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Year : 2020  |  Volume : 10  |  Issue : 4  |  Page : 179-187

Migraine: Update and Future Perspectives

1 Biomedical Genetics Research Laboratory (BMGRL), School of Biosciences and Technology, VIT University, Vellore, Tamil Nadu, India
2 Government Vellore Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Submission14-Apr-2020
Date of Decision20-May-2020
Date of Acceptance21-Jul-2020
Date of Web Publication01-Oct-2020

Correspondence Address:
Anne S.T. Sahithi
Biomedical Genetics Research Laboratory (BMGRL), School of Biosciences and Technology, VIT University, Vellore, Tamil Nadu-632014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnpnd.ijnpnd_26_20

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Migraine is a disease known as polyneuropathy, which is intolerable to the sufferer, family and community. Persistent headaches mark this condition in patients with migraine. The primary focus of this review article is to summarise the current findings of the migraine epidemiology, prevalence, neuroimaging tools, risk factors and prospects. Currently, a rise in migraine cases has been reported for persons of age between 25 and 55 years. A rapid increase in migraine cases was reported for people having lower socioeconomic status. Patients with migraine have shown an increase in the incidence of mental illness and co-morbidity. These patients are diagnosed using various neuroimaging tools such as (a) computerized tomography (CT), (b) magnetic resonance imaging (MRI), (c) functional (fMRI), (d) PET (Positron Emission Tomography), (e) SPECT (Single-Photon Emission Computed Tomography), (f) CEPs (Cortical Evoked Potentials), (g) MEG (Magnetoencephalography), and (h) Diffusion Tensor Imaging (DTI). In clinical practice, Headache Impact Test (HIT-6 ™) is used to measure the pain impact in patients with migraine. Precipitating factors such as (a) caffeine, (b) sleep apnea, (c) sleep deprivation, (d) stress, and (e) depression that cause migraine have been discussed in detail. The prospects for the future research have been discussed based on (a) Pain and psychological factors, (b) cognitive techniques, (c) new developments in treatment, and (d) neuromodulation. In this review, it is concluded with the possibility of reducing the progression of migraine disease through pathopsychological knowledge. Also, the progression can be reduced by implementing high research standards in clinical studies.

Keywords: Migraine, prevalence, polyneuropathy, risk factors

How to cite this article:
Sahithi AS, Muthu T, Saraswathy R. Migraine: Update and Future Perspectives. Int J Nutr Pharmacol Neurol Dis 2020;10:179-87

How to cite this URL:
Sahithi AS, Muthu T, Saraswathy R. Migraine: Update and Future Perspectives. Int J Nutr Pharmacol Neurol Dis [serial online] 2020 [cited 2022 Aug 11];10:179-87. Available from:

Key Messages;

• Headache is a multifactorial disorder identified with visual or sensory symptoms

• Global Burden of Disease, Migraine ranked as the world’s third most severe condition.

• HIT 6 measures adverse effects of headaches on vitality, social suffering, and cognitive function.

• Non-modifiable risk factor for Migraine is age, female sex, and low educational status.

• Understanding of migraine as prospective disease offers challenges and rewards in the future.

   Introduction Top

Migraine is a generally multifactorial and neurological issue that is described by episodes of Headache. Nausea, affectability to light, and noise are combined side effects that generally last for 24 to 72 hours.[1] This condition lasts nearly 15% of the people around the world.[2] The side effects associated with headaches can be severe and cause noticeable burdens on social-like victims.[2] As indicated by the Global Burden of Disease Study (GBD-2015), Migraine was positioned as the third most common issue in the world. The inability was found in both males and females underneath the age of 50 years around the world.[3] Migraine disorder is common among women of all age groups compared to men, 17% of women experience it yearly and when contrasted with men 6% experience the ill effects of headaches[4]

Migraine also tends to run in families. Headache has two significant types: Migraine with and without aura, described by brain pain with bright highlights regarding the 3rd ICHD guidelines 2018.[5] Recent research proposes that the subtypes of migraine headache pain may have severe neurological diseases.[6] Symptoms of migraine result in four phases such as (a) prodrome, (b) aura, (c) throbbing phase, and (d) postdrome. These phases originate from hypothalamus, brainstem, and cortex. These parts of the brain lead to various interactions between multiple predisposing genes, hormone fluctuations and environmental factors [Figure 1].[5],[7]
Figure 1 Description of migraine.[7]

