Original Article

Cephalalgia
2020, Vol. 40(14) 1633–1644
Googling migraine: A study of Google ! International Headache Society 2020
Article reuse guidelines:
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DOI: 10.1177/0333102420942241
migraine management journals.sagepub.com/home/cep

Rachid Bojazar1 , Thien Phu Do1, Jakob Møller Hansen2,

David W Dodick3 and Messoud Ashina1

Abstract
Introduction: Health information is one of the most frequently searched topics on the internet. In this observational
cross-sectional study, we evaluated the content of the highest indexed Google search results related to migraine
management.
Methods: We identified the five most used search terms related to migraine management via Google Trends in the time
period 1 January 2004 to 2 October 2019. We entered each search term into Google’s search engine and retrieved the
search results from the first three pages from each search query. We stratified the recommended treatment options and
evaluated the websites using the DISCERN tool.
Results: In total, 73 unique websites recommended a total of 77 different migraine treatment options, consisting of 35
(45%) acute and 42 (55%) preventive treatments. For acute treatments, pharmacological options were more frequently
recommended (88% of websites), whereas non-pharmacological options were more frequent among preventive treat-
ments (67%). Evaluation of the consumer health information using the DISCERN tool showed that non-governmental
organizations had the highest mean total score with 3.8 (
0.19).
Conclusions: Googling when looking for migraine treatments reveals a multitude of management proposals of varying
quality. Non-governmental organizations provide the overall highest quality of written consumer health information on
migraine treatments among search results. We encourage stakeholders to optimize and distribute high-quality and peer-
reviewed information on migraine management.

Keywords
Online, patient information, internet, headache, health information, consumer
Date received: 14 January 2020; revised: 6 April 2020; accepted: 23 May 2020

