How to address the full impact of migraine

In this symposium held at the 8th Congress of the European Academy of Neurology, Vienna, June 24−28 2022, Professor Dawn Buse (Department of Neurology at Albert Einstein College of Medicine, New York, USA), Professor Uwe Reuter (Charité University Hospital, Berlin, Germany), and Professor Simona Sacco (University of L’Aquila, Italy) discuss how the number of days a person experiences migraine a month not only impacts symptom and disability burden on these days, but also ‘interictal burden’ on days when migraine is not experienced. Proper discussion between healthcare professionals and their patients is needed to help assess and treat both migraine symptoms and burdens, with the ‘ask-tell-ask’ method proving useful in this realm. Preventative medication, including the use of calcitonin gene-related peptide monoclonal antibodies, can reduce migraine severity and number of days a migraine is experienced, and also reducing interictal burden.

The large (n=21,143), USA based, OVERCOME study found that for people with migraine, disability, migraine symptom range, and headache severity increased with increasing number of headache days.1,2 Due to such experiences, work productivity can be affected, both through being absent and being present but not able to properly carry out tasks.3-5 Additionally reported are impacts of migraine on participating in family activities6 and the decision to have children.7 There are also economic burdens of migraine with regard to healthcare costs.8

Interictal burden describes how migraine can affect a person beyond symptom days

Even on days when a person is not experiencing a migraine, discussed Professor Buse, they may experience ‘interictal burden.’ This can be assessed using the Migraine Interictal Burden Scale (MIBS-4), which asks how much headaches affect work/school; planning and social/leisure activities; overall life; and feeling helpless.9 In the OVERCOME study, use of this measure revealed that 78% of people reported interictal burden, with 50% reporting it as severe.10 Such interictal burdens can include anxiety and avoiding aspects of daily life that may induce a headache.11

These findings, discussed Professor Buse, show that “migraine-specific quality of life (QoL) is substantially affected.”


Optimizing diagnosis and treatment

One important aspect of migraine and prevention Professor Reuter discussed was that patients may not feel comfortable discussing how their current migraine treatments are working and/or the burden migraine has on them. He encouraged healthcare professionals (HCPs) to build trust and open communication regarding providing a correct diagnosis, QoL, and setting up an effective management plan.

Professor Reuter also discussed the importance of using the correct lexicon to communicate what is known about preventative medication and explain how it can decrease the frequency of headache days and improve QoL.12 In the ‘Ask-Tell-Ask’ strategy, a patient is first asked to explain the issue in their own words, the HCP then tells the patient the relevant facts about their diagnosis and treatment, then, to confirm understanding, asks the patient to recall the information in their own words.9

Patients need proper investigation of symptoms and interictal burden

In the American Migraine Communication study, using this strategy, along with open-ended questioning, led to HCPs having a better understanding of a patients' migraine frequency and interictal burden, more frequent discussions regarding acute and preventative treatment strategies, and, from both the patient and HCP perspective, more satisfaction with the clinical visit.9,13


Calcitonin gene-related peptide monoclonal antibody (CGRP mAb) treatments to address interictal burden

The OVERCOME study revealed that even some people with ≥15 migraines a month had not sought care for such and that 81.6 % of people with 4−7 monthly headache days and 71.1% with ≥15 migraines a month were not taking a preventative medication, despite the majority being eligible for such.1

A variety of studies have investigated use of a CGRP mAb as preventative medication. While, importantly, studies have found direct impacts on levels of severe pain when a migraine was experienced,14 also importantly are findings on overall QoL, including on interictal burden. For instance, in one clinical trial, a CGRP mAb led to significant reductions in Migraine Disability Assessment Questionnaire scores compared to baseline following 4−6 months application15 and in the OVERCOME study, of those taking a CGRP mAb, 79.2% overall and 74.6% with ≥15 migraine days/month had higher Patient Global Impression of Improvement scores compared with baseline.16

Preventative medication can help with both symptoms and interictal burden

A real-world study also found benefits in patient-reported outcomes in those receiving a CGRP mAb,17 with another finding this medication provided an improvement in headache-related impacts on life.14 CGRP mAbs have also been shown to impact work productivity including decreases in missed time from work and impairment while working.18

However, some people are non-responsive to CGRP mAbs, with one study finding approximately 47% of patients with episodic or chronic migraine had a less than 50% responder rate19 and another finding this in approximately 37% of patients.20 Of note though, said Professor Sacco, these studies only measured monthly migraine days and did not assess factors such as residual burden where rates may be different.

