Improvement in most bothersome symptom or monthly migraine days? Which contributes most to quality of life?

Improvement in the most bothersome symptom contributes more to improvement in health-related quality of life than a reduction in monthly migraine days for patients treated with an anti-calcitonin gene-related peptide monoclonal antibody after two to four prior preventive treatment failures. This is the finding of a study presented at AAN 2023.

Anti-calcitonin gene-related peptide monoclonal antibody efficacy mediators

Efficacy mediators were canonical symptoms in Model 1 and patient-identified most bothersome symptom in Model 2

Efficacy measures mediating the effect of an anti-calcitonin gene-related peptide monoclonal antibody (anti-CGRP mAb) on improvement in health-related quality of life (HRQoL) in patients with migraine were analysed using data from DELIVER (NCT04418765). DELIVER was a randomized, double-blind, placebo-controlled trial evaluating the safety and efficacy of an anti-CGRP mAb in patients with migraine and two to four prior preventive migraine treatment failures.1

For the analysis it was assumed that the change from baseline in the three Migraine-Specific Quality of Life Questionnaire (MSQ) domain scores — Role-Function Restrictive, Role-Function Preventive, and Emotional Function2 — could be used to estimate the change from baseline in HRQoL.

A reduction in monthly migraine days explained only one-third of the improvement in quality of life in Model 1

Two structural equation models identified potential effect mediators from treatment versus placebo on HRQoL.

  • In Model 1, these mediators were canonical symptoms as defined by International Headache Society diagnostic criteria3 — monthly migraine days (MMD), severe migraine, nausea, light sensitivity, and pulsating headache — a backwards elimination method was used to identify mediators with p values less than 0.05 for the association with HRQoL.

A reduction in monthly migraine days explained only 17% of the improvement in quality of life in Model 2

  • In Model 2, the mediator was patient-identified most bothersome symptom (PI-MBS). PI-MBS categories included nausea, vomiting, light sensitivity, sound sensitivity, mental cloudiness, fatigue, pain with activity, mood changes, and “other.” The most commonly reported categories were pain with activity (24.6%), fatigue (14.1%), and nausea (13.9%).


Improvement in the most bothersome symptom contributed most to improvement in health-related quality of life

The analysis revealed that a reduction in MMD explained only approximately one-third of HRQoL improvement in Model 1. Reductions in MMDs, the percentage of severe migraine attacks, and canonical symptoms insufficiently explained how the anti-CGRP mAb treatment improved patients’ HRQoL.

An improvement in most bothersome symptom explained 69% of the improvement in quality of life in Model 2

In Model 2, 86% of the impact of anti-CGRP mAb treatment on HRQoL was explained by either an improvement in PI-MBS (69%) or a reduction in MMD (17%). The impact due to improvement in PI-MBS was therefore much greater than that of a reduction in MMD.

These results suggest that discussing improvements in a patient’s PI-MBS after starting a preventive migraine treatment provides a fuller picture of the impact of the treatment on the patient’s HRQoL than a discussion on the reduction in MMD.4


This study and poster were sponsored and supported by H. Lundbeck A/S (Copenhagen, Denmark).

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

  1. Ashina M, Lanteri-Minet M, Pozo-Rosich P, et al. Safety and efficacy of eptinezumab for migraine prevention in patients with two-to-four previous preventive treatment failures (DELIVER): a multi-arm, randomised, double-blind, placebo-controlled, phase 3b trial. Lancet Neurol. 2022;21(7):597-607. doi:10.1016/S1474-4422(22)00185-5.
  2. Jhingran P, Osterhaus JT, Miller DW, Lee JT, Kirchdoerfer L. Development and validation of the Migraine-Specific Quality of Life Questionnaire. Headache. 1998;38(4):295-302. doi:10.1046/j.1526-4610.1998.3804295.
  3. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211. doi:10.1177/0333102417738202.
  4. Jönsson L, Awad SF, Regnier SA, et al. Patient-identified most bothersome symptom as a driver of health-related quality of life experienced by patients with migraine. Poster P8.010 presented at AAN 2023, April 22–27, Boston, MA.
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