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Abstract

Objective

To evaluate the eligibility of migraine for classification as a Primary Care-Sensitive Condition (PCSC), and to discuss the public health, clinical, and economic implications of this designation in enhancing access to care across different healthcare systems.

Background

Primary Care-Sensitive Conditions are health issues for which timely and effective management in primary care can reduce the need for hospitalization and specialist care. Although migraine is a leading cause of disability worldwide and frequently results in emergency visits and productivity loss, it remains underrecognized in PCSC classifications. This narrative review explores whether migraine fulfills the criteria for PCSC designation and how such recognition may contribute to improved outcomes and system efficiency, particularly in low- and middle-income countries.

Methods

We conducted a narrative review based on the five criteria established by Solberg and Weissman for defining PCSCs: (1) existence of evidence supporting primary care management; (2) public health relevance; (3) diagnostic clarity at the primary care level; (4) potential to avoid hospitalizations through early intervention; and (5) the possibility of hospitalization in severe cases. Global data on migraine epidemiology, diagnosis, treatment, and health system impact were analyzed in this framework.

Results

Migraine fulfills all five criteria for classification as a PCSC. It is highly prevalent and disabling, with substantial economic and social impacts. Diagnosis can be reliably established in primary care using the International Classification of Headache Disorders (ICHD-3) and screening tools like ID-Migraine™, while management is feasible through patient education and preventive strategies. Despite this, underdiagnosis, lack of provider training, and limited access to effective therapies — especially in resource-constrained settings — continue to drive unnecessary hospitalizations. Integrating migraine care into primary care has shown promising outcomes in pilot initiatives globally. Structured interventions, such as professional training and non-pharmacological strategies, have demonstrated cost-effectiveness and improved patient outcomes. Classifying migraine as a PCSC could guide policy reforms, enhance early intervention, and reduce reliance on emergency services.

Conclusion

Migraine meets criteria for a PCSC and recognizing that offers an opportunity to reframe policy, guide resource allocation and reduce avoidable hospitalizations decreasing the global burden of the disease by promoting timely diagnosis and improving equitable access to care. Strengthening primary care systems and embedding migraine management into routine practice are critical for achieving better health outcomes and more sustainable healthcare delivery.

Graphical abstract

This is a visual representation of the abstract.

Keywords

Primary health care migraine headache human health services accessibility

Introduction

Primary Care-Sensitive Conditions (PCSCs) refer to a group of health issues where timely and effective management within primary care settings can significantly reduce the need for hospitalizations and secondary or tertiary care interventions. These conditions are considered “sensitive” to the scope and capacity of primary care because early, proactive intervention at the community level improves health outcomes, minimizes complications, and lowers the likelihood of emergency department visits or hospital admissions (1,2).

Effective management of PCSCs involves practices such as early detection, continuous patient monitoring, education, and lifestyle modifications. These strategies not only enhance patient outcomes but also optimize healthcare resources by emphasizing prevention and early treatment, ultimately alleviating the burden on hospitals, specialists, and emergency services (3,4).

This review underscores the importance of clear definitions and consistent classifications of PCSCs to improve healthcare efficiency. As non-communicable diseases (NCDs) continue to rise globally, identifying and classifying specific conditions as PCSCs becomes increasingly essential for enhancing patient outcomes and ensuring cost-effective care delivery.

Migraine, a highly prevalent and disabling neurological disorder, is a compelling candidate for inclusion as a PCSC. Migraine is among the most common neurological disorders, affecting 1.16 billion individuals worldwide. It is recognized as a major cause of disability, ranking first among individuals aged 5 to 19 years and second among adults aged 20 to 59 years (5). The disorder presents substantial social and economic challenges, largely driven by missed workdays, diminished productivity, and frequent emergency department visits for acute pain management (5).

Classifying migraine as a Primary Care-Sensitive Condition would enable healthcare systems to prioritize early intervention at the community level, reducing avoidable hospitalizations and emergency visits while alleviating overall healthcare costs (6,7). Beyond cost reduction, this approach supports timely management, prevents progression to chronic disability, and enhances quality of life for those affected (8,9). Importantly, such recognition would also elevate migraine within public health agendas, making its burden visible, facilitating the monitoring of inequalities, and guiding the allocation of resources, training, and funding to strengthen primary care (10).

