More education on migraine features is needed

Migraine tends to be underdiagnosed and misdiagnosed at primary and secondary levels of care and education at these levels needs to improve. ICHD-3 criteria likely to be missed included aura, pain aggravation by physical activity, pain intensity, and photophobia.

Dr Lucas Overeem (Charité University Medicine Berlin, Germany) collected data from a retrospective, cross-sectional study including all patients who presented at the tertiary headache clinic between December 2015 and January 2023 [1]. Diagnoses were classified as self-reported by patients (based on their instructions from primary or secondary care doctors), diagnoses from a headache specialist (using doctor letters), and diagnoses according to the ICHD-3. Patients with missing doctor’s letters from lower levels or who had non-headache pain, such as facial pain or other syndromes, were excluded. In total, 1,468 patients were included in the analyses (75% women, mean age 43 years).

Overall, 97% of migraine diagnoses from the primary or secondary level of care were confirmed at the tertiary level of care; however, 32% of migraine diagnoses from the tertiary level of care were not provided at the primary or secondary levels of care. Furthermore, while 98% of migraine diagnoses from the primary or secondary level of care were confirmed using ICHD-3 criteria, 28% of the ICHD-3 criteria-diagnosed patients did not receive a correct diagnosis in primary or secondary care. The diagnosis concordance between the tertiary level of care and ICHD-3 criteria was 99%. Diagnostic criteria which were more likely to be missed at the primary or secondary level of care included aura, pain aggravation by physical activity, pain intensity of 6–9 on a visual analogue scale, nausea, vomiting, and photophobia.

“We found that migraine was underdiagnosed, tension-type headache overdiagnosed, and cluster headache underrecognised and misdiagnosed at the primary and secondary levels of care,” said Dr Overeem. “We identified that the absence of clinical criteria features led to misdiagnosis or missed diagnosis in lower levels of care, but it’s important to note that not all criteria always have to be fulfilled. We suggest that education and awareness improvement should continue, to help improve the diagnostic agreement.”

1. Overeem LH, et al. Consistency between headache diagnoses and ICHD-3 criteria across different levels of care. 18^th European Headache Congress, 4–7 December 2024, Rotterdam, the Netherlands.

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Posted on 6 January 20256 January 2025