Case Study

The chronic condition we should be talking about: Challenges and opportunities in migraine care

While a growing number of patients in the United States struggle with migraine, the chronic condition is frequently misdiagnosed or met with insufficient and fragmented treatment. Dive into this case study to understand the challenges faced by migraine patients at key points of the care journey and learn how providers can make a difference.


Migraine data spotlight

A growing number of patients in the United States are struggling with migraine. Migraine patients deal with a variety of challenges throughout the patient care pathway that can cause insufficient care. This can lead to adverse impacts on patients, employers, and health systems.


Estimated number of people in the U.S. suffering from migraine.5


Estimated annual direct migraine medical costs in the U.S.6


Total estimated indirect cost associated with migraine in the U.S., with 81% due to absenteeism (defined as full days of productive workforce loss).7


Migraine is the fifth leading cause of disability in the U.S. (measured in number of years).8


How Pfizer and Optum identified gaps in migraine care

Pfizer and Optum1 worked together to collect provider insights and identify gaps in care within the current workflows for migraine screening and management in the primary care setting. Pfizer partnered with Optum across three regions — the West, Midwest, and Northeast — to understand providers’ approaches to migraine care and identify opportunities to optimize the migraine patient journey. Although Optum providers were interviewed, these insights are applicable to all health systems looking to improve their migraine care strategy. As part of this process, Pfizer and Optum:

1. Interviewed clinicians and other subject matter experts in primary care and neurology at Optum sites to identify current migraine patient management workflows and care gaps.

2. Facilitated a joint design workshop with migraine subject matter experts to address the care gaps identified in interviews. As a result of the design workshop, Pfizer and Optum developed several migraine resources.

3. Used these insights to develop a toolkit to help health systems and providers more efficiently diagnose and treat patients with migraine, as well as migraine education materials to help patients better understand migraine symptoms and treatments.

The following sections outline what Pfizer and Optum found to be the most critical challenges to effective migraine care — and potential solutions to those challenges.

Because no diagnostic test can positively identify migraine, it can be a challenge to diagnose. While a few migraine screening tools, such as ID-Migraine,9 have been developed, they are not widely used in primary care workflows. According to provider interviews facilitated by Optum, primary care providers (PCPs) instead make initial diagnostic decisions based on their own clinical experience with migraine. This method is not always effective, because short appointment times can hinder provider-patient dialogue and limit PCPs’ ability to take comprehensive patient histories.1

When patients are unsure about the symptoms of migraine, the difference between headache and migraine, or whether tailored migraine treatment options are available, they may normalize their symptoms or attempt to use over-the-counter medications for pain relief.10 A recent survey showed that 45.5% of people hesitated to seek care for migraine over one year, and 41.8% did not seek care at all.10 Their reasons varied. Some were unsure their headaches were serious enough to warrant care (29.4%), others were concerned that healthcare providers wouldn’t take their concerns seriously (34.9%), and nearly one-third were concerned about the cost of care (28.7%).10

While PCPs may sometimes have limited experience with migraine diagnosis and treatment, they are also the most likely provider to see migraine patients pre-diagnosis. It is essential that PCPs have access to the right tools to recognize when a patient might be experiencing migraine, properly diagnose the condition, and educate patients.1

Recommendation: Consider integrating a standardized approach to the diagnostic assessment of migraine patients.

  • Incorporate screening and educational tools into the workflow that facilitate patientprovider communication about migraine.
  • Decide who will capture patients’ migraine history and impacts on quality of life, where in the workflow they will capture that information, and how they will ensure it is included in patient records. 
  • Develop a way to make patients’ migraine information readily available to inform treatment and management discussions.

Each migraine and each migraine patient may respond differently to treatments. As migraine treatment continues to advance, PCPs may benefit from system-supported educational updates about acute and preventive migraine management options, as well as how to apply evidence-based migraine treatment guidelines when making decisions.1

According to provider interviews facilitated by Optum, PCPs may rely on two to four familiar migraine treatment options. When those medications don’t work, PCPs will often refer to a specialist, which can result in patients waiting months for treatment. This dynamic leads to undertreatment, and 74.1% of surveyed migraine patients reported unmet needs related to inadequate acute treatment.11 Even when PCPs feel comfortable with the range of available treatment options, finding the right treatment plan for a patient can take time, often requiring a stratified approach and ongoing communication to assess treatment effectiveness. There is no right way to follow up with patients over time, so tools that enable a two-way dialogue between patients and providers about treatment plans are beneficial.