Introduction
The general migraine literacy appears to be poor in
spite of a high prevalence (1). In both America and
Europe, health information is one of the most frequent- 1
Danish Headache Center and Department of Neurology, Rigshospitalet
ly searched topics on the internet (2). Today, many Glostrup, Faculty of Health and Medical Sciences, University of
patients view the internet as a valuable and reliable Copenhagen, Glostrup, Denmark
2
source of heath related information and consult the Danish Headache Knowledge Center, Rigshospitalet Glostrup, Glostrup,
Denmark
internet before seeking a professional diagnosis (2). 3
Mayo Clinic, Scottsdale, AZ, USA
Despite the benefit of easily accessible health informa-
tion, the possibility of misinformation leading to unfor- Corresponding author:
tunate actions or psychological distress should be a Messoud Ashina, Danish Headache Center, Department of Neurology,
Rigshospitalet Glostrup, Faculty of Health and Medical Sciences,
concern. To ensure the best possible treatments for
University of Copenhagen, Valdemar Hansen Vej 5, DK-2600 Glostrup,
patients, health care providers ought to familiarize Denmark.
themselves with patterns in patients’ self-care (3). Email: ashina@dadlnet.dk
1634
Google is both the most world’s most visited website
and most used search engine making this the first (and
sometimes) only source of health information.
Google provides indexation by sorting through
internet websites and data via multiple proprietary
algorithms (4). These algorithms consider a variety of
variables when ranking different search results. In part,
Google’s algorithms favour newly uploaded content as
well as websites that many users seem to appreciate
when conducting searches, as well as references from
other websites. According to Google, this provides an
opportunity for assessment of reliability and authority.
Computer software determines which websites to visit
and index, including the frequency and volume of
indexed data (5).
Given the accessibility of the internet, multiple
attempts have been made to elucidate the available
tools for assessing quality and reliability of online
health information (6). These attempts include website
readability scoring systems and quality certification.
Besides these approaches, the utilization of standard-
ized instruments to evaluate the framework and con-
tent of written consumer health information has been
used. The DISCERN instrument is an example of a
validated questionnaire to assess consumer health
information. The DISCERN instrument was formed
on systematic input from an expert panel including
clinical specialists, general practitioners and self-help
group members (7). It facilitates standardized but yet
flexible appraisal of online consumer health informa-
tion (8).
The aim of this observational cross-sectional study is
to evaluate the content of the highest indexed websites
about migraine treatment on Google.
Methods
Search strategy
We used Google Trends to identify the most frequent
migraine-related search query on Google (9). Google
Trends tracks Google searches and provides rankings
for past search queries since 2004. Search terms are
scored relative to the total amount of searches per-
formed on Google. This is quantified by Relative
Search Volume (RSV), ranging from 0–100, where
100 is the most frequently searched term at the given
time (10). By entering “migraine” as a search term,
Google Trends suggests the highest indexed related
search terms to the search term “migraine”. This func-
tion is used to determine which search terms to use
when screening for information related to treatment.
On 2 October 2019, at approximately 16:15, we entered
each search term into Google’s Trends search engine.
The searches were performed on a Windows
Cephalalgia 40(14)
10-operated computer using Mozilla Firefox in
Glostrup, Greater Copenhagen, Denmark. All cookies,
previous search history and temporary internet files
were deleted prior to search entry. In Private Mode,
we set Google Trends to capture worldwide non-real-
time search data from 1 January 2004 (earliest possible
date) to 2 October (date of search query), capturing all
categories of web searches. We then identified the five
most frequent (top) related queries to migraine treat-
ment. Only the top five search queries in relation to
migraine treatment were eligible for further explora-
tion. These five search terms were then entered in
Google. We repeatedly cleared cookies, web browsing
history, and temporary internet files before and
between search queries. The search results (e.g.
Uniform Resource Locators – URLs) from the first
three Google pages were retrieved for each search
query. The rationale for a cutoff of three Google
pages is that most people doing an online search will
look no further than the first three pages generated
(11). We excluded duplicate websites and defective
website links across search terms.
Content analysis
For each search query, we screened the content of each
website for information related to migraine manage-
ment. We recorded whether there were recommenda-
tions of headache diary usage and cautions against
medication overuse headache. Furthermore, we
assessed the nature of recommended treatments (e.g.
acute, preventative, non-pharmacological, pharmaco-
logical interventions) and stratified the recommended
treatment options accordingly. Finally, we grouped the
websites by information provider type based on their
self-reported purpose on the website’s “About us”
sections.
Two authors (RB, TPD) independently used the
DISCERN tool to evaluate the contents of each web-
site. The DISCERN instrument is a validated tool
which was developed to assess the quality for written
consumer health information on treatment choices. It
consists of a brief questionnaire of 16 questions divided
into three sections. Questions 1 through 8 are named
Section 1, where the reliability of the information is
assessed – for example, the framework of the conveyed
message. Section 2 consists of questions 9 through 15,
where the quality of information is evaluated. Question
16 addresses the rater’s overall impression of the
source. The DISCERN score scale ranges from 1 to
5, where 1 is low quality, 3 is partial quality, and 5 is
high quality information (7). We defined agreement as
consensus within one score. In case of disagreement, we
resolved any discrepancy by re-assessing the website in
question.
Bojazar et al. 1635

Most used search terms on Google in relation to “Migraine” identified

through Google Trends

“Migraine “Excedrin” “Excedrin “Migraine “Migraine

treatment” (n = 30) migraine” relief” medicine”
(n = 30) (n = 30) (n = 29) (n = 30)

Website exclusion (n = 76)

• Duplicates (n = 75)
• Defective link (n = 1)

Pool total number of search results on the first

three pages of Google (n = 73)

Website exclusion (n = 7)

• Articles in peer-
reviewed journals
(n = 7)

Stratification of Evaluation of
recommended websites using the
treatments DISCERN tool
(n = 73) (n = 66)

Figure 1. Flowchart of the search strategy, web searches and processing of results.

Approval of a scientific ethics committee is not
required as the data is publicly available. We collected,
stratified and evaluated the data using Microsoft Excel
Version 1908, Microsoft Office 365 ProPlus (Microsoft,
2019) and IBM SPSS Statistics Version 26 (IBM, 2019).
Data availability
All data for this article is available per request.
Results
A flowchart of the search strategy and results is pre-
sented in Figure 1. We identified the following search
terms from Google Trends, which were the highest
indexed migraine treatment-related terms on Google
(in ranked order): “migraine treatment”, “excedrin”,
“excedrin migraine”, “migraine relief”, and “migraine
medicine”. ExcedrinVR is an over-the-counter
pharmaceutical product containing aspirin, paraceta-
mol and caffeine.
Table 1 and Figure 2 shows the search terms and
relative search volume. Historically, “excedrin” had the
largest change in popularity over time, with peak
change in interest around January of 2012. The other
four search terms showed sporadic change in interest in
search volume over time. Of note, the curves in
Figure 2 shows the change in search volume of a
search term relative to itself.
Search results
Input of these search terms into Google yielded a total
of 149 search hits from the first three pages. We
removed 75 duplicates and one defective link. The
remaining 73 websites were pooled, and the content
of these websites were subsequently analyzed by
1636 Cephalalgia 40(14)

