What is the recommended workup for identifying causes of migraines?

Recommended Workup for Identifying Causes of Migraines

Neuroimaging (CT or MRI) is not usually warranted in patients with typical migraine features and normal neurological examination, but should be considered when there are unexplained abnormal findings on neurological examination or atypical headache features. 1

Initial Diagnostic Approach

• Establish diagnosis through thorough medical history applying ICHD-3 criteria, which should include:

  • Age at onset of headache
  • Duration of headache episodes
  • Frequency of headache episodes
  • Pain characteristics (location, quality, severity, aggravating/relieving factors)
  • Accompanying symptoms (photophobia, phonophobia, nausea, vomiting)
  • Aura symptoms (if any)
  • History of acute and preventive medication use 1

• Suspect migraine without aura in patients with:

  • Recurrent moderate to severe headache
  • Unilateral and/or pulsating pain
  • Accompanying symptoms such as photophobia, phonophobia, nausea and/or vomiting 1

• Suspect migraine with aura in patients with the above symptoms plus recurrent, short-lasting visual and/or hemisensory disturbances 1

• Obtain family history of migraine, as it has a strong genetic component and is often positive in migraine patients 1

Neuroimaging Guidelines

• Neuroimaging should be considered in patients with:

  • Unexplained abnormal findings on neurological examination (Grade B recommendation) 1
  • Atypical headache features or headaches that do not fulfill the definition of migraine (Grade C recommendation) 1

• Warning signs that may warrant neuroimaging (though evidence is limited):

  • Headache worsened by Valsalva maneuver
  • Headache that awakens the patient
  • New-onset headache in older patients
  • Progressively worsening headache 1

• Neuroimaging is not usually warranted in patients with:

  • Migraine and normal findings on neurological examination (Grade B recommendation) 1

Trigger Identification

• Have patients maintain a headache diary to identify potential triggers, as up to 75.9% of patients report specific trigger factors 2

• Common triggers to assess include:

  • Dietary factors (alcohol, caffeine, foods containing tyramine or nitrates)
  • Environmental factors (stress, fatigue, perfumes, fumes, glare, flickering lights)
  • Hormonal changes
  • Sleep disturbances 1, 2

• Consider that trigger profiles are highly individualized - studies show that 85% of patients with identified triggers have unique profiles 3

Additional Diagnostic Considerations

• Assess for medication overuse headache using ICHD-3 criteria:

  • Headache on ≥15 days/month
  • Regular overuse of acute headache medication (non-opioid analgesics on ≥15 days/month or other acute medications on ≥10 days/month for ≥3 months) 1

• Consider comorbid conditions that may influence migraine presentation:

  • Anxiety/depression
  • Insomnia
  • Post-traumatic stress disorder 4

Pitfalls to Avoid

• Avoid unnecessary neuroimaging in patients with typical migraine features and normal neurological examination, as the prevalence of significant intracranial abnormality is approximately 0.2% in this population 1

• Be cautious in differentiating true migraine triggers from premonitory symptoms that may be mistaken for triggers 2

• Recognize that some factors rated as triggers by patients may actually be components of the clinical picture of migraine attacks rather than causative factors 2

• Avoid promoting excessive avoidance behavior toward factors whose role as triggers is uncertain, as this can be ineffective and frustrating for patients 2

By following this structured approach to migraine workup, clinicians can effectively diagnose migraine, identify potential triggers, and determine when additional investigations such as neuroimaging are warranted based on evidence-based guidelines.