Bridging the Gap Between Male, Female Migraine Diagnosis

Migraine more commonly affects women than men at a rate of 18% vs 6%, though symptoms and treatment are similar for each sex.¹ Despite the difference in prevalence rates, migraine has been ranked as the third most common disease worldwide in both sexes.²

Men and women with migraine alike experience diminished quality of life, as well as a range of problems pertaining to occupational, familial, and social functioning.¹ Recent studies, however, suggest that not only are men less likely to suffer from migraine, but they may also be less likely than women to receive a proper diagnosis.

Research published in Headache in May 2016 found that female sex was one of the predictors of receiving an appropriate diagnosis of chronic migraine, echoing findings of a 2013 study of episodic migraine that showed that women were far more likely to receive a correct diagnosis than men (OR 4.25; 95% confidence interval, CI, 1.61-11.2).^3,4 The 2016 study included data from 1254 participants with chronic migraine who were part of the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. The findings indicated an overall gap in migraine care — particularly for men. Of the 40.8% of men and women who consulted a health care provider for headache, 24.6% received a correct diagnosis. An accurate diagnosis was more likely for women (OR 1.93; 95% CI, 1.03-3.61) as well as for patients with worse migraine severity and those seeing a specialist (OR 1.25; 95% CI, 1.14-1.37 and OR 2.38; 95% CI, 1.54-3.69, respectively).

Notably, men are less likely to seek medical care for a variety of health complaints, including pain-related ones. A systematic review published in the Journal of Health Services Research & Policy in 2011, for example, reported on 5 studies that showed a greater likelihood of women consulting a physician for headache compared to men.⁵

It is also important to note that many women are in the care of an obstetrician-gynecologist (OB-GYN) during the years when migraine symptoms may be worse, presenting more opportunities in general for migraine to be diagnosed.⁶ OB-GYNs may also specifically “ask patients about a history of headaches because of the American College of Obstetrics and Gynecology (ACOG) warning against using estrogen in patients with migraine with aura,” said Mia Minen, MD, MPH, director of the NYU Langone Headache Center and assistant professor of neurology at NYU Langone Medical Center. “This may lead to more migraine diagnoses and also more referrals to neurology for migraine diagnosis and treatment,” she told Neurology Advisor.

Even when men with migraine do see a doctor, there is less of a chance that they will receive an accurate diagnosis. “I do not think clinicians have a gender bias, but they may be excessively reliant on an ‘index of suspicion’ driven by gender,” said Richard B. Lipton, MD, the Edwin S. Lowe professor and vice chair of neurology, professor of psychiatry and behavioral sciences, and director of the Montefiore Headache Center at the Albert Einstein College of Medicine in New York. “Clinicians know that migraine is more common in women than in men and may be predisposed to assign a migraine diagnosis to women with headache,” he told Neurology Advisor. He likens it to the barrier to diagnosis for cardiovascular disease in women, which may stem from clinicians’ awareness that it more commonly occurs in men.

Despite the observed disparity in diagnosis, there does not seem to be a treatment disparity between men and women. In the 2016 study, for instance, there were no predictors of proper treatment among patients who were already consulting a physician. “Once a diagnosis is made, men are likely to be treated appropriately — the barrier is at the level of diagnosis, not treatment,” according to Dr Lipton. He said that neurologists should keep in mind that although migraine is more common in women, it does occur in men. “It is much more common in men than primary headache disorders which show a male preponderance, such as cluster headache. For patients with long-standing, recurrent, disabling headache, migraine is a very likely diagnosis,” he said.

To promote change beyond the neurology clinic and further increase the chance of proper diagnosis and treatment for all patients with migraine, neurologists should collaborate with physicians of other specialties, such as “emergency medicine and primary care, to educate them about migraine diagnosis and treatment options,” advised Dr Minen. “In doing so, they can teach about the epidemiology of the disorder, including the fact that men suffer from migraines too,” she said.

References

1. Rossi P, Nappi G. Migraine in men: fact sheet. A publication to mark European Migraine Day of Action 2014. Funct Neurol. 2014; 29(3): 149–151.
2. Steiner TJ, Stovner LJ, Birbeck GL. Migraine: the seventh disabler. Headache. 2013;53(2):227-9.
3. Dodick DW, Loder EW, Manack Adams A, et al. Assessing Barriers to Chronic Migraine Consultation, Diagnosis, and Treatment: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. Headache. 2016 May 3; doi:10.1111/head.12774 [Epub ahead of print]
4. Lipton RB, Serrano D, Holland S, Fanning KM, Reed ML, Buse DC. Barriers to the diagnosis and treatment of migraine: effects of sex, income, and headache features. Headache. 2013; 53(1):81-92.
5. Hunt K, Adamson J, Hewitt C, Nazareth I. Do women consult more than men? A review of gender and consultation for back pain and headache. J Health Serv Res Policy. 2011 Apr; 16(2): 108–117.
6. Sacco S, Ricci S, Degan D, Carolei A. Migraine in women: the role of hormones and their impact on vascular diseases. J Headache Pain. 2012; 13(3): 177–189.