Does a 21-year-old male with a history of intermittent headaches for 11 months, presenting with a frontal headache and sensitivity to light, who has previously responded to Toradol (ketorolac) and Rizatriptan (rizatriptan), but had no relief with Rizatriptan (rizatriptan) this time, meet the criteria for a migraine diagnosis?

Does This Patient Meet Criteria for Migraine?

This patient does NOT currently meet ICHD-3 diagnostic criteria for migraine without aura because he has only had intermittent headaches for 11 months without documentation of at least five attacks fulfilling all required criteria. However, his clinical presentation is highly suggestive of migraine, and he should be treated as a probable migraine case given his previous positive response to migraine-specific therapy. 1

Analysis Against ICHD-3 Diagnostic Criteria

Migraine Without Aura Requirements (What's Missing):

Criterion 1 - Attack Frequency:

• Requires: At least five attacks that fulfill criteria 2-5 1
• This patient: Has "intermittent headaches for 11 months" but the exact number of discrete attacks is not documented
• Critical gap: We need to establish if he has had ≥5 separate attacks meeting all criteria 1

Criterion 2 - Duration:

• Requires: Headache lasting 4-72 hours when untreated or unsuccessfully treated 1
• This patient: Current headache since "this morning" (duration unclear), and no documentation of typical attack duration
• Assessment: Insufficient information to confirm this criterion 1

Criterion 3 - Pain Characteristics (Need 2 of 4):

• Unilateral location: ❌ (frontal, not clearly unilateral)
• Pulsating quality: ❓ (not documented)
• Moderate or severe intensity: ✓ (6/10 pain, previously described as severe enough to seek clinic treatment)
• Aggravation by routine physical activity: ❓ (not documented) 1
• Assessment: Only 1 of 4 characteristics clearly documented

Criterion 4 - Associated Symptoms (Need 1 of 2):

• Nausea and/or vomiting: ❌ (explicitly denied)
• Photophobia AND phonophobia: ❌ (only photophobia documented, phonophobia not mentioned) 1
• Critical issue: ICHD-3 requires BOTH photophobia and phonophobia together, not just one 1

Criterion 5 - Exclusion:

• Not better accounted for by another diagnosis: ✓ (no red flags present) 1

Why This Still Looks Like Migraine Clinically

Despite not meeting strict diagnostic criteria, several features strongly suggest migraine:

• Previous treatment response: He responded to Toradol (ketorolac) and rizatriptan at a clinic months ago, which is highly specific for migraine 2, 3
• Recurrent pattern: 11-month history of intermittent headaches suggests episodic disorder 1
• Photophobia: Present during attacks, which is characteristic of migraine even if phonophobia wasn't documented 1
• Moderate-severe intensity: 6/10 pain with previous "worst" headache requiring clinic visit 1
• Age and stress trigger: 21-year-old male with stress-related attacks fits typical migraine demographics 1

Critical Diagnostic Pitfall

The ICHD-3 criteria require both photophobia AND phonophobia together as associated symptoms when nausea/vomiting are absent. 1 This patient only has documented photophobia, which technically disqualifies him from meeting Criterion 4. However, this may represent incomplete history-taking rather than true absence of phonophobia—most migraine patients have both when specifically asked. 1

Recommended Clinical Approach

Obtain a more detailed headache history to establish:

1. Total number of similar attacks over the past 11 months (need ≥5) 1
2. Typical duration of untreated attacks (need 4-72 hours) 1
3. Presence of phonophobia (sound sensitivity) during attacks 1
4. Whether pain is pulsating/throbbing 1
5. Whether routine physical activity worsens the headache 1
6. Family history of migraine (strengthens diagnosis) 1

If additional history confirms ≥5 attacks with duration 4-72 hours, at least 2 pain characteristics, and both photophobia and phonophobia, then the diagnosis of migraine without aura is established. 1

Treatment Implications Despite Diagnostic Uncertainty

Treat this patient as probable migraine based on:

• Previous documented response to migraine-specific therapy (rizatriptan + ketorolac) 2, 3
• Current presentation consistent with migraine attack 1
• No alternative diagnosis suggested 1

Current attack management: Since rizatriptan failed this time, consider combination therapy with NSAID (ketorolac 30 mg IV or naproxen 500 mg PO) plus antiemetic (metoclopramide 10 mg IV), which has superior efficacy to monotherapy 2. The previous success with Toradol + rizatriptan suggests he responds to combination approaches. 2

Important consideration: Rizatriptan failure in one attack does not rule out migraine—the FDA label explicitly states "if a patient has no response for the first migraine attack treated with rizatriptan, the diagnosis of migraine should be reconsidered before administering to treat subsequent attacks," but this patient DID respond previously, suggesting true migraine with variable treatment response. 3