Diagnosing Primary Headache Disorders in Patients with Bodily Distress Disorder

Diagnostic Criteria for Primary Headache Disorders

The International Headache Society recommends assigning a separate migraine diagnosis when the patient has at least 5 attacks meeting specific criteria, with a duration of 4-72 hours, and at least two of the following: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine physical activity, and at least one of the following: nausea/vomiting or both photophobia and phonophobia together 1, 2
The American Academy of Neurology suggests that chronic migraine warrants separate diagnosis when headache occurs ≥15 days/month for >3 months, and on ≥8 days/month, headache meets migraine criteria or responds to triptan/ergot treatment, with a prior history of at least 5 attacks meeting migraine without aura criteria 1, 2
The European Neurology Society recommends considering separate diagnosis for tension-type headache when it has a bilateral location with pressing/tightening quality, mild to moderate intensity not aggravated by routine physical activity, and lacks migraine-associated symptoms 5, 6

The American Headache Society advises implementing headache diaries to document attack frequency, duration, intensity, associated symptoms, and medication use, which is essential for distinguishing a primary headache disorder from diffuse somatic complaints 1, 5, 7
The National Institute of Neurological Disorders and Stroke suggests applying validated screening instruments such as ID-Migraine or MS-Q to identify patients likely meeting migraine criteria 5, 6

The Mayo Clinic recommends that the decision to diagnose separately should be influenced by whether the headache causes significant disability, requires migraine-specific treatment, and demonstrates a clear episodic pattern 3, 4
The American College of Physicians advises that neuroimaging is indicated only when red flags are present, not for routine diagnosis, and that frequent headache and frequent disability correlate strongly with depression, anxiety, and impaired quality of life 3, 5, 6