Migraine is a primary headache disorder with complex pathophysiology and variable clinical manifestations. It impacts approximately 15% of population worldwide and up to 35% in Europe annually (1, 2). Migraine ranks as the world's second leading cause of disability and the primary cause among young women (3). Considering its widespread and growing prevalence leading to substantial burden, migraine management necessitates specialized healthcare services, which vary in accessibility and cost-effectiveness across and within countries (4, 5). Accessibility to migraine care is hindered by geographical constraints, a scarce number of headache specialists, and the requirement for frequent patient follow-ups (6–9). These barriers were exacerbated by the COVID-19 pandemic, which severely restricted traditional in-person medical interactions, underscoring the critical need for alternative healthcare delivery methods (10). In response, telemedicine has emerged as a viable solution, presenting the opportunity to overcome these challenges by enabling remote healthcare services and ensuring continuity and accessibility in migraine care (11, 12). With ongoing technological advancements, telemedicine use is expected to increase, particularly in headache management, where its implementation was already notable even before the pandemic (11, 13, 14).

Previous studies suggest that telemedicine for headache management is non-inferior to traditional in-person consultations in effectiveness. Additionally, the advantages of remote healthcare services, particularly saved time and expenses, are especially significant for patients with limited access to healthcare (15). To evaluate the impact of telemedicine on migraine management, we conducted a national e-survey in Lithuania. We hypothesized that telemedicine yields satisfactory disease management results for migraine patients and is underutilized in Lithuania. The study aimed to assess migraineurs' previous experiences with telemedicine and to identify potential barriers and facilitators for its wider implementation in the future.

Consistent with our hypothesis, the results of this study highlight a relatively low engagement in telemedicine for migraine management in Lithuania. Among those surveyed, 35.2% had at least one remote consultation, yet only 17% were consulted by a neurologist. This finding indicates a significant gap in telehealth usage in Lithuania, compared with 57.5% of respondents participating in telemedicine services reported in a survey by the American Migraine Foundation in 2020 (16). The modest adoption of telemedicine services in Lithuania may be attributed to the country's compact geography, which facilitates easier access to healthcare facilities. In contrast, larger nations, such as Norway and the USA, where healthcare facilities can be more remote, rely more heavily on telemedicine (8, 17, 18).

This study demonstrated that patients with more MHDs, chronic migraine and preventive treatment use, also with more severe headaches influenced by higher pain scores and increased monthly acute medication use were more frequently consulted remotely by GPs and neurologists. Similar outcomes, underscoring the association between migraine severity and the incidence of consultations with healthcare professionals, have been corroborated by other studies (19, 20). Moreover, our findings, which reveal that GPs consult headache patients remotely more frequently than neurologists, partially align with the migraine care model proposed by Ashina et al., which advocates for the management of the majority of headache patients within primary care settings (1). However, the implementation of these recommendations in Lithuania is facing significant obstacles. Our healthcare system mandates neurologists as the initial prescribers of reimbursed triptans for migraine attack treatment. Additionally, anti-CGRP/Rc monoclonal antibodies, a leading preventative treatment among those surveyed, are reimbursed for both episodic and chronic migraine prevention, necessitating regular neurologist follow-up every 3–9 months (1, 7). Therefore, our findings indicate a lower frequency of consultations with neurologists than might be anticipated or necessary for optimal care, pointing to a potential shortfall in migraine management within the Lithuanian healthcare framework. The study's results suggest several key factors contributing to the underutilization of teleneurology services. A significant portion of our study participants without telemedicine experience reported disinterest or even a personal opposition against remote consultations (69.7% and 12.2%, respectively) and 18% noted a scarcity of available services. These findings are contrary to other studies demonstrating significantly higher acceptance rates of telehealth in headache care from both patients and healthcare providers (16–18). The reluctance to adopt telemedicine in specific patient cohorts remain, mainly influenced by the lack of technological skills, data safety concerns, anticipated negative outcomes and other (21).

Multiple studies have supported the effectiveness and patient satisfaction with teleconsultations, in addition to some indicating no significant difference from in-person visits (11, 15, 22–24). In our study, the rates of prescribing new treatments proved to be lower compared to those reported in similar study by Chiang et al. (16). However, our data indicate that the overall experience with remote neurology consultations was more favorable, as neurologist prescriptions were 84.6% effective for acute and 70.0% for preventative medications, compared to 70.4% of effective GP-prescribed acute treatment. This discrepancy underscores the potential for improvement in GP training on headache management or in refining patient triage for specialist care. Other studies have reported significant treatment success through telemedicine, with effectiveness rates ranging from 40% to over 50% in Norway and China (22, 25). The marked diverge of our results from these findings could be explained by the difference in efficacy measures, notably, in our study, only perceived efficacy was evaluated in contrast to quantitative efficacy measures in previous studies. The observed higher referral rates to emergency departments (EDs) by GPs compared to neurologists may reflect GPs' roles as a primary point of contact for headache patients, possibly encountering more acute cases or exercising greater caution. This finding supports the expansion of telemedicine services to reduce headache-related ED visits (16). Moreover, there is a clear need for precise and universally applicable guidelines for assessing neurological emergencies and for strengthening communication between neurologists and GPs, an issue that could be addressed by adopting robust guidelines recommended in the Consensus Statement by Eigenbrodt et al. (7).

