Sabina Cevoli ¹ Piero Barbanti ^2,3* Cinzia Finocchi ⁴ Laura Benedan ⁵ Paolo Mariani ⁵ Nicoletta Orthmann ⁶ Salvatore Bauleo ⁷ Paola Brusa ⁸ Dorella Cianci ⁹ Luca Marozio ⁸ Sara Masseroni ¹⁰ Roberto Sangermani ¹¹ Fabio Frediani ¹⁰ Gianni Allais ⁸

• ¹ Unit of Neuroradiology, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Emilia-Romagna, Italy
• ² IRCCS San Raffaele Roma srl, Roma, Italy
• ³ San Raffaele University, Roma, Italy
• ⁴ San Paolo Hospital, Milan, Italy
• ⁵ University of Milano-Bicocca, Milan, Lombardy, Italy
• ⁶ Onda Foundation, Milano, Italy
• ⁷ AUSL Bologna, Bologna, Italy
• ⁸ University of Turin, Turin, Piedmont, Italy
• ⁹ Libera Università Maria SS. Assunta, Rome, Italy
• ¹⁰ Santi Paolo e Carlo Hospital, Milano, Italy
• ¹¹ Independent researcher, Milano, Italy

Background: Migraine is a highly underestimated and burdensome disease. Real-world studies evidence that migraine is more frequent and severe in women than men. However, to this day, no diagnostic-therapeutic pathways exist to satisfy the specific needs of female patients.Methods: In this study, migraine experts, specialists in women's health, patient, and decision makers, analyzed the diagnostic and therapeutic options for women with migraine across various ages and health conditions within the Italian healthcare system. A Delphi approach was used to formulate statements and achieve a consensus. Results: Gaps in clinical practice were identified, and strategies to accommodate women's needs were proposed. The experts agreed that a socio-behavioral intervention should be planned before any pharmacological treatment in pediatric/adolescent female patients and that the assessment of migraine with aura is considered crucial for adult women requiring contraceptive therapy. Acupuncture emerged as an effective treatment for pregnant and breastfeeding women, and hormonereplacement therapy selection in menopausal patients requires careful consideration to mitigate safety risks. The experts highlighted the absence of literature and guidelines for the management of migraine in women undergoing assisted reproductive procedures or oncological treatment. In light of these observations, the experts advocated the establishment of multidisciplinary collaborations between neurologists/headache specialists and other healthcare professionals, including general practitioners, pediatricians, gynecologists, and oncologists. Comprehensive migraine education for all healthcare professionals potentially involved in managing the disease, including pharmacists, was emphasized. Efforts to increase migraine awareness among women should be prioritized.The insights gained from this Italian consensus study should serve to develop an improved, female-specific pathway to diagnose and treat migraine.