stratification of the recommended treatment options. treatment, 45 out of 73 (62%) websites caution against
We evaluated 66 of these 73 websites using the medication overuse headache.
DISCERN tool, as seven websites were excluded due The 73 included websites recommended 77 different
to them being articles in peer-reviewed journals. treatment options (Table 2). Sixty-seven websites
(92%) recommended at least one of 35 acute migraine
treatment options. The majority, 64 websites (88%)
Migraine management recommended at least one of 15 acute pharmacological
treatments. Thirty-seven websites recommended at
Thirty-two websites out of 73 (44%) websites recom-
least one of 20 non-pharmacological treatments.
mended that patients track their symptoms using a
Regarding preventive treatment, 49 websites (67%) rec-
headache diary. In the context of pharmacological
ommended at least one of 42 different options. Forty-
six websites (63%) recommended at least one of 18
Table 1. Overview of the most popular search terms related to
preventive non-pharmacological treatments and 40
migraine. Relative search volume is the quantity of search inter-
est relative to the highest point of the chart for the given time. A websites (55%) recommended at least one of 24 phar-
value of 100 is peak popularity for that term. A value of 50 macological treatments. Thirty-six out of 73 websites
denotes that the term is half as popular as the term with the (49%) recommends only pharmacological treatments,
value of 100. A value of 0 means that there was insufficient data whereas six out of 73 websites (8%) strictly recom-
for this term. mends non-pharmacological options.
Search term Relative search volume (RSV)
Information provider type
Migraine treatment 39
Excedrin 32 Figure 3 shows websites grouped by website category
Excedrin migraine 32 per treatment provider type. Grouping of websites by
Migraine relief 28 information provider type revealed eight different cat-
Migraine medicine 27 egories: 16 e-commerce websites (22%), 11 websites by
medical professionals (15%), 11 health information

Figure 2. Popularity of search terms over time. Figure 2 depicts the worldwide popularity of the five mentioned search queries over
time, compared to itself. Google Trends data were available from 1 January 2004 until 2 October 2019. In the upper bar of Figure 2,
each search term is marked with colours corresponding to the curve for that specific search term. Note that a curve represents the
term’s change in search volume over time compared to itself. The change in volume is not normalized to the four other search terms.
Therefore, a higher value over time depicts a change of number of searches for that specific search term. The used search terms and
their relative search volume values are listed in Table 1. Google and the Google logo are registered trademarks of Google LLC, used
with permission. Data source: Google Trends https://www.google.com/trends.
Bojazar et al. 1637

Table 2. Characteristics of migraine treatment options as recommended in internet search results. The table depicts the recom-
mended treatment options and the number/percentage of websites which recommend them. The table is organised by nature of
treatment option. Treatment options are divided into acute/preventive and further into modality of treatment, e.g. pharmacological/
non-pharmacological.

Number of websites
Recommendation n ¼ 73 (100%)

Headache diary 32 (44%)