The necessity for some form of physical evaluation in headaches remains, even in a remote setting. Robblee et al. have significantly contributed to this aspect by detailing a process for remote physical examination, thereby enhancing the effectiveness of teleneurology in the management of primary headache disorders (26). Our study shows that 81.2% of remote neurologist consultations focused on follow-up care, mainly for treatment prescriptions. This indicates that initial visits are typically held in person, often necessitating physical examinations. Such a pattern may explain why some physicians prefer telephone follow-ups to primary remote consultations (17, 27). Nonetheless, the reliance on teleconsultations has its limitations as they cannot entirely replace in-person appointments, especially for crucial procedures like fundus assessment, which cannot be performed remotely (13, 26).

Respondents with previous teleconsultation experience were more likely to acknowledge the benefits of remote consultations, such as reduced transportation costs, the convenience of receiving consultations from home, and minimal disruption to daily schedules. Similar advantages, including improved access to headache specialist, a favorable safety profile and the option of an in-person follow-up, were also described in other publications (13, 28–31). Additionally, some evidence from study in Switzerland suggest that positive experiences with telemedicine can accelerate its broader implementation (32). Conversely, our data demonstrate that participants without telemedicine experience expressed greater concerns, including inadequate assessments, higher risk of misdiagnoses, and unsuitable treatments. Other perceived disadvantages previously reported in the literature include the absence of direct interaction, technical difficulties and costs associated with technology use (13, 28–32).

Our results align with previous studies (28, 30, 33) with 67.3% of respondents expressing a preference for mixed-mode appointments in the future. Contrary to the United States, where only 7.1% of headache patients declined telemedicine (16), 29.0% of our respondents expressed a preference for exclusively in-person consultations in the future. Manual work, lower education levels, higher medication intake were identified as key correlates that have also been summarized in other reviews (21, 34). An intriguing finding from our study emerged suggesting that respondents who had their primary neurology appointments remotely were less likely to choose teleconsultations in the future. A plausible explanation for this could be the absence of physical interactions, a component that patients often deem essential, underscoring the advantage of a hybrid approach that combines initial in-person consultations (13, 29, 30, 33). Furthermore, our study revealed that patients who identified more disadvantages in telemedicine care and had lower evaluations of previous remote experiences with a general practitioner (GP) showed a greater preference for in-person visits. This supports the findings of Reinhardt et al. in a scoping review, indicating that negative remote experiences influence future preferences (21). Notably, the potential impact of specific medical procedures, such as onabotulinumtoxinA injections and peripheral nerve blocks, on these preferences was also considered in our investigation. However, given their very rare application in Lithuania, it is unlikely that these treatments have significant effect on the inclination toward hybrid or contact-only consultations as observed among our respondents.

A mere 3.7% of participants indicated a preference for telemedicine-only consultations, pointing to limited prospects of fully remote headache management. This data diverge from findings in Portugal, where 12% of headache patients selected teleconsultations as their preferred medical visit model (30). In our study, the sole significant indicator suggesting a heightened patient preference for remote-only consultations was the perception of fewer disadvantages associated with telemedicine.

The strengths of this study are highlighted by its geographically comprehensive participant base from all Lithuanian regions and a substantial sample size of 847 migraineurs. It introduces novel data on the role of telemedicine in headache care, capturing patient experiences and perspectives on the benefits and drawbacks of remote management. These insights are pivotal for policymakers, offering a foundation to tailor healthcare policies toward effective telehealth integration in headache care. This study has some limitations. Internet-based surveys frequently encounter challenges related to demographic representativeness, exacerbated by disparities in age, internet accessibility and digital literacy (35). The lack of interpersonal engagement can contribute to discrepancies in question interpretation. The dependence on self-reported diagnoses and absent external verification introduces a potential bias that casts doubt on the veracity of the migraine diagnosis. There is an absence of detailed data to ascertain whether the choice of consultation method offered to patients applied to the first or follow-up consultations. Furthermore, our investigation does not differentiate between pre-pandemic, pandemic, and post-pandemic periods, marking a limitation that could have offered deeper insights into the evolving dynamics of telemedicine usage. Additionally, the recruitment strategy, leveraging specific online platforms and groups, might have biased the sample toward those more actively engaged in managing their condition.

In conclusion, our findings suggest that telemedicine contributes to effective and satisfactory migraine management, despite its limited use in Lithuania. Individuals who have utilized telemedicine for headache demonstrated a more positive perception toward this technology, recognizing a greater number of advantages, and fewer concerns about misdiagnosis or inappropriate treatment, compared to those who have not been consulted remotely. About one-third of participants remained hesitant about adopting telemedicine in the future, underscoring its potential disadvantages. These findings reinforce the idea that the attitudes and experiences of patients significantly shape their future consultation preferences.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethical approval was not required for the studies involving humans because as the anonymized nature of the data collection prevented individual identification, obtaining ethics approval was not required in accordance to the Vilnius Regional Biomedical Research Ethics Committee, adhering to Principle 26 of the General Data Protection Regulation. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and institutional requirements. The research was conducted via anonymized internet surveys due to the minimal risk and the preservation of participant anonymity, which inherently protects their privacy and confidentiality.

SA: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. DP: Conceptualization, Formal analysis, Visualization, Writing – original draft, Writing – review & editing. AD: Formal analysis, Visualization, Writing – original draft, Writing – review & editing. MJ: Writing – original draft, Writing – review & editing. KR: Conceptualization, Methodology, Supervision, Writing – original draft, Writing – review & editing.