health Inc., Plymouth Meeting, PA.
(17)	International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004; 24 Suppl 1:9-160. Abstract: This important document was intended to aid both researchers and clinicians in appropriately classifying headaches. Diagnostic standards that serve as the basis for classifying migraineurs in research and clinical practice are presented
(18)	Jhingran P, Cady RK, Rubino J, Miller D, Grice RB, Gutterman DL. Improvements in health-related quality of life with sumatriptan treatment for migraine. J Fam Pract 1996; 42(1):36-42. Abstract: BACKGROUND. The debilitating effects of migraine might be reduced in patients using an effective migraine medication. The serotonin (5HT1) receptor agonist sumatriptan has been shown in clinical trials to alleviate headache and associated symptoms in the majority of patients treated. METHODS. Three hundred forty-four (344) patients with migraine were allowed to treat an unlimited number of migraine attacks for up to 24 months with subcutaneous sumatriptan (6 mg). Open-label oral sumatriptan (100 mg) could be used between 1 hour and 24 hours after the initial injection for treatment of recurrent or persistent headache. On four occasions during the treatment period, patients completed the Medical Outcomes Study Short Form-36 Health Survey, a general health status instrument; the Migraine-Specific Quality of Life Questionnaire, a disease-specific instrument; and a series of questions designed to measure the impact of migraine on productivity and disability. RESULTS. Treatment with sumatriptan was associated with significant (P < .05) improvements relative to baseline in three of the Short Form-36 Health Survey quality-of-life dimensions (Bodily Pain, General Health Perceptions, and Social Functioning) and three of the Migraine-Specific Quality of Life Questionnaire dimensions (Role Function-Restrictive, Role Function-Preventive, and Emotional Function). Significant (P < .05) improvements in patient-rated productivity and reductions in patient-rated disability also occurred during the trial. CONCLUSIONS. Patients using sumatriptan to treat migraines for up to 24 months experienced improvements in disability and productivity as well as in health-related quality of life as measured either by a general health status instrument or a disease-specific instrument
(19)	Joish VN, Cady PS, Shaw JW. Health care utilization by migraine patients: a 1998 Medicaid population study. Clin Ther 2000; 22(11):1346-1356. Abstract: BACKGROUND: In the last decade, a number of studies have documented the economic impact of migraine headaches on society. Although previous research has shown that patients with migraine headache consume a greater amount of health care resources than those without migraine, the economic impact of this condition on a Medicaid population has not been assessed. OBJECTIVE: The purpose of this study was to compare the health care resource utilization of-patients with and without migraine headache in the Idaho Medicaid population. METHODS: Idaho Medicaid claims from 1998 were reviewed to identify cases and controls. Four controls, matched for age, sex, race, and residence, were obtained for each case. Physician services, hospital services, emergency room services, and prescription use were compared between the 2 groups. Multivariate analyses were performed to determine differences between the 2 groups after controlling for potential confounders. RESULTS: Eighty percent of the cases were female, and 94% of the patients were white. Patients with migraine headache had statistically significantly higher health care resource consumption than matched controls (P < 0.05). Total log costs for prescription use, physician services, and hospital services were significantly higher (P < 0.001) in the migraine group even after controlling for migraine-associated comorbid conditions and demographic variables. CONCLUSIONS: Total health care costs for migraine patients were 1.6 times higher than for matched controls. The results of this study suggest that migraine is a significant economic burden to the Medicaid program
(20)	Legg RF, Sclar DA, Nemec NL, Tarnai J, Mackowiak JI. Cost benefit of sumatriptan to an employer. J Occup Environ Med 1997; 39(7):652-657. Abstract: Benefit and occupational health managers need information on whether new treatments, such as sumatriptan, for migraine headache improve organizational or individual performance. A work productivity outcomes assessment was conducted among sumatriptan-using employees of an Independent Practice Association-health maintenance organization population. Of the 164 sumatriptan users, 101 full-time employees were surveyed by telephone once in an open-label, before-after design. The results revealed that lost labor costs, a function of days missed from work and reduced productivity at work as a result of migraine, were decreased after sumatriptan treatment initiation. Incremental benefit of this reduction in lost productivity is valued at $435/month per employee. The sumatriptan cost associated with this benefit is $43.78/month. The benefit-to-cost ratio is 10:1. Other costs and benefits were excluded. In conclusion, the availability of sumatriptan for migraine headache treatments in this IPA-HMO resulted in improved work productivity and had a net benefit for the employer