Caution against medication overuse headache 45 (62%)
Acute treatment 67 (92%)
Non-pharmacological 37 (51%)
Relaxation 25 (34%)
Sleep 22 (30%)
Place wrapped ice pack on head/neck 19 (26%)
Drink fluids 13 (18%)
Transcranial magnetic stimulation 12 (16%)
Biofeedback 11 (15%)
Acupuncture 10 (14%)
Mindfulness 9 (12%)
Massage 9 (12%)
GammaCore nVS 8 (11%)
Yoga 8 (11%)
Meal 7 (10%)
Herbs 6 (8%)
Acupressure 5 (7%)
Essential oils 5 (7%)
Cognitive behavioural therapy 4 (5%)
Transcutaneous supraorbital nerve stimulation 4 (5%)
Remote electrical neuromodulation (REN) 3 (4%)
Ginger 3 (4%)
Marijuana 1 (1%)
Pharmacological treatment 64 (88%)
NSAID 42 (58%)
Excedrin 40 (55%)
Triptans 37 (51%)
Paracetamol (Acetaminophen) 36 (49%)
Anti-emetics 24 (33%)
Ergot alkaloids 22 (30%)
Opioids 14 (19%)
Barbiturates 9 (12%)
Anti CGRP small molecules 9 (12%)
Vitamins and minerals 7 (10%)
Isometheptene mucate 7 (10%)
Lasmiditan 7 (10%)
Steroid injection (prednisone or dexamethasone) 7 (10%)
Sphenopalatine ganglion block 3 (4%)
Pseudoephedrine 1 (1%)
Preventive treatment 49 (67%)
Non-pharmacological 46 (63%)
Avoid triggers 38 (52%)
Sleep 29 (40%)
Meal 28 (38%)
Relaxation 26 (36%)
Exercise 26 (36%)
Drink fluids 22 (30%)
Herbs 17 (23%)
Acupuncture 16 (22%)
Biofeedback 14 (19%)
(continued)
1638 Cephalalgia 40(14)

Table 2. Continued.
Number of websites
Recommendation n ¼ 73 (100%)

Transcranial magnetic stimulation 12 (16%)

Transcutaneous electrical nerve stimulation 12 (16%)
Cognitive behavioral therapy 7 (10%)
Surgical treatment 5 (7%)
Massage 5 (7%)
GammaCore nVS 3 (4%)
Marijuana 2 (3%)
Focused ultrasound 1 (1%)
Migraine glasses 1 (1%)
Pharmacological treatment 40 (55%)
Botox 30 (41%)
Beta blockers 26 (36%)
Anti-CGRP monoclonal antibodies 25 (34%)
Tricyclic antidepressants 24 (33%)
Anticonvulsants 24 (33%)
Vitamins and minerals 19 (26%)
L-type calcium channel blockers 18 (25%)
Angiotensin II blockers 10 (14%)
Anti-CGRP small molecules 7 (10%)
Serotonin receptor antagonists 7 (10%)
Triptans* 7 (10%)
NSAIDs* 6 (8%)
Hormonal contraceptives* 5 (7%)
SNRI 5 (7%)
SSRI 4 (5%)
Melatonin 3 (4%)
NSAIDs 2 (3%)
MAOIs 1 (1%)
Quetiapine 1 (1%)
Tonabersat 1 (1%)
Transient receptor potential vanilloid type 1 antagonists 1 (1%)
Nitric oxide synthase inhibitors 1 (1%)
NMDA receptor antagonists 1 (1%)
Gap junction blockers 1 (1%)
*These were specific recommendations for menstrual-related migraine.

corporation websites (15%), 10 non-profit organiza-
tions (14%), nine news websites (12%), seven articles
from peer-reviewed journals (10%), five governmental
information service websites (7%), and four biotech
company websites (5%).
In total, 77 different migraine treatment options
were recommended across all eligible websites. Thirty-
five options (45%) were acute treatment recommenda-
tions and 42 (55%) were preventive treatments. Of the
acute treatments, 20 (57%) were non-pharmacological
and 15 (43%) were pharmacological. Out of the 42
preventive treatment options, 18 (43%) were non-
pharmacological, whereas the remaining 24 (57%)
were pharmacological.
Health information corporations cover the largest
fraction of acute non-pharmacological treatments
with 20 out of 20 (100%) recommended options.
Health information corporations also cover the
largest fraction of total acute treatments with 34
out of 35 options (97%). Health information corpora-
tion and non-profit organizations cover an
equal number of acute pharmacological treatments
with 14 out of 15 options (93%). Regarding preventive
treatment recommendations, health information
corporations covers the largest total number of preven-
tive treatments with 41 out of 42 (98%). Furthermore,
health information corporations cover the largest
fraction of both non-pharmacological preventive
treatments with 17 out of 18 (94%) options
and pharmacological preventives with 24 out of
24 (100%).
Table 3 is an overview of the respective information
provider types and contains examples of websites in
each category.
Bojazar et al. 1639

Distribution of health information providers

Biotech company, n = 4, 5%
Governmental information service, n = 5, 7%
E-commerce website, n = 16, 22%

Peer-reviewed journal, n = 7, 10%

News, n = 9, 12%
Medical professionals, n = 11, 15%

Non-profit organization, n = 10, 14%

Health information corporation, n = 11, 15%

Figure 3. Distribution of health information providers. This pie chart showing the distribution of health information providers found
in the processed web search results. The total number of web search results after removal of duplicates and a defective link is 73.