Recommendation: Consider prioritizing PCP education on migraine management and develop acute and preventive migraine treatment plans.

  • Ensure providers that manage migraine patients are educated on evidence-based guidelines for treatment. Consider updating order sets or treatment pathways to include all available treatment options. 
  • Identify providers, NPs, PAs or other care team members outside of the neurology office who are comfortable treating migraine, and ensure PCPs know how to access their services. 
  • Consider using a digital or printed tool to encourage shared decision-making between patients and providers on migraine treatment and management plans.

There is a lack of guidance about what and how to communicate across care settings to manage migraine patients.1 For example, while emergency departments manage individual migraine attacks, they may not coordinate care to ensure migraine patients have follow-up appointments for ongoing management.

Although most migraine patients are seen in the PCP office, without education, PCPs may struggle to establish a comprehensive provider-patient dialogue about migraine management over time. Patients who are referred to neurology may also experience extensive wait times when treatment could have been managed through other care settings.

Recommendation: Provide clear guidance on transition of care and followup communication for ongoing management of migraine patients.

  • Establish health system guidance for the transition of migraine patient care from PCP to PCP, PCP to specialty care, ED to PCP, or ED to specialty care. 
  • Ensure providers know which elements to document in the medical record when collecting a patient’s history of migraine and response to prescription and over-thecounter treatments. 
  • Consider digital solutions such as telehealth, e-visits, or other ways to engage with migraine patients to effectively and efficiently assess migraine treatment.

3 insights to elevate your migraine management strategy

Insight 1: Rather than reinventing the wheel, apply validated primary care protocols and experience in chronic disease management to migraine management.

Primary care providers often rely on their personal experience managing migraine, leading to missed care improvement opportunities, as well as inconsistent standards across providers with different experiences and treatment backgrounds. This doesn’t mean health systems need to create a new migraine care protocol themselves. Instead, existing, clinically-validated migraine care protocols are available for health systems to implement.

While standardizing protocols may seem daunting, health systems can apply their experiences standardizing care for other chronic diseases to migraine management. Consider which chronic disease management structures and strategies are already in place across different disease states that may scale to migraine management. This could include leveraging different care team members to support PCPs, creating processes to refer patients to ongoing support within and outside the system, or increasing education and awareness of screening protocols to support diagnosis. The most efficient organizations will identify existing processes and resources that can work for their migraine strategy.    

Insight 2: Because PCPs are already overburdened, embed new migraine strategies that make it easier to manage migraine.

Implementing new migraine strategies requires PCPs to be open to changing their behavior. Since they have a lot on their plates, skepticism among PCPs about process changes is understandable. Any system-wide migraine strategy must consider how to make changes easy for PCPs to adopt. Consider the following strategies:

  • Embed nuanced migraine assessment and treatment tools into the electronic health record (EHR) that don’t make PCPs feel distracted or impeded when making a diagnosis. Consider an EHR-embedded tool that helps providers make treatment decisions and provides migraine diagnosis and treatment guidelines as needed. 
  • Incorporate migraine-specific training into standing education sessions. 
  • Ensure that migraine information is endorsed or delivered by a headache specialist or neurologist, as they are viewed as authorities for migraine guidance. 
  • Enlist patients to be engaged and active in their own migraine management through patient education and symptom tracking tools so they come to appointments with information about the severity and frequency of their symptoms. 
  • Evaluate strategies to deploy nursing staff and advanced practice providers (APPs), who may have more availability in their schedules than physicians. For example, to facilitate PCP capacity, assign patients with established diagnoses and treatment plans to an APP for ongoing care management.

Insight 3: Help patients participate in managing their migraine by educating them early and often.

Finding the right treatment plan for each patient can take time, and a lack of patient awareness about migraine diagnosis and treatment may cause further delays in care. Providing education materials early — either during triage via a nurse line, at the first primary care visit, or through the patient portal — can help patients describe their migraine experiences, advocate for proper migraine care, and reduce hesitancy to trying new treatments.

Patient education is also essential to any treatment plan that helps patients proactively manage their own condition, which boosts treatment adherence and improves patient outcomes. In addition to face-to-face education efforts, providers might use supplementary patient education materials, including:

  • A digital or printed migraine treatment plan listing the patient’s acute and preventive medications, their potential side effects, and criteria for when to call their PCP.
  • Migraine tracking tools, such as migraine diaries that track headache days, triggers, symptoms, and treatment effectiveness.
  • Patient-centered videos or handouts with details about migraine symptoms and treatment.