(21)	Legg RF, Sclar DA, Nemec NL, Tarnai J, Mackowiak JI. Cost-effectiveness of sumatriptan in a managed care population. Am J Manag Care 1997; 3(1):117-122. Abstract: We conducted an open-labeled study to determine whether sumatriptan is more cost-effective than other therapies used to treat migraine headache. We contacted by phone 220 sumatriptan users enrolled in QualMed, a health maintenance organization (HMO) in Spokane, Washington. Of these, 203 met the inclusion criteria and 164 (81%) completed our telephone survey. The main outcome measures were healthcare costs to the HMO and number of days free of migraine-related disability before and after sumatriptan treatment. Before sumatriptan treatment, 89% of patients reported severe migraine, compared with 63% after sumatriptan treatment. The number of monthly migraine disability days decreased from 6.5 days per month before sumatriptan to 3.9 days per month after sumatriptan. Healthcare utilization rates (ie, number of hospitalizations, emergency department visits) and costs were lower after the patients began taking sumatriptan. The number of different over-the-counter medicines and prescription medications (other than sumatriptan) taken for migraine disabilities decreased. Although total drug expenditures per month increased, the total migraine healthcare expenditure was 41% lower after sumatriptan was initiated. The cost-effectiveness ratio was 47% more favorable after patients started taking sumatriptan. Overall, patients reported fewer migraine-related disabilities, had lower migraine severity scores, and used fewer healthcare resources when taking sumatriptan. These changes resulted in a better cost-effectiveness ratio for migraine treatment
(22)	Lipton RB, Diamond S, Reed M, Diamond ML, Stewart WF. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache 2001; 41(7):638-645. Abstract: OBJECTIVE: A population-based survey was conducted in 1999 to describe the patterns of migraine diagnosis and medication use in a representative sample of the US population and to compare results with a methodologically identical study conducted 10 years earlier. METHODS: A survey mailed to a panel of 20 000 US households identified 3577 individuals with severe headache meeting a case definition for migraine based on the International Headache Society (IHS) criteria. Those with severe headache answered questions regarding physician diagnosis and use of medications for headache as well as headache-related disability. RESULTS: A physician diagnosis of migraine was reported by 48% of survey participants who met IHS criteria for migraine in 1999, compared with 38% in 1989. A total of 41% of IHS-defined migraineurs used prescription drugs for headaches in 1999, compared with 37% in 1989. The proportion of IHS-defined migraineurs using only over-the-counter medications to treat their headaches was 57% in 1999, compared with 59% in 1989. In 1999, 37% of diagnosed and 21% of undiagnosed migraineurs reported 1 to 2 days of activity restriction per episode (P<.001); 38% of diagnosed and 24% of undiagnosed migraineurs missed at least 1 day of work or school in the previous 3 months (P<.001); 57% of diagnosed and 45% of undiagnosed migraineurs experienced at least a 50% reduction in work/school productivity (P<.001). CONCLUSIONS: Diagnosis of migraine has increased over the past decade. Nonetheless, approximately half of migraineurs remain undiagnosed, and the increased rates of diagnosis of migraine have been accompanied by only a modest increase in the proportion using prescription medicines. Migraine continues to cause significant disability whether or not there has been a physician diagnosis. Given the availability of effective treatments, public health initiatives to improve patterns of care are warranted
(23)	Lipton RB, Scher AI, Kolodner K, Liberman J, Steiner TJ, Stewart WF. Migraine in the United States: epidemiology and patterns of health care use. Neurology 2002; 58(6):885-894. Abstract: OBJECTIVE: To determine the prevalence and distribution of migraine in the United States as well as current patterns of health care use. METHODS: A random-digit-dial, computer-assisted telephone interview (CATI) survey was conducted in Philadelphia County, PA, in 1998. The CATI identifies individuals with migraine (categories 1.1 and 1.2) as defined by the diagnostic criteria of the International Headache Society with high sensitivity (85%) and specificity (96%). Interviews were completed in 4,376 subjects to identify 568 with migraine. Those with 6 or more attacks per year (n = 410) were invited to participate in a follow-up interview about health care utilization and family impact of migraine; 246 (60.0%) participated. RESULTS: The 1-year prevalence of migraine was 17.2% in females and 6.0% in males. Prevalence was highest between the ages of 30 and 49. Whereas 48% of migraine sufferers had seen a doctor for headache within the last year (current consulters), 31% had never done so in their lifetimes and 21% had not seen a doctor for headache for at least 1 year (lapsed consulters). Of current or lapsed consulters, 73% reported a physician-made diagnosis of migraine; treatments varied. Of all migraine sufferers, 49% were treated with over-the-counter medications only, 23% with prescription medication only, 23% with both, and 5% with no medications at all. CONCLUSION: Relative to prior cross-sectional surveys, epidemiologic profiles for migraine have remained stable in the United States over the last decade. Self-reported rates of current medical consultation have more than doubled. Moderate increases were seen in the percentage of migraine sufferers who use prescription medications and in the likelihood of receiving a physician diagnosis of migraine
