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Factors contributing to inaccurate migraine diagnosis: a prospective study at a tertiary hospital in Southern Thailand
(2026-12-01)
Suwanlaong, Kanokrat
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Sittisomwong, Sirianong
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Dutsadeethammo, Duangkamon
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Anukoolwittaya, Prakit
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Rattanawong, Wanakorn
Background: Migraine is a common and disabling neurological disorder, yet diagnostic accuracy remains suboptimal, especially in non-specialist settings. Misdiagnosis may lead to delayed treatment, medication overuse, and reduced quality of life. The objective of this study was to estimate the proportion of patients with migraine attending the headache clinic who were misdiagnosed or not diagnosed as having migraine before attending the headache clinic, and to identify factors associated with inaccurate migraine diagnosis among patients before attending a tertiary hospital in Southern Thailand. Methods: A prospective, cross-sectional study was conducted at Songkhla Hospital between July 2024 and April 2025. Adult patients (≥ 18 years) with a final migraine diagnosis confirmed by two blinded independent neurologists were enrolled. Participants were divided into two groups: (1) an appropriate diagnosis group, defined as patients who received a correct diagnosis of migraine at their initial consultation with any physicians prior to attending the headache clinic; and (2) an inappropriate diagnosis group, defined as patients who were previously misdiagnosed with another headache disorder or had not been diagnosed with migraine before their headache clinic visit. Data on demographics, clinical features, and the specialty of the first attending physician were analyzed using univariable and multivariable logistic regression. Results: 90 patients were included (87.8% female, mean age 43.4 ± 14.8 years). 43.3% had been misdiagnosed at their initial visit. The most common incorrect diagnoses were tension-type headache and sinusitis. Multivariable analysis identified five independent factors significantly associated with inappropriate diagnosis: male sex (adjusted OR 7.77, 95% CI 1.07–56.50, p = 0.043), bilateral headache (aOR 3.90, 95% CI 1.25–12.13, p = 0.019), lack of worsening by physical activity (aOR 5.09, 95% CI 1.54–16.89, p = 0.008), presence of vertigo/dizziness (aOR 4.39, 95% CI 1.22–15.83, p = 0.024) and initial consultation with a non-neurologist (aOR 7.92, 95% CI 2.63–23.88, p < 0.001),. Conclusion: Misdiagnosis of migraine remains frequent in clinical practice, particularly among patients initially evaluated by non-neurologists. Atypical symptom profiles—such as bilateral pain, lack of activity-related exacerbation, or associated vertigo—contribute to diagnostic inaccuracy. Enhanced awareness and targeted education for primary physicians are essential to improve diagnostic precision and reduce treatment delay.
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Diagnosis challenges and accessibility barriers to migraine management in Southeast Asia: results from the South-East Asia Local breAch on MigraiNe Treatment (SEALANT) study
(2026-12-01)
Rattanawong, Wanakorn
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Hiransuthikul, Akarin
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Anukoolwittaya, Prakit
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
Background: Migraine is one of the leading causes of disability among all neurological diseases, yet major gaps persist in diagnosis and access to effective treatment, particularly in low- and middle-income regions. Southeast Asia and East Asia are characterised by marked socioeconomic diversity, variable healthcare infrastructure, and limited availability of migraine-specific therapies. We aimed to assess physician-reported barriers to migraine diagnosis and management across Southeast Asian and East Asian countries. Methods: The South-East Asia Local breAch on MigraiNe Treatment (SEALANT) study was a multinational, cross-sectional, web-based survey conducted between Nov 1, 2024, and Aug 31, 2025. Physicians involved in migraine care from Laos, Indonesia, Malaysia, the Philippines, Singapore, Taiwan, and Thailand were eligible. Survey domains included diagnostic barriers, clinic accessibility, acute and preventive treatment practices, awareness of medication overuse headache, access to calcitonin gene-related peptide (CGRP)–targeted therapies, and migraine-related stigma. Countries were categorised by World Bank income classification. Data were analysed descriptively, and comparisons were made across income groups. All results are based on physicians’ perceptions of routine clinical practice rather than objectively verified patient-level data. Results: A total of 686 physicians participated (mean age 39.0 years [SD 9.9]), of whom 79.8% were neurologists. Overall, 70.0% of respondents reported an insufficient number of neurology/headache clinics, increasing to 87.2% in lower-middle-income countries. Physicians reported that approximately 60.0% of patients were correctly diagnosed with migraine before specialist consultation, while 44.9% were perceived to experience diagnostic delays exceeding one year. According to physician reports, acute migraine management relied predominantly on non-specific analgesics, with opioids remaining widely available and prescribed across all income settings. Reported use of migraine-specific acute therapies and preventive treatments was limited. Although CGRP-targeted preventive therapies were widely regarded by physicians as effective (77.1%), many perceived that these treatments should not yet be reimbursed. Conclusion: Substantial and inequitable gaps persist in migraine diagnosis and management across Southeast Asia and East Asia, as perceived by physicians, driven by shortages of specialist services, delayed diagnosis, reliance on non-specific treatments, and restricted access to migraine-specific therapies. Addressing migraine as a public health priority through health-system strengthening, education, and equitable access to evidence-based treatments is essential to reduce disability in the region.