History of the PCSC concept

The concept of using health outcomes as indicators of system performance emerged in the 1970s with the proposal of sentinel health events—deaths considered avoidable given available medical interventions, interpreted as signals of potential deficiencies in care delivery (11). Building on this idea, the notion of “avoidable” or “preventable” hospitalizations was introduced in the United States in the early 1990s, highlighting that many admissions could be prevented with timely access to effective ambulatory care (12). Soon after, analyses of hospital discharge data identified a set of 12 avoidable hospital conditions defined under ICD-9-CM, showing higher rates among uninsured and Medicaid patients (13). In 1993, the Institute of Medicine incorporated this approach into its framework by recommending hospitalizations for Ambulatory Care Sensitive Conditions (ACSCs) as outcome indicators of access to primary care (14). The underlying rationale is that timely and effective primary care can prevent, treat, or control selected acute, chronic, and vaccine-preventable conditions, thereby reducing the risk of unnecessary hospitalization (13 –15).

The terms PCSCs and ACSCs are used interchangeably in the literature, both describing diagnoses for which hospitalizations could be avoided with timely and effective out-of-hospital care. The choice of terminology usually reflects the organization of each health system. In practice, the two terms are conceptually equivalent and serve the same purpose as indicators of health system performance (11,16 –18).

The classification of conditions considered sensitive to ambulatory or primary care varies by country and is determined by the scope of available services and the structure of the health system in each context (11,16). In general, the development of these lists follows a similar process, beginning with a literature review to identify candidate conditions, followed by structured consensus methods such as expert panels or Delphi surveys (17). Methodological differences are frequent and contribute to variability across countries: for instance, while some lists include acute, chronic, and vaccine-preventable conditions, others restrict the scope to chronic diseases only (16,17). The criteria proposed by Solberg (19) and Weissman (13) are often used to guide the selection of conditions, recommending (i) the existence of previous studies, (ii) clarity in the definition and coding of diagnoses, (iii) represent a relevant public health burden, (iv) the hospitalization is potentially avoidable by timely and effective ambulatory care, and (v) require hospitalization when the health problem occurs. Spain (20) and Germany (21,22) explicitly incorporated these criteria into their national lists, while Brazil (18) applied a similar framework but added a sixth requirement, namely the absence of financial incentives. In contrast, other countries, including the United States (15), Canada (23), Australia (24), Portugal (17), and the United Kingdom (25,26), developed their lists mainly through expert consensus, Delphi processes, or pragmatic adaptations of existing international models, without direct reliance on Solberg and Weissman. This diversity illustrates that, while the guiding principles are shared, the operationalization of ACSC/PCSC lists remains strongly influenced by local contexts and methodological choices.

The most widely adopted conditions across countries are relatively consistent, including asthma, chronic obstructive pulmonary disease, congestive heart failure, angina, hypertension, diabetes complications, pneumonia/influenza, gastroenteritis/dehydration, iron-deficiency anemia, pyelonephritis, and vaccine-preventable diseases. Still, methodological approaches differ: some lists are limited to chronic diseases, whereas others also include acute and vaccine-preventable conditions, leading to important variability (16).

Migraine and other headache disorders are not commonly included in lists of PCSCs (16). However, in Germany, a consensus study published in 2015 formally incorporated migraine and other headache syndromes as PCSCs (22), not only recognizing their potential for effective management at the primary care level but also acknowledging them as an important cause of hospitalizations that could be avoided through timely and appropriate ambulatory care.

Migraine meets the criteria for a PCSC

Scientific evidence

There is robust scientific evidence supporting the management of migraine at the primary care level. Early intervention has been shown to improve outcomes, reduce disease progression, and minimize the need for specialist referrals and hospital admissions. In Brazil, a public health initiative in the North Region of the Federal District achieved a 95% reduction in neurology consultation waitlists within 18 months by empowering primary care providers to manage headache disorders effectively (27). In Europe, it is estimated that with appropriate support and training, primary care can meet the needs of up to 90% of patients presenting with headache, most of whom have migraine (28). Headache is the most common neurological symptom seen in primary care (29), and general practitioners should possess the necessary basic skills to diagnose migraine to rule out secondary causes and to apply evidence-based treatment algorithms (30). An European multicentric study revealed that 72% of migraine patients referred to specialized headache centers had been incorrectly diagnosed by general practitioners (30), and in Austria, France, and the UK, fewer than 10% of eligible patients received preventive treatment in primary care settings (31).

