Migraine is a prevalent, disabling neurological disorder with significant, underestimated economic consequences. Its indirect costs, mainly from presenteeism and absenteeism, constitute a major burden. Existing studies provide heterogeneous cost estimates due to varied methods and regional economic differences, limiting a harmonized global understanding. Given sex differences in migraine, understanding potential cost disparities between males and females is also vital for targeted interventions.

This systematic review, registered with PROSPERO (CRD42024605831) and following PRISMA guidelines, utilized PubMed and Web of Science. Search terms covered migraine, economic burden, and productivity loss. Four independent reviewers screened articles, extracting and standardizing cost data to 2025 USD adjusted for purchasing power parity. A narrative synthesis analyzed cost estimates by productivity components and sex.

Forty-five studies were included from 366 references, with an aggregate sample size of 3,849,116 (30% male, 70% female) across multiple countries. Presenteeism accounted for 61.3% of productivity costs, outweighing absenteeism (38.7%). Males accounted for 53.3% of total costs, despite lower representation. Methodological heterogeneity led to varied estimates, but presenteeism's dominance was consistent.

Migraine places a significant indirect economic burden globally, primarily due to presenteeism outweighing absenteeism. The finding that males incurred a higher total indirect cost share despite lower prevalence highlights complex interactions between gender, work patterns, and migraine impact that warrant further investigation. High heterogeneity in cost estimates necessitates more standardized methodologies in future research to enable robust cross-country comparisons. Overall, these findings highlight the critical need for workplace interventions that address both missed workdays and reduced on-the-job productivity, and emphasize that tailoring interventions to account for gender-specific differences in migraine burden and workplace dynamics could improve management strategies and reduce the overall economic burden.