What are the different types of migraines?

Types of Migraine

According to the International Classification of Headache Disorders (ICHD-3), there are three main types of migraine: migraine without aura, migraine with aura, and chronic migraine. 1 Each type has distinct diagnostic criteria and clinical presentations that are important for proper diagnosis and management.

Migraine Without Aura

Migraine without aura (previously called common migraine) is the most prevalent type, characterized by:

• Recurrent headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
• At least 5 attacks fulfilling the diagnostic criteria
• Headache with at least two of these characteristics:
  • Unilateral location
  • Pulsating quality
  • Moderate to severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity
• During headache, at least one of:
  • Nausea and/or vomiting
  • Photophobia and phonophobia

In children and adolescents, attacks may last 2-72 hours 1.

Migraine With Aura

Migraine with aura (previously called classic or classical migraine) affects approximately one-third of migraine patients and features:

• At least 2 attacks fulfilling the diagnostic criteria
• One or more fully reversible aura symptoms:
  • Visual (most common, >90% of aura cases)
  • Sensory (occurs in ~31% of cases)
  • Speech and/or language
  • Motor
  • Brainstem
  • Retinal
• At least 3 of these 6 characteristics:
  • At least one aura symptom spreads gradually over ≥5 minutes
  • Two or more aura symptoms occur in succession
  • Each individual aura symptom lasts 5-60 minutes
  • At least one aura symptom is unilateral
  • At least one aura symptom is positive (e.g., scintillations, pins and needles)
  • The aura is accompanied by or followed within 60 minutes by headache

Importantly, many individuals with migraine with aura also experience attacks without aura. In such cases, both migraine with aura and migraine without aura should be diagnosed 1.

Chronic Migraine

Chronic migraine is defined as:

• Headache (migraine-like or tension-type-like) occurring on ≥15 days/month for >3 months
• Fulfilling criteria for migraine on ≥8 days/month
• In a person who has had at least five attacks fulfilling criteria for migraine without aura and/or migraine with aura
• Not better accounted for by another ICHD-3 diagnosis

Chronic migraine is not a static condition - patients may revert to episodic migraine and vice versa 1.

Other Notable Migraine Types

Vestibular Migraine

Vestibular migraine is characterized by:

• At least 5 episodes with vestibular symptoms of moderate or severe intensity
• Current or previous history of migraine with or without aura
• One or more migraine features with at least 50% of vestibular episodes
• Episodes lasting 5 minutes to 72 hours
• Not better accounted for by another vestibular or ICHD-3 diagnosis 1

Typical Aura Without Headache

Also known as acephalgic migraine, this rare subtype features:

• Typical migraine aura symptoms (usually visual)
• No subsequent headache
• Occurs exclusively in 4% of migraine patients
• May occur in up to 38% of patients with migraine with aura at some point 2

Clinical Distinctions Between Migraine Types

There are important clinical differences between migraine types:

• Genetic differences: Migraine with aura shows different heritability patterns compared to migraine without aura 3, 4
• Comorbidity differences: Migraine with aura has stronger associations with certain conditions, particularly stroke risk 3, 5
• Neuroimaging differences: Brain structure and function alterations differ between migraine with and without aura 3
• Treatment response differences: Some evidence suggests different responses to acute and preventive therapies between migraine types 3, 5

Diagnostic Pitfalls to Avoid

• Mistaking migraine aura for transient ischemic attack (TIA) - aura symptoms typically spread gradually (≥5 min) and occur in succession, while TIA symptoms have sudden, simultaneous onset 1
• Failing to diagnose both migraine with aura and migraine without aura in patients who experience both types of attacks
• Overlooking chronic migraine in patients with frequent headaches
• Misdiagnosing medication-overuse headache (≥15 headache days/month with regular overuse of acute headache medications) as chronic migraine 1

Understanding these different migraine types is essential for accurate diagnosis and appropriate management strategies tailored to each patient's specific migraine presentation.