These gaps underscore the urgent need for better training and implementation of evidence-based practices. The “Lifting The Burden” (LTB) campaign has demonstrated that even basic training can significantly enhance the confidence and competence of primary care professionals in managing migraine, with sustained improvements in clinical outcomes and cost-effectiveness through reduced resource wastage (32,33).

Further supporting this view, evidence from Estonia evaluated the impact of a structured educational program for general practitioners (GPs) in headache management. The initial study showed that after the intervention, GPs ordered significantly fewer diagnostic investigations (from 26% to 4%), initiated treatment more often (from 58% to 81%), and used more specific diagnoses such as migraine and tension-type headache instead of vague terms like “pericranial myalgia.” Although referral rates showed a downward trend, the overall reduction was not statistically significant at that time (33). A follow-up study three years later confirmed the durability of these effects, demonstrating not only sustained but in some cases enhanced improvements. Importantly, referral rates decreased significantly from 39.5% at baseline to 19.9%, the use of precise diagnostic categories increased further, and the inappropriate use of “pericranial myalgia” virtually disappeared. However, a partial resurgence in laboratory testing was observed, suggesting that while the benefits of medical education persist for several years, reinforcement at intervals of 2–3 years may be necessary to maintain best practices (32).

Complementary evidence comes from another study, which assessed the effectiveness of a brief intervention (BI) delivered by GPs to patients with medication-overuse headache (MOH). The intervention, conducted during a single consultation lasting approximately nine minutes, aimed to raise awareness about the risks of MOH and to encourage patients to reduce medication use. After three months, the brief intervention demonstrated significant clinical benefits compared with usual care. Patients in the intervention group experienced a mean reduction of 7.3 headache days and 7.9 days of medication use per month. Strikingly, 50% of patients receiving BI no longer met criteria for chronic headache, compared with only 6% in the usual care group. Furthermore, 67% of those in the intervention arm no longer fulfilled the criteria for medication overuse, versus just 3% in the control group (34).

Together, these findings confirm that migraine can be effectively managed at the primary care level when appropriate resources, training, and care models are in place.

Ease of diagnosis

Migraine can be effectively diagnosed at the primary care level using internationally validated tools. The International Classification of Headache Disorders (ICHD-3) provides detailed diagnostic criteria that can be applied in routine consultations to distinguish between different headache types based on a thorough patient history (35). Screening instruments such as the ID-Migraine™ (Table 1), a validated three-question tool focusing on nausea, photophobia, and functional disability, may assist in identifying patients likely to have migraine, with a sensitivity of 81% and a positive predictive value of 93% (36). However, as noted in the literature, ID-Migraine is a screening rather than a diagnostic instrument and should only be applied after secondary headache “red flags” have been excluded. In this context, its role must be interpreted cautiously: reliance on ID-Migraine™ without subsequent confirmation using ICHD-3 criteria risks reinforcing simplified approaches that may inadvertently replace the structured diagnostic process. Since primary-care providers can and must apply ICHD-3 criteria to establish a definitive diagnosis, the value of ID-Migraine™ lies primarily in raising suspicion of migraine rather than serving as a stand-alone tool. The absence of measurable biomarkers for migraine reinforces the need for careful clinical evaluation, appropriate training, and structured follow-up to ensure diagnostic accuracy and avoid overlooking secondary causes (22).

Table 1.

Overview of the three-item ID migraine™ screening tool for primary care.

Three-Item ID Migraine™ Screener	Description
Purpose	A validated and reliable screening tool for identifying migraine headaches.
Questions	Do you feel nauseated or sick to your stomach when you have a headache? Does light bother you more than when you don’t have a headache? During your headaches, does it limit your ability to work, study, or function normally?
Ease of Use	Simple to administer during routine consultations.
Sensitivity and Predictive Value	High sensitivity (81%) and positive predictive value (93%).
Impact on Primary Care	Helps improve migraine recognition, facilitating timely diagnosis and treatment.

These tools, when applied appropriately, demonstrate that accurate diagnosis in primary care is achievable, facilitating early intervention and reducing the need for specialist involvement, while preventing progression to chronic migraine or medication overuse headache.