Table 3. Overview of information provider types. Table 3 shows the defined information provider types with examples of websites.
The information provider types of webpages are derived from the websites’ “About us” sections, where websites describe their
purpose. Websites with identical purposes are grouped together.

Website category Example of websites

Biotech company Allergan, eNeura, etc.

E-commerce website
Governmental information
service
Health information corporation
Medical professionals
News
Non-profit organization
Peer-reviewed journal
Amazon, Walmart, etc.
Food and Drug Administration, National Health Service, etc.
Healthline, WebMD, etc.
MayoClinic, Southern Cross, etc.
ABC News, The Washington Post, etc.
The Migraine Trust, Headache Australia, etc.
Articles in The Journal of Headache and Pain, Headache, The Journal of Head and Face Pain etc.

Table 4 lists the remaining website categories
and corresponding percentage of treatment
recommendations.
Quality of websites on treatment options
Figure 4 shows the quantification of reliability and
quality of conveyed health information on treatment
using the DISCERN instrument. The figure reports
consensus results of DISCERN between raters. Non-
profit organizations had the highest mean total
DISCERN score of 3.8 (
0.19). Non-profit organiza-
tions had the highest mean DISCERN score for
Section 1, which addresses reliability, with a rating of
4.1 (
0.22). Medical professionals had the highest
mean DISCERN score for Section 2, which rates qual-
ity of information, with a rating of 3.8 (
0.17).
Statistical significance of DISCERN scores were estab-
lished between groups with a one-way ANOVA.
Differences between categories were significant in
Section 1, regarding reliability (p < 0.001); Section 2,
regarding quality of content (p ¼ 0.029), and mean
total DISCERN score (p < 0.001).
We quantified the level of agreement between raters
by weighted Cohen’s kappa coefficient due to the ordi-
nal nature of the DISCERN scale. The estimated
agreement between raters was kappa ¼ 0.489, 95% CI
(0.448, 0.530), p < 0.001.
1640 Cephalalgia 40(14)

Table 4. Stratification of internet search results by provider type. The table shows website categories and how many treatment
options they cover per type of treatment. Treatment types entails acute/preventive and pharmacological/non-pharmacological. Data
are presented as number of treatments covered and percentage of total number of treatment options – for example, n (percentage).
Website categories are listed in alphabetical order.

Acute Preventive

Non- Non-
Website category Total pharmacological Pharmacological Total pharmacological Pharmacological

Biotech company 10 (29%) 9 (45%) 1 (7%) 9 (21%) 7 (39%) 2 (8%)

E-commerce website 16 (46%) 7 (35%) 9 (60%) 19 (45%) 12 (67%) 7 (29%)
Governmental information service 12 (34%) 7 (35%) 5 (33%) 20 (48%) 10 (56%) 10 (42%)
Health information corporation 34 (97%) 20 (100%) 14 (93%) 41 (98%) 17 (94%) 24 (100%)
Medical professionals 27 (77%) 15 (75%) 12 (80%) 28 (67%) 13 (72%) 15 (63%)
News 14 (40%) 8 (40%) 6 (40%) 14 (33%) 9 (50%) 5 (21%)
Non-profit organisation 30 (86%) 16 (80%) 14 (93%) 30 (71%) 16 (89%) 14 (58%)
Peer-reviewed journal 18 (51%) 5 (25%) 13 (87%) 22 (52%) 8 (44%) 14 (58%)

(a) (b) Mean DISCERN score for Section 2

Mean DISCERN score for Section 1
Biotech company 3.1 (±0.43)
Biotech company 2.4 (±0.35)
E-commerce website 2.6 (±0.24)
E-commerce website 2.2 (±0.26)
Governmental information service 3.7 (±0.26)
Governmental information service 3.8 (±0.26)
Health information corporation 3.5 (±0.15)
Health information corporation 3.5 (±0.2)
Medical professionals 3.8 (±0.17)
Medical professionals 3.7 (±0.21)
News 3.2 (±0.15)
News 3 (±0.11)
Non-profit organization 3.6 (±0.12)
Non-profit organization 4.1 (±0.22)
1 2 3 4 5
1 2 3 4 5

