- Open Access
Triptans in the Italian population: a drug utilization study and a literature review
© Springer-Verlag 2008
- Received: 19 December 2007
- Accepted: 30 January 2008
- Published: 4 March 2008
Previous studies performed in selected populations show a poor utilization of triptans for migraine. The objectives of our study were to establish patterns of triptans utilization in a large sample, covering 1/10 of Italian population (5.57 millions), and to perform a review of published studies on this topic. We investigated drug prescription database collected during 2006 from 33 health authorities distributed in 8 different regions. About 0.6% of the subjects received at least one prescription of triptans in 1 year: 77.7% were females and 22.3% males. Age distribution shows that 9.5% of patients were aged above 65, and received prescriptions for 8.2% of packages. The review of the literature suggests that these percentages of utilization are common to several countries, and shows that occasional triptan users who received only one prescription in 1 year are a large percentage (40–60%); moreover, a minor population of triptan users utilize a large amount of total triptans. Finally triptans are frequently prescribed in people aged above 65 years, a population in which triptans are contraindicated or not recommended. Our study and the analyzed ones indicate suboptimal treatment of migraine patients with triptans and also an incorrect use in some patients (triptan abusers, elderly).
- Triptan abusers
- Usage patterns
- Prescription data
- Literature review
Since the commercialization of the new antimigraine drug sumatriptan about 20 years ago, scientific societies, pharmaceutical companies and headache specialists, have tried to highlight the migraine pathology in the population, arguing that it was underestimated. In the following years many other drugs, in the pharmacological class of triptans, became available.
The average percentage of migraine in the world is regarded as around 9% of the overall population . However, until today, migraine remains under-diagnosed and under-treated in at least 50% of patients, and less than 50% of migraine patients had consulted a physician [1, 2]. The efficacy of triptans has been shown in several randomized, double-blind, placebo-controlled trials . However these studies were carried out in selected populations and under controlled conditions. Utilization patterns of specific anti-migraine drugs in community patients and the experiences of patients with these drugs in real life setting have been studied less extensively. Recently we have performed a study evaluating triptans utilization in a health authority in Tuscany covering about 225,000 residents [4, 5]. We have extended this study to establish the patterns of use of triptans in a large sample of Italian population  and review other studies on this topic.
Study on the Italian population
In the reimbursement system of the Italian National Health Service, all prescribed drugs included within the essential level of assistance (LEA) are recorded by regional health authorities in association with the demographic characteristics of patients. Therefore, medication records of individual patients are quite complete in drugs prescription databases. This allows for accurate investigations in drug utilization in our setting. The patterns of triptans prescription in the 33 health authorities distributed in 8 Italian regions were investigated. The population studied was 5.57 millions inhabitants, that represents 9.5% of the Italian population. We analysed prescription database using the ATC classification (Anatomical Therapeutic Chemical classification) NO2CC: triptans, dispensed during 1 year (2006).
Dosage units contained in triptans packages available in Italy in 2005–2006
Tablet 50–100 mg
Suppository 25 mg
Nasal spray 10–20 mg
Injection 6 mg
Tablet 2.5 mg
Soluble tablet 2.5 mg
Tablet 5–10 mg
Soluble tablet 10 mg
Tablet 20–40 mg
Tablet 12.5 mg
Tablet 2.5 mg
Tablet 2.5 mg
Studies were identified through a Medline search on Internet (Pubmed Medline, 2000 version; address http://www4.ncbi.nlm.nih.gov/PubMed/). This search covered the period from 1991 to June 2007.
Study on the Italian population
Demographic characteristics of the population studied
Pattern of triptans utilization in a sample of 5,549,731 Italian residents
The distribution of triptan packages prescribed was: rizatriptan 26%, sumatriptan 20.1%, almotriptan 17.3%, zolmitriptan 13.9%, eletriptan 12.6%, frovatriptan 10%.
Prevalence of triptan users
Prevalence of triptans users in population studies
Percentage of new users of triptans
The prevalence of triptans utilization in migraine patients in different countries was reported to be 3–19% (average 10%) , while other population studies show a similar prevalence: 7.5% , 8% , 9.8% . Therefore the percentage of triptan utilization in the population has a good relation to the pathology, showing that less than 10% of patients use a triptan.
Frequency of triptan use
Lohman et al.  report that 12.5% of triptan users utilized more than one drug product and received 25% of the total number of dosage units. Ifergane et al.  report that, among patients who filled more than one prescription, 14.3% tried a second triptan; in this group 52.1% purchased only one prescription of the new triptan. Tepper et al.  showed that 91% of the patients remained on the same triptan during the study period. In conclusion 10–15% of triptans users change the type of triptan during the period of 1 year.
