How Migraine Is Treated After Diagnosis in the US: What a 154,353-Person Study Found

What Happens After a Migraine Diagnosis?

More than 10% of adults in the United States live with migraine, but there has been little recent large-scale data on what happens to people in the first few years after they are diagnosed. Who makes the diagnosis, what medications people receive, and how often those medications are actually designed for migraine are basic questions that hadn't been answered well with current data.¹

The Migraine Insights in Diagnosis and Treatment (MIND) study, published this week in Headache, looked at insurance records for 154,353 US adults with a new migraine diagnosis and followed what they were prescribed over the next three years. The results show that many people were given medications that aren't specific to migraine, including opioids and butalbital, while far fewer received migraine-specific treatment.¹

How the Study Worked

MIND is a retrospective cohort study that used the Optum Market Clarity database, a large US database of insurance claims linked to medical records. The researchers identified adults whose first recorded migraine diagnosis fell between July 2018 and June 2021.¹

To make sure these were truly new diagnoses, people had to have at least 12 months of insurance records before diagnosis with no migraine diagnosis and no migraine-specific medications. They also needed at least 36 months of continuous coverage afterward, so their prescriptions could be followed for three full years.¹

Of 911,128 people newly diagnosed with migraine in the database, 154,353 met every requirement. Their average age was 46.1 years, 81.1% were women, and 66.3% had commercial insurance. All of the analyses were descriptive, meaning the researchers reported what happened without testing what caused it.¹

These rates matter for treatment choices. Some preventive medications also treat anxiety, depression, or sleep problems, and others can make them worse, so these conditions are part of choosing the right treatment.

Who Made the Diagnosis

Primary care clinicians made almost half of the first migraine diagnoses. Neurologists made fewer than 1 in 5. Nearly 9 in 10 diagnoses happened in outpatient settings such as clinics and offices, rather than in a hospital or emergency department.¹

Only 16.2% of people had a diagnostic test within 30 days before or after their diagnosis.¹ Migraine is diagnosed from a person's history and examination, and most people with typical migraine don't need testing, so a low rate here isn't necessarily a problem.

The large share of primary care diagnoses is the more important finding. It means most people's early treatment is shaped by clinicians who see many conditions and may have had little training in headache medicine. Coming to that first visit prepared helps, and our appointment summary sheet puts your attack frequency, medications, and what has or hasn't worked on one page.

Acute Treatment: What People Took for Attacks

Within three years of diagnosis, 72.1% of people filled at least one prescription for a migraine medication. Of the whole group, 61.0% filled a medication for treating migraine attacks.¹

Among people who received acute treatment, the first prescriptions were most often a nonsteroidal anti-inflammatory drug (NSAID), at 62.8%, followed by a triptan, at 35.0%.¹

NSAIDs are a reasonable first step for many people, and they work well for some migraine attacks. Our review of over-the-counter painkillers compared with gepants and lasmiditan covers how they compare. Still, triptans have been the standard migraine-specific acute treatment for decades, and only about a third of people who received acute treatment started with one. Our complete guide to triptans explains the options and how to use them.

Opioids and Butalbital

The most concerning numbers in the study involve opioids and butalbital. In the three years after their migraine diagnosis, 71,199 people (46.1%) filled at least one opioid prescription, and 19,359 people (12.5%) filled a prescription for butalbital.¹

The opioid number needs some context. Insurance claims record that a prescription was filled, not why it was written. Some of these opioids were likely prescribed for other reasons, such as dental work, surgery, or an injury. Butalbital is different, because it is used almost entirely for headache.

Even with that caveat, the numbers are high. Opioids and butalbital are not recommended as routine migraine treatment. Both are strongly linked to medication overuse headache, where frequent use of acute medication makes headaches more frequent. A large international survey we covered recently found that people with migraine who use opioids for migraine report more disability.

Prevention: Who Got It and What They Got

Within three years, 40.6% of people filled a prescription for a migraine preventive. Among them, the first preventive was most often a beta blocker, such as propranolol (Inderal), at 23.2%, or an anticonvulsant, such as topiramate (Topamax) or valproate (Depakote), at 21.6%.¹

Migraine-specific preventives were rarely the first choice. CGRP monoclonal antibodies, such as erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality), were the first preventive for 8.1%. Preventive gepants, such as atogepant (Qulipta) and rimegepant (Nurtec ODT), were first for only 1.2%.¹

Starting with an older preventive isn't wrong in itself. Beta blockers and topiramate have good evidence, and insurers often require people to try them first. Our overview of migraine preventive medications compares the options, and the new AAN and AHS prevention guideline explains where CGRP-targeted treatments now fit.

The study can't tell us how many people needed prevention and didn't get it, because claims data doesn't include how many migraine days each person had. Even so, a 40.6% prevention rate next to a 46.1% opioid rate suggests that many people may have been treating frequent attacks with acute medications instead of preventing them. We've written before about how undertreating migraine can raise the risk of it becoming chronic.

What This Study Can't Tell Us

MIND describes prescribing patterns in a very large group, but insurance claims have built-in limits.

The Pfizer connection is a possible conflict of interest, since a finding that migraine-specific drugs are underused supports the case for drugs the company sells. That doesn't make the numbers wrong. The data came from a large independent claims database, and the analysis was purely descriptive, which leaves little room to shape the results. The limitation to keep in mind is the interpretation, not the counts.

What This Means for You

If you've recently been diagnosed with migraine, these results are a useful checklist for your own care.

The Bottom Line

This is one of the largest recent looks at how migraine is treated in the US in the years right after diagnosis. Most people received some kind of treatment, but much of it wasn't designed for migraine. Opioids and butalbital were common, and the newer migraine-specific preventives were rarely the first choice. Claims data can't explain every prescription, but the overall pattern is consistent with what headache specialists have been saying for years. Many people with migraine are treated with medications that aren't specific to migraine, and better education for clinicians and patients could change that.¹