What are the diagnostic criteria for migraine headaches?

Diagnostic Criteria for Migraine Headaches

The International Classification of Headache Disorders (ICHD-3) provides the definitive diagnostic criteria for migraine, which includes specific parameters for migraine without aura, migraine with aura, and chronic migraine. 1, 2

Migraine Without Aura

Required Criteria:

• A. At least 5 attacks fulfilling criteria B-D
• B. Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated)
• C. Headache has at least 2 of the following 4 characteristics:
  1. Unilateral location
  2. Pulsating quality
  3. Moderate or severe pain intensity
  4. Aggravation by or causing avoidance of routine physical activity
• D. During headache, at least 1 of the following:
  1. Nausea and/or vomiting
  2. Photophobia and phonophobia
• E. Not better accounted for by another ICHD-3 diagnosis 1

Special Considerations:

• In children and adolescents, attacks may last 2-72 hours 1
• While unilateral location is a characteristic feature, population-based data indicate that approximately 40% of individuals with migraine report bilateral pain 1
• Prodromal symptoms may include depressed mood, yawning, fatigue, and food cravings 1
• Postdromal symptoms can last up to 48 hours and often include tiredness, concentration difficulties, and neck stiffness 1

Migraine With Aura

Required Criteria:

• A. At least 2 attacks fulfilling criteria B and C
• B. One or more of the following fully reversible aura symptoms:
  1. Visual
  2. Sensory
  3. Speech and/or language
  4. Motor
  5. Brainstem
  6. Retinal
• C. At least 3 of the following 6 characteristics:
  1. At least 1 aura symptom spreads gradually over ≥5 minutes
  2. Two or more aura symptoms occur in succession
  3. Each individual aura symptom lasts 5-60 minutes
  4. At least 1 aura symptom is unilateral
  5. At least 1 aura symptom is positive
  6. The aura is accompanied, or followed within 60 minutes, by headache
• D. Not better accounted for by another ICHD-3 diagnosis 1

Special Considerations:

• Visual aura is the most common type (>90% of affected individuals), classically presenting as fortification spectra 1
• Sensory symptoms occur in approximately 31% of affected individuals, usually as unilateral paresthesia 1
• When multiple symptoms occur during an aura, the acceptable maximal duration is the number of symptoms multiplied by 60 minutes 1
• Motor symptoms may last up to 72 hours 1
• Positive symptoms include scintillations and pins and needles 1

Chronic Migraine

Required Criteria:

• Headache occurring on ≥15 days/month for >3 months
• Fulfilling criteria for migraine on ≥8 days/month
• Not better accounted for by another ICHD-3 diagnosis 2

Diagnostic Approach

1. Thorough history taking:

   • Document frequency, duration, and timing of headaches
   • Assess pain characteristics (location, quality, intensity)
   • Evaluate associated symptoms (nausea, vomiting, photophobia, phonophobia)
   • Identify triggers and aggravating factors
   • Review current and past treatments 2

2. Physical and neurological examination:

   • Perform to exclude secondary causes of headache
   • Normal examination is expected in primary headache disorders 2

3. Neuroimaging:

   • Not routinely indicated for typical migraine presentations with normal neurological examination
   • The probability of finding significant abnormalities on neuroimaging in patients with migraine and normal neurological examination is approximately 0.2% 2
   • Indicated for:
     • Sudden severe headache
     • Headache worsened by Valsalva maneuver
     • Headache causing awakening from sleep
     • Headache with rapidly increasing frequency or severity 2

High-Specificity Diagnostic Combinations

• The combination of "unilateral location, severe intensity, aggravation by physical activity" has 100% specificity for migraine 3
• Other highly specific combinations for migraine include:
  • "Severe intensity + nausea"
  • "Pulsating quality + nausea"
  • "Pulsating quality + migrainous location + aggravation by physical activity" 3

Common Diagnostic Pitfalls

1. Failure to recognize chronic migraine:

   • Often misdiagnosed as frequent episodic migraine or tension-type headache
   • Requires careful documentation of headache frequency and characteristics 4

2. Overlooking medication overuse:

   • Can occur with frequent use of acute medications (≥15 days/month for NSAIDs, ≥10 days/month for triptans)
   • May complicate diagnosis and management 2

3. Misdiagnosis of overlapping headache types:

   • Headaches with features of both migraine and tension-type headache can be challenging to classify
   • Using specific symptom combinations can help differentiate these cases 3

4. Incomplete assessment of aura symptoms:

   • Failing to document the temporal evolution and characteristics of aura
   • Not recognizing less common aura manifestations 5

5. Inadequate exclusion of secondary headaches:

   • Particularly important in patients with new-onset headache, change in headache pattern, or red flag features
   • Neuroimaging should be considered when secondary causes are suspected 2