(24)	Lipton RB, Scher AI, Steiner TJ et al. Patterns of health care utilization for migraine in England and in the United States. Neurology 2003; 60(3):441-448. Abstract: OBJECTIVE: To assess patterns of medical consultation, diagnosis, and medication use in representative samples of adults with migraine in England and the United States. METHODS: Validated computer-assisted telephone interviews were conducted in the United Kingdom (n = 4,007) and the United States (n = 4,376). Individuals who reported six or more headaches per year meeting the criteria for migraine were interviewed. RESULTS: Patients with migraine in the United Kingdom were more likely to have consulted a doctor for headache at least once in their lifetime (86% vs 69%, p < 0.0001), but also were more likely to have lapsed from medical care (37% vs 21%, p < 0.001). In the United States, patients with migraine who had consulted made more office visits for headache and were more likely to see a specialist. In the United States, but not in the United Kingdom, women with migraine were more likely than men to consult doctors for headache. Patients with migraine in the United Kingdom were more likely to receive a medical diagnosis of migraine (UK 67%, US 56%; p < 0.05). Patterns of medication use were similar in both countries, with most people treating with over-the-counter (OTC) medications. Substantial disability occurred in a high proportion of those who never consulted (UK 60%, US 68%), never received a correct medical diagnosis (UK 64%, US 77%), and treated only with OTC medication (UK 72%, US 70%). CONCLUSION: Medically unrecognized migraine remains an important health problem both in the United States and the United Kingdom. Furthermore, there may be barriers to consultation for men in the United States that do not operate in the United Kingdom
(25)	Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache 2001; 41(7):646-657. Abstract: OBJECTIVE: To describe the prevalence, sociodemographic profile, and the burden of migraine in the United States in 1999 and to compare results with the original American Migraine Study, a 1989 population-based study employing identical methods. METHODS: A validated, self-administered questionnaire was mailed to a sample of 20 000 households in the United States. Each household member with severe headache was asked to respond to questions about symptoms, frequency, and severity of headaches and about headache-related disability. Diagnostic criteria for migraine were based on those of the International Headache Society. This report is restricted to individuals 12 years and older. RESULTS: Of the 43 527 age-eligible individuals, 29 727 responded to the questionnaire for a 68.3% response rate. The prevalence of migraine was 18.2% among females and 6.5% among males. Approximately 23% of households contained at least one member suffering from migraine. Migraine prevalence was higher in whites than in blacks and was inversely related to household income. Prevalence increased from aged 12 years to about aged 40 years and declined thereafter in both sexes. Fifty-three percent of respondents reported that their severe headaches caused substantial impairment in activities or required bed rest. Approximately 31% missed at least 1 day of work or school in the previous 3 months because of migraine; 51% reported that work or school productivity was reduced by at least 50%. CONCLUSIONS: Two methodologically identical national surveys in the United States conducted 10 years apart show that the prevalence and distribution of migraine have remained stable over the last decade. Migraine-associated disability remains substantial and pervasive. The number of migraineurs has increased from 23.6 million in 1989 to 27.9 million in 1999 commensurate with the growth of the population. Migraine is an important target for public health interventions because it is highly prevalent and disabling
(26)	Litaker DG, Solomon GD, Genzen JR. Impact of sumatriptan on clinic utilization and costs of care in migraineurs. Headache 1996; 36(9):538-541. Abstract: BACKGROUND: Although migraine headaches affect a large segment of the population, no objective measure of therapeutic success is currently available. Comparing visit frequency and associated costs of care before and after introduction of a new therapy represents an important surrogate measure of success. METHODS: One hundred four patients regularly attending a headache clinic for migraines at a tertiary care hospital were instructed in the use of a new abortive migraine therapy. Medical appointment and financial systems were searched retrospectively for visit frequency and associated patient care and institutional costs. The number of visits and mean costs 18 months before and after initiation of therapy were compared using the signed rank test and paired t-test, respectively. RESULTS: The median number of visits made by study subjects to the headache clinic fell significantly following sumatriptan test dosing (P < 0.001). Prior to the new treatment, mean total patient care and institutional costs were $228.59 and $112.81 per person, respectively, and fell to $135.93 and $78.16 (P < 0.001) after therapy began. CONCLUSIONS: These data suggest that many patients with migraine benefit from sumatriptan, seek medical attention in a headache clinic less often, and incur fewer costs following initiation of treatment with this drug
(27)	Lofland JH, Johnson NE, Batenhorst AS, Nash DB. Changes in resource use and outcomes for patients with migraine treated with sumatriptan: a managed care perspective. Arch Intern Med 1999; 159(8):857-863. Abstract: BACKGROUND: Migraine headaches result in significant patient suffering and high costs to managed care organizations and employers. Studies that evaluate patient outcomes and the financial consequences of migraine treatment are important from a clinical and an economic perspective. METHODS: This prospective, observational study assessed the outcomes of migraineurs in a mixed model staff/ independent practice association managed care organization for patients previously diagnosed as having migraine who received their first prescription for sumatriptan. Data collected included medical as well as pharmacy claims and patient surveys to measure changes in satisfaction, health-related quality of life, workplace productivity, and nonworkplace activity after sumatriptan therapy was initiated. RESULTS: A total of 178 patients completed the study. Results showed significant decreases in the mean number of migraine-related physician office visits, emergency department visits, and medical procedures in the 6 months after sumatriptan therapy compared with