The untold story of migraineurs at micro level: a patient-centred public health perspective

Sir,

Despite living in a technological world, multiple structural and social determinants of our society impede our progress towards realizing the Sustainable Development Goals, especially in health and well-being. A prime reason for this is the inadequate attention paid to the contextual and social processes that precipitate and perpetuate illness. For community medicine or public health, understanding the “why” behind disease requires sustained communication built on trust that allows patients to articulate experiences at the root-cause level. Many chronic conditions, including migraine, arise from a complex interplay between biological vulnerability and psychosocial stressors, which are often under-recognized in routine clinical care. Approaching these chronic ailments, including migraine, requires integration of medicinal and contextual grounds.

THE SILENT EPIDEMIC OF MIGRAINE

Migraine remains one of the leading causes of disability worldwide, yet its burden, and underlying aetiology, particularly in terms of emotions and psychological baggage, is frequently underestimated, a trend common for low- and middle-income countries.¹ In clinical interactions with patients attending a tertiary care center, a recurring observation was the substantial economic and psychosocial burden experienced at the individual and household level. These were the cases of emotional turbulence, income dissatisfaction, and study stress, often accompanied by the inability to articulate/identify the stressors. Females, especially, were more prone to this turmoil because of societal obligations, caregiving roles and associated moral responsibilities. While discussions around gender equality have gained prominence, equity in lived experience, particularly in decision-making autonomy, education, and emotional agency, remains limited for many women from lower socioeconomic backgrounds. These inequities have contributed to sustained stress, reduced coping capacity, and heightened vulnerability to chronic pain conditions such as migraine and tension-type headache (TTH).

TTH, MIGRAINE AND MARRIAGE

Marriage is a common institution in India shaped by the cultural, economic and familial expectations. These societal norms often have a deep implication, at times creating uneven societies and a profound impact on the marginalized communities.² Among marginalized and economically vulnerable families, early marriage of women remains common, often driven by financial constraints or perceived social obligations. In several cases, women reported limited agency in marital decision-making and ongoing emotional suppression following marriage. Such post-marital stressors characterized by role overload, financial strain, emotional silencing, and lack of familial support may act as potent triggers or perpetuating factors for headache disorders.³ Chronic stress is a well-established precipitant for both migraine and TTH, influencing neurobiological pathways involved in pain modulation.^4,5 In this context, headache disorders may represent not only a neurological condition but also a somatic expression of sustained psychosocial distress, thus creating a vicious cycle not just emotionally, but physically and economically as well.

NEED FOR A SHIFT TOWARDS ROOT-CAUSE ORIENTED CARE

Conversations with migraine sufferers consistently highlighted stress as a central trigger, compounded by financial responsibilities, emotional burden, and the unmet need to be heard and validated. While epidemiological and clinical evidence on migraine is extensive, there remains a gap in addressing the downstream determinants that sustain disease chronicity and disability. A narrow focus on symptomatic treatment, without attention to contextual stressors, risks incomplete care and suboptimal outcomes.

Hence, there is a pressing need to shift from a purely biomedical model that stems from this gender aggregated disparity. An integrated, patient-centered approach incorporating the elements of the social, emotional, and economic realm of health is needed. At the functional level, this requires healthcare systems and public health programs to incorporate counselling, effective communication, and contextual assessment into routine care.

POLICY IMPLICATIONS AND FUTURE DIRECTIONS

Current health programs must expand their scope to address factors that operate at the core of human experience, cutting across communities and geographies. As lifestyle-related and stress-mediated conditions continue to rise, their cumulative impact will extend beyond physical morbidity. Addressing migraine through a root-cause–oriented, human-centred lens has the potential to reduce disability, improve quality of life, and contribute meaningfully to broader public health goals. A paradigm shift that integrates clinical management with social and psychosocial interventions is essential to alter the trajectory of chronic headache disorders and to enable individuals, particularly women from vulnerable backgrounds, to realise their full potential and finally live a quality life.

REFERENCES

1. 1. Husøy AK, Xu YY, Steinmetz JD, Aalipour MA, Aalruz H, Abdulah DM, et al. Global, regional, and national burden of headache disorders, 1990–2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet Neurol. 2025;24(12):1005-15.
2. 2. Srivastava A. Marriage as a perceived panacea to mental illness in India: reality check. Indian J Psychiatry. 2013;55(2):S239-42.
3. 3. Goyal N, Jain R, Sodani AK, Chouksey D. Marriage and migraine in Indian females: a study on impact of marital satisfaction on migraine-related disability and quality of life. Int J Health Clin Res. 2021;4(1):260-8.
4. 4. Radat F. Stress and migraine. Rev Neurol Paris. 2013;169(5):406-12.
5. 5. Sauro KM, Becker WJ. The stress and migraine interaction. Headache. 2009;49(9):1378-86.