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The Rational Clinical Examination | Clinician's Corner

Does This Patient With Headache Have a Migraine or Need Neuroimaging?

Michael E. Detsky, BSc; Devon R. McDonald, BSc; Mark O. Baerlocher, MD; George A. Tomlinson, PhD; Douglas C. McCrory, MD, MHSc; Christopher M. Booth, MD, FRCPC
JAMA. 2006;296(10):1274-1283. doi:10.1001/jama.296.10.1274.
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Context In assessing the patient with headache, clinicians are often faced with 2 important questions: Is this headache a migraine? Does this patient require neuroimaging? The diagnosis of migraine can direct therapy, and information obtained from the history and physical examination is used by physicians to determine which patients require neuroimaging.

Objective To determine the usefulness of the history and physical examination that distinguish patients with migraine from those with other headache types and that identify those patients who should undergo neuroimaging.

Data Sources and Study Selection A systematic review was performed using articles from MEDLINE (1966-November 2005) that assessed the performance characteristics of screening questions in diagnosing migraine (with the International Headache Society diagnostic criteria as a gold standard) and addressed the accuracy of the clinical examination in predicting the presence of underlying intracranial pathology (with computed tomography/magnetic resonance imaging as the reference standard).

Data Extraction Two authors independently reviewed each study to determine eligibility, abstract data, and classify methodological quality using predetermined criteria. Disagreement was resolved by consensus with a third author.

Data Synthesis Four studies of screening questions for migraine (n = 1745 patients) and 11 neuroimaging studies (n = 3725 patients) met inclusion criteria. All 4 of the migraine studies illustrated high sensitivity and specificity if 3 or 4 criteria were met. The best predictors can be summarized by the mnemonic POUNDing (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling). If 4 of the 5 criteria are met, the likelihood ratio (LR) for definite or possible migraine is 24 (95% confidence interval [CI], 1.5-388); if 3 are met, the LR is 3.5 (95% CI, 1.3-9.2), and if 2 or fewer are met, the LR is 0.41 (95% CI, 0.32-0.52). For the neuroimaging question, several clinical features were found on pooled analysis to predict the presence of a serious intracranial abnormality: cluster-type headache (LR, 10.7; 95% CI, 2.2-52); abnormal findings on neurologic examination (LR, 5.3; 95% CI, 2.4-12); undefined headache (ie, not cluster-, migraine-, or tension-type) (LR, 3.8; 95% CI, 2.0-7.1); headache with aura (LR, 3.2; 95% CI, 1.6-6.6); headache aggravated by exertion or a valsalva-like maneuver (LR, 2.3; 95% CI, 1.4-3.8); and headache with vomiting (LR, 1.8; 95% CI, 1.2-2.6). No clinical features were useful in ruling out significant pathologic conditions.

Conclusions The presence of 4 simple historical features can accurately diagnose migraine. Several individual clinical features were found to be associated with a significant intracranial abnormality, and patients with these features should undergo neuroimaging.

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Figure. Suggested Algorithm for the Approach to Headache
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*POUNDing: Pulsatile quality; duration 4-72 hOurs; Unilateral location; Nausea and vomiting; Disabling intensity.
†Cluster-type headache, abnormal findings on neurologic examination, undefined headache (ie, not cluster-, migraine-, or tension-type), headache with aura, headache aggravated by exertion or valsalva-like maneuver, headache with vomiting.

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