DIAGNOSIS OF MIGRAINE

DIAGNOSIS OF MIGRAINE

The recognition of migraine has been enhanced by the introduction of diagnostic 

criteria for both migraine with and without aura (formerly known as 

“classic” and “common” migraine, respectively) by the International Headache

 Society (IHS). 

The listed contains features distinguishing migraine from 

the other two most common headache disorders, tension and cluster. Particularly

 salient diagnostic features from these tables, as well as additional clinical pearls,

 include: migraine headaches are not necessarily unilateral; the patient’s 

activity during the headache is particularly helpful diagnostically (migraineurs 

lie still, patients with cluster headache pace or rock back and forth, and the 

activity of those with tension headaches is largely unaffected); individuals 

may experience more than one variety of migraine, or even different headache 

disorders (typically migraine and tension); many patients with a history 

of motion sickness (especially carsickness during childhood) are migraineurs; 

headaches associated with nausea +/- vomiting after minor head trauma are 

probably migrainous (so-called “footballers migraine”); and migraine frequently 

manifests initially in childhood with cyclic vomiting and abdominal pain, 

carsickness, “footballers migraine” or combinations thereof. 

·   age of onset;

·   family history;

·   site or sites of pain;

·   duration;

·   character;

·   intensity;

·   mode of onset;

·   time between onset to peak pain;

·   temporal profile;

·   aggravating or precipitaing factors;

·   alleviating factors;

·   associated neurologic, ophthalmologic and autonomic features;

·   prior and current medication use, including dosage, schedule, and efficacy (inquiry into use of over-       the counter (OTC) medications, as well as prescribed ones, is vital);

·   caffeine use;

·   history of head trauma;

·   results of prior neuroimaging studies;

·   a complete review of systems; and

·   why the patient is currently seeking medical attention.

 Although most headaches are benign, one should bevigilant in searching for “red flags,” potentially indicating more ominous etiologies, including:

• abrupt onset of a new, severe headache (“worst headache of my life”);

• a progressive headache course;

• onset with exertion, including sexual intercourse;

• onset of headache during or after middle age;

• headache associated with a decreased level of consciousness;

• headache associated with meningeal signs, fever, indurated

• temporal arteries or other significant physical findings;

• clear postural features of the headache, especially exacerbation

• supine and relief standing;

• significant worsening of headache with Valsalva maneuver;

• failure to fit a “benign” headache profile ;

• and any headache in a patient with a known, serious, medical condition, such as cancer, immunocompromise, or infection.

A patient without any “red flags,” whose presentation conforms to one of the common headache disorders, and with a normal physical examination, does not necessarily need any ancillary tests. For an in-depth discussion of further evaluation and treatment of headaches associated with “red flags,” which may represent dangerous conditions such as subarachnoid hemorrhage; infectious or carcinomatous meningitis or encephalitis; raised intracranial pressure secondary to neoplasm, abscess, or intracranial hemorrhage; temporal arteritis or other vasculitides, the reader is directed to several excellent reviews.