Migraine Quick Guides

Flowchart: Diagnosing and Treating Migraine
Migraine (adult)
This algorithm addresses the management of migraine, including for patients in the acute care setting (e.g., emergency department).
In acute care settings the likelihood of a severe headache being caused by an alternative and sometimes life-threatening condition is significant, so careful evaluation may be necessary before concluding the headache is due to migraine.
**Flowchart best viewed on a desktop computer.
Headache: suspect migraine
The following 3 questions (ID migraine) with the mnemonic P-I-N, can be used to screen a patient for migraine in a primary care setting:
- Does light bother you when you have a headache? (Photophobia)
- Have headaches limited your activities for a day or more in the last 3 months? (Impairment)
- Are you nauseated or sick to your stomach when you have a headache? (Nausea)
If 2 or 3 answers are affirmative, there is a 93% chance the patient has migraine.
Note that ID migraine does NOT exclude secondary headache.
Perform history and physical examination
History of present illness
- Temporal characteristics
- Age of patient at headache onset
- Pattern of headache episodes (e.g., seasonal, monthly, weekly, hour of day)
- New symptoms (e.g., visual, neurologic)
- Association with menstrual cycle
- Time between start of episode and peak intensity
- Stable or changing features over past 6 months or over lifetime (e.g., progressively worsening over days or weeks)
- Frequency and duration of acute episodes
- Number of headache days per month
- Headache characteristics
- Type of pain (e.g., pulsatile, throbbing, pressing, sharp)
- Location of pain (e.g., unilateral, bilateral, changing sides, radiating)
- Severity of pain (e.g., scale of 0 to 10)
- Associated symptoms (e.g., nausea, vomiting, photophobia, phonophobia)
- Premonitory symptoms (e.g., mood change, fatigue, cognitive changes, food craving, yawning, neck stiffness)
- Aura (visual, sensory, speech and/or language, motor, brainstem, retinal)
- Autonomic features (e.g., nasal stuffiness, rhinorrhea, tearing, eyelid ptosis or edema)
- Factors that aggravate or relieve headache
- Effect of routine physical activity (e.g., walking or climbing stairs) on pain
- Effect of position changes
- Relationship to food and alcohol
- Possible association with environmental factors
- Effects of exogenous hormones
- Treatments tried (pharmacologic and non-pharmacologic) and relative efficacy
Past medical history
- Presence of other medical conditions associated with migraine (e.g., asthma, irritable bowel syndrome, depression, anxiety, Raynaud’s phenomenon, obstructive sleep apnea, idiopathic gastroparesis, interstitial cystitis)
Family history
- Family history of migraine or other primary headache disorder
Social history
- Recent changes in health or lifestyle
- Recent head trauma
- Change in sleep, exercise, weight, or diet
- Change in work (disability) or lifestyle
- Change in birth control
Physical examination
- Vital signs
- Evaluation of extracranial structures
- Scalp arteries
- Cervical paraspinal muscles
- Examination of the neck in flexion versus lateral rotation for meningeal irritation
- Even a subtle limitation of neck flexion may be considered abnormal
- Neurologic examination
- Awareness, consciousness, confusion, or memory impairment
- Cranial nerve examination
- Optic fundi
- Visual fields
- Pupillary symmetry and reactivity
- Ocular motility
- Facial sensation
- Facial strength
- Symmetry of muscle tone and strength (may be as subtle as arm or leg drift)
- Deep tendon reflexes
- Plantar responses
- Sensation
- Coordination
- Gait
Diagnose migraine
Migraine without aura is a recurrent headache disorder with episodes lasting 4 to 72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and association with nausea and/or photophobia and phonophobia. Some patients also experience a premonitory phase hours or days before the headache and a resolution phase after the headache. Premonitory and resolution symptoms may include mood change, fatigue, cognitive changes, food craving, yawning, neck stiffness.
