Neurol Clin Pract. 2026 Jun;16(3):e200615. doi: 10.1212/CPJ.0000000000200615. Epub 2026 Apr 28.
ABSTRACT
BACKGROUND AND OBJECTIVES: Refractory migraine (RM) is associated with substantial disability, yet its clinical and health care utilization patterns remain poorly characterized in large, real-world populations. Understanding how preventive treatment progression relates to health care use and patient characteristics may inform earlier identification and care strategies. We sought to evaluate demographic, clinical, and health care utilization patterns in chronic migraine according to the number of preventive medication trials using a large cross-institutional electronic health record (EHR) database.
METHODS: We conducted a retrospective observational study using the Epic Cosmos Cross-institutional EHR Database from January 1, 2016, to December 31, 2024. Adults with chronic migraine (International Classification of Diseases, Tenth Edition code G43.7) were included. Preventive medication trials were categorized into 5 classes: antihypertensives, antidepressants, antiseizure agents, calcitonin gene-related peptide-targeted therapies, and onabotulinumtoxinA. We evaluated demographics, comorbidities, and health care utilization metrics, including inpatient or outpatient dihydroergotamine (DHE) infusions, emergency department (ED) visits for headache, MRI brain orders, and patient EHR portal recency (MyChart). Marginal changes were defined as the percentage point change in outcomes between medication classes. Chi-squared tests and analysis of variance were used with significance set at p < 0.05.
RESULTS: A total of 1,572,698 patients were identified by our search criteria; 21.2% were prescribed no preventive medications and 2.5% were prescribed all 5 classes, meeting the study’s definition of RM. Health care utilization increased significantly with each additional medication class. The greatest marginal increases occurred between zero to 1 classes for MyChart access (43-day decrease), 1 to 2 classes for ED visits (+9.2%), and 4 to 5 classes for DHE administration (+6.1%) and MRI brain orders (+4.9%). Patients prescribed more preventive classes were older, a higher percentage female sex, White race, with public insurance, residence in the Northeast United States, and live in less socially vulnerable areas. Comorbidity burden increased progressively, with 94.6% of refractory patients having at least 1 comorbidity, most commonly anxiety (78.1%), depression (71.5%), hypertension (56.0%), and asthma (36.3%). All differences were statistically significant (p < 0.001).
DISCUSSION: Higher health care utilization, greater comorbidity burden, and distinct geographic patterns are observed with increasing numbers of preventive medication trials in chronic migraine. These findings highlight the complexity of RM and underscore the need for earlier identification and more equitable access to comprehensive migraine care.
PMID:42114071 | DOI:10.1212/CPJ.0000000000200615
