Overcoming obstacles to effective treatment of patients with migraine (Statement of the expert group on optimizing treatment of patients with migraine)

Despite the development of basic principles and a wide arsenal of therapeutic and preventive agents, the effective treatment of migraine patients in daily practice is associated with some well-identified obstacles. Among many obstacles to effective treatment, several key factors can be identified: low patients' awareness of the nature of the disease, its course and prognosis, methods of treatment and prevention, low rate of patients' referral for medical care and unsatisfactory level of diagnosis in clinical practice, inadequate training of physicians in the field of headache, nonoptimal use of symptom management and preventive treatment strategies. The article discusses the most common problems and strategies to optimize treatment of migraine patients.

1. United Nations (2015). Transforming our world: the 2030 Agenda for Sustainable Development. United Nations, New York. A/RES/70/1. Available at: https://sdgs.un.org/sites/default/files/publications/21252030 Agenda for Sustainable Development web.pdf (accessed 01.06.2023).

2. Martelletti P, Leonardi M, Ashina M, et al. Rethinking headache as a global public health case model for reaching the SDG 3 HEALTH by 2030. J Headache Pain. 2023 Oct 27;24(1):140. doi: 10.1186/s10194-023-01666-2

3. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020 Oct 17;396(10258):1204-22. doi: 10.1016/S0140-6736(20)30925-9. Erratum in: Lancet. 2020 Nov 14;396(10262):1562. doi: 10.1016/S0140-6736(20)32226-1

4. Dong L, Dong W, Jin Y, et al. The Global Burden of Migraine: A 30-Year Trend Review and Future Projections by Age, Sex, Country, and Region. Pain Ther. 2025 Feb;14(1):297-315. doi: 10.1007/s40122-024-00690-7. Epub 2024 Dec 11.

5. Stovner LJ, Hagen K, Linde M, Steiner TJ. The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates. J Headache Pain. 2022 Apr 12;23(1):34. doi: 10.1186/s10194-022-01402-2

6. Blumenfeld AM. Clinician-Patient Dialogue About Preventive Chronic Migraine Treatment. J Prim Care Community Health. 2020 Jan-Dec;11:2150132720959935. doi: 10.1177/2150132720959935

7. Glembotskaya GT, Kozub OV. Pharmacyeconomical estimation “burden” of migraine in Russian Federation. Klinicheskaya pharmakologia i terapiya = Clinical Pharmacology and Therapy. 2013;22(2):83-6 (In Russ.).

8. Shimizu T, Sakai F, Miyake H, et al. Disability, quality of life, productivity impairment and employer costs of migraine in the workplace. J Headache Pain. 2021 Apr 21;22(1):29. doi: 10.1186/s10194-021-01243-5

9. Begasse de Dhaem O, Sakai F. Migraine in the workplace. eNeurologicalSci. 2022 Jun 6;27:100408. doi: 10.1016/j.ensci.2022.100408

10. Igarashi H, Sano H, Kondo H, et al. Characteristics of patients who seek medical attention for headache and those who do not: cross-sectional survey and linked medical claims data analysis in Japan. BMJ Open. 2024 Apr 29;14(4):e077686. doi: 10.1136/bmjopen2023-077686

11. Brusa P, Allais G, Scarinzi C, et al. Selfmedication for migraine: A nationwide crosssectional study in Italy. PLoS One. 2019;14(1):e0211191. doi: 10.1371/journal.pone.0211191

12. Kovalchuk NA, Kiryanova EA, Tabeeva GR. Medication adherence in migraine patients (data of an online survey). Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2021;13(4):81-7. doi: 10.14412/2074-2711-2021-4-81-87 (In Russ.).