the 6 months before sumatriptan was used (P<.05). Four of the health-related quality-of-life dimensions and the physical component summary score measured by the SF-36 (which is a valid, reliable general health status instrument) showed significant improvements at 6 months compared with patients' scores before use of sumatriptan (P<.05). Health-related quality of life measured by the disease-specific instrument MSQ (Migraine-Specific Quality of Life Questionnaire-Version 1.0, 1992 Glaxo Wellcome Inc, Research Triangle Park, NC) showed significant improvement at 3 and at 6 months compared with baseline scores (P<.05). There were also improvements in patient satisfaction and significant reductions in time lost from workplace productivity and nonworkplace activity. CONCLUSION: In the 6 months after sumatriptan therapy was initiated, health care resource use and time lost from workplace productivity and nonworkplace activity were reduced, while health-related quality of life and patient satisfaction scores improved for the managed care migraineurs enrolled in this study
(28)	Lofland JH, Kim SS, Batenhorst AS et al. Cost-effectiveness and cost-benefit of sumatriptan in patients with migraine. Mayo Clin Proc 2001; 76(11):1093-1101. Abstract: OBJECTIVE: To investigate the cost-effectiveness and cost-benefit of initiating sumatriptan therapy in patients with acute migraine who were previously taking nontriptan drugs. PATIENTS AND METHODS: This is an economic analysis of a prospective, pretest-posttest, observational 6-month outcomes study of 178 patients with a physician diagnosis of migraine who received their first prescription for sumatriptan between October 1994 and August 1996 and were members of a mixed-model managed care organization in western Pennsylvania. Migraine-related resource use data were obtained from the managed care organization's medical and pharmacy claims databases. The primary outcome measure for this economic analysis was the total disability time that patients experienced because of migraine. Patients reported time missed from work and usual nonwork activities because of migraine on self-administered questionnaires at baseline and at 3 and 6 months after initiation of sumatriptan. RESULTS: Initiation of sumatriptan resulted in a decrease of 662 migraine-disability-days for work and 1236 migraine-disability-days for nonwork activities during the 6 months of the study (decrease from 27.8 to 17.2 days per person), totaling 1898 migraine-disability-days averted with sumatriptan therapy. Migraine-related medical costs were lower after sumatriptan was initiated ($18,351 vs $26,192), whereas migraine-related pharmacy costs were lower with prior nontriptan drug therapy ($22,209 vs $74,861). The overall net cost savings after sumatriptan was initiated in these patients was $222,332 ($1249 per patient) with a benefit-to-cost ratio of $5.67 gained for each health care dollar spent from a societal perspective. The incremental cost-effectiveness ratio was $25 for each additional migraine-disability-day averted by using sumatriptan vs nontriptan drug therapy. Sensitivity analysis showed that changes in medical costs had little effect on the ratios and that sumatriptan remained cost-beneficial across a wide range of patient wages. CONCLUSION: This study showed that initiation of sumatriptan in patients previously receiving nontriptan therapy was cost-effective and had an economic benefit for patients, employers, and society. Sumatriptan also helped patients and physicians achieve goals recommended by the US Headache Consortium by reducing patients' disability and thus improving their ability to function at work and nonwork activities
(29)	Lofland JH, Locklear JC, Frick KD. Different approaches to valuing the lost productivity of patients with migraine. Pharmacoeconomics 2001; 19(9):917-925. Abstract: OBJECTIVE: To calculate and compare the human capital approach (HCA) and friction cost approach (FCA) methods for estimating the cost of lost productivity of migraineurs after the initiation of sumatriptan from a US societal perspective. DESIGN: Secondary, retrospective analysis to a prospective observational study. SETTING: A mixed-model managed care organisation in western Pennsylvania, USA. PATIENTS: Patients with migraine using sumatriptan therapy. INTERVENTIONS: Patient-reported questionnaires collected at baseline, 3 and 6 months after initiation of sumatriptan therapy. OUTCOME MEASURES: The cost of lost productivity estimated with the HCA and FCA methods. RESULTS: Of the 178 patients who completed the study, 51% were full-time employees, 13% were part-time, 18% were not working and 17% changed work status. Twenty-four percent reported a clerical or administrative position. From the HCA, the estimated total cost of lost productivity for 6 months following the initiation of sumatriptan was $US117905 (1996 values). From the FCA, the six-month estimated total cost of lost productivity ranged from $US28329 to $US117905 (1996 values). CONCLUSIONS: This was the first study to retrospectively estimate lost productivity of patients with migraine using the FCA methodology. Our results demonstrate that depending on the assumptions and illustrations employed, the FCA can yield lost productivity estimates that vary greatly as a percentage of the HCA estimate. Prospective investigations are needed to better determine the components and the nature of the lost productivity for chronic episodic diseases such as migraine headache
