EHF/EAN & AHS recommendations on migraine diagnosis & management

Migraine is a prevalent and disabling primary headache disorder that remains underdiagnosed and undertreated. This article highlights key recommendations in a 10-step approach to migraine diagnosis and treatment endorsed by the European Headache Federation (EHF) and European Academy of Neurology (EAN), as well as a 2024 position statement update of the American Headache Society (AHS) on migraine preventive treatment.

How to diagnose migraine?
The EAN/EHF-endorsed approach suggests that migraine diagnosis should be based on medical history and diagnostic criteria set out in the 3rd edition of the International Classification of Headache Disorders (ICHD-3). The validated 5-item, self-administered Migraine Screen Questionnaire (MS-Q) can be used as a screening tool to facilitate migraine diagnosis in primary care. [Nat Rev Neurol 2021;17:501-514; Cephalalgia 2018;38:1-211; BMC Neurol 2010;10:39] 

Migraine without aura
According to the ICHD-3 criteria, a diagnosis of migraine without aura can be made in patients with ≥5 attacks with the features below:

• Headaches lasting 4–72 hours (when untreated or unsuccessfully treated)
• Headaches with ≥2 of the following features:

        -  Unilateral location

        -  Pulsating pain

        -  Moderate or severe pain intensity

        -  Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

• Headaches with ≥1 of the following features:

        -  Nausea and/or vomiting

        -  Photophobia and phonophobia

• Not better accounted for by another ICHD-3 diagnosis [Cephalalgia 2018;38:1-211]
  
  

Migraine with aura
ICHD-3 diagnostic criteria for migraine with aura are the presence of ≥2 attacks with the features below:

• ≥1 of the following fully reversible aura symptoms:

         - Visual

         - Sensory

         - Speech and/or language

         - Motor

         - Brainstem

         - Retinal

• ≥3 of the following characteristics:

        -  ≥1 aura symptom spreads gradually over ≥5 minutes

        -  ≥2 aura symptoms occur in succession

        -  Each aura symptom lasts 5–60 minutes

        -  ≥1 aura symptom is unilateral (aphasia is always regarded as a unilateral symptom; dysarthria may or may not be)

        -  ≥1 aura symptom is positive (scintillations and pins and needles are positive symptoms of aura)

        -  Aura symptom accompanied or followed within 60 minutes by headache

• Not better accounted for by another ICHD-3 diagnosis [Cephalalgia 2018;38:1-211]

Chronic migraine
Chronic migraine, according to ICHD-3 diagnostic criteria, can be diagnosed in patients with ≥15 headache days per month for >3 months, with ≥5 attacks fulfilling any of the following for ≥8 days per month for >3 months:

• Criteria for migraine without aura
• Criteria for migraine with aura
• Believed by the patient to be migraine at onset and relieved by a triptan or an ergot derivative
• Not better accounted for by another ICHD-3 diagnosis [Cephalalgia 2018;38:1-211]

What are the treatment options?
Gepants are recommended in the EAN/EHF-endorsed 10-step approach as one of the options for acute treatment of migraine, while calcitonin gene–related peptide (CGRP)–targeting therapies are recommended as one of the options for preventive treatment. [Nat Rev Neurol 2021;17:501-514]

How to evaluate treatment response and AEs, and manage complications?
Use of headache calendars is recommended in the EAN/EHF-endorsed approach for evaluation of treatment response and adverse events (AEs). [Nat Rev Neurol 2021;17:501-514]

“Approximately 90 percent of patients who seek professional care for migraine should be managed in primary care,” the authors pointed out. “Referral to specialist care should be reserved for patients whose condition is diagnostically challenging, difficult to treat, or complicated by comorbidities. Specialist referral is indicated for patients with chronic migraine.”

How to plan long-term follow-up?
The EAN/EHF-endorsed approach suggests long-term management of migraine in primary care. Primary care physicians are advised to maintain the stability of effective treatment and react appropriately to any change that may call for review. [Nat Rev Neurol 2021;17:501-514]

AHS 2024 position statement update
In a 2024 position statement update, the AHS recommended that CGRP-targeting therapies, including rimegepant, should be considered as first-line options for migraine prevention. “Initiation of these therapies should not require prior trial and failure of other classes of migraine preventive treatment,” the AHS experts noted. [Headache 2024;64:333-341]

“The evidence for the efficacy, tolerability and safety of CGRP-targeting migraine preventive therapies is substantial and vastly exceeds that for any other preventive treatment approach. The evidence remains consistent across different individual CGRP-targeting treatments and is corroborated by extensive ‘real-world’ clinical experience,” they pointed out.