- At least 5 headaches fulfilling criteria B, C, and D
- Headaches last 4 to 72 hours (untreated or unsuccessfully treated)
- Each headache has at least 2 of the following 4 characteristics:
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravated by or cause avoidance of routine physical activity (e.g., walking or climbing stairs)
- During a headache, at least 1 of the following characteristics is present:
- Nausea and/or vomiting
- Photophobia and phonophobia
- Headaches are not better accounted for by another ICHD-3 diagnosis
Migraine with aura is a recurrent headache disorder that causes episodes of reversible focal neurological symptoms that usually develop gradually over 5 to 20 minutes and last for <60 minutes. A headache with the features of migraine without aura usually follows the aura symptoms. Less commonly, the headache lacks migrainous features or is completely absent. Auras are most often visual, but can also involve sensory, speech and/or language, motor, brainstem, retinal disturbances. Some patients also experience a premonitory phase hours or days before the headache and a resolution phase after the headache. Premonitory and resolution symptoms may include mood change, fatigue, cognitive changes, food craving, yawning, neck stiffness.
Note: Many patients who experience migraine attacks with aura also have attacks without aura, or aura without headache.
- At least 2 headaches fulfilling criteria B and C
- Each headache has ≥1 of the following fully reversible aura symptoms:
- Visual (e.g., seeing bright spots or flashes of light)
- Sensory (e.g., sensitivity to touch)
- Speech and/or language (e.g., aphasia)
- Motor
- Brainstem
- Retinal
- Each headache has at least 3 of the following 6 characteristics:
- At least 1 aura symptom spreads gradually over ≥5 minutes
- 2 or more aura symptoms occur in succession
- Each individual aura symptom lasts 5 to 60 minutes
- At least 1 aura symptom is unilateral
- At least 1 aura symptom is positive (e.g., scintillations, pins and needles)
- The aura is accompanied, or followed within 60 minutes, by headache
- Headaches are not better accounted for by another ICHD-3 diagnosis and transient ischemic attack has been excluded
Patient education
Patient education includes:
- Setting realistic expectations, including:
- Expected benefits of treatment
- How long it will take to reach treatment goals
- Selecting a particular treatment, based on factors such as:
- Frequency and severity of headaches
- Degree of headache-related disability
- Associated symptoms including nausea and vomiting
- Response to (and tolerance of) specific medications
- Comorbidities
- Coexisting conditions such as heart disease, pregnancy, and uncontrolled hypertension may limit treatment choices
- Following the treatment regimen
- Understanding adverse effects
- Tracking progress (e.g., diary cards, flow charts, headache calendars to mark days of disability or missed work, school, and family activities)
- Avoiding migraine triggers
Migraine triggers
- Temperature (exposure to heat or cold)
- Bright lights or glare
- Noise
- Head or neck injury
- Weather changes
- Motion
- Odors (e.g., smoke, perfume)
- Flying or high altitude
- Physical strain
- Acute or chronic stress, or relaxation after stress
- Skipping meals
- Unhealthy diet
- Disturbed sleep patterns
- Smoking
- Menarche
- Puberty
- Ovulation
- Menstruation
- Using oral contraceptives or estrogen therapy
- Pregnancy
- Birth of a child
- Menopause
- Anger
- Excitement or exhilaration
- Let-down response following period of stress
- Nitroglycerin
- Oral contraceptives
- Hormone therapy
- Medications for erectile dysfunction
Dietary triggers (which vary considerably from patient to patient)
- Citrus fruit
- Aspartame
- Caffeine
- Aged cheese
- Chocolate
- Alcohol (red wine, beer)
- Foods containing nitrites
- Foods containing monosodium glutamate (MSG)
However, food may not consistently precipitate a migraine — even if a given product has been a trigger in the past.
Classify by severity of attack
While headache is the usual reason for which patients seek treatment, non-head pain migraine symptoms (e.g. nausea, vomiting, light sensitivity, noise sensitivity) are often as or more debilitating than the head pain of migraine and should be considered.
Mild
Headache intensity is mild but patient is able to continue their daily routine with minimal alteration.