Migraine Diagnosis

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.

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.

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.

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.