Migraine%20headache Diagnosis

Diagnostic Criteria

Migraine Headache without Aura¹

• At least 5 attacks with any 2 of the following headache characteristics and should last from 4-72 hours without treatment or had unsuccessful treatments:
  • Unilateral
  • Throbbing or pulsating in nature
  • Pain is considered moderate to severe
  • Usual physical activity (eg walking or climbing stairs) aggravates pain
• Plus any one of the following symptoms:
  • Nausea and/or vomiting
  • Photophobia and phonophobia
• Headache is not better accounted for by another International Classification of Headache Disorders (ICHD)-3 diagnosis

Migraine Headache with Aura¹

• Headache with accompanying or preceding transient focal neurological symptoms
• At least 2 attacks with ≥1 of the following fully reversible aura symptoms:
  • Visual symptoms including positive features (flickering lights, spots or lines) and/or negative features (loss of vision)
  • Sensory symptoms including positive features (pins and needles) and/or negative features (numbness)
  • Speech and/or language (eg dysphasic speech disturbance)
  • Motor
  • Brainstem
  • Retinal
• At least 3 of the following characteristics:
  • At least 1 aura symptom develops gradually over ≥5 minutes
  • ≥2 aura symptoms that occur in succession
  • Every aura symptom lasts 5-60 minutes (if 3 symptoms occur during an aura, 3 x 60 minutes is the acceptable maximum duration; motor symptoms can last up to 72 hours)
  • ≥1 unilateral aura symptom (eg aphasia)
  • ≥1 positive aura symptom (eg scintillations and pins and needles)
  • Headache occurs with the aura or 60 minutes after the aura
• Headache is not better accounted for by another ICHD-3 diagnosis

 Chronic Migraine¹

• Headache (tension-type-like or migraine-like) occurring for ≥15 days per month for >3 months with the following characteristics:
  • Attacks last for 4-72 hours (without treatment or had unsuccessful treatment)
  • ≥2 of the following features are present: Unilateral location, pulsating quality, pain is moderate or severe in intensity, aggravated by or resulting to avoidance of routine physical activity (eg walking or climbing stairs)
• ≥5 attacks fulfilling the following criteria:
  • Presence of headache with ≥2 of the 4 characteristics mentioned in the above diagnostic criteria for migraine headache without aura plus during headache there is a presence of 1 of the symptoms mentioned in the above criteria for migraine headache without aura
  • Presence of ≥1 fully reversible aura symptoms enumerated in the above diagnostic criteria for migraine headache with aura plus ≥3 of the characteristics mentioned in the above criteria for migraine headache with aura
• On ≥8 days/month for >3 months, the patient has any of the following characteristics:
  • Presence of headache with ≥2 of the characteristics mentioned in the above diagnostic criteria for migraine headache without aura plus having 1 of the following during headache: Nausea and/or vomiting or photophobia and phonophobia
  • Presence of ≥1 fully reversible aura symptoms enumerated in the above diagnostic criteria for migraine headache with aura plus ≥3 of the characteristics mentioned in the above criteria for migraine headache with aura
  • Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
• Headache is not better accounted for by another ICHD-3 diagnosis

Status Migrainosus

• Usually severe and debilitating migraine headache that requires aggressive treatment
• Often caused by medication (eg analgesic) overuse
• Treatment may start with intravenous fluids and electrolyte replacement if indicated
• Some patients may need hospitalization for rehydration, control of vomiting by giving antiemetics and abortive therapy
• Abortive therapy includes parenteral triptan without ergot and/or Dihydroergotamine 8-12 hours after the last dosage of triptan
• Ketorolac intramuscular/intravenous or sodium valproate can be given if Dihydroergotamine or triptan is contraindicated or ineffective

• Therapy decision is made based on severity of headache

Severity Categories

Moderate

• Patient is not completely incapacitated but daily activities are greatly hindered by headache

Severe

• Patient’s daily activities are not performed or they are greatly altered because of headache

Status migrainosus

• Severe headache that lasts >72 hours

Evaluation to determine if patient should receive migraine prophylactic treatment

• When indicated, prophylactic treatment should be used in addition to acute therapy

Indication for prophylactic therapy may be based on:

• Frequency of attacks is ≥4 days per month
• Patients feel that migraines are significantly interfering with their normal daily activities even with acute treatment lasting for ≥4 days per month
• Failure and contraindication of acute therapies
• Overuse of acute therapy defined as:
  • ≥10 days per month for combination analgesics, ergot derivatives, opioids, triptans, and a combination of drugs from different classes that are not individually overused
  • ≥15 days per month for Paracetamol, non-opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) including Aspirin
• Adverse effects from acute therapies
• Patient preference
• Menstrual migraine
• Cost of acute therapy
• Presence of neurologic damage from uncommon migraine types 
• Duration of individual attacks >24 hours

Initial assessment should include but is not limited to:

• Detailed history
  • Headache characteristics (nature of pain, severity, location, frequency, duration)
  • Functional impairment
    • Assessment of impact on patient’s life and lifestyle is necessary for planning the best management and may be done using the Migraine Disability Assessment (MIDAS) instrument or Headache-attributed Lost Time (HALT) indices which estimates the total productive time lost due to the disabling effect of headache
  • Accompanying symptoms
  • Past medical history
  • Family history of migraines
  • Social history
  • Medical history
• Thorough physical and neurological examination

Any of the following signs and symptoms may suggest secondary headache:

• Symptoms suggesting systemic illness (eg fever)
• Any other neurological signs or symptoms (focal or non-focal)
• Most severe headache ever experienced by patient
• Persistent or progressive worsening of headache
• Change in usual headache pattern
• Awakening of patient from sleep
• New onset in patient >50 years of age
• Valsalva maneuver (eg sneezing, coughing, bending forward or lying down or exertion) precipitates headache
• Seizures
• Maximum severity at onset of headache