(30)	Miller DW, Martin BC, Loo CM. Sumatriptan and lost productivity time: a time series analysis of diary data. Clin Ther 1996; 18(6):1263-1275. Abstract: Two previously conducted clinical studies assessed lost nonworkplace activity time and lost workplace productivity time due to migraine symptoms in subjects using sumatriptan for 6 months to treat their migraines after a 12- to 18-week period of using their usual therapy without sumatriptan. Although statistically significant differences in lost nonworkplace activity time and lost workplace productivity time between the usual therapy and sumatriptan treatment periods were detected using the Wilcoxon signed-rank test, this test could not determine whether differences were attributable to inherent trends in the data. This current study employed time series analysis, which detects and controls for preexisting trends in data, to further explore the possibility that the observed reductions in lost time in the two clinical studies were related to management of the subjects with sumatriptan. The intercepts and slopes of the computed linear models suggest that the initiation of sumatriptan therapy produced savings of 0.8 hours of nonworkplace activity time and 0.5 hours of workplace productivity time per patient per week. These savings were sustained throughout the sumatriptan treatment period. Preexisting trends in the data were not detected in the models. Thus the productivity gains are not associated with either time effects or the statistical phenomenon of regression to the mean, but variables that are extreme in initial measurements will tend to be closer to the center of the distribution in subsequent measurements. This strengthens the hypothesis that management of migraine with sumatriptan is associated with reductions in lost productivity time
(31)	Mushet GR, Miller D, Clements B, Pait G, Gutterman DL. Impact of sumatriptan on workplace productivity, nonwork activities, and health-related quality of life among hospital employees with migraine. Headache 1996; 36(3):137-143. Abstract: This prospective, open-label study evaluated the effects of subcutaneous sumatriptan versus usual therapy on workplace productivity, activity time outside of work, and health-related quality of life in 43 men or women who were hospital employees diagnosed with migraine according to international Headache Society criteria. Patients treated migraines with their usual therapy for 12 to 18 weeks followed by subcutaneous sumatriptan for 6 months. Health-related quality of life measurements obtained at baseline, after usual therapy, and after sumatriptan therapy included the Short Form-36 Health Survey and the Migraine-Specific Quality of Life Questionnaire. Patient daily diaries were used to capture data on migraine symptoms and on Lost Workplace Productivity and Non-workplace Activity Time. Traditional clinical efficacy measures were obtained to support the pharmacoeconomic data. Clinical data showed that the percentage of treated migraine days per patient on which the patient experienced relief (moderate or severe pain reduced to mild or none) was 75% with sumatriptan and 25% with usual therapy. The mean time to meaningful relief was 1.1 hours during the sumatriptan phase and 4.2 hours during the usual therapy phase. Lost Workplace Productivity and Nonworkplace Activity Time was 35% lower with sumatriptan therapy (1.5 hours) compared with usual therapy (2.3 hours). Time missed from work due to symptoms, time worked with symptoms, and time normal activities were carried on with symptoms were each lower during sumatriptan therapy compared with usual therapy. Scores on each of the three Migraine-Specific Quality of Life Questionnaire dimensions and on the Role-Emotional dimension of the Short Form-36 were significantly more favorable after sumatriptan than after usual therapy (P < 0.05). These data demonstrate that treatment of migraines with sumatriptan for 6 months following usual therapy for 12 to 18 weeks was associated with improvement in clinical efficacy, reduction in lost workplace productivity and nonworkplace activity time, and enhancement of key dimensions of health-related quality of life among employees of a large university hospital
(32)	Osterhaus JT, Gutterman DL, Plachetka JR. Healthcare resource and lost labour costs of migraine headache in the US. Pharmacoeconomics 1992; 2(1):67-76. Abstract: Migraine headache is responsible for significantly more healthcare resource and lost labour costs than previously reported. Costs associated with migraine were assessed via a survey conducted in 940 patients, 70% of whom responded. All met the International Headache Society's diagnostic criteria for migraine and had participated in one of two multicentre, single-dose, parallel-group, randomised, placebo-controlled clinical trials designed to assess the efficacy of an anti-migraine compound. Migraine frequency and costs, in terms of healthcare resource utilisation and lost labour (decreased productivity and missed workdays), were assessed. Over 90% of respondents visited a clinic and nearly 50% presented to an emergency room for treatment of migraine-related symptoms at least once in the year prior to the survey. These 648 respondents used an estimated $US529 199 per year in healthcare services. 89% of employed respondents reported that job performance was adversely affected by migraine and over 50% of them missed at least two days of work per month. Depending on the estimates used for migraine prevalence and using 1986 estimates of median earnings for the US work force, the extrapolated costs to employers ranged from $US5.6 billion to $US17.2 billion dollars annually due to decreased productivity and missed work days. The cost of migraine is not fully appreciated by the medical community or by society
(33)	Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000 55: 754-762. Abstract: The Quality Standards Subcommittee (QSS) of the American Academy of Neurology (AAN) is charged with developing practice parameters for physicians. This practice parameter summarizes the results from the four evidence-based reviews on the management of patients with migraine: specifically, acute, preventive, and nonpharmacologic treatments for migraine, and the role of neuroimaging in patients with headache. Only the specific treatment guidelines are summarized.
