Exploring Cognitive Difficulties in Migraine: Aligning Subjective and Objective Findings

Laura Sebrow, PhD

(Credit: LinkedIn)

Studies have shown that patients with migraine frequently report experiencing cognitive challenges including problems with language, attention, executive function, and memory. However, findings from objective cognitive testing studies in this patient population may be often inconsistent and show small effect sizes, possibly because of the inclusion of patients across different migraine phases. A recently presented cross-sectional study revealed that patients who exhibited difficulty with word finding as a migraine prodrome symptom had weaker interictal objective cognitive performance in processing speed, language, and memory compared with those who did not have difficulty.¹

In the study, 72 patients with migraine from a tertiary headache center answered questions about prodromal cognitive symptoms and also completed a formal cognitive performance battery during the interictal migraine phase. Of these, 17 reported difficulty finding words, and 29 patients reported difficulty concentrating. Moreover, 15 patients, among those who reported difficulty finding words, also experienced difficulty concentrating. Findings showed that patients who had difficulty finding words during the prodrome migraine phase demonstrated weaker performance across multiple cognitive measures compared with those who did not. In contrast, researchers reported no significant differences in cognitive performance between patients who reported difficulty concentrating versus those who did not.

These results were presented at the 2025 American Headache Society (AHS) Annual Meeting, held June 19-22, in Minneapolis, Minnesota, by Laura Sebrow, PhD, a postdoctoral neuropsychology fellow in the Department of Neurology at North Shore University Hospital. During the meeting, Sebrow sat down with NeurologyLive^® to provide her perspective on the clinical implications of the findings from the study and explain how the cognitive symptoms were described by patients with migraine. In the conversation, she underscored the value of assessing both subjective and objective measures during clinical evaluation as well as emphasized the importance of tailoring management strategies to each individual’s cognitive profile.

NeurologyLive: What was the interest behind this type of study?

Laura Sebrow, PhD: The purpose of my study is to look at the relationships between subjective cognitive difficulties and objective cognitive performance during the interictal phase. A lot of patients report cognitive difficulties during that prodromal period. There's a lot of research that’s been coming out in recent years about prodromal cognitive symptoms. However, there's a lot of inconsistent research regarding objective cognitive performance during that interictal period. So, I wanted to look at the association between those 2 things, and what we found is that there are significant associations between prodromal word-finding difficulty in patients with migraine and objective cognitive performance during that interictal period.

How do patients describe their word-finding or concentration difficulties during the prodromal phase and how might these symptoms guide clinical assessment?

When patients report word-finding difficulties, typically, they describe problems with finding that exact word they want to use like that tip-of-the-tongue problem or they may know what they want to convey, but they just have trouble forming the words to express their thoughts. These are symptoms that have been described in prior research in people with migraine during that prodromal phase.

Now, when people describe concentration difficulties, they may describe issues with sustaining their attention or maintaining their focus. So, for example, let's say they're reading a book and they just find themselves reading the same paragraph over and over again or even the same sentence over and over again. We’ll hear that sometimes. Or maybe they're having a conversation with someone, and they're physically there, but they're not really there. They may be zoning out, or they get distracted really easily.

So, if patients are experiencing problems with word-finding or concentration difficulties, it's important to explore these symptoms further not just by asking them what the difficulties are, but knowing when these difficulties tend to happen, and also how it’s impacting their functioning day to day. Because once we have that information, that's going to help guide our assessment and really highlight which cognitive areas warrant closer attention.

What is the clinical relevance of aligning subjective cognitive complaints with objective performance measures during the interictal period?

Some patients with migraine report difficulties with their cognition during that interictal phase. Now, when we do a cognitive evaluation, we need to pay very close attention to both their subjective cognitive symptoms and also their objective cognitive performance. We focus on multiple domains, so that will include attention, speed of processing, executive functioning, language, visuospatial abilities, and memory.

It’s important to align their subjective experience with the objective cognitive performance because that’s really going to help build a complete clinical picture. I recently had a patient who came in with memory problems, and they asked me, “Why are we doing all this? There are so many areas that you’re looking at.” Just to provide an example, if a patient comes in with memory problems, what we sometimes see on exam is that they’re having issues or we see weaknesses in other areas of cognitive functioning, such as attention or executive functioning, and that’s impacting their memory and therefore contributing to their memory concerns.

If they’re having a conversation with someone and they’re not really paying very close attention, then later on they may say, “Ah, I completely forgot what they said in that conversation” but really, they didn’t fully process what was said in the first place. So that information that we get from the cognitive exam, and aligning their subjective experience with the cognitive exam, can really help guide our interpretation and also allow us to provide more tailored recommendations.

How should clinicians approach management or even counseling when patients report cognitive disruptions between their migraine attacks?

When patients are reporting cognitive disruptions between their migraine attacks, it’s important for us to recognize that these symptoms may be part of that broader migraine experience. It’s not just limited to their head pain.

Once we have an understanding of their cognitive difficulties, and also understand the nature and extent of these difficulties, then we can start thinking about management. Now, management doesn’t always mean a formal intervention. It can mean providing compensatory cognitive strategies. For some patients, that may mean organizational strategies or maybe adjusting task demands when they feel like they’re not at their best cognitively.

Really, the goal is to provide practical, patient-centered recommendations for them. It needs to be more individualized, it’s not a one-size-fits-all. We can’t just provide the same recommendation to every single patient. That’s not going to work. Like I said before, we need to tailor those recommendations according to what the patient needs and also what really matters most to them.

Transcript edited for clarity. Click here for more coverage of AHS 2025.

REFERENCES
1. Sebrow L. The Relationships between Subjective Word Finding and Concentration Difficulties during the Migraine Prodrome and Interictal Objective Cognitive Performance. Presented at: 2025 AHS Annual Meeting; June 19-22; Minneapolis, MN. Scientific Abstracts 1 Session.