Posted by: seattledizzygroup | August 31, 2014

Diagnosing and Managing Migraine Headaches

Diagnosing & Managing Migraine Headaches

by Meredith Mancuso, DPT

of MOSAIC Physical Therapy

(Presented to Seattle Dizzy Group on 7/12/14)

This presentation gives criteria for diagnosing migraine headaches and offers ways to reduce and manage symptoms including a Migraine Diet.


What is a Migraine?

  • Migraines are neurological events.
  • The most common symptom is a headache, although one is not required to have the diagnosis of a migraine.
  • Events range from no pain to severe pain with permanent ischemic change (change in blood flow).
  • Most common non-pain form of a migraine is VISUAL, but any aura symptom can occur in the absence of pain including DIZZINESS.

What are the 4 Phases of a Migraine?

1.  Prodromal Phase: Early Warning Signs

Several hours before the migraine begins (and sometimes even the day before) many people notice unusual sensations. They may feel:
  • Either unusually energetic and excitable or depressed
  • Irritable
  • Thirsty
  • Cravings for certain foods
  • Sleepy, with frequent yawning
  • Need to urinate more

2.  Aura Phase: Strange Sensations Arise

This phase usually last minutes. About 1 in 5 people with migraine develop an “aura” that begins before the headache or starts along with it. An aura is often described as a fuzzy vision outline. An aura may not occur with every headache. An aura can include:

Changes in vision
Often visual symptoms begin first during the aura phase. Vision changes may include:
  • A flickering, jagged arc of light. This may take a complicated shape. It usually appears on the left or right side of your vision. Over a few minutes, it may spread in size.
  • An area of vision loss. This problem, especially when combined with flickering lights, can make driving or focusing your eyes on small objects difficult.
  • Hallucinations
Skin sensations

This part of the aura may cause tingling or “pins and needles” sensations in the body. It may also cause numbness. These feelings often affect the face and hands but can spread out across the body. The sensations may continue to expand over the next several minutes.

Language problems
During the aura phase of a migraine, you may have trouble communicating with others. Symptoms may include:
  • Difficulty expressing thoughts while speaking or writing
  • Trouble understanding spoken or written words
  • Confusion
  • Trouble concentrating

*Aura symptoms may continue to grow more severe during migraine*

3.  Attack Phase: The Headache Begins

The attack portion of a migraine episode can last for a few hours to several days. During this phase of the migraine, the person usually wants to rest quietly and finds normal activities difficult.

A defining quality of migraines is their pain. The pain of a migraine:
  • Usually begins above the eyes.
  • Typically affects one side of the head, but it may strike the entire head or move from one side to the other. It may also affect the lower face and the neck.
  • Tends to have a throbbing intensity (May throb worse during physical activity or when you lean forward).
  • May get worse if you become physically active.
Other symptoms that may arise during this phase include:
  • Unusual sensitivity to light, sounds, and smells
  • Light-headedness and fainting
  • Nausea and vomiting

4.  Postdromal Phase: After the Storm

Following the most severe phase of the migraine, you may not feel well for up to a day. Symptoms of this post-migraine phase may include:
  • Extreme tiredness
  • Sluggishness
  • Confusion
  • Head pain that flares up when you lean over or move quickly, or you may experience a rush of blood to the head

How Do We Determine You Actually Have a Migraine?

  • WE CAN’T!! There are no tests for determining migraine headaches.
  • The diagnosis is based on history of the ICDH-II.
  • Physical exam and imaging (MRI) are used to rule out any other issues such as tumors, etc.

Migraine Headache Criteria for Diagnosis:

The following are the ICHD-II (International Classification for Headache Disorders) criteria for migraine without aura:

  • 5 headaches of moderate to severe intensity (interrupts your life) in your life time—over time can range from mild to severe
  • Lasting 4-72 hours without treatment in adults (2 hours minimum in children)
  • Light sensitivity and sound sensitivity OR nausea/vomiting
  • Must have at least 2 of the following:
    • Inhibits daily activity
    • Aggravated by routine activity
    • Throbbing/pulsing
    • Head pain localizes (unilateral or bitemporal)

Additional Complaints and Features that Help in Making the Case for a Migraine Diagnosis:

  • Motion sickness and/or sleepwalking especially in childhood
  • Scintillating scotomata – VISUAL AURA with or without pain
  • Family history (family members with migraine history)
  • Hormonal and food triggers
  • Headache with caffeine withdrawal
  • Headache with sensory complaints
  • Balance deficits around the event

Ways to Manage Migraines:

  • Reduce risk factors
  • Manage motion sensitivity (This may require physical therapy)
  • Manage stress and anxiety
  • Manage diet



Reduce or Avoid:

Instead Use:
Beverages Chocolate and cocoa, alcoholic beverages aged in wood containers (red wine, port, sherry, scotch, bourbon, gin, chardonnay), sugar-free non-alcoholic drinks with Aspartame or Nutrasweet All other beverages including: wine aged in metal containers (including chardonnay and red wines of the “Naked” brand), sugar-free non-alcoholic drinks with saccharine or Splenda
Cheeses Stilton, bleu, cheddar, mozzarella, cheese spread, Roquefort, provolone, gruyere, muenster, feta, parmesan, brie, brick, camembert types, gouda, Romano American, cottage, farmer, ricotta, cream, Canadian, processed cheese slice
Nuts Almonds, walnuts, cashews Peanuts
Beans Garbanzo, chick peas All others
Smