Image vs. Reality: What Does a Migraine Attack Really Look Like?

By Freda Kreier | October 10, 2023 | Posted in

A new study finds that popular stock images depicting a migraine attack are not realistic, nor are they representative of how people view their own attacks.

Stock images showing a person having a migraine attack usually feature a beautiful, slender white woman touching her hands to both temples in pain. These stereotypical images are everywhere, especially on the Internet. You’ll also find them on advertisements recruiting participants for migraine studies or promoting new treatments, and even at conferences.

Yet those who have migraine agree that these images don’t accurately depict the condition. That is the conclusion of new research, led by Bianca Raffaelli, a neurologist at Charité Universitätsmedizin Berlin, Germany.

Building upon the same group’s previous work, which included study participants in Berlin, this new survey study of 174 migraine patients treated in Rostock, a smaller rural city in east Germany, found that 10 of the most downloaded stock images depicting migraine attacks were only moderately realistic. The images were also only moderately representative of patients’ own attacks. Nor did the images succeed when patients considered the extent to which the depictions represented society’s view of migraine attacks.

When the investigators compared the current results to their prior findings from 366 patients in Berlin, a much larger urban area, they found that the patients in Rostock rated the images as more realistic and representative than their big city counterparts did.

The new study is one of the few to look at media representations of migraine, and it “validates that more than 40% of people who have migraine don’t agree that these images represent their experience,” said Robert Shapiro, a neurologist at the University of Vermont, Burlington, US, who was not involved in the study.

The inaccurate portrayal of migraine in mass media could be exacerbating the stigma that many people with migraine already experience, highlighting the need for images that better reflect the full experience of migraine and who has it.

The work appeared in PLoS ONE on August 18, 2023.

Portraying an invisible condition  
Migraine is an “invisible” condition – there are few outward signs and, as of today, no biomarkers that serve as objective indicators of disease. But there is one obvious symptom during an attack: head pain.

In 2020, Shapiro, along with researchers at the University of Copenhagen, co-authored the first study to examine typical photographic images portraying a person with migraine. They found that among nearly 300 stock images from Shutterstock and Google Images, almost all of them were suggestive of head pain or light sensitivity, but not other symptoms. Further, the models used in the images were overwhelmingly white, slender women of adult age, with closed eyes and hands on both sides of the head.

These depictions of migraine started to stick out to Raffaelli when she attended conferences. The stereotypical images of the sort Shapiro and his colleagues identified were everywhere, she said. Such depictions risk making life even more difficult for people with a disease that is underrecognized and undertreated.

“People with migraine are not taken as seriously as they should be,” said Raffaelli.

As someone who has migraine herself, Raffaelli knew that the reality of this condition was much more complicated than the images suggested, and she wanted to know whether other people felt the same way.

Building upon an earlier study
So, in 2021, Raffaelli and her colleagues surveyed healthcare professionals and migraine patients at the hospital in Berlin where she worked about their perception of Internet images of migraine attacks. The web-based survey showed study participants the 10 most frequently downloaded stock images from Adobe Stock based on the search word “migraine.” All survey participants rated how realistic the images were in depicting a migraine attack (realism score), while the patients were also asked how representative the images were of their own experience of migraine (representation score), on a scale of 0% to 100%.

Nearly 700 healthcare workers and patients took the survey. The findings confirmed many of Raffaelli’s suspicions. Both groups agreed that the images weren’t very realistic, with the average realism score coming in at just under 50%. Patients also didn’t feel the images represented their own experience of migraine attacks, as indicated by a mean representation score of just 44%.

However, both groups rated images showing men more realistic than images with women, and images with older people more realistic than those featuring younger individuals. This was somewhat unexpected considering that the bulk of people with migraine are younger women, said Raffaelli. But “our society is still very patriarchal. So pain from an old man is probably perceived as more realistic than from a young woman,” she said.

