In 2015, the United Nations established Sustainable Development Goal 3, which aims to “Ensure healthy lives and promote well-being for all at all ages”, outlining the goal to reduce global population mortality and disease burden by 2030 [24]. Women suffering from migraine, particularly WCBA, are closely linked to this goal, as migraine is the most common and disabling disease in this population, with a higher prevalence of associated complications, leading to a greater overall disease burden [25]. Undoubtedly, a thorough understanding of the prevalence trends of migraines in WCBA is crucial for assessing the potential of achieving the related health goals. However, there is currently a lack of comprehensive literature analyses on the prevalence, incidence, and DALYs related to migraine in this population across different countries and regions globally, with previous studies primarily focusing on specific age groups or countries [16, 26]. Therefore, we believe it is necessary to promptly enhance and update the data on the burden of migraine in the global population of WCBA, enabling policymakers to understand the situation and formulate effective prevention and control strategies. This study is the first comprehensive estimation of the prevalence, incidence, and DALYs of migraine in WCBA over the past 32 years using GBD 2021 data on a global scale.

A significant increase in the cases of prevalent, incident, and DALYs of migraines related to WCBA was reported globally, with a percentage change of 48%, 43%, and 47%, respectively, over the past 32 years. This growth may be associated with the global population increase of 45%. Moreover, the prevalence rates and DALY rates of migraine in WCBA globally increased. Conversely, the incidence rates exhibited a declining trend over time. This result implies that there are more existing patients, and the growth speed of new cases is slowing down, possibly due to the decline in the proportion of WCBA in the global population from 25.57% in 1990 to 24.67% in 2021 [27]. Furthermore, this trend could be attributed to the significant advancements in diagnosis, prevention, and prognosis resulting from the accumulated clinical experience among neurological healthcare professionals over the past 32 years, as well as the development of sophisticated diagnostic and therapeutic technology systems.

In 2021, the highest rates of prevalence, incidence, and DALY were shown in high SDI regions. This is consistent with previous research findings, where countries with higher SDI levels bear a higher burden of migraine disease [28]. The rate trends of prevalence, incidence, and DALYs of migraine among WCBA observed in this study differ from the general assumption regarding disease burden in relation to SDI. In general, higher SDI levels are associated with more robust healthcare systems and higher-quality medical services, resulting in a reduced disease burden. In this study, the highest cases and the most significant growth trends in rates of prevalence, incidence, and DALYs of migraine among WCBA were observed in middle SDI regions. These findings are similar to those studies on the global population of all age groups in the same region, indicating that the burden of migraine among WCBA is highest in this region [26]. The most reasonable hypothesis for this result is that, with the economic development of the middle SDI region, there is an increase in migraine triggers and disease diagnosis reporting among WCBA. However, rapid urbanization and industrialization have accelerated changes in people's lifestyles, including sedentary habits, stress, lack of physical activity, overuse of medications and electronic devices, and deterioration of sleep patterns, exacerbating the incidence of migraine. Furthermore, influenced by the local cultural background and the potential stigmatization of headache disorders, such as migraine among WCBA, indirectly weaken the capacity to control the disease burden through sustained economic growth and social development [29, 30].

Over the past 32 years, the most significant increases in prevalence rates and DALY rates of migraine among WCBA were showed in East Asia and Andean Latin America, which may be attributed to social factors such as industrialization or urbanization, inadequate healthcare services, and poor air quality [31, 32]. The significant variations of the cases of prevalence, incidence, and DALYs of migraine among WCBA across different countries were shown in our study. There is a notable polarization trend, particularly among countries in high SDI regions, with differences reaching up to 16-fold between some nations. Notably, the highest percentage changes in the cases of migraine among WCBA were observed in high-income countries, such as Qatar and the United Arab Emirates consistent with global population trends [33]. The opposite trend observed in a few countries may indicate that healthcare and public health management efforts in this field have achieved positive effects in reducing migraine triggers and improving the disease. Continued monitoring of the trends in these countries may provide insights into global migraine prevention and control strategies. Finally, it is essential to develop targeted prevention and treatment measures based on the individual burden of this disease.