(c) Mean total DISCERN score

Biotech company 2.7 (±0.41)

E-commerce website 2.3 (±0.24)

Governmental information service 3.7 (±0.24)

Health information corporation 3.5 (±0.17)

Medical professionals 3.7 (±0.18)

News 3.1 (±0.13)

Non-profit organization 3.8 (±0.19)

1 2 3 4 5

Figure 4. DISCERN scores of consumer health information grouped by website category. These figures provide an overview of
mean DISCERN scores according to each section of the questionnaire. (a) Scores for Section 1 (reliability; questions 1 through 8), (b)
scores for Section 2 (quality of content; questions 9 through 15), (c) total DISCERN score (all 16 questions). Data shows mean (

standard error of the mean) to the right side of each column for category of information provider type. The reported results
are means of consensus scores between raters. The DISCERN tool rates information quality, scoring from 1 to 5, where 1 is low
quality, 3 is partial quality, and 5 is high quality information. Columns are arranged in alphabetical order. Statistical significance of
DISCERN scores were established between groups with a one-way ANOVA. Differences between categories were significant in
Section 1, regarding reliability (p < 0.001); Section 2, regarding quality of content (p ¼ 0.029); and mean total DISCERN score
(p < 0.001).
Bojazar et al.
Discussion
The current study investigated migraine treatment
information on the internet. The highest indexed web-
sites recommended a total of 77 acute and preventive
treatment options, both non-pharmacological and
pharmacological. Health information corporation is
the health information provider type which covers the
broadest number of treatments. Non-profit organiza-
tions comprise the most reliable provider type, whereas
medical professionals provide the highest quality of
information. Non-profit organizations also had the
highest mean total DISCERN score.
Migraine management
Ranking of treatment recommendations shows that
treatment modalities of anecdotal evidence rank high-
est among acute non-pharmacological options.
Relaxation, sleep, and placing ice packs on the head
are ranked highest among acute non-pharmacological
treatments. These treatments are cheap and easily
accessible compared to for example medical
devices. In addition, the nature of the aforementioned
treatments is based on anecdotal evidence, which may
be why they are highly indexed on Google, as
these treatments are generally favoured by patients
(12).
Among acute pharmacological treatments, the most
frequently reported treatments are non-migraine spe-
cific treatments such as non-steroidal anti-inflammato-
ry drugs (NSAIDs) rather than migraine-specific
therapeutics like triptans. NSAIDs are available as
over-the-counter analgesics and cheaper in most
countries, which may make them preferred over
migraine-specific drugs (13,14). Fourteen websites
(19%) mention opioids as a treatment option, and
despite specifying opioids as a last-resort option, the
high number of websites covering opioids in the con-
text of migraine is problematic. Opioids are potentially
addictive and not recommended in any guidelines
(15,16). Considering that 64 websites (88%) recom-
mend pharmacological treatment, as well as 49% of
websites only recommends pharmacological options,
it is noteworthy that only 45 websites (62%) caution
against medication overuse headache, highlighting a
major challenge in online-based patient education.
Among preventive treatments, non-pharmacological
treatments are most frequently covered, with avoidance
of triggers as the most frequent recommendation, fol-
lowed by sleep, meals and relaxation. As with acute
treatments, cheap and easily applicable interventions
are favoured over migraine-specific products. This
may underline the previously described anecdotal
nature of internet treatment recommendations.
1641
Botox is the most frequently covered preventive
pharmacological treatment, followed by beta blockers
and anti-CGRP monoclonal antibodies. Concurrently,
conventional preventive therapeutics like beta blockers
and tricyclic antidepressants are still frequently recom-
mended, which may be because they are first choice
preventives in medical practices (15).
Online health information on migraine treatments
covers an extensive number of treatment options,
which can be problematic for patients seeking health
information online. Considering the estimated
level of health literacy (17), most online seekers
of health care information may not have the tools
to evaluate and compare different treatment
options, therefore the high number of treatments rec-
ommended by websites may complicate patient’s self-
care (18).
Furthermore, the high number of non-validated
treatment recommendations can disrupt the overlap
between health care professionals’ and patients’ scope
of interpretation of optimal migraine treatment.
Inability to eliminate discrepancies between the treat-
ment expectations of patients and healthcare professio-
