The hallmarks of migraine: a paper and a wager

The story behind "Hallmarks of primary headache: part 1 – migraine"

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BioMed Central
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Hallmarks of primary headache: part 1 – migraine - The Journal of Headache and Pain

Background and aim Migraine is a common disabling conditions which, globally, affects 15.2% of the population. It is the second cause of health loss in terms of years lived with disability, the first among women. Despite being so common, it is poorly recognised and too often undertreated. Specialty centres and neurologists with specific expertise on headache disorders have the knowledge to provide specific care: however, those who do not regularly treat patients with migraine will benefit from a synopsis on the most relevant and updated information about this condition. This paper presents a comprehensive view on the hallmarks of migraine, from genetics and diagnostic markers, up to treatments and societal impact, and reports the elements that identify migraine specific features. Main results The most relevant hallmark of migraine is that it has common and individual features together. Besides the known clinical manifestations, migraine presentation is heterogeneous with regard to frequency of attacks, presence of aura, response to therapy, associated comorbidities or other symptoms, which likely reflect migraine heterogeneous genetic and molecular basis. The amount of therapies for acute and for prophylactic treatment is really wide, and one of the difficulties is with finding the best treatment for the single patient. In addition to this, patients carry out different daily life activities, and might show lifestyle habits which are not entirely adequate to manage migraine day by day. Education will be more and more important as a strategy of brain health promotion, because this will enable reducing the amount of subjects needing specialty care, thus leaving it to those who require it in reason of refractory condition or presence of comorbidities. Conclusions Recognizing the hallmarks of migraine and the features of single patients enables prescribing specific pharmacological and non-pharmacological treatments. Medical research on headaches today particularly suffers from the syndrome of single-disease approach, but it is important to have a cross-sectional and joint vision with other close specialties, in order to treat our patients with a comprehensive approach that a heterogeneous condition like migraine requires.

This was not the first time in which I coordinated a large effort on the Journal of Headache and Pain. Surely, this was the time in which I enjoyed more ... as the story begins and ends with a wager. 

The wager was to coordinate a complex task, in which the idea was to bring together a set of recognized experts in their respective fields, together with some "future experts", to get to a simple point: creating a "masterpiece" for migraine-related science. But also, creating a ground for a cultural position on the way in which migraine is approached. But also, combining different expertise and experiences, mixing that of recognized scientists and clinicians with that of people who are promising in their fields, the so called future experts. And, in the middle of this, we had to put together all of the knowledgeable about migraine. This could be quite complex, and boring: so, we turned it into a funny activity. And we did it.

Synthesizing a 47-page long paper is almost impossible, but here I wish to provide some ideas on the worth of this work. We decided that the idea behind the term "hallmarks" should not be strict, i.e. the most typical and distinctive sign and symptoms, but large: and we included issues related to personal impact, economic evaluation, workplace impact, pharmacovigilance...so not only a strict scientific and clinical paper, but a cultural one. Although simple, our conclusion on the most relevant hallmark of migraine, was that migraine has common and individual features together. The common ones basically include migraine clinical manifestations, i.e. unilateral location of headache, with pulsating quality, pain of moderate/severe intensity, which is aggravated by physical activity and associated to either nausea, photophobia or phonophobia. Apart from this, migraine is a land of heterogeneity, which likely reflects genetics and molecular bases, as well as the different exposure to environmental factors. All of this determines a variable response to treatments and the need to manage migraine with a multi-modal approach.

However, medical research on headaches particularly suffers from the syndrome of single-disease niche sub-specialties, determining a poor propensity for comparison among different disciplines and areas of intervention, including medical, behavioral and related to prevention in a public health perspective. The output of this monolithic approach is that research results might be brilliant, but yet lack a systematic project articulation. This is evident in the little to no interpretative vision of research findings, resulting in a reduced attractiveness of funding.

This is precisely the cultural value of the hallmarks of migraine paper: presenting an updated view on migraine knowledge with a paramount vision on the persons who suffer from it. Researchers and clinicians with an interest on migraine must have a cross-sectional and joint vision with other niche disease specialties and must stop relegating themselves to the role of fine technicians in the service of an organ or a function.

Presenting this view on migraine was our wager. We did it and we enjoyed while doing it: so enjoy reading as we enjoyed writing.

