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.

Treatment & Management

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Media Gallery

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 without aura.
Overview of migraine treatment. Five steps.
International Headache Society (IHS) classification of secondary headaches.

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Table 1. Abortive Medication Stratification by Headache Severity

Moderate	Severe	Extremely Severe
NSAIDs	Naratriptan	DHE (IV)
Isometheptene	Rizatriptan	Opioids
Ergotamine	Sumatriptan (SC,NS)	Dopamine antagonists
Naratriptan	Zolmitriptan	Lasmiditan
Rizatriptan	Almotriptan
Sumatriptan	Frovatriptan
Zolmitriptan	Eletriptan
Almotriptan	DHE (NS/IM)
Frovatriptan	Ergotamine
Eletriptan	Dopamine antagonists
Zavegepant intranasal	Zavegepant intranasal
Dopamine antagonists	Lasmiditan
DHE=Dihydroergotamine; NSAIDs=nonsteroidal anti-inflammatory drugs

Table 2. Preventive Drugs for Migraine

First line	High efficacy	Beta blockers Tricyclic antidepressants Divalproex Topiramate
First line	Low efficacy	Verapamil
Second line	High efficacy	Methysergide Flunarizine MAOIs CGRP inhibitors Botulinum toxin
Second line	Unproven efficacy	Cyproheptadine Gabapentin
MAOIs = monoamine oxidase inhibitors

Table 3. Preventive Medication for Comorbid Conditions

Comorbid Condition	Medication
Hypertension	Beta blockers
Angina	Beta blockers
Stress	Beta blockers
Depression	Tricyclic antidepressants, SSRIs
Overweight	Topiramate, protriptyline
Underweight	Tricyclic antidepressants (nortriptyline, protriptyline)
Epilepsy	Valproic acid, topiramate
Mania	Valproic acid
SSRIs = selective serotonin reuptake inhibitors

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Author

Jasvinder Chawla, MD, MBA Chief of Neurology, Hines Veterans Affairs Hospital; Professor of Neurology, Loyola University Medical Center

Jasvinder Chawla, 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, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

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

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

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Acknowledgements

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