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 disabiliÂty worldwide, and the leading cause of disability among women aged 15–49 years. In Hong Kong, migraine is relativeÂly 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 primaÂry care,” highlighted Wong. “The Chinese term for migraine, which literally translates to ‘one-sided headache’, has led some PCPs to mistakenly believe that bilaterÂal headache cannot be a symptom of migraine.”
“Many patients, even those with seÂvere symptoms, don’t realize they are exÂperiencing 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 diagÂnosis and prolonged, unnecessary sufferÂing,” 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 miÂgraine was adequately treated.”
These observations reflect the findÂings 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 nonspecialÂist 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 headÂache was a unique feature of migraine. [J Headache Pain 2021;22:45; Headache 2011;51:232-236]
“Unlike tension-type headaches, miÂgraines 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 sympÂtoms can severely disrupt work, school, and daily activities, ultimately diminishing a person’s QoL,” explained Wong. [J HeadÂache Pain 2021;22:45; J Headache Pain 2023;24:92; J Clin Med 2022;11:6925]
“Therefore, accurate and timely diÂagnosis 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 feaÂtures of migraine, particularly its two main subtypes: migraine without aura and miÂgraine with aura. (Table 1) Many patients with migraine also experience a prodroÂmal phase (before the headache) and/or a postdromal phase (after the headache). Common symptoms include hyperactivity, hypoactivity, depression, food cravings, reÂpetitive yawning, fatigue and neck stiffness or pain. [Cephalalgia 2018;38:1-211]
Migraine with aura involves transient neurological symptoms that usually preÂcede or accompany the headache. Visual aura is the most common type, occurring in >90 percent of patients with aura, alÂthough sensory and speech disturbancÂes 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. “HowÂever, with appropriate education, such as through continuing medical education [CME] programmes, PCPs are fully capaÂble 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 cerebrovasÂcular disease, and require urgent evaluaÂtion.” (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 headÂache 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 treatÂment 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 anÂtagonists (gepants) represent a major breakthrough in both acute and prevenÂtive treatment of migraine. These agents work by blocking the CGRP receptor, thereby inhibiting trigeminovascular nociÂception — a key mechanism in migraine pathophysiology. [J Oral Facial Pain Headache 2023;37:25-32]
The American Headache SociÂety (AHS) now recommends CGRP-targeted treatments, including gepants, as first-line options for migraine preÂvention, 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 ranÂdomized phase III trials (eg, ADVANCE, ELEVATE and PROGRESS) involving patients with episodic (4–14 MMDs) or chronic (≥15 MHDs, ≥8 MMDs) miÂgraine, once-daily oral gepant as preÂventive therapy markedly reduced miÂgraine frequency and improved patients’ functioning within 4 weeks of initiation vs placebo. Furthermore, patients experiÂenced sustained benefits with continued treatment. Treatment-related adverse events primarily involved constipation (7.4 percent) and nausea (2.2 percent). [Neurology 2025;104:e210212; CephÂalalgia 2025;45:1-12; J Headache Pain 2025;26:122]
“In our clinical experience, most paÂtients respond to gepants within the first month of treatment initiation,” remarked Wong. “If migraine symptoms do not improve after 2–3 months, the treatÂment may be ineffective and should be reassessed. Overall, gepants are well-tolerated. We’ve observed mild constipaÂtion in some patients, but this has not reÂsulted in treatment discontinuation.”
Practical advantages for primary care
“With oral gepants currently apÂproved 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 concepÂtion, while injectable therapies require a washout period of about 6 months.” [Lancet Neurol 2022;21:284-294]
Summary
Accurate diagnosis of migraine reÂquires 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 confiÂdently diagnose migraine, initiate preÂventive 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.
