Making the Diagnosis: Migraine in Clinical Practice

In patients suspected of having migraine, it is important to ask pointed questions to determine if

the patient’s symptoms are consistent with the second edition of the International Classification of
Headache Disorders (ICHD-2) diagnostic criteria for migraine headache.

ICHD-2 Diagnostic Criteria for Episodic Migraine

Patient experienced five or more headaches At least two of the following U-MAP characteristics
are present:
• Unilateral location
• Moderate or severe pain
• Aggravated by, or causing avoidance of, routine
physical activity
• Pulsating quality

Each headache attack lasts 4–72 hours At least one of the following:
• Nausea and/or vomiting
• Photophobia and phonophobia

Symptoms not attributed to another medical disorder

The occurrence of frequent severe headaches could be an indication that a patient has a specific
headache disorder, or it could be a sign of a more serious medical condition. Certain red-flag
features of headache can suggest that a more serious medical condition is causing the headache.
The mnemonic SNOOP can help the clinician identify potentially serious secondary causes of
headache.

Systemic symptoms (fever, weight loss) and secondary risk factors such as human
S immunodeficiency virus (HIV) and cancer

Neurologic symptoms or abnormal signs, such as confusion, impaired alertness, or

N impaired consciousness

Onset: Sudden, abrupt, or split second, which could indicate a vascular abnormality
O of increased intracranial pressure

Older: New-onset and progressive headaches that occur in patients older than 50
O could indicate a secondary condition such as giant cell arteritis

Previous headache history or headache progression: Is this the patient’s first severe
P headache, or is there a change in the attack frequency, severity, or clinical features?