Physicians across Southeast and East Asia describe significant gaps and inequalities in migraine care in the region, driven by specialist shortage, diagnostic delay, reliance on nonspecific medications, and limited access to migraine-specific therapies, as reflected in survey data from the SEALANT study.
Diagnostic challenges
According to 70 percent of respondents, there were not enough neurology/headache clinics in their country. This perceived shortage declined with increasing national income level: 87.2 percent in lower-middle income countries (LMIC), 65.8 percent in upper-middle income countries (UMIC), and 51.1 percent in high income countries (HIC) (p<0.001). [J Headache Pain 2026;27:47]
The respondents noted that approximately 60 percent of patients received correct migraine diagnosis before specialist consultation, and 44.9 percent of patients were believed to experience diagnostic delays exceeding 1 year.
The consultation time allotted for each patient was insufficient, with 59.4 percent of respondents reporting that they could spend only a maximum of 15 min per visit. Despite this, 58.3 percent said their patients waited less than 1 week on average for an appointment.
During consultations, pharmacological treatment was the most frequently discussed (86 percent), followed by general migraine education including pathophysiology, triggers, and nonpharmacological strategies (75.7 percent), while disease burden was least discussed (68.1 percent).
Treatment gaps
Generally, survey responses indicated that in the management of acute attacks in the region, migraine-specific therapies were underused in favour of nonspecific analgesics, with opioids remaining widely available and prescribed across all national income settings.
Only 28.5 percent of respondents indicated that their patients used migraine-specific medications such as triptans. Meanwhile, 76.2 percent still prescribed opioids—which are not recommended by any major treatment guidelines for migraine management—with 7.8 percent of them representing frequent prescribers.
Notably, in HIC, there was a higher proportion of respondents who prescribed triptans (56.5 percent) and who reported never prescribing opioids (46.7 percent) compared with those in UMIC and LMIC (between 39 percent and 22.1 percent and between 22 percent and 22.7 percent, respectively; p<0.001 for both).
The respondents identified several challenges associated with the use of acute medications, such as cost (32.8 percent), insufficient efficacy (27.5 percent), and adverse effects (22.5 percent). Limited efficacy was the main concern in HIC, whereas cost was the primary issue in LMIC and UMIC.
In terms of preventive medications, 60 percent of respondents stated that they “always” or “usually” prescribed these medications. Reasons for not initiating preventive therapy included tolerability concerns (29.1 percent), cost (28.6 percent), and limited efficacy (26.5 percent). Cost was the major concern for LMIC.
When asked about newer migraine-specific preventive medications, most respondents believed that they were clinically effective (77.1 percent) and have fewer side effects than conventional options (59.7 percent) and felt that they should be reimbursed (69.8 percent). There was a notable subset of respondents who, while acknowledging the drugs’ efficacy, viewed such medications as not cost-effective. This finding was consistent across all national income groups.
Addressing unmet needs
“Based on physicians’ perspectives, the SEALANT study identifies substantial unmet needs in migraine diagnosis and management across Southeast and East Asia,” said first author Dr Wanakorn Rattanawong from King Mongkut’s Institute of Technology Ladkrabang, Bangkok, Thailand, and colleagues.
The survey data “reflect perceived challenges in routine clinical practice and highlight areas where targeted education, health-system strengthening, and context-appropriate policy measures may help improve migraine care delivery in the region,” Rattanawong and colleagues added.
At the clinical level, targeted training programs for general practitioners and nonheadache specialists may help facilitate early recognition and diagnosis of migraine, particularly in settings with limited specialist availability, the authors pointed out.
“At the policy level, Ministries of Health may consider integrating migraine prevention and management into national disease strategies, with emphasis on early diagnosis, appropriate use of migraine-specific therapies, and prevention of medication overuse headache,” they continued.
Rattanawong and colleagues added that specialist access and consultation efficiency could be optimized by establishing standardized referral pathways between primary care and neurology/headache services. Meanwhile, inappropriate opioid use in migraine should be reduced with opioid prevention programs and guideline-aligned prescribing.
“Finally, reimbursement approaches tailored to local healthcare systems may help improve access to migraine-specific preventive treatments while keeping costs manageable,” they said.
The survey included responses from 686 physicians (mean age 39 years, 79.8 percent neurologists) involved in migraine care from Indonesia, Laos, Malaysia, Philippines, Singapore, Taiwan, and Thailand. Majority of them were neurologists (79.8 percent), 6.3 percent were general practitioners, 6 percent were internists, and 4.5 percent were headache specialists. Most of the physicians (69.1 percent) were from UMIC.