What are the diagnostic criteria to differentiate mild from moderate to severe migraines (Migraine Headaches)?

From the Guidelines

Migraines are differentiated by severity based on their impact on daily functioning and associated symptoms, with treatment guided by the severity level, as recommended by the American College of Physicians in 2025 1.

Differentiation of Migraine Severity

Mild migraines involve mild to moderate pain that doesn't significantly interfere with daily activities, minimal sensitivity to light or sound, and can often be managed with over-the-counter medications like NSAIDs (such as aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or acetaminophen, as suggested by the clinical guideline from the American College of Physicians 1.

• Key characteristics of mild migraines include:
  • Mild to moderate pain
  • Minimal impact on daily activities
  • Limited sensitivity to light and sound
• Treatment for mild migraines may include:
  • NSAIDs
  • Acetaminophen
  • Combination of NSAID and acetaminophen

Moderate to Severe Migraines

Moderate migraines present with more intense pain that partially limits normal activities, increased sensitivity to light and sound, and may require prescription medications such as triptans (like almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) or combination analgesics, as indicated by the guideline 1.

• Characteristics of moderate to severe migraines include:
  • More intense pain
  • Partial to complete limitation of normal activities
  • Increased sensitivity to environmental stimuli
  • Possible nausea or vomiting
• Treatment for moderate to severe migraines may include:
  • Triptans
  • Combination therapy of a triptan and an NSAID or acetaminophen
  • CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) for those who do not tolerate or have inadequate response to combination therapy
  • The ditan lasmiditan for those who do not tolerate or have inadequate response to all other pharmacologic treatments

Importance of Severity Classification

The classification of migraine severity is crucial because it guides the treatment approach, with preventive medications being more important for those with frequent moderate to severe attacks, as noted in the guideline 1.

• Preventive medications may include:
  • Topiramate
  • Propranolol
  • Newer CGRP antagonists
• It is essential to counsel patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy, and to be aware of medication overuse headache, a potential complication of migraine treatment 1.

From the Research

Differentiating Mild from Moderate to Severe Migraines

To differentiate mild from moderate to severe migraines, several factors and treatment approaches can be considered:

• Mild to Moderate Migraines:
  • Oral NSAIDs are the first choice for treatment 2
  • Acetaminophen is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women 2
  • Nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines 3
• Moderate to Severe Migraines:
  • Oral or nasal spray triptans and ergotamine/caffeine compounds are recommended for treatment 2
  • Triptans are first-line treatments for moderate to severe migraines 3
  • Antiemetics can be used as a supplement to alleviate nausea and vomiting 2

Treatment Strategies

Treatment strategies for migraines can be tailored based on the severity of the attack:

• Stratified Care: The administration of treatment should follow the concept of "stratified care" 2
• Early Treatment: Taking medication early in an attack can help ensure that migraine treatment is cost-effective 3
• Combination Therapy: A combination of a triptan and a NSAID can yield a better efficacy compared with either therapy alone 2

Assessment and Management

Assessing and managing all aspects of migraine is crucial for effective treatment:

• Impact of Migraine: Migraine can substantially impair a person's functions during attacks and diminish health-related quality of life (HRQoL) during and between attacks 4
• Tools for Assessment: Several tools are available to help physicians assess the impact of migraine on the daily activities and HRQoL of their patients, such as the 36-Item Short-Form Health Survey and the Headache Impact Test 4