In terms of age patterns, a particularly severe new burden of migraine among WCBA globally was observed in the 15–19 age group in 2021. During this age group, females face challenges such as increased academic pressure and rapid physical and mental development, especially during adolescence and menarche. This highlights the importance of special attention and health management for this age group. A rising trend in the cases of prevalence, incidence, DALYs, and incidence rates of migraine among WCBA over the past 32 years globally with age, with the highest increase observed in the 45–49 age group, particularly in middle SDI regions. Additionally, there is a trend of transition in the proportion of migraine cases among WCBA from younger age groups to older age groups, with the most significant increase observed in the 45–49 age group. This phenomenon may be the result of a combination of biological, genetic, psychological, and social factors. The fluctuation of sex hormones, especially estrogen and progesterone, may play a key role in the onset of migraines in women, with women aged 45–49 experiencing hormonal fluctuations during perimenopause and menopause, which may contribute to the increased frequency of migraine attacks [10, 34]. As WCBA age, they face increasingly complex work and social relationships and may even experience a midlife crisis leading to greater stress. On the other hand, during this time, they must juggle multiple roles, including work, family care, and childcare, necessitating high levels of energy and positive emotions, which may result in fatigue or anxiety, exacerbating the frequency of migraine attacks and complications [35]. Furthermore, women have lower thresholds for stress and pain compared to men, making them more susceptible to migraines. The high prevalence and frequency of migraines in women further perpetuate the ongoing gendered “gendering” of this condition. For example, some pharmaceutical marketing attempts to position migraines as a “women’s disease”, further exacerbating gender bias and disadvantaging female patients seeking help [36]. Furthermore, studies have shown that Headache (specifically migraine) is the main manifestation of the neuro-COVID-19 complex, and COVID-19 seems to enhance existing migraine symptoms and morbidity [37]. Furthermore, the insufficient diagnosis and treatment of migraines globally represent a common issue, leading to an increasing heavy burden of migraines with age. The above-mentioned study emphasizes the need for targeted intervention measures, particularly addressing the most common risk factors among the WCBA population.

Pregnancy is an inevitable concern for WCBA, and the significant burden of severe migraines and associated complications in this population hinders the achievement of the United Nations’ Sustainable Development Goals. Compared to the general obstetric population, pregnant women with migraines are at a higher risk of adverse outcomes for both the mother and the newborn, including GDM, HDP, low birth weight, preterm delivery, and cesarean section, which may be associated with medication use and disease activity [14]. In babies born to women with migraine, the duration of hospitalization was longer, and respiratory problems were more common [38]. Therefore, there is an urgent need for large-scale, evidence-based medicine research on the prevention and treatment of migraine in pregnant women to provide personalized and optimal diagnosis and treatment strategies for clinical physicians. Furthermore, it was striking that almost 20% of women with migraine in the American registry for migraine research database results attested to pregnancy avoidance because of migraine [39]. Therefore, closely monitoring clinical conditions, controlling disease activity, and adjusting medication treatment plans promptly are crucial for women who suffer from migraine before and during pregnancy.

It is worth noting that HC is one of the most commonly used contraceptive methods among WCBA. The use of HC by WCBA can impact the burden of migraine and should be considered in the comprehensive management of migraine in women. However, a survey involving 851 gynaecologists in Germany revealed that they actively consider migraine before and during the prescribing of hormonal contraceptives, and the diagnosis of migraine influences their prescribing behaviour. Although progestogen monotherapy is not associated with additional stroke risk, investigated gynaecologists remained reluctant to prescribe this estrogen-free contraception for migraine with aura. The study also revealed that more than 3/4 of patients with a history of migraine are actively engaged in preventive migraine treatment upon initiating HC, for further migraine treatment the majority of gynecologists would recommend patients refer to a neurologist. This highlights the close overlap between the specialities of neurology and gynecology regarding the patient collective of WCBA suffering from migraine [15]. Another survey involving 115 female healthcare providers revealed that only 6% were aware of migraine treatment guidelines, and only 37% had received headache-specific education, which indicates they appear to have several knowledge gaps in the management of patients with migraine [40]. These may further exacerbate the burden of migraines in WCBA. Therefore, future improving interdisciplinary collaboration between gynaecologists and neurologists may improve migraine treatment for WBCA suffering migraine.

There are several limitations to this study. Firstly, the estimates presented in this paper are not comprehensive as we solely focused on migraines in WCBA as a level four disease rather than level three "headache disorders". Due to lower healthcare standards in some underdeveloped countries, there may be misdiagnosis and underdiagnosis of the condition, leading to an underestimation of the burden. Secondly, the data obtained from the GBD largely relies on modelling data, as GBD collaborators utilize numerous statistical modelling methods, especially in countries where original data is lacking. Thirdly, the burden of migraine is complex to define under one aspect, the disability weights definitions are still very partial as a result, reliable "measurability" of the disability is very difficult. Furthermore, it is important to note the lagged nature of GBD data. Therefore, on the one hand, there is a need for further development of scales and coefficients referring to patients’ disability which might inform future GBD definitions of DW specific to migraine. on the other hand, additional real-world studies are needed to validate the results for a more accurate and comprehensive assessment.