Earlier action needed on migraine

Stigma and lack of awareness around migraine are causing late diagnosis and delays in treatment, headache specialist Dr David Burke tells Pat Kelly

There are an estimated 880,000 migraineurs in Ireland and the World Health Organisation (WHO) classifies migraine as the seventh-most disabling illness worldwide, and the world’s most common neurological condition. Migraine is often inherited, and affects around 12 to 15 per cent of people at any given time, according to Migraine Ireland.

The condition is three times more common in women, but it can present challenges in terms of diagnosis. Treatment can also be difficult to tailor for the patient, as symptoms can be very individualised. Migraine in young people is a serious health issue, but again, diagnosis can be a challenge as their presentation may be different compared to adults.

Dr David Burke is a GP with a special interest in headache and has been working in the Headache Clinic in Tallaght Hospital, Dublin, for the past three-and-a-half years. Dr Burke’s interest in headache disorders developed when he worked in neurology as a postgraduate and also because he himself is a migraineur. He emphasised that with new treatments and enhanced understanding of migraine, this is an exciting space to work in.

Dr Burke highlighted the familial aspect of the many migraine cases he sees, as well as the need for greater awareness of the nuances of the condition among healthcare professionals.

“Migraine is seen fairly frequently in families and I have seen family members suffer with it,” he told the Medical Independent (MI).

“Across the board, including in general practice, migraine is under-diagnosed and under-treated.

“Primarily, my role in the Headache Clinic is to treat patients, but equally importantly, to get that knowledge out of the clinic and out to the communities. I work frequently with GPs, visiting GP practices to discuss diagnosing and managing migraine, to try to bridge the gap between primary and secondary care.”

Disability

Despite the frequently cited statistics, migraine remains under-recognised as one of the most severe causes of burden of disease worldwide, he emphasised.

“It is still recognised as the sixth-highest cause of years lived with disability, and according to the WHO’s global burden of disease in women under 50, migraine is the leading cause of years lived with disability,” said Dr Burke.

“If we extract that data to Ireland, it equates to more than two million days lost from work and school in the Republic of Ireland every year.”

That burden impacts people in their careers, with parenting, and in relationships. Dr Burke said he often sees these impacts in everyday practice and he has regularly seen people delay having children because of their struggles with migraine, which also impacts their relationships.

Not only do patients have to deal with the implications of migraine, there is also a remaining stigma around the condition.

“In public perception, sometimes it is trivialised and looked upon as ‘just a headache’,” said Dr Burke.

“That plays into structural stigma, where a workplace often doesn’t consider migraine to be a serious condition that warrants sick-leave. In healthcare, we are under-resourced to deal with it, with only a handful of headache specialists and headache nurse specialists in Ireland. That all leads to internalised stigma, where patients absorb that stigma and delay seeking care. That just further exacerbates their suffering.”

Dr Burke also pointed out that migraine and depression can have a bi-directional relationship, and patients with migraine frequently experience depression, and vice-versa. There is some data to support the idea that the effective treatment of migraine also reduces symptoms of depression, he added.

Diagnosis

Dr Burke acknowledged that for a non-headache specialist, making a definitive diagnosis of migraine can be challenging.

“I would recommend – especially to primary care physicians, because we are the coalface of medicine, and often the first healthcare encounter a person with migraine will have – to try to get a detailed history of the patient’s headache,” he told MI.

“There are three questions that are part of a tool called the ID Migraine tool, which asks patients whether they have had the following associated with their headaches in the past three months: Nausea; sensitivity to light with the headache; and headaches limiting their ability to work, study, or to do what they need to do that day? If a patient answers ‘yes’ to two out of those three questions, there is a high likelihood, or an 80 per cent chance, that they are suffering with migraine. That’s a good basis to start from.”

As doctors are aware, the next step is to recognise and deal with any ‘red-flag’ signs or symptoms and using a screening tool called SNNOOP10 can help systematically identify those. In primary care, if there is uncertainty as to whether migraine is the diagnosis, a headache diary can also be a useful tool, Dr Burke explained.

“A headache diary can be of huge benefit, because a patient can go away for a month, or for up to three months, with their headache diary and write down their symptoms,” he said.

“That will further elicit some of the very common patterns of migraine, which can help us get a fuller picture and help us to diagnose migraine.

“Unfortunately, what we sometimes see is that patients are labelled with an ‘unspecified’ headache disorder,” Dr Burke continued.

“They go undiagnosed for months, which delays subsequent treatment and exacerbates their symptoms, and puts them at further risk of chronification of their headaches. The migraine can go from episodic, to a very disabling chronic migraine.”

Patients often ask about triggers that might provoke a migraine, such as certain foods, caffeine, or alcohol, Dr Burke explained. However, he pointed out that recent data suggest that some of this food consumption is actually a craving that is triggered in the prodromal period, rather than it necessarily being a ‘trigger’.

“What we do recommend to patients is that while their diary can help them to identify some triggers, they should not focus too much on things like food,” he said.

“We know that alcohol can be a trigger, and we recommend coffee in moderation, but certainly what we used to believe – in terms of cheese or chocolate – we used to think they are triggers, but recent studies suggest that this is actually a craving that is triggered in the prodromal period.”

Training

Dr Burke was asked if, considering the burden on healthcare and other resources due to migraine, there is enough emphasis placed on migraine diagnosis and treatment in GP training.

“This comes back to the question of structural stigma,” Dr Burke responded. “Across the board, in healthcare, university and the hospital system, there is very little time given to education [on migraine] for both undergraduates and postgraduates. As a result, hospital consultants and primary care physicians come out of university with little understanding of migraine, and perhaps a diminishing of the condition,” he said.

“Then, when patients present with what looks like a severe headache, migraine is often not considered as a diagnosis.”

Internalised stigma also plays a part in treatment delays, he added – a patient often dismisses their symptoms and sometimes will not even accept a diagnosis of migraine.

Proactive treatment

Dr Burke also highlighted the need to address this multi-level stigma associated with migraine as something that he and his colleagues are proactively trying to address.

“That stigma will decrease along with increased awareness, which will hopefully lead to a more timely diagnosis in primary care, and of course timely treatment,” he told MI.

“The International Headache Society’s position statement of 2025 is calling for what they have titled ‘Early treatment in migraine: A call to shift prevention from attacks to disease progression’. This is a call for a shift from reactive treatment, which is where we are, to preventive treatment once the disability is already established and they are already having frequent attacks,” said Dr Burke.

“This emphasises the need to start preventive treatment early, where they are perhaps having four attacks per month or even fewer when attacks are significantly disabling.

“Early treatment can effectively reduce the burden on the patient and influence the trajectory of the disease,” he concluded.

“We often see in the clinic that patients who come to us with chronic migraine, who have been treated late with preventive therapy, are often refractive to the mediation we can offer them. We are calling on physicians in hospitals and in primary care to start preventive treatment early.”

Across the board, including in general practice, migraine is under-diagnosed and under-treated