Migraine is a common neurological disorder that can severely diminish quality of life. Quantifying migraine-related changes in a real-world population over time can increase understanding of the natural history of migraine and improve clinical care of individuals with migraine. The Observational survey of the Epidemiology, treatment, and Care Of MigrainE (OVERCOME) is a web-based study that longitudinally assessed migraine-related outcomes in a demographically representative adult population with migraine in the United States. Migraine disease status was classified as “overall improved,” “overall worsened,” or “no net change” based on changes in monthly headache days (MHDs), the Migraine Disability Assessment Scale (MIDAS) score, and the Migraine-Specific Quality-of-Life Questionnaire–Role Function-Restrictive (MSQ-RFR) domain score over 1 year. Migraine-related characteristics and patient-reported outcomes were evaluated for each group. Among 11,634 individuals with migraine who completed the baseline and 1-year follow-up surveys, 40.4

Using data from the OVERCOME study, we examined the influence of household income on access to specialty care and use of recommended acute and preventive treatments for migraine in a large population-based study. This analysis from the OVERCOME study, a multicohort, web-based survey (2018–2020) among adults with migraine in the US, examined the influence of annual household income on (1) care-seeking, (2) the highest level of care received (emergency department/urgent care, primary care, specialty care), and (3) use of acute or preventive treatments recommended by the American Headache Society. We used standardized mean differences and logistic regression (LR) models to estimate the magnitude of differences in health care behavior as a function of household income and insurance status. Among OVERCOME (US) respondents with migraine who provided demographic information (n = 56,667), a higher proportion of people in the lowest income group (< 25,000) received their highest level of migraine care in the emergency department/urgent care setting versus the proportion in the highest income group [≥100,000: 12.3

Background and objectives Prior studies assessing cerebrovascular reactivity (CVR) in participants with migraine primarily utilized Doppler ultrasonography and focused on large vascular territories due to limitations of available technology. Newer functional MRI techniques detect alterations in CVR at much higher spatial resolution and, when coupled with an anatomical scan, allow correlation with specific brain regions. The goal of this study was to measure and compare CVR in participants with migraine during (ictal) versus between (interictal) spontaneous attacks using functional magnetic resonance imaging.Methods This is an observational cohort study in which CVR was measured using breath-hold BOLD functional MRI during spontaneous migraine attacks involving lateralized headache. All participants returned for a repeat scan when free of all migraine symptoms. CVR was assessed by comparing BOLD activity during the ictal versus interictal scans in the entire group as well as by headache laterality.Results Eighteen participants completed the study [77.8% female; mean (SD) age 38.4 (13.6) years]. Comparing the ictal to the interictal scan in the full cohort, no voxel clusters met significance criteria. When stratified by headache laterality, two significant clusters were identified (one decreased/one increased CVR) in 6 participants with right-sided headache. The cluster demonstrating decreased CVR was in the left planum temporale/left Heschl's gyrus. The cluster demonstrating increased CVR was in the right crus I of the cerebellum. No clusters met significance criteria in 12 participants with left-sided headache.Conclusion Cerebrovascular reactivity was not observed to differ significantly during the ictal compared to the interictal state in the full cohort but did differ in the subgroup of participants with right-sided headache.

