Challenges in Diagnosing a Migraine

Peter L. Salgo, MD: What are the challenges, in terms of diagnosis? How do you parse this out? Someone comes to you and says, “Doctor, I hate my headaches. They’re terrible.” How do you tell the difference between a headache and a migraine? What do you do?

Peter Goadsby, MD, PhD: I think time is the biggest challenge that physicians have. It requires time to take a history. It does not take a lot of time, but it does require time. It requires some engagement with the patient. You need to ask a series of questions. There is actually a short form to do this, the so-called ID-Migraine questionnaire. One can ask about headache, disability, and light sensitivity. They can ask a few simple questions. In essence, a little bit of time spent with the patient will usually dissect out the diagnosis.

Peter L. Salgo, MD: What do patients complain of?

Jill Dehlin, RN: I would like to add that migraine is very difficult to diagnose because there are no diagnostic procedures that will diagnose migraine at this time.

Peter L. Salgo, MD: There’s no migraine test? There’s no blood test? There is nothing that lights up green and says, “You’ve got a migraine”?

Jill Dehlin, RN: That’s correct. Many people think that they have a sinus headache, a tension headache, or that they’re using too many NSAIDs [nonsteroidal anti-inflammatory drugs]. They’re using them every day, and they think that they are having rebound headaches from using too many NSAIDs. So, it’s very difficult.

Peter L. Salgo, MD: So the challenge is, if I understand you, at least in part, getting patients to describe what they’ve got?

Jill Dehlin, RN: Exactly. And actually getting the person in to see the physician. Many people who have migraine are not diagnosed. This is not through the fault of physicians, but also because they’re not presenting themselves to their physician’s office with something as trivial as a headache, right?

Peter L. Salgo, MD: Well, migraines are not trivial.

Jill Dehlin, RN: No, I’m being facetious.

Peter L. Salgo, MD: Oh, I understand.

Malaika Stoll, MD, MPA: At times, it’s also an access issue. It’s hard to get in to see the doctor, at times. I think people put it off for various reasons, like you suggested. On the part of our systems, there are some challenges that we face in terms of access.

Peter L. Salgo, MD: Let me get one more definition on and off the table. Migraine versus something called a cluster headache. What’s a cluster headache?

Peter Goadsby, MD, PhD: A cluster headache, again, is a brain disease, or a brain disorder. If I was to contrast them, a cluster headache is an episodic disorder; it tends to cluster. A patient will have 1, 2, up to 8 attacks per day. This will happen every day. The attacks will last for a couple of hours—perhaps 2 hours—and will happen for 6, 8, 10 weeks. Then the attacks will stop and will go away until the following year. This will happen once or twice a year. They happen in these very distinct clusters. This tends to happen in men more than in women: 3 males to every female. The incidence of migraine is 3 females to every male. A very big distinction is that more than 9 out of 10 migraine patients will prefer not to move about. They’ll stay still. They’ll just want to withdraw. More than 9 out of 10 cluster patients would prefer to get up, run around, and bang their heads against a wall. The behavior of the two will almost tell you what’s going on.

Peter L. Salgo, MD: So, it’s a wall sign? We can call it that.

Jill Dehlin, RN: My friends who have cluster headaches find that the pain is the worst pain known to humankind. Of people who have had childbirth, kidney stones, or surgery, they feel that the pain that they experience during a cluster attack is off the charts. It’s often referred to as a suicide headache.

Peter L. Salgo, MD: Oh my gosh. I’m going to ask the $24-trillion question: What causes migraine? What is the root cause of these things?

Peter Goadsby, MD, PhD: Currently, we think that migraine is a combination of what you inherit, your genetic load, and what happens to you in the environmental load. I think most of us, in the headache field, think that it’s more or less impossible to have a migraine unless you’ve got the genetic material, so to speak. So, a very strong family history. It’s very unusual not to be able to dig around and find a parent’s history of this. And, if you can’t find it on the mom or dad’s side a useful side to look is on the dad’s mom’s side, because it tends to skip males. That’s probably because of hormonal changes. I tell patients, “If you’ve got migraine, it’s a poor choice of parents.”

Peter L. Salgo, MD: I was going to say, this sounds like a Freudian explanation. “Blame your parents.”

Peter Goadsby, MD, PhD: Something like that.

Peter L. Salgo, MD: It all goes back to your early training.