13. Gendolla A, Brown JD, Mercadante AR, et al. The incremental burden and healthcare resource utilization among people with migraine in Europe: Insights from the 2020 European National Health and Wellness Survey. Cephalalgia. 2024 Dec;44(12):3331024241276415. doi: 10.1177/03331024241276415

14. Gallup. Wellcome Global Monitor – First Wave Findings. 2019. Available at: https://wellcome.org/reports/wellcome-global-monitor/2018

15. Groth M, Katsarava Z, Ehrlich M. Results of the gErman migraine PatIent Survey on medical Care and prOPhylactic treatment Experience (EPISCOPE). Sci Rep. 2022 Mar 17;12(1):4589. doi: 10.1038/s41598-022-08716-w

16. Young WB, Park JE, Tian IX, Kempner J. The stigma of migraine. PLoS One. 2013;8(1):e54074. doi: 10.1371/journal.pone.0054074. Epub 2013 Jan 16.

17. Shapiro RE, Nicholson RA, Seng EK, et al. Migraine-Related Stigma and Its Relationship to Disability, Interictal Burden, and Quality of Life: Results of the OVERCOME (US) Study. Neurology. 2024 Feb 13;102(3):e208074. doi: 10.1212/WNL.0000000000208074. Epub 2024 Jan 17.

18. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache. 2015 Jan;55(1):3-20. doi: 10.1111/head.12499

19. Lipton RB, Munjal S, Buse DC, et al. Unmet Acute Treatment Needs From the 2017 Migraine in America Symptoms and Treatment Study. Headache. 2019 Sep;59(8):1310-23. doi: 10.1111/head.13588. Epub 2019 Aug 13.

20. Bentivegna E, Galastri S, Onan D, Martelletti P. Unmet Needs in the Acute Treatment of Migraine. Adv Ther. 2024 Jan;41(1):1-13. doi: 10.1007/s12325-023-02650-7. Epub 2023 Nov 9.

21. Lipton RB, Buse DC, Serrano D, et al. Examination of unmet treatment needs among persons with episodic migraine: results of the American Migraine Prevalence and Prevention (AMPP) Study. Headache. 2013 Sep;53(8):1300-11. doi: 10.1111/head.12154. Epub 2013 Jul 23.

22. Smelt AF, Louter MA, Kies DA, et al. What do patients consider to be the most important outcomes for effectiveness studies on migraine treatment? Results of a Delphi study. PLoS One. 2014 Jun 16;9(6):e98933. doi: 10.1371/journal.pone.0098933

23. Lipton RB, Hamelsky SW, Dayno JM. What do patients with migraine want from acute migraine treatment? Headache. 2002 Jan;42 Suppl 1:3-9. doi: 10.1046/j.1526-4610.2002.0420s1003.x

24. Davies GM, Santanello N, Lipton R. Determinants of patient satisfaction with migraine therapy. Cephalalgia. 2000 Jul;20(6):554-60. doi: 10.1046/j.1468-2982.2000.00082.x

25. Lipton RB, Fanning KM, Serrano D, et al. Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine. Neurology. 2015 Feb 17;84(7):688-95. doi: 10.1212/WNL.0000000000001256. Epub 2015 Jan 21.

26. Dobrynina LA, Afanasev MA, Belopasova AV, et al. The management of high-frequency episodic and chronic migraines with calcitonin gene-related peptide monoclonal antibody. Annaly klinicheskoy i eksperimental'noy nevrologii = Annals of Clinical and Experimental Neurology. 2023;17(2):22-7. doi: 10.54101/ACEN.2023.2.3 (In Russ.).

27. Meyers JL, Davis KL, Lenz RA, et al. Treatment patterns and characteristics of patients with migraine in Japan: A retrospective analysis of health insurance claims data. Cephalalgia. 2019 Oct;39(12):1518-34. doi: 10.1177/0333102419851855. Epub 2019 Jun 1.

28. Ueda K, Ye W, Lombard L, et al. Realworld treatment patterns and patient-reported outcomes in episodic and chronic migraine in Japan: analysis of data from the Adelphi migraine disease specific programme. J Headache Pain. 2019 Jun 7;20(1):68. doi: 10.1186/s10194-019-1012-1

29. Martelletti P, Curto M. Unmet needs for migraine. Curr Med Res Opin. 2021 Nov;37(11):1957-9. doi: 10.1080/03007995.2021.1976738. Epub 2021 Sep 16.