Accurate recognition of migraine is crucial, as patients who were initially misdiagnosed had substantially higher healthcare utilization and costs compared with those diagnosed correctly. Misdiagnosis occurred most frequently in the outpatient setting and was largely attributed to primary care providers, underscoring the challenges of distinguishing migraine from conditions such as sinusitis, nonspecific headache, or cervical pain. These diagnostic errors led to nearly double the rate of emergency visits, a sixfold increase in neurologist consultations, and significantly greater inpatient and outpatient expenditures. Such findings emphasize that improving diagnostic accuracy at the first point of care can reduce unnecessary resource use, financial burden, and delays in effective treatment for patients with migraine (37).

Public health relevance

Migraine presents a global public health challenge, being the second leading cause of disability worldwide and the leading cause in individuals under 50 years of age (5). The burden of migraine is particularly concerning, with a prevalence of 14.7 among the adult population (38). Despite its high prevalence, headache disorders, including migraine, have been historically underrecognized in public health policies, leaving a gap in care delivery.

Migraine is associated with significant socioeconomic costs, contributing to absenteeism, reduced productivity, and increased healthcare utilization.

The chronic nature of migraine severely impairs quality of life and frequently renders individuals unable to perform daily activities, resulting in absenteeism, diminished workforce efficiency, and increased reliance on healthcare services. In Latin America, migraine emerges as one of the leading contributors to the socioeconomic burden, responsible for productivity losses equivalent to approximately 1.5–2% of GDP across the region in 2022. These losses, largely driven by presenteeism and absenteeism, extend beyond missed workdays to encompass frequent emergency department visits and dependence on specialized care. Although migraine does not directly increase mortality, its productivity losses are comparable to those of neoplasms, underscoring its profound impact on workforce output and overall economic performance (39).

Integrating migraine care into primary settings can alleviate the burden on emergency departments, ensuring that patients receive timely treatment and preventing unnecessary hospitalizations. By empowering primary care teams, healthcare providers can reduce the likelihood of chronic migraine development and avoid medication overuse complications, improving patient outcomes and healthcare efficiency.

Primary care resolution capacity

Primary care providers (PCPs) are crucial in managing migraine by offering comprehensive and preventive care, ensuring that patients receive timely intervention to avoid the need for hospital-based treatment. Research shows that most migraine cases can be effectively managed within primary care, preventing progression to chronic migraine and complications such as medication overuse headache, both of which increase disability and healthcare costs (40,41).

While international evidence demonstrates the effectiveness of pharmacologic treatments—such as triptans and CGRP inhibitors—in primary care settings (40), it is important to note that these medications are not available in many countries. This limitation poses significant challenges for the management of migraine in Low-middle income countries (LMIC), where PCPs must rely on more accessible, but less targeted treatment options, reducing the effectiveness of care and increasing the risk of disability.

The absence of such therapies in primary care makes it even more essential to empower PCPs with diagnostic skills, patient education tools, and preventive strategies to manage migraine effectively using available resources. Strengthening PCPs’ ability to provide early and continuous care is critical to reducing the frequency and severity of migraine attacks and avoiding unnecessary referrals to tertiary services (35). Additionally, educating patients about lifestyle modifications and offering consistent follow-up helps mitigate the burden of migraine, ensuring better long-term outcomes despite limited access to specialized treatments.

PCPs can optimize healthcare resource utilization by triaging uncomplicated cases and referring only complex situations to specialists. This aligns with the principles of PCSCs, emphasizing early intervention and continuous management to prevent complications, reduce hospitalizations, and promote equitable access to care. Reinforcing primary care migraine management is essential to address healthcare disparities and ensure timely, effective treatment even in resource-limited environments.

Hospitalization requirement in severe cases

Although most migraine cases can be effectively managed within primary care, hospitalization may be necessary in more severe situations, such as status migrainosus or medication overuse headache. These cases often present with prolonged or treatment-resistant attacks, requiring advanced interventions that exceed the capabilities of primary care providers.

Headache consistently represents a meaningful share of ED demand—typically 1,2–3,2% of all visits across datasets and hospitals (42 –48). In U.S. national surveillance for 2009–2010, “headache or pain in the head” was the fourth most common reason for ED presentation, accounting for 3.1% of encounters (48). Among ED headache visits, migraine emerges as the leading specific primary diagnosis (roughly 17–70% across studies), yet a large fraction of cases leave without a definitive label and are coded as “unspecified headache” (42 –44,46,47,49,50).

Hospital admission after an ED visit for headache tends to be low to moderate (about 4–8%) (43,44,49). By contrast, imaging demand is high—particularly head CT—so that in general headache cohorts roughly 43–57% of patients receive a scan (43 –46,49).

