What are the diagnostic criteria and evaluation methods for migraine headaches in a patient presenting with headache symptoms, including frequency, duration, severity, and associated symptoms such as aura, nausea, or sensitivity to light and sound?

How to Diagnose Migraine

Migraine diagnosis is primarily clinical, based on a detailed medical history and systematic application of the International Classification of Headache Disorders-3 (ICHD-3) criteria, with physical examination serving as confirmation and neuroimaging reserved only when red flags suggest secondary causes. 1

Diagnostic Criteria for Migraine Without Aura

Diagnose migraine without aura when a patient has experienced at least 5 lifetime attacks meeting all of the following criteria: 2, 1

• Headache duration: 4-72 hours when untreated or unsuccessfully treated (2-72 hours in children and adolescents under 18 years) 2

• At least 2 of these pain characteristics: 2, 1

  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity (walking, climbing stairs)

• At least 1 of these accompanying symptoms during headache: 2, 1

  • Nausea and/or vomiting
  • Both photophobia AND phonophobia (must have both)

• Not better accounted for by another ICHD-3 diagnosis 2

Diagnostic Criteria for Migraine With Aura

Diagnose migraine with aura when a patient has experienced at least 2 attacks with fully reversible aura symptoms plus specific temporal characteristics: 2, 1

• One or more fully reversible aura symptoms: 2

  • Visual (most common)
  • Sensory
  • Speech and/or language
  • Motor
  • Brainstem
  • Retinal

• At least 3 of these 6 characteristics: 2, 1

  • At least one aura symptom spreads gradually over ≥5 minutes
  • Two or more aura symptoms occur in succession
  • Each individual aura symptom lasts 5-60 minutes (motor symptoms may last up to 72 hours)
  • At least one aura symptom is unilateral
  • At least one aura symptom is positive (scintillations, pins and needles)
  • The aura is accompanied by or followed by headache within 60 minutes

• Not better accounted for by another ICHD-3 diagnosis 2

Diagnostic Criteria for Chronic Migraine

Diagnose chronic migraine when headaches occur ≥15 days per month for >3 months with migraine features on ≥8 days per month: 2, 1

• Headache (migraine-like or tension-type-like) on ≥15 days/month for >3 months 2
• Patient has had at least 5 previous attacks meeting criteria for migraine without aura and/or migraine with aura 2
• On ≥8 days/month for >3 months, any of the following are met: 2
  • Criteria for migraine without aura
  • Criteria for migraine with aura
  • Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
• Not better accounted for by another ICHD-3 diagnosis 2

Note that chronic migraine is not static—reversion to episodic migraine is common, and retransformation to chronic migraine can subsequently occur. 2

Essential History Components

Obtain the following information systematically to apply ICHD-3 criteria: 2, 1

• Frequency and pattern: Number of attacks, episodic versus daily/near-daily 2
• Duration of each attack: Measured in hours 2
• Pain location: Unilateral versus bilateral 2
• Pain quality: Pulsating, throbbing, pressing, or other 2
• Pain severity: Mild, moderate, or severe 2
• Effect of physical activity: Does routine activity worsen the headache? 2
• Accompanying symptoms: Nausea, vomiting, photophobia, phonophobia 2
• Aura symptoms: Visual disturbances, sensory changes, speech difficulties, their duration and temporal relationship to headache 2
• Age of onset: Migraine typically begins at or around puberty 2
• Family history: Migraine has a strong genetic component with higher prevalence among first-degree relatives 2, 3
• Menstrual relationship: In women, document timing relative to menstrual cycle 4

Screening Tools to Improve Diagnostic Accuracy

Use validated screening questionnaires to rapidly identify migraine in clinical practice: 1

• ID-Migraine (3-item questionnaire): Sensitivity 0.81, specificity 0.75, positive predictive value 0.93 1, 3
• Migraine Screen Questionnaire (MS-Q, 5-item): Sensitivity 0.93, specificity 0.81, positive predictive value 0.83 1, 3

Implement a headache diary to document pattern and frequency of headaches, accompanying symptoms, acute medication use, triggers, and menstrual cycle relationship—this is essential for accurate diagnosis and reducing recall bias. 1, 3

Medication-Overuse Headache: A Critical Diagnostic Pitfall

Always assess for medication-overuse headache, which can complicate migraine diagnosis and requires different management: 2, 3

• Headache on ≥15 days/month in a patient with pre-existing headache disorder 2
• Regular overuse for >3 months of: 2
  • Non-opioid analgesics on ≥15 days/month, OR
  • Any other acute medication or combination on ≥10 days/month
• Not better accounted for by another ICHD-3 diagnosis 2

Red Flags Requiring Investigation

Perform neuroimaging (MRI preferred) only when red flags suggest secondary causes: 1, 3

• Thunderclap headache ("worst headache of life") 1, 3
• New-onset headache after age 50 1, 3
• Progressive worsening headache 1, 3
• Headache awakening patient from sleep 1, 3
• Headache with Valsalva, cough, or exertion 1, 3
• Focal neurological symptoms or signs 1, 3
• Unexplained fever with neck stiffness 1, 3
• Recent head or neck trauma 1, 3
• Altered consciousness, memory, or personality 3

MRI is the preferred neuroimaging modality for most cases when secondary causes are suspected. 1

Physical Examination

Physical examination is most often confirmatory in migraine diagnosis—the medical history is the mainstay. 2 Perform a focused neurological examination to identify any focal deficits or signs suggesting secondary causes. 2 A normal examination supports the diagnosis of primary migraine when ICHD-3 criteria are met. 2

Strengthening Diagnostic Suspicion

Suspicion of migraine should be strengthened by: 2

• Family history of migraine (often positive but may be under-reported) 2
• Onset of symptoms at or around puberty 2
• Recurrent pattern over time with similar characteristics 2

When Fewer Than Required Attacks Have Occurred

If a patient otherwise meets criteria for migraine without aura but has had fewer than 5 attacks, code as "probable migraine without aura" rather than definitive migraine. 2 One or a few attacks may be difficult to distinguish from symptomatic migraine-like attacks, which is why at least 5 attacks are required for definitive diagnosis. 2