It is estimated that 40 million people in the U.S. suffer from migraine.¹ Though common, migraine is one of the most underdiagnosed and undertreated neurologic conditions, in part because there is no diagnostic lab test for migraine.^2,3 Migraine is the second most common cause for disability outside of low back pain⁴ and costs the U.S. economy an estimated $78 billion per year.⁵ In addition, there are fewer than 700 certified headache specialists in the United States.⁶ In April 2024, migraine management experts met to discuss how to improve the diagnosis and treatment of migraine in the primary care setting. Read on for three key takeaways from the Advisory Board webcast, Why primary care is the missing piece in migraine management.

Since patient and health system challenges may exist along the migraine care journey, health systems will need to analyze the current diagnostic, treatment, management, and referral approaches, and then evaluate where gaps in care may exist.²

For example, migraine patients are often diagnosed by their primary care provider (PCP). While PCPs are usually the first point of contact for people with migraine, many haven’t received comprehensive training in migraine management and there is no easy diagnostic lab test.³ As a result, they don’t always feel confident diagnosing, treating, and managing migraine.⁷

In addition, primary care clinics may not be set up to support migraine diagnosis and treatment. For instance, a single yearly appointment doesn’t give PCPs time to gather a full history of migraine symptoms and treatment attempts,⁸ and the physical exam itself is unlikely to reveal migraine. On top of that, diagnostic criteria for migraine are typically developed for headache specialists and neurologists, so it can be difficult to determine how to apply them in a primary care setting.

When PCPs aren’t confident in confirming or treating a migraine diagnosis, they often refer patients to a specialist. But there aren’t enough headache specialists or neurologists to sustainably handle all migraine patients without strain on the healthcare system. Choosing to refer most or all migraine patients to specialists can leave patients waiting months before their pain is addressed.⁹

To truly improve the outcomes of migraine care, health organizations must make it easier for PCPs to participate in change. Supporting PCPs with education, standardized workflow, and supporting resources can minimize additional clinical and administrative burden to an already overburdened PCP practice.^2,10

Integrate standardized migraine tools into the primary care workflow. While no diagnostic test can positively identify migraine,³ a variety of migraine tools are available to help PCPs narrow down a diagnosis and consider available treatments. Tools might include an overview of acute and preventive treatment options, migraine diaries to assess how patients are experiencing migraines over time, and screening tools like ID Migraine. Some tools may be programmed into the electronic health record (EHR) so that PCPs can easily select evaluation questions to ask patients, be quickly educated on symptoms that require a referral, and prescribe medications.

Give PCPs time to learn about migraine diagnosis and treatment. Relying on grand rounds to educate PCPs about migraine is not enough. In addition to granting providers access to education from the National Headache Foundation and other organizations, health systems can create alternative forms of learning. For example, organizations might give PCPs time to do a preceptorship where they spend a half day every week in a headache specialist’s office for several weeks. Or, organizations could organize interactive lunch-and-learn events where PCPs can listen to a 15-minute lecture on migraine diagnosis, acute therapies, and preventive therapies.

Empowering patients to play a role in their migraine management can encourage patient adherence to prescribed treatments and make management easier for PCPs.^2,8

In tandem with learning via provider education, PCPs can create “therapeutic alliances” with patients by establishing a framework to talk about migraine. Once a patient is diagnosed with migraine, a provider in the clinic may educate patients about the role of urgent care, the ER, and telehealth in managing migraine attacks. Patients can also learn about acute and preventive treatments for migraine and how to track the frequency and severity of migraine symptoms.

Migraine management plans are based on patient history and responses to treatment. Providing education materials early — either during triage via a nurse line, at the first primary care visit, or through the patient portal — can help patients describe their migraine experiences, advocate for proper migraine care, and alleviate hesitancy to try new treatments.

Learn more about how the Migraine Health System Toolkit addresses gaps in migraine care.

Vincent Martin, MD

Director of the Headache and Facial Pain Center at the University of Cincinnati Gardner Neuroscience Institute.

Dr. Martin is the Director of the Headache and Facial Pain Center at the University of Cincinnati Gardner Neuroscience Institute.  He is also the Professor of Clinical Medicine in the Division of Internal Medicine as well as the President of the National Headache Foundation.

Heather Nelson

Health Systems Lead, Migraine Market Shaping Team, Pfizer Inc.

Heather is currently focused on uncovering opportunities to improve care gaps for migraine patients within health systems as a member of Pfizer’s Market Shaping Team. She has worked in healthcare for over 22 years and held roles in sales, account management, operations and team leadership.  Heather has a passion for cross functional collaboration and improving patient outcomes through quality improvement.

Heather graduated from the University of Wisconsin-Madison with a Bachelor's degree in Biochemistry and Nutritional Science.

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