What are the diagnostic criteria for migraine?

Migraine Diagnostic Criteria

Migraine diagnosis is based on the International Classification of Headache Disorders-3 (ICHD-3) criteria, which require a detailed clinical history documenting specific headache characteristics, duration, associated symptoms, and frequency patterns—no biomarker or imaging is needed for diagnosis. 1

Migraine Without Aura (Common Migraine)

This is the most common presentation and requires all five of the following criteria 1:

1. At least 5 attacks meeting the remaining criteria

2. Duration: 4-72 hours (untreated or unsuccessfully treated)

3. At least TWO of these four pain characteristics:

   • Unilateral location
   • Pulsating quality
   • Moderate or severe intensity
   • Aggravated by or causes avoidance of routine physical activity (walking, climbing stairs)

4. At least ONE of the following during headache:

   • Nausea and/or vomiting
   • Both photophobia AND phonophobia

5. Not better explained by another ICHD-3 diagnosis

Clinical Shortcut for Primary Care

For rapid screening in busy clinical settings, if any two of the following are present, migraine without aura is highly likely: unilateral location, throbbing quality, nausea, photophobia, or phonophobia 2. The POUND mnemonic (Pulsating, 4-72 hOurs duration, Unilateral, Nausea, Disabling) is also useful—if 4 of 5 criteria are met, the likelihood ratio is 24 for migraine 3.

Migraine With Aura

This requires all four criteria 1:

1. At least 2 attacks meeting criteria 2 and 3

2. One or more fully reversible aura symptoms:

   • Visual (most common—flashing lights, zigzag lines, scotomas)
   • Sensory (tingling, numbness)
   • Speech/language
   • Motor
   • Brainstem
   • Retinal

3. At least THREE of these six characteristics:

   • At least one aura symptom spreads gradually over ≥5 minutes (key differentiator from stroke/TIA)
   • Two or more aura symptoms occur in succession
   • Each aura symptom lasts 5-60 minutes
   • At least one aura symptom is unilateral
   • At least one aura symptom is positive (flashing lights, tingling—not just loss of function)
   • Aura is accompanied by or followed by headache within 60 minutes

4. Not better explained by another ICHD-3 diagnosis

Critical distinction: Aura symptoms spread gradually over ≥5 minutes and occur sequentially, whereas stroke/TIA symptoms have sudden, simultaneous onset 1. Many patients have both migraine with and without aura—diagnose both when present 1.

Chronic Migraine

This is a distinct entity requiring all four criteria 1:

1. Headache ≥15 days/month for >3 months (can be migraine-like or tension-type-like)

2. Prior history: Patient has had at least 5 attacks meeting criteria for migraine without aura and/or migraine with aura

3. On ≥8 days/month for >3 months, any of the following:

   • Meets criteria for migraine without aura (criteria 3 and 4)
   • Meets criteria for migraine with aura (criteria 2 and 3)
   • Patient believed it was migraine at onset and it was relieved by triptan or ergot

4. Not better explained by another ICHD-3 diagnosis

Important caveat: Chronic migraine is not static—patients can revert to episodic migraine and vice versa 1. Always screen for medication overuse headache in chronic migraine patients.

Essential History Elements

The medical history is the mainstay of diagnosis 1. Document:

• Age at onset (typically around puberty)
• Duration of individual attacks
• Frequency of attacks
• Pain characteristics: location, quality, severity, aggravating/relieving factors
• Associated symptoms: photophobia, phonophobia, nausea, vomiting
• Aura symptoms if present (type, duration, progression)
• Acute and preventive medication use (including frequency—critical for medication overuse)
• Family history (strong genetic component; often positive in first-degree relatives) 1

When to Suspect Migraine

Suspect migraine without aura when you see recurrent moderate-to-severe headache that is unilateral and/or pulsating with photophobia, phonophobia, nausea, and/or vomiting 1.

Suspect migraine with aura when the above features are accompanied by recurrent, short-lasting visual and/or hemisensory disturbances 1.

Suspect chronic migraine when headache occurs ≥15 days/month 1.

Strengthen suspicion with positive family history and symptom onset at or around puberty 1.

Diagnostic Aids

• Headache diary: Essential for documenting attack frequency, duration, characteristics, and medication use—useful for both initial diagnosis and ongoing assessment 1
• HIT-6 (Headache Impact Test): Assess migraine-related disability 4
• Hospital Anxiety and Depression scale (HAD): Screen for comorbidities that increase chronic migraine risk 4

Physical Examination and Neuroimaging

Physical examination is typically confirmatory and normal in primary migraine 1. Neuroimaging is not required for diagnosis when history meets ICHD-3 criteria and examination is normal 1, 4, 5.

Order neuroimaging when:

• Abnormal neurologic examination (LR 5.3 for intracranial pathology) 3
• Cluster-type headache features (LR 10.7) 3
• Undefined headache not fitting migraine/tension/cluster pattern (LR 3.8) 3
• Headache with aura in atypical presentation (LR 3.2) 3
• Headache aggravated by exertion/Valsalva (LR 2.3) 3
• Headache with vomiting as isolated feature (LR 1.8) 3

Common Pitfalls

• Don't require all pain characteristics: Only 2 of 4 pain features are needed for migraine without aura
• Don't confuse photophobia OR phonophobia: Migraine without aura requires both photophobia AND phonophobia (or nausea/vomiting as alternative)
• Don't miss medication overuse: In chronic migraine, always assess for overuse (≥15 days/month of non-opioid analgesics or ≥10 days/month of triptans/combination medications for >3 months) 1
• Don't diagnose based on single attack: Migraine without aura requires ≥5 attacks; migraine with aura requires ≥2 attacks
• Don't overlook aura without headache: Some patients have aura followed by minimal or no headache—still meets criteria if headache occurs within 60 minutes of aura 1