What is the approach to diagnose and treat migraine?

How to Diagnose Migraine

Migraine diagnosis is primarily clinical, based on a detailed medical history using ICHD-3 criteria—no neuroimaging or laboratory testing is required unless red flags suggest a secondary headache disorder. 1

Clinical Suspicion: When to Consider Migraine

Suspect migraine without aura in patients presenting with: 1

• Recurrent moderate to severe headache
• Unilateral and/or pulsating pain quality
• Accompanying symptoms: photophobia, phonophobia, nausea, and/or vomiting

Suspect migraine with aura when the above features occur with: 1

• Recurrent, short-lasting visual and/or hemisensory disturbances
• Aura symptoms lasting 5-60 minutes
• At least one aura symptom that is unilateral and positive (not just loss of function)
• Headache follows within 60 minutes of aura

Suspect chronic migraine in patients with: 1

• ≥15 headache days per month for >3 months
• On ≥8 days/month, headaches meet criteria for migraine or respond to triptans/ergots

Strengthen your suspicion if: 1

• Positive family history of migraine (strong genetic component)
• Symptom onset at or around puberty

Essential Medical History Components

The medical history is the mainstay of diagnosis—you must systematically document: 1

• Age at onset of headache
• Duration of individual headache episodes
• Frequency of headache episodes
• Pain characteristics: location, quality (pulsating vs. pressing), severity, aggravating factors (physical activity), relieving factors
• Accompanying symptoms: photophobia, phonophobia, nausea, vomiting
• Aura symptoms (if present): type, duration, progression pattern
• Medication history: both acute and preventive treatments, including frequency of use

Diagnostic Aids to Enhance Accuracy

Use validated tools to support your clinical diagnosis: 1

• Headache diaries: Daily entries documenting attack characteristics, useful for both initial diagnosis and ongoing re-evaluation
• Three-item ID-Migraine questionnaire: Identifies likely migraine based on headache-associated nausea, photophobia, and disability 1
• Migraine Screen Questionnaire: Five-item validated screening tool 1

Physical Examination

Physical examination is confirmatory—it should be normal in primary migraine. 1 Look specifically for:

• Focal neurological deficits (their presence suggests secondary causes)
• Signs of increased intracranial pressure
• Meningeal signs
• Fever or systemic illness indicators

When Neuroimaging Is Indicated

Neuroimaging is NOT routinely needed for migraine diagnosis. 1 The only role for neuroimaging is to exclude secondary headache disorders when red flags are present. 1

Red Flags Requiring Investigation: 1

From history:

• Thunderclap headache (sudden, severe onset)
• Atypical aura features
• Recent head trauma
• New onset headache in patient >50 years old
• Progressive worsening of headache pattern

From examination:

• Unexplained fever
• Impaired memory or cognitive changes
• Focal neurological symptoms or signs
• Papilledema

When imaging is needed, MRI is preferred over CT because it offers higher resolution without ionizing radiation. 1 However, be aware that MRI can reveal clinically insignificant abnormalities (white matter lesions, arachnoid cysts, meningiomas) that may alarm patients and trigger unnecessary further testing. 1

Differential Diagnosis Considerations

Before confirming migraine, exclude: 1

• Other primary headache disorders: tension-type headache, cluster headache, trigeminal autonomic cephalalgias
• Secondary headache disorders: particularly when red flags are present 2, 3
• Medication-overuse headache: Headache on ≥15 days/month with regular overuse of acute medications (non-opioid analgesics ≥15 days/month for ≥3 months, or other acute medications ≥10 days/month for ≥3 months) 1

Common Diagnostic Pitfalls

Avoid these mistakes:

• Don't order routine neuroimaging—this exposes patients to unnecessary radiation and can lead to incidental findings that cause anxiety and further unnecessary testing. 1
• Don't conflate medication-overuse headache with chronic migraine—while they often coexist, they are distinct diagnoses requiring different management approaches. 1
• Don't miss atypical presentations—in patients presenting with atypical symptoms, take extra care to exclude other serious neurological conditions before diagnosing migraine. 1
• Don't underestimate family history—it may be under-reported by patients, so ask specifically about headache disorders in first-degree relatives. 1

Special Considerations

For hemiplegic migraine, diagnosis requires: 4

• At least two attacks with fully reversible motor weakness as aura
• Motor symptoms lasting 5-72 hours
• Gradual spread of motor aura over ≥5 minutes
• Neuroimaging (MRI) is recommended to exclude stroke/TIA, which presents with sudden simultaneous onset rather than gradual spread 4