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logoFocus on the person A guide to supporting people with migraine
What a headache! Unpicking headache classification, recognising red flag symptoms and identifying indicators for referral

Migraine affects over 1 billion people worldwide and is the leading cause of disability in people aged 15-49 years.1,2 Within the UK, 10 million people or more regularly experience migraine attacks, and over 1 million have chronic migraine, classified as at least eight occurrences of migraine per month.3

In the UK, migraine is:3

the most common neurological reason for consulting a GP

(4.4% of all primary care consultations each year)

the most common neurological reason for A&E attendance

(which increased 14% from 2016 to 2021)

Migraine is frequently under-diagnosed. Furthermore, referrals to neurology services may be unnecessary, or overlooked when needed, and patients may be inappropriately or insufficiently treated, which can result in A&E attendance.3

Migraine diagnosis algorithm
STEP 1. EXCLUDING SECONDARY HEADACHE

A secondary headache may be diagnosed when a de novo headache is experienced, or a pre-existing primary headache becomes chronic or substantially more frequent or severe, in close temporal relation with another disorder recognised as being able to cause that headache. Secondary headaches can arise from:4

  • a trauma or injury to head or neck
  • a cranial or cervical vascular disorder
  • a non-vascular intracranial disorder
  • substance or substance withdrawal
  • an infection
  • a disorder of homeostasis
  • a disorder of cranium, neck, facial or cervical structure
  • a psychiatric disorder
RED FLAGS for secondary headaches5

Observation of any one of the following red flags would warrant further investigation and/or referral (taken from a published algorithm-based approach to the diagnosis of chronic daily headache).6 Please note this list is not exhaustive.

Review which condition to consider for each red flag symptom

Sudden onset of severe headacheConditions to consider
  • Subarachnoid haemorrhage
  • Bleed into a mass or AVM
  • Mass lesion
Worsening pattern of pre-existing headacheConditions to consider
  • Mass lesion
  • Subdural haematoma
  • Medication overuse*

*Consider specialist referral and/or inpatient withdrawal of overused medication for people who are using strong opioids, or have relevant comorbidities, or in whom previous repeated attempts at withdrawal of overused medication have been unsuccessful.6

Headache with cancer, HIV or other systemic illnessConditions to consider
  • Meningitis
  • Encephalitis
  • Lyme disease
  • Systemic infection
  • Collagen vascular disease
  • Giant cell arteritis
Focal neurological signs other than typical visual/ sensory auraConditions to consider
  • Mass lesion
  • AVM
  • Collagen vascular disease
PapilloedemaConditions to consider
  • Mass lesion
  • Pseudotumour
  • Encephalitis
  • Meningitis
Triggered by cough, exertion, orgasm or ValsalvaConditions to consider
  • Subarachnoid haemorrhage
  • Mass lesion
New onset of headache during pregnancy or postpartumConditions to consider
  • Cortical vein/ cranial sinus thrombosis
  • Carotid dissection
  • Pituitary apoplexy
AVM: arteriovenous malformation
STEP 2. DIAGNOSING PRIMARY HEADACHE DISORDER

It is important to take a detailed history to aid in the accurate diagnosis of a headache disorder. A headache diary from the patient may help.7

History should include (but not necessarily be limited to):7

  • reasons for consulting now
  • for how long migraines have been occurring
  • frequency and duration of attacks
  • nature of pain
  • associated symptoms, including nausea, photophobia, photophonia
  • impact on daily function
  • triggers/ relieving factors
  • steps taken to manage headache
  • medication used
  • state of health between attacks
DIFFERENTIAL DIAGNOSIS of primary headache4
Scroll left to view table
  MIGRAINE TENSION-TYPE HEADACHE CLUSTER HEADACHE
Frequency required to make a diagnosis ≥5 attacks ≥10 episodes
Frequency: on average <1 day per month		 ≥5 attacks
Frequency: one every other day to eight per day
Duration 4-72 hours 30 mins-7 days 15-180 mins
Headache characteristics Unilateral
Pulsating quality		 Bilateral
Pressing or tightening (non-pulsating) quality		 Unilateral
Orbital, supra-orbital and/or temporal pain
Pain intensity Moderate/ severe Mild/ moderate Severe/ very severe
Associated symptoms
  • Nausea and/or vomiting
  • Photophobia and/or phonophobia
  • Aura* (fully reversible visual, sensory, speech/ language, motor, brainstem, retinal aura symptoms)
 No nausea or vomiting Ipsilateral to headache:
  • conjunctival injection and/or lacrimation
  • nasal congestion and/or rhinorrhoea
  • eyelid oedema
  • forehead and facial sweating
  • miosis and/or ptosis
Association with activity Aggravated by or causing avoidance of physical activity Not aggravated by routine physical activity Restlessness/ agitation

*Although migraine with aura does not always involve headache, many patients who experience migraine without aura also experience migraine with aura (and should be diagnosed with both).4

STEP 3. DEFINING MIGRAINE SUBCATEGORY

Migraine can be categorised according to frequency4

Episodic migraine4

Headache or migraine occurring
on <15 days per month

Chronic migraine4

Headache occurring on ≥15 days/ month, including migraine on ≥8 days, for >3 months

Menstrual and menstrually related migraine4

Some women experience migraine associated with their menstrual cycles, typically without aura. Migraine attacks during menstruation tend to be longer and accompanied by more severe nausea than those at other times in the cycle.