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Epidemiology of Migraine

According to IHS classification Headache is differentiated into various types, and the most pronounced were Migraine with and without aura [Table 1]. Migraine without aura (MWOA) is a common type of Migraine in which specific and related symptoms are characteristic of the clinical syndrome. Approximately 75% of cases with MWOA has been reported worldwide.[8] Migraine with aura (MWA) is described by central neurological indications that go with the cerebral pain. Migraine rates are reported and are higher in females (70%) than males (30%) and are highest in reproductive years (aged 25 to 55).[9] Headache is a confusion of repeated attacks. The attack occurs over for several hours to days. Four stages for a typical migraine: prodrome (before Headache), aura (right before Headache), throbbing stage (neuralgia) and postdrome (where the migraine ends).[9] During these phases, symptoms such as hyper-hypo activity, depression carvings for specific foods, fatigue, yawing, and neck pain. A typical aura with Migraine has the same diagnostic criteria as MWOA but has no motor nerve weakness.
Table 1 Classification for MWOA and MWA by ICHD-3 ©International Headache Society (IHS) 2013–2018

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For migraine with aura, symptoms of visual are considered reversible. The positive and negative features for such case includes lines, flickering lights or spots and vision loss, respectively. Also, sensory symptoms are reversible (e.g. needles and pins- positive features) and (e.g. numbness- negative features). Moreover, the possibilities for dysphasic speech disturbance are reversible.[10],[11],[12]

Another sub-type of Headaches called Familial hemiplegic Migraine (FHM) that passes through the family has specific features of MWA along with motor weakness as same as hemiplegic Migraine.[13],[14],[15],[16],[17] Chronic progressive cerebellar ataxia occurs independently after the migraine attacks.[18],[19],[20],[21] The four different specific and genetic sub-forms of migraine [Table 2] that are categorized according to IHS- 2018.
Table 2 Sub-forms of FHM by © IHS in the year 2013–2018

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Presentation and Prognostic Indicators of Migraine

The Headache Impact Test (HIT-6 ™) aims to provide headache pain impact worldwide and is used in the screening of Migraine, and patients suffer from Migraine in both research and clinical practice.[22] HIT-6 measures the undesirable effect of trouble on vitality, mental and social suffering, cognitive function, and the severity of the Headache [Figure 2].[23] HIT-6 designed using Kosinski et al.,[24] 89 items (54- existing antagonistic headache and 35- recommended by physicians). HIT-6 provides excellent internal stability, test consistency, construct legitimacy and sensitivity in patients.[25] Migraine diagnostic criteria should be improved to analyze this disorder and for personalized treatment.[26] HIT-6 questionnaires are easy, simple to assessment used for the evaluation of the migraine on a patient’s life. HIT 6 is a dependable and compelling tool for measuring the effects of stress on headaches in everyday life for both chronic and episodic suffers from migraines.[27] Furthermore, this tool is used to find a difference between chronic, episodic and non-headache patients and useful for the physicians to obtain pertinent data and perceive the burden of a patient with Headache.[25] Also, an easy tool to assist, evaluate and provide effective treatment by obtaining direct input other than the occurrence of Headache since the patients suffer.[25]
Figure 2 Headache Impact Test (HIT-6™) and ©Quality Metric Incorporated.

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Neuroimaging Tools

Neuroimaging is the utilization of different methods to directly or by implying visual structure, capacity or pharmacology of a sensory system. And also, is an often new order in medicine, neuroscience and brain science. Physicians who are specialized in the presentation and understanding of neurological images in clinical settings are known as neurologists. Neuroimaging methods can aid in the diagnosis of migraine as well as in the distinction of migraine variants from other neurodegenerative conditions. Clinically severe neurological conditions in people with headaches followed by migraines with no atypical symptoms or warning flags are less frequent than in the general population.

