Key Points for Migraine History Taking
A comprehensive migraine history must systematically document headache frequency using a headache diary, as patients cannot accurately report this information from memory alone and typically underreport milder headache days, leading to systematic underdiagnosis. 1
Essential Temporal Characteristics
- Age at onset of headaches, with typical onset at or around puberty 2
- Duration of individual headache episodes (must be 4-72 hours for migraine diagnosis) 2
- Frequency of headache episodes - specifically ask "Do you feel like you have a headache of some type on 15 or more days per month?" to effectively assess for chronic migraine 1
- Pattern over time - document whether headaches are episodic (<15 days/month) or chronic (≥15 days/month for >3 months) 1, 3
Pain Characteristics to Document
- Location of pain (typically unilateral) 4, 5
- Quality of pain (typically throbbing) 5
- Severity of pain 4
- Aggravating factors 4
Accompanying Symptoms
Aura Symptoms (If Present)
- Gradual spread of aura symptoms over ≥5 minutes 4
- Succession of symptoms 4
- Unilateral presentation 4
- Duration of aura (typically 5-72 hours) 4
- Motor weakness specifically for hemiplegic migraine 4
- Timing - headache accompanies or follows aura within 60 minutes 4
Medication History - Critical for Diagnosis
- Acute medication use patterns - document frequency and types of medications used 1
- Medication overuse - specifically assess for use of compound analgesics, opioids, triptans, or ergot derivatives on ≥10 days per month 6, 7
- Response to previous treatments 1
Family and Risk Factor History
- Family history of migraine - strengthens diagnostic suspicion due to strong genetic component 1, 2
- Comorbid conditions including cardiovascular disease, psychiatric disorders, metabolic conditions 7
- Obesity and lifestyle factors that may contribute to chronicization 7
Red Flags Requiring Urgent Evaluation
- New-onset headache after age 50 2
- Sudden-onset or "thunderclap" headache 2
- Progressive worsening of headaches 1
- Headache worsening when lying down 2
- Focal neurological symptoms 2
- Recent head or neck trauma 2
- Systemic signs or symptoms 2
- Seizures or altered consciousness during attacks 4
Essential Diagnostic Tool
- Headache diary - must be maintained to accurately document pattern and frequency of headaches, accompanying symptoms, acute medication use, triggers, and menstrual cycle relationship in women 1
- Only 20-25% of individuals who fulfill criteria for chronic migraine receive correct diagnosis, largely due to incomplete headache frequency reporting without a diary 1
Common Pitfalls to Avoid
- Failing to use a headache diary results in systematic underestimation of headache frequency 1
- Focusing only on severe headaches while ignoring milder headache days leads to missed diagnoses of chronic migraine 1
- Not asking specifically about medication use patterns prevents identification of medication overuse headache 1
- Patients usually report only their "severe headache days" while failing to mention milder headaches 1