nals can lead to suboptimal treatments (18).
Information provider type
E-commerce websites constitute the largest group of
health information providers of migraine treatments.
This is perhaps due to ExcedrinVR being frequently
entered in migraine-related searches on the internet,
likely derived from non-migraine specific over-the-
counter analgesics being widely used as acute
migraine relief medication (19). The high search
volume index of e-commerce websites can be suggestive
of migraineurs using Google in search of acute relief.
The abrupt increase in searches on ExcedrinVR
around January of 2012 is likely due to the recall of
the drug by the manufacturer at the time (20). The
manufacturer at the time recalled all lots because of
reports of chipped pills and faulty packaging, which
could result in bottles containing foreign tablets, cap-
lets or capsules (20).
Furthermore, Google is often used as a gateway to
e-commerce websites across website types (21). Over-
the-counter treatment options are therefore readily
available for patients to buy directly from the internet
without a prescription (22). Restricted access to health-
care, for example in a private healthcare setting, could
incite patients to seek available over-the-counter treat-
ments instead of consulting a professional. Taken
together, this might explain the high indexation of
e-commerce websites.
Stratification analysis of treatment options with
respect to provider types revealed that health
1642
information corporations are providing the broadest
coverage of information on migraine treatment
options. Health information corporations are for-
profit organizations, which entails a financial incite-
ment for providing a large volume of information
with opportunities for both advertisements and spon-
sored content on websites. Though this can be found
on such websites, it is specified per advertisement.
Furthermore, high information volume can favour
websites in terms of high Google search result ranking,
as there is potentially a broader coverage of search
term matches (10).
Quality of websites
Non-profit organizations had the highest mean total
DISCERN score. When solely observing Section 1 of
the DISCERN tool, which addresses the reliability of
the conveyed message, non-profit organizations score
highest with a mean score of 4.1 (
0.22).
The DISCERN instrument favours information that
is conveyed with clear purpose, framework, and multi-
ple solutions. This might explain why non-profit organ-
isations obtain the highest score in Section 1 and why
medical professionals did not, despite obtaining the
highest mean score on quality of information. Non-
profit organisations scored highest in Section 1 which,
when added with scores from Section 2, resulted in the
highest mean total DISCERN score. Our results may
suggest that, among the highest indexed websites, med-
ical professionals do not prioritise the framework of a
message despite being an important factor in patient
education (23).
The discrepancy of health information quality
between different websites is similar to previous find-
ings in other medical conditions with analysis and eval-
uation of content (24,25). This suggests that some
challenges in online health information is similar
across medical conditions.
Websites recommending treatment options based
on anecdotal evidence rank relatively high in
DISCERN scoring. This is consistent with health
information consumers heavily weighing anecdotal
information for treatment choices (12). Websites with
information on migraine treatment can obtain a high
DISCERN score regardless of the evidence behind rec-
ommendation of the treatment, which might explain
why conventional evidence-based approaches are not
favoured.
Strengths and limitations
Google Trends is a search string compositor based on
monitoring of Google entries. It is not a proxy marker
Cephalalgia 40(14)
for epidemiological data, but rather a depiction of
queries. We do not use Google searches as a surrogate
for epidemiological data, therefore this limitation does
not necessarily apply to our study. Furthermore,
Google uses proprietary methods to determine index-
ation of websites. The degree of variability, and thereby
generalisability, was not assessed in this study, due to
the searches being conducted on a single computer in
Greater Copenhagen, Denmark. Although we cannot
exclude regional differences in a Google search, we
believe the clearance of temporary internet files and
strict use of English search terms will limit potential
differences.
This is a cross-sectional study of internet
websites while the content is constantly indexed.
However, this is an inherent limitation in studies of
online content.
The DISCERN tool for evaluation of written con-
sumer health information does not require an assess-
ment of interrater reliability. Nevertheless, we
quantified the level of agreement between raters by
weighted Cohen’s kappa coefficient due to the ordinal