Computerized tomography is used to detect atrophy of tissues.[28] Magnetic resonance imaging is used to find tissue atrophy that is more sensitive to grey matter.[29] At the same time, Functional MRI (fMRI) helps in the detection of changes in the level of blood oxygenation (BOLD signal) that represent synaptic activity.[30] Positron Emission Tomography can determine whether there are any improvements in glucose metabolism.[31] Single-Photon Emission Computed Tomography detects a change in cerebral perfusion.[32] Cortical evoked potentials used to detect sensory stimulation through sight, sound, or touch. Magnetoencephalography assists with the estimation of magnetic fields and, implicitly, gives more detailed knowledge of electrical activity in the brain.[33] Diffusion Tensor Imaging considers coordination and structure in white matter fields.[34] Typical results of various brain imaging techniques used in the diagnosis of migraine, its advantages and disadvantages are discussed [Table 3].
Table 3 Brain imaging techniques usage, merits, and demerits

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Role and diagnosis of migraine patients using neuroimaging

Determining patients who need neurological treatment to prove appropriate and showing situations that can be eliminated is discussed. In this review article, six studies of brain imaging scan results in subjects with migraine are focused [Table 4].
Table 4 Characteristics of the research involved

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Five hundred and thirty (14.5%) images experienced significant differences in rates proposed by each consultant. There were no significant abnormalities on MRI (46%) compared to CT (28%).[35] Among 45 patients, 13 (28.8%) underwent MRI and showed that white matter foci were significantly higher in patients with aura (8 [40%] of 20) than in patients without aura (5 [20%] of 25).[36]

Intracranial disorders were more common in headache sufferers than in people without headaches (29% versus 22%, respectively; P = 0.041). This association disappears when people with only white pigment are excluded from analysis.[37] A study conducted by Mullally and Hall to determine if a patient needs neurological imaging, who is likely to be more severely impaired. Out of 100 patients diagnosed with migraine, including 41 subjects with chronic migraine and normal neuroimaging, most scans were regular (82%) but 17% were abnormal.

One patient had a severe abnormality: a meningioma that eventually required surgery and radiation therapy.[38] Of these, 63 patients with migraine did not have an aura, and 17 patients with migraine had an aura. Two MRA procedures were interrupted due to claustrophobia, and two more MRA studies were unreliable due to artefacts of movement. Only one patient from the remaining 240 aneurysms was suspected using MRA. However, conventional angiography does not confirm any cerebrovascular disorders. All other tests were standard in this retrospective study screening of migraine patients with MRA.[39] Wang analyzed the data of brain imaging between 1070 subjects with migraine (including 665 participants with migraine) and 1070 subjects with healthy gender and age-matched controls, without "red flags" or abnormal findings from the assessment. None of the 382 subjects with those who had CT showed significant anomalies. Of 688 patients receiving MRI, only 4 patients with Headache had significant visual imbalances (0.58%), including three patients with migraine (0.67%). Abnormalities included two hydrocephalus subjects and two with throat and nose tumours. Healthy controls had five abnormalities (0.73%) which were not significantly different.[40]


Migraine prevalence rates have been widely reported and range from 2.6% to 21.7%, with an average of about 12% with differences between countries and within the same state.[41],[42] Familial link in a patient with Migraine is secure and suggests the significant genetic factor to migraine risk.[43] Differentiation of cases into different categories is essential; therefore, headache frequency studies (ICHD-3 beta) are mainly focused.

