Why did you decide to focus your neurology practice on headache medicine?

Headache medicine is an intellectually challenging area in neurology. I also have personal experience with migraine and understand its impact on personal and professional functioning, which gives me a different level of clinical insight and perspective. My personal perspective evolved into a clinical and academic interest, particularly around diagnostic challenges, comorbidity management and a rapidly changing treatment landscape with the introduction of CGRP-targeted therapies, as well as the major impact evidence-based treatments can have on patients’ level of functioning and quality of life. Newer medications are lifechanging for many migraine patients, so this work is very fulfilling.

What would you like people to better understand about migraine?

It’s not just a headache. Migraine is a very complex, chronic neurological disease with recurrent, severe, disabling attacks of pain and associated symptoms such as nausea, vomiting and light and sound sensitivity. It’s also a primary headache disorder, which means it isn’t secondarily caused by something. There is no test to confirm the diagnosis; it is a clinical diagnosis. Unfortunately, migraine continues to be associated with significant stigma and misconceptions. Some believe patients use migraine as an excuse to avoid responsibilities or gain sympathy. They may also doubt it’s a real medical condition. Research has shown that experiencing stigma increases the risk of disability among migraine patients and contributes to greater interictal burden and reduced quality of life across all headache frequency categories.

Regarding treatment, it’s important to understand how and why we use medications. Acute treatments abort or reduce pain and associated symptoms, as well as disability associated with an individual attack. Preventive treatments are taken on a recurrent basis (e.g., daily, monthly or quarterly) to reduce the severity and frequency of attacks. Effective management using preventive medications helps decrease overall health-care resource utilization, as well as costs associated with migraine and related disability.

What is migraine’s impact on society?

Patients with migraine have high health-care resource utilization, prescription medication costs, healthcare provider visits, emergency room visits and diagnostic testing rates. It’s considered the second-leading cause of disability globally and the leading cause of disability among people under age 50. This is a disease with significant psychosocial, emotional, mental and physical impacts on the person, their family and their co-workers. Furthermore, people with migraine are at increased risk for comorbidities such as insomnia, depression, anxiety, chronic pain syndromes and more.

How can migraine affect people at work?

The health-care and productivity cost burden in Canada potentially exceeds $1 billion annually in some provinces,³ and work productivity loss accounts for a large share of indirect economic costs. Importantly, migraine is about 1.7 times more prevalent in women than in men, with peak prevalence among people in their 30s and 40s.2 That’s a time of life when many are thinking about starting a family, excelling in their careers, applying for promotions, and experiencing their most productive years at work. Yet patients report significant impairment in working and activity limitations due to migraine.

What are the barriers to diagnosis and treatment?

Migraine can be missed in busy primary care offices, walk-in clinics and emergency rooms, where visits are understandably brief. Just 36% of patients who meet criteria for chronic migraine (at least 15 headache days a month of which at least eight are migraine, for at least three months of a calendar year) consult a headache specialist and receive an appropriate diagnosis. Only about 16% of patients who consult a health-care professional who is not a headache specialist receive a diagnosis of chronic migraine.⁴

While there is no cure, effective use of acute and preventive medications can help reduce the severity and frequency of acute attacks, health-care resource utilization, costs associated with migraine and overall disability. But too many Canadian migraine patients are undertreated, with few using recommended acute or preventive medications.

Newer medications are more costly than some first-line oral generics, but they’re made specifically for migraine and tend to be better tolerated and more effective. For patients to gain access to them, however, we often have to cycle through two or more older medications, sometimes for up to three months’ duration. In addition, treatment initiation is frequently delayed while patients wait for confirmation their medication costs will be covered.

Every week that passes by before a patient starts optimal treatment means lost productivity, professionally and personally.

What can employers do to better support people with migraine?

In Canada, coverage for migraine treatments varies by province and territory and by employer-sponsored benefits plan. Employers can review and enhance health benefits to include newer acute and preventive therapies when clinically appropriate. They can provide coverage for allied health services such as physiotherapy and psychotherapy, which can support evidence-based, non-pharmacological management of migraine and comorbidities.

Ideally, they can also streamline the burden of paperwork, which is becoming unsustainable. Access to better-tolerated, higher-efficacy migraine therapies is often constrained by complex prior authorization processes, step therapy requirements and repeated documentation of therapeutic failures. This diverts substantial clinical time away from direct patient care and delays timely access to appropriate therapy for patients with this disabling disease.

How can workplace accommodations help people with migraine contribute their best at work?

Workplace accommodations can make a measurable difference by reducing common triggers, allowing earlier treatment and preventing acute attacks from escalating to prolonged, disabling events.

Flexible scheduling lets employees work during their most functional hours and rest as needed to avoid escalation. Allowing remote work if appropriate, through part-time or hybrid models, may remove triggers such as fluorescent lights, loud noises, odours, long screen exposure and shared environments. It may also allow rapid access to acute medications and rest time. Permitting short, unscheduled breaks to step away from screens, get water and take medication when necessary may prevent the need for a full sick day.

Softer lighting, natural lighting, desk lamps instead of bright overhead fluorescent lights and anti-glare screens can help with light sensitivity, which can be experienced between acute attacks. Quiet, low-stimulus work areas, noise reduction zones, noise cancelling headphones and private rooms instead of open cubicles can help with sound sensitivity, which may also exist between acute attacks. Scent-free environments are important as well.

Overall, accommodation policies that reduce triggers, allow flexibility and support early management of acute attacks can improve the employee’s quality of life, reduce disability, increase productivity and decrease long-term costs associated with chronic absenteeism and disability claims.