Overview of Migraine Diagnosis

Learn the basics of diagnosing migraine and questions to ask your patient

Migraine is by far the most common headache type for which patients seek help from providers. In addition, migraine is frequently underdiagnosed and undertreated. This makes it extremely important for primary care providers to understand how to diagnose migraine.

This article provides an overview of how and when to diagnose migraine, including clinical pearls and questions to ask your patients.

Clinical Pearls

  • Make sure to rule out secondary headache when diagnosing primary headache disorder.
  • Neuroimaging is not indicated in patients with recurrent headache with clinical features of migraine, normal neurologic examination findings and no red flags.
  • Neuroimaging, sinus or cervical spine x-ray scans and electroencephalograms (EEG) are generally not acceptable for routine assessment of patients with headache.
  • Clinical history, family history and physical/neurologic examination findings are usually sufficient to make a diagnosis of migraine.
  • Patients seeking help for bilateral headaches that interfere with daily activities are likely to have migraine rather than tension-type headache and might require migraine-specific medication.
  • Consider diagnosis of migraine in patients with previous diagnosis of recurring sinus headache.
  • Medication overuse headache (a secondary headache disorder) should be considered present in patients with migraine (or tension-type headache) using combination analgesics, opioids or triptans 10 or more days a month, or acetaminophen/NSAIDs 15 or more days a month.
  • Comprehensive migraine therapy typically includes managing healthy lifestyle modifications, avoiding triggers, using preventive/acute medications, creating a status migrainosus action plan, using non-pharmacologic therapies and/or devices and using migraine self-management strategies.
  • A substantial number of patients who might benefit from preventive therapy do not receive it.
  • Keeping a headache diary is helpful to track progress/acute medications.

Questions to Ask Your Patients

Asking patients about alleviating factors can help in acquiring the clinical history for a migraine patient.

Here are some examples of questions to ask:

  • Do you need to sleep or rest for relief? Migraine patients often need to sleep/rest for relief (compared to cluster headache patients who are often agitated/pacing around).
  • Do you prefer to rest in a dark room? A positive answer could indicate light sensitivity, or photophobia
  • Do you prefer to rest in a quiet place? This could indicate sound sensitivity, or phonophobia.
  • Do you prefer to rest keeping still? This could indicate movement sensitivity, or kinesiophobia.
  • Do you prefer to avoid perfume/cologne or other strong smells? This could indicate smell sensitivity, or osmophobia.
  • Do you prefer to avoid touching your scalp/neck? This could indicate cutaneous allodynia.

A helpful hint in determining headache frequency is to ask how many days of true headache freedom they have every month.

Primary care practitioners are essential to identifying and treating headache disorders. The American Headache Society’s First Contact – Headache in Primary Care program provides educational resources to empower healthcare professionals and improve headache and migraine care. Learn more about the program here.

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