Migraine-Related Nausea Increases Patients' Pain and Medical Costs

Clinical depression, progression to chronic migraine, and visits to emergency rooms are more common among patients with episodic migraine and persistent frequent nausea.



NEW ORLEANS—Headache-related nausea occurs in about 80% of persons with migraine in the US population. Nausea is frequent (ie, occurs at least half the time) and persistent over two years in nearly 40% of migraineurs, and this group is said to have persistent frequent nausea. These data are among the results from a large population survey, the American Migraine Prevalence and Prevention (AMPP) study, which was presented at the 64th Annual Meeting of the American Academy of Neurology.

Among those with persistent frequent nausea, half were severely affected by their condition, according to the Headache Impact Test, compared with 28% of migraineurs who were free of nausea, reported Richard B. Lipton, MD, the Edwin S. Lowe Professor and Vice Chair in Neurology at Albert Einstein College of Medicine in the Bronx, New York. Nearly 5% of migraineurs with persistent frequent nausea experienced a progression from episodic to chronic migraine, compared with 1% of migraineurs who did not have nausea.

Estimated annual direct costs for overnight hospital stays were 8.2 times higher among migraineurs who experienced persistent frequent nausea, in comparison with those who never experienced headache-related nausea. The estimated costs of emergency room visits were 5.4 times higher for patients who experienced persistent frequent nausea than they were for patients who never experienced headache-related nausea.

Patients with the most frequent headache-related nausea also spent 2.2 times more on visits to neurologists or headache specialists and 1.7 times more on visits to primary care physicians or gynecologists than patients without headache-related nausea. “The trends in utilization and costs are particularly concerning given that half (49.5%) of this US population-based sample of migraineurs fell in the highest nausea frequency category,” said Michael L. Reed, PhD, founder of Vedanta Research in Chapel Hill, North Carolina.

A Detailed Analysis of the Effects of Migraine-Related Nausea
Various studies have found headache-related nausea to be associated with decreased quality of life, but researchers had not previously examined the frequency and effects of persistent nausea associated with migraine, said Dr. Lipton. He, Dr. Reed, and their colleagues analyzed data provided by 3,673 respondents to the AMPP survey who met a case definition of migraine.

The researchers defined persistent frequent nausea according to the reports of nausea symptom frequency that the AMPP study collected in 2007 and 2008. The investigators also analyzed variables such as headache-related disability (as measured by the Migraine Disability Assessment questionnaire), headache impact (as measured by the Headache Impact Test 6), rates of clinical depression and anxiety, headache pain intensity, and triptan use.

To estimate the direct health care costs associated with nausea frequency in patients with episodic migraine, Dr. Lipton and his colleagues reviewed cross-sectional data for 6,448 individuals with migraine who had also responded to the AMPP study in 2009. The majority of patients were female and older than 34. All levels of household income were equally represented among respondents.

Migraineurs described the frequency of their headache-related nausea using the categories of “Never,” “Rarely,” “Less Than Half the Time,” and “Half the Time or More.” All participants provided 12 months of data on their outpatient and inpatient medical visits, as well as their histories of CT and MRI tests.

Migraine-Related Nausea Is Linked to Psychological Distress
About 86% of participants with persistent frequent nausea were female, compared with 71% of patients who had no headache-related nausea. Compared with nausea-free patients, a greater proportion of migraineurs with persistent frequent nausea used triptans (6.4% versus 19.3%) and experienced moderate or severe pain at least half the time (55.6% versus 81.6%).

Persistent frequent nausea also was associated with greater rates of adverse psychological effects. Approximately 19% of migraineurs with persistent frequent nausea reported experiencing clinical depression, compared with nearly 14% of patients without nausea. Patients with persistent frequent nausea also reported a higher rate of anxiety (ie, 9.7%) than those without nausea (ie, 7.7%), but the difference was not statistically significant.

The higher rate of progression to chronic migraine among patients with persistent frequent nausea was surprising, according to the investigators. This result “suggests that persistent nausea, in addition to heightening disease impact, may also contribute to or be associated with disease progression,” said Dr. Lipton.

Nearly 21% of migraineurs who experienced nausea half the time or more reported visiting a primary care physician at least once during the previous 12 months, compared with nearly 9% of migraineurs with no nausea. Six times as many patients who experienced nausea half the time or more visited a mental health professional in the previous 12 months, compared with patients with no nausea (ie, 1.2% versus 0.2%). In addition, 7.3% of patients who experienced nausea half the time or more visited an emergency department in the previous 12 months, compared with 1.9% of patients with no nausea.

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