What is the initial step in a migraine workup?

Initial Step in Migraine Workup

The initial step in a migraine workup is a thorough medical history focused on headache characteristics, which is the mainstay of migraine diagnosis according to the International Classification of Headache Disorders (ICHD-3) criteria. 1

Comprehensive Medical History

The medical history should systematically include:

• Age at onset of headache
• Duration of headache episodes (typically 4-72 hours for migraine)
• Frequency of headache episodes
• Pain characteristics:
  • Location (often unilateral)
  • Quality (typically pulsating)
  • Severity (moderate to severe)
  • Aggravating factors (routine physical activity)
  • Relieving factors
• Accompanying symptoms:
  • Photophobia and phonophobia
  • Nausea and/or vomiting
• Aura symptoms (if any)
• History of acute and preventive medication use
• Family history of migraine 2, 1

Diagnostic Criteria Application

After collecting a comprehensive history, apply the ICHD-3 diagnostic criteria to determine the specific type of migraine:

Migraine Without Aura

• At least 5 attacks fulfilling criteria
• Headache attacks lasting 4-72 hours
• At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by activity
• At least one of: nausea/vomiting, photophobia and phonophobia 2, 1

Migraine With Aura

• At least 2 attacks fulfilling criteria
• One or more fully reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, retinal)
• At least three characteristics including gradual spread of symptoms, succession of symptoms, duration of 5-60 minutes 2, 1

Chronic Migraine

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

Physical Examination and Red Flags Assessment

After the medical history, perform a focused neurological examination to rule out secondary causes and identify red flags that would necessitate further investigation:

Red Flags Requiring Urgent Neuroimaging

• "Worst headache of life"
• New headache pattern after age 50
• Headache worsened by Valsalva maneuver
• Headache that awakens patient from sleep
• Headache with focal neurological deficits
• Progressively worsening headache pattern 1

Focused Neurological Examination

• Complete neuro-ophthalmologic examination
• Visual acuity and fields testing
• Fundoscopic examination
• Extraocular movement assessment
• Pupillary responses 1

Common Pitfalls to Avoid

1. Failure to identify secondary headaches: Always assess for red flags that may indicate a more serious underlying condition.

2. Medication overuse headache: Screen for overuse of acute medications (≥15 days/month for NSAIDs, ≥10 days/month for triptans).

3. Misdiagnosis: Ensure systematic application of ICHD-3 criteria rather than relying on assumptions.

4. Inadequate history taking: The medical history is the cornerstone of migraine diagnosis; insufficient detail can lead to misdiagnosis.

5. Unnecessary neuroimaging: In the absence of red flags, routine neuroimaging is not recommended for typical migraine presentations 1, 3.

Brain MRI with contrast is preferred over CT for non-emergent situations when neuroimaging is indicated 1.

By following this systematic approach to migraine diagnosis, clinicians can accurately identify the specific type of migraine and develop an appropriate treatment plan while avoiding unnecessary testing in patients with typical presentations.