Diagnostic Approach to Migraine

Introduction to Migraine Diagnosis

The International Headache Society recommends that migraine diagnosis should be based on clinical features using validated criteria, not laboratory tests 1, 2
Validated screening tools like the three-item ID-Migraine questionnaire (sensitivity 0.81, specificity 0.75) or the five-item Migraine Screen Questionnaire (sensitivity 0.93, specificity 0.81) can help identify likely migraine cases 1, 2
Headache diaries documenting pattern, frequency, accompanying symptoms (nausea, photophobia, phonophobia), and medication use are more valuable than laboratory tests for diagnosis 1, 2

The presence of red flags such as thunderclap headache, atypical aura, progressive headache worsening over time, headache onset after age 50, headache described as "worst headache of life", unexplained fever or neck stiffness, focal neurological symptoms, weight loss, or altered consciousness may indicate a secondary headache disorder 3

Neuroimaging (MRI preferred over CT except when acute intracranial hemorrhage is suspected) may be indicated when red flags are present 3, 4
The American Academy of Neurology recommends against ordering unnecessary laboratory tests for typical migraine presentations without red flags 4

The American Headache Society advises against relying on laboratory tests rather than clinical criteria for primary migraine diagnosis 1, 2
Failing to recognize red flag symptoms that warrant further investigation may lead to delayed diagnosis or mismanagement of secondary headache disorders 3
Overlooking the need for neuroimaging when red flags are present may result in missed diagnoses of underlying conditions 3