Migraine headache in adults

The key to diagnosis of common forms of migraine is history and examination. Before starting treatment for migraine, it is important to ensure that the patient meets International Classification of Headache Disorders, third edition (ICHD-3) criteria for migraine or probable migraine.[3]Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211. https://www.ichd-3.org/wp-content/uploads/2018/01/The-International-Classification-of-Headache-Disorders-3rd-Edition-2018.pdf http://www.ncbi.nlm.nih.gov/pubmed/29368949?tool=bestpractice.com A single patient can have more than one headache diagnosis. The diagnosis of migraine does not preclude the diagnosis of another headache disorder if criteria are met.

History

Headache is the key historical feature that supports a diagnosis of migraine. Recurrent headaches that interfere with the patient's ability to function are often migraines but additional migraine features should be sought. Migraine is often unilateral, but, unilateral headache is not required for the diagnosis of migraine.

Patients should be asked about key features of the history: aura symptoms, pulsating/throbbing pain, location of pain, intensity, worsening with routine physical activity, photophobia, phonophobia, and nausea or vomiting.[3]Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211. https://www.ichd-3.org/wp-content/uploads/2018/01/The-International-Classification-of-Headache-Disorders-3rd-Edition-2018.pdf http://www.ncbi.nlm.nih.gov/pubmed/29368949?tool=bestpractice.com Use of a headache diary or calendar may assist with this.[39]Eigenbrodt AK, Ashina H, Khan S, et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol. 2021 Aug;17(8):501-14. https://www.nature.com/articles/s41582-021-00509-5 http://www.ncbi.nlm.nih.gov/pubmed/34145431?tool=bestpractice.com ​ Not every feature is required to meet criteria for migraine. Headaches should last between 4 and 72 hours. See Criteria.

Diagnostic tests

Diagnostic testing for people with headache is primarily to exclude concerning or problematic causes for headache, as there is no specific test revealing the causes of pain in the head. In many cases where the history is compatible with a diagnosis of migraine and the neurological examination is normal, no testing is necessary.[39]Eigenbrodt AK, Ashina H, Khan S, et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol. 2021 Aug;17(8):501-14. https://www.nature.com/articles/s41582-021-00509-5 http://www.ncbi.nlm.nih.gov/pubmed/34145431?tool=bestpractice.com

Features that should increase suspicion of a dangerous underlying headache or migraine mimic can be summarised using the 'SNOOP4' mnemonic:

• Systemic symptoms: fever, weight loss

• Neurological symptoms or abnormal signs: confusion, impaired alertness or consciousness

• Onset: sudden, abrupt, or split-second

• Older: new-onset and progressive headache, especially in patients aged >50 years

• 4 'P's

  • Pattern change (increased frequency)

  • Papilloedema

  • Precipitating factors (valsalva, etc)

  • Positional aggravation[40]American headache society. When does a patient with headache need a workup?​ Jan 2021 [internet publication]. https://d1fakw34cbtrm5.cloudfront.net/PDFs/Headache-Topics/AHS-First-Contact-Headache-WorkUp.pdf

Imaging

• Neuroimaging is not needed for patients with headaches consistent with migraine who have a normal neurological examination, with no atypical features or red flags present.[39]Eigenbrodt AK, Ashina H, Khan S, et al. Diagnosis and management of migraine in ten steps. Nat Rev Neurol. 2021 Aug;17(8):501-14. https://www.nature.com/articles/s41582-021-00509-5 http://www.ncbi.nlm.nih.gov/pubmed/34145431?tool=bestpractice.com [41]Evans RW, Burch RC, Frishberg BM, et al. Neuroimaging for migraine: the American Headache Society systematic review and evidence-based guideline. Headache. 2020 Feb;60(2):318-36. https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.13720 http://www.ncbi.nlm.nih.gov/pubmed/31891197?tool=bestpractice.com [42]American College of Radiology. ACR appropriateness criteria: headache. 2022 [internet publication]. https://acsearch.acr.org/docs/69482/Narrative ​​[43]American College of Radiology. Ten things physicians and patients should question. Choosing Wisely, an initiative of the ABIM Foundation, 2021 [internet publication]. https://web.archive.org/web/20230330210926/https://www.choosingwisely.org/societies/american-college-of-radiology [44]American Academy of Neurology. Five things physicians and patients should question. Choosing Wisely, an initiative of the ABIM Foundation, 2022 [internet publication]. https://web.archive.org/web/20221205215637/https://www.choosingwisely.org/societies/american-academy-of-neurology

• Magnetic resonance imaging (MRI) imaging (with contrast) is the recommended test for patients with concerning headaches in nearly all situations. Computed tomography (CT) brain (without contrast) is recommended for the emergency evaluation of acute headache to evaluate for intracranial haemorrhage. In all other situations MRI is the preferred test, unless contraindicated.[42]American College of Radiology. ACR appropriateness criteria: headache. 2022 [internet publication]. https://acsearch.acr.org/docs/69482/Narrative

• Vascular imaging (CT, MRI, or conventional angiography) may be appropriate for patients where there is concern for unruptured aneurysm, arterial dissection, or venous occlusion.[42]American College of Radiology. ACR appropriateness criteria: headache. 2022 [internet publication]. https://acsearch.acr.org/docs/69482/Narrative

Laboratory testing and serologies

• Routine laboratory testing may reveal thyroid abnormalities, anaemia, or electrolyte abnormalities contributing to a headache disorder, and may be appropriate based on the patient's history and prior medical care. Erythrocyte sedimentation rate and C-reactive protein are appropriate to exclude meningitis, and to evaluate for vasculitis and giant cell arteritis in older patients.[45]van der Geest KSM, Sandovici M, Brouwer E, et al. Diagnostic accuracy of symptoms, physical signs, and laboratory tests for giant cell arteritis: a systematic review and meta-analysis. JAMA Intern Med. 2020 Oct 1;180(10):1295-1304. https://www.doi.org/10.1001/jamainternmed.2020.3050 http://www.ncbi.nlm.nih.gov/pubmed/32804186?tool=bestpractice.com

Lumbar puncture

• Lumbar puncture (LP) is generally recommended for all patients undergoing urgent evaluation for abrupt-onset headache, especially if CT imaging is negative. CT imaging may miss up to 6% of patients with a subarachnoid haemorrhage.[46]Byyny RL, Mower WR, Shum N, et al. Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage. Ann Emerg Med. 2008 Jun;51(6):697-703. http://www.ncbi.nlm.nih.gov/pubmed/18207607?tool=bestpractice.com

• Patients with headache and fever or altered cognition require imaging and LP to evaluate for meningitis or encephalitis.

• Patients with papilloedema should undergo LP after imaging for measurement of cerebrospinal fluid pressure.

• Consider LP for inpatients with frequent headaches that are unresponsive to standard treatments.

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  Diagnostic lumbar puncture in adults: animated demonstration

  How to perform a diagnostic lumbar puncture in adults. Includes a discussion of patient positioning, choice of needle, and measurement of opening and closing pressure.

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