What is the initial step in a migraine workup?

Initial Step in Migraine Workup

The initial step in a migraine workup is obtaining a detailed medical history that systematically applies ICHD-3 diagnostic criteria, as this clinical history alone is the mainstay of migraine diagnosis and typically sufficient without neuroimaging unless red flags are present. 1, 2

Essential Historical Elements to Document

The medical history must capture specific elements to apply diagnostic criteria:

Core Headache Characteristics

• Age at onset: Migraine typically begins at or around puberty 1, 3
• Attack duration: Must be 4-72 hours when untreated for migraine without aura 1
• Attack frequency: Document number of lifetime attacks (need ≥5 for migraine without aura diagnosis) and monthly frequency (≥15 days/month suggests chronic migraine) 1, 3
• Pain location: Unilateral location supports migraine diagnosis 1
• Pain quality: Pulsating quality is characteristic of migraine 1
• Pain severity: Moderate to severe intensity distinguishes migraine from tension-type headache 1
• Aggravating factors: Worsening with routine physical activity (walking, climbing stairs) is a key migraine feature 1

Associated Symptoms

• Nausea and/or vomiting 1
• Photophobia and phonophobia (both must be present for diagnostic criteria) 1
• Aura symptoms: Visual, sensory, speech/language, motor, brainstem, or retinal symptoms that are fully reversible, spread gradually over ≥5 minutes, and last 5-60 minutes 1

Medication History

• Acute medication use: Document all medications including non-prescription analgesics, frequency of use (≥15 days/month for non-opioid analgesics or ≥10 days/month for other acute medications suggests medication-overuse headache) 1, 3, 4
• Preventive medication history: Prior trials and responses 1

Family History

• First-degree relatives with migraine: Migraine has a strong genetic component and family history strengthens diagnostic suspicion 1, 3

Red Flags Requiring Investigation

Screen for secondary headache causes that necessitate neuroimaging or further workup:

• Thunderclap headache ("worst headache of life") suggests subarachnoid hemorrhage 3, 5
• New-onset headache after age 50 raises concern for giant cell arteritis or secondary causes 3, 5
• Progressive worsening headache or headache awakening patient from sleep suggests space-occupying lesion 3, 5
• Headache with Valsalva, cough, or exertion indicates increased intracranial pressure 3, 5
• Focal neurological symptoms/signs beyond typical aura 3, 5
• Unexplained fever with neck stiffness suggests meningitis 3, 5
• Recent head/neck trauma 3, 5
• Altered consciousness, memory, or personality 3

Diagnostic Aids for Initial Assessment

Screening Questionnaires

• ID-Migraine (3-item): Sensitivity 0.81, specificity 0.75, positive predictive value 0.93 3, 2
• Migraine Screen Questionnaire (5-item): Sensitivity 0.93, specificity 0.81, positive predictive value 0.83 3, 2

Headache Diary

• Essential tool to reduce recall bias and document pattern, frequency, triggers, accompanying symptoms, and medication use over time 3, 2, 4
• Diary entries that consistently fail to meet ICHD-3 criteria over multiple attacks rule out migraine 3

Physical Examination Role

Physical examination serves primarily as confirmation rather than diagnosis:

• Neurologic examination: Should be performed in all patients to exclude secondary causes 1, 4
• Head and neck examination: Focused assessment indicated in all patients 4
• Most often confirmatory: The examination typically confirms the clinical diagnosis made by history 1

When Neuroimaging is NOT Needed

Neuroimaging should only be performed when red flags suggest secondary causes 3, 2, 6. The history alone is sufficient for diagnosing primary migraine in the absence of warning signs 1, 2.

Common Pitfalls to Avoid

• Over-reliance on imaging: Routine neuroimaging is not indicated for typical migraine presentations without red flags 3, 2
• Missing medication-overuse headache: Always document frequency of all acute medication use, including non-prescription analgesics obtained from others 4
• Incomplete attack characterization: Failure to document all ICHD-3 criteria elements leads to diagnostic uncertainty 1
• Ignoring family history: Under-reporting by patients is common, but family history significantly strengthens migraine diagnosis 1, 3