Expert tips for accurate diagnosis and treatment of migraine

What are the questions to ask to make an accurate diagnosis of migraine? What are the five steps of shared decision-making that facilitate personalized treatment for patients with migraine? Professor Halker Singh, Mayo Clinic, Scottsdale, AZ, and Professor Ailani, Medstar Georgetown University Hospital, Washington DC, shared their expertise in a case presentation-based session at AAN 2021.

Only around 26% of patients with episodic migraine and 5% with chronic migraine receive the three steps of healthcare required to receive guideline-defined appropriate pharmacologic therapy,1 said Professor Halker Singh. These steps are:

An accurate diagnosis is key for effective treatment

  • Consultation with a physician
  • Accurate diagnosis
  • Treatment


Questions to ask to make an accurate diagnosis

Dig deeper into patients’ histories, particularly for light and sound sensitivity, aura, nausea, and frequency

Professor Ailani highlighted the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria for a diagnosis of migraine without aura. They are at least five attacks during lifetime with headache lasting 4–72 hours plus:

  • Two of the following—unilateral location, pulsating quality, moderate or severe intensity, aggravation by or causing avoidance of routine physical activity
  • At least one of—nausea and/or vomiting, photophobia and phonophobia
  • Not better accounted for by another ICHD-3 diagnosis2

In practice, there is no typical presentation, said Professor Ailani. Headaches can also vary within a patient and the patient might not think of them all as migraine.

Professors Halker Singh and Ailani highlighted the importance of always digging deeper into patients’ histories, particularly in terms of light and sound sensitivity, aura, nausea, and headache frequency.

Aura and nausea mean different things to different people, said Professor Ailani. Ask patients what aura and nausea mean to them. Asking a patient “What would you choose to do during an attack,” may reveal light and sound sensitivity and nausea.

Ask how many days per month are completely headache free

Furthermore, patients often only describe their worst attack, so ask questions to determine the true frequency and duration of attacks such as:

  • When you have an attack and don’t take medication how long does it last?
  • How many headache days do you have a month (in addition to migraine days)?
  • How many days per month are you completely headache free?

Professor Halker Singh presented a case history of a patient who described 3–4 headache episodes per month and otherwise fulfilled the ICDH-3 criteria for migraine.

On further questioning, it became clear that the patient had been completely headache free for only 6 days a month over the past 6 months.

This high frequency of headache days, in addition to an 8-year history of recurrent headaches, led to an accurate diagnosis of chronic migraine—i.e. headache occurring on 15 or more days/month for more than 3 months, which on at least 8 days/month has the features of migraine headache.2


Discuss migraine-related disability when considering preventive treatment

Ask detailed questions to determine the true extent of migraine-related disability

Migraine is the leading cause of years lived with disability in people under 50 years of age worldwide,3 said Professor Halker Singh, so it is important to determine the extent of migraine-related disability for all patients with migraine.

Furthermore, many patients with migraine are not symptom free between migraine attacks, and the interictal burden, which can be quite disabling, includes:

  • Anxiety—10% of patients
  • Avoidance of social and work commitments—14% of patients
  • Not symptom free—26% of patients4

Shared decision-making facilitates appropriate personalized preventive therapy decisions

So, the total migraine burden for any one patient is the sum of their ictal and interictal burden, added Professor Halker Singh.

For patients with migraine-related disability, which may affect their ability to work, a shared decision-making approach will facilitate appropriate personalized preventive therapy decisions, said Professor Ailani. She highlighted the five steps of the SHARE approach as follows:5

  1. Seek the patient’s participation
  2. Help the patient explore and compare treatment options
  3. Assess the patient’s values and preferences
  4. Reach a decision with the patient
  5. Evaluate the patient’s decision

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

  1. Lipton RB, et al. Headache 2013;53:81–92.
  2. Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38:1–211.
  3. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Lancet 2017;390:1211–59.
  4. Lampl C, et al. J Headache Pain 2016;17:9.
  5. Agency for Healthcare Research and Quality. Available at: Accessed 19 April 2021.
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