European Journal of Cardiovascular Medicine

Migraine, a debilitating neurological disorder characterized by recurrent headaches, ranks as the second leading cause of disability globally, affecting over 1.1 billion people worldwide [1]. Its profound impact on productivity, quality of life, and healthcare costs underscores its status as a critical public health challenge. In India, recent epidemiological data reveal that migraine affects approximately 15% of adults, with higher prevalence among women and urban populations [2]. Despite its ubiquity, migraine remains underdiagnosed and undertreated, particularly in low-resource settings, whereas the healthcare systems grapple with fragmented infrastructure and limited awareness [3]. The management of migraine hinges on timely diagnosis and evidence-based interventions, as outlined in the International Classification of Headache Disorders-3 (ICHD-3) and guidelines from the Indian Academy of Neurology [4]. First-line therapies such as triptans and prophylactic agents (e.g., beta-blockers, anticonvulsants) are proven to reduce disability, yet their utilization remains suboptimal in clinical practice [5]. Studies attribute this gap to knowledge deficits among healthcare professionals (HCPs), misconceptions about migraine severity, and overreliance on analgesics [6,7]. For instance, a 2022 survey of Indian physicians found that only 35% adhered to ICHD-3 criteria, while 60% prescribed NSAIDs as first-line therapy despite their limited efficacy in severe cases [8]. In Eastern India, where 70% of the population resides in rural areas with limited access to specialized care, migraine management faces unique challenges [9]. Cultural stigma, economic barriers, and a shortage of neurologists exacerbate disparities in care. A 2023 study in Bihar highlighted that <20% of primary care providers received formal training in headache disorders, leading to diagnostic inaccuracies and therapeutic inertia [10]. However, comprehensive data on HCPs’ knowledge, attitudes, and practices (KAP) remain scarce, hindering targeted interventions. This study aims to bridge this gap by assessing KAP toward migraine among HCPs in Eastern India. Findings will inform policy reforms, enhance guideline adherence, and foster patient-centered care models in a region burdened by healthcare inequities.

Objectives:

• To evaluate HCPs’ knowledge of migraine diagnostic criteria and evidence-based therapies.
• To assess attitudes toward migraine management, including perceived barriers and stigmatization.
• To analyze practices in prescribing patterns and patient education.
• To compare KAP between urban and rural practitioners and specialists vs. generalists.

Study Design:

A cross-sectional questionnaire-based study was conducted in hospitals and clinics located in Bihar, in the eastern part of India. The study was carried out over a period of six months, from January to June 2024.

Participants:

Inclusion Criteria: Physicians, neurologists, GPs practicing in Eastern India, and willing to participate in the study.

Exclusion Criteria: Non-practicing/international HCPs and Incomplete responses.

Sample Size: 300 (calculated by using Cochran’s formula, 95% CI, 5% margin of error), Stratified random sampling (specialists vs. non-specialists) was used.

Data Collection Tool: A pre-validated KAP questionnaire (Cronbach’s α = 0.82) was used, divided into:

Knowledge (15 questions): Patho-physiology, diagnostic criteria (ICHD-3), treatment options.

Attitude (10 questions): Perceived importance of migraine care, barriers.

Practice (10 questions): Prescription habits, patient counseling.

Statistical Analysis: Software SPSS v26 was used for analysis. Frequencies, percentages were used for Descriptive Statistics, and the Chi-square test (categorical variables) and Logistic regression (predictors of good KAP) were used for Inferential Statistics. P-value< 0.05 is considered significant.

Table 1: Demographic Characteristics of Participants

The study included 300 participants, consisting of 80 neurologists and 220 general practitioners (GPs)/physicians. The majority were male (71.7%), with a higher proportion of male neurologists (68.8%) compared to GPs (72.7%). Experience levels varied significantly between specialties: nearly half of GPs (47.7%) had less than five years of experience, whereas most neurologists (43.7%) had over ten years. Work settings were evenly split between the government and private sectors (50% each), with no notable differences between neurologists and GPs [Table 1].

Table 2: Logistic Regression Analysis of Factors Influencing Optimal Practice

Specialization, experience, and prior training significantly influenced optimal migraine management. Neurologists were 3.45 times more likely to follow best practices than GPs (95% CI: 1.89–6.31, *p*=0.001). Clinicians with over ten years of experience had nearly double the odds (aOR=1.98, *p*=0.019), and those with prior training were 2.76 times more likely to adhere to guidelines (*p*=0.002). These findings highlight the impact of specialization and training on clinical decision-making [Table 2].

Table 3: Prescribing Patterns for Acute Migraine

Significant differences emerged in migraine treatment preferences. Neurologists prescribed triptans more frequently (60%) compared to GPs (25%, *p*<0.001), whereas GPs relied more on NSAIDs (70% vs. 35%, *p*<0.001). Combination drugs showed no significant difference (25% vs. 15%, *p*=0.08), suggesting that neurologists follow more specialized treatment protocols [Table 3].

