Initial Work-Up for a 20-Year-Old Female with Migraine
The initial work-up is primarily clinical, based on a detailed headache history and physical examination, with neuroimaging reserved only for patients with red flag features suggesting secondary causes. 1
Essential History Components
Obtain the following specific details to apply ICHD-3 diagnostic criteria 1:
- Age at onset and duration of headache episodes 1
- Frequency of attacks (critical for distinguishing episodic from chronic migraine) 1
- Pain characteristics: location (unilateral vs bilateral), quality (throbbing vs pressing), severity, aggravating factors (routine physical activity), and relieving factors 1
- Associated symptoms: photophobia, phonophobia, nausea, vomiting 1
- Aura symptoms: visual distortions, scotomas, hemisensory disturbances (typically lasting 5-60 minutes) 1
- Menstrual relationship: temporal pattern relative to menstrual cycle, as hormonal fluctuations commonly trigger migraine in young women 2, 3
- Medication history: current acute and preventive medication use, frequency of analgesic use (to assess for medication-overuse headache risk) 1
- Family history: migraine has strong genetic component and is often positive in first-degree relatives 1
- Triggers: hormonal changes, certain foods, sensory stimuli, missed meals, stress 1
Physical and Neurological Examination
Perform a thorough physical and neurological examination to identify any abnormal findings that would suggest secondary headache disorders 1.
Red Flags Requiring Neuroimaging
Neuroimaging (preferably MRI over CT) is indicated ONLY when red flags are present 1:
- History red flags: thunderclap headache, headache worsened by Valsalva maneuver, awakening from sleep, new onset in older person, progressive worsening, atypical aura, recent head trauma 1, 2
- Examination red flags: unexplained fever, impaired memory, focal neurological deficits, abnormal neurologic examination 1, 2
In patients with normal neurologic examination and typical migraine features, neuroimaging is not warranted and can be harmful due to radiation exposure and detection of clinically insignificant abnormalities that lead to unnecessary testing 1.
Diagnostic Tools
Use validated screening tools to support diagnosis 1:
- Headache diary: daily entries recording headache characteristics, timing, triggers, and medication use 1, 2
- Three-item ID-Migraine questionnaire: screens for nausea, photophobia, and disability 1
- Migraine Screen Questionnaire: five-item validated tool 1
Diagnostic Criteria Application
Suspect migraine without aura if the patient has 1:
- At least two of: unilateral location, throbbing character, moderate-to-severe intensity, worsening with routine activity
- At least one of: nausea/vomiting, photophobia and phonophobia
- At least five lifetime attacks meeting these criteria
Suspect migraine with aura if visual or hemisensory disturbances precede or accompany headache 1.
Laboratory Testing
No routine laboratory testing is required for typical migraine presentation with normal examination 1. Blood work is only indicated if secondary causes are suspected based on clinical features.
Common Pitfalls to Avoid
- Do not order neuroimaging for reassurance alone - this exposes patients to unnecessary radiation and can reveal incidental findings causing alarm 1
- Do not overlook menstrual relationship - approximately 50% of female migraineurs have increased risk during premenstrual phase, which may require specific management strategies 2, 3, 4
- Do not miss medication-overuse pattern - regular use of acute medications ≥10-15 days/month for >3 months can cause medication-overuse headache 1
- Screen for migraine with aura specifically - this has critical implications for contraceptive safety, as combined hormonal contraceptives are absolutely contraindicated due to elevated stroke risk 5, 6