This survey was promoted by a panel of six headache specialists, members of the Italian Neurological Association for Headache Research (Associazione Neurologica Italiana per la Ricerca sulle Cefalee, ANIRCEF). The survey was administered in July 2024; it was distributed via email, accompanied by a cover letter, to 200 HCPs with certified expertise in headache across the Italian national territory. Results were collected and data were analyzed in September 2024.

Up to 125 participants answered the survey (response rate: 63%). Of these, 85 respondents provided complete information on specialty and geographic distribution.

The survey comprised 65 items focusing on disease perception, diagnosis and management of women with migraine, as well as strategies to improve the current care while considering the varying needs across different life stages and health conditions. The questionnaire was derived from a previously validated Delphi study (19). The characteristics of panelists involved in the original Delphi study were comparable to those of the current survey respondents in terms of migraine expertise and specialty distribution, and no further validation was deemed necessary. As in the original Delphi study, most of the items (n=57 statements) were assessed using a 4-point Likert scale to evaluate the level of agreement, with response options ranging from 1 (“Fully Disagree”) to 4 (“Fully Agree”). A priori consensus criteria were applied, with agreement defined as ≥67% of respondents selecting either “Partially Agree” or “Fully Agree”. In addition, the survey also included questions that required respondents either to select from multiple options or to rank available choices. (19).

Among the 85 HCPs who reported their specialty and geographic distribution, respondents were located across 13 Italian regions (68.2% from Northern Italy, 12.9% from Central Italy, and 18.8% from Southern Italy). The majority were neurologists (92%), with smaller proportions of other specialists, including clinical pharmacologists and internists (7%), who are involved in migraine care within specialized centers. Within the neurologist subgroup, 81% reported more than 10 years of experience in migraine management and 67% were based in hospitals or in migraine-specialized centers.

The complete results of the survey are presented in Supplementary Table S1 in Supplementary Materials. The following sections summarize the main findings.

Respondents believe that most women consider migraine either as a symptom of other disorders (59/125; 47.2%) or as a pathology (50/125; 40.0%), with a smaller proportion regarding it as a normal recurring condition (16/125; 12.8%; Q1). Most respondents (91/122; 74.6%) agreed that women with migraine are uncertain about where to seek appropriate care (Q2). The survey results confirm the substantial burden of migraine in women (Q3), with 93.3% (111/119) of respondents acknowledging its profound social impact, including reduced quality of life, impaired relationships, and the need for support, and 87.2% (102/117) recognizing significant work-related consequences (presenteeism, absenteeism and limited professional opportunities; Q4). Stigma also emerged as a critical concern (94/119; 81.0%, Q5).

According to 42.1% of respondents (48/114), women typically wait more than 5 years after symptom onset before undergoing their first medical assessment (Q6). Of even greater concern, 37.7% (43/114) reported that a diagnosis is made only after at least 1 year following the initial medical evaluation, and 14.0% (16/114) indicated diagnostic delays extending beyond 5 years (Q7). Access to headache specialists is also delayed: only 3.5% of respondents (4/114) reported that patients are seen within 1 month, whereas the majority indicated longer waiting times (6–12 months: 43/114; 37.7%; over 1 year: 21/114; 18.4%; Q8). Overall, the current care is widely judged as insufficient (86/114, 75.4%; Q9), characterized by lack of multidisciplinarity (97/114; 85.1%; Q10), lack of continuity of care (86/113; 76.1%; Q11), insufficient territorial medical references (84/113; 74.3%; Q12). The survey responses clearly reveal the heterogeneous and non-standardized nature of migraine care across Italy (103/113; 91.2%; Q13).

In most cases, respondents believe that the initial point of contact is a HCP other than a neurologist, most commonly the pediatrician for children (94/110; 85.5%), the GP for adolescents (80/110; 72.7%) and adults with menstrual or menstrual-related migraine (66/110; 60.0%), the gynecologist for adult women with migraine who are pregnant/breastfeeding (91/110; 82.7%) or are undergoing contraceptive therapy (85/110, 77.3%), or oncologist for women with migraine undergoing oncological treatment (99/110; 90.0%; Q14). Regardless of the current pattern of care, most respondents agreed that pediatric patients with migraine should ideally be managed by their pediatrician (71/109; 65.1%), while 53.2% (58/109) also identify the child neuropsychiatrist as a key reference figure for this age. From adolescence onward, respondents regard the neurologist as the principal point of reference for all female patients with migraine, with agreement across age life phases and health conditions ranging between 68.8% (75/109) and 88.1% (96/109). In patients with comorbidities or requiring specialized care, additional specialists, such as gynecologists for pregnant or breastfeeding women (84/109; 77.1%) and oncologists for women undergoing oncological treatments (82/109; 75.2%), should complement the role of neurologists. By contrast, non-clinical HCPs (e.g., pharmacists, psychologists) are generally not regarded as primary points of reference in migraine management (Q15).

