Migraine Headache Workup

Updated: Apr 18, 2023
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Helmi L Lutsep, MD  more...
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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

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

The development of an objective, quantitative biologic measurement of headache-pain severity could help to improve the diagnosis of migraine and enable more accurate assessments of treatment efficacy. In a study by Nguyen et al, as previously mentioned, quantitative sensory testing found significant differences in the perception of vibrotactile stimulation in patients with migraine compared with controls, including stimulus amplitude discrimination, temporal order judgment, and duration discrimination. [55]

A 2013 study suggested that high peripheral blood levels of calcitonin gene-related peptide (CGRP), a neurotransmitter that causes vasodilation, can aid in the diagnosis of chronic migraine by serving as a biomarker for permanent trigeminovascular activation. The migraine patients in the study had a CGRP level of 74.90 pg/mL, significantly higher than those in the other participants. Blood samples in the study were obtained between, rather than during, migraine attacks. Additionally, patients with chronic migraine with a history of aura had significantly higher CGRP levels than chronic migraine sufferers who had never experienced an aura. [75, 76, 77]

Tests for migraine and headache

The American Headache Society released a list of 5 commonly performed tests or procedures that are not always necessary in the treatment of migraine and headache, as part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign. The recommendations include: [2, 3]

  • Don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine.

  • Don't perform computed tomography (CT) imaging for headache when magnetic resonance imaging (MRI) is available, except in emergency settings.

  • Don't recommend surgical deactivation of migraine trigger points outside of a clinical trial.

  • Don't prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.

  • Don't recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache.

Insurance status and migraine care

A study by Wilper et al found that insurance status affects migraine care in the United States. After controlling for age, gender, race, and geographic location, the investigators found evidence that patients with migraines with no insurance or with Medicaid are less likely than privately insured patients to receive either abortive or prophylactic migraine therapy.

This difference, according to the report, is at least partially due to the fact that persons who are uninsured or on Medicaid receive more medical care in emergency departments and less treatment in physicians’ offices than do persons with private insurance, resulting in a greater frequency of substandard migraine care. [78]


Indications for 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: [79]

  • First or worst severe headache

  • Change in the pattern of previous migraine

  • Abnormal neurologic examination

  • Onset of migraine after age 50 years

  • New onset of headache in an immunocompromised patient (eg, one with cancer or HIV infection)

  • 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 (especially in children, but also in adults)

CT scanning 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 MRA are more sensitive for the detection of aneurysm or arteriovenous malformation.


Lumbar Puncture Indications

Indications for LP include the following:

  • First or worst headache of a patient's life

  • Severe, rapid-onset, recurrent headache

  • Progressive headache

  • Unresponsive, chronic, intractable headache

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