OBJECTIVE:To assess patterns of statistical associations among migraine stigma, psychological factors, and disability during the active migraine attack phase (the ictal disability burden) and in between attacks (the interictal disability burden). BACKGROUND:Previous work suggests perceived stigma toward migraine is an important contributor to migraine disability. Yet, it is currently unclear how migraine stigma is connected to disability and vice versa. Psychological distress factors (i.e., perceived stress, anxiety symptoms, depression symptoms, and pain catastrophizing) are putative variables that might contribute to associations between stigma and disability. METHODS:This was a web-based cross-sectional survey study of 103 American adults with active migraine conducted during 2024 to 2025. Relationships among perceived migraine-related stigma, perceived stress, anxiety and depression symptoms, pain catastrophizing, ictal disability, and interictal disability were assessed. Information was collected using a battery of questionnaires including the Migraine-Related Stigma questionnaire, MIDAS, Migraine Interictal Burden Scale-4, Pain Catastrophizing Scale (headache version), Generalized Anxiety Disorder-7 questionnaire, Patient Health Questionnaire-9, and Perceived Stress Scale-4. Associational variable analysis, an alternative framework for nonexperimental cross-sectional mediation studies, was used to examine associational patterns. RESULTS:Perceived stress was shown to partially account for variance between perceived migraine stigma and ictal disability (effect = 0.10, 95% confidence interval [CI] [0.01, 0.24]), whereas pain catastrophizing was found to partially account for the association between stigma and interictal disability (effect = 0.04, 95% CI [0.01, 0.09]). Transposing stigma and disability to examine reverse associations, perceived stress was found to partially account for the ictal disability-stigma association (effect = 0.03, 95% CI [0.0002, 0.07]), whereas depressive symptoms (effect = 0.25, 95% CI [0.04, 0.54]) and pain catastrophizing (effect = 0.44, 95% CI [0.11, 0.91]) were shown to partially account for associations between interictal disability and stigma. CONCLUSIONS:Among psychological variables examined, perceived stress and pain catastrophizing carried significant portions of stigma's relationship with ictal and interictal disability, respectively. Moreover, perceived stress (ictally) and depression symptoms/pain catastrophizing (interictally) accounted for portions of disability's relationship with stigma.

This statement provides general principles of the American Academy of Neurology's (AAN) approach when invited to provide guidance to policymakers on a variety of types of therapies that may have neurologic treatment benefits, but for which available evidence is limited or for which there is no US Food and Drug Administration-approved indication. In these instances, the AAN recommends an approach in which the patient and neurologist carefully review all available evidence and discuss the potential risks and benefits of the therapy, including when patients are contemplating asserting their right to try.

This statement provides general principles of the American Academy of Neurology's (AAN) approach when invited to provide guidance to policymakers on a variety of types of therapies that may have neurologic treatment benefits, but for which available evidence is limited or for which there is no US Food and Drug Administration-approved indication. In these instances, the AAN recommends an approach in which the patient and neurologist carefully review all available evidence and discuss the potential risks and benefits of the therapy, including when patients are contemplating asserting their right to try.

OBJECTIVE:To estimate rates of migraine progression and assess predictors of progression in a large, longitudinal cohort study using the traditional definition and two alternative definitions of migraine progression. BACKGROUND:Traditionally, migraine progression is defined as moving from episodic migraine (EM) with ≤ 14 monthly headache days (MHD) to chronic migraine (CM) with ≥ 15 MHDs of which 8 are attributable to migraine. This definition does not take into account changes in the full range of potential headache days, disability, or impact on function. METHODS:The Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study identified, characterized, and followed a representative sample of adults with migraine in the United States. Migraine was defined based on the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria. We estimated rates of migraine progression at 1 year of follow-up using three definitions: (1) traditional EM-to-CM transition, (2) increase of ≥ 5 MHDs (MHD progression), and (3) increase of ≥ 5 points on the Migraine Disability Assessment (MIDAS) scale (MIDAS progression). The analysis identified sociodemographic, clinical, and migraine-related characteristics associated with each definition of progression from a set of 67 candidates and then determined the association with progression for each candidate predictor and each definition of progression. RESULTS:A total of 11,634 participants met ICHD-3 criteria for migraine at baseline and completed the 1-year follow-up survey. The average age was 48.2 years, and average years living with migraine was 22.8 years. The sample was 75.6% female (8793/11,634), 84.4% White (9814/11,634), 6.5% Black (757/11,634), and 7.6% Hispanic (889/11,634). The majority (89.2%, 10,374/11,634) had EM at baseline, and among these, 4.7% progressed to CM over 1 year of follow-up. Rates of progression at 1 year were higher using other definitions of progression, with 9.6% (1087/11,329) reporting an increase in ≥ 5 MHDs and 21.7% (2519/11,630) reporting an increase of ≥ 5 MIDAS points. Across all three definitions of progression, ever taking preventive medications for migraine placed people at lower odds of progressing (odds ratio [95% confidence interval]: EM-to-CM transition, 0.7 [0.57-0.85]; MHD progression, 0.9 [0.75-1.00]; MIDAS progression, 0.8 [0.73-0.91]), while the presence of depression placed people at higher odds of progressing (odds ratio [95% confidence interval]: EM-to-CM transition, 1.3 [1.05-1.69]; MHD progression, 1.4 [1.21-1.67]; MIDAS progression, 1.2 [1.04-1.34]). CONCLUSION:This work expands the concept of migraine progression, exploring two alternative definitions that modify the potential range of MHD changes and take disability into account. This analysis identified never having used preventive medications for migraine and presence of depression as risk factors across all three definitions of progression. This work may more accurately identify persons with progression and at risk of migraine progression, setting the stage for trials of preventive intervention and ultimately more effective practice.