Raffaelli’s Berlin study was the first to look at how healthcare workers and patients perceived common images of migraine attacks. But her colleagues soon pointed out that this research might not be widely representative of people with migraine. That’s because Berlin is a large, international city. People in more rural areas, who previous research suggested may be more trusting of media representations of health information than city dwellers are, might see the stock images differently.

Neither realistic nor representative
So, for the new study, Raffaelli and colleagues repeated the experiment in Rostock, a town of just 200,000 inhabitants at the Baltic Sea.

A total of 174 people with migraine being treated at a hospital in Rostock responded to the survey, rating 10 Adobe Stock images on a 0 to 100 score where a score of 0 meant the image was not realistic or representative at all, and a score of 100 meant the image was fully realistic or representative. This time, the survey also asked participants to rate how well the images represented society’s view of migraine attacks (society score).

The patients from Rostock rated the images as only moderately realistic (a mean realism score of approximately 60), and also only moderately representative (a mean representation score of 57). The society score reached only 58. And, as in the earlier Berlin study, participants rated images featuring older people as more realistic and representative than images of younger people.

When comparing the results from the Rostock study to those of the Berlin study, the researchers found that the Rostock participants found the images more realistic and representative than the Berlin participants did. To explain that finding, the researchers suggested that the lower average levels of education they documented among the Rostock participants may have made them more likely to trust media representations of health information. The more ethnically homogenous background of the Rostock participants may have also played a role, among other factors.

Another interesting difference between the two studies was that, unlike the Berlin participants, the Rostock group did not rate the realism or representation of the images differently in male vs. female models, perhaps due to differences in gender norms in each area.

Migraine is more than a headache
But, overall, the realism and representation scores for the Adobe images were pretty measly for both groups, especially considering how widespread these images are, said Raffaelli.

The results make clear that stock image portrayals of migraine attacks don’t match what migraine is like for people who experience it. While it is true that migraine is about three times more prevalent in women than in men, it affects all genders, ages, ethnic backgrounds, and body types.

The typical depictions of migraine also ignore a lot about the pathophysiology of the condition.

“The common understanding is that migraine is just a bad headache,” Shapiro said. But migraine is also characterized by many non-headache symptoms, including nausea, aura, sensitivity to light or sound, vertigo, and cognitive impairments  – features of the condition that the images do not address.

This incomplete representation of migraine could make the problem of stigma even worse, with severe consequences for patients.

“Stigma is a huge driver of quality of life among people who are living with migraine,” Shapiro said.

One of the ways to address stigma may be to change the way migraine is represented in mass media, said Raffaelli. For instance, stock images of migraine could try to represent other symptoms of migraine beyond the headache pain.

The field has already started to move in that direction. For instance, the Coalition for Headache and Migraine Patients (CHAMP), a nonprofit organization that brings together patient advocacy organizations focused on migraine and headache, already recommends using images that display a wider array of symptoms and a broader range of ages, races, ethnicities, and gender.

In this regard, healthcare workers on the frontlines have an important role to play, according to Raffaelli.

“We could and should aim for more,” she told Migraine Science Collaborative.

Encouragingly, Raffaelli has already started noticing a wider array of body types and races in the images she sees at conferences. This progress might reflect a growing shift in Europe towards more diversity in who receives the mass media spotlight, said Raffaelli.

“I have the feeling that something is changing,” she says. “That’s good.”

Freda Kreier is a freelance science journalist based out of Washington, DC.

Perception of typical migraine images on the internet: Comparison between a metropolis and a smaller rural city in Germany.
Hamann et al.
PLoS One. 2023 Aug 18;18(8):e0290318.

Patients’ and health care workers’ perception of migraine images on the Internet: cross-sectional survey study.
Raffaelli et al.
J Med Internet Res. 2021 Nov 12;23(11):e32707.

The stereotypical image of a person with migraine according to mass media.
Gvantseladze et al.
Headache. 2020 Jul;60(7):1465-71.

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