What are the diagnostic criteria for migraine?

Migraine Diagnostic Criteria

Migraine diagnosis is based on the International Classification of Headache Disorders (ICHD-3) criteria, which require a specific number of attacks with defined headache characteristics, associated symptoms, and exclusion of other causes.

Migraine Without Aura (Common Migraine)

The diagnosis requires at least 5 attacks meeting all of the following criteria 1:

Headache Duration

• 4-72 hours when untreated or unsuccessfully treated 1
• Important pediatric exception: In children and adolescents (<18 years), attacks may last 2-72 hours 1
• If the patient falls asleep during an attack and wakes without headache, duration is counted until awakening 1

Headache Characteristics (≥2 of 4 required)

• Unilateral location 1
• Pulsating quality 1
• Moderate or severe pain intensity 1
• Aggravation by or causing avoidance of routine physical activity (e.g., walking, climbing stairs) 1

Associated Symptoms (≥1 required during headache)

• Nausea and/or vomiting 1
• Both photophobia AND phonophobia 1

Exclusion Criterion

• Not better accounted for by another ICHD-3 diagnosis 1

Clinical pitfall: Patients with fewer than 5 attacks meeting these criteria should be coded as "probable migraine without aura" rather than definitive migraine 1.

Migraine With Aura (Classic Migraine)

The diagnosis requires at least 2 attacks meeting the following criteria 1:

Aura Symptoms (≥1 fully reversible symptom required)

• Visual 1
• Sensory 1
• Speech and/or language 1
• Motor 1
• Brainstem 1
• Retinal 1

Aura Characteristics (≥3 of 6 required)

• At least 1 aura symptom spreads gradually over ≥5 minutes 1
• Two or more aura symptoms occur in succession 1
• Each individual aura symptom lasts 5-60 minutes 1
• At least 1 aura symptom is unilateral 1
• At least 1 aura symptom is positive (e.g., scintillations, pins and needles) 1
• The aura is accompanied by or followed within 60 minutes by headache 1

Important timing note: When multiple aura symptoms occur, the acceptable maximum duration is calculated as number of symptoms × 60 minutes (e.g., 3 symptoms = 180 minutes maximum) 1. Motor symptoms may last up to 72 hours 1.

Chronic Migraine

The diagnosis requires all of the following 1, 2:

• Headache on ≥15 days per month for >3 months 1, 2
• Prior history of at least 5 attacks meeting criteria for migraine without aura and/or migraine with aura 1, 2
• On ≥8 days per month for >3 months, the headache meets criteria for migraine without aura OR migraine with aura OR is believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative 1, 2
• Not better accounted for by another ICHD-3 diagnosis 1

Critical distinction: Chronic migraine significantly impairs quality of life and daily functioning more than episodic migraine, with greater personal and societal burden and more frequent comorbidities 2, 3.

Practical Clinical Approach

Key Historical Features to Elicit

• Age at onset (typically at or around puberty) 1
• Family history (often positive in migraine patients) 1
• Attack frequency and duration 1
• Pain location, quality, and severity 1
• Aggravating and relieving factors 1
• Accompanying symptoms (photophobia, phonophobia, nausea, vomiting) 1
• Presence and characteristics of aura symptoms 1

Common Diagnostic Pitfall

The most frequent error is failing to recognize that both photophobia AND phonophobia must be present together for migraine without aura (not just one or the other) 1. However, nausea/vomiting can substitute for this requirement 1.