BACKGROUND:Stigma is emerging as an important social contributor to migraine-related disability and other outcomes. Currently, there are no published validated measures of migraine-specific measures of stigma. OBJECTIVES:This secondary post hoc analysis of a cross-sectional cohort study aimed to develop a questionnaire to evaluate migraine-related stigma. METHODS:Based on focus group discussions among persons with migraine and literature review, a panel of migraine experts iteratively developed 12 candidate items for the migraine-related stigma (MiRS) questionnaire, which aims to measure if and how people living with migraine perceive they are viewed in a stigmatizing manner by others. The United States ObserVational survey of the Epidemiology tReatment and Care Of MigrainE (OVERCOME) study identified people with active migraine within a demographically representative United States (US) adult sample and administered the novel MiRS questionnaire in addition to questionnaires assessing sociodemographics, monthly headache days, and migraine disability score (Migraine Disability Assessment) among other data. Exploratory factor analysis was then utilized to evaluate the structure of the MiRS items and determine the Cronbach's alpha described internal consistency of the factors. RESULTS:This exploratory factor analysis was a secondary post hoc analysis of a cross-sectional cohort study derived from the OVERCOME population-based web survey, which was conducted in a United States sample of 61,932 adults with migraine. The mean (standard deviation) age was 41.7 (14.8) years, 74.5% (n = 46,122) were female, and 70.3% (n = 43,564) identified as White. Two factors were identified: MiRS-external perception of Secondary Gain (eigenvalue = 21.5, percentage of total variance = 88.9%) and MiRS-external perception of Minimizing Burden of migraine (eigenvalue = 2.7, percentage of total variance = 11.1%). The two factors were correlated (r = 0.66) and a non-orthogonal varimax rotation showed that eight items loaded onto the MiRS-Secondary Gain factor, and four items loaded onto the MiRS-Minimizing Burden factor. CONCLUSION:This population-based study of >60,000 people with migraine allowed the development and validation of the first migraine-specific measure of perceived external stigma for people with migraine. This study demonstrated that MiRS consists of two internally consistent subscales: Secondary Gain and Minimizing Burden. This may be a useful tool for quantifying perceived migraine-related stigma to understand determinants of migraine-related stigma and test interventions to reduce perceived migraine-related stigma.

Despite expert recommendations against using opioids for migraine treatment, their use remains common in the USA. We aimed to evaluate the use of opioids among people with active migraine using data from the Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) (US) study. This observational, longitudinal, web-based survey study included a demographically representative sample of adults with migraine in the USA (2018–2020). Participants with migraine (International Classification of Headache Disorders, third edition [ICHD-3]) and ≥ 1 headache in the previous 12 months were identified via a questionnaire and/or self-reported diagnosis. Information on opioid use for acute migraine treatment was collected. Demographics, clinical, and migraine-related characteristics among those with current opioid use and those with non-use were evaluated in the cross-sectional analysis using standardized mean difference (SMD). Multivariable analysis was conducted using machine learning (least absolute shrinkage and selection operator regression, random forest) and logistic regression models to assess factors associated with current opioid use. Of 61,932 respondents with active migraine, 13,331 (21.5

BackgroundUnderstanding characteristics and reasons associated with using calcitonin gene-related peptide monoclonal antibodies (CGRP mAb) for migraine prevention may help clinicians individualize treatment plans and achieve better patient outcomes.MethodsWe analyzed 2019-2020 cohort data of OVERCOME (US), a population-based survey among adults with migraine. Eligible participants were categorized based on current CGRP mAb usage ("NEVER" and "EVER" users ["Continued", "Switched" and "Discontinued"]). Machine learning techniques followed by logistic regression were used to examine, among 60 sociodemographic, clinical, migraine-related- and migraine treatment utilization characteristics, those associated with CGRP mAb use status.ResultsOf 39,113 participants, 25.6% had ever used migraine preventive medication(s) and 5.0% used CGRP mAbs (of which 46.1% Continued, 14.7% Switched and 39.3% Discontinued). Top factors associated with higher odds of CGRP mAb EVER vs. NEVER use were currently using recommended acute medication (odds ratio (OR) = 2.43; 95% confidence interval (CI) = 2.09-2.82) and contraindications for triptan use (OR = 2.32; 95% CI = 2.06-2.60). Continuing use vs. switching or discontinuing was most associated with current use of botulinum toxin for migraine (OR = 2.21; 95% CI = 1.42-3.44 and OR = 4.53; 95% CI = 3.14-6.55, respectively).ConclusionsAt the time of survey, CGRP-targeted mAbs remain underutilized for migraine and multiple characteristics are associated with CGRP mAb use patterns.

Migraine is associated with various types of stigma. This study aims to evaluate stigmatizing attitudes towards people with migraine by people without active migraine. OVERCOME (US) was a web survey among adults from a representative US population-based sample that collected information about stigmatizing attitudes of people without active migraine (i.e., no migraine/severe headaches in the previous 12 months) toward people with migraine and related conditions. The following associations were examined in the current analysis: (1) association between stigma toward migraine and relationship to people with migraine, (2) association between stigma toward migraine and sex, and (3) association between stigma toward migraine and historical headache/migraine status. We further compared stigmatizing attitudes toward people with migraine compared to people with chronic low back pain and epilepsy. In this observational, population-based study, a total of 11,997 respondents without active migraine were queried about attitudes and beliefs about people with migraine. With a mean age of 47.4 (standard deviation 17.3) years, the majority of the respondents were female (51.1

Despite a variety of available treatment options for migraine, many people with migraine do not seek medical care, thereby reducing opportunities for diagnosis and effective treatment and potentially leading to missed opportunities to reduce the burden of disease. Understanding why people hesitate to seek care for migraine may help healthcare professionals and advocates address barriers and improve outcomes. The aim of this study, in a large adult population sample in the United States (US), was to identify factors associated with and reasons for hesitating to seek healthcare for migraine. The web-based OVERCOME (US) survey study identified adults with active migraine in a demographically representative US sample who answered questions about hesitating to seek care from a healthcare provider for migraine and reasons for hesitating. Supervised machine learning (random forest, least absolute shrinkage and selection operator) identified factors associated with hesitation; logistic regression models assessed association of factors on hesitation. The study results show that of the 58,403 participants with active migraine who completed the OVERCOME (US) baseline survey and provided responses to the question on hesitating to seek care for migraine, 45.1

OBJECTIVE:To identify the most common locations of cluster headache pain from an international, non-clinic-based survey of participants with cluster headache, and to compare these locations to other cluster headache features as well as to somatotopic maps of peripheral, brainstem, thalamic, and cortical areas. BACKGROUND:Official criteria for cluster headache state pain in the orbital, supraorbital, and/or temporal areas, yet studies have noted pain extending beyond these locations, and the occipital nerve appears relevant, given the effectiveness of suboccipital corticosteroid injections and occipital nerve stimulation. Furthermore, cranial autonomic features vary between patients, and it is not clear if the trigeminovascular reflex is dermatome specific (e.g., do patients with maxillary or V2 division pain have more rhinorrhea?). Finally, functional imaging studies show early activation of the posterior hypothalamus in a cluster headache attack. However, the first somatosensory area to be sensitized is unclear; the first area can be hypothesized based on the complete map of pain locations. METHODS:The International Cluster Headache Questionnaire was an internet-based cross-sectional survey that included a clickable pain map of the face. These data were compared to several other datasets: (1) a meta-analysis of 22 previous publications of pain location in cluster headache (consisting of 6074 patients); (2) four cephalic dermatome maps; (3) participants' survey responses for demographics, autonomic features, and effective medications; and (4) previously published somatotopic maps of the brainstem, thalamus, primary somatosensory cortex, and higher order somatosensory cortex. RESULTS:One thousand five hundred eighty-nine participants completed the pain map portion of the survey, and the primary locations of pain across all respondents was the orbital, periorbital, and temporal areas with a secondary location in the lower occiput; these primary and secondary locations were consistent with our meta-analysis of 22 previous publications. Of the four cephalic dermatomes (V1, V2, V3, and a combination of C2-3), our study found that most respondents had pain in two or more dermatomes (range 85.7% to 88.7%, or 1361-1410 of 1589 respondents, across the four dermatome maps). Dermatomes did not correlate with their respective autonomic features or with medication effectiveness. The first area to be sensitized in the canonical somatosensory pathway is either a subcortical (brainstem or thalamus) or higher order somatosensory area (parietal ventral or secondary somatosensory cortices) because the primary somatosensory cortex (area 3b) and somatosensory area 1 have discontinuous face and occipital regions. CONCLUSIONS:The primary pain locations in cluster headache are the orbital, supraorbital, and temporal areas, consistent with the official International Classification of Headache Disorders criteria. However, activation of the occiput in many participants suggests a role for the occipital nerve, and the pain locations suggest that somatosensory sensitization does not start in the primary somatosensory cortex.