Table 4: Government vs. Private Practitioners’ Awareness

Private practitioners demonstrated greater awareness of ICHD-3 diagnostic criteria (62% vs. 48%, *p*=0.02) and were more likely to prescribe triptans (45% vs. 25%, *p*<0.001) compared to government healthcare providers. This suggests that practice settings may influence knowledge and prescribing behavior in migraine management [Table 4].

Table 5: Barriers to Migraine Management (Ranked)

The most prominent barrier was lack of time for patient counseling (mean score=4.2/5), followed by limited access to prophylactic treatments (3.9) and patient preference for analgesics (3.7). These findings indicate systemic challenges in migraine care, emphasizing the need for better resources and patient education to improve adherence to evidence-based practices [Table 5].

The findings of this study shed light on critical gaps and challenges in migraine management among healthcare professionals (HCPs) in Eastern India. Despite the high prevalence of migraine in India (14%) and its significant contribution to disability-adjusted life years (DALYs), our results reveal persistent inadequacies in knowledge, attitude, and practice (KAP) that hinder optimal care delivery [11,12].

Knowledge Gaps and Diagnostic Challenges:

Only 65% of HCPs correctly identified the International Classification of Headache Disorders-3 (ICHD-3) criteria, with 40% aware of triptans as first-line therapy. This aligns with studies from low- and middle-income countries (LMICs), where non-specialists often lack familiarity with evidence-based guidelines [13,14]. For instance, a Nigerian study reported that only 32% of GPs could define migraine accurately, mirroring our findings [15]. The underutilization of triptans, a cornerstone of acute migraine therapy, reflects systemic issues such as limited exposure to updated guidelines and restricted access to specialized drugs in public healthcare settings [16]. This gap is concerning, given that migraine-specific therapies reduce disability and improve quality of life [17].

Attitude-Practice Disconnect:

While 72% of HCPs acknowledged migraine as a serious condition, only 58% adhered to guideline-recommended practices. This paradox echoes global trends where positive attitudes fail to translate into action due to time constraints, patient preferences for analgesics, and skepticism toward prophylactic therapies [18,19]. In rural India, Kulkarni et al. (2015) similarly found that 60% of HCPs relied on NSAIDs despite recognizing their limitations, driven by cost and accessibility barriers [20].

Specialists vs. Non-Specialists: A Stark Divide

Neurologists demonstrated 3.45 times higher odds of optimal practice compared to GPs (Table 2), consistent with studies highlighting the role of specialization in migraine care [21]. In contrast, GPs often lack confidence in managing complex cases, leading to more prescription of analgesics (70% vs. 35% for neurologists) and underuse of prophylactic agents (Table 3) [22]. This disparity underscores the need for bridging the gap between primary and tertiary care through collaborative models and referral networks.

Government vs. Private Sector Disparities:

Government practitioners lagged behind private peers in ICHD-3 awareness (48% vs. 62%) and triptan use (25% vs. 45%) (Table 4). These findings mirror systemic inequities in India’s healthcare system, where public facilities grapple with outdated drug formularies and high patient loads, limiting time for patient education [23]. Similar challenges have been reported in hypertension management, where public-sector HCPs face barriers in implementing guidelines.

Barriers to Optimal Care:

Thematic analysis identified resource constraints (e.g., lack of MRI access) and patient-related factors (e.g., non-compliance due to cost) as key barriers (Figure 3). These resonate with the WHO’s emphasis on social determinants of health in migraine management. Additionally, the weak correlation between knowledge and practice (r = 0.45) suggests that improving care requires more than education—it demands structural reforms, such as integrating migraine into national non-communicable disease (NCD) programs and ensuring drug availability.

Implications for Policy and Practice:

1. Education and Training: Mandatory CME programs focusing on ICHD-3 criteria and prophylactic therapies could reduce knowledge gaps. Successful models from Brazil, where guideline adherence improved by 40% post-training, offer a roadmap [24].
2. Drug Accessibility: Including triptans and CGRP inhibitors in state essential drug lists would enhance equity.
3. Digital Solutions: Mobile health tools for symptom tracking and decision support could mitigate time constraints, as demonstrated in Kenya’s migraine management pilot [25].

Limitations:

1. Regional Bias: Findings may not generalize to other Indian states with different healthcare infrastructures.
2. Self-Reporting Bias: Practices were not directly observed, risking overestimation of adherence.
3. Cross-Sectional Design: Longitudinal studies are needed to assess causal relationships.

Future prospects:

1. Longitudinal Studies: Track the impact of training interventions on practice outcomes.
2. Rural-Urban Comparisons: Explore disparities in migraine care accessibility.
3. Patient-Centered Research: Investigate patient perspectives on treatment barriers and preferences.

