Migraine diagnosis in primary care: How?

Optimal management of migraine requires prompt diagnosis in the primary care setting. This article highlights recommendations on migraine diagnosis endorsed by the European Headache Federation (EHF) and European Academy of Neurology (EAN), which are applicable to settings including primary care.

Migraine underdiagnosed
Although prevalent with debilitating effects, migraine remains underdiagnosed and suboptimally managed. [Neurol Ther 2024;13:257-281] In China, for example, a population-based survey (n=5,041) revealed that 52.7 percent of patients with migraine were previously undiagnosed. [J Headache Pain 2013;14:47] More recently, a survey across 11 specialized headache clinics in South Korea showed that migraine was diagnosed at an average of 10.1 years after symptom onset. [J Headache Pain 2021;22:45]

Consequences of underdiagnosis
If improperly managed or left untreated, episodic migraine may transform into difficult-to-treat chronic migraine. Transformation of episodic migraine into chronic migraine is reported to occur at annual rates of about 3 percent in population-based studies and up to 14 percent in a clinic-based study. [J Neurol 2023;270:5692-5710]

Furthermore, migraine with aura is associated with an increased risk of stroke and patent foramen ovale, while neuroimaging studies have revealed a higher prevalence of asymptomatic structural brain lesions in individuals with migraine. [J Neurol Neurosurg Psychiatry 2020;91:593-604; Front Neurol 2020;10.3389/fneur.2020.543485]

EHF/EAN-endorsed approach to migraine diagnosis
The EHF/EAN-endorsed 10-step approach to migraine diagnosis and management suggests that approximately 90 percent of patients who seek professional care for migraine should be managed in primary care. Referral to specialist care should be reserved for patients whose condition is diagnostically challenging, difficult to treat, or complicated by comorbidities. [Nat Rev Neurol 2021;17:501-514]

When to suspect migraine? How to diagnose?
The 10-step approach, developed to promote best clinical practices, recommends that migraine should be suspected in patients with:

• Recurrent headache of moderate to severe intensity
• Visual aura
• Family history of migraine
• Symptom onset at or around puberty

Diagnosis of migraine should be based on medical history and criteria set out in the 3rd edition of the International Classification of Headache Disorders (ICHD-3).

MS-Q aids diagnosis in primary care
The 5-item, self-administered Migraine Screen Questionnaire (MS-Q), validated in the primary care setting, is recommended in the EHF/EAN-endorsed 10-step approach as a screening tool to facilitate migraine diagnosis. [BMC Neurol 2010;10:39; Nat Rev Neurol 2021;17:501-514] A score of ≥4 points indicates possible migraine:

1. Do you have frequent or intense headaches?                                       Yes (1) / No (0)
2. Do your headaches usually last more than 4 hours?                             Yes (1) / No (0)
3. Do you usually suffer from nausea when you have a headache?            Yes (1) / No (0)
4. Does light or noise bother you when you have a headache?                  Yes (1) / No (0)
5. Does headache limit any of your physical or intellectual activities?         Yes (1) / No (0)

In a cross-sectional, observational multicentre study involving 9,670 adult patients (mean age, 48.9 years; female, 61.9 percent) who attended >370 primary care centres for any reason, the MS-Q was confirmed to be useful for early detection and assessment of migraine, with a Kappa coefficient of 0.82 for concordance with International Headache Society (IHS) criteria, sensitivity of 82 percent, specificity of 97 percent, and positive and negative predictive values of 95 percent and 94 percent, respectively. No significant differences in identification of de novo (5.7 percent vs 6.1 percent) and hidden (26.6 percent vs 24.1 percent) migraine were found with MS-Q vs IHS criteria. [BMC Neurol 2010;10:39]