Migraine Diagnosis
Diagnostic Resources
- Migraine Diagnostic Questionnaire: 15 Key Questions
- GP Migraine Algorithm: The Treatment of Migraine
- Patient Treatment Plan
- IHS Classification of Headache Disorders
- NICE Guidelines on Headache
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Management of Migraine
for Health Professionals
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Diagnosing Migraine
(I.H.S Criteria)
The International Headache Society (I.H.S) criteria for diagnosing Migraine are both inclusive (certain features must be present) and exclusive (secondary headaches must first be ruled out). The criteria are outlined below. Please note that none of the features, even headache,are compulsory in order to make a diagnosis so the criteria should be used with a certain flexibility in practice.
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Criteria for Diagnosing
Migraine Without Aura
A. At least five attacks fulfilling B-D
B. Attacks lasting 4-72 hours if untreated or unsuccessfully treated
C. Headache has at least two of the following characteristics
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by or causing avoidance of routine physical activity
D. During headache, at least one of the following
- Nausea and / or vomiting
- Photophobia / Phonophobia
E. Headache not attributable to any other disorder
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Criteria for Diagnosing
Migraine With Aura
A. At least two attacks fulfilling criteria B-D
B. Aura consisting of at least one of the following, but no motor weakness:
- Fully reversible visual symptoms including positive features (e.g. flickering lights, spots or lines) and /or negative features (i.e. loss of vision)
- Fully reversible sensory symptoms including positive features (i.e. pins and needles) and / or negative features (i.e. numbness)
- Fully reversible dysphasic speech disturbance
C. At least two of the following:
- Homonymous visual symptoms and / or unilateral sensory symptoms
- At least one aura symptom develops gradually over ≥5 minutes and / or different aura symptoms occur in succession over ≥5 minutes.
- Each symptom lasts ≥5 and ≤60 minutes
D. Headache fulfilling criteria B-D for Migraine without Aura begins during the aura or follows aura within 60 minutes
E. Headache not attributed to another disorder
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Rare forms of Migraine
1-3% of all migraine does not fit the standard diagnostic criteria for ‘Migraine with Aura’ or ‘Migraine without Aura’.
Basilar Migraine
Basilar artery migraine is a rare form of Migraine with Aura seen most commonly in young women and has an aura that is believed to be due to vertebro-basilar ischaemia.
Features of the aura may include:
- vertigo
- dysarthria
- ataxia
- diplopia
- bilateral visual impairment or sensory symptoms
The headache associated with Basilar migraine is usually occipital.
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Rare forms of Migraine
Hemiplegic Migraine
Hemiplegic Migraine is a rare form of Migraine and has two separate variations:
Familial Hemiplegic Migraine (FHM) – which is a genetic condition linked to mutations of specific genes on chromosomes 1 and 19
Sporadic Hemiplegic Migraine (SHM) – has no genetic link
Both FHM and SHM usually begin in childhood and cease during adult years. They also share the same symptoms. Because the symptoms are also indicative of vascular disease, a full neurological examination is necessary to rule out other causes and confirm the diagnosis
In addition to the symptoms of typical migraine, the following symptoms may present:
- Episodes of prolonged aura (up to several days or weeks)
- Hemiplegia
- Impaired consciousness ranging from confusion to profound coma
- Headache, which may begin before the hemiplegia or be absent
- Ataxia
Status Migrainosus
In this condition a patient, often with a previous history of migraine, suffers an unrelenting migraine (>72 hours) which is refractory to conventional therapy. The pain is severe, unilateral and throbbing.
Retinal Migraine
Retinal Migraine is a rare form of migraine in which the patient experiences vascular spasm affects the vessels supplying blood to the eye, resulting in a fully reversible visual loss. Retinal migraine is a diagnosis of exclusion and embolic and other vascular diseases need to be ruled out.
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The Migraine Association of Ireland
is a Non-Profit Patient Charity
Tension-Type
Headache
Tension-type headache is the most common type of primary headache with a lifetime prevalence of up to 78%. However, episodic tension-type headache requires little intervention from medical professionals as it rarely produces significant disability. It usually presents as a low impact, mild to moderate band-like featureless headache.
Patients with frequent episodic tension-type headache (1-15 days of TTH per month) often have co-existing Migraine without aura. Patients should be educated to differentiate between the two disorders and encouraged to use a Headache Diary to record individual episodes so that treatment can be maximised and medication-overuse headache avoided.
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I.H.S. Criteria for diagnosing
episodic tension-type headache.
A. At least ten episodes occurring < 15 days per month on average and fulfilling criteria B-D.
B. Headache lasting from thirty minutes to seven days.
C. Headache has at least two of the following characteristics:
- Bilateral location
- Pressing, tightening (non-pulsating) quality
- Mild to moderate intensity
- Not aggravated by routine physical activity
D. Both of the following:
- No nausea or vomiting
- No more than one of photophobia or phonophobia
E. Not attributed to another disorder
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Migraine is a
Complex
Neurological
Disorder
That Affects Different Areas of The Brain
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Chronic Tension
Type Headache
People with chronic tension-type headache (CTTH) usually have a history of episodic tension-type headache but may have no history of migraine. Many patients use excessive amounts of analgesics, and they may also have concomitant depression.
CTTH usually present as diffuse or bilateral and frequently involve the posterior head and neck. The I.H.S diagnostic criteria are outlined below.
The overuse of analgesics may convert episodic tension-type headaches into CTTH. These headaches are characterised by a daily low-grade headache that is temporarily controlled by the use of the offending acute medication, only to return as the medication wears off. Over time the offending medication loses effectiveness and escalating medication use occurs. If the medication is abruptly withdrawn, a severe rebound headache results. Prophylactic therapies are usually ineffective. CTTH associated with medication overuse will usually not improve without the patient discontinuing the medication. This leads to a period where the headaches will initially worsen.
The problem of CDH is exacerbated by the fact that many patients do not realise that excessive or frequent self-medication may perpetuate or exacerbate their headache. Explaining the condition to the patient is an important step in encouraging medication withdrawal.
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I.H.S. Criteria for
Diagnosing Chronic
Tension type Headache
A. Headache occurring on ≥15 days per month on average for > 3 months and fulfilling criteria B-D.
B. Headache lasts hours or may be continuous.
C. Headache has at least two of the following characteristics:
- Bilateral location
- Pressing, tightening (non-pulsating) quality
- Mild to moderate intensity
- Not aggravated by routine physical activity
D. Both of the following
- No more than one of photophobia or phonophobia or mild nausea
- Neither moderate or severe nausea nor vomiting
E. Not attributed to another disorder
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