19th June 2023

Diagnosis

Migraine is a common primary headache disorder characterised by intermittent moderate to severe headaches and associated symptoms such as photophobia, phonophobia, visual disturbance, nausea, and vomiting.

There are several different types of migraine, the clinical features and diagnostic criteria of which are detailed below.

Migraine without aura

At least 5 attacks fulfilling the following:

• Headache lasting 4-72 hrs in adults
• Headache with at least 2 of the following characteristics:
  • Unilateral
  • Pulsating quality
  • Moderate to severe intensity
  • Aggravation by, or causing avoidance of, routine activities of daily life
• Headache with associated symptoms, including at least one of the following:
  • Nausea and /or vomiting
  • Photophobia and phonophobia

• Headache not accounted for by any other diagnosis

Migraine with aura

At least 2 attacks fulfilling the following:

• One or more typical fully reversible aura symptoms, including
  • Visual symptoms – e.g. zigzag lines, scotomas
  • Sensory symptoms – e.g. unilateral paraesthesia or numbness
  • Speech and/or language symptoms – e.g. dysphasia

• At least 3 of the following:
  • ≥ 1 aura symptom spreads gradually over at least 5 mins
  • 2 or more aura symptoms occur in succession
  • Each individual aura symptom last 5-60 mins
  • ≥ 1 aura symptom is unilateral
  • ≥ 1 aura symptom is positive (e.g. zigzag lines, scintillating scotoma, as opposed to negative symptoms such as temporary visual loss and dark spots.)
  • The aura is accompanied or is followed within 60 mins by headache.

• Headache not accounted for by any other diagnosis

It should be noted that occasionally, aura can occur without headache or can be atypical in nature, e.g. causing motor weakness, diplopia, or decreased consciousness. These presentations often prompt further urgent investigation to rule out a more serious cause, such as a cerebrovascular event.

Episodic and chronic migraines

Differentiation depends on the frequency of headaches:

• Episodic – migraine on < 15 days per month
• Chronic – headache ≥ 15 days per month (with migraine features ≥ 8 days per month)

Menstrual-related migraine

Suspected when migraine occurs in the days immediately before and after the start of menstruation for consecutive menstrual cycles.