30. Matsumori Y, Ueda K, Komori M, et al. Burden of Migraine in Japan: Results of the ObserVational Survey of the Epidemiology, tReatment, and Care Of MigrainE (OVERCOME [Japan]) Study. Neurol Ther. 2022 Mar;11(1):205-22. doi: 10.1007/s40120-021-00305-9

31. Pascual J, Panni T, Dell'Agnello G, et al. Preventive treatment patterns and treatment satisfaction in migraine: results of the OVERCOME (EU) study. J Headache Pain. 2023 Jul 17;24(1):88. doi: 10.1186/s10194-023-01623-z. Erratum in: J Headache Pain. 2023 Oct 20;24(1):142. doi: 10.1186/s10194-023-01679-x

32. Lampl C, MaassenVanDenBrink A, Deligianni CI, et al. The comparative effectiveness of migraine preventive drugs: a systematic review and network meta-analysis. J Headache Pain. 2023 May 19;24(1):56. doi: 10.1186/s10194-023-01594-1

33. Sacco S, Braschinsky M, Ducros A, et al. European Headache Federation consensus on the definition of resistant and refractory migraine: Developed with the endorsement of the European Migraine & Headache Alliance (EMHA). J Headache Pain. 2020 Jun 16;21(1):76. doi: 10.1186/s10194-020-01130-5

34. Migraine. Adults. Clinical guidelines of the Ministry of Health of the Russian Federation, 2024. Available at: https://base.garant.ru/410613100 (In Russ.).

35. Bentivegna E, Onan D, Martelletti P. Unmet Needs in Preventive Treatment of Migraine. Neurol Ther. 2023 Apr;12(2):337-42. doi: 10.1007/s40120-023-00438-z. Epub 2023 Feb 4.

36. Azimova YuE, Sergeev AV, Osipova VV, Tabeeva GR. Diagnostic and treatment of headaches in Russia: results of questionnairebased survey. Rossijskiij zhurnal boli = Russian Journal of Pain. 2010;(4):12-7 (In Russ.).

37. Hepp Z, Dodick DW, Varon SF, et al. Persistence and switching patterns of oral migraine prophylactic medications among patients with chronic migraine: A retrospective claims analysis. Cephalalgia. 2017 Apr;37(5):470-85. doi: 10.1177/0333102416678382. Epub 2016 Nov 12.

38. State Register of Medicines. Available at: https://grls.rosminzdrav.ru/GRLS.aspx (In Russ.).

39. Tabeeva GR, Filatova EG, Amelin AV, et al. Alternative and complementary treatments for migraine. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2024;16(1):4-15. doi: 10.14412/2074-2711-2024-1-4-15 (In Russ.).

40. Golovacheva VA, Golovacheva AA. Cognitivebehavioral therapy in the treatment of patients with chronic migraine and emotional impairment: A prospective randomized trial with a two-year follow-up period. Consilium Medicum. 2024;26(11):745-51. doi: 10.26442/20751753.2024.11.203055 (In Russ.).

41. Ashina M, Buse DC, Ashina H, et al. Migraine: integrated approaches to clinical management and emerging treatments. Lancet. 2021 Apr 17;397(10283):1505-18. doi: 10.1016/S0140-6736(20)32342-4. Epub 2021 Mar 25.

