What is the best way to assess and manage headaches in a patient?

Headache Assessment Using Validated Disability Scales

Use the MIDAS (Migraine Disability Assessment) questionnaire as your primary tool to assess headache impact and guide treatment intensity, as it directly measures lost productivity across work, household, and social domains over the preceding 3 months. 1, 2

Primary Assessment Tools

MIDAS Questionnaire (First-Line)

• MIDAS quantifies disability by measuring days of reduced productivity in three domains: work/school days missed, work/school days with reduced effectiveness, and household/social activity days missed 1, 2
• The total MIDAS score stratifies patients into four disability grades: Grade I (0-5, minimal disability), Grade II (6-10, mild), Grade III (11-20, moderate), and Grade IV (≥21, severe disability requiring aggressive treatment) 1, 2
• Patients with chronic migraine (≥15 headache days/month) typically score in Grade IV with mean scores of 34.9, compared to 19.3 in episodic migraine 3
• Use MIDAS scores to determine treatment intensity: Grade IV patients require preventive therapy, not just acute treatment 1, 2

HIT-6 (Headache Impact Test) as Complementary Tool

• HIT-6 correlates with MIDAS (r=0.52) but captures different aspects of disability, particularly headache intensity impact 4
• HIT-6 is more sensitive to pain intensity, while MIDAS is more sensitive to headache frequency 4
• 79% of specialty clinic patients fall into the most severe HIT-6 category versus 57% in the most severe MIDAS category, suggesting HIT-6 may overestimate disability 4
• Using both instruments together provides more comprehensive disability assessment 4

Essential Diagnostic Elements Before Scaling

Red Flag Screening (SNNOOP10 Approach)

• Immediately obtain neuroimaging before any disability assessment if red flags are present: thunderclap headache, new headache after age 50, progressive worsening, nocturnal awakening, Valsalva aggravation, or new neurological deficits 1, 5, 2
• CT without contrast is first-line for acute presentations; MRI with and without contrast is superior for persistent headaches 5
• If neuroimaging is normal but subarachnoid hemorrhage is suspected, perform lumbar puncture 5

Headache Diary (Mandatory for Accurate Assessment)

• Require patients to maintain a headache diary documenting frequency, duration, intensity, associated symptoms (nausea, photophobia, phonophobia), and medication use 1, 2
• Diaries are essential because patients cannot accurately recall headache frequency without documentation 1
• Ask directly: "Do you feel like you have a headache of some type on 15 or more days per month?" to identify chronic migraine 1

Screening Questionnaires for Diagnosis

• ID-Migraine (3-item questionnaire) has sensitivity 0.81 and specificity 0.75 for identifying migraine based on nausea, photophobia, and disability 1, 6
• MS-Q (5-item questionnaire) has higher sensitivity (0.93) and specificity (0.81) but requires more questions 1
• These tools screen for migraine but require confirmation with full history and ICHD-3 criteria 1, 6

Follow-Up Assessment Protocol

Timing of Reassessment

• Evaluate treatment response 2-3 months after initiation or treatment change, then every 6-12 months 1
• Use MIDAS at each follow-up to objectively measure treatment effectiveness 1, 2

Treatment Optimization Tools

• mTOQ-4 (Migraine Treatment Optimization Questionnaire) evaluates acute medication effectiveness at follow-up visits 1
• HURT questionnaire (8-item Headache Under-Response to Treatment) assesses overall treatment effectiveness and generates specific management suggestions 1

Critical Pitfalls to Avoid

Medication Overuse Headache

• Document all analgesic use including over-the-counter medications, as frequent use (≥10 days/month for triptans, ≥15 days/month for simple analgesics) causes medication overuse headache 1, 2, 7
• Medication overuse headache transforms episodic migraine into chronic daily headache and must be identified before disability scales can accurately reflect primary headache burden 7

Misinterpretation of Disability Scores

• Do not use disability scales alone to diagnose headache type—they measure impact, not etiology 4, 8
• High disability scores in the absence of typical migraine features should prompt reconsideration of diagnosis and possible specialist referral 1

Missing Comorbidities

• Screen for depression and anxiety using BDI-II, PHQ-9, or HADS, as psychiatric comorbidities correlate equally with HIT-6 and MIDAS (r=0.42) and impair treatment effectiveness 4, 8, 7