Health professionals

Diagnosing Migraine

Migraine is a complex condition whose manifestations have haunted humans for more than 4,000 years. Migraine, in the clinical sense, is a syndrome, a collection of symptoms, which is at once its fascination and for some its aggravation. Headache, in general, and migraine not less as an example, are not quick fix conditions. It is not a part of neurology that can, or should, be dealt with in a few minutes and then forgotten.

Attempts to do so will often result in an unsatisfying experience for both doctor and patient. Migraine is rather more like hypertension, persistent and in need of attention over a period of time, but, it must be said, infinitely more interesting. Migraine is not a static condition so there will be periods when patients need relatively little attention and periods when they will need closer monitoring and advice. Time spent collecting a clear history will be well paid in therapeutic success.

Migraine diagnosis

The diagnosis of migraine is made by identifying a recurrent headache with certain features, no significant neurological signs on physical examination nor abnormal findings on investigation. The International Headache Society has codified the diagnosis and this system provides useful pointers that can be simplified (Table 1) and should be used with flexibility in clinical practice.

Migraine is an episodic headache with certain associated features, such as sensitivity to light, sound or movement, and often with nausea or vomiting. None of the features is compulsory, and indeed given that the migraine aura, visual disturbances with flashing lights or zigzag lines moving across the field, or other neurological symptoms, is reported in only about 15% of patients, a high index of suspicion is required.

 At its most simple level migraine is headache with associated features and tension-type headache is headache which is featureless. Having eliminated a secondary headache, such as brain tumour, meningitis or giant cell arteritis, from consideration, the clinical picture of migraine should be sought.

Table 1. Simplified diagnostic criteria for migraine in adults Repeated attacks of headache lasting 4-72 hours which have these features:

at least 2 of:	at least 1 of:
unilateral pain throbbing pain aggravation by movement moderate or severe intensity	nausea/vomiting photophobia and phonophobia

If headache with associated features describes migraine attacks, then "headachy" describes the migraine sufferer over their lifetime. The migraine sufferer inherits a tendency to have headache that is amplified at various times by their interaction with their environment, the much-discussed triggers. Migraine sufferers may have headache when they sleep in, when they wake up early, when they skip meals, when they have stress or when they relax. The brain of the migraineur seems more sensitive to sensory stimuli or change and this tendency is even more notably amplified in females during their menstrual cycle.

It is within this broad context that migraine can be successfully managed. It has been said that migraine can never occur daily, a statement based purely on opinion and without any supportive data. This author takes the view that there is a very distinctive syndrome of Chronic Migraine, which is part of the group of headaches known as Chronic Daily Headache, which is simply the most severe end of a complex biology, is frequently complicated by medication overuse and often requires referral. Only development of disease markers will settle this issue clearly.

Reproduced from The National Association of Fundholding Practices (Official Yearbook & Annual Review 1998) and with kind permission of Professor Peter J. Goadsby and Scorpio Publishing.
Migraine Diagnosis and Treatment Overview Peter J. Goadsby BMedSc MB BS MD PhD DSc FRACP FRCP (Professor of Neurology, Department of Neurology, University of California, San Francisco.)