This study underscores the urgent need for multifaceted interventions to improve migraine care in Eastern India. By addressing knowledge gaps, enhancing resource allocation, and fostering collaboration across healthcare tiers, stakeholders can mitigate the burden of this debilitating condition and align with global efforts to prioritize headache disorders as a public health priority. The study reveals that while neurologists exhibit robust knowledge and adherence to evidence-based practices, general practitioners (GPs) and non-specialists lag significantly in diagnostic accuracy, therapeutic choices, and patient education. Key findings highlight a moderate overall knowledge   level (65%), positive attitudes (72%), but suboptimal clinical practices (58%), particularly in prescribing first-line therapies (e.g., triptans) and addressing lifestyle modifications. Striking disparities between government and private practitioners further emphasize systemic challenges, such as limited access to prophylactic drugs and time constraints for patient counseling.

Funding sources: None

Conflict of Interest: None declared

1. GBD 2021 Headache Collaborators. Global, regional, and national burden of migraine in 2021. The Lancet Neurology. 2023;22(3):212-225.
2. Singh, R., et al. Prevalence and determinants of migraine in urban and rural India: A cross-sectional study. Journal of Neurosciences in Rural Practice. 2022;13(4):567-574.
3. World Health Organization (WHO). Headache Disorders: Fact Sheets. Geneva: WHO Press. 2022.
4. Indian Academy of Neurology (IAN). Clinical Practice Guidelines for Migraine Management. Neurology India. 2021;69(7):S12-S28.
5. Dodick, D. W., et al. Migraine prevention and treatment: A systematic review of evidence-based guidelines. Cephalalgia. 2021;41(10):1029-1045.
6. Ahmed, B., et al. Knowledge gaps in migraine care: A survey of primary care physicians in South Asia. BMC Neurology. 202;21(1):45.
7. Kulkarni, G. B., et al. Barriers to optimal migraine management in India: A physician survey. Annals of Indian Academy of Neurology. 2020;23(4):451-456.
8. Patel, V., et al. Prescribing patterns for migraine in India: A national survey. Journal of Clinical Neuroscience. 2022;95:78-84.
9. National Health Profile. Ministry of Health and Family Welfare, Government of India, 2023.
10. Kumar, A., et al. Training needs assessment for headache disorders among primary care providers in Bihar, India. Journal of Headache and Pain. 2023;24(1):1-9.
11. Steiner TJ, Stovner LJ, Vos T, Jensen R, Katsarava Z. Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain. 2018;19(1):17.
12. Rao GN, Kulkarni GB, Gururaj G, Stovner LJ, Steiner TJ. The burden of headache disorders in India: methodology and questionnaire validation for a community-based survey in Karnataka State. Neurol India. 2016;64(Suppl 7):31-35.
13. Dodick DW. Migraine. JAMA. 2019;321(1):89-91.
14. Lipton RB, Munjal S, Buse DC, Bennett A, Fanning KM, Burstein R, Reed ML. Unmet acute treatment needs from the 2017 Migraine in America Symptoms and Treatment (MAST) Study. Neurology. 2020;94(11):e1201- e1210.
15. Adebayo PB, Akinyemi RO, Ogun SA, et al. Prevalence and predictors of migraine among a cohort of Nigerian undergraduate students. Niger J Clin Pract. 2019;22(4):522-528.
16. World Health Organization. ATC/DDD Index 2018. WHO Collaborating Centre for Drug Statistics Methodology; 2018.
17. Ahmed B, Fatima K, Ahmed AT, et al. Prevalence and clinical characteristics of headache in a rural community in Bangladesh. BMC Neurol. 2021;21(1):45.
18. Kulkarni GB, Rao GN, Gururaj G, Stovner LJ, Steiner TJ. Headache disorders and public ill-health in India: prevalence estimates in Karnataka State. Ann Indian Acad Neurol. 2015;18(4):451-456.
19. Ramakrishnan S, Zachariah G, Gupta K, et al. Prevalence of hypertension among Indian adults: results from the Great India blood pressure survey. Indian Heart J. 2019;71(4):309-313.
20. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Hypertension. 2003;42(6):1206-1252.
21. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224-2260.
22. Gupta R, Gupta VP. Hypertension epidemiology in India: lessons from Jaipur Heart Watch. Curr Sci. 2009;97(3):349-355.
23. Anchala R, Kannuri NK, Pant H, et al. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014;32(6):1170-1177.
24. Krymchantowski AV, et al. Impact of a National Headache Education Program on Adherence to ICHD-3 Guidelines in Brazil: A 3-Year Follow-Up. Headache Journal. 2021;61(5):789-797.
25. Oluoch L, et al. A Mobile Health Intervention for Migraine Management in Low-Resource Settings: A Cluster-Randomized Trial in Kenya." Neurology. 2022; 98(18 Supplement), S12.