Can a headache be classified as a migraine in the absence of vomiting, photophobia, phonophobia, or aura?

Can a Headache Be Migraine Without Vomiting, Photophobia, Phonophobia, or Aura?

Yes, a headache can still be classified as migraine without aura even if the patient does not experience vomiting, photophobia, phonophobia, or aura—as long as nausea is present alongside the required headache characteristics. 1

Understanding the Diagnostic Flexibility

The ICHD-3 criteria for migraine without aura require either nausea/vomiting or both photophobia and phonophobia together—not all of these symptoms simultaneously. 2, 1 This is a critical diagnostic nuance that is frequently misunderstood in clinical practice.

Required Components for Diagnosis

To diagnose migraine without aura, you need:

• At least 5 attacks meeting the full criteria 2, 1

• Duration of 4-72 hours when untreated (2-72 hours in children/adolescents) 2, 1

• At least 2 of these 4 headache characteristics: 2, 1

  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity

• At least 1 of the following associated symptom criteria: 2, 1

  • Nausea and/or vomiting, OR
  • Both photophobia AND phonophobia together

The Critical Pitfall

A common diagnostic error is assuming that both photophobia and phonophobia must be present in every migraine case. 1 In reality, if a patient has nausea (even without vomiting), this alone satisfies the associated symptom requirement, and neither photophobia nor phonophobia needs to be present. 2, 1

Clinical Scenarios Where This Applies

A patient presenting with:

• Unilateral, pulsating headache
• Moderate-to-severe intensity
• Worsening with physical activity
• Nausea (but no vomiting, photophobia, or phonophobia)

This meets full criteria for migraine without aura if they have experienced at least 5 such attacks lasting 4-72 hours. 2, 1

What About Aura?

The absence of aura simply means the diagnosis is migraine without aura rather than migraine with aura—it does not exclude migraine as a diagnosis. 2, 1 Migraine without aura is actually the most common subtype of migraine. 3

Additional Diagnostic Considerations

While not required for diagnosis, some patients may report step-headache (painful thump with each footstep during walking), which has 64.67% sensitivity and 100% specificity for migraine, providing additional diagnostic support when present. 4