Despite affecting at least 12% of the US population, our understanding of migraines is limited due to a combination of difficulties with diagnosis, an extremely complex genetic picture, and the historic lack of investment in studying conditions that primarily affect women.
On August 31, 2026, the American Academy of Neurology and the American Headache Society released updated migraine treatment guidelines, the first ones since 2012. Experts have applauded the new guidelines, citing the fact that previous guidelines had contained no guidance about preventive treatment. Many are hoping that drawing awareness to preventive treatments and how to use them will increase their utilization. Importantly, the new guidelines draw specific attention to a newer type of medication, called CGRP targeting-drugs, which include brand names such as Emgality and Ajovy. The guidelines treat these as first-line treatments rather than recommending them only after other options have failed. Older treatments, such as Botox and topiramate, are still recommended as well, as they have a strong evidence base.
This seems to be an encouraging step in the right direction. But it begs the question of why we know so little about migraine and why so many people who need treatment are not being treated or aren’t getting the treatment they need.
In case you’ve never had the pleasure of having one, migraines tend to be extremely debilitating. The entire cycle of a migraine can last several days or longer. This often includes the actual migraine attack, which can last a few hours to a few days, and a “postdrome,” in which people tend to feel exhausted, worn out, or “out of it,” which can last for a day or even longer. Some chronic migraine sufferers get 15 or more migraines a month, so if you do the math, they are spending virtually the entire month under a migraine’s spell in one form or another. Migraines can be with or without “aura,” which refers to sensory or speech symptoms that come before and/or during the headache or migraine attack. Aura can include vision changes, like seeing flashes, floaters, or pinwheels, ringing in the ears (tinnitus), sensitivity to touch, or sometimes profound difficulty speaking or concentrating. Many people have migraine “triggers” that they come to identify over time. Common ones include lack of food, dehydration, stress, sleep deprivation, weather changes (often stormy weather can trigger it), or exposure to bright lights, loud sounds, or strong smells. But most migraine sufferers will tell you that not only do they have multiple triggers, many of which are hard to avoid, but that it’s common for them to have migraines with no identifiable trigger. There are some classic symptoms, like a one-sided pounding or throbbing headache, nausea, or sensitivity to light and sound, but there are also a whole host of other symptoms that are associated with migraine. For example, one migraine sub-type that’s gotten some attention recently, vestibular migraine, is characterized by severe dizziness and vertigo, most often without any trace of a headache. This dispels the idea that migraines have to be accompanied by head pain – they do not, and this makes the picture even murkier.
As may seem obvious by now, the process of diagnosing migraines can be very challenging. Nothing shows up on any kind of imaging test, so clinicians must determine the diagnosis through taking a careful history and asking about symptoms. There is a widespread lack of education and training about migraine in medical settings. It is challenging to teach because the symptoms can look very different in different people, often involve multiple bodily and sensory systems, and may mimic other conditions. A single person may experience a range of different types of migraines throughout their life, and many of these types can have varying symptoms, almost looking like a separate disorder.
Finally, there is good evidence to suggest that migraine has been understudied in part because it is a condition that predominantly affects women. For most of the history of study of migraine (and any disease), the work has been done by male scientists on male rodents. It is only relatively recently that this has started to change, and we have a lot of catching up to do. In addition, chronic pain has not always been a priority in our medical research environment, and this is no different.
If you suffer from migraine, do not be discouraged. This is a fast-growing area of research, and a number of effective medications have come out since the last set of guidelines was released. The key is to continue to educate yourself about the potential signs and symptoms of migraine and to keep close track of your symptoms. Using a journal or a symptom tracking app can be helpful because your ability to articulate what you’re experiencing, when, for how long, and how often will be essential in getting you access to needed treatment.