Migraine incidence: age and gender

Headache is more typical in young boys than girls before adolescence, but when adolescents reach migraine incidence rates increment quickly in girls compared to boys. The migraine attack increases in childhood and at an early age to 40 years, but later it slowly decreases in women. The highest prevalence of Migraine is reported between 25 to 55 years in both women and men. Raieli et al.[44] assessed the frequency of Migraine in the population of students aged from 11 −14 years; the occurrence of Migraine was approximately 3.0% with girls a slightly higher rate in Italy. Ayatollahi et al.[45] reported the migraine prevalence of pediatric population in Southern Iran and Saudi Arabia among the subjects aged 11–18 years and was 6.1% in Iran and approximately (2%–9%) sharp increase in the frequency rate of Migraine found in 10–11 years the boys and girls in Saudi Al Jumah et al.[46] stated prevalence of Migraine ranged from 3.7% to 4.9% in the United Kingdom. Migraine prevalence was higher among the boys from 3 to 7 years, and later it was equal for both gender at the age of 7–11 years, and it increased only in girls after 11 years. Among adults, it ranges from 3.3% to 21.9% for women and 0.7% to 16.1% for men. In 1989 Migraine I study conducted in the United States gathered statistical data from 15,000 households, and ten years later (1999), the US Migraine II study was conducted[47] (which used as virtually identical methodology). The reported frequency of Migraine reported 18% and 6% in women and men. Center for Disease Control (CDC), reported having increased by 60% from 25.8 per 1,000 to 41 per 1,000 during 1981-1989 48. Community relativistic research conducted by Stang et al.[49] from the medical records of Olmsted Country, Minnesota, reported that the frequency of migraine is increasing. In India, the occurrence of Migraine reported by Malik et al.[50] is common among female gender (65.15%) compared to male gender (35.85%). That might likely reveal an evident rather than an increase in migraine prevalence.[51]

Precipitating Factors

Migraine is a devastating disorder affecting their individual, family and society. The most essential and non-modifiable possibility influence for Migraine is age, female sex and low educational status.[48],[52] Individuals with Migraine are bound to experience psychiatric co-morbidities − such as anxiety, depression and various respiratory problems.[53] The specific risk for any individual may be unknown. Still, the triggers that are known: fatigue, blood glucose imbalances, stress, charged emotional states, physical tension, bright lights, visual disturbance, food intakes like cheese, citrus fruits, chocolate, caffeine, hormonal imbalances, dehydration, sensory disorder, and climate changes like humidity and medications. Studies have recognized neurological, vascular systems to be involved in migraine susceptibility and pathophysiology. Recently, American Migraine Prevalence and Prevention Study (the AMPP study) conducted an extensive epidemiological survey focusing on the patterns of prevention in the US with the help of headache specialists for preventive treatment.[54] According to neurologists, three groups were identified based on their preventive medicine [Table 5].
Table 5 AMPP study classification and prevention

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Caffeine is considered as a hazard factor for Migraine and just as withdrawal reason for Headache. Dietary and medicinal caffeine exposure to coffee, chocolates and tea is widespread.[54] Caffeine causing withdrawal migraine has been accounted in individuals who intake about 1 cup of coffee/day.[55] Few patients are very conscious to caffeine when they consume 1-2 cups per day and can lead to withdrawal symptoms of Migraine reported by Scher et al.,[56] narrowing down caffeine slowly is significant.

Sleep apnea and sleep deprivation

Several studies, both out-patient and population-based studies suggest that Headache is related to sleep disorder like Sleep Apnea and Sleep Deprivation.[57] Sleep apnea is strongly associated with cluster headaches.[58] The incidence of snoring in a group of chronic daily headache (CHD) and episodic headache subjects (OR=2.02 [1.2 to 3.3, P < .005]) was compared by Scher et al.[59] where CHD subjects were probable to be consistent snorers than episodic headache subjects. Odds Ratio (OR) for consistent snoring remain evaluated after adjustment for factors (age, sex, marital status, alcohol consumption, hypertension and BMI) associated with Sleep Apnea OR = 2.86 [1.7 to 5.0, P < .005]). The limitation of the survey is that out-patients are self-detailed because it is possible that, in population-based examinations, a positive pre-sleep estimate of Apnea is considered to be 50% to 80%. Mandibular innovation devices are suggested to be useful for Obstructive Sleep Apnea (OBS).[60] Lack of sleep (Sleep Deprivation), and Excessive sleepiness is a well-known trigger to cause Migraine reported by Sahota et al.[51] Sleep is recommended as a treatment for a migraine if it can be achieved.[51]

