Migraine: A common headache disorder that is underdiagnosed and undertreated

Migraine is a common chronic health condition and a leading cause of disability globally. However, even in Canada, with a universal health-care system, migraine is underdiagnosed and undertreated.

This is an important public health issue since migraine is associated with reduced quality of life, affecting social life and relationships, productivity and overall health.

Increasing awareness of migraine symptoms is critical for those living with undiagnosed migraine, since getting a clinical diagnosis is the first step to receiving appropriate and effective care.

But this alone will not solve the burden associated with migraine. Policymakers need to act now to remove the barriers to accessing migraine medications in Canada, particularly as new medications are marketed.

What is migraine?

Migraine is a neurological disorder characterized by moderate to severely painful headache attacks. Pain typically affects one side of the head and presents with nausea or vomiting, sensitivity to light or sound and interference with routine physical activity.

Around 20 per cent of individuals with migraine have aura, which manifests as transient visual, sensory (such as tingling or numbness), movement, speech or other central nervous system disturbances.

Migraine can be episodic (fewer than 15 headache days per month) or chronic (15 or more headache days per month for longer than three months). In both cases, migraine is considered a chronic health condition, which means the disease tends to be long-term and is caused by a combination of genetic, physiological, environmental and behavioural factors.

Impact of migraine

The association between migraine with poor quality of life and disability is well-established. Migraine is associated with lost productivity and with other health conditions including asthma, epilepsy and cardiovascular disease. Furthermore, migraine can contribute to mental health problems, including depression and anxiety.

The 2019 Global Burden of Disease Study revealed migraine is the leading cause of disability in young women and second overall (in all ages and both sexes), in terms of years lived with a disability, a measure of the impact of a disease on quality of life.

This is important since migraine is extremely common globally. Canada is no stranger to this trend, where migraine affects 4.7 per cent of men and 11.8 per cent of women each year. The prevalence of migraine is highest among women and girls of reproductive age. It affects 11 per cent of 12- to 29-year-old women and girls, and nearly 18 per cent of women aged 30 to 49 years.

Historically, migraine has been underdiagnosed

These numbers underestimate the true prevalence of migraine since they only count cases diagnosed by a health-care professional. Factors influencing diagnosis include an individual’s ability and willingness to access care, and a physician identifying and correctly diagnosing migraine.

One study of women in Canada reported that only 51 per cent of those identified as having migraine ever consulted a physician about the headaches they experience. Data suggests that health-seeking behaviour contributes to the underdiagnosis of episodic migraine.

However, research has demonstrated that for chronic migraine, most individuals report consulting a physician about their headaches. This suggests that in people with chronic migraine specifically, underdiagnosis may be driven by the failure to receive a correct diagnosis from a health-care provider.

In individuals with migraine, receiving a diagnosis is associated with being female and with older age. A study in the United States also identified higher income as a factor.

Migraine-specific medications are under-used

Medications approved specifically to treat migraine attacks are effective at relieving symptoms in individuals who do not experience relief from over-the-counter options, including acetaminophen (such as Tylenol) and ibuprofen (such as Advil).

Triptans are among the oldest migraine-specific medications, and the first-line treatment for migraine for those who do not get relief from over-the-counter medications. However, because they affect blood vessels, triptans should not be used by people with certain types of underlying vascular disease.

Triptans have been available in Canada since the 1990s. The Canadian Headache Society strongly recommends their use in migraine therapy. Seven triptans are approved by Health Canada for use in adults.

Despite this, many individuals living with migraine in Canada do not use or have not tried migraine-specific medications. A recent review found that most individuals with episodic migraine had not tried migraine-specific medication and use non-prescription medications to manage migraine symptoms, indicating a gap in the medical management of migraine in Canada.

Challenges to accessing migraine-specific medications in Canada include their high cost and limited coverage through provincial public drug insurance programs, such as the Ontario Drug Benefit.

Provider knowledge may also explain the underuse of migraine-specific therapies in Canada. Opiates and non-steroidal anti-inflammatory drugs are prescribed more commonly than migraine-specific therapies in Ontario emergency departments, indicating room for physician training in treating migraine.

As new migraine-specific medications are approved in Canada, it is important that those who need them can access these treatments. Initiatives such as British Columbia’s recent decision to cover the cost of certain calcitonin gene-related peptide (CGRP) inhibitors can help. These medications are used to prevent migrainous headaches, and cost over $600 per month.

Steps you can take if you think you might have migraine

Migraine Buddy is a migraine tracking app with a questionnaire to help individuals determine if they may have migraine and should discuss their symptoms with a physician.

Effective treatment options exist to manage migraine, which can be accessed through a physician. Tools such as the Traffic Light of Headache, with green, yellow and red corresponding to headache severity, can assist individuals with migraine in making treatment decisions to manage their symptoms.

With access to appropriate treatments, individuals living with migraine can manage their condition and live life to the fullest.

Melina Albanese receives funding from the Guiding interdisciplinary Research On Women’s and girls’ health and Wellbeing (GROWW) program and the Queen Elizabeth II Graduate Scholarship in Science and Technology.