Percentage of probable triptans abusers among triptan users
Sondergaard (Denmark 2000) 
Lugardon (France 2002) 
Lohman (Netherlands 2001) 
Dekker (Netherlands 2005) 
Pavone (Italy 2005) 
Perearnau (France 2003) 
A consistent percentage of triptans is prescribed for people over the age of 65. In the Italian population this percentage is 7.6–9.5% [5, 6], higher than that reported (3.2–3.5%) in the France population [10, 27]. A previous study shows that sumatriptan users over 65 years were 3% . This is a population at major risk of hypertension and cardiovascular diseases, and it is also a population in which clinical trials have been not performed and so triptans are not recommended.
A very low percentage (about 10%) of migraine patients utilized triptans.
When utilized, triptans were prescribed only once in a year in a large percentage (40–60%) of patients.
A minority of patients (5–10%) utilize a large amount (40–45%) of triptans, and some of these are classified as triptans abusers.
A considerable percentage of triptans are prescribed in people aged over 65.
The low percentage of triptans users can be due to the low rate of diagnosis of migraine and the high utilization of over-the-counter drugs (OTC). Less than 50% of people suffering from migraine are not recognized by their general practitioner as having migraine and less than 30% of these have adequate management of migraine . Possible causes of underdiagnosis and management by general practitioner are: poor time to spend with the patient, complexity of diagnostic criteria of IHS , variability of the clinical manifestations in migraine patients [30, 31], high utilization of OTC drugs , and high cost of triptans.
The authors would like to thank Marno Institute (Castelnuovo Misericordia, Livorno, Italy) for their valuable collaboration in managing the data on triptans prescription.
- MacGregor EA, Brandes J, Eikermann A (2003) Migraine prevalence and treatment patterns: the global migraine and zolmitriptan evaluation survey. Headache 43:19–26View ArticlePubMedGoogle Scholar
- Lipton RB, Diamond S, Reed M, Diamond ML, Stewart WF (2001) Migraine diagnosis and treatment: results from the American Migraine Study II. Headache 41:638–645View ArticlePubMedGoogle Scholar
- Ferrari MD, Roon KI, Lipton RB, Goadsby PJ (2001) Oral triptans (serotonin 5-HT1B/1D agonists) in acute migraine treatment: a meta-analysis of 53 trials. Lancet 358:1668–1675View ArticlePubMedGoogle Scholar
- Panconesi A, Pavone E, Banfi R (2006) Triptan utilization patterns: a study based on patients prescription records of an Italian health authority in Tuscany. J Headache Pain 7:266–267 (abstract)Google Scholar
- Pavone E, Banfi R, Vaiani M, Panconesi A (2007) Patterns of triptans use: a study based on the records of a community pharmaceutical department. Cephalalgia 27:1000–1004View ArticlePubMedGoogle Scholar
- Panconesi A, Pavone E, Vaiani M, Banfi R, Cinaglia I (2007) Pattern of triptans use in the population: why the sub-utilization? Cephalalgia 27:741 (abstract)Google Scholar
- Gaist D (1999) Use and overuse of sumatriptan. Pharmacoepidemiological studies based on prescription register and interview data. Cephalalgia 19:735–761View ArticlePubMedGoogle Scholar
- Etemad LR, Yang W, Globe D, Barlev A, Johnson KA (2005) Costs and utilization of triptan users who receive drug prophylaxis for migraine versus triptan users who do not receive drug prophylaxis. J Manag Care Pharm 11:137–144PubMedGoogle Scholar
- Lohman JJHM, van der Kuy-de Ree MM (2005) Patterns of specific antimigraine drug use—a study based on the records of 18 community pharmacies. Cephalalgia 25:214–218View ArticlePubMedGoogle Scholar
- Perearnau P, Vuillemet F, Schick J, Weill G (2006) Patterns of prescription and usage of triptans in Alsace (France): misuse is frequent and avoidable. Rev Neurol 162:347–357View ArticlePubMedGoogle Scholar
- Dekker F, Wiendels NJ, van der Vliet C, de Valk V, Knuistingh A, Ferrari MD, Assendelft WJJ (2007) Triptan use and overuse in the Netherlands, a national pharmaco-database analysis. Cephalgia 27:683 (abstract)Google Scholar
- Ifergane G, Wirguin I, Shvartzman P (2006) Triptans—Why once? Headache 46:1261–1263View ArticlePubMedGoogle Scholar
- Lugardon S, Roussel H, Sciortino V, Montastruc JL, Lapeyre-Mestre M (2007) Triptan use and risk of cardiovascular events: a nested-case-control study from the French health system database. Eur J Clin Pharmacol 63:801–807View ArticlePubMedGoogle Scholar