(34)	Schulman EA, Cady RK, Henry D et al. Effectiveness of sumatriptan in reducing productivity loss due to migraine: results of a randomized, double-blind, placebo-controlled clinical trial 46. Mayo Clin Proc 2000; 75(8):782-789. Abstract: OBJECTIVE: To determine the effect of sumatriptan on migraine-related workplace productivity loss. PATIENTS AND METHODS: In this randomized, double-blind, placebo-controlled, parallel-group trial, adult migraineurs self-injected 6 mg of sumatriptan or matching placebo to treat a moderate or severe migraine within the first 4 hours of a minimum of an 8-hour work shift. Outcome measures included productivity loss and number of patients returning to normal work performance 2 hours after injection and across the work shift, time to return to normal work performance, and time to headache relief. RESULTS: A total of 206 patients underwent screening, 140 (safety population) of whom returned for clinic treatment. Of these 140 patients, 119 received migraine treatment in the workplace (intent-to-treat population), 116 of whom comprised the study population. Of these 116 patients, 76 self-administered sumatriptan, and 40 self-administered placebo. Sumatriptan treatment tended to reduce median productivity loss 2 hours after injection compared with placebo (25.2 vs 29.9 minutes, respectively; P = .14). Significant reductions in productivity loss were obtained across the work shift after sumatriptan treatment compared with placebo (36.8 vs 72.6 minutes, respectively; P = .001). Significantly more sumatriptan-treated patients vs placebo-treated patients experienced shorter return to normal work performance at 2 hours (53/76 [70%] vs 12/40 [30%], respectively) and across the work shift (64/76 [84%] vs 23/40 [58%], respectively; P < .001). Significantly more sumatriptan-treated patients experienced headache relief 1 hour after injection compared with placebo-treated patients (48/76 [63%] vs 13/40 [33%], respectively; P = .004). CONCLUSION: Across an 8-hour work shift, sumatriptan was superior to placebo in reducing productivity loss due to migraine
(35)	Schwartz BS, Stewart WF, Lipton RB. Lost workdays and decreased work effectiveness associated with headache in the workplace. J Occup Environ Med 1997; 39(4):320-327. Abstract: Little is known about the impact of different types of headache on lost work time and work effectiveness in the United States. Estimation of the distribution and magnitude of the impact of headache in the workplace is necessary before workplace interventions can be developed. During 1993 and 1994 in Baltimore County, Maryland, study subjects were contacted by random-digit dialing and interviewed by telephone about their headaches. Headache diagnoses were assigned using International Headache Society criteria for migraine and episodic tension-type headache. Measures of workplace impact were derived based on self-reports of missing work because of headache and frequency and magnitude of reduced work level because of headache. Of the 13,343 respondents, 9.4% reported missing work more than rarely because of headache, 31% reported that their work level was reduced more than rarely by headache, and 9.2% reported that their work level was reduced more than 50% by headaches during work. In accounting for both actual lost workdays and reduced effectiveness at work, individuals lost the equivalent of 4.2 days per year because of headache. Of the 9922 annual estimated actual lost workdays because of headache, 57% were due to migraine and 43% were due to tension-type and other headache types. Of the 23,287 annual estimated reduced effectiveness workday equivalents, 64% were due to tension-type and other headache types, and 36% were due to migraine. Headache type, headache severity, and education level were each independent predictors of workplace impact of headache. Subjects with migraine headache were much more likely to report actual lost workdays because of headache, whereas tension-type and other headache types accounted for a large proportion of decreased work effectiveness because of headache. The results have implications regarding the control of indirect costs in the workplace because of headache, and on workplace-based treatment and prevention programs
(36)	Snow V, Weiss K, Mottur-Pilson C. Pharmacologic management of acute attacks of migraine and prevention of migraine headache. Ann Intern Med. 2002 Nov 19;137(10):840-9. Abstract: Migraine headache is a common disorder seen in primary care. It affects 18% of women and 6.5% of men in the United States, almost half of whom are undiagnosed or undertreated. These guidelines, developed by the American Academy of Family Physicians and the American College of Physicians-American Society of Internal Medicine, with assistance from the American Headache Society, are based on two previously published papers. The target audience for these guidelines is primary care physicians.
