Sex-related disparities in migraine recognition and management: insights from a tertiary headache center cohort

Migraine is a highly prevalent and disabling neurological disorder that is often underdiagnosed and undertreated, particularly in early stages of care. Sex-related factors may contribute to this gap. This study investigates sex-related disparities in migraine recognition and management before and after presentation at a tertiary headache center and examines whether these disparities are linked to differences in clinical presentation. In this retrospective cross-sectional study, we included patients diagnosed with migraine between December 2015 and January 2023 at the Headache Center of Charité – Universitätsmedizin Berlin. We analyzed sex-related differences in prior diagnosis, clinical presentation, migraine burden, and treatment strategies both before referral and following tertiary care evaluation. Among 1,130 patients with migraine (82% women, 18% men), men were significantly less likely than women to have received a migraine diagnosis prior to tertiary center evaluation (57.0% vs. 73.8%; OR = 0.47, p < 0.001). Clinical presentation also differed between sexes: men reported lower pain intensity and shorter attack duration, whereas women more frequently experienced unilateral headache, nausea, vomiting, photophobia, and osmophobia. In women, canonical migraine features (unilateral headache, pulsating pain, aggravation by physical activity, and migraine-associated symptoms) were each associated with lower odds of missed diagnosis before referral. By contrast, in men, pressing headache quality substantially increased the likelihood of missed diagnosis. Women were also more likely than men to have used triptans and received prophylactic treatment prior to tertiary evaluation. Men with migraine are substantially less likely than women to receive an accurate diagnosis in routine care. While canonical migraine features facilitate recognition in women, non-prototypical symptoms reduce diagnostic accuracy in men. These findings reveal a critical gap in clinical awareness that may contribute to persistent underdiagnosis and delayed treatment in men. Not applicable.