What laboratory tests are recommended for patients presenting with migraines?

Laboratory Testing for Migraine

Routine laboratory tests are not recommended for typical migraine presentations without red flag symptoms, as migraine diagnosis should rely on clinical criteria from the International Headache Society, not laboratory investigations. 1, 2

When Laboratory Tests Are NOT Needed

• For straightforward migraine cases meeting ICHD-3 diagnostic criteria with normal neurological examination, no laboratory workup is indicated. 2
• The American Academy of Neurology specifically recommends against ordering unnecessary laboratory tests for typical migraine presentations. 2
• Validated screening tools like the three-item ID-Migraine questionnaire (sensitivity 0.81, specificity 0.75) are more valuable than laboratory tests for diagnosis. 1, 2
• Ordering routine laboratory panels for uncomplicated migraine leads to unnecessary costs and potential false-positive results requiring further workup. 2

Red Flag Symptoms Requiring Laboratory Workup

Laboratory testing becomes appropriate when red flags suggest secondary headache disorders: 2

• Thunderclap headache or "worst headache of life" 2
• New-onset headache after age 50 2
• Progressive headache worsening over time 2
• Headache awakening patient from sleep 2
• Headache worsened by Valsalva maneuver 2
• Unexplained abnormal neurological examination findings 2
• Unexplained fever or neck stiffness 2
• Focal neurological symptoms or altered consciousness 2

Specific Laboratory Tests When Red Flags Present

When secondary causes must be excluded based on red flags, consider: 2

• Thyroid function tests (TSH, free T4) to evaluate for hypothyroidism or hyperthyroidism that can cause headaches 2
• Complete blood count (CBC) to evaluate for anemia or hematologic abnormalities 2
• Basic metabolic panel to evaluate for electrolyte disturbances, kidney function, and glucose levels 2
• Erythrocyte sedimentation rate (ESR) if temporal arteritis is suspected in patients over 50 2
• Liver function tests to rule out hepatic causes of headache 2
• Serum calcium to evaluate for hyperparathyroidism 2
• Urinary drug screen to rule out illicit substances (cocaine, amphetamines) that can cause headaches 2

Neuroimaging Takes Priority Over Laboratory Tests

When red flags are present, brain MRI with and without contrast is the preferred diagnostic study—not laboratory tests—as it is more valuable for ruling out structural causes like tumors, vascular malformations, or inflammatory processes. 2

• MRI is preferred over CT due to higher resolution and absence of radiation exposure. 2
• Laboratory tests alone are insufficient to rule out serious secondary causes when red flags exist. 2
• Consider lumbar puncture if increased intracranial pressure is suspected, especially with papilledema on fundoscopic examination. 2

What IS Valuable for Migraine Management

Instead of laboratory tests, focus on these clinical tools: 1, 2

• Headache diary documenting frequency, duration, intensity, and associated symptoms (nausea, photophobia, phonophobia) 1, 2
• Medication use tracking to identify potential medication overuse headache (analgesics >15 days/month or triptans >10 days/month) 2
• Assessment tools like HIT-6 (Headache Impact Test) or MSQ (Migraine-Specific Quality-of-Life Questionnaire) to measure disability and treatment response 1, 2
• Headache calendars to record temporal occurrence of headaches and related events such as menstruation 1

Critical Pitfalls to Avoid

• Do not order routine laboratory panels for straightforward migraine cases—this wastes resources and creates false-positive results. 2
• Do not rely on laboratory tests rather than clinical criteria for primary migraine diagnosis. 2
• Do not overlook the need for neuroimaging when red flags are present—laboratory tests alone cannot exclude serious pathology. 2
• Do not confuse typical migraine symptoms (photophobia, phonophobia, nausea) with red flags—these are expected features of migraine. 1