ObjectiveThe goal of this study was to clarify whether clinical differences exist between patients with migraine who experience headache that is typically left-sided ("left-migraine") versus right-sided ("right-migraine") during attacks.BackgroundMigraine has been associated with unilateral headache for millennia and remains a supportive trait for the clinical diagnosis of migraine of the International Classification of Headache Disorders. It is currently unknown why headache in migraine is commonly unilateral, and whether headache-sidedness is associated with other clinical features.MethodsThis is a cross-sectional study comparing left- versus right-migraine using all available intake questionnaires of new patients evaluated at an academic tertiary headache center over a 20-year period. Eligibility was based on patient written responses indicating the typical location of headache during attacks. In our analyses, the side of headache (left or right) was the predictor variable. The outcomes included various migraine characteristics and psychiatric comorbidities.ResultsWe identified 6527 patients with migraine, of which 340 met study eligibility criteria. Of these, 48.8% (166/340) had left migraine, and 51.2% (174/340) had right migraine. When comparing patients with left- versus right-migraine, patients with left migraine experienced 3.6 fewer headache-free days (95% confidence interval [CI] 1.3-5.9; p = 0.002) and 2.4 more severe headache days (95% CI 0.8-4.1; p = 0.004) in the previous 4 weeks. No significant differences in age, sex, handedness, migraine characteristics, or psychiatric comorbidities were identified between the two groups.ConclusionsPatients with migraine with typically left-sided headache during attacks reported a higher burden of headache frequency and severity than those with typically right-sided headache during attacks. These findings may have implications for our understanding of migraine pathophysiology, treatment, and clinical trial design.Plain Language SummaryIn this study, we wanted to learn if patients with migraine who typically experience left-sided headache during attacks show differences in migraine features or psychiatric comorbidities compared to patients who typically experience right-sided headache during attacks. We reviewed the intake questionnaires of all new patients diagnosed with migraine at an academic headache center over the last 20 years. Our main finding was that patients with typically left-sided headache reported more headache days and more severe headache days than patients with typically right-sided headache. In this study, we wanted to learn if patients with migraine who typically experience left-sided headache during attacks show differences in migraine features or psychiatric comorbidities compared to patients who typically experience right-sided headache during attacks. We reviewed the intake questionnaires of all new patients diagnosed with migraine at an academic headache center over the last 20 years. Our main finding was that patients with typically left-sided headache reported more headache days and more severe headache days than patients with typically right-sided headache.