(37)	Stang PE, Osterhaus JT. Impact of migraine in the United States: data from the National Health Interview Survey. Headache 1993; 33(1):29-35. Abstract: Data from the 1989 National Health Interview Survey concerning migraine occurrence and impairment were analyzed to assess the impact of migraine on the US population. About four of every one hundred persons in the United States were found to have migraine, accounting for nearly 10 million individuals. Migraine was most prevalent in those aged 25 to 44 years and was about 2.5 times more frequent in females than males. Migraine was most common in whites (85%) and those with low household income. In women, migraine prevalence increased with the level of education. About 10% of migrainous children missed at least one day of school over a two-week period due to migraine; nearly 1% missed four days. Migraineurs were bedridden for about three million days per month and had an estimated 74.2 million days per year of restricted activity due to migraine. The potential cost of lost productivity was estimated at $1.4 billion per year for the estimated 6,196,378 migraineurs who worked outside the home. It is difficult to derive similar estimates for costs of lost productivity in housewives; however, housewives experienced an estimated 38 million days per year of restricted activity. Eighty-five percent of females and 77% of males reported a physician visit at some point for their migraine. Migraine is a relatively common disease whose social and financial impact has been poorly understood
(38)	Stewart WF, Lipton RB, Liberman J. Variation in migraine prevalence by race. Neurology 1996; 47(1):52-59. Abstract: PURPOSE: Estimates of migraine prevalence from African and Asian populations are lower than those observed in European and North American populations. To determine if these international differences reflect differences in cultural, environmental, or genetic factors, we compared the prevalence of migraine among Caucasians, African Americans, and Asian Americans in the United States. If genetic factors predominate, racial differences should persist in the United States. METHODS: In Baltimore County, Maryland, 12,328 individuals 18 to 65 years of age were selected by random-digit dialing and interviewed by telephone about their headaches. Migraine diagnoses were assigned using International Headache Society criteria. RESULTS: In women, migraine prevalence was significantly higher in Caucasians (20.4%) than in African (16.2%) or Asian (9.2%) Americans. A similar pattern was observed among men (8.6%, 7.2%, and 4.2%). African Americans were less likely to report nausea or vomiting with their attacks, but more likely to report higher levels of headache pain. In contrast, African Americans tended to be less disabled by their attacks than Caucasians. There were no statistically significant differences in associated features between Asian American and Caucasian migraineurs. CONCLUSIONS: In the United States, migraine prevalence is highest in Caucasians, followed by African Americans and Asian Americans. While differences in socioeconomic status, diet, and symptom reporting may contribute to differences in estimated prevalence, we suggest that race-related differences in genetic vulnerability to migraine are more likely to predominate as an explanatory factor
(39)	Stewart WF, Lipton RB, Simon D. Work-related disability: results from the American migraine study. Cephalalgia 1996; 16(4):231-238. Abstract: Migraine headache is a highly prevalent, often severely painful and frequently disabling disorder. The indirect costs related to disability greatly exceed the direct cost of medical care. The objective of this paper is to describe work-related disability associated with migraine headache and predictors of disability. In a two-stage survey of the US population, we estimate missed workdays and impairment at work in a sample of 1663 migraine suffers, age 18 years and older. Lost workday equivalents (LWDE) was derived as the sum of actual missed workdays and the product of percentage effectiveness at work and days at work with the most severe headache. Overall, reported actual lost workdays and reduced effectiveness at work contributed approximately equally to total LWDE. A total of 51.1% of females and 38.1% of male migraineurs experienced six or more LWDE per year. This subgroup of migraine sufferers accounted for about 90% of the total LWDE experienced by all respondents. Among women, headache duration was the strongest predictor of LWDE followed by less significant associations with number of symptoms and pain level. Among men, only pain level was significantly associated with LWDE. Among sociodemographic factors, disability was more likely among older (40+) subjects and less likely among individuals with higher education and higher income (females only), even after adjusting for headache features. Health-care interventions may yield the greatest individual benefit (by reducing pain and disability) and the greatest societal benefit (by reducing indirect costs) if they are directed to those who account for the greatest proportion of disability
(40)	Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States. Relation to age, income, race, and other sociodemographic factors. JAMA 1992; 267(1):64-69. OBJECTIVE--To describe the magnitude and distribution of the public health problem posed by migraine in the United States by examining migraine prevalence, attack frequency, and attack-related disability by gender, age, race, household income, geographic region, and urban vs rural residence. DESIGN--In 1989, a self-administered questionnaire was sent to a sample of 15,000 households. A designated member of each household initially responded to the questionnaire. Each household member with severe headache was asked to respond to detailed questions about symptoms, frequency, and severity of headaches. SETTING--A sample of households selected from a panel to be representative of the US population in terms of age, gender, household size, and geographic area. PARTICIPANTS--After a single mailing, 20,468 subjects (63.4% response rate) between 12 and 80 years of age responded to the survey. Respondents and non-respondents did not differ by gender, household income, region of the country, or urban vs rural status. Whites and the elderly were more likely to respond. Migraine headache cases were identified on the basis of reported symptoms using established diagnostic criteria. RESULTS--17.6% of females and 5.7% of males were found to have one or more migraine headaches per year. The prevalence of migraine varied considerably by age and was highest in both men and women between the ages of 35 to 45 years. Migraine prevalence was strongly associated with household income; prevalence in the lowest income group (less than $10,000) was more than 60% higher than in the two highest income groups (greater than or equal to $30,000). The proportion of migraine sufferers who experienced moderate to severe disability was not related to gender, age, income, urban vs rural residence, or region of the country. In contrast, the frequency of headaches was lower in higher-income groups. Attack frequency was inversely related to disability. CONCLUSIONS--A projection to the US population suggests that 8.7 million females and 2.6 million males suffer from migraine headache with moderate to severe disability. Of these, 3.4 million females and 1.1 million males experience one or more attacks per month. Females between ages 30 to 49 years from lower-income households are at especially high risk of having migraines and are more likely than other groups to use emergency care services for their acute condition.