42. Lenz B, Katsarava Z, Gil-Gouveia R, et al; European Headache Federation and Lifting The Burden: the Global Campaign against Headache. Headache service quality evaluation: implementation of quality indicators in primary care in Europe. J Headache Pain. 2021 Apr 28;22(1):33. doi: 10.1186/s10194-021-01236-4

43. Kim BK, Chu MK, Yu SJ, et al. Burden of migraine and unmet needs from the patients' perspective: a survey across 11 specialized headache clinics in Korea. J Headache Pain. 2021 May 24;22(1):45. doi: 10.1186/s10194-021-01250-6. Erratum in: J Headache Pain. 2021 Jun 11;22(1):56. doi: 10.1186/s10194-021-01270-2

44. Edmeads J. Communication issues in migraine diagnosis. Can J Neurol Sci. 2002 Jun;29 Suppl 2:S8-10. doi: 10.1017/s0317167100001876

45. Haghdoost F, Togha M. Migraine management: Non-pharmacological points for patients and health care professionals. Open Med (Wars). 2022 Nov 23;17(1):1869-82. doi: 10.1515/med2022-0598

46. Eigenbrodt AK, Ashina H, Khan S, et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol. 2021 Aug;17(8):501-14. doi: 10.1038/s41582-021-00509-5. Epub 2021 Jun 18.

47. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211. doi: 10.1177/0333102417738202

48. Cousins G, Hijazze S, Van de Laar FA, Fahey T. Diagnostic accuracy of the ID Migraine: a systematic review and meta-analysis. Headache. 2011 Jul-Aug;51(7):1140-8. doi: 10.1111/j.1526-4610.2011.01916.x. Epub 2011 Jun 7.

49. Schwedt TJ, Lipton RB, Goadsby PJ, et al. Characterizing Prodrome (Premonitory Phase) in Migraine: Results From the PRODROME Trial Screening Period. Neurol Clin Pract. 2025 Feb;15(1):e200359. doi: 10.1212/CPJ.0000000000200359. Epub 2024 Oct 8.

50. Fraser CL, Hepschke JL, Jenkins B, Prasad S. Migraine Aura: Pathophysiology, Mimics, and Treatment Options. Semin Neurol. 2019 Dec;39(6):739-48. doi: 10.1055/s-0039-1700525. Epub 2019 Dec 17.

51. Pavlovic JM, Buse DC, Sollars CM, et al. Trigger factors and premonitory features of migraine attacks: summary of studies. Headache. 2014 Nov-Dec;54(10):1670-9. doi: 10.1111/head.12468

52. American Headache Society. The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache. 2019 Jan;59(1):1-18. doi: 10.1111/head.13456. Epub 2018 Dec 10. Erratum in: Headache. 2019 Apr;59(4):650-1. doi: 10.1111/head.13506

53. Moreno-Ajona D, Villar-Martinez MD, Goadsby PJ. New Generation Gepants: Migraine Acute and Preventive Medications. J Clin Med. 2022 Mar 16;11(6):1656. doi: 10.3390/jcm11061656

54. Mitsikostas DD, Waeber C, Sanchez-Del-Rio M, et al. The 5-HT1F receptor as the target of ditans in migraine – from bench to bedside. Nat Rev Neurol. 2023 Aug;19(8):489-505. doi: 10.1038/s41582-023-00842-x. Epub 2023 Jul 12.

55. Martelletti P, Luciani M, Spuntarelli V, Bentivegna E. Deprescribing in migraine. Expert Opin Drug Saf. 2021 Jun;20(6):623-5. doi: 10.1080/14740338.2021.1907342. Epub 2021 Mar 25.

56. Lipton RB, Stewart WF, Stone AM, et al; Disability in Strategies of Care Study group. Stratified care vs step care strategies for migraine: the Disability in Strategies of Care (DISC) Study: A randomized trial. JAMA. 2000 Nov 22-29;284(20):2599-605. doi: 10.1001/jama.284.20.2599

57. Tzankova V, Becker WJ, Chan TLH. Pharmacologic prevention of migraine. CMAJ. 2023 Feb 6;195(5):E187-E192. doi: 10.1503/cmaj.221607

58. Pellesi L, Garcia-Azorin D, Rubio-Beltran E, et al. Combining treatments for migraine prophylaxis: the state-of-the-art. J Headache Pain. 2024 Dec 5;25(1):214. doi: 10.1186/s10194-024-01925-w

59. Ferreira VL, Mainka FF, Wiens A, Pontarolo R. Effectiveness of Calcitonin GeneRelated Peptide Monoclonal Antibodies in the Prevention of Migraine: A Systematic Review and Meta-Analysis of Observational Cohort Studies. Clin Drug Investig. 2023 Sep;43(9):669-80. doi: 10.1007/s40261-023-01301-7. Epub 2023 Sep 4.

