#migraineawareness2021
How to Diagnose Migraine?
Migraine is a highly prevalent and disabling disease, yet so many people living with migraine are still undiagnosed and undertreated. The key to improving the treatment of migraine begins with the identification of migraine symptoms followed by a prompt and accurate diagnosis. Migraine is diagnosed based on clinical criteria provided by the International Classification of Headache Disorders, 3rd edition. Obtaining an adequate medical history is therefore key. Physical and neurologic examination is also important to exclude any abnormal findings or features suggestive of a secondary cause for headache. The diagnostic criteria for migraine includes recurrent headache attacks, that have at least 2 of the following 4 characteristics: unilateral location, pulsating quality, moderate to severe intensity, and aggravation by routine physical activity, AND at least 1 of the following 2 associated features: nausea and/or vomiting or sensitivity to light and sound. This is the diagnosis of migraine without aura. About 30% of people living with migraine may also have aura, which is defined as a fully reversible focal neurologic symptom that lasts 5 to 60 minutes. There are three typical types of aura symptoms (visual, sensory, and speech/language symptoms). Visual aura symptoms are most common and occur in more than 90% of people with migraine with aura. The aura symptoms often present with scotoma or fortification spectra. It should also be noted that those who experience sensory and/or speech/language aura symptoms, will most often also experience visual aura symptoms. This is the diagnosis of migraine with aura. The two most common differential diagnoses to migraine are tension-type headache and medication overuse headache. Common pitfalls in the diagnosis of migraine are the misconceptions that migraine is unilateral in location – about 40% of people with migraine have bilateral pain and that migraine has a pulsating quality – many people with migraine will describe a band-like or vice-like pain. A bilateral, pressure-like pain that is moderate to severe in intensity and worsened with physical activity like walking can meet criteria for migraine. About 2% of the population has chronic migraine which is defined as having 15 or more headache days per month of which at least 8 days meet criteria for migraine. To obtain an accurate count of headache days per month, I recommend asking these 2 questions: (1) How many days per month do you have a headache? and (2) How many days per month do you NOT have any headache whatsoever? These 2 questions will help capture all headache days for an accurate diagnosis as patients often only report their most severe debilitating days, instead of all the days they have migraine symptoms. This will improve the diagnosis and thus treatment of chronic migraine, the most severe, disabling form of migraine disease. To review: (1) A diagnosis of migraine is primarily based on the medical history and should include duration, frequency, pain characteristics, accompanying symptoms, and possible aura symptoms. (2) Do not fall into the pitfalls of misdiagnosis of migraine, a bilateral, pressure-like pain that is moderate to severe in intensity and worsened with physical activity can meet criteria for migraine, and (3) Ask about the number of headache days AND non-headache days per month to increase your diagnostic accuracy of chronic migraine.



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