Additionally, recurrent visits to the emergency department (ED) due to headache significantly increase the likelihood of hospitalization. In a study conducted at a tertiary hospital, patients with more than one ED visit for headache within a year were over three times more likely to be hospitalized than non-recurrent patients. These hospitalizations incur substantially higher costs, with inpatient treatment averaging 11.7 times the cost of a single ED visit (51).

System organization—not just volumes and tests—strongly shapes ED demand for headache. Where primary care access is limited, ED use rises (45,46,52). In a U.S. Medicaid cohort, residence in counties with fewer general practitioners independently increased the odds of ED use for migraine, and a greater number of hospitals also correlated with higher ED reliance (52). In London, patients frequently reported difficulty obtaining timely GP appointments, low confidence in GP expertise, and fragmented continuity (locum coverage); these reports appeared alongside a ∼14% increase in headache admissions over five years (46). In Ireland, most outpatient neurology referrals originated in general practice (≈83%), yet many patients arrived with prior imaging while fewer than 30% had attempted preventive therapy and documentation was often incomplete—clear pathway gaps before the ED (45). Complementing this, a Swiss prospective study showed that about half of patients who already met migraine criteria had never been formally diagnosed before their ED visit, underscoring missed upstream opportunities (50).

Evidence from the United States shows that rural populations rely disproportionately on emergency departments for migraine care and often receive suboptimal treatment, including a higher use of opioids. These disparities are linked to socioeconomic vulnerability, reduced access to neurologists, and limited availability of preventive care. Such findings highlight the risks of leaving migraine management dependent on emergency services and reinforce the need to strengthen primary care as the first point of contact (53).

Implications are direct: when first-contact care cannot provide timely diagnosis and early prevention, the ED becomes a substitute. Building rapid-access community headache pathways, supporting GPs with concise diagnostic and treatment tools, and standardizing referral information can shift care toward earlier diagnosis and effective outpatient management—reducing low-value testing and the need for admission.

Current limitations and barriers to including migraine in PCSC lists

Historical exclusion of headache disorders

Despite migraine high prevalence and disabling burden, headache disorders have historically been excluded from most PCSC lists (15,17,18,20,21,23 –26). This omission has likely been influenced by a persistent under recognition of their population-level impact, limited training and support for headache diagnosis and management in primary care, and the perception that optimal care requires specialist involvement—factors that collectively deprioritize headache within primary-care–sensitive policy agendas.

Need for policy changes and awareness campaigns

Policy reforms are necessary to incorporate migraine into PCSC frameworks. Primary care providers require enhanced training to diagnose and manage migraine effectively. Additionally, public health campaigns can reduce the stigma associated with migraine and highlight the importance of treating it as a serious medical condition. These campaigns should aim to raise awareness among both healthcare providers and the public about the value of including migraine in PCSC classifications.

Pilot studies are recommended to evaluate the impact of this inclusion, focusing on reductions in hospitalizations and emergency visits, along with improvements in patient outcomes and quality of life.

Strategies for treatment with available resources

Despite advances in migraine diagnosis and management, significant barriers continue to prevent many patients from receiving adequate care. These obstacles arise at multiple levels, including limited access to healthcare professionals, delays in diagnosis, and insufficient treatment options. For example, the Chronic Migraine Epidemiology and Outcomes (CaMEO) study revealed that fewer than 5% of individuals with chronic migraine successfully navigate the full care pathway, which includes obtaining consultations, accurate diagnoses, and appropriate acute and preventive treatments (54). Such systemic inefficiencies and resource limitations leave the majority of patients underserved, highlighting the urgent need for improved healthcare delivery.

Socioeconomic disparities further exacerbate these challenges. A lack of health insurance often prevents individuals from accessing effective therapies, while those with access still face inconsistencies in diagnosis, particularly affecting men and lower-income populations. For instance, studies indicate that women are more likely to receive a migraine diagnosis than men, even when presenting with similar symptoms (55). Additionally, logistical barriers and limited public awareness contribute to low consultation rates, perpetuating a cycle of misdiagnoses and untreated conditions.

The appropriate use of available medications remains crucial. Even less specific treatments, when used timely and correctly, can provide meaningful relief and prevent migraine from progressing to chronic forms. Early intervention not only improves quality of life but also enhances the effectiveness of preventive strategies, which are essential for reducing the frequency and severity of episodes. By combining acute and preventive approaches, it is possible to optimize outcomes and mitigate the risk of complications, such as medication overuse headaches (MOH), in resource-constrained settings (40).

