Migraine Headache Initial Assessment

Last updated: 28 July 2025

Content on this page:

Content on this page:

Clinical Presentation

Signs and Symptoms  

The phases of migraine attack are:

  • Prodrome that appears 24-48 hours before headache occurs (eg mood changes, food cravings, fatigue, yawning, etc)
  • Aura that occurs in 25% of individuals with migraine which is most often visual but can be sensory, verbal or motor disturbances
  • Headache that is usually unilateral with throbbing or pulsatile quality and accompanying nausea, vomiting, photophobia or phonophobia
  • Postdrome (eg confusion, decreased appetite, sore or stiff muscles, tiredness)



Migraine Headache_Initial Assesment 1Migraine Headache_Initial Assesment 1




The premonitory and resolution symptoms include hyperactivity, hypoactivity, depression, cravings for particular foods, repetitive yawning, fatigue, and neck stiffness and/or pain.  

The signs and symptoms suggestive of secondary headache are symptoms suggesting systemic illness (eg fever), any other neurological signs or symptoms (focal or non-focal), the most severe headache ever experienced by the patient, persistent or progressive worsening of headache, change in usual headache pattern, awakening of patient from sleep, new onset in patient >50 years of age, Valsalva maneuver (eg sneezing, coughing, bending forward or lying down or exertion) precipitates headache, seizures, and maximum severity at onset of headache. 

History

A detailed history consists of headache characteristics (nature of pain, severity, location, frequency, duration), presence of an aura, prodrome and/or postdrome, and functional impairment, which is an assessment of the impact on the patient’s life and lifestyle. Assessment of functional impairment is necessary for planning the best management and may be done using the Migraine Disability Assessment (MIDAS) instrument or Headache-attributed Lost Timec (HALT) indices, which estimate the total productive time lost due to the disabling effect of headache. Accompanying symptoms, past medical history, family history of migraines, social history, and medical history should also be included.



Migraine Headache_Initial Assesment 2Migraine Headache_Initial Assesment 2

Physical Examination

A thorough physical and neurological examination should be done in the evaluation of migraine headache.

Diagnosis or Diagnostic Criteria

Based on the Headache Classification Committee of the International Headache Society (IHS), the international classification of headache disorders are as follows:  

Migraine Headache without Aura1

  • At least five attacks with any two of the following headache characteristics and these should last from 4-72 hours without treatment or had unsuccessful treatments:
    • Unilateral
    • Throbbing or pulsating in nature
    • Pain is considered moderate to severe
    • Usual physical activity (eg walking or climbing stairs) aggravates pain
  • Plus, any one of the following symptoms:
    • Nausea and/or vomiting (N/V)
    • Photophobia and phonophobia
  • Headache is not better accounted for by another International Classification of Headache Disorders (ICHD)-3 diagnosis

Migraine Headache with Aura1

  • Headache with accompanying or preceding transient focal neurological symptoms
  • At least two attacks with ≥1 of the following fully reversible aura symptoms:
    • Visual symptoms including positive features (flickering lights, spots or lines) and/or negative features (loss of vision)
    • Sensory symptoms including positive features (pins and needles) and/or negative features (numbness)
    • Speech and/or language (eg dysphasic speech disturbance)
    • Motor
    • Brainstem
    • Retinal
  • At least three of the following characteristics:
    • At least one aura symptom develops gradually over ≥5 minutes
    • ≥2 aura symptoms that occur in succession
    • Every aura symptom lasts 5-60 minutes (if three symptoms occur during an aura, 3 x 60 minutes is the acceptable maximum duration; motor symptoms can last up to 72 hours)
    • ≥1 unilateral aura symptom (eg aphasia)
    • ≥1 positive aura symptom (eg scintillations and pins and needles)
    • Headache occurs with the aura or 60 minutes after the aura
  • Headache is not better accounted for by another ICHD-3 diagnosis

Chronic Migraine1

  • Headache (tension-type-like or migraine-like) occurring for ≥15 days per month for >3 months with the following characteristics:
    • Attacks last for 4-72 hours (without treatment or had unsuccessful treatment)
    • ≥2 of the following features are present: Unilateral location, pulsating quality, pain is moderate or severe in intensity, aggravated by or resulting to avoidance of routine physical activity (eg walking or climbing stairs)
  • ≥5 attacks fulfilling the following criteria:
    • Presence of headache with ≥2 of the four characteristics mentioned in the above diagnostic criteria for migraine headache without aura plus during headache there is a presence of one of the symptoms mentioned in the above criteria for migraine headache without aura
    • Presence of ≥1 fully reversible aura symptoms enumerated in the above diagnostic criteria for migraine headache with aura plus ≥3 of the characteristics mentioned in the above criteria for migraine headache with aura
  • On ≥8 days/month for >3 months, the patient has any of the following characteristics:
    • Presence of headache with ≥2 of the characteristics mentioned in the above diagnostic criteria for migraine headache without aura plus having one of the following during headache: Nausea and/or vomiting or photophobia and phonophobia
    • Presence of ≥1 fully reversible aura symptoms enumerated in the above diagnostic criteria for migraine headache with aura plus ≥3 of the characteristics mentioned in the above criteria for migraine headache with aura
    • Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
  • Headache is not better accounted for by another ICHD-3 diagnosis

Episodic Migraine

  • Occurs <15 days per month, further categorized as low and high frequency
    • Low frequency: 1-9 days per month
    • High frequency: 10-14 days per month

1Reference: Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38(1):18-24.