Background and ObjectivesThis population-based analysis characterizes the relative frequency of migraine-related stigma and its cross-sectional relationship to migraine outcomes. We hypothesized that migraine-related stigma would be inversely associated with favorable migraine outcomes across headache day categories. MethodsOVERCOME (US) is a web-based observational study that annually recruited a demographically representative US sample and then identified people with active migraine using a validated migraine diagnostic questionnaire. It also assessed how frequently respondents experienced migraine-related stigma using a novel 12-item questionnaire (Migraine-Related Stigma, MiRS) that contained 2 factors; feeling that others viewed migraine as being used for Secondary Gain (8 items, alpha = 0.92) and feeling that others were Minimizing disease Burden (4 items, alpha = 0.86). We defined 5 groups: (1) MiRS-Both (Secondary Gain and Minimizing Burden often/very often; (2) MiRS-SG (Secondary Gain often/very often); (3) MiRS-MB (Minimizing Burden often/very often); (4) MiRS-Rarely/Sometimes; (5) MiRS-Never. Using MiRS group as the independent variable, we modeled its cross-sectional relationship to disability (Migraine Disability Assessment, MIDAS), interictal burden (Migraine Interictal Burden Scale-4), and migraine-specific quality of life (Migraine Specific Quality of Life v2.1 Role Function-Restrictive) while controlling for sociodemographics, clinical features, and monthly headache day categories. ResultsAmong this population-based sample with active migraine (n = 59,001), mean age was 41.3 years and respondents predominantly identified as female (74.9%) and as White (70.1%). Among respondents, 41.1% reported experiencing, on average, >= 4 monthly headache days and 31.7% experienced migraine-related stigma often/very often; the proportion experiencing migraine-related stigma often/very often increased from 25.5% among those with <4 monthly headache days to 47.5% among those with >= 15 monthly headache days. The risk for increased disability (MIDAS score) was significant for each MiRS group compared with the MiRS-Never group; the risk more than doubled for the MiRS-Both group (rate ratio 2.68, 95% CI 2.56-2.80). For disability, interictal burden, and migraine-specific quality of life, increased migraine-related stigma was associated with increased disease burden across all monthly headache day categories. DiscussionOVERCOME (US) found that 31.7% of people with migraine experienced migraine-related stigma often/very often and was associated with more disability, greater interictal burden, and reduced quality of life.

ImportanceOpen burn pits have commonly been used for waste disposal by the US military but have not been systematically investigated as an independent risk factor for headache disorders.ObjectiveTo evaluate the association between exposure to open burn pits and incidence of headache and migraine.Design, Setting, and ParticipantsThis retrospective cohort study used data from the Veterans Health Administration Headache Cohort along with data from the US Department of Defense and the Airborne Hazards and Open Burn Pit (AH&OBP) Registry to assess registry participants with potential exposure to open burn pits in the Veterans Health Administration from April 1, 2014, through October 31, 2022. Participants were included by linking data from the AH&OBP Registry to their US Department of Defense and Veterans Health Administration electronic health records. Those with preexisting headache were removed from the analytic sample. The analysis was conducted between November 1, 2022, and January 31, 2024.ExposureOpen burn pit exposure composite variables based on the registry questionnaire were examined, specifically being near open burn pits, days near open burn pits, and having open burn pit duties.Main Outcomes and MeasuresPrimary incident outcomes included medically diagnosed headache disorders and medically diagnosed migraine.ResultsThe analytic sample included 247 583 veterans (mean [SD] age, 27.9 [7.7] years; 222 498 [89.9%] male). After covariates were controlled for at baseline, participants who were near an open burn pit with open burn pit duties had the highest adjusted odds of medically diagnosed headache disorders (adjusted odds ratio [AOR], 1.59; 95% CI, 1.46-1.74), migraine (AOR, 1.60; 95% CI, 1.43-1.79), and self-reported disabling migraine (AOR, 1.93; 95% CI, 1.69-2.20) compared with those without exposure. The 2 highest quartiles of cumulative burn pit exposure (290-448 days and >448 days) had significantly higher adjusted odds of medically diagnosed headache (290-448 days: AOR, 1.20; 95% CI, 1.09-1.31; >448 days: AOR, 1.55; 95% CI, 1.41-1.70) and migraine (290-448 days: AOR, 1.19; 95% CI, 1.07-1.34; >448 days: AOR, 1.48; 95% CI, 1.32-1.65).Conclusions and RelevanceIn this cohort study, a dose-dependent association existed between open burn pit exposure and medically diagnosed headache and migraine. These new data identify potentially important associations between open burn bit exposure and new-onset headache among service personnel as well as a possible health condition that may be encountered more frequently in Veterans Health Administration facilities during mandatory screening for military exposures.