Pure menstrual
migraine4

Migraine occurring exclusively on Day 1 ± 2 of menstruation, in ≥2 out of 3 menstrual cycles, and at no other times of the cycle

Menstrually related migraine4,6

Migraine occurring predominantly on Day 1 ± 2 of menstruation, in ≥2 out of 3 menstrual cycles, but additionally at other times of the cycle

Medication overuse headache (MOH)

Migraine may be concurrent with medication overuse headache.4

MOH4,6

Headache occurring on ≥15 days/ month in a patient with a pre-existing headache disorder.
Regular overuse for >3 months of one or more medications used for acute or symptomatic treatment of headache:

  • triptans, opioids, ergots on combination analgesics on ≥10 days per month
  • paracetamol, aspirin or an NSAID, either alone or in any combination, on ≥15 days per month

NSAID: non-steroidal anti-inflammatory drugs

Referral: management of migraine is possible in primary care for the majority of patients3

Although migraine in general can be managed in the primary care setting,3,8 referral to neurology or specialist community headache services should be considered:

  • when a red flag symptom for secondary headaches is observed6
  • for atypical neurological symptoms6
  • for prolonged aura7
  • for daily migraine7
  • when diagnosis is uncertain7,9
  • when there is insufficient response to treatments8,9
  • for withdrawal of overused medication in people using strong opioids, with relevant comorbidities or with a history of unsuccessful withdrawal attempts6
  • Urgent referral to A&E may also be appropriate, for example to exclude an intracranial bleed.10
COMMON MIGRAINE TRIGGERS AND PRE-DISPOSING TRIGGERS
Non-modifiable risk factors:
  • Genetics (increased risk for immediate family members of people with migraine). This familial link appears stronger for migraine with aura compared with migraine without aura11
  • Gender (approximately three times more common in women)12
  • Age (prevalence highest in the 18-44 year age group)13
Triggers include:
  • Hormonal changes, including premenstrual periods and perimenopause14,15
  • Stress, including 'let-down' after stressful periods15
  • Diet, including alcohol and specific foods15
  • Weather changes, including low pressure15
  • Sensory stimulation15
USE OF HEADACHE DIARIES

Headache diaries can be used to:16

 

  •  
  • assist diagnosis
  • identify triggers and predictors
  • reveal patterns in attacks
  • assess treatment response
  •  

Several mobile health apps for monitoring migraine are also available, for which high satisfaction rates among patients have been reported.17

Diary16

Recommend patients to keep a note of their headaches, eg:

 

  •  
  • when it occurs
  • duration
  • pain severity
  • aggravating and alleviating factors
  • associated symptoms
  • medication used
  • potential triggers
  •  
A diary is available to download from The Migraine Trust here 

Reference

Ashina M, Katsarava Z et al. Migraine: epidemiology and systems of care. Lancet 2021;397(10283):1485-1495 Steiner T J, Stovner L J et al. Migraine is first cause of disability in under 50s: will health politicians now take notice?
J Headache Pain 2018;19(1):17The Migraine Trust. State of the migraine nation. Dismissed for too long, 2021. Available at: migrainetrust.org. Accessed August 2022Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition. Cephalalgia 2018;38(1):1-211Bigal M E, Lipton R B. The differential diagnosis of chronic daily headaches: an algorithm-based approach. J Headache Pain 2007;8(5):263-272National Institute for Health and Care Excellence (NICE). Clinical guideline 150. Headache in over 12s: diagnosis and management, 19 September 2012. Available at: nice.org.uk. Accessed August 2022British Association for the Study of Headache. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type headache, cluster headache, medication-overuse headache, September 2010. Available at: bash.org.uk. Accessed August 2022Sacco S, Braschinsky M et al. European Headache Federation consensus on the definition of resistant and refractory migraine: developed with the endorsement of the European Migraine & Headache Alliance (EMHA). J Headache Pain 2020;21(1):76NHS. Migraine. Diagnosis. Available at: nhs.uk. Accessed August 2022Sahni R, Weinberger J. Management of intracerebral hemorrhage. Vasc Health Risk Manag 2007;3(5):701-709Goadsby P J, Holland P R et al. Pathophysiology of migraine: a disorder of sensory processing. Physiol Rev 2017;97(2):553-622Al-Hassany L, Haas J et al. Giving researchers a headache - sex and gender differences in migraine. Front Neurol 2020;11:549038Peters G L. Migraine overview and summary of current and emerging treatment options. Am J Manag Care 2019;25(2 Suppl):S23-S34MacGregor E A. Migraine, menopause and hormone replacement therapy. Post Reprod Health 2018;24(1):11-18Marmura M J. Triggers, protectors, and predictors in episodic migraine. Curr Pain Headache Rep 2018;22(12):81The Migraine Trust. Keeping a headache diary. Available at: migrainetrust.org. Accessed August 2022Noutsios C D, Boisvert-Plante V et al. Telemedicine applications for the evaluation of patients with non-acute headache: a narrative review. J Pain Res 2021;14:1533-1542
PP-NNT-GBR-0091. November 2022
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