The survey highlighted the importance of psychosocial, behavioral, and educational aspects for the optimal management of migraine in pediatric and adolescent female patients with migraine. Most respondents (104/109; 95.4%) agreed that social factors potentially triggering migraine attacks should be thoroughly investigated (Q16), and 92.5% (99/107) endorsed socio-behavioral interventions as the preferred first-line approach to prevent or reduce episodes (Q17). A combined socio-behavioral and pharmacological strategy was supported by 93.5% (100/107) of respondents when socio-behavioral measures alone are insufficient (Q18). According to 75.5% (80/106) of respondents, the psychologist should be consulted only in cases of suspected stress or anxiety (Q19), whereas 90.5% (95/105) of respondents endorsed psychiatrist involvement when a psychopathological disorder is suspected (Q20). The need to increase parental awareness of migraine and its symptoms strongly emerged as a unanimous priority (105/105, 100%; Q21).

Figure 1 presents a flowchart outlining the core components of an optimized diagnostic–therapeutic care pathway for pediatric and adolescent female patients with migraine, developed on the basis of the survey responses.

The management of migraine in adult women has been analyzed in relation to medical needs that may arise during adulthood (i.e., menstrual migraine, contraceptive use, fertility or oncological treatments) as well as physiological transitions, including menopause.

The need to guarantee continuity of care for women with migraine across all life stages strongly emerged from the survey's responses (92/93; 98.9%; Q43); management of patients should take place either in headache centers/specialized clinics (85/93; 91.4%; Q44) or through community-based care (85/93; 91.4%; Q45), while 97.9% (91/93) of respondents advocated for a shared-care model between headache centers and territorial facilities (Q46). The caregiver was also recognized as playing a key role in migraine management, as reported by 80.7% of respondents (75/93; Q47).

Digital health solutions were also considered relevant for strengthening collaboration among centers, including the use of a dedicated digital platform to facilitate communication and information sharing (80/93; 86.0%; Q48), and telemedicine (79/93; 84.9%; Q49).

Continuous education on migraine is widely regarded as essential across all healthcare levels, with strong support for mandatory training for pharmacists (79/93; 84.9%; Q51), GPs and pediatricians (89/91; 96.7%; Q54), and specialists (83/91; 91.2%; Q57). Nearly all respondents (89/91; 97.8%) highlighted the need for more evidence to guide migraine care in specific settings (i.e., women undergoing assisted reproduction or oncological treatments; Q59).

Raising awareness of migraine should also be prioritized, with broad support for the implementation of diverse initiatives (e.g., the use of social media platforms, the number of “headache awareness days”, the availability of questionnaires in pharmacies, agreement >85%; Q60–Q63). Nearly all respondents (93.4%; 91/91) agreed on the usefulness of providing women with a pamphlet outlining the significance of symptoms and the different phases of the patient journey (Q64). Respondents also identified other relevant themes, such as medical reference figures for migraine care (76/91; 83.5%), symptom neglect (61/91; 67.0%), socio-economic disease burden (51/91; 56.0%; Q65).

Figure 3 illustrates the fundamental pillars and correspondent practical strategies to improve the current management of migraine in women, based on the respondents' opinions.

The high burden of migraine among women in Italy has been consistently observed in both national and international studies (4–8, 17). A recent global analysis revealed that Italy was among the countries where the migraine burden remains higher than expected given available resources (20). This pattern has been largely confirmed by the surveyed HCPs, who also acknowledged the stigma surrounding migraine in women. Respondents also noted that many women misinterpret migraine symptoms and fail to recognize them as a genuine disease, contributing to delays in seeking professional care.

Despite the detrimental impact of migraine on the Italian female population, current care is far from being optimal. Respondents highlighted the lack of multidisciplinary approaches, poor continuity of care, and the absence of clear medical references.