BACKGROUND:Stigmatization and trivialization of headache confront individuals with headache disorders, but the degree to which media may contribute is incompletely understood. OBJECTIVE:The objective of this study was to quantify the frequency of disparaging metaphorical use of the words "headache" and "migraine" in articles and summaries of major publications. METHODS:This longitudinal study analyzed a dataset of 1.3 million articles and summaries written by authors and editors of 38 major publications. Data cover written publications from 1998 up to 2017. The use of the words "headache" or "migraine" in articles and summaries by major publications was rated by two authors (P.Z. and A.V.) as either "metaphorical" or "medical" based on their contextual application. Pearson's chi-squared test was applied to assess differences in the frequency of metaphorical use of "headache" in comparison to "migraine." Secondary outcomes were the source of publication and time of publication. RESULTS:A total of 6195 and 740 articles included the words "headache" or "migraine," respectively; 7100 sentences contained the word "headache" and 1652 sentences contained the word "migraine." Among a random sample of 1000 sentences with the word "headache," there was a metaphorical use in 492 (49.2% [95% CI, 46.1-52.3]) sentences. Among a random sample of 1000 sentences with the word "migraine," there was a metaphorical use in 45 (4.5% [95% CI, 3.2-5.8]) sentences. The five most prevalent sources were CNN, Fox News, The New York Times, The Guardian, and The Washington Post. There was an overall increase in the number of articles containing the words "headache" or "migraine" from database inception until analysis (1998 up to 2017). The database included no articles containing either "headache" or "migraine" in 1998; in 2016, this number was 1480 articles. CONCLUSIONS:In this longitudinal study, major publications applied a metaphorical use of "headache" about half of the time. The metaphorical use of "headache" is 11-fold greater than the metaphorical use of "migraine" in the same media sample. These depictions may contribute to the trivialization of headache and the stigmatization of individuals with headache disorders. Studies with individuals affected by headache disorders are needed to clarify potential influences.

