What are the diagnostic criteria for migraine?

Migraine Diagnostic Criteria

Migraine diagnosis relies entirely on clinical history using the International Classification of Headache Disorders, 3rd Edition (ICHD-3) criteria, which define three main types: migraine without aura, migraine with aura, and chronic migraine. 1

Migraine Without Aura (Common Migraine)

At least 5 attacks must occur before definitive diagnosis can be made. 1, 2 Each attack must fulfill all of the following:

Headache Duration

• 4-72 hours when untreated or unsuccessfully treated in adults 1, 2
• 2-72 hours in children and adolescents 2, 3
• Duration is counted only until awakening if the patient falls asleep during an attack 3

Headache Characteristics (At Least 2 Required)

• Unilateral location 1, 2
• Pulsating quality 1, 2
• Moderate or severe pain intensity 1, 2
• Aggravation by or causing avoidance of routine physical activity (walking, climbing stairs) 1, 2

Associated Symptoms (At Least 1 Required)

• Nausea and/or vomiting 1, 2
• BOTH photophobia AND phonophobia together 1, 2

Critical diagnostic pitfall: Both photophobia and phonophobia must be present together to satisfy this criterion; however, nausea/vomiting alone can substitute for this requirement. 2

Exclusion Criterion

• Not better accounted for by another ICHD-3 diagnosis 1

Migraine With Aura (Classic Migraine)

At least 2 attacks must occur that fulfill the following criteria: 1, 2

Aura Symptoms (At Least 1 Required, Fully Reversible)

• Visual (most common, occurring in >90% of aura cases—typically fortification spectra) 1, 2
• Sensory (paresthesia/numbness, usually unilateral in face or arm, occurring in ~31% of aura cases) 1, 2
• Speech and/or language 1, 2
• Motor 1, 2
• Brainstem 1, 2
• Retinal 1, 2

Aura Characteristics (At Least 3 of 6 Required)

• At least one aura symptom spreads gradually over ≥5 minutes 1, 2
• Two or more aura symptoms occur in succession 1, 2
• Each individual aura symptom lasts 5-60 minutes 1, 2
• At least one aura symptom is unilateral 1, 2
• At least one aura symptom is positive 1, 2
• The aura is accompanied with or followed by headache within 60 minutes 1, 2

Important note: Visual aura can occur without subsequent headache and remains part of the migraine spectrum. 3

Exclusion Criterion

• Not better accounted for by another ICHD-3 diagnosis 1

Chronic Migraine

Chronic migraine requires all three of the following criteria: 1, 2

1. Headache (migraine-like or tension-type-like) on ≥15 days per month for >3 months 1, 2

2. Prior history of at least 5 attacks meeting criteria for migraine without aura and/or migraine with aura 1, 2

3. On ≥8 days per month for >3 months, any of the following:

   • Criteria for migraine without aura are met 1, 2
   • Criteria for migraine with aura are met 1, 2
   • Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative 1, 2

Chronic migraine is not static: Reversion to episodic migraine is common, and retransformation to chronic migraine can subsequently occur. 1

Medication-Overuse Headache (Frequently Coexists with Chronic Migraine)

All three criteria must be met: 1, 3

1. Headache on ≥15 days per month in an individual with a pre-existing headache disorder 1

2. Regular overuse for >3 months of acute headache medications:

   • Non-opioid analgesics on ≥15 days/month for ≥3 months, OR 1, 3
   • Any other acute medication or combination on ≥10 days/month for ≥3 months 1, 3

3. Not better accounted for by another ICHD-3 diagnosis 1

Key Historical Features to Elicit

Systematically document the following to apply ICHD-3 criteria: 2, 3

• Age at onset (onset at or around puberty strengthens suspicion) 1
• Family history (migraine has strong genetic component; prevalence higher among first-degree relatives) 1
• Attack frequency and duration 2, 3
• Pain location, quality, and severity 2, 3
• Aggravating and relieving factors 2, 3
• Accompanying symptoms (nausea, vomiting, photophobia, phonophobia) 2, 3
• Presence and characteristics of aura symptoms (onset pattern, duration, complete reversibility) 2, 3
• Prodromal symptoms (depressed mood, yawning, fatigue, food cravings) 1
• Postdromal symptoms (tiredness, concentration difficulties, neck stiffness lasting up to 48 hours) 1

Critical Differential Diagnosis Considerations

Migraine aura versus transient ischemic attack (TIA): 2

• Migraine aura: Symptoms spread gradually, occur in succession, have "marching" quality over ≥5 minutes 2
• TIA: Sudden, simultaneous onset with maximal deficit at onset 2

Red flags requiring urgent evaluation (NEVER migraine): 3

• Loss of consciousness 3
• Persistent neurological deficits that do not completely resolve 3

Diagnostic Tools

Physical examination is typically normal and serves only to exclude secondary causes rather than confirm migraine. 2, 3

Neuroimaging should only be used when a secondary headache disorder is suspected based on red flags or atypical presentation. 1, 2

Prospective headache diaries are essential to document attack frequency, duration, associated symptoms, and medication use—information that retrospective recall consistently underestimates. 3

No laboratory test, imaging study, or biomarker can confirm migraine—diagnosis depends exclusively on pattern recognition from patient history. 3