What tests should be ordered for a patient presenting with migraines?

Diagnostic Testing for Migraine Headaches

For patients presenting with typical migraine symptoms, no specific diagnostic tests are necessary as migraine is primarily a clinical diagnosis based on history and physical examination. 1

Clinical Evaluation Approach

History Taking

• Obtain comprehensive headache history including:
  • Age at onset of headache
  • Duration of headache episodes (typically 4-72 hours)
  • Frequency of headache episodes
  • Pain characteristics (location, quality, severity)
  • Aggravating and relieving factors
  • Associated symptoms (photophobia, phonophobia, nausea, vomiting)
  • Aura symptoms (if any)
  • History of acute and preventive medication use 2

Physical Examination

• Perform neurological examination (typically normal in migraine)
• Check vital signs
• Conduct fundoscopic examination
• Examine neck for stiffness
• Palpate temporal arteries 1

Diagnostic Tools

• Headache diaries: Record daily entries of headache occurrence, severity, associated symptoms, and medication use
• Headache calendars: Track temporal patterns of headaches and related events (e.g., menstruation)
• Screening questionnaires:
  • Three-item ID-Migraine questionnaire (evaluates nausea, photophobia, and disability)
  • Five-item Migraine Screen Questionnaire (MS-Q) 2, 1

When to Consider Additional Testing

Additional testing should be considered when "red flag" symptoms are present:

• Neuroimaging (MRI or CT) is indicated for:

  • Thunderclap headache (sudden onset)
  • New headache onset after age 50
  • Progressively worsening headache pattern
  • Headache awakening patient from sleep
  • Headache worsened with Valsalva maneuver
  • Associated fever or neck stiffness
  • Focal neurological deficits
  • Unexplained systemic symptoms
  • Head trauma history
  • Positional aggravation 1, 3

• CT without contrast is preferred if intracranial hemorrhage is suspected 3

• MRI is generally preferred for most other concerning causes of headache 3

Laboratory Testing

• Laboratory tests are not routinely indicated for typical migraine presentations 1
• Consider laboratory testing only when red flag symptoms are present to rule out secondary causes 1

Diagnostic Criteria

Migraine diagnosis should be based on the International Classification of Headache Disorders (ICHD-3) criteria:

• At least 5 attacks fulfilling the following:
  • Headache attacks lasting 4-72 hours
  • At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by routine physical activity
  • During headache, at least one of: nausea/vomiting, photophobia and phonophobia 1

Common Pitfalls to Avoid

• Overlooking red flags in patients with established migraine (they can still develop secondary headaches)
• Confusing migraine aura with TIA (migraine aura typically develops gradually over ≥5 minutes)
• Missing chronic migraine diagnosis (headache ≥15 days/month for >3 months)
• Failing to recognize medication overuse headache 1

By following this systematic approach to evaluating patients with suspected migraine, clinicians can make an accurate diagnosis while avoiding unnecessary testing in typical presentations, and appropriately identifying cases requiring further investigation.