60. Özge A, Baykan B, Bicakci S, et al. Revolutionizing migraine management: advances and challenges in CGRP-targeted therapies and their clinical implications. Front Neurol. 2024 Jun 13;15:1402569. doi: 10.3389/fneur.2024.1402569

61. Giri S, Tronvik E, Linde M, et al. Randomized controlled studies evaluating Topiramate, Botulinum toxin type A, and mABs targeting CGRP in patients with chronic migraine and medication overuse headache: A systematic review and meta-analysis. Cephalalgia. 2023 Apr;43(4):3331024231156922. doi: 10.1177/03331024231156922

62. Haghdoost F, Puledda F, Garcia-Azorin D, et al. Evaluating the efficacy of CGRP mAbs and gepants for the preventive treatment of migraine: A systematic review and network meta-analysis of phase 3 randomised controlled trials. Cephalalgia. 2023 Apr;43(4):3331024231159366. doi: 10.1177/03331024231159366. Erratum in: Cephalalgia. 2024 Jun;44(6):3331024241255216. doi: 10.1177/03331024241255216

63. Tabeeva GR, Katsapava Z. Current concept of the pathophysiology of migraine and new targets for its therapy. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2020;12(4):143-52. doi: 10.14412/2074-2711-2020-4-143-152 (In Russ.).

64. Sergeev AV, Guziy EA, Kovalchuk NA, et al. The role of dopaminergic genes in chronic migraine and medication-overuse headache. Rossijskiij zhurnal boli = Russian Journal of Pain. 2024;22(4):24-9. doi: 10.17116/pain20242204124 (In Russ.).

65. Belyaeva II, Subbotina AG, Eremenko II, et al. Pharmacogenetics in Primary Headache Disorders. Front Pharmacol. 2022 Feb 10;12:820214. doi: 10.3389/fphar.2021.820214

66. Buse DC, Loder EW, Gorman JA, et al. Sex differences in the prevalence, symptoms, and associated features of migraine, probable migraine and other severe headache: results of the American Migraine Prevalence and Prevention (AMPP) Study. Headache. 2013 Sep;53(8):1278-99. doi: 10.1111/head.12150. Epub 2013 Jun 28.

67. Irimia P, Garcia-Azorin D, Nunez M, et al. Persistence, use of resources and costs in patients under migraine preventive treatment: the PERSEC study. J Headache Pain. 2022 Jul 7;23(1):78. doi: 10.1186/s10194-022-01448-2

68. Schwedt TJ, Buse DC, Argoff CE, et al. Medication Overuse and Headache Burden: Results From the CaMEO Study. Neurol Clin Pract. 2021 Jun;11(3):216-26. doi: 10.1212/CPJ.0000000000001037

69. Ha H, Gonzalez A. Migraine Headache Prophylaxis. Am Fam Physician. 2019 Jan 1;99(1):17-24.

70. Pavelic AR, Wöber C, Riederer F, Zebenholzer K. Monoclonal Antibodies against Calcitonin Gene-Related Peptide for Migraine Prophylaxis: A Systematic Review of RealWorld Data. Cells. 2022 Dec 29;12(1):143. doi: 10.3390/cells12010143

71. Tabeeva GR, Kosivtsova OV, Kovalchuk NA, Orlyuk TA. Refractory migraine. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2024;16(2):76-86. doi: 10.14412/2074-2711-2024-2-76-86 (In Russ.).

72. Ornello R, Andreou AP, De Matteis E, et al. Resistant and refractory migraine: clinical presentation, pathophysiology, and management. EBioMedicine. 2024 Jan;99:104943. doi: 10.1016/j.ebiom.2023.104943. Epub 2023 Dec 23.