Moreover, innovative therapies such as CGRP monoclonal antibodies remain entirely unavailable in the public healthcare systems of many low- and middle-income countries, leaving numerous patients without access to modern, evidence-based treatments (56).

Preventive strategies must be emphasized as a cornerstone of migraine management, not only to reduce the long-term burden of the disease but also to enhance the effectiveness of acute treatments (40). By prioritizing preventive care and leveraging the resources currently available, clinicians can bridge the gap between existing limitations and effective migraine management, enabling better outcomes even within resource-constrained systems.

Non-pharmacological strategies are a fundamental component of migraine management, providing valuable options to complement pharmacological treatments. Lifestyle modifications and physical activity have demonstrated a protective effect against migraine, contributing to improved overall health and better management of symptoms (40).

By incorporating non-pharmacological approaches into migraine management, clinicians can provide more comprehensive care that empowers patients to actively participate in their treatment. These strategies, alongside pharmacological interventions, create a holistic framework for improving long-term outcomes and quality of life in patients with migraine (56).

Global approaches to headache management

In Europe, structured headache services employing a three-tier system have been proposed to provide cost-effective and equitable care (57). This system begins with Level 1 providers, typically primary care physicians or, in some countries, clinical officers or nurses. With basic training in headache management, these providers are equipped to diagnose and treat most common primary headache disorders, such as tension-type headaches and less severe migraine, while identifying secondary headaches that require further investigation. Level 2 providers, often general neurologists or physicians with additional theoretical and practical training in headache medicine, manage more complex primary headaches and some secondary headache disorders, representing approximately 8–10% of cases. Finally, Level 3 providers, who are highly specialized physicians in academic medical centers, focus on the remaining 1–2% of cases involving rare or highly complex primary headaches, as well as the full spectrum of secondary headache disorders (28). Pilot programs implementing this system in countries such as the Netherlands, Russia, and Georgia have demonstrated promising outcomes (57).

In the Netherlands, a study on the cost-effectiveness of using migraine-trained nurses for follow-up in primary care practices found that while practice-specific costs increased, total costs at a societal level were likely to decrease. This model also enhanced service capacity at the primary care (level 1) level, allowing more efficient allocation of resources (58).

In Russia, the Yekaterinburg Headache Initiative, launched in 2012, aimed to address the high burden of headache disorders through three main goals: increasing government awareness of headache as a public health issue to gain political support, implementing the three-tier model of headache care, and developing educational initiatives for primary care providers, nonspecialist neurologists, pharmacists, and the general public. Despite challenges in securing government support, the initiative holds promise as a scalable model for improving headache care both regionally and nationally (59).

In Georgia, where no healthcare provision for headache previously existed, two level-3 specialty headache clinics were established with support from the LTB. These clinics served as a foundation for building capacity in levels 1 and 2. Unexpectedly, their success inspired other non-state agencies to open additional headache clinics, significantly expanding access to care for patients who had previously gone untreated. Furthermore, lobbying efforts with pharmaceutical companies led to substantial reductions in the cost of triptans, transforming these essential medications from being scarcely used to widely affordable and accessible (57,60).

The Americas exhibits substantial variations in migraine prevalence and treatment accessibility. A Pan-American study, the Americas’ Migraine Observatory Study (AMIGOS), found that Brazil, Canada, and the United States have some of the highest migraine prevalence rates in the region, with Brazil reaching 14.1%. Despite these numbers, underdiagnosis and limited access to effective therapies remain common challenges, particularly in low- and middle-income countries. Addressing these gaps requires standardized protocols and greater investment in public health education and training for healthcare providers (61).

In Asia, countries like India and Nepal report high prevalence rates of headache disorders, yet access to care remains limited, particularly in rural areas. In China, the implementation of the “SMART” program (Screen, Migraine, Aura, Red flags, and Treatment) has emerged as a promising approach to improving headache management. This systematic disease management model standardizes the screening, diagnosis, and treatment of migraine, providing neurologists with clear protocols to enhance care delivery. A key component of the program is its continuing medical education initiative, which has trained over 600 rural and urban neurologists with a specific interest in headache medicine. Another cornerstone of the program is the “train-the-trainer” model, where trained neurologists return to their communities to educate other local healthcare providers, thereby disseminating knowledge and promoting effective headache management at the primary care level (level 1). This combination of structured training and knowledge transfer has demonstrated significant potential for scalability and adaptability, particularly in resource-constrained or low-income settings (62).

