Taking migraine medication too late, in insufficient doses, or not starting preventive treatment early enough may contribute to migraine progression and chronification.
Within 60 minutesAcute migraine medication should be taken within 60 minutes of onset; delaying past this window significantly reduces effectiveness
What the researchers found
The review identifies four forms of medication underuse in migraine:
1. Taking inappropriate medications for the pain level and disability
2. Taking medication too late (more than 60 minutes after onset, or after allodynia develops)
3. Discontinuing treatment due to side effects or perceived lack of effect
4. Poor adherence to preventive medications
For acute treatment, the key problem is failing to halt the progression from peripheral nerve activation to central sensitization. Once central sensitization occurs (marked by allodynia, where normal touch becomes painful), acute medications are much less effective.
For preventive treatment, inadequate efficacy and side effects of conventional drugs lead to high discontinuation rates. Anti-CGRP medications partially address this by offering better tolerability and targeting the underlying CGRP pathway. The review suggests starting anti-CGRP treatment during low-frequency episodic migraine rather than waiting until attacks become frequent or chronic.
Why it matters
The migraine field has focused heavily on medication overuse headache. This review highlights the opposite problem: not treating enough. If undertreated episodic migraine progresses to chronic migraine, patients face far worse outcomes and quality of life. The recommendation to start CGRP-targeting preventives earlier challenges current stepwise treatment guidelines.
The numbers in context
- Acute medication should be taken within 60 minutes of migraine onset
- Central sensitization (allodynia) marks the point where acute treatment effectiveness drops
- Anti-CGRP treatment may be more beneficial when started during low-frequency episodic migraine
- Conventional preventive drugs have high discontinuation rates due to side effects
How the study worked
Comprehensive narrative review of published evidence on medication underuse in migraine, covering both acute and preventive treatments. Examines the pathophysiology of migraine progression from peripheral to central sensitization.
Who was studied
Review focused on migraine patients at risk for disease progression due to medication underuse
What this study cannot tell us
This is a narrative review advocating a position. The evidence for early CGRP treatment preventing chronification is still limited. The concept of medication underuse is not well-defined in clinical guidelines. Some of the pathophysiology described is based on animal models. The review does not address cost-effectiveness of early CGRP treatment or practical barriers to access.
How to read the evidence
Rated moderate: evidence-based narrative review presenting a clinical position on underuse, supported by published data.
When this study was published
Published in 2024. Challenges the traditional focus on medication overuse by highlighting the equally important problem of underuse.
The bigger picture
The migraine field has focused heavily on medication overuse. This review highlights an equally important problem — undertreated episodic migraine that progresses to chronic migraine, affecting patient quality of life and healthcare costs.
Questions still open
- Could early CGRP antibody treatment prevent chronic migraine development?
- How can clinicians identify undertreated migraine patients?
Common questions
Can undertreating migraines make them worse?
When should you take migraine medication?
Read the original research
Medication "underuse" headache.
Cephalalgia : an international journal of headache, 44(4), 3331024241245658
Citation
Rattanawong, Wanakorn; Rapoport, Alan; Srikiatkhachorn, Anan. (2024). Medication "underuse" headache.. Cephalalgia : an international journal of headache, 44(4), 3331024241245658. https://doi.org/10.1177/03331024241245658