From the Guidelines
A migraine workup should begin with a thorough clinical history and physical examination to rule out secondary causes, followed by diagnostic tests and referral to a specialist if necessary, as recommended by the most recent guidelines 1.
Key Components of Migraine Workup
- A thorough clinical history focusing on headache characteristics, frequency, duration, triggers, and associated symptoms like aura, nausea, or photophobia
- Physical and neurological examinations to rule out secondary causes
- Patients should maintain a headache diary documenting triggers, symptoms, and medication effectiveness
- Neuroimaging (MRI or CT) is recommended for patients with abnormal neurological findings, sudden-onset severe headaches, or changes in established headache patterns
- Laboratory tests may include complete blood count, metabolic panel, and thyroid function tests to exclude other conditions
Importance of Early Diagnosis and Treatment
Early diagnosis allows for appropriate management strategies including preventive medications and lifestyle modifications to reduce migraine frequency and severity. The American College of Physicians recommends considering treating mild episodic migraine headache with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1.
Preventive Therapy and Patient Education
Patients with frequent or severe migraines should be evaluated for preventive therapy, with recommended first-line agents including propranolol, timolol, amitriptyline, divalproex sodium, and sodium valproate 1. Patient education and engagement in the formulation of a management plan are crucial, including discussing therapeutic options, benefits, and harms, and encouraging patients to track their progress through daily diaries.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Migraine Workup
- The physical examination of migraine is crucial in identifying the extracranial origins of the patient's headache, which can reassure both the patient and the examiner that the headache is benign and treatable 2.
- A study on triptans in migraine found that triptan treatment does not increase the risk of stroke, myocardial infarction, cardiovascular death, or mortality in general practice 3.
- In patients with multiple sclerosis (MS), headaches, especially migraines, are common and can be a cause of significant comorbidity, and their treatment should be addressed in the same fashion as in the non-MS population 4.
- A review of clinical insights and radiological features on MS comorbid with migraine found that migraine can impact the perception of some symptoms and the presence of some comorbidities in MS, and that medications for migraine and MS should be administered considering both adverse events and multiple drug interactions 5.
- The American Headache Society systematic review and evidence-based guideline on neuroimaging for migraine recommends that neuroimaging may be considered for presumed migraine in certain situations, such as unusual, prolonged, or persistent aura, but is not necessary for patients with headaches consistent with migraine who have a normal neurologic examination and no atypical features or red flags present 6.
Key Considerations
- Physical examination to identify extracranial causes of migraine headache 2.
- Careful selection of preventive medicines for headaches in patients with MS due to their side effect profiles 4.
- Consideration of the potential impact of migraine on the perception of symptoms and comorbidities in MS 5.
- Use of neuroimaging in patients with migraine only when certain criteria are met, such as atypical features or red flags 6.