Sponsor highlight: Tools to advance your system migraine strategy

Improving migraine care from diagnosis to management may seem overwhelming for health systems given the bulk of other responsibilities on their plate. This is why Pfizer and Optum developed a suite of resources to help health systems better diagnose and treat migraine throughout the care pathway with the Migraine Health System Toolkit.

How the Migraine Health System Toolkit addresses gaps in migraine care

Gaps in migraine careToolkit solutions
  • Patients may lack awareness of migraine symptoms and treatment or management options.
  • Migraine patient education video includes four modules with an overview of migraine symptoms, treatment, and management options.
  • Limited care standardization can prolong care delivery and may lead to underdiagnosis of migraine.
  • Migraine pathway provides health systems with example strategies to enhance workflows and standardize care delivery.
  • Patients may lack a comprehensive symptom tracker, which can limit information for effective treatment plans.
  • Migraine management plan includes a patient support guide with information on diagnosis and treatment, a migraine diary, and the treatment plan to help patients track symptoms.

Learn more about the Migraine Health System Toolkit.

Liam Frieswick, Michaela Dipillo, and Jennifer Fierke contributed to the writing of this case study.

1 Note: Unless otherwise specified, all information in this case study came from Optum interviews with Optum providers.

2 Durham PL. CGRP-Receptor Antagonists – a Fresh Approach to Migraine Therapy? N Engl J Med. March 11, 2004.

3 Diagnosis. The Migraine Trust. Accessed March 7, 2024.

4 Maurya A, Qureshi S, Jadia S, et al. “Sinus Headache”: Diagnosis and Dilemma?? An Analytical and Prospective Study. Indian J Otolaryngol Head Neck Surg. January 19, 2019.

5 Law H, Chung MH, Nissan G, et al. Hospital Burden of Migraine in United States Adults: A 15-year National Inpatient Sample Analysis. Plast Reconstr Surg Glob Open. April 23, 2020.

6 Gooch CL, Pracht E, Borenstein AR. The Burden of Neurological Disease in the United States: A Summary Report and Call to Action. Ann Neurol. April 2017.

7 Hawkins K, Wang S, Rupnow MFT. Indirect Cost Burden of Migraine in the United States. J Occup Environ Med. April 2007.

8 Mokdad AH, Ballestros K, Echko M, et al. The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States. JAMA. April 10, 2018.

9 Lipton RB, Dodick D, Sadovsky R, et al. A Self-Administered Screener for Migraine in Primary Care: The ID Migraine Validation Study. Neurology. August 2003.

10 Shapiro RE, Nicholson RA, Zagar AJ, et al. Reasons for Hesitating to Consult for Migraine Care: Results of the OVERCOME (US) Study. Headache. June 3, 2021.

11 Lipton RB, Munjal S, Buse DC, et al. Unmet Acute Treatment Needs From the 2017 Migraine in America Symptoms and Treatment Study. Headache. August 13, 2019.

About the sponsor

Breakthroughs That Change Patients’ Lives. At Pfizer, we apply science and our global resources to bring therapies to people that extend and significantly improve their lives. We strive to set the standard for quality, safety and value in the discovery, development and manufacture of health care products, including innovative medicines and vaccines. Every day, Pfizer colleagues work across developed and emerging markets to advance wellness, prevention, treatments and cures that challenge the most feared diseases of our time. Consistent with our responsibility as one of the world's premier innovative biopharmaceutical companies, we collaborate with health care providers, governments and local communities to support and expand access to reliable, affordable health care around the world. For more than 170 years, we have worked to make a difference for all who rely on us. 

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This report is sponsored by Pfizer, an Advisory Board member organization. Representatives of Pfizer helped select the topics and issues addressed. Advisory Board experts maintained final editorial approval, and conducted the underlying research independently and objectively. Advisory Board does not endorse any company, organization, product or brand mentioned herein.

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This case study is sponsored by Pfizer. Advisory Board experts conducted the underlying research independently and objectively.

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  • Hospitals and health systems
  • Physicians and medical groups

  • You will learn about gaps in care within the current workflows for migraine screening and management in the primary care setting.
  • You will have recommendation checklists to guide improvements to your migraine treatment plans in primary care.
  • You will have access to tools and resources in the Migraine Health System Toolkit that address gaps in migraine care.



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