Migraine: Symptoms and Diagnosis
Migraine is a neurological disorder in its own right, not simply a “severe headache”. The diagnosis is usually based on the characteristic history of attacks and the neurological examination. There is no blood test or MRI finding that, by itself, confirms a diagnosis of migraine.
Migraine can also present in different ways: the pain is not always one-sided, it does not always have to be clearly throbbing, and some attacks may occur without nausea or marked sensitivity to light. The diagnosis therefore depends on the overall pattern rather than on one isolated symptom.
Features that suggest migraine
A typical untreated or unsuccessfully treated migraine attack without aura usually lasts from several hours to several days. Migraine is particularly characterised by a combination of several clinical features.
Migraine without aura: the typical clinical pattern
According to the International Classification of Headache Disorders, ICHD-3, the diagnosis of migraine without aura considers the recurrence of attacks, their duration, and the combination of characteristic symptoms.
The headache usually has at least two of the following four features:
- unilateral location;
- pulsating quality;
- moderate or severe intensity;
- aggravation by routine physical activity or avoidance of such activity.
During the attack there is also at least one of the following:
- nausea and/or vomiting;
- sensitivity to both light and sound.
A migraine attack may have several phases
Not every patient experiences every phase, and different attacks in the same person may not always follow exactly the same pattern.
Prodrome
Several hours, and sometimes a day before the headache, some people experience fatigue, yawning, changes in mood, difficulty concentrating, changes in appetite or neck discomfort.
Aura
Reversible visual, sensory or speech/language symptoms that usually develop gradually and last for a limited period of time.
Headache
The pain may be accompanied by nausea, sensitivity to light and sound, and reduced tolerance of ordinary daily activity.
Postdrome
After the pain improves, some patients continue to experience fatigue, weakness, difficulty concentrating or changes in mood.
Aura is more than simply “spots in front of the eyes”
Aura most commonly presents with visual phenomena: shimmering lines, zigzags, bright geometric shapes or a gradually changing area of the visual field.
Sensory symptoms can also occur, such as gradually spreading tingling or numbness, as well as reversible speech or language symptoms.
Typical aura is characterised by gradual development and complete reversibility. An individual aura symptom usually lasts between 5 and 60 minutes.
When medical assessment is especially important
- the aura occurs for the first time;
- a symptom begins suddenly and is immediately maximal;
- persistent weakness develops in an arm or leg;
- the neurological symptoms differ from previous attacks;
- a symptom lasts much longer than usual;
- the first similar episode occurs later in life.
In these situations, new neurological symptoms should not automatically be attributed to migraine.
Episodic and chronic migraine
Episodic migraine
When headache occurs on fewer than 15 days per month, migraine is generally classified as episodic.
Even a few severe migraine attacks each month may significantly affect work, family life and normal daily activities.
Chronic migraine
Chronic migraine is diagnosed when headache occurs on 15 or more days per month for more than three months, with migraine features on at least 8 days per month.
Not every recurrent headache is migraine
| Type | Typical features |
|---|---|
| Migraine | Attacks lasting hours, moderate or severe pain, reduced tolerance of activity, nausea, and sensitivity to light and sound. |
| Tension-type headache | More often bilateral, pressing or tightening pain. Routine physical activity does not usually worsen it, and nausea is less characteristic. |
| Cluster headache | Extremely severe unilateral pain around the eye or temple, relatively short repeated attacks, tearing, nasal symptoms, redness of the eye and marked restlessness. |
| Cranial neuralgia | Very brief, often electric-shock-like or shooting pains that may be triggered by touch, talking or chewing. |
| Secondary headache | A new or clearly changed headache pattern, neurological symptoms, fever, trauma, systemic disease or other features that require investigation for another cause. |
Is MRI needed to diagnose migraine?
In most typical cases, migraine is a clinical diagnosis.
If the history is consistent with migraine, the neurological examination is normal, and there are no concerning features, neuroimaging is not required simply to “confirm migraine”.
Nonspecific white-matter changes on MRI may be seen in people with migraine and do not, by themselves, establish the cause of the headache. Imaging therefore always needs to be interpreted in the context of the clinical picture.
When MRI or another investigation may be needed
- a first or unusually severe attack;
- a clear change in the usual headache pattern;
- progressive increase in frequency or severity;
- unusual or prolonged aura;
- persistent neurological symptoms;
- post-traumatic headache;
- other features suggesting a possible secondary headache.
A new headache deserves separate assessment
Even a person with a long history of migraine can develop a headache of a different cause. The situation should be reassessed if the usual headache pattern changes substantially.
Urgent medical assessment is particularly important for a sudden extremely severe headache, new weakness or numbness, speech disturbance, altered consciousness, seizure, fever with neck stiffness, or severe headache after significant trauma.
What to record in a headache diary
For migraine diagnosis, understanding the pattern over several weeks or months is usually more useful than remembering only one particularly severe attack.
Headache days
Record how many days per month you have headache, not only the number of individual attacks.
Pain characteristics
Where the pain is located, how severe it is, whether it throbs, and whether it interferes with walking, work or normal activities.
Associated symptoms
Nausea, sensitivity to light, sensitivity to sound, aura and other symptoms.
Duration
When the attack started, how long it lasted, and whether the pain disappeared completely between attacks.
Medication
Which medicines were taken, how soon after the pain began, and how well they worked.
Recurring patterns
Sleep, menstrual cycle, missed meals, stress, alcohol and other circumstances, if the association is reproducible.
What needs to be established during the consultation
Is it really migraine?
Determine whether the history is consistent with migraine without aura, migraine with aura or another headache disorder.
How frequent is the headache?
Distinguish episodic from chronic migraine and establish the actual number of headache days.
Could there be another cause?
Assess clinical warning signs and decide whether MRI, CT, vascular imaging or other investigations are needed.
Could medication use be maintaining the headache?
Review the frequency of analgesics, triptans and other medications used to treat attacks.
The next question is how to treat migraine
This page is primarily about diagnosis. Once migraine has been established, treatment depends on attack frequency, severity, response to acute treatment and whether preventive treatment is needed.
Migraine diagnosis with Dr Lidiia Prakhova
Dr Lidiia Prakhova is a specialist neurologist with more than 35 years of clinical experience. Migraine and other headache disorders are among the areas of her outpatient neurological practice.
During the consultation, the pattern and frequency of attacks, neurological examination, previous investigations and the need for additional testing are assessed. An individual treatment strategy can then be developed.
Frequently asked questions about migraine symptoms and diagnosis
Does migraine always affect only one side of the head?
Can migraine occur without aura?
Can migraine be diagnosed by MRI?
Does migraine always cause nausea?
When is migraine considered chronic?
Can aura occur without a subsequent headache?
Is it useful to keep a headache diary?
Main medical sources
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38(1):1–211. doi:10.1177/0333102417738202.
- International Headache Society. 1.1 Migraine without aura. ICHD-3.
- International Headache Society. 1.2 Migraine with aura. ICHD-3.
- International Headache Society. 1.3 Chronic migraine. ICHD-3.
- Evans RW, Burch RC, Frishberg BM, et al. Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence-Based Guideline. Headache. 2020;60(2):318–336. doi:10.1111/head.13720.
When headaches recur, the first step is to identify the correct headache type
Migraine is usually diagnosed from the clinical picture. The purpose of the consultation is to understand the pattern of attacks, identify signs suggesting another cause, decide whether further investigations are necessary and then select an appropriate treatment strategy.
