Migraine headache diagnosis is based on the presence of certain symptoms outlined by the International Headache Society (IHS). These diagnostic criteria create a standardized framework for physicians in distinguishing migraine headache from the other most common headache types, including tension and cluster.
A diagnosis of migraine headache may be made when a patient has at least five occurrences of headache that meet the following criteria:
- Headache attacks or episodes that last four to 72 hours (untreated or unsuccessfully treated)
- Headache that has at least two of the following characteristics:
- Unilateral location
- Pulsating or throbbing quality
- Moderate to severe intensity
- Aggravation by walking stairs or similar routine physical activity
- During headache, at least one of the following symptoms:
- Nausea or vomiting (or both)
- Photophobia and phonophobia (unusual sensitivity to light and sound)
- No evidence of another related disease
In order to receive optimum treatment, an accurate diagnosis of the headache or migraine must be made. To ascertain the cause or causes of the headaches, your health care practitioner will first take your headache history.
The most important part of your health care practitioner’s evaluation of your headaches is called the “headache history.” It is important to describe your headache symptoms and characteristics as vividly as possible. Your headaches can be more accurately diagnosed when you tell your doctor:
- Your age when the headaches started
- How long you have been experiencing them
- If you experience one kind of headache pain or multiple kinds
- How frequently and when the headaches occur
- What triggers the headaches, if known (for example, certain situations, foods, or medications)
- Family members with headaches
- Symptoms between headaches
- How your life has been affected by the headaches
It is also important to tell your health care provider about the presence of other symptoms, such as:
- Location of the pain
- The feeling or nature of the pain
- Severity of the headache pain, using a scale from one (mild) to 10 (severe)
- Duration of the headache
- Sudden or gradual onset of the headache
- Headache with or without warning or with accompanying symptoms
- What time of day the headache usually occurs
- Presence of aura (changes in vision, blind spots, or bright lights) before the headache
- Frequency of headaches
You should also tell your doctor if you've been treated in the past for headaches, what medications (both prescribed and over-the-counter) you have taken in the past, and what medications are currently being taken. Don't hesitate to list them, bring the bottles, or ask your pharmacist for a printout.
Studies performed by other doctors who may have evaluated your headaches in the past, including X-rays and other imaging tests are also very important -- you should also bring these to your appointment. This will save time, repetition of tests, and help your doctor arrive at a diagnosis and create a treatment plan more quickly.
Physical and neurological exams to diagnose headaches
After completing the headache history portion of the evaluation, the doctor will perform a complete physical and neurological exam. The doctor will look for signs and symptoms of an illness that may be causing the headaches, such as:
- Fever or abnormalities in breathing, pulse, or blood pressure
- Nausea, vomiting
- Changes in personality, inappropriate behavior
- Mental confusion *Seizures
- Loss of consciousness
- Excessive fatigue, wanting to sleep all of the time
- High blood pressure
- Muscle weakness, numbness, or tingling
- Speech difficulties
- Balance problems and falling
- Vision changes (blurry vision, double vision, blind spots)
The focus of neurological tests is to rule out diseases of the brain or nerves that may cause headaches and migraines, including epilepsy or multiple sclerosis. Some tests may also look for physical or structural abnormalities in the brain that may cause headache, such as:
- Abscess, or brain infection
- Hemorrhage, or bleeding within the brain
- Bacterial or viral meningitis
- Increased intracranial pressure
- Hydrocephalus, or abnormal build-up of fluid in the brain
- Infection of the brain such as Lyme disease
- Encephalitis, or inflammation and swelling of the brain
- Blood clots
- Head trauma
- Sinus blockage or disease
- Blood vessel abnormalities
- Aneurysm, or a "bubble" in the wall of a blood vessel that can leak or rupture
Psychological Evaluation for Diagnosing Headaches
While a consultation with a psychologist is not a routine part of headache evaluation, it may be done to identify what, if any stress factors may be triggering your headaches. You’ll be asked to complete a computerized questionnaire to provide more in-depth information to your health care provider.
Your health care provider should be able to determine the type of headaches you are having after evaluating the results of the headache history and physical, neurological, and psychological exams. In the event that you have a serious problem, additional tests will be ordered. Possible additional tests can include diagnostic tests.
Additional tests may be necessary in order investigate other medical conditions that may be the cause of your headaches or migraines. These tests are listed below. Bear in mind that these tests are not helpful in diagnosing migraine, cluster, or tension headaches; they simply rule out other, potentially dangerous or life-threatening conditions that also present with headaches as a symptom.
Blood Chemistry and Urinalysis - These tests are used to determine many medical conditions, including diabetes, thyroid problems, and infections, which can cause headaches. They can also give your physician an inside look at your overall health.
CT Scan - This is a test in which X-rays and computers are used to produce an image of a cross-section of the body. A CT scan of the head may be recommended if you headaches occur daily.
MRI - This test produces very clear pictures, or images, of the brain and other soft-tissues without the use of X-rays. An MRI may be recommended if you have daily or almost daily headaches and/or when the CT scan does not show definitive results. MRI uses a large magnet, radio waves, and a computer to produce these images. In addition, a MRI scan is used to evaluate certain parts of the brain that are not as easily viewed with CT scans, such as the spine at the level of the neck and the back portion of the brain.
Sinus X-Ray - Although the CT scan and MRI provide detailed findings, your physician may order this test when your symptoms may indicate sinus problems.
EEG -Electroencephalogram is not a standard part of a headache evaluation, but may be performed if seizures occur with the headaches.
Eye Exam - An eye pressure test performed by an eye doctor (ophthalmologist) will rule out glaucoma or pressure on the optic nerve as a cause of headaches.
Spinal Tap -A spinal tap is the removal of spinal fluid from the spinal canal (located in the back). This procedure is performed to look for conditions such as infections of the brain or spinal cord. The test can itself cause a temporary headache.
Mayo Foundation for Medical Education and Research. 2001-2010. (Online) www.mayoclinic.com/health/migraine-headache accessed 02.24.2010
Jon Glass, MD. 2009. Diagnosing Migraines. (Online) http://www.webmd.com/migraines-headaches/guide/making-diagnosis-doctors-exam?page=2 accessed 02.24.2010
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