Yu et al. The Journal of Headache and Pain (2020) 21:53 The Journal of Headache https://doi.org/10.1186/s10194-020-01117-2 and Pain RESEARCH ARTICLE Open Access Migraine treatment and healthcare costs: retrospective analysis of the China Health Insurance Research Association (CHIRA) database Shengyuan Yu1, Yanlei Zhang2*, Yuan Yao2 and Haijun Cao2 Abstract Background: Adult migraine remains underdiagnosed and undertreated, despite significant negative effects on physical and emotional functioning. Information on prescribing patterns and treatment costs of migraine in China is limited. Methods: This retrospective analysis of the China Health Insurance Research Association (CHIRA) medical insurance claims database in 2016 to 2017 evaluated treatment patterns, direct medical costs, and healthcare resource utilization among adults with migraine in mainland China. Results: Of 108,375 patients with headache-related outpatient visits, 10,652 were adults with migraine (mean age 51.4 years, 55.4% female). Common comorbidities were major depressive disorder (4.1%), insomnia (3.8%), and anxiety (2.3%). Migraine patients were prescribed acute medication (26.4%), preventive medication (15.0%), and Chinese patent and herbal medicines (24.5% and 11.7%, respectively). Of patients prescribed acute medication, 68.8% received non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs), 7.1% received opioids, while only 3.3% received triptans. Mean annual outpatient costs per patient were 46.5 United States dollars (USD), with mean (standard deviation) 1.8 (2.0) outpatient visits per year. Medication costs for traditional Chinese medicine (22.4 USD per patient) were higher than for Western medicine (13.5 USD). Conclusion: Among migraine patients in China, NSAIDs were commonly prescribed as acute medication, while utilization of migraine-specific triptans and preventive medications was low. Keywords: Migraine disorder, Adult, Drug prescriptions, Acute medication, Preventive medication, Retrospective studies Background life [1–3]. Migraine has an estimated global prevalence Migraine is a primary headache disorder characterized of 14.4% and is the second highest cause of years lived by disabling attacks of moderate-to-severe pain, accom- with disability based on the Global Burden of Disease panied by nausea, photophobia, or phonophobia, which Study [3]. impair ability to function and adversely impact quality of In China, population-based estimates of the 1-year prevalence of migraine range from 7.9% to 14.3% in adults [4–6]. Health-related quality-of-life studies in * Correspondence: [email protected] 2Lilly Suzhou Pharmaceutical Co., Ltd. Shanghai Branch, 19F, Centre T1, HKRI China, including Taiwan, have demonstrated substantial Taikoo, No. 288, Shimen No.1 Road, Shanghai 200021, China negative effects of migraine on physical and emotional Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Yu et al. The Journal of Headache and Pain (2020) 21:53 Page 2 of 7 functioning, impacting work, household, and leisure ac- treatment patterns, direct medical costs, and healthcare tivities [5, 7–9]. In a population of 1.4 billion, migraine resource utilization among adult patients with migraine presents a significant clinical burden in China. in mainland China. Migraine treatment guidelines for China are consistent with those for Europe and the United States (US) in sup- Methods porting a stratified approach to acute (abortive) treat- Dataset ment, whereby medication choice is based on attack The CHIRA database is a medical insurance manage- severity and symptoms, the efficacy and side effect pro- ment information system initiated in 2007 that contains file of the drug, and the patient’s previous response to nationwide consecutive inpatient and outpatient visit acute treatment [10–12]. Chinese guidelines recommend claims data of urban basic medical insurance in China. non-steroidal anti-inflammatory drugs (NSAIDs), acet- With approximately 95% of the population in mainland aminophen, compound analgesics containing caffeine China covered by public medical insurance, the CHIRA (cautioning that caffeine could increase the risk of drug database is a valuable resource of real-world evidence addiction and medication overuse headache), and trip- for medical costs in China [16]. CHIRA data are col- tans; opioids, barbiturates, and ergotamine derivatives lected annually from the local insurance centers of a are not recommended for regular use [10]. random de-identified sample of selected areas of China Preventive (prophylaxis) treatment can be offered in including at least 2% of municipalities, at least 2% of the case of recurring migraine that is interfering with provincial capital cities, and at least 5% of prefecture- daily routine despite acute treatment; failure of, contra- level cities. The database contains patient basic informa- indication to, or side effects from acute medications; risk tion, medical institution information, diagnosis results, of acute medication overuse; circumstances such as healthcare service utilization, medication prescription, hemiplegic migraine; high or increasing attack fre- and healthcare expenditure details. quency; and patient preference [13]. Metoprolol, pro- CHIRA granted permission to access the anonymized pranolol, flunarizine, valproic acid, and topiramate are database for the purposes of this study. Only anon- the recommended preventives based on Level A evi- ymized information was accessible from the CHIRA dence in Chinese and European guidelines [10, 11]. An database and therefore institutional ethics approval and estimated 34% to 39% of patients with migraine in Eur- informed consent were not required. ope and the US are eligible for preventive migraine treatment [14, 15]. However, in the European Eurolight Patient selection study, less than 14% of eligible patients actually received All outpatient visit and healthcare use information for preventive medication, and in the American Migraine the diagnosis and treatment of headache in 2016 and Prevalence and Prevention (AMPP) study, 32% of never- 2017 was extracted from the CHIRA database. Adult pa- users of preventive treatment would benefit from their tients (≥18 years) were selected who had a primary diag- use, suggesting undertreatment and inadequate disease nosis of migraine, identified by International Statistical management [14, 15]. Classification of Diseases and Related Health Problems Information on the prescribing patterns and treatment revision 10 (ICD-10) code (ICD-10 G43.0, G43.1, G43.2, costs of migraine in mainland China is limited. Although G43.3, G43.8, G43.9) and supplemented by searching there is substantial evidence for the economic burden of physician Chinese character descriptions against transla- migraine in the US and Europe, this information cannot tions from the World Health Organization Chinese ver- be generalized to China because of the differences in sion of ICD-10. Patients were excluded if they had diagnosis and treatment practices, availability of pre- cluster headache (ICD-10 G44.0), malignancy, schizo- scription medication, and use of traditional Chinese phrenia, or stroke, or were receiving hemodialysis or medicine alongside Western medicine. A population- peritoneal dialysis. based survey in China in 2009 estimated the total annual direct costs of migraine diagnosis and treatment to be Outcome measures 58.0 billion Chinese yuan renminbi (CNY) (8.4 billion Patient information identified from the CHIRA database US dollars [USD]) [5]. However, this survey relied on included age, gender, comorbidities (predefined as anx- patient-reported information for migraine diagnosis and iety, major depressive disorder, epilepsy, fremitus, and healthcare resource use. Hence, there is a need for insomnia), and medical insurance type (Urban Employee China-specific data reflecting local diagnostic and treat- Basic Medical Insurance or Urban Residents Basic Med- ment practices and the use of complementary medicine. ical Insurance). This retrospective analysis of the China Health Insur- Medications prescribed in the 2016–2017 period for ance Research Association (CHIRA) nationwide medical the treatment of migraine or for pain relief were insurance claims data aimed to understand the identified and categorized according to class of acute Yu et al. The Journal of Headache and Pain (2020) 21:53 Page 3 of 7 medication (including aspirin, paracetamol, non- Annual visit