Issue 3 • 2022
© 2022 The Royal Australasian College of Physicians
Chronic migraines go undiagnosed despite wider availability of treatment
A recent paper in the Internal Medicine Journal found that migraine patients have been underserviced in terms of receiving treatment, with many going undiagnosed or never being prescribed an acute medication to treat their migraines.
If you’ve ever had a migraine, you’ll recognise that throbbing of the temples, the head-spinning, or the searing sensitivity to any light source. If you’re lucky, it will eventually pass and not return for some time. But for the estimated 3 per cent of Australians diagnosed with chronic migraines, treatment options need to be updated to help them manage the recurring pain and discomfort.
This is what Dr Michael Eller and Dr Shuli Chen, RACP Fellows and neurologists, focus on in their recent Internal Medicine Journal article, Migraine management: an update for the 2020s. The article found that migraine patients had been underserviced in terms of receiving treatment, with only one-third of patients being diagnosed with chronic migraine, and two-thirds never being prescribed an acute medication such as triptan to treat their migraines.
ICHD diagnostic criteria for chronic migraine A. Headache (migraine-like or tension-type-like) on ≥15 days/month for >3 months and fulfilling criteria B and C. B. Occurring in a patient who has had at least five attacks fulfilling criteria B-D for 1.1 Migraine without aura and/or criteria B and C for 1.2 Migraine with aura. C. On ≥8 days/month for >3 months fulfilling any of the following:
a. 1 criteria C and D for 1.1 Migraine without aura b. 2 criteria B and C for 1.2 Migraine with aura c. 3 criteria A and B for 1.5 Probable migraine
D. Not better accounted for by another ICHD-3 diagnosis.
Dr Eller says there are many sufferers that may believe nothing can be done about their migraines and don’t seek a diagnosis as a result.
“One of the biggest hurdles to addressing migraines is diagnosis,” Dr Eller says.
“We want the public to know that if you speak to your doctor about your migraines and get a diagnosis – there are treatment options available that are proven to help.
“This latest review of the development of preventatives and treatments should give significant hope to migraine sufferers.”

A new mode of treatment The newest additions to migraine preventative agents are the calcitonin gene-related peptide (CGRP) monoclonal antibodies. Four monoclonal antibodies have been developed: one targeting the CGRP canonical receptor (erenumab) and three targeting the CGRP (eptinezumab, fremanezumab and galcanezumab).
Preventives used to treat migraines
  • Oral preventives: propranolol, amitriptyline, pizotifen, candesartan, nortriptyline, sodium valproate, topiramate
  • OnabotulinumtoxinA
  • CGRP monoclonal antibodies: galcanezumab, fremanezumab, erenumab, eptinezumab
Currently, galcanezumab and fremanezumab are available on the PBS for patients that have failed, not tolerated, or have contraindications to at least three preventative migraine medications.
As Dr Eller explains, “For many migraine sufferers, simple interventions like the prescribing of triptans will see a big improvement in their ability to manage a migraine.
“For some patients where the initial treatments aren’t adequate – there is a range of preventative treatments that are now on the pharmaceutical benefits scheme.
“The availability of monoclonal antibody treatments, which are migraine specific, well tolerated and now government subsidised, has meant that there are more options for migraine sufferers.”
The availability of these treatments on the PBS widens the scope to improve healthcare delivery for people with chronic migraines. Encouraging more people to seek a diagnosis and ensuring they are well-informed of treatment options is also vital to helping more Australians manage the pain and discomfort of migraines.
Read the full paper in Volume 52, Issue S4 of RACP’s Internal Medicine Journal.