---
title: Migraine Diagnosis and Prophylaxis
description: A clinical reference guide on the diagnosis and preventive treatment of migraine headaches.
keywords: [migraine, headache, prophylaxis, preventive, ICHD-3]
category: clinical
---

## Migraine Diagnosis

Migraine is a common neurological disorder characterized by recurrent, moderate to severe headaches often accompanied by nausea, vomiting, photophobia, and phonophobia. Diagnosis of migraine is primarily clinical, based on the patient's reported symptoms and history. The International Classification of Headache Disorders, 3rd edition (ICHD-3) provides the following diagnostic criteria for migraine without aura:

1. At least 5 attacks fulfilling the following criteria:
   - Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated)
   - Headache has at least two of the following characteristics:
     - Unilateral location
     - Pulsating quality
     - Moderate or severe pain intensity
     - Aggravation by or causing avoidance of routine physical activity
   - During the headache, at least one of the following:
     - Nausea and/or vomiting
     - Photophobia and phonophobia
2. No better account of the headache can be given by another ICHD-3 diagnosis.

For migraine with aura, the ICHD-3 criteria include the presence of fully reversible aura symptoms (e.g., visual, sensory, speech/language, motor, brainstem, or retinal disturbances) that develop gradually over ≥5 minutes and last <60 minutes.

Additional diagnostic evaluation may include neuroimaging (MRI or CT) to rule out secondary causes of headache, particularly in patients with atypical features or new-onset headache. Laboratory testing is generally not required for migraine diagnosis but may be considered to evaluate for other conditions.

## Migraine Prophylaxis

Migraine prophylaxis aims to reduce the frequency, severity, and disability associated with migraine attacks. Preventive treatment is recommended for patients who experience:

- ≥4 migraine days per month
- Significant disability or impairment in quality of life
- Contraindication, failure, or overuse of acute migraine treatments

The American Headache Society (AHS) and other clinical guidelines recommend the following first-line oral prophylactic medications for migraine:

1. Antiepileptic drugs:
   - Topiramate: Start at 25 mg once daily, titrate up to 100 mg twice daily.
   - Valproic acid/divalproex sodium: Start at 250 mg twice daily, titrate up to 1000-1500 mg per day.
2. Beta-blockers:
   - Propranolol: Start at 40 mg twice daily, titrate up to 240 mg per day.
   - Metoprolol: Start at 25 mg twice daily, titrate up to 200 mg per day.
3. Calcitonin gene-related peptide (CGRP) monoclonal antibodies:
   - Erenumab: 70 mg or 140 mg subcutaneously once monthly.
   - Fremanezumab: 225 mg subcutaneously once monthly or 675 mg every 3 months.
   - Galcanezumab: 240 mg subcutaneously once, then 120 mg once monthly.

Other preventive medications that may be considered include antidepressants (amitriptyline, venlafaxine), angiotensin II receptor blockers (candesartan), and calcium channel blockers (flunarizine).

When selecting a preventive medication, factors to consider include the patient's comorbidities, contraindications, and tolerability. Patients should be monitored for adverse effects, and the medication dose should be titrated gradually to the effective and tolerated dose.

## Monitoring and Adjustments

Patients on migraine prophylaxis should be monitored regularly, typically every 3-6 months, to assess treatment response and tolerability. Objective measures of effectiveness may include:

- Reduction in migraine days per month
- Decrease in migraine severity or duration
- Improvement in functional disability or quality of life

If the patient does not experience a clinically meaningful response (e.g., ≥50% reduction in migraine days) after 2-3 months of treatment at the maximum tolerated dose, the medication should be switched or an additional preventive therapy added.

For patients who achieve a good response, prophylactic treatment may be continued for 6-12 months before attempting a gradual withdrawal to assess the need for ongoing therapy. Patients should be monitored closely during medication tapering, as migraine attacks may recur.

## Contraindications and Considerations

Certain patient populations require special consideration when prescribing migraine prophylaxis:

1. Pregnancy and lactation:
   - Topiramate and valproic acid are contraindicated due to the risk of teratogenicity.
   - Propranolol and metoprolol are generally considered safe during pregnancy and breastfeeding.
   - CGRP monoclonal antibodies have limited data in pregnancy and are not recommended.
2. Cardiovascular disease:
   - Beta-blockers are contraindicated in patients with severe bradycardia, heart block, or decompensated heart failure.
   - Calcium channel blockers and angiotensin II receptor blockers may be preferred in patients with cardiovascular comorbidities.
3. Renal or hepatic impairment:
   - Dose adjustments may be required for medications primarily eliminated by the kidneys (e.g., topiramate) or liver (e.g., valproic acid).

Patients should be counseled on the potential adverse effects of migraine prophylactic medications, such as cognitive impairment, weight changes, and sedation, and encouraged to report any concerning symptoms.

## Comorbidities and Multidisciplinary Approach

Migraine often coexists with other medical and psychiatric conditions, such as depression, anxiety, sleep disorders, and chronic pain syndromes. A comprehensive, multidisciplinary approach to migraine management is recommended, involving the coordination of care between neurologists, primary care providers, mental health professionals, physical therapists, and other specialists as needed.

Addressing comorbidities and adopting a biopsychosocial model of care can improve migraine outcomes and quality of life. Treatment strategies may include:

- Screening and management of mental health conditions
- Optimization of sleep hygiene and management of sleep disorders
- Incorporation of non-pharmacological therapies, such as cognitive-behavioral therapy, relaxation techniques, and physical therapy
- Coordination of care between providers to ensure appropriate medication management and minimization of polypharmacy

By adopting a holistic, patient-centered approach to migraine care, healthcare providers can better support patients in achieving long-term control of their headaches and improving their overall well-being.