What are the diagnostic criteria and treatment options for migraines?

Diagnosis and Management of Migraine Headaches

The diagnosis of migraine is primarily clinical, based on specific ICHD-3 criteria including recurrent moderate to severe headaches with unilateral location, pulsating quality, aggravation by physical activity, and associated symptoms like photophobia, phonophobia, nausea, or vomiting. 1, 2

Diagnostic Criteria for Migraine

Migraine Without Aura

• At least 5 attacks fulfilling the following criteria:
  • Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
  • Headache has at least 2 of these characteristics:
    • Unilateral location
    • Pulsating quality
    • Moderate or severe pain intensity
    • Aggravation by routine physical activity
  • During headache, at least 1 of the following:
    • Nausea and/or vomiting
    • Photophobia and phonophobia
  • Not better accounted for by another diagnosis 1, 2

Migraine With Aura

• At least 2 attacks with:
  • One or more fully reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, or retinal)
  • At least 3 of these characteristics:
    • At least 1 aura symptom spreads gradually over ≥5 minutes
    • Two or more aura symptoms occur in succession
    • Each aura symptom lasts 5-60 minutes
    • At least 1 aura symptom is unilateral
    • At least 1 aura symptom is positive
    • Aura accompanied/followed within 60 minutes by headache 1, 2

Chronic Migraine

• Headache on ≥15 days/month for >3 months
• Fulfilling migraine criteria on ≥8 days/month 1, 2

Diagnostic Approach

Key History Elements

• Age at onset
• Duration and frequency of episodes
• Pain characteristics (location, quality, severity)
• Aggravating and relieving factors
• Associated symptoms (photophobia, phonophobia, nausea, vomiting)
• Aura symptoms (if any)
• Medication use history
• Family history (often positive in migraine patients) 1, 2

Diagnostic Aids

• Headache diaries - record pattern, frequency, and symptoms
• Headache calendars - track temporal occurrence and related events
• ID-Migraine questionnaire - screens based on nausea, photophobia, and disability 1

Red Flags Requiring Further Investigation

• Thunderclap headache (sudden severe onset)
• Atypical aura
• Head trauma history
• Progressive headache pattern
• Positional aggravation
• New onset after age 50
• Unexplained fever or neck stiffness
• Focal neurological deficits 2

Treatment Approach

Acute Treatment Algorithm

1. First-line for mild to moderate attacks:

   • NSAIDs: ibuprofen (400-800mg), naproxen sodium (500-550mg), or aspirin (900-1000mg) 2, 3
   • Acetaminophen for those who cannot take NSAIDs 3, 4

2. First-line for moderate to severe attacks:

   • Triptans (sumatriptan, rizatriptan, zolmitriptan)
   • Consider combination of triptan with NSAID for enhanced efficacy 2, 3

3. Second-line options:

   • Antiemetics (metoclopramide, domperidone) for associated nausea
   • Consider non-oral routes when significant nausea/vomiting is present
   • Gepants or ditans for patients with contraindications to triptans 2, 3, 5

Important Medication Considerations

• Triptans are contraindicated in:

  • Uncontrolled hypertension
  • Coronary artery disease
  • Basilar or hemiplegic migraine
  • Wolff-Parkinson-White syndrome 2, 6

• Sumatriptan may cause:

  • Chest/throat/neck tightness or pressure
  • Potential for serotonin syndrome with SSRIs/SNRIs
  • Blood pressure elevation 6

• Avoid opioids and butalbital-containing medications due to:

  • Questionable efficacy
  • Significant adverse effects
  • Risk of dependency 2, 3

Preventive Treatment

Indicated when:

• More than two headaches per week
• Headaches on ≥15 days/month for >3 months (chronic migraine) 2

Preventive Options

• First-line medications:

  • Beta-blockers
  • Topiramate
  • Tricyclic antidepressants 2

• For chronic migraine:

  • OnabotulinumtoxinA (Botox) - effective for chronic migraine with ≥15 headache days/month 2, 7
  • Note: Botox requires monitoring for serious side effects including problems with swallowing, speaking, or breathing 7

• Non-pharmacological prevention:

  • Regular sleep schedule
  • Regular meals and hydration
  • Stress management
  • Trigger identification and avoidance
  • Regular exercise 2

Medication Overuse Headache Prevention

• Limit acute headache medications to ≤2 days per week
• Suspect medication overuse headache if using:
  • NSAIDs ≥15 days/month
  • Triptans ≥10 days/month 1, 2

Common Pitfalls to Avoid

• Overlooking red flags in patients with known primary headache disorders
• Failing to recognize medication overuse headache
• Confusing migraine aura with TIA (migraine aura typically develops gradually over ≥5 minutes)
• Missing chronic migraine diagnosis 2

By following these diagnostic criteria and treatment algorithms, clinicians can effectively diagnose and manage migraine headaches, improving patient outcomes and quality of life.