Migraine is a common and debilitating neurological disorder that significantly impacts daily functioning and quality of life (QoL). Despite its high prevalence, migraine remains underdiagnosed and undertreated, particularly in the primary care setting. In an interview with MIMS Doctor, Professor Lawrence Wong, Emeritus Professor of the Department of Medicine and Therapeutics, Chinese University of Hong Kong, highlighted the importance of early diagnosis and timely intervention in migraine management. He noted that calcitonin gene-related peptide (CGRP)–targeted therapies, specifically oral gepants, offer a convenient and effective option for primary care providers (PCPs) to prevent migraine attacks and reduce the long-term burden of the condition.
Unmet needs in diagnosis and management
The Global Burden of Disease study 2019 (GBD2019) identified migraine as the second leading cause of disability worldwide, and the leading cause of disability among women aged 15–49 years. In Hong Kong, migraine is relatively common, with a reported prevalence of 10.3 percent among Chinese women. [J Headache Pain 2020;21:137; BMJ Open 2024;14:e084228]
“Migraine is often misdiagnosed as a common headache, particularly in primary care,” highlighted Wong. “The Chinese term for migraine, which literally translates to ‘one-sided headache’, has led some PCPs to mistakenly believe that bilateral headache cannot be a symptom of migraine.”
“Many patients, even those with severe symptoms, don’t realize they are experiencing migraines and often mistake the condition for tension-type headaches,” Wong added. This misunderstanding, combined with limited awareness of newer treatment options, leads to delayed diagnosis and prolonged, unnecessary suffering,” he added. “One of my patients had been living with daily headaches for 20 years, relying solely on daily use of over-the-counter [OTC] analgesics. Once he received an accurate diagnosis and the right treatment for migraine, he made a full recovery and became analgesic-free. He later shared that he hadn’t realized he had been functioning at just 70 percent of his capacity for all those years until his migraine was adequately treated.”
These observations reflect the findings of a Korean study, which showed an average of 10.1 years from symptom onset to a confirmed migraine diagnosis, likely due to limited awareness of migraine features among patients and nonspecialist physicians. On average, patients had visited 3.9 hospitals before receiving care at a specialized headache clinic run by neurologists. About half (55.6 percent) of the patients believed that unilateral headache was a unique feature of migraine. [J Headache Pain 2021;22:45; Headache 2011;51:232-236]
“Unlike tension-type headaches, migraines are typically more severe, last longer, from several hours to days, and are often accompanied by disabling symptoms, such as nausea, vomiting and sensory disturbances. These symptoms can severely disrupt work, school, and daily activities, ultimately diminishing a person’s QoL,” explained Wong. [J Headache Pain 2021;22:45; J Headache Pain 2023;24:92; J Clin Med 2022;11:6925]
“Therefore, accurate and timely diagnosis is crucial, especially now that effective treatments are available,” he emphasized.
How to diagnose migraine?
The International Classification of Headache Disorders, 3rd edition (ICHD-3), diagnostic criteria are the gold standard for diagnosing migraine. It is essential for PCPs to recognize the distinguishing features of migraine, particularly its two main subtypes: migraine without aura and migraine with aura. (Table 1) Many patients with migraine also experience a prodromal phase (before the headache) and/or a postdromal phase (after the headache). Common symptoms include hyperactivity, hypoactivity, depression, food cravings, repetitive yawning, fatigue and neck stiffness or pain. [Cephalalgia 2018;38:1-211]
Migraine with aura involves transient neurological symptoms that usually precede or accompany the headache. Visual aura is the most common type, occurring in >90 percent of patients with aura, although sensory and speech disturbances can also occur. (Table 1) [Cephalalgia 2018;38:1-211]
“While specialists routinely use the ICHD-3 criteria to diagnose migraine, most PCPs do not,” pointed out Wong. “However, with appropriate education, such as through continuing medical education [CME] programmes, PCPs are fully capable of effectively diagnosing and managing migraine, especially since effective oral medications are now available. This should not be the sole responsibility of specialists.”
When to refer patients for specialist care?
“If a migraine is particularly severe, causes significant functional impairment, or fails to respond to optimal standard treatment, the patient should be referred to a neurologist or headache specialist,” advised Wong. “Referral is also warranted when red flags are present, as these signs may indicate secondary causes, such as brain tumours, meningitis, or cerebrovascular disease, and require urgent evaluation.” (Table 2) [Semin Neurol 2010;30:74- 81; Life (Basel) 2022;12:142; Neurology 2019;92:134-144]
Oral gepants for targeted migraine prevention
Prophylactic treatment should be considered when migraines are frequent (4–14 monthly migraine days [MMDs] for episodic migraine or ≥15 monthly headache days [MHDs] for chronic migraine), severe (3–4 intense attacks/month), or significantly impact daily life. “It’s not just about the number of days,” explained Wong. “If the migraines are severe or disrupt daily function, prophylactic treatment should be considered. The goal is to give patients as many headache-free days as possible — ideally, every day should be headache-free.” [Headache 2024;64:333-341]
Small-molecule CGRP receptor antagonists (gepants) represent a major breakthrough in both acute and preventive treatment of migraine. These agents work by blocking the CGRP receptor, thereby inhibiting trigeminovascular nociception — a key mechanism in migraine pathophysiology. [J Oral Facial Pain Headache 2023;37:25-32]
The American Headache Society (AHS) now recommends CGRP-targeted treatments, including gepants, as first-line options for migraine prevention, without requiring prior failure of other preventive therapies. [Headache 2024;64:333-341]
The efficacy, tolerability and safety of gepants have been well established in clinical trials and are further supported by real-world clinical experience. In randomized phase III trials (eg, ADVANCE, ELEVATE and PROGRESS) involving patients with episodic (4–14 MMDs) or chronic (≥15 MHDs, ≥8 MMDs) migraine, once-daily oral gepant as preventive therapy markedly reduced migraine frequency and improved patients’ functioning within 4 weeks of initiation vs placebo. Furthermore, patients experienced sustained benefits with continued treatment. Treatment-related adverse events primarily involved constipation (7.4 percent) and nausea (2.2 percent). [Neurology 2025;104:e210212; Cephalalgia 2025;45:1-12; J Headache Pain 2025;26:122]
“In our clinical experience, most patients respond to gepants within the first month of treatment initiation,” remarked Wong. “If migraine symptoms do not improve after 2–3 months, the treatment may be ineffective and should be reassessed. Overall, gepants are well-tolerated. We’ve observed mild constipation in some patients, but this has not resulted in treatment discontinuation.”
Practical advantages for primary care
“With oral gepants currently approved for migraine prophylaxis in Hong Kong, PCPs are now better equipped to manage migraine without the logistical challenges of storing and administering injectables,” said Wong. “Furthermore, oral gepants may offer added flexibility for women planning pregnancy as they can be discontinued shortly before conception, while injectable therapies require a washout period of about 6 months.” [Lancet Neurol 2022;21:284-294]
Summary
Accurate diagnosis of migraine requires thorough understanding of its symptoms and the ability to recognize red flags that may signal secondary causes. With appropriate training and clinical awareness, PCPs can confidently diagnose migraine, initiate preventive treatment, and know when to refer for specialist care. The availability of oral gepants empowers PCPs to manage migraine more proactively and effectively. Timely intervention not only improves outcomes, but can also be life-changing for many individuals living with migraine.
