How can the Socrates method be used to rule out migraine?

SOCRATES for Migraine Evaluation

SOCRATES is not a validated tool for migraine diagnosis—instead, use the ICHD-3 criteria with structured history-taking focused on temporal patterns, pain characteristics, and accompanying symptoms, supplemented by screening tools like ID-Migraine or headache diaries. 1, 2, 3

Why SOCRATES is Insufficient for Migraine

SOCRATES (Site, Onset, Character, Radiation, Associations, Time course, Exacerbating/relieving factors, Severity) is a general pain assessment mnemonic that lacks the specificity required for migraine diagnosis. The International Headache Society developed the ICHD-3 criteria specifically for headache disorders, which prioritize specificity over sensitivity and require systematic documentation of features that SOCRATES does not adequately capture 1.

The Correct Approach: Structured Migraine-Specific History

Temporal and Pattern Questions (Critical for Diagnosis)

• Age at onset: Migraine typically starts at or around puberty 2
• Duration of episodes: Must be 4-72 hours for migraine without aura 2, 3
• Frequency: Document whether episodic or ≥15 days/month (suggesting chronic migraine) 2
• Time of day: Note when headaches occur and relationship to menstrual cycle in females 2

Pain Characteristics (At Least 2 Required for Diagnosis)

• Location: Unilateral (though can be bilateral) 3
• Quality: Pulsating/throbbing character 2, 3
• Severity: Moderate to severe intensity 3
• Aggravating factors: Worsened by routine physical activity 2, 3

Accompanying Symptoms (At Least 1 Required)

• Nausea and/or vomiting 2, 3
• Photophobia AND phonophobia (both must be present) 1, 2, 3

Aura Symptoms (If Present)

• Visual disturbances, numbness, tingling, or speech difficulties lasting 5-60 minutes 2
• Gradual spread over ≥5 minutes with at least one unilateral symptom 3
• Aura accompanied by or followed by headache within 60 minutes 3

Validated Screening Tools (Superior to SOCRATES)

ID-Migraine Questionnaire (3 Questions)

• Sensitivity 0.81, specificity 0.75, positive predictive value 0.93 1, 3
• Asks about headache-associated nausea, photophobia, and disability 1

Migraine Screen Questionnaire (MS-Q, 5 Questions)

• Sensitivity 0.93, specificity 0.81, positive predictive value 0.83 1, 3
• Includes questions on frequency, intensity, length, nausea, photophobia, phonophobia, and disability 1

Headache Diary

• Essential for accurate diagnosis and reducing recall bias 3
• Should document pattern, frequency, accompanying symptoms, acute medication use, triggers, and menstrual cycle relationship 1, 3

Red Flags to Rule Out Secondary Causes (Not Captured by SOCRATES)

• Thunderclap headache ("worst headache of your life") suggesting subarachnoid hemorrhage 2, 4, 5
• New-onset headache after age 50 3, 6
• Progressive worsening headache 3
• Headache awakening patient from sleep (may indicate increased intracranial pressure) 2, 3
• Headache with Valsalva, cough, or exertion 3, 6
• Focal neurological symptoms/signs 3, 5
• Fever with neck stiffness 3, 5
• Recent head/neck trauma 3, 6

Common Pitfalls to Avoid

• Do not rely on SOCRATES alone—it misses critical migraine-specific features like photophobia/phonophobia combination and the 4-72 hour duration requirement 1, 3
• Medication overuse screening is essential: Taking acute medications ≥15 days/month for non-opioid analgesics or ≥10 days/month for other acute medications may indicate medication-overuse headache 2
• Neuroimaging is NOT needed for typical migraine with normal neurological examination—reserve for red flag features only 3, 4, 5
• "Sinus headache" is often misdiagnosed migraine—recurrent "sinus headaches" should prompt migraine evaluation 4