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Headache
Life Sciences > Health Sciences > Clinical Medicine > Neurology > Neurological Disorders > Headache
Migraine
Life Sciences > Health Sciences > Clinical Medicine > Neurology > Neurological Disorders > Headache > Migraine
SDG 3: Good Health & Wellbeing
Research Communities > Community > Sustainability > UN Sustainable Development Goals (SDG) > SDG 3: Good Health & Wellbeing

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Focus India

Headache disorders, especially migraine, constitute a major neurological health challenge and are increasingly recognized as leading contributors to disability worldwide. Their impact extends beyond episodic pain, influencing cognitive performance, emotional well-being, and overall quality of life. India carries a substantial share of the global migraine burden, yet remains affected by significant gaps in awareness, diagnosis, access to specialist care, and research output. Although global research has clarified many aspects of headache pathophysiology, the expression of these disorders varies across populations due to genetic, environmental, cultural, and healthcare access factors in the Indian context.

Migraine, in particular, demonstrates substantial heterogeneity in symptom patterns, triggers, and response to therapy, underscoring the need for population specific data. India’s vast and heterogeneous population offers a unique opportunity to generate locally relevant epidemiological, clinical, and translational insights. In many regions, underdiagnosis and inadequate treatment remain persistent problems, often compounded by stigma and limited awareness. Understanding the burden of headache disorders within specific communities in India is essential for designing effective public health strategies, improving diagnostic pathways, and tailoring management approaches. Moreover, the chronic nature of recurrent headaches places a significant economic burden on individuals and healthcare systems through lost productivity and frequent medical consultations. Through this Collection, we aim to stimulate nationally driven research, foster collaboration across institutions and care settings, and strengthen India’s contribution to global headache and brain health science.

Topics of interest include but are not limited to:

  • Epidemiology of migraine in India
  • Management strategies of migraine in Indian patients
  • Cultural perceptions of tension-type headache
  • Treatment approaches for cluster headaches
  • Trigeminal autonomic cephalalgias in diverse populations
  • Chronic daily headache management strategies
  • Impact of lifestyle factors on headache prevalence
  • Public health initiatives for headache awareness
  • Innovations in headache research methodologies

We welcome submissions from author groups with their main affiliated institution in India. Cross-international authorship groups are welcome to submit their work to The Journal of Headache and Pain outside of this Collection.

This Collection supports and amplifies research related to SDG 3, Good Health and Well-Being.

All submissions in this collection undergo the journal’s standard peer review process. Similarly, all manuscripts authored by a Guest Editor(s) will be handled by the Editor-in-Chief. As an open access publication, this journal levies an article processing fee (details here). We recognize that many key stakeholders may not have access to such resources and are committed to supporting participation in this issue wherever resources are a barrier. For more information about what support may be available, please visit OA funding and support, or email OAfundingpolicy@springernature.com or the Editor-in-Chief.

Publishing Model: Open Access

Deadline: Dec 01, 2026

Chronobiology of Headaches

The recurrence and associated clinical features of headaches are significantly affected by circadian rhythms and internal biological cycles in our bodies. Changes in the operation of our hypothalamus master clock and the periodic release of hormones due to genetic predisposition are likely to influence the cyclical manifestation of headache pain. There exists a bidirectional association between the frequency of headaches and the recurrence of the seasons. In this regard, headaches resemble other functional diseases, including mood disorders, anxiety, unpleasant gastrointestinal illnesses, and sleep disorders, among others. Circadian disruption is a significant contributor to headache recurrence. Irregular sleep-wake patterns, night shift work, and jet lag can lead to a state of circadian misalignment, where the body's internal clock is out of sync with external time cues.

This thematic series aims to investigate the neurological, genetic, and hormonal foundations, along with the clinical and morpho-functional correlations, of the association between chronobiological rhythms and the rhythmic occurrence of primary and secondary headache attacks. This is also considering the cyclical manifestation of other systemic and central illnesses that are significantly associated with headaches. Nonetheless, it will be intriguing to investigate novel behavioural strategies, potentially transdisciplinary, and pharmaceutical methods aimed at addressing these chronobiological factors. The exploration of how circadian entrainment and resetting can alleviate headache burden presents an important new frontier in treatment.

This Collection supports and amplifies research related to SDG 3, Good Health and Well-Being.

All submissions in this collection undergo the journal’s standard peer review process. Similarly, all manuscripts authored by a Guest Editor(s) will be handled by the Editor-in-Chief. As an open access publication, this journal levies an article processing fee (details here). We recognize that many key stakeholders may not have access to such resources and are committed to supporting participation in this issue wherever resources are a barrier. For more information about what support may be available, please visit OA funding and support, or email OAfundingpolicy@springernature.com or the Editor-in-Chief.

Publishing Model: Open Access

Deadline: Oct 31, 2026