TOPLINE:

Patients with resistant and refractory migraine underwent more diagnostic tests, particularly neuroimaging, than those with non-resistant or non-refractory migraine; however, headache misdiagnoses, most often involving cervical spine disorders or sinusitis, occurred more frequently in non-resistant or non-refractory and resistant migraine cohorts than in the refractory migraine cohort.

METHODOLOGY:

• Using baseline cross-sectional data from a prospective study conducted across 15 European tertiary headache centres, researchers analysed 689 patients (median age, 46 years; 82.7% women) with episodic or chronic migraine between 2020 and 2022.
• Participants were categorised as those with refractory migraine (n = 73), resistant migraine (n = 261), or non-resistant or non-refractory migraine (n = 355) according to the European Headache Federation criteria.
• Previous diagnostic tests included brain and cervical spine MRI, brain CT, x-rays of the skull, and selected specialist consultations, and headache misdiagnoses included cervical spine disorders, sinusitis, temporomandibular joint disorders, and hormonal disturbances.
• The primary objective was to determine the number and proportion of participants who underwent diagnostic tests and/or received prior headache misdiagnoses.
• Clinical data for each participant were collected via structured interviews and the review of medical records at baseline and after 6 months.

TAKEAWAY:

• Overall, 48.7% of patients underwent a single brain MRI and 34.4% had multiple scans; cervical spine MRI was performed once in 28.1% and repeatedly in 8.9% of patients, and 34.3% underwent brain CT once and 18.2% underwent multiple times. Skull x-ray was performed once in 9.8% and multiple times in 2.5%.
• Among all participants, 28.0% had at least one prior headache misdiagnosis, most commonly cervical spine disorders (10.4%), followed by sinusitis (9.1%), hormonal disorders (4.6%), and temporomandibular joint disorders (3.0%).
• Misdiagnoses were frequently reported in those with resistant migraine (31.2%), followed by those with non-resistant or non-refractory migraine (28.5%) and those with refractory migraine (15.1%; P = .025).
• Misdiagnosis rates were not associated with patient characteristics such as age, sex, or disease duration; however, the performance of diagnostic testing varied by disease duration and the presence of chronic migraine or medication overuse.

IN PRACTICE:

"Our findings emphasize a need for better diagnostic accuracy and care pathway for all individuals with migraine and particularly for those most in need of effective prevention," the authors wrote.

SOURCE:

This study was led by Federico De Santis, University of L'Aquila, L'Aquila, Italy. It was published online on June 04, 2026, in Cephalalgia.

LIMITATIONS:

The use of baseline cross-sectional data may have introduced recall bias. Previous misdiagnoses and diagnostic tests were reported as either present or absent, which likely increased the risk for underreporting. The study did not use standardised definitions or central quality control for misdiagnoses.

DISCLOSURES:

This study received publication support from a grant provided by the Italian Ministry of Health — Ricerca Finalizzata 2021. Some authors declared receiving honoraria, honoraria for lectures and presentations, consulting fees, and research grants from various pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.