Non-response is an issue as the worldwide ‘My Migraine Voice’ survey (n=11,266, migraine ≥4/month) of non-responders to at least one preventative medication found that 80% of respondents had to cancel plans, 52% reported migraine interfered with their cognitive abilities, 50% said they experienced a lack of energy, and 43% said they felt hopeless or helpless.21

For those where people indicated that preventative medication did not help them, it may, Professor Reuter pondered, be due to them not taking their medication for long enough as OVERCOME study results revealed that nearly a third took their preventative treatment for <3 months,22 which, he discussed “is not enough to achieve significant improvement.”

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.


  1.  Lipton RB, et al. Diagnosis, consultation, treatment, and impact of migraine in the US: Results of the OVERCOME (US) study. Headache 2022;62:122–40.
  2. Reed ML, et al. Symptom patterns, disability, and physician visits among a US sample of people with migraine: Results of the OVERCOME study. 61st Annual Scientific Meeting American Headache Society; July 11-14, 2019; Philadelphia, PA.
  3. Ford JH, et al. A real-world analysis of migraine: A cross-sectional study of disease burden and treatment patterns. Headache 2017;57:1532–44.
  4. Doane MJ, et al. The humanistic and economic burden of migraine in Europe: A cross-sectional survey in five countries. Neurol Ther 2020;9:535–49.
  5. Buse DC, et al. Burden of illness among people with migraine and ≥ 4 monthly headache days while using acute and/or preventive prescription medications for migraine. J Manag Care Spec Pharm 2020;26:1334–43.
  6. Buse DC, et al. Impact of migraine on the family: Perspectives of people with migraine and their spouse/domestic partner in the CaMEO Study. Mayo Clin Proc 2016; S0025-6196(16)00126-9.
  7. Ishii R, et al. Effect of migraine on pregnancy planning: Insights from the American Registry for Migraine Research. Mayo Clin Proc 2020;95:2079–89.
  8. Raval AD, Shah A. National trends in direct health care expenditures among US Adults with migraine: 2004 to 2013. J Pain 2017;18:96–107.
  9. Buse DC, et al. Assessing and managing all aspects of migraine: Migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clin Proc 2009;84:422–35.
  10. Lipton RB, et al. Migraine diagnosis, disability, and work productivity impact in migraine:Results of the OVERCOME (International) Study. The International Headache Congress –IHS and EHF Joint Congress; September 8-12, 2021; Virtual.
  11. Lampl C, et al. Interictal burden attributable to episodic headache: Findings from the Eurolight project. J Headache Pain 2016;17:9.
  12. Blumenfeld AM. Clinician-patient dialogue about preventive chronic migraine treatment. J Prim Care Community Health 2020;11:2150132720959935.
  13. Hahn SR, et al. Healthcare provider-patient communication and migraine assessment: Results of the American Migraine Communication Study, Phase II. Curr Med Res Opin 2008;24:1711–18.
  14. Lipton RB, et al. Patient-reported outcomes, health-related quality of life, and acute medication use in patients with a ≥ 75% response to eptinezumab: Subgroup pooled analysis of the PROMISE trials. J Headache Pain 2022;23:23.
  15. Buse DC, et al. Migraine-related disability, impact, and health-related quality of life among patients with episodic migraine receiving preventive treatment with erenumab. Cephalalgia 2018;38:1622–31.
  16. Shapiro RE, et al. CGRP monoclonal antibody use and patient-reported improvement of migraine: Results of the OVERCOME study. Migraine Trust Symposium; October 3-9, 2020; Virtual.
  17. Torres-Ferrús M, et al. The impact of anti-CGRP monoclonal antibodies in resistant migraine patients: A real-world evidence observational study. J Neurol 2021;268:3789–98.
  18. Lanteri-Minet M, et al. Effect of erenumab on functional outcomes in patients with episodic migraine in whom 2-4 preventives were not useful: Results from the LIBERTY study. J Neurol Neurosurg Psychiatry 2021;92:466–72.
  19. Ornello R, et al. Comparing the relative and absolute effect of erenumab: Is a 50% response enough? Results from the ESTEEMen study. J Headache Pain 2022;23:38.
  20. Altamura C, et al. When should we consider chronic patients as non-responders to monoclonal antibodies targeting the CGRP pathway? J Neurol 2022;269:1032–4.
  21. Martelletti P, et al. My Migraine Voice survey: A global study of disease burden among individuals with migraine for whom preventive treatments have failed. J Headache Pain 2018;19:115.
  22. Evers S, et al. Clinical characteristics, treatment satisfaction and barriers to treatment for patients with migraine: Results from OVERCOME (EU), the European Observational Survey of the Epidemiology, Treatment and Care of Migraine. The International Headache Congress –IHS and EHF Joint Congress; Septermber 8-12, 2021; Virtual.