How to diagnose migraine headaches

Not sure if your patient has migraine headaches? Check out our article and learn the criteria for diagnosing migraines.
Last update28th Feb 2021

Migraine is a complex neurophysiological disease characterized by episodic, and sometimes chronic, and progressive forms of headache. There are associated neurologic and non-neurologic symptoms that accompany the head pain.

Note that the International Headache Society classification for migraine includes migraine without aura, with aura, chronic migraine, and associated migraine complications. Additionally, there are separate categories for gastrointestinal symptoms and vertigo which can be associated with migraine.

Basic diagnostic criteria for migraine

All International Classification of Headache Disorders criteria always include a statement that, in order to apply a certain diagnosis, the syndrome must not be better accounted for by any other diagnosis.

There are four basic diagnostic criteria for all migraine types:

  1. The headache will last 4­–72 hours if left untreated or unsuccessfully treated.
  2. The headache has at least two of the following four characteristics:
  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravated by routine physical activity such as walking or climbing stairs or the migraine sufferer will avoid these activities
  1. During a migraine headache, at least one of the following is present:
  • Nausea and / or vomiting
  • Photophobia and phonophobia
  1. Finally, there should be a history of at least five attacks having occurred which fulfill the above criteria.
Figure 1. Four basic diagnostic criteria of all migraine types include headache duration of 4–72 hours if not successfully treated, pain that has at least two characteristics—unilateral, pulsing, moderate or severe intensity, or aggravated with physical activity— and reported nausea and vomiting and / or photophobia and phonophobia, as well as a history of five attacks meeting these criteria.

Diagnostic criteria for migraine with aura

For migraine that occurs with an aura, there are several other criteria that must be met for a diagnosis. Remember that an aura refers to a group of symptoms—visual, sensory, or other central nervous system symptoms—which are fully-reversible, and develop gradually:

  • Visual changes such as spots, clouded fields, flashes of light or scintillations
  • Sensory symptoms such as numbness or pins and needles
  • Speech and / or language dysfunction
  • Motor power loss
  • Brainstem dysfunction such as diplopia, dizziness, or facial sensory changes
Figure 2. Symptoms of aura.

In addition to all of the basic migraine criteria, there are several others that must be fulfilled to diagnose migraine with aura:

  1. There must be at least two attacks that have any of the symptoms of aura above.
  2. Aura symptoms must have at least three of the following six characteristics:
  • At least one aura symptom spreads gradually over five minutes
  • Two or more aura symptoms occur in succession
  • Each individual aura symptom lasts 5–60 minutes
  • At least one aura symptom is unilateral
  • At least one aura symptom is positive, meaning a symptom of an added sensory perceptive phenomena such as scintillating lights or pins and needles
  • The aura is accompanied, or followed within 60 minutes, by a headache
Figure 3. Additional criteria to diagnose migraine with aura.

Non-diagnostic criteria of migraine

Migraine headaches have a female to male gender ratio of approximately 3:1. There are many comorbid conditions with migraine, including depression, anxiety, sleep disorders, and obsessive-compulsive disorder.

Figure 4. Migraine has a female to male ratio of 3:1.

There may be a genetic predisposition to migraine. Those predisposed typically can identify triggering mechanisms such as certain foods, weather changes, fasting, sleep disturbances, stress, and hormonal fluctuations.

Figure 5. Possible triggers for migraine.

There are also migraines which provoke neurologic dysfunction known as complicated migraines. One example is a form of migraine called a hemiplegic migraine which will produce neurologic dysfunction, appearing as stroke-like symptoms, on one side of the body. These events run in families, and testing can be done to determine if genetic human leukocyte antigen (HLA) types associated with the syndrome are present.

Figure 6. Hemiplegic migraine produces stroke-like symptoms and typically run in families.

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Recommended reading

  • Ferguson, LW and Gerwin, R. 2005. Clinical Mastery in the Treatment of Myofascial Pain. Baltimore: Lippincott Williams & Wilkins.
  • Fernández-de-las-Peñas, C, Arendt-Nielsen, L, and Gerwin, R. 2010. Tension-Type and Cervicogenic Headache—Pathophysiology, Diagnosis and Management. Boston: Jones and Bartlett Publishers.
  • Goadsby, PJ and Silberstein, SD. 1997. Headache. Vol 17 of Blue books of practical neurology. Boston: Butterworth-Heinemann.
  • Goadsby, PJ, Silberstein, SD, and Dodick, DW. 2005. Chronic Daily Headache for Clinicians. Hamilton: BC Decker.
  • Silberstein, SD, Lipton, RB, and Goadsby, PJ. 2002. Headache in Clinical Practice. 2nd edition. London: Martin Dunitz.
  • Ward, TN. 2012. Migraine diagnosis and pathophysiology. Continuum (Minneap Minn). 18: 753–763. PMID: 22868539

About the author

Robert Coni, DO EdS
Neurohospitalist, Medical Director and Coordinator at the Grand Strand Medical Center, and Clinical Assistant Professor at the University of South Carolina.
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