Migraine Treatment Gap Is Rooted in a Lack of Awareness

Migraine Stages and Associated Symptoms

According to the Mayo Clinic, there are four stages of migraine: prodrome, aura, attack, and postdrome. Each step is associated with its own set of symptoms.

Prodrome, typically occurring one or two days before the onset of a migraine, can be associated with symptoms such as constipation, mood changes, food cravings, neck pain or stiffness, increased urination, and fluid retention. Aura can occur before or during a migraine, including visual phenomena, vision loss, pins and needles in the limbs, facial or body numbness, and difficulty speaking.

Attack is the actual duration of the migraine, which can last anywhere from 4 to 72 hours, depending on the patient and interventional approaches. This phase is when the trademark symptoms of migraine occur, such as pain on one or both sides of the head, a throbbing or pulsing head pain, sensitivity to light and sound, nausea, and vomiting.

Postdrome is the opposite of prodrome, occurring after a migraine for up to one-day post-attack. Feelings of elation, confusion, or fatigue can occur during postdrome.

Type and Prevalence

Migraines are divided into two categories: episodic and chronic. Chronic migraine is characterized by having 15 or more migraine days per month for three or more months. Meanwhile, episodic migraine refers to having fewer than 15 migraine days per month.

The condition is most common in women and those between the ages of 20 and 50. While only 5.6% of men in the United States report migraines, approximately three times as many women in the US, 17.1%, suffer from the condition.

Eric Pearlman, MD, PhD, the Associate Vice President of Neuroscience-Clinical Design for Eli Lilly and Company, told LifeSciencesIntelligence that at any given time, approximately one-third of women in a primary care waiting room have migraines.

Causes

The actual causes of migraine are not fully understood. While the diagnostic pathway includes imaging to rule out structural issues, clinicians suspect genetics and environmental factors may contribute to migraines in those without structural problems.

A list of migraine triggers — provided by the Mayo Clinic — includes the following:

• hormonal changes in women
• alcohol or caffeine consumption
• stress
• sensory stimuli
• sleeping pattern changes
• physical exertion
• weather changes
• medication
• food or food additives

Treatment

The neurology community has made significant headway in treating migraines with multiple medications available to treat the condition at the time of the migraine and drugs or devices to prevent onset.

Treatment Gap

Although effective treatment options — which can be effective for a large portion of the migraine community — have been made available, there is a persistent treatment gap. “The neuroscience community knows that of those people who are impacted enough by migraine to warrant acute treatment and preventive treatment, the majority don't get the appropriate treatment,” noted Pearlman.

Data from the American Migraine Prevalence and Prevention Study found that 56% of respondents reported inadequate migraine relief.

Pearlman explained that there are multiple reasons for this gap. Eli Lilly explored some of these gaps in a study called OVERCOME, a population-based survey of people with migraine that recruited over 60,000 participants in the United States.

According to Pearlman and Amanda Carlton, a patient advocate, the most significant barriers to adequate migraine relief are knowing when to see a provider, getting a diagnosis, stigma, and getting the proper treatment.

Stigma and Knowing When to See a Provider

“The first gap is that people with migraine who have a level of impairment or disability from the disease don't even know they have migraine. They don't think there's anything to be done about it. Then even those who know they have migraines or think they have migraines don't go to a doctor and don't seek care,” commented Pearlman.

Many of these patients believe that their migraines do not warrant a doctor’s visit or would not be taken seriously, which widens the ever-present treatment gap.

Knowing when to see a provider goes hand in hand with stigma, said Pearlman as he discussed the challenges to addressing the stigma associated with migraines.

“Patients don't want to bring it up because they're afraid they won't be taken seriously, that their disease will be minimized,” commented Pearlman. “Providers don't want to bring it up because they fear they don't have good options to offer patients.”

One of the most challenging issues to tackle is the frame of reference most people — specifically those who do not have migraines — have. Unfortunately, someone who doesn’t get migraines or only experiences the occasional headache may not understand the impact that a migraine may have on a person’s ability to function. Many people have the misconception that people with migraines are using them to get out of doing things.

Carlton and Pearlman emphasized the importance of addressing the stigma associated with migraines and acknowledging that the patient’s experiences are valid and warrant medical attention in some cases.

Getting a Diagnosis

Another contributing factor to the migraine treatment gap is getting a diagnosis — or the right one. Assuming patients can get to a provider’s office and move past the stigma associated with the disease, a diagnosis is an essential part of the treatment journey.

“Of those that go to a provider, not all of them get a diagnosis of migraine,” added Pearlman. Even patients who see a provider may not be able to explain the extent of their migraines which presents a diagnostic barrier.

He notes, “Physicians behave very differently if they ask, ‘How's your headache?’ and a patient responds with ‘it's okay. I take Tylenol and Motrin, and I'm okay’ versus ‘I have headache eight days out of a month, and I missed four days of work and had to reschedule a dinner date with my husband because I just couldn't function.’” Explaining the extent of migraines is a necessary part of the diagnostic process.

Pearlman also shared that those diagnosed with migraine do not necessarily receive appropriate treatment as defined by the American Academy of Neurology and the American Headache Society. He, alongside many others, believes that the major contributor to a lack of diagnosis or the appropriate treatment of migraines is rooted in the minimal understanding of the impact of migraines.

Finding the Right Medication

After getting to a doctor and obtaining a diagnosis, patients must ensure that they are finding the proper medication. With so many available on the market, getting the appropriate treatment for each patient may take trial and error.

Carlton shared that, early on in her migraine journey, she was given a medication to treat migraines that wasn’t providing adequate symptom relief and was interfering with her quality of life. “The medication I received to treat the active migraine always gave me bad symptoms. So I was worried about whether I was going to function with a migraine or if I was going to function on the medication. And usually, I couldn't function with either,” she noted.

It wasn’t until she saw a different provider and got a second opinion that she realized that preventative options were available.

Addressing the Issue with Education

Most, if not all, of the issues exacerbating the migraine treatment gap, are due to poor understanding or awareness of the condition and its extent. Educational efforts can go a long way in addressing each of these issues. By educating patients and the general public on migraines and their impacts, the healthcare community can minimize barriers, including stigma, preventing patients from seeing a provider.

Additionally, incorporating migraine assessments into primary care settings may help minimize the number of patients receiving insufficient treatment. Pearlman shared that Eli Lilly has a Think Talk Treat Migraine program geared toward primary care providers to help them know what questions to ask to diagnose and treat migraines.

He notes that providers are urged to ask patients, "Do you have a headache? Is your headache associated with either nausea, sensitivity to light, or impacting your ability to function?" Patients who answer yes to these questions most likely do have migraines. “It doesn't take long in a primary care encounter to ask these questions. And so, providers just need to ask,” continued Pearlman.

Finally, provider education on up-to-date treatment opportunities, their side effects, and efficacy may improve treatment understanding and allow providers to offer additional effective treatments.

Editor's Note: This article has been updated to reflect Pearlman's newly updated position and the proper capitalization of OVERCOME.