Migraine Diagnosis and Treatment: A Knowledge and Needs Assessment of Women's Healthcare Providers

Allison M. S. Verhaak PhD; Anne Williamson PhD; Amy Johnson MD; Andrea Murphy APRN; Matthew Saidel MD; Abigail L. Chua DO; Mia Minen MD, MPH; Brian M. Grosberg MD


Headache. 2021;61(1):69-79. 

In This Article

Abstract and Introduction


Background: Studies suggest that migraine is often underdiagnosed and inadequately treated in the primary care setting, despite many patients relying on their primary care provider (PCP) to manage their migraine. Many women consider their women's healthcare provider to be their PCP, yet very little is known about migraine knowledge and practice patterns in the women's healthcare setting.

Objective: The objective of this study was to assess women's healthcare providers' knowledge and needs regarding migraine diagnosis and treatment.

Methods: The comprehensive survey assessing migraine knowledge originally developed for PCPs was used in this study, with the addition of a section regarding the use of hormonal medications in patients impacted by migraine. Surveys were distributed online, and primarily descriptive analyses were performed.

Results: The online survey was completed by 115 women's healthcare providers (response rate 28.6%; 115/402), who estimated that they serve as PCPs for approximately one-third of their patients. Results suggest that women's healthcare providers generally recognize the prevalence of migraine, but experience some knowledge gaps regarding migraine management. Despite 82.6% (95/115) of survey respondents feeling very comfortable or somewhat comfortable with diagnosing migraine, only 57.9% (66/114) reported routinely asking patients about headaches during annual visits. Very few were familiar with the American Academy of Neurology guidelines on preventative treatment (6.3%; 7/111) and the Choosing Wisely Campaign recommendations on migraine treatment (17.3%; 19/110), and many prescribed medications known to contribute to medication overuse headache. In addition, only 24.3% (28/115) would order imaging for a new type of headache, 35.7% (41/115) for worsening headache, and 47.8% (55/115) for headache with neurologic symptoms; respondents cited greater tendency with sending patients to an emergency department for the same symptoms. Respondents had limited knowledge of evidence-based, non-pharmacological treatments for migraine (i.e., biofeedback or cognitive behavioral therapy), with nearly none placing referrals for these services. Most providers were comfortable prescribing hormonal contraception (mainly progesterone only) to women with migraine without aura (80.9%; 89/110) and with aura (72.5%; 79/109), and followed American College of Obstetricians and Gynecologists (ACOG) guidelines to limit combination hormonal contraception for patients with aura. When queried, 6.3% or less (5/79) of providers would prescribe estrogen-containing contraception for women with migraine with aura. Only 37.3% (41/110) of respondents reported having headache/migraine education. Providers indicated interest in education pertaining to migraine prevention and treatment (96.3%; 105/109), migraine-associated disability (74.3%; 81/109), and diagnostic testing (59.6%; 65/109).

Conclusion: Women's healthcare providers appear to have several knowledge gaps regarding the management of migraine in their patients. These providers would likely benefit from access to a headache-specific educational curriculum to improve provider performance and patient outcomes.


Migraine is approximately three times more prevalent in women than men in the United States (18% of women and 6% of men), especially during reproductive years.[1–3] Sex differences in migraine prevalence begin to emerge following puberty and onset of menses, suggesting the role of female sex hormones (i.e., estrogen) in observed clinical differences.[4] Many women experience migraine before or during menses, known as menstrual migraine, with premenstrual drops in estrogen level thought to precipitate these attacks.[5–7] Furthermore, many women experience worsening migraine symptoms during the postpartum and perimenopausal period.[8–10] In addition to higher prevalence of migraine, women also report increased risk of headache recurrence, a longer attack duration, a longer recovery period, and greater disability, compared with men.[11] The importance of considering the role of sex hormones in migraine treatment has also been implicated, as estrogen-associated headaches may be less responsive to standard treatment, and patients may benefit from hormonal suppression.[12–14] Given these findings, it is critical that providers managing migraine for female patients are sufficiently educated in the nuances of headache diagnosis and treatment.

Much of migraine treatment occurs within the primary care setting, with migraine visits accounting for 5 million to 9 million primary care office visits per year in the United States.[15] However, studies suggest problematic migraine care within the primary care setting, including inaccurate diagnoses, inadequate use of preventative and acute pharmacological treatments, lack of orders for neuroimaging studies with warning signs present, and a paucity of referrals for non-pharmacological, evidence-based treatments for migraine.[16,17] Survey results of primary care providers' (PCPs) headache educational needs and wishes suggest preferences for direct contact with expert providers and educational content during staff meetings.[17] Few studies have attempted to bridge the knowledge gap in migraine treatment within the primary care setting, with mixed benefit.[18] In addition, challenges in developing migraine educational programs have been reported, including low provider attendance and utilization of services offered.[18]

Previous research suggests that 20%-40% of women consider their obstetrician/gynecologist (OB-GYN) to be their PCP.[19,20] To the knowledge of the authors, no study exists which has examined women's healthcare providers' knowledge and educational needs concerning migraine diagnosis and treatment. Given the high percentage of women with migraine whose headache treatment is likely managed by their women's healthcare provider, it is critical to first understand migraine treatment knowledge gaps, in order to better design a targeted, effective educational intervention. In addition to the needs assessment among PCPs as reported by Minen et al,[17] this study also sought to explore the use of hormonal therapies in the context of migraine, across various hormonal milestones. Last, this study sought to conduct limited, exploratory post hoc analyses regarding differences in knowledge and/or practice patterns, based on the frequency by which providers reported serving as PCP for their patients. Based on previous research in which PCPs reported a moderate-to-high level of comfort in managing migraine for their patients,[17] it was expected that those providers reporting a higher frequency of serving as PCP for patients would also report higher levels of comfort with managing migraine.