Diagnosis and management of migraine in adults: a population-based study in England

Background Previous work has highlighted that migraine is underdiagnosed and undertreated in primary care.

Aim To characterise diagnosis and treatment patterns among patients with migraine in England.

Design & setting A retrospective cohort study using the Clinical Practice Research Datalink Aurum linked to the 2019 Index of Multiple Deprivation dataset.

Method The study cohort included patients presenting to general practices with migraine at age≥18 years from September 2012 to May 2023 (index event). Prescribed medications 12 months after index were compared across sociodemographic stratifications (age, sex, ethnicity, and deprivation). Medication overprescription was defined as≥10 days’ (opioids/triptans) or≥15 days’ (analgesics/antipyretics/NSAIDs) supply in 3 consecutive months.

Results 1,534,807 patients with any headache/migraine were observed attending primary care in England. 876 233 (57.1%) were coded with undifferentiated/unclassified headache and 606 928 (39.5%) with a primary headache disorder. Migraine was the most coded primary headache disorder, with 476 191 adults (78.5%), constituting the final sample used for subsequent analyses. Only 36.5% of the migraine cohort were prescribed preventive medication. 17.9% of those prescribed amitriptyline, 31.3% prescribed propranolol, and 31.2% prescribed topiramate reached SIGN 155/NICE CKS recommended doses. 62.6% of the migraine cohort were prescribed an acute medication: triptan (36.6%), opioid (9.6%). 23.6% of triptan users and 44.3% of opioid users exhibited medication overprescription, consistent with the ICHD-3 medication overuse definition.

Conclusion The majority of headache presenting to primary care remains undifferentiated/unclassified. Only one-third of patients diagnosed with migraine receive triptans or preventive medication. Acute medication overprescription is common and preventive medicines are poorly optimised.