nature of the DISCERN scale. The estimated agree-
ment between raters was kappa ¼ 0.489, 95% CI
(0.448, 0.530), p < 0.001. The estimated kappa can be
interpreted as moderate strength of agreement (26,27)
and is similar to the strength of agreement of the
founding expert panel of the DISCERN tool (7).
Estimations of interrater reliability on online informa-
tion is elusive as the content is heterogeneous. This
emphasised the need for the two raters to settle
any disagreement in rating by re-assessing the website
in question.
When assessing the content of websites, the authors
were not blinded to the publisher of the websites, which
can constitute a source of bias. However, extraction of
data from the website in a blinded manner (e.g. web-
scraping) is considered a violation of the terms of use
of the websites (28,29). Furthermore, the purpose
of the study is to assess the results from googling
migraine, therefore content presentation is included in
this scope.
Conclusion
Googling when looking for migraine treatments reveals
a myriad of management recommendations of varying
quality. Patients use the internet in the context of self-
treatment before consulting healthcare professionals,
which should incentivise health care professionals, gov-
ernmental service providers and other stakeholders to
provide reliable information of high quality. We
encourage stakeholders to optimise the distribution of
Bojazar et al.
high-quality and peer-reviewed information on
migraine management, possibly in the context of a
Key findings
• Among acute treatments, pharmacological treatments are most frequently covered and most commonly
non-migraine specific treatments such as non-steroidal anti-inflammatory drugs (NSAIDs) rather than
migraine-specific therapeutics like triptans.
• Among preventive treatments, non-pharmacological treatments are most frequently covered, with avoid-
ance of triggers as the most frequent recommendation, followed by sleep, meals and relaxation.
• E-commerce websites dominate the highest-ranked indexed migraine-related websites on Google.
Declaration of conflicting interests
The authors disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: RB, TPD, JMH report no conflicts of interest. DWD
reports the following conflicts: Personal fees: Amgen, AEON,
Association of Translational Medicine, University Health
Network, Daniel Edelman Inc., Autonomic Technologies,
Axsome, Aural Analytics, Allergan, Alder
BioPharmaceuticals, Biohaven, Charleston Laboratories,
Clexio, Dr Reddy’s Laboratories/Promius, Electrocore
LLC, Eli Lilly, eNeura, Neurolief, Novartis, Ipsen, Impel,
Satsuma, Supernus, Sun Pharma (India), Theranica, Teva,
Vedanta, WL Gore, Nocira, PSL Group Services,
University of British Columbia, XoC, Zosano, ZP Opco,
Foresite Capital, Oppenheimer; Upjohn (Division of Pfizer),
Pieris, Revance, Equinox, Salvia, Amzak Health. Speaking
fees: Eli Lilly, Novartis Canada, Amgen. Speakers Bureaus:
None. CME fees or royalty payments: HealthLogix,
Medicom Worldwide, MedLogix Communications, Mednet,
Miller Medical, PeerView, WebMD Health/Medscape,
Chameleon, Academy for Continued Healthcare Learning,
Universal Meeting Management, Haymarket, Global
Scientific Communications, Global Life Sciences, Global
Access Meetings, UpToDate (Elsevier), Oxford University
Press, Cambridge University Press, Wolters Kluwer Health;
Stock options: Precon Health, Aural Analytics, Healint,
Theranica, Second Opinion/Mobile Health, Epien, Nocira,
Matterhorn/Ontologics, King-Devick Technologies;
Consulting without fee: Aural Analytics, Healint, Second
Opinion/Mobile Health, Epien; Board of Directors: Epien,
Matterhorn/Ontologics, King-Devick Technologies. Patent:
17189376.1-1466:vTitle: Botulinum Toxin Dosage Regimen
for Chronic Migraine Prophylaxis without fee; Research
funding: American Migraine Foundation, US Department
of Defense, PCORI, Henry Jackson Foundation;
Professional society fees or reimbursement for travel:
American Academy of Neurology, American Brain
Foundation, American Headache Society, American
1643
scientific society; for example, The International
Headache Society.
Migraine Foundation, International Headache Society,
Canadian Headache Society.
MA reports personal fees from Allergan, Amgen, Alder,
Eli Lilly, Novartis and Teva. He participated in clinical trials
as the principal investigator for Alder, Amgen, ElectroCore,
Novartis and Teva trials; he has no ownership interest and
does not own stocks of any pharmaceutical company, and
also serves as associated editor of Cephalalgia, Headache,
and co-editor of the Journal of Headache and Pain. MA is
the President of the International Headache Society and
General Secretary of the European Headache Federation.
Funding
The authors disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: The Lundbeck Foundation funded the publication of
this article.
ORCID iD
Rachid Bojazar https://orcid.org/0000-0001-9565-483X
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