These examples highlight the importance of investing in primary care as the cornerstone of headache management. Empowering Level 1 providers through education and resources ensures timely diagnosis and treatment for most patients, reducing the burden on specialized services. Strengthening primary care not only enhances access and equity but also provides a cost-effective and scalable approach to addressing the global burden of migraine, particularly in resource-limited settings.

Technology and innovation

Telemedicine to support primary care

Telemedicine has proven to be a viable tool for the diagnosis and management of headache disorders, particularly migraine, within primary care. Adapted neurological examinations, conducted via virtual platforms, allow clinicians to assess key aspects such as cranial nerve function, motor and sensory deficits, and headache-related red flags. Although these evaluations may lack the depth of in-person examinations, they provide sufficient information in most cases to establish a diagnosis and initiate appropriate treatment (63).

The advantages of telemedicine are particularly evident in migraine care. Virtual consultations enable timely access to healthcare, reduce logistical barriers such as travel time, and allow patients to be evaluated in their own environments, minimizing exposure to triggers like bright lights or noise. Telemedicine also facilitates follow-up visits, ensuring continuity of care for chronic migraine patients. Furthermore, it supports interdisciplinary approaches by enabling collaboration between primary care providers and headache specialists (63).

However, some limitations remain. The inability to perform certain physical tests, such as fundoscopy or detailed sensory exams, and the reliance on stable internet connections can pose challenges. Despite these drawbacks, telemedicine is a valuable alternative, especially in underserved regions, where access to headache specialists is limited. By integrating telemedicine into primary care, healthcare systems can expand assistance to headache patients, reduce diagnostic delays, and improve equity in migraine management (63).

Potential for artificial intelligence in screening and management (64)

Artificial intelligence (AI) holds significant promise in enhancing the screening, diagnosis, and management of headache disorders, particularly migraine. Through machine learning (ML) algorithms, AI has been applied to classify headache disorders with impressive accuracy, reaching over 90% in some studies. These models utilize diverse datasets, including patient-reported symptoms, medical records, and neuroimaging data, allowing for tailored diagnostic approaches. For example, ML models have demonstrated the ability to distinguish between migraine, tension-type headaches, and secondary headaches, providing a valuable decision-support tool for primary care providers, especially those with limited experience in headache management.

Beyond classification, AI is increasingly being explored for predicting headache trajectories and treatment responses. Algorithms can analyze patterns in patient data to forecast headache onset, leveraging inputs such as triggers, premonitory symptoms, and wearable sensor data. Although early results in headache forecasting remain modest, the feasibility of such models suggests they could play a pivotal role in personalized headache management by enabling timely preventive interventions.

AI's applications extend to optimizing treatment selection. Predictive models have been used to identify likely responders to specific therapies, such as CGRP monoclonal antibodies or botulinum toxin A. These advances could streamline treatment pathways, reduce trial-and-error prescribing, and enhance patient outcomes.

Despite its potential, AI's integration into clinical practice faces challenges, including the need for high-quality, harmonized datasets and the development of user-friendly tools that align with clinical workflows. Ethical considerations, such as data privacy and algorithmic transparency, are critical to fostering trust among patients and healthcare providers. Addressing these challenges is essential to unlocking AI's transformative potential in headache care, particularly in resource-limited settings where primary care serves as the first point of contact.

Economic and health system impact of classifying migraine as a PCSC

Cost Savings:

Early and effective management of migraine in primary care is expected to reduce the cost for healthcare systems. By preventing frequent emergency department visits and hospital admissions, the burden on secondary and tertiary healthcare facilities is reduced (32,33).

Economic models from other PCSCs, such as asthma and diabetes, indicate that timely primary-care intervention can lower system costs; by analogy, similar effects are plausible for migraine—particularly when prevention and patient education are emphasized (6).

Improved Patient Outcomes:

Classifying migraine as a PCSC would likely lead to improved patient outcomes, including fewer migraine attacks, reduced disability, and enhanced quality of life. These improvements also translate into increased workforce productivity, with fewer days lost to migraine-related illness, thus benefiting both individual patients and the broader economy (16).

