What are the diagnostic criteria and management guidelines for migraine, according to the International Classification of Headache Disorders (ICHD)?

Diagnostic Criteria and Management Guidelines for Migraine

The diagnosis of migraine is primarily clinical, based on systematic application of the International Classification of Headache Disorders-3 (ICHD-3) criteria through detailed medical history, with physical examination serving as confirmation and neuroimaging reserved only when red flags suggest secondary causes. 1, 2

ICHD-3 Diagnostic Criteria

Migraine Without Aura

Requires at least 5 lifetime attacks meeting all of the following criteria: 1

• Headache duration: 4-72 hours when untreated or unsuccessfully treated 1
• At least 2 pain characteristics:
  • Unilateral location 1
  • Pulsating quality 1
  • Moderate or severe intensity 1
  • Aggravation by or causing avoidance of routine physical activity (walking, climbing stairs) 1
• At least 1 accompanying symptom:
  • Nausea and/or vomiting 1
  • Both photophobia AND phonophobia 1
• Not better accounted for by another ICHD-3 diagnosis 1

Migraine With Aura

Requires at least 2 attacks meeting the following criteria: 1

• One or more fully reversible aura symptoms:

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

• At least 3 of these 6 characteristics:

  • At least one 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 one aura symptom is unilateral 1
  • At least one aura symptom is positive (scintillations, pins and needles) 1
  • Aura accompanied by or followed by headache within 60 minutes 1

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

Chronic Migraine

Defined as headache on ≥15 days/month for >3 months with the following: 1

• Patient has had at least 5 prior attacks meeting criteria for migraine without aura and/or migraine with aura 1
• On ≥8 days/month for >3 months, any of the following:
  • Criteria for migraine without aura are met 1
  • Criteria for migraine with aura are met 1
  • Headache believed by patient to be migraine at onset and relieved by triptan or ergot derivative 1
• Not better accounted for by another ICHD-3 diagnosis 1

Note that chronic migraine is not static—reversion to episodic migraine is common. 1

Essential Medical History Components

The medical history is the mainstay of diagnosis and must systematically include: 1

• Age at onset of headache 1
• Duration of individual headache episodes 1
• Frequency of headache episodes 1
• Pain characteristics: location, quality, severity, aggravating factors, relieving factors 1
• Accompanying symptoms: photophobia, phonophobia, nausea, vomiting 1
• Aura symptoms if present: type, duration, progression pattern 1
• History of acute and preventive medication use 1
• Family history of migraine (often positive due to strong genetic component) 1

Diagnostic Tools and Screening Instruments

ID-Migraine Questionnaire

This 3-item screening tool has sensitivity 0.81, specificity 0.75, and positive predictive value 0.93 for diagnosing migraine. 2 It identifies patients likely to have migraine based on headache-associated nausea, photophobia, and disability. 1

Migraine Screen Questionnaire (MS-Q)

This 5-item tool has sensitivity 0.93, specificity 0.81, and positive predictive value 0.83. 2 It screens for migraine frequency, intensity, length, associated nausea, photophobia, phonophobia, and disability. 1

Headache Diary

Essential for accurate diagnosis and reducing recall bias—should document pattern and frequency of headaches, accompanying symptoms, acute medication use, triggers, and menstrual cycle relationship. 1, 2 Daily entries record temporal occurrence of headaches and related events. 1

Headache diaries should not be conflated with headache calendars, which are simpler tools used primarily for follow-up to record minimum frequency of migraine, headache intensity, and medication use. 1

Clinical Suspicion Algorithm

Suspect migraine without aura when: 1

• Recurrent moderate to severe headache 1
• Pain is unilateral and/or pulsating 1
• Accompanying symptoms include photophobia, phonophobia, nausea, and/or vomiting 1

Suspect migraine with aura when: 1

• Above symptoms are present PLUS 1
• Recurrent, short-lasting visual and/or hemisensory disturbances 1

Suspect chronic migraine when: 1

• Patient has ≥15 headache days per month 1

Suspicion should be strengthened by: 1

• Positive family history of migraine 1
• Onset of symptoms at or around puberty 1

Red Flags Requiring Investigation

Investigations including neuroimaging are only indicated when red flags suggest secondary causes: 2

• Thunderclap headache 2
• New-onset headache after age 50 2
• Progressive worsening headache 2
• Headache awakening patient from sleep 2
• Headache with Valsalva, cough, or exertion 2
• Focal neurological symptoms/signs 2
• Unexplained fever with neck stiffness 2
• Recent head/neck trauma 2

When neuroimaging is needed, MRI is the preferred modality. 2

Critical Pitfall: Medication-Overuse Headache

Must screen for medication-overuse headache, defined as: 1

• Headache on ≥15 days/month in patient with pre-existing headache disorder 1
• Regular overuse for >3 months of acute headache medications: 1
  • Non-opioid analgesics on ≥15 days/month for ≥3 months OR 1
  • Any other acute medication or combination on ≥10 days/month for ≥3 months 1

This is a common complication that can transform episodic migraine into chronic daily headache and must be identified and addressed. 1, 3

Probable Migraine

The ICHD-3 criteria prioritize specificity over sensitivity, so "probable migraine" is diagnosed when migraine-like attacks are missing one feature required to fulfill all criteria for a migraine type or subtype. 1 This diagnosis is pending confirmation during early follow-up. 1