Diagnosis

Migraine is associated with recurrent attacks that can vary in frequency, duration and resulting disability. Correctly diagnosing migraine can take time and, on average, patients with migraine spend longer periods awaiting correct diagnosis, compared to headache sufferers (Naujoks et al., 2016).

There is no test to definitively diagnose migraine and no biomarkers are currently available to assist in the process (International Headache Society, 2013). In some cases, computed tomography (CT) or magnetic resonance image (MRI) scans are used during the diagnostic journey; however, this is only to rule out other causes of headache.

There are three key diagnostic components for migraine:

  • medical history (Katsarava et al., 2012)
  • examination, including complete neurological assessment (International Headache Society, 2013)
  • exclusion of other causes (Katsarava et al., 2012)

Table 4: Differentiating migraine from other primary headache diseases (Russell, 2007; Burch et al., 2015; International Headache Society, 2018)

Differentiating migraine from other primary headache diseases (Russell, 2007; Burch et al., 2015; International Headache Society, 2018)


International guidelines are available for migraine diagnosis (Manack et al., 2009; International Headache Society, 2018). In total, the International Classification of Headache Disorders 3 (ICHD-3) lists 14 distinct diagnoses for headache disorders, however severe headache patients may receive multiple sub-diagnoses that fall into one or more of the main diagnostic categories.

Migraine classification by ICHD-3 criteria.

Figure 12: Migraine classification by ICHD-3 criteria (Lipton & Silberstein, 2015; International Headache Society, 2018). ICHD-3 = International Classification of Headache Disorders 3.

Aura sub-diagnoses

Migraine can be further divided into two major subtypes: with- and without aura. Classification of each is based on the ICHD criteria (Katsarava et al., 2012; International Headache Society, 2018).  

Migraine classification criteria for diagnosis of migraine with aura and migraine without aura.

Figure 13: Migraine classification criteria for diagnosis of migraine with aura and migraine without aura (Lipton & Silberstein, 2015; International Headache Society, 2018).

Headache frequency sub-diagnoses

The 2004 ICHD-2 guidelines provided a definition of, and distinction between, episodic migraine versus chronic migraine, which was further refined within the 2018 ICHD-3 guidelines. Classification of migraines as episodic or chronic depends on attack frequency (Katsarava et al., 2012; International Headache Society, 2018):

  • episodic migraine accounts for 92% of patients with migraine and is defined by a headache frequency of <15 days/month (either untreated or unsuccessfully treated) (Buse et al., 2012; Katsarava et al., 2012)
  • chronic migraine is diagnosed in 8% of patients with migraine and is defined by a headache frequency of ≥15 days/month for ≥3 months PLUS a headache that has features of migraine for ≥8 days/month (Buse et al., 2012; Katsarava et al., 2012)

It is important for physicians to bear in mind that migraine may worsen over time, with increasing headache frequency (Bigal & Lipton, 2008) and may evolve, transitioning from episodic to chronic – a process termed ‘chronification’ (Manzoni et al., 2013). Conversely, migraine may also transition from chronic to episodic (Bigal & Lipton, 2008).