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Expert consensus on gepants for acute and preventive treatment of migraine in Thailand
(2025-12-01)
Anukoolwittaya, Prakit
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Rattanawong, Wanakorn
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Vongvaivanich, Kiratikorn
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
Introduction: Gepants, a calcitonin gene-related peptide (CGRP) receptor antagonist, is a class of migraine therapeutic options with extensive evidence supporting a favorable efficacy and safety profile. However, as a novel class of medication in Thailand, specific guidelines or recommendations regarding rational drug use are currently unavailable. This could hinder physicians from utilizing the medications for eligible patients and prevent pharmacists from providing information to physicians and patients. Main body: In order to develop consensus-based statement recommendations, a modified Delphi approach was employed, which included two rounds of surveys, discussions, and voting. General recommendations were made, as well as specific recommendations of gepants in both acute and preventive treatment roles. Additionally, clinical settings where gepants could be suitable options were identified, along with the recommendations for their use in special populations and relevant precautions. Conclusion: Gepants can serve as both acute and preventive therapy for migraines. They provide an alternative to first-line therapies for patients with limitations to conventional agents, including contraindications or intolerance. Gepants can be utilized as monotherapy or in combination with other treatment approaches. Optimal prescribing practices for eligible patients could ensure that patients receive maximum benefit with minimal risk.
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CGRP-targeted therapy fulfilling the treatment gap in medication-underuse setting: a retrospective cohort study at a tertiary headache center in Thailand, a lower-middle-income country
(2025-12-01)
Roongrojwittayakul, Sirawit
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Anukoolwittaya, Prakit
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Hiransuthikul, Akarin
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
Background: Migraine preventive treatment is essential to reducing the burden of disease. However, discontinuation of oral migraine preventive medications (OMPMs) remains common due to suboptimal efficacy and tolerability, especially in lower-middle-income countries, which may contribute to migraine progression—a situation that has led to the introduction of the concept of “Medication Underuse Headache”. The calcitonin gene-related peptide monoclonal antibody (CGRP mAbs) might close the gap in this situation. This study aimed to investigate the treatment patterns of migraine preventive medications over six months at a tertiary headache center in Thailand and to explore the association between each preventive medication class and discontinuation rates. Methods: A single-center retrospective cohort study was conducted between 2021 and 2023. Adult patients who were diagnosed with migraine and received at least one preventive medication at their first visit to the Headache Clinic at King Chulalongkorn Memorial Hospital were included, with a minimum follow-up period of six months. The primary outcome was the discontinuation of any migraine preventive medication from the baseline regimen during follow-up visits. A multivariable Cox regression model, adjusted for sex, age, and diagnosis, was used to explore baseline factors associated with the discontinuation of preventive migraine medications. Results: Among the 100 eligible patients (mean age [SD]: 39.6 [14.4] years; 87.0% female), 41.0% (41/100) discontinued at least one preventive medication, most commonly due to intolerance to side effects (53.7%, 22/41) and lack of treatment effectiveness (34.1%, 14/41). The highest discontinuation rates were observed with serotonin norepinephrine reuptake inhibitors at 53.8% (7/13), calcium channel blockers at 37.5% (6/16), and beta-blockers at 25.6% (11/43). Notably, no patients discontinued CGRP mAbs. Patients using CGRP mAbs at baseline had a significantly higher rate of discontinuing at least one other oral preventive medication compared to those who did not use CGRP mAbs: 31.7% vs. 25.4% at month 3, and 55.4% vs. 33.4% at month 6 (p = 0.04). After adjustment, baseline use of CGRP mAbs was significantly associated with an increased risk of discontinuing at least one medication in the regimen (adjusted odds ratio 2.16; 95% CI: 1.16 to 4.03, p = 0.02). Conclusion: Discontinuation of preventive migraine treatment remains a significant issue in Thailand. CGRP mAbs were associated with higher treatment persistence and may help reduce polypharmacy in migraine management.
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Filling the data gap on CGRP mAb therapy in low- to middle-income countries in Southeast Asia: insights from a real-world study in Thailand
(2024-12-01)
Anukoolwittaya, Prakit
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Hiransuthikul, Akarin
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Pongpitakmetha, Thanakit
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Thanprasertsuk, Sekh
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Rattanawong, Wanakorn
Background: Most real-world data on CGRP mAbs have been published from high-income countries such as the USA, Western countries, Japan, Korea, and Singapore. However, data from low- and middle-income countries in Southeast Asia is lacking. This is the first real-world study from Thailand to describe the efficacy of CGRP mAbs therapy in migraine patients and to analyze the response trends between episodic migraine and chronic migraine. Methods: We conducted a single-center, real-world retrospective chart review study with an observation period of 6 months after CGRP mAbs initiation. We aim to compare treatment responses to CGRP mAbs between EM and CM patients. Results: A total of 47 Thai patients were enrolled (median [IQR] age 37.2 [28.6–50.4] years; 85.1%F, 44.7% EM; 70.2% galcanezumab). There was no difference in baseline characteristics and migraine disability assessment (MIDAS) between EM and CM. The overall ≥ 30%, ≥ 50%, and ≥ 70% monthly migraine day reduction rates at 6 months were 89.0%, 71.6%, and 58.5% with higher responders in EM. There was a significant decrease in monthly headache days (MHDs) over time (adjusted β = -0.42, p < 0.001) and a significant decrease in MIDAS score over time after the initiation of CGRP mAbs (adjusted β = -1.12, p = 0.003). However, there were no differences between the two diagnoses. There was no significant decrease in the number of abortive medication pills used over time after the initiation of CGRP mAbs. CM had a significantly steeper trend compared to those with EM. Conclusion: The first real-world study in Thailand demonstrated that CGRP mAbs therapy had efficacy for migraine treatment, as evidenced by a reduction in MHDs, decreased disability, and reduced use of abortive medications. Additionally, the response pattern to CGRP mAbs therapy was similar between EM and CM in terms of MHDs reduction and MIDAS score improvement.

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