• Is a recurrent, episodic headache disorder that may or may not include an aura.
• Occurs in up to 12% of the general population; more frequent in women than men, and mostly occurs in adults aged 30 to 39.migraine, migrane
• Is a major cause of disability and was ranked second worldwide in 2016 among all diseases with respect to years of life lived with disability.

The International Classification of Headache Disorders, 3rd edition (ICHD-3) lists the following criteria for diagnosing migraine.

Migraine without aura

A. At least five attacks fulfilling criteria B through D.

B. Headache attacks lasting 4 to 72 hours (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 (i.e. walking or climbing stairs).

D. During headache at least one of the following:

• Nausea, vomiting, or both.
• Photophobia and phonophobia.

E. Not better accounted for by another ICHD-3 diagnosis.

Migraine with aura

A) At least two attacks fulfilling criteria B and C

B) One or more of the following fully reversible aura symptoms:

• Visual.
• Sensory.
• Speech and/or language.
• Motor.
• Brainstem.
• Retinal.

C) At least three of the following six characteristics:

• At least one aura symptom spreads gradually over ≥5 minutes.
• Two or more symptoms occur in succession.
• Each individual aura symptom lasts 5 to 60 minutes.
• At least one aura symptom is unilateral.
• At least one aura symptom is positive (i.e. tingling as opposed to numbness).
• The aura is accompanied, or followed within 60 minutes, by headache.

D) Not better accounted for by another ICHD-3 diagnosis.

• History.
• Physical examination, including complete neurologic examination.
  • Neurologic exam should be normal in patients who are between episodes, and in patients who have migraine without aura.
  • Focal motor or sensory deficits may be observed in patients who have migraine with aura or variants.
• Neuroimaging is not necessary in most patients with migraine.

When should you perform neuroimaging?

The following “red flags” may warrant head CT without contrast (contrast or MRI may be indicated):

• The “first or worst” headache.
• Recent significant change in the pattern, frequency, or severity of headaches.
• New or unexplained neurologic symptoms or signs.
• Headache always on the same side.
• Headaches not responding to treatment.
• New-onset headaches after age 50 years.
• New-onset headaches in patients with cancer or HIV infection.
• Associated symptoms and signs such as fever, stiff neck, papilledema, cognitive impairment, or personality change.

Patients presenting with thunderclap (sudden onset, maximal intensity instantly) headache require CT without contrast to rule out medical emergencies such as subarachnoid hemorrhage.

When should you perform a lumbar puncture?

• A lumbar puncture (LP) is indicated for the diagnosis of an infectious CNS process, subarachnoid hemorrhage not detected by CT without contrast (> 6hrs post onset), or idiopathic intracranial hypertension. Consider if:
  • The “first or worst” headache.
  • Severe, rapid onset of a recurrent headache.
  • Progressive headache.
  • Atypical chronic intractable headache.
  • Headache accompanied by alterations in mental status, fever, and meningeal signs.
• Perform head CT scan before LP if:
  • Immunocompromised (i.e. HIV infection, immunosuppressive therapy, solid organ or hematopoietic stem cell transplant).
  • Known CNS disease (i.e. mass lesion, stroke, focal infection).
  • New onset seizure.
  • Papilledema.
  • Altered level of consciousness.
  • Focal neurological deficit.

Differential diagnosis beyond migraine includes

• Cluster headache:
  • Severe, throbbing, unilateral pain occurring over the orbitotemporal region.
  • One or several attacks per day.
  • Each episode lasts minutes to hours.

• Tension-type headache:
  • Bilateral, squeezing or band-like pain.
  • Variable frequency.
  • Each episode lasts hours to days.

• Medication overuse headache:
  • Occurs in conjunction with 15 or more days per month of medication overuse (overuse of at least 1 acute treatment drug for more than 3 months).
  • Worsens (usually in frequency) as the use of acute medications becomes more frequent.

1. Elsevier Point of Care: Migraine in adults

   
   

2. Cutrer M. (2018). Pathophysiology, clinical manifestations, and diagnosis of migraine in adults. UpToDate. Cited August 12, 2019.

   
   

3. Gallagher RM. Headache. Conn’s Current Therapy 2019. Elsevier Health Sciences; 2018 Dec 6. Cited 2019 Aug 12. p19-25.

   
   

4. Chawla J. Differential diagnosis of migraine. Medscape CME/CE. 2019 May 28. Cited 2019 Aug 12.

   
   

5. Rubin D, Halpern Kornblau D, Conway E, Caplen, S. Neurologic Disorders. In:  Walls R, Hockberger R, Gausche-Hill M, editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Elsevier. 2017. p. 2182-2200.e2.