Diagnosis

Several sets of guidelines have been developed to assist in the diagnosis of migraine:

The International Headache Society Classification of Headache Disorders

The second edition of the International Classification of Headache Disorders^[1] has been described as “perhaps the single-most important document to read for physicians taking an interest in the diagnosis and management of headache patients”. Developed by the International Headache Society, it was designed with the intention of promoting worldwide agreement in the way that that headache is classified.

A detailed classification of migraine with and without aura according to the second edition of The International Headache Society Classification of Headache Disorders is provided here.

HCPC guidelines

Although The International Headache Society Classification of Headache Disorders provides comprehensive and precise information on various headache disorders, the detailed nature of the guidelines may make them an impractical clinical tool for primary care physicians. Indeed, most primary care physicians rate their knowledge of the guidelines as especially poor.^[2]
The Headache Care for Practising Clinicians (HCPC) guidelines may be a more useful tool to assist in the diagnosis of migraine in primary care. These international guidelines are targeted towards healthcare professionals with an interest in headache, including physicians, nurses, pharmacists and other practitioners.

Twelve principles of migraine management have been identified by HCPC. Of these, two relate to screening and diagnosis.^[3]

Almost all headaches are benign/primary and can be managed by all practising clinicians.
Use questions/a questionnaire to assess the impact of migraine on daily living and everyday activities, for diagnostic screening and to aid management decisions.

The HCPC guidelines can be accessed by clicking here.

US Headache Consortium

The guidelines of the US Headache Consortium^[4]provide the following recommendations for diagnostic testing in non-acute headache patients (encompassing all headache syndromes that have occurred for at least four weeks during a patient’s lifetime).

Procedures of diagnostic screening and confirmatory differential diagnosis should be conducted.
Diagnosis should be based on The International Headache Society Classification of Headache Disorders.
Neuroimaging should be considered in patients with non-acute headache and an unexplained abnormal finding on neurological examination
- Neuroimaging is not usually warranted in patients with migraine and a normal neurological examination
- A lower threshold for neuroimaging may be applied for patients with atypical headache features or patients who do not fulfil the strict definition of migraine or other primary headache disorder (or who have some additional risk factor, such as immune deficiency).

The following symptoms significantly increase the odds of finding a significant abnormality on neuroimaging in patients with non-acute headache:

Rapidly increasing headache frequency
History of dizziness or lack of co-ordination
History of subjective numbness or tingling
History of headache causing awakening from sleep (although this can occur with migraine and cluster headache).

References:
1. International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24 Suppl 1: 9-160.
2. Dowson A, Shapero G, Baos V, Smith R, Sakai F, Lacoste J, et al. Primary care needs assessment for guidance on headache management. Headache Care 2004;2: 43-6.
3. Dowson AJ, Sender J, Lipscombe S, Cady RK, Tepper SJ, Smith R, et al. Establishing principles for migraine management in primary care. Int J Clin Pract 2003;57: 493-507.
4. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000;55: 754-62.,

Treatment

Diagnosis