- Sondergaard J, Foged A, Kragstrup J, Gaist D, Gram LF, Sindrup SH, Muckadell HUS, Larsen BO, Herborg H, Andersen M (2006) Intensive community pharmacy intervention had little impact on triptan consumption: a randomized controlled trial. Scand J Prim Health Care 24:16–21View ArticlePubMedGoogle Scholar
- Hoffman L, Mayzell G, Pedan A, Farrel M, Gilbert T (2003) Evaluation of a monthly coverage maximum (drug-specific quantity limit) on the 5-HT1 agonists (triptans) and dihydroergotamine nasal spray. J Manag Care Pharm 9:335–345PubMedGoogle Scholar
- Lucas C, Auray J-P, Gaudin A-F, Dartigues J-F, Duru G, Henry P, Lanteri-Minet M, Pradalier A, Chazot G, El Hasnaoui A (2004) Use and misuse of triptans in France: data from the GRIM2000 population survey. Cephalalgia 24:197–205View ArticlePubMedGoogle Scholar
- Lucas C, Chaffaut C, Artaz M-A, Lanteri-Minet M (2005) FRAMIG 2000: medical and therapeutic management of migraine in France. Cephalalgia 25:267–279View ArticlePubMedGoogle Scholar
- Williams D, Cahill T, Dowson A, Fearon H, Lipscombe S, O’Sullivan E, Rees T, Strang C, Valori A, Watson D (2002) Usage of triptans among migraine patients: an audit in nine GP practices. Curr Med Res Opin 18:1–9PubMedGoogle Scholar
- Ferrari A, Pasciullo G, Savino G, Cicero AFG, Ottani A, Bertolini A, Sternieri E (2004) Headache treatment before and after the consultation of a specialized centre: a pharmacoepidemiology study. Cephalalgia 24:356–362View ArticlePubMedGoogle Scholar
- Jelinski SE, Becker WJ, Christie SN, Giammarco R, Mackie GF, Gawel MJ, Eloff AG, Magnusson JE (2006) Clinical features and pharmacological treatment of migraine patients referred to headache specialists in Canada. Cephalalgia 26:578–588View ArticlePubMedGoogle Scholar
- Gaist D, Andersen M, Aarup AL, Hallas J, Gram LF (1997) Use of sumatriptan in Denmark in 1994–5: an epidemiological analysis of nationwide prescription data. Br J Clin Pharmacol 43:429–433PubMed CentralView ArticlePubMedGoogle Scholar
- Rahimtoola H, Buurma H, Tijssen CC, Leufkens HG, Egberts ACG (2003) Single use of sumatriptan: a patient interview study. Headache 43:109–116View ArticlePubMedGoogle Scholar
- Tepper S, Allen C, Sanders D, Greene A, Boccuzzi S (2003) Coprescription of triptans with potentially interacting medications: a cohort study involving 240,268 patients. Headache 43:44–48View ArticlePubMedGoogle Scholar
- Visser WH, de Vriend RH, Jaspers MW, Ferrari MD (1996) Sumatriptan in clinical practice: a 2-year review of 453 migraine patients. Neurology 47:46–51View ArticlePubMedGoogle Scholar
- Limmroth V, Katsarava Z, Fritsche G, Przywara S, Diener HC (2002) Features of medication overuse headache following overuse of different acute headache drugs. Neurology 59:1011–1014View ArticlePubMedGoogle Scholar
- Headache Classification Committee of the International Headache Society (2004) The international classification of headache disorders. Cephalagia 24(Suppl 1):1–160Google Scholar
- Roussel H, Lo Re G, Honorat C, Alonso M, Sciortino V (2006) The use of triptan in ambulatory medicine in Midi-Pyrenees region: clinical and pharmacological contra-indications and drug abuse. Therapie 61:507–516View ArticlePubMedGoogle Scholar
- Rahimtoola H, Egberts ACG, Buurma H, Tijssen CC, Leufkens HG (2001) Patterns of ergotamine and sumatriptan use in the Netherlands from 1991 to 1997. Cephalalgia 21:596–603View ArticlePubMedGoogle Scholar
- De Diego EV, Lanteri-Minet M (2005) Recognition and management of migraine in primary care: influence of functional impact measured by the headache impact test (HIT). Cephalalgia 25:184–190View ArticlePubMedGoogle Scholar
- Nachit-Ouinekh F, Dartigues J-F, Chrysostome V, Henry P, Sourgen C, El Hasnaoui A (2005) Evolution of migraine after 10-year follow-up. Headache 45:1280–1287View ArticlePubMedGoogle Scholar
- Woeber C, Woeber-Bingoel C, Schmidt K, Zingerle R, Hattinger N, Hartl T, Zahlbruckner L, Boettcher A, Hanslik K, Aydinkoc K, Geuder E, Wessely P (2005) Symptomatology, impact and treatment of 6,000 headache attacks and episodes: the pamina study. Cephalalgia 25:646 (abstract)Google Scholar
- Lygberg AC, Rasmussen BK, Jorgensen T, Jensen R (2005) Prognosis of migraine and tension-type headache: a population-based follow-up study. Neurology 65:580–585View ArticleGoogle Scholar
- Bigal M, Rapoport A, Aurora S, Sheftell F, Tepper S, Dahlof C (2007) Satisfaction with current migraine therapy: experience from three centers in US and Sweden. Headache 47:475–479View ArticlePubMedGoogle Scholar