Conclusion and future directions

Summary of Key points

Migraine meets all the criteria for classification as a PCSC, given its high prevalence, burden on patients and healthcare systems, and the ability to manage it effectively in primary care. By updating PCSC lists to include migraine, healthcare systems can optimize the management of this condition, reduce unnecessary hospitalizations, and improve overall health outcomes. Beyond clinical effectiveness, its recognition as a PCSC would bring migraine into the center of public health agendas, making its burden visible, enabling the monitoring of inequalities, and guiding the allocation of resources, training, and funding to strengthen community-based care.

Call to action

Policymakers and healthcare organizations should prioritize the inclusion of migraine in PCSC lists to improve care pathways for this prevalent condition. Further research is needed to assess the long-term impact of classifying migraine as a PCSC, particularly in diverse healthcare settings. This research should focus on how such a classification could improve patient outcomes, reduce hospital strain, and lead to healthcare cost savings in the long run.

Article highlights

Migraine meets internationally established criteria for classification as a Primary Care-Sensitive Condition (PCSC), supporting early intervention to reduce avoidable hospitalizations and improve patient outcomes.

The absence of migraine from PCSC classifications perpetuates gaps in public health policies and delays the implementation of effective care models.

Recognizing migraine as a PCSC can increase its visibility in public health agendas and drive the development of structured, equitable, and cost-effective care pathways.

Integrating technological innovations—such as telemedicine and artificial intelligence—into primary care has the potential to optimize migraine management and expand access to care.

Early identification and treatment of migraine within primary care systems can generate significant economic benefits by reducing emergency visits, hospitalizations, and productivity losses.

Footnotes

Acknowledgments

None.

Author contributions

Welber Sousa Oliveira: Conceptualization, Methodology, Investigation, Writing – Original Draft, Writing – Review & Editing.

Erlene Roberta Ribeiro dos Santos: Conceptualization, Writing – Review & Editing.

Patrícia Machado Peixoto: Conceptualization, Writing – Review & Editing.

Vanise Grassi: Writing – Review & Editing.

Marcos Vinicius Soares Pedrosa: Conceptualization, Writing – Review & Editing.

Rami Burstein: Writing – Review & Editing.

Mario Fernando Prieto Peres: Conceptualization, Methodology, Writing – Review & Editing, Project administration, Supervision.

Consent to participate

Not applicable.

Consent for publishing

All authors have read and approved the final version of the manuscript and agree to its submission to and publication in Cephalalgia should it be accepted.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study. Any additional information is available from the corresponding author upon reasonable request.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Welber Sousa Oliveira declares no conflict of interest.

Erlene Roberta Ribeiro dos Santos declares no conflict of interest.

Patrícia Machado Peixoto declares no conflict of interest.

Vanise Grassi declares no conflict of interest.

Marcos Vinicius Soares Pedrosa declares no conflict of interest.

Rami Burstein declares no conflict of interest with respect to the research, authorship, and/or publication of this article.

Mario Fernando Prieto Peres has received consulting fees from AbbVie-Allergan, Ache, Eli Lilly, Eurofarma, Libbs, Lundbeck, Kenvue, Novartis, Pfizer, Sanofi-Aventis, and Teva.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Open practices

Not applicable.

ORCID iDs

Welber Sousa Oliveira

Erlene Roberta Ribeiro dos Santos

Patrícia Machado Peixoto

Vanise Grassi

Marcos Vinicius Soares Pedrosa

Rami Burstein

Mario Fernando Prieto Peres

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Migraine as a primary care-sensitive condition: Building pathways to accessible care

Abstract

Objective

Background

Methods

Results

Conclusion

Keywords

Introduction

History of the PCSC concept

Migraine meets the criteria for a PCSC

Scientific evidence

Ease of diagnosis

Public health relevance

Primary care resolution capacity

Hospitalization requirement in severe cases

Current limitations and barriers to including migraine in PCSC lists

Historical exclusion of headache disorders

Need for policy changes and awareness campaigns

Strategies for treatment with available resources

Global approaches to headache management

Technology and innovation

Telemedicine to support primary care

Potential for artificial intelligence in screening and management (64)

Economic and health system impact of classifying migraine as a PCSC

Conclusion and future directions

Summary of Key points

Call to action

Article highlights

Footnotes

Acknowledgments

Author contributions

Consent to participate

Consent for publishing

Data availability statement

Declaration of conflicting interests

Funding

Open practices

ORCID iDs

References