Imagine a society in which everyone had migraine. The lights in stores would be dimmer. Music in bars would be quieter, and no one would wear perfume. Everyone would take breaks throughout the workday. Workplaces would have quiet, dark retreats where employees could go to manage symptoms. If someone could not come to work or had to go home early, staffing would be available for easy and adequate coverage. And, if everyone had migraine, migraine stereotypes would lose their power. Everyone would know that migraine is not “just a headache,” that the cacophony of neurologic symptoms that comprise a migraine attack can be disabling. People with migraine would never be considered unreliable at work, or so quickly dismissed as exaggerating to avoid responsibilities, or need to assiduously hide that they were experiencing impairments from migraine at all. If everyone had migraine, then navigating life with migraine would just be navigating life. Migraine occurs in a social context.1 Unexpected attacks can be disabling events that pull individuals from their routines, interfere with the fulfillment of social roles and expectations, and disrupt social systems.2, 3 The pace of an assembly line is determined by the slowest worker, perhaps the one having a migraine attack. Migraine is a problem for all of us, whether or not we have the disease. And we have two options to respond to the societal problem of migraine: interconnectedness and accommodation, or stigma and blame. The social interconnectedness that amplifies the impact of migraine also provides opportunities to reconceptualize the problem in a manner that may benefit everyone in society. Everyone stands to gain from better migraine management if that speeds our social assembly line. Employers would have more engaged and productive workers.4, 5 The government would oversee a more productive economy. The health system would benefit from lower emergency care utilization for a chronic disease. Families would be more engaged, and partners and parents would be more fulfilled. And individuals with migraine would have reduced symptoms and disability. On the other hand, migraine stigma discredits and isolates people with migraine in an effort to diminish their disruption to societal status quo.6, 7 A particularly stigmatizing migraine stereotype is that people with migraine are responsible for their illness. If we continue to blame individuals with migraine for their illness, it absolves us of responsibility for accommodating their illness. This strategy may provide short-term relief from psychological discomfort for stigmatizers,6 but in the long term is detrimental to people with migraine and society as a whole. Our paper8 joins other recent studies in demonstrating the negative impact that migraine stigma has on people with migraine. In our study, we found that people with migraine recruited from neurology offices in the New York City area (n = 121) reported stigma at levels similar to patients with epilepsy.8 The experience of stigma was strongly and uniquely associated with higher disability and poorer quality of life, even when migraine symptoms and psychological factors were considered. Our preliminary validation of a social ecological model for migraine found that stigma (a variable that represents the interaction between the person and the social systems in which they are embedded) mediated the relationship between monthly headache days and migraine-related disability and quality of life.8 This link suggests that if we want to understand the whole picture of migraine quality of life, we have to understand the role of stigma. These results were not surprising. They joined multiple other research reports describing the negative health consequences of stigma in chronic illnesses broadly,9-11 and migraine specifically.12, 13 Several lines of research are needed to better understand and ultimately reduce migraine stigma. For the individual with migraine, interventions are urgently needed to reduce the impact of living with a stigmatized disease. Mindfulness interventions show promise for diminishing the impact of disease stigma on the self-perception of individuals who have the disease.14 Other strategies such as self-compassion, loving-kindness, and social support interventions may also be fruitful avenues to explore.15 At minimum, healthcare providers should be aware of the extent to which stigma negatively impacts their patients with migraine and strive to create a compassionate healing environment where migraine stereotypes have no safe haven, and where migraine is not the sole defining identity of the individuals who seek our clinical care. Stigma emerges when migraine interferes with conformance to societal norms; therefore, interventions to reduce migraine stigma must take place at a societal level.16 Cross-cultural study of migraine stigma provides a distinct opportunity to evaluate the extent to which society-level changes in how people with migraine are perceived can impact the individual experience of migraine stigma. Clinical trials evaluating microsystem (family, classroom, immediate coworkers) and mesosystem (workplace, school system) interventions can evaluate which systems-level changes bring about the largest reductions in stigma and greatest improvement in quality of life among anyone with migraine embedded in those systems. A recent single-arm pilot study suggests that workplace headache education programs hold promise for modifying headache-related beliefs among workers.17 Early-stage optimization of family, workplace, and school-level interventions is needed to develop interventions most likely to be effective. Cluster randomized trials are needed to demonstrate efficacy to modify societal migraine stigma and improve migraine quality of life among those with migraine. Our work makes it reasonable to hypothesize that perceived stigma may be a risk factor for migraine progression, one that could be modifiable with some of the above interventions. It is possible that reducing stigma may actually alter the prognosis of migraine. It should also be noted that the benefit of systems-level interventions has the potential to extend far beyond those with migraine. Certain researchers have suggested that the brains of people with migraine are simply more sensitive to environmental homeostatic threats that are problematic for all humans.18 Indeed, many of the changes that could make routine daily life more palatable for people with migraine are beneficial for much broader groups of society.19 Almost everyone would benefit from more breaks at work, increased hydration, and eating small frequent meals throughout the day. If these behaviors became more normative, people with migraine would experience health benefits but so would their coworkers, friends, and family. The impact of the global pandemic on increasing flexibility of knowledge worker's schedules, and changes in expectations around working while sick, have benefitted people with migraine, while the positive impact on a number of other groups including parents and caregivers and people with other chronic illnesses have been well-documented.20 Moreover, the global movement toward implementing a 32-h workweek may particularly benefit people living with migraine to manage their work–life balance more effectively. Researchers and healthcare providers cannot view migraine in isolation. Instead, we must work toward understanding the social systems in which people with migraine are embedded, and the reciprocal relationships between migraine and social norms. Elizabeth K. Seng, has consulted or served on an advisory board for GlaxoSmithKline, Click Therapeutics, Theranica, and AbbVie, and received research funding from NCCIH (R01AT011005-01A1 MPIs: Seng and Shallcross) and the Veteran’s Health Administration (the Headache Center of Excellence Research and Evaluation Center and VA HSR&D, IRP 20-002 PI: Damush). Amanda Parker, declares no conflicts of interest. Robert E. Shapiro, has received financial and/or authorship compensation for research consulting with Lilly, Lundbeck, AbbVie, and Theranica. Dawn C. Buse, has received research support from the FDA and the National Headache Foundation. She serves as consultant, advisory board member, or has received honoraria or research support from AbbVie/Allergan, Amgen, Biohaven, Eli Lilly, Lundbeck, Novartis, and Teva and serves on the editorial board of Current Pain and Headache Reports. Matthew S. Robbins, serves on the board of directors of the American Headache Society and New York State Neurological Society, the editorial boards of Headache, Current Pain and Headache Reports, and Continuum, and receives book royalties from Wiley. Richard B. Lipton, has received research support from the National Institutes of Health, the FDA, and the National Headache Foundation. He serves as consultant, advisory board member, or has received honoraria or research support from AbbVie/Allergan, Amgen, Biohaven, Dr. Reddy’s Laboratories (Promius), electroCore, Eli Lilly, GlaxoSmithKline, Lilly, Lundbeck, Merck, Novartis, Teva, Vector, and Vedanta Research. He receives royalties from Wolff’s Headache, 8th edition (Oxford University Press, 2009), and Informa. He holds stock/options in Biohaven, and Manistee.