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Specific headache criteria useful for migraine diagnosis

What components of the history and physical examination are helpful in determining which patients with a headache have a migraine or need neuroimaging?

What components of the history and physical examination are helpful in determining which patients with a headache have a migraine or need neuroimaging?

Synopsis

These investigators hoped to determine which components of the history and physical examination can help identify patients with a migraine and those who should undergo neuroimaging.

After a thorough search of the Medline database and secondary sources including citations from relevant studies, two authors independently reviewed studies for inclusion and methodologic quality.

Disagreements were resolved by consensus with a third author. Studies were included if they assessed the accuracy of the history and physical examination in predicting the diagnosis of migraine using criteria developed by the International Headache Society.

Similar studies assessing clinical criteria predicting significant intracranial pathology in adults with non-traumatic headache were also included. From a total of 771 potential studies on migraine diagnosis, four studies of 1,745 patients met inclusion criteria.

Of these, only one study met level one quality criteria for a diagnosis article and only one study included patients from the primary care setting.

Eleven neuroimaging studies with 3,725 patients met inclusion criteria, with only one study meeting level one quality criteria.

Statistically significant individual criteria for distinguishing migraine from tension-type headache included: nausea (positive likelihood ratio [+LR] = 19, negative likelihood ratio [-LR] = 0.19), photophobia (+LR = 5.8, -LR = 0.24), phonophobia (+LR = 5.2, -LR = 0.38) and exacerbation by physical activity (+LR = 3.7, -LR = 0.24).

Data from a single study with the fewest methodological concerns evaluating the combination of findings led the authors to recommend a mnemonic: POUNDing (Pulsatile quality; duration of four to 72 hOurs; Unilateral location; Nausea or vomiting; Disabling intensity).

Patients with four or more of these criteria are most likely to have migraine headaches (+LR = 24).

Criteria increasing the risk of intracranial pathology include: cluster-type headache (+LR = 11); abnormal neurologic examination result (+LR = 5.3); undefined headache (+LR = 3.8); headache with aura (+LR = 3.2); headache aggravated by exertion or valsalva-like manoeuvre (+LR = 2.3), and headache with vomiting (+LR = 1.8).

No clinical features from the history and physical examination are useful for significantly reducing the likelihood of intracranial pathology.

Level of evidence

3a (see infopoems.com/concept/ebm_loe. cfm)

Reference

Detsky ME et al. Does this patient with headache have a migraine or need neuroimaging? JAMA 2006;296:1274-1283.

Bottom line: Useful clinical criteria from the history and physical examination for distinguishing migraine from tension-type headache include: nausea, photophobia, phonophobia and exacerbation by physical activity.

Combined findings useful for distinguishing migraine can be summarised by the mnemonic POUNDing (Pulsatile quality; duration of four to 72 hOurs; Unilateral location; Nausea or vomiting; Disabling intensity). Patients with four or more are most likely to have migraines.

Criteria increasing the intracranial pathology risk include: cluster-type headache; headache with aura; undefined headache; abnormal neurologic examination result; headache aggravated by exertion; and headache with vomiting.

No clinical features from the history and physical examination are useful for significantly reducing this risk.

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