Migraine affects at least 39 million US adults, according to the Association of Migraine Disorders,¹ causing lost workdays, time away from family, and other quality of life issues. Worldwide, about 10% of people are affected by migraine and women are three times as likely to be affected as men.²

As dismal as some of the statistics are, the outlook for patients has brightened considerably in recent years, due to several factors.

Practical Pain Management (PPM) spoke to Deena Kuruvilla, MD, FAHS, medical director of the Westport Headache Institute in Westport, CT, chair of the women’s health section for the American Headache Society, and a member of the executive board of the Association of Migraine Disorders, to provide an update on these key developments.

Understanding Migraine Pathways
Deena Kuruvilla, MD, FAHS

PPM: How has the understanding of migraine changed recently?

Dr. Kuruvilla: I think migraine is much more recognized now as a disease. Prior to [several] new treatment approaches coming out in 2017, 2018, people bypassed or passed off migraine as just a headache. Many doctors and loved ones didn’t recognize migraine as a disease. They’d say, ‘It’s a headache, you should be able to get over this.

PPM: What moved that needle, from viewing migraine as a minor issue to a disease to be taken seriously?

Dr. Kuruvilla: Migraine is much more understood than even 5 years ago. I think it also has to do with the fact that we now have preventive treatments that target a specific migraine pathway. It isn’t just the availability [of these treatments] but the fact that these medications were specifically made for migraine.² Prior to 2017 and 2018, we used other things that had been developed for other medical conditions to prevent migraine.

For instance, we used blood pressure medications, seizure medications, and antidepressants. Now, we have a whole class of treatments that are injected, as well as oral treatments that target a specific mechanism known to cause migraine. (See also, tools for migraine diagnosis.)

There’s also more research now. We are identifying different phases of migraine. With these new treatments, for example, we can target the prodrome phase. That’s the first phase of migraine, kind of like a warning that the migraine is coming. Maybe it’s neck pain or stiffness of the neck, anxiety, or depression. We are identifying dozens more [symptoms] than that.

We also have five FDA-cleared, non-invasive devices that work for migraine: Nerivio, Cefaly, gammaCore, eNeura TMS device, and Relivion.

PPM: What ongoing migraine research are you most excited about?

Dr. Kuruvilla: I’m involved in a study to better characterize a person with migraine. It is called the Migraine Clinical Outcome Assessment System, or MICOAS.⁵ We are going to be starting a study with Wake Forest University as well to study mindfulness in people with migraine.

PPM: Migraine seems to be increasing in the US. Have you experienced this in your clinical work?

Dr. Kuruvilla: I do think the rates are going up. People are ever-changing. I’ve noted in my practice that the children and grandchildren of my migraine patients have worse disease, so that can become magnified. And genetics is a huge part.

There is a higher percentage of obesity and mental health illness (eg, anxiety and depression), which are directly linked with migraine. Women with a higher BMI are significantly more likely to have migraine than those with a normal BMI. Sleep issues are greater than ever, and sleep is directly tied to migraine.

Difficult-to-Treat Migraine

PPM: What hope is there for the subset of patients with difficult-to treat-migraine?

Dr. Kuruvilla: In addition to layering preventive treatment and layering as-needed treatment, the key to successful care for people with chronic migraine is really making it multidisciplinary. Whether someone has a history of trauma or depression, we have to make sure we have a psychologist on board. Cognitive behavioral therapy, mindfulness, meditation, and biofeedback have been studied in clinical trials to treat people with migraine. There is evidence for acupuncture as well.⁶

PPM: What advice do you have for clinicians who may be discouraged about a lack of success in treating migraine?

Dr. Kuruvilla: The biggest mistake I see is not asking for help. Develop a relationship with a headache specialist for guidance, even if the specialist can’t see the patient because they are usually booked out.

Layering treatment is good. I see healthcare providers starting a treatment, stopping a treatment. Often, they have to layer treatment.

For example, just because you start a medication, and it’s not working, some providers are inclined to stop and that’s not what we want to do. Add on a treatment instead of stopping. Think about the new medications, but sometimes the old [may be what a patient needs].

When to Refer for Migraine

PPM: How can a clinician in say, primary care, who is not a headache or migraine specialist, decide when it’s time to refer?

Dr. Kuruvilla: In general, providers should have a higher threshold to refer. There are a very limited number of headache specialists and neurologists across the United States. Editor’s Note: According to the American Headache Society, there are fewer than 700 United Council for Neurologic Subspecialities specialists in the US.


  1. Association of Migraine Disorders. Education for Patients and Medical Professionals. Available at: www.migrainedisorders.org/education/ Accessed December 12, 2022.
  2. Walter K. What is migraine? JAMA. 2022;327(1):93. doi:10.1001/jama.2021.21857
  3. Sandoe C, Lipton R, Buse D, et. al. Interictal burden of migraine: correlations with other measures of migraine burden and effects of galcanezumab migraine-preventive treatment. Neurology. April 13, 2021; 96(15 Supplement).
  4. Weiss C. Mayo Clinic Q & A: Treatment Options for Migraine. August 7, 2022. Available at: https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-treatment-options-for-migraine/ Accessed Dec. 12, 2022.
  5. Hoffman M. Neurology Live: The MiCOAS Project and the importance of patient-reported outcomes. June 10, 2022. Available at: www.neurologylive.com/view/micoas-project-importance-patient-reported-outcomes-migraine Accessed Dec. 12, 2022.
  6. Li YX, Xiao XL, Zhong DL, et al. Effectiveness and safety of acupuncture for migraine: An overview of systematic reviews. Pain Res Manag. 2020;2020:3825617. Published 2020 Mar 23. doi:10.1155/2020/3825617