The spectrum of migraine: Barriers to our care - Gaps in diagnosis, treatment and knowledge of individuals with CM in the US
Tuesday, June 17, 2014 at 7:40PM
Sharron E. Murray


"Awareness is the greatest agent for change." - Eckhart Tolle

Migraine is a debilitating neurological disease characterized by migraine attacks that are divided into episodic (EM) and chronic (CM) by the number of headache days (EM</= 15 days per month, CM>/= 15 days per month). The disease affects about 38-39 million of us in the US. 

We need to be aware that as our attacks increase in frequency, so do a host of other problems that can complicate our treatment and contribute to our headache-related disability. In an effort to help us have a better understanding of the challenges we may face and offer suggestions on ways to overcome these burdens and receive optimal care, this article addresses: 


To begin with, let's review what happens as we progress from episodic to chronic migraine in relation to our diagnosis; comorbidities; sociodemographic, disability, and employment characteristics; and, risk factors for progression of episodic to chronic migraine (CM).


In a study that estimated remission rates of subjects with CM, identified predictors of CM remission, and assessed the influence of remission on headache-related disability, (Manack, Buse et al, 2011), our migraines were classified as follows: 

Comorbidities and Sociodemographic, Disability, and Employment Characteristics  

We need to be aware that, as we progress along the spectrum from LFEM to CM:

That said, returning to the study by Manack and Buse, results showed:

Given this information, it would seem that, as the study authors propose, an accurate diagnosis is necessary to determine where, as individuals, we fit in the migraine spectrum. Once our position is established, the goal of our treatment can be directed toward reducing attack frequency so that:

Risk factors for progression of EM to CM

In line with this approach, a review defining the differences between EM and CM, (Katsarava, Buse, et al, 2011), outlined non-modifiable and modifiable factors that are believed to increase our risk of progression from EM to CM. This is important for us to know because once we identify our personal risk factors, we are able to work with our doctor to improve or eliminate our modifiable ones, decrease the frequency of our attacks and, if we have CM, increase our chances for remission.

Non-modifiable risk factors are reported as:

Modifiable risk factors are listed as:

*As mentioned above, these risk factors may be comorbid with migraine. Here, it is beneficial for us to know that along with directing treatment towards our personal comorbidities and individual risk factors, preventive pharmacological and non-pharmacological treatments and strategies have been shown to help decrease the frequency of our attacks.  


Now, let's look at CM. About 3-7 million people in the US are believed to live with CM. In an effort to bring more awareness to the individual, society and the health care systems about the burden of CM, a recent study (CaMEO) examined self-reported headache diagnosis rates, health care consultation patterns, and knowledge and use of preventive treatments among a large, US population-based sample of individuals with CM (Buse, Lipton et al, 2014).

Gaps in diagnosis, treatment and knowledge

In this instance, headache types were classified as migraine, CM/transformed migraine (TM), or CM/TM/chronic daily headache (CDH). Results demonstrated:

Awareness of preventive treatments and strategies among all respondents with CM was as follows:

The authors conclude these data demonstrate gaps in the diagnosis, treatment, and knowledge of individuals with CM in the US and offer opportunities for improvement in care.

Opportunities for improvement in care

"The natural healing force within each of us is the greatest force in getting well." - Hippocrates

Another finding in the CaMEO study showed more respondents who were under the care of a "headache specialist" consulted a "nonprescribing" health care professional for a headache than those who were not under such care. These "nonprescribing" health care professionals included: chiropractors, massage therapists, acupuncturists, physical therapists, psychologists or other health care professionals, naturopaths, and occupational therapists.

A recent article addressed the use of complementary alternative medicine, "CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don't," (Cowan, 2014). The author suggests "that until such time as the body of scientific literature adequately addresses non-conventional approaches, physicians must acknowledge and understand, as best as possible, CAM approaches which are in common use by patients." 

Given this information, it is important to know that even though more research is necessary to establish evidence-based guidelines for some non-pharmacological therapies, many of us use these treatments and strategies because along with quieting our minds, calming our bodies, combating feelings of hopelessness and despair, and decreasing the frequency and severity of our attacks, they give us a feeling of empowerment. As well, because medications alone do not work for a number of us and lead to medication overuse headaches,  (MOHs) they give us a viable option for therapy.  

3 ways to help us overcome barriers to care are: 

For me, effective communication with my doctor facilitated my diagnosis of CM and MOHs. And, even though they were foreign to me at the time, non-pharmacological therapies like biofeedback, acupuncture, meditation, diaphragmatic breathing, and healing touch, became instrumental in my remittance to EM. As well, along with trigger management, regular exercise, and a healthy diet and lifestyle habits, they continue to be the foundation of my remission.


Cowan, R.P., M.D., F.A.H.S., F.A.A.N. (2014). "CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don't." Headache Currents.  April, 25. DOI: 10.1111/head.12364.

Buse, D., C., Lipton, R., et al (2014). "Barriers to Chronic Migraine Care: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study" Neurology. April 8, 2014 vol. 82 no. 10 Supplement I9-1.004.

Buse, D., C., Lipton, R., et al (2014). "Barriers to Chronic Migraine Care: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study." Poster presented at the 66th annual Academy of Neurology Annual Scientific Meeting. Philadedelphia, PA. April 26- May 3.

Buse, D., C., Silberstein, S., D., et al. (2013). "Psychiatric comorbidities of episodic and chronic migraine." J Neurol.  Aug;260(8):1960-9. DOI 10.1007/s00415-012-6725-x.

Lipton, R., Serrano, D., et al. (2014). "Sociodemographic, Disability, and Employment Differences Between Persons With Chronic and Episodic Migraine: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) study". Neurology. April 8, 2014 vol. 82 no.10 Supplement S41.002.

Katsarava, Z., Buse, D.C., et al. (2012). "Defining the Differences Between Episodic Migraine and Chronic Migraine." Curr Pain Headache Rep. February; 16(1): 86-92.

Manack, A., Buse, D.C., et al. ( 2011). "Rates, predictors and consequences of remission from chronic migraine to episodic migraine." Neurology.  Feb 22;76(8):711-8. doi: 10.1212/WNL.0b013e31820d8af2.

Sharron Murray MS, RN is an author and coauthor CaMEO Study, "Life With Migraine". Currently, Sharron is active in the migraine community as a writer, advocate, American Migraine Foundation Partner, moderator for the American Migraine Foundation "Move Against Migraine" Facebook Group, and member of the National Headache Foundation Patient Leadership Council. 

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN

This article is not intended as a substitute for medical advice. If you have specific concerns about your health or nutrition, please contact a qualified professional. 

Copyright 2014  Sharron E. Murray

Updated February, 2019

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