Globally, 40% of the population is affected by headache disorders, making it one of the most prevalent neurological disorders.1 Headaches are among the most common medical complaints, impacting a younger population than many other chronic conditions. The Healthcare Cost and Utilization Project’s Nationwide Emergency Sample from 2011 showed that between the ages of 20 and 44 years, headaches were among the top 5 reasons for presentation to the emergency department.2 About 13% of the American population suffers from migraine,3 which ranks within the top 10 most disabling disorders in many countries.4 Headache disorders affect one’s work productivity, interpersonal relationships, and mental health.1
Despite its prevalence, people with headache disorders face many barriers in acquiring effective care, with lack of knowledge placed as the principal barrier, leading to the underdiagnosis and undertreatment of headache disorders.1 Delaying effective interventions can increase the frequency and severity of headache disorders, potentially leading to the chronification of headaches.5 Assessing the efficacy of treatment is imperative to the treatment of headache disorders.
Pain is a dominant symptom of headaches and migraines, although it can be a difficult feature for patients to describe. Pain scales, such as asking a patient to rate their pain on a scale from 1 to 10, attempt to give patients a way to communicate the level of pain they are feeling. This number can have its benefits, as it is simple and can be a measure that health care workers use over time to track changes in pain severity, although it can have its drawbacks.
One of the main drawbacks to pain scales is the subjective nature of pain. What one patient describes as an 8 of 10 could be what another patient describes as a 5 of 10 due to different pain tolerances. Other factors and stressors can influence what a patient reports, making the scale subjective to circumstances that a pain scale is not intended to measure.
Using this number to communicate, a patient might report pain above or below what they perceive, accounting for how the health care team would perceive this number and direct treatment accordingly. Social factors can play a role, where someone might report an augmented number to reflect how they want their loved ones to perceive their pain management, whether higher for the sake of empathy or lower to attempt to reflect a better-managed state.
Chronic and recurrent conditions like headaches and migraines are not accurately expressed by single responses on a pain scale. With single pain ratings, a comprehensive view of a patient’s condition is reduced to a number given in a single instance, despite the changing nature of pain that can lead it to fluctuate higher or lower.
Despite these drawbacks, which many health care workers are familiar with, pain rating scales are still common practice when assessing pain severity in acute and chronic cases. This decision largely comes from the leverage of insurance companies, who want to see a quantified number to describe a patient’s condition. Governing bodies can further perpetuate the use of pain rating scales. The Center for Medicare and Medicaid Services uses the percentage of older patients who received a Pain Assessment Value Set to determine pain as a measure of quality.6 Governing bodies have the capability to combat this, such as the United States Department of Human and Health Services stating in their Pain Management Best Practices Report that initiatives to report pain through pain scores have led to aggressive treatment to lower the number and have consequently increased opioid use.7
Clinical trials employ other measures to detect more comprehensive changes in someone’s condition, such as the APPRAISE (NCT03927144) trial,7 which utilizes the Patient’s Global Impression of Change (PGIC) scale. The PGIC scale encompasses a broader description of change compared to a pain scale, including symptoms, emotions, and quality of life. The Functional Pain Scale is a reliable and validated tool that can help with the assessment of pain by asking the patient the level of interference pain has with daily activities of life.8
Although pain is a common symptom of headaches and migraines, it is not the only one. Nausea, fatigue, and photophobia are common symptoms of headaches that are not accounted for in a pain scale but would be considered in the PGIC. Unlike other migraine types where head pain is a chief complaint of patients, vestibular migraines are more closely associated with vertigo and dizziness, and these symptoms are omitted from a pain scale.9
The PGIC scale takes a holistic approach to chronic and recurrent pain, which should be applied when evaluating headache disorders. Although the PGIC scale can be affected by subjective factors as well, there is a step towards patient-centered care where the focus is not treating a number; rather, the focus is treating their view of improvement and accounts that patients can consider differing aspects when measuring their personal improvement.
With a chronic or recurrent headache disorder, it’s important to have trends that show a broader extent of progress rather than a single number. The PGIC scale asks the patient to describe the change since starting treatment, so it gains insight into the management of the patient’s chronic condition on a day-to-day basis as compared with a single instance. The increased depth of the question leads patients to reflect further on the extent to which headache and migraine have impacted them and whether they have improved or worsened over time and saves time.
About The Authors
Nazam Mian, PharmD, is a clinical pharmacist who is a strong advocate for individualized care and expanding patient access. He has experience collaborating with other health care providers to bring optimal outcomes, both in acute settings and transitions of care.
Josephine Kochou Varda, PharmD, BCPS, is a clinical pharmacist with a special interest in headache medicine, neurology, and patient-centered care. Her professional interests include optimizing medication therapy, improving patient outcomes, and advancing evidence-based pharmacy practice.
Lastly, the PGIC scale can reflect the patient’s satisfaction with a treatment plan. It’s important to assess if a patient perceives a treatment plan is benefiting them, improving their quality of life, and having a positive impact on their daily life. If a patient is not perceiving these benefits and is dissatisfied with a treatment plan after an adequate trial, it’s important to make appropriate changes to patient care that improves outcomes.
The burden of chronic and recurrent headache disorders is difficult to assess in a standardized manner. This difficulty is due to each patient having different perceptions of symptoms that can be challenging to express and every patient having distinct hardships that they consider to be impactful. The patient care process should be centered around the patient, which includes assessment.
Standard pain scales are easy to collect, but with that ease comes a simplistic view that does not fully reflect the complexity associated with headache disorders. The goal of treatment should be improvement based on the patient’s perception and improving their quality of life and functionality. Pain scales can assist in this process, but questions directed at the impact on daily life and perception of improvement from treatment incorporate what is significant to the patient, making it the guiding principle of treatment.
READ MORE: Headache and Migraine Resource Center
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REFERENCES
1. World Health Organization. Migraine and other headache disorders. Published March 6, 2024. Accessed April 15, 2025. https://www.who.int/news-room/fact-sheets/detail/headache-disorders
2. Weiss AJ, Wier LM, Stocks C, Blanchard J. Overview of Emergency Department Visits in the United States, 2011. Healthcare Cost and Utilization Project (HCUP) Statistical Brief No. 174. Agency for Healthcare Research and Quality; 2014. Accessed April 15, 2025.
3. Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41(7):646-657. doi:10.1046/j.1526-4610.2001.041007646.x
4. Stovner LJ, Nichols E, Steiner TJ, et al. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17(11):954-976. doi:10.1016/S1474-4422(18)30322-3
5. Torres-Ferrús M, Ursitti F, Alpuente A, et al. From transformation to chronification of migraine: pathophysiological and clinical aspects. J Headache Pain. 2020;21(1):42. doi:10.1186/s10194-020-01111-8
6. Centers for Medicare & Medicaid Services. 2025 Part C and D Star Ratings Technical Notes. Published 2024. Accessed April 15, 2025. https://www.cms.gov/files/document/2025-star-ratings-technical-notes.pdf
7. US Department of Health and Human Services. Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Published May 2019. Accessed April 15, 2025. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
8. Pozo-Rosich P, Dolezil D, Paemeleire K, et al. Early use of erenumab vs nonspecific oral migraine preventives. JAMA Neurol. 2024;81(5):461-470. doi:10.1001/jamaneurol.2024.0368
9. Gloth FM III, Scheve AA, Stober CV, Chow S, Prosser J. The Functional Pain Scale: reliability, validity, and responsiveness in an elderly population. J Am Med Dir Assoc. 2001;2(3):110-114. doi:10.1016/S1525-8610(04)70176-0