Notably, the results suggest that most women initially consult a range of HCPs other than neurologists, reflecting their uncertainty in navigating the healthcare system. While GPs should serve as the primary point of contact for early recognition and preliminary management of migraine (21, 22), respondents consistently considered neurologists to be the ideal central medical reference for all women from adolescence onward, irrespective of age, comorbidities, or concomitant treatments.

Although less common than in adults, migraine still affects a substantial proportion of children and adolescents, with increasing prevalence from childhood to adolescence, particularly among females (23, 24). In pediatric patients, management strategies are generally similar between sexes; however, from adolescence onward, sex-related differences emerge, necessitating preferential involvement of the neurologist. In line with guidelines recommendations (25, 26), respondents have reiterated the importance of lifestyle and behavioral interventions, as well as enhanced education to avoid triggers and reduce headache frequency. Psychological support may be warranted in cases of anxiety or stress; indeed, anxiety and depression may coexist with migraine in children and adolescents (27), potentially contributing to headache persistence (28). Psychiatrists may also play a role in managing pediatric patients with psychiatric comorbidities (29, 30). Pharmacological therapy may also be considered (25, 26) although clinical trials have demonstrated a high placebo response in children and adolescents, leading to a lower overall therapeutic gain from medications (31). The key components of the ideal diagnostic–therapeutic care pathway for female pediatric patients as derived from the survey are summarized in Figure 1.

During adulthood, women's physiological changes and sex-specific medical conditions influence migraine patterns, thereby necessitating tailored care. Although management strategies are relatively well established for menstrual migraine, menopausal migraine, and migraine in women using contraceptives, they remain largely undefined in contexts such as pregnancy, breastfeeding, cancer therapy, and assisted reproduction. The framework presented in Figure 2 outlines the diagnostic-therapeutic priorities according to female life stages and clinical circumstances, as emerged from the survey responses and discussed below.

To improve migraine care in women, strategies should address three key priorities: (1) ensuring continuity of care, (2) strengthening healthcare professional training, and (3) promoting migraine awareness. Figure 3 summarizes the main strategies emerged from the survey's responses to address these priorities. Continuity of care between community services and specialized headache centers should be reinforced, with digital platforms and telemedicine supporting information exchange and shared management. Regular training is required to enhance knowledge of migraine, its diagnosis, and available treatment options among all HCPs involved in women's care. Involvement of key stakeholders such as healthcare systems and scientific societies is crucial to increase the number of training programs and educational initiatives to enhance HCPs' understanding of migraine in women. Practical steps may include offering national/local workshops led by headache specialists and developing practical tools to support clinical decision-making and encourage adherence to guidelines. Launching multidisciplinary educational campaigns in collaboration with relevant professional societies (e.g., neurology, primary care, gynecology) may also foster inter-specialty collaboration and expand the network of local HCPs equipped to manage migraine effectively. Equally important is the promotion of awareness among patients and the general public, both to strengthen recognition of migraine as a disabling neurological disorder requiring medical attention and to reduce the stigma that continues to surround women with migraine. Patient associations can collaborate with HCPs and policymakers to disseminate accurate, accessible information. Several strategies were perceived as valuable for increasing public awareness, including the use of social media platforms, a greater number of dedicated “headache awareness days”, and the availability of screening tools such as ID-Migraine questionnaires in pharmacies. An informative pamphlet designed for women with migraine could help accelerate diagnosis and promote optimal management by sensitizing patients to migraine symptoms and advising on appropriate HCP consultation. By simultaneously tackling these three key areas, meaningful progress can be made in improving care for women with migraine.

The key strengths of this study are the relatively large and diverse sample of Italian HCPs that responded to the survey. Although the majority of respondents were neurologists, the participation of non-neurologist professionals with proven experience in migraine care provided valuable multidisciplinary input. Future research should aim to involve a broader range of specialties to capture additional perspectives and further strengthen the multidisciplinary approach to migraine care.

In addition to the predominance of neurologists, most respondents were based in Northern Italy, within specialized centers. Consequently, subgroup analyses by specialty, region, practice setting, or years of experience were not feasible, as many subgroups included too few participants to allow for meaningful comparisons.

Additional limitations that may have influenced the findings and their interpretation include the potential for recall bias and the reliance on self-reported perceptions, which are inherently subject to personal interpretation and reporting inaccuracies. Moreover, the survey reflects the perspectives of expert HCPs only and does not incorporate patient views. Future studies would benefit from integrating patient-reported outcomes and preferences to provide a more comprehensive understanding of female migraine care needs.