Migraine Headache Workup

  • Author: Jasvinder Chawla, MBBS, MD, MBA; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: May 25, 2011
 

Approach Considerations

Migraine is a clinical diagnosis. Diagnostic investigations are performed for the following reasons:

  • Exclude structural, metabolic, and other causes of headache that can mimic or coexist with migraine
  • Rule out comorbid diseases that could complicate headache and its treatment
  • Establish a baseline for treatment and exclude contraindications to drug administration
  • Measure drug levels to determine compliance, absorption, or medication overdose
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Laboratory Studies

The choice of laboratory and/or imaging studies is determined by the individual presentation. For example, in an older person with compatible findings (eg, scalp tenderness), measurement of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may be appropriate to rule out temporal/giant cell arteritis.

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Neuroimaging

Neuroimaging is not necessary in patients with a history of recurrent migraine headaches and a normal neurologic examination. Neuroimaging is indicated for any of the following[53] :

  • Onset of migraine after age 50 years
  • Change in the pattern of previous migraine
  • First or worst severe headache
  • New onset of headache in a patient with cancer or HIV infection
  • Headache with an abnormal neurologic examination
  • Headache with fever
  • Migraine and epilepsy
  • New daily persistent headache
  • Escalation of headache frequency/intensity in the absence of medication overuse headache
  • Posteriorly located headaches in children

CT scan of the head is indicated to rule out intracranial mass or hemorrhage in selected or atypical cases. A negative CT scan may miss some small subarachnoid hemorrhages, tumors, and strokes, particularly those in the posterior fossa. A CT scan without intravenous contrast also may miss some aneurysms. MRI and magnetic resonance angiography are more sensitive for detection of aneurysm or arteriovenous malformation.

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Visual Field Testing

Visual field testing should be performed in patients with persistent visual phenomena.

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Lumbar Puncture

Indications for LP include the following:

  • First or worst headache of a patient's life
  • Severe, rapid-onset, recurrent headache
  • Progressive headache
  • Atypical chronic intractable headache

Neuroimaging (CT scan or MRI) should precede LP to rule out a mass lesion and/or increased intracranial pressure.

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Contributor Information and Disclosures
Author

Jasvinder Chawla, MBBS, MD, MBA  Chief of Neurology, Hines Veterans Affairs Hospital; Associate Professor and Director, Neurology Residency Training Program, Loyola University Medical Center

Jasvinder Chawla, MBBS, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Blanda, MD  Chair, Department of Emergency Medicine, Summa Health System Akron City/St. Thomas Hospital; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

Michelle Blanda, MD, is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ronald Braswell, MD  Associate Professor, Department of Ophthalmology, University of Alabama-Birmingham

Ronald Braswell, MD is a member of the following medical societies: American Academy of Ophthalmology and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Joseph Carcione Jr, DO, MBA  Consultant in Neurology and Medical Acupuncture, Medical Management and Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans

Joseph Carcione Jr, DO, MBA is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Jane W Chan, MD  Professor of Neurology/Neuro-ophthalmology, Department of Medicine, Division of Neurology, University of Nevada School of Medicine

Jane W Chan, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Medical Association, North American Neuro-Ophthalmology Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Eric R Eggenberger, DO, MS, FAAN  Professor, Vice-Chairman, Department of Neurology and Ophthalmology, Colleges of Osteopathic Medicine and Human Medicine, Michigan State University; Director of Michigan State University Ocular Motility Laboratory; Director of National Multiple Sclerosis Society Clinic, Michigan State University

Eric R Eggenberger, DO, MS, FAAN is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Osteopathic Association, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Jacqueline Freudenthal, MD  Co-Investigator, Ophthalmic Consultants Centre, Toronto

Jacqueline Freudenthal, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, and Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

Deborah I Friedman, MD, MPH  Professor of Ophthalmology and Neurology, University of Rochester School of Medicine and Dentistry; Consulting Staff, Strong Memorial Hospital

Deborah I Friedman, MD, MPH is a member of the following medical societies: American Academy of Neurology, American Academy of Ophthalmology, American Headache Society, American Neurological Association, Association for Research in Vision and Ophthalmology, North American Neuro-Ophthalmology Society, Society for Neuroscience, and United Council of Neurologic Subspecialties, Certification in Headache Medicine

Disclosure: MAP Pharmaceuticals Grant/research funds Site PI (through university); AGA Medical Grant/research funds Site PI (through university); Teva Grant/research funds Site PI (through university); Pfizer Grant/research funds Site PI; Neurology Reviews Honoraria Editorial board; Merck Grant/research funds Site PI

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Edsel Ing, MD, FRCSC  Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Toronto East General Hospital, Canada

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

David Y Ko, MD  Associate Professor of Clinical Neurology, Associate Director, USC Adult Epilepsy Program, Keck School of Medicine of the University of Southern California

David Y Ko, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and American Headache Society

Disclosure: GSK Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching; Lundbeck Consulting fee Consulting; Westward Consulting fee Consulting

Edward A Michelson, MD  Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Soma Sahai-Srivastava, MD  Director of Neurology Ambulatory Care Services, LAC and USC Medical Center; Assistant Professor, Department of Neurology, Keck School of Medicine of the University of Southern California

Soma Sahai-Srivastava, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, and American Medical Association

Disclosure: Nothing to disclose.

Jeff T Wright, MD  Instructor, Department of Emergency Medicine, Summa Health System; Corporation President and Consulting Staff, Summa Emergency Associates, Inc

Jeff T Wright, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Brian R Younge, MD  Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Robert A Egan, MD  Director of Neuro-Ophthalmology, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, and Oregon Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD  Professor, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, Oregon Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association

Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

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Migraine headache. Example of a visual migraine aura as described by a person who experiences migraines. This patient reported that these visual auras preceded her headache by 20-30 minutes.
Migraine headache. Example of a central scotoma as described by a person who experiences migraines. Note the visual loss in the center of vision.
Migraine headache. Example of a central scotoma as described by a person who experiences migraine headaches. Again note the visual loss in the center of vision.
Migraine headache. Example of visual changes during migraine. Multiple spotty scotomata are described by a person who experiences migraines.
Migraine headache. Frank visual field loss can also occur associated with migraine. This example shows loss of the entire right visual field as described by a person who experiences migraines.
International Headache Society criteria for migraine.
Overview of migraine treatment. Five steps.
International Headache Society (IHS) classification of secondary headaches.
Table 1. Abortive Medication Stratification by Headache Severity
Moderate Severe Extremely Severe
NSAIDsNaratriptanDHE (IV)
IsomethepteneRizatriptanOpioids
ErgotamineSumatriptan (SC,NS)Dopamine antagonists
NaratriptanZolmitriptan
RizatriptanAlmotriptan
SumatriptanFrovatriptan
ZolmitriptanEletriptan
AlmotriptanDHE (NS/IM)
FrovatriptanErgotamine
EletriptanDopamine antagonists
Dopamine antagonists
Table 2. Preventive Drugs
First lineHigh efficacyBeta-blockers



Tricyclic antidepressants



Divalproex



Topiramate



Low efficacyVerapamil



NSAIDs



SSRIs



Second lineHigh efficacyMethysergide



Flunarizine



MAOIs



Unproven efficacyCyproheptadine



Gabapentin



Lamotrigine



Table 3. Preventive Medication for Comorbid Conditions
Comorbid Condition Medication
HypertensionBeta-blockers
AnginaBeta-blockers
StressBeta-blockers
DepressionTricyclic antidepressants, SSRIs
UnderweightTricyclic antidepressants
EpilepsyValproic acid, Topiramate
ManiaValproic acid
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