(41)	Streator SE, Shearer W. Pharmacoeconomic impact of sumatriptan on migraine. Am J Manag Care 1996; February. Abstract: A retrospective review of medical and pharmacy claims was conducted in two metwork independent practice association health maintencance organizations (with 80,000 members total) to examine the direct care costs of administering injectable sumatriptan for the treatment of migraine headache. Data on a migraine subpopulation for the 6 months before and the 6 months after the release of injectable sumatriptan were compared. The number of emergency room encounters increased for members using sumatriptan, but the number of migraine sufferers admitted to the emergency room decreased by 62 percent. Despite the poptential savings resulting from the reduction in emergency room use, the increase in migraine drug costs secondary to sumatriptan utilization negated any healthcare cost savings and increased the total direct cost by 193 percent.
(42)	Von Korff M, Stewart WF, Simon DJ, Lipton RB. Migraine and reduced work performance: a population-based diary study. Neurology 1998; 50(6):1741-1745. Abstract: OBJECTIVE: This article estimates lost work days and lost work day equivalents in a population sample of migraineurs, differentiating work loss due to headache episodes that met criteria for migraine from migrainous headaches not meeting full criteria and nonmigrainous headaches. METHODS: A random digit dialing survey of 5,071 adults identified 800 subjects with migraine headaches. By clinical examination, a subsample of 225 met migraine diagnostic criteria; 174 of these patients completed at least 11 weeks of daily diaries. This report concerns the subgroup of 122 individuals with regular paid employment. Subjects completed a daily diary over a 3-month period to assess the occurrence of headaches and International Headache Society (IHS) criteria for each headache occurrence. We report estimates of lost work days and lost work day equivalents by type of headache. RESULTS: Participants reported headaches on 8.1 work days, of which 2.2 headache days met criteria for migraine (IHS 1.1, 1.2), and an additional 2.1 headache days were migrainous without meeting full migraine criteria (IHS 1.7). On average, migraineurs missed 1.1 days of work due to headache in 3 months, of which 0.7 lost work days were due to migraine and 0.3 were due to migrainous headaches. When at work with headache, work effectiveness was reduced 41% for migraine headaches, 28% for migrainous headaches, and 24% for other headaches. Over 3 months, migraineurs experienced an average of 3.0 lost work day equivalents, of which 1.4 were due to migraine and an additional 0.7 were due to migrainous headaches. The most disabled 20% of the participants accounted for 77% of the lost work days; 40% of subjects accounted for 75% of the lost work day equivalents. CONCLUSIONS: Employed migraine sufferers experienced considerable work loss and reduced work performance due to headache. The most severely affected migraineurs accounted for most of the reduced work performance. Targeting the most severely affected persons may be necessary to reduce work loss among migraineurs substantially
(43)	Weaver MB, Mackowiak JI, Solari PG. Triptan therapy impacts health and productivity. J Occup Environ Med 2004; 46(8):812-817. Abstract: New sumatriptan users in a California health plan were surveyed on the impact of migraine using a newly developed migraine impact measure, the Headache Impact Test-6. Productivity and satisfaction with migraine therapy also were assessed. After sumatriptan was initiated, participants reported significantly fewer workdays missed, fewer days worked with headache, and greater productivity while headache symptoms were present. In addition, almost 50% less members used narcotics/opioids, while the frequency, duration, and severity of migraines decreased. Initiation of sumatriptan therapy is associated with improvements in absenteeism and presenteeism, clinical outcomes (Headache Impact Test-6), and satisfaction. The benefits of triptan therapy extend to the employer, who sees a decrease in lost productivity, fewer emergency room visits, and less narcotics use in employees with migraine. Managed care organizations that provide this pharmacotherapy may foster greater satisfaction among members and employer customers

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