Depression and stress

Migraine headache is related with depression and stress has been reported by Breslau et al. and Zwart et al.[61],[62],[63] cross-sectional and bi-directional with different types of psychiatric conditions. The frequency of depression was found to be 28.1% among Migraine, for probable Migraine is 19.5% and 23.9% for both groups pooled together and for the healthy control group, 10.3% reported by Patel et al.[64] Psychological, behavioural therapy (CBT) focuses on the intellectual and passionate parts to treat brain pain in addition to the usual open preparation like yoga.[65] Intervention using this CBT Holroyd et al.[66] has yield approximately 35 % to 50 % in the reduction of migraine and tension-type Headache. Migraine sufferers are suggested by antidepressants, which can help solve sleep problems and anxiety.[50]

Prospect for the Future

Understanding of Migraine as prospective disease offer challenges and success in the future—treatment for migraine patients in the future of greater importance in cooperation between patients and physicians.[67]

Pain and psychological factors

Gate control theory (GCT) of pain shows that pain perception is a combination of peripheral stimuli and cortical variables such as state of mind and nervousness. The relationship between mood disorders and Migraine was reported bi-directionally by Breslau et al.[68] This bidirectional relationship would dispute that psychological techniques have importance in the supervision of migraine patients. Pharmacological and psychological interventions contribute to the treatment of headaches.

Cognitive techniques

Cognitive healing techniques are found to be successful for patient management than high analgesic intake and awareness of migraine education. Recognition, functional pain coping, reduced headache severity, and reduced medication use may be helpful for the people.[69] Behavioural interventions helped reduction in distress up to 40-60 % in an average individual with headache Holroyd.[69],[70] Cognitive-Behavioural Therapy (CBT) is known to follow the NICE guidelines for Headache as a non-pharmacological intervention used for managing depression and anxiety.[71],[72] Manage a specific problem with the skills taught in CBT and to manage headache disorders such as (minor pain from disabling pain, suffering, improving headache-related disability, quality of life living). CBT effectiveness, in the absence of pain relief, is unique to psychological interventions.

New developments in treatment

FDA recently permitted a mixture of sumatriptan and naproxen, which may decrease migraine recurrence in some patients.[73],[74] CGRP, a promising receptor antagonist, is being developed for acute intervention. CGRP antagonists such as Olcegepant and telcagepant show a valuable effect on Migraine. Also, the mechanism of action of this antagonist does not include vasoconstriction reported by Ho et al.[75] The anti-epileptic drug (AED) topiramate and valproate sodium, the FDA approved drug is migraine prophylaxis and is significantly helpful for patients when treating prophylactic migraine.[76]


Neuromodulation has emerged in recent years for both preventive and intense headache treatment.[77] Invasive exciting techniques such as the occipital nerve stimulation (ON) and sphenopalatine lymph nodes stimulation (SPG) are used to manage migraine patients.[78],[79] Present-day non-obtrusive devices that focus on the sensory system are non-intrusive vagus nerve (nVNS), Supra-orbital nerve provocation and transcranial direct current (tDCS) agitation.[80],[81] Transcranial cathodal and anodal through current incentive on visual cortex as a therapeutic effect in Migraine is another emerging neurological treatment technique.[82],[83] Although the evidence of available neuromodulation techniques is accomplished, further studies are needed to confirm their efficacy in Migraine.

   Conclusion Top

Migraines are unbearable and a burden for the sufferer, family and society. The investigative technique has overcome the need for detailed history to arrive at a more accurate diagnosis than the drug. The development of profiling the patient’s history is time-consuming. Still, it is in need to find the right questionnaire, the right decision, and the right diagnosis and to give the right treatment for the patients within the right timeframe. The reduction and organization of Migraine can be possible by patient education to understand the effects of migraine treatment. Modifiable risk factors are essential to consider as part of migraine management. Besides, clinical studies are needed to see the sights of the biochemical and biomarker of brain imaging for disease progression. Migraine is a ’biological’ and not a ’psychological’ entity. Cognitive and emotional activity in hyper can amplify pain awareness, while psychological factors related to inadequate treatment response. However, the pathophysiological knowledge of migraines and high research standards in clinical studies may allow the prevention of disease progression in people at risk.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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