What are the key points to cover when taking a migraine history?

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

• Nausea and vomiting 4, 5
• Photophobia (light sensitivity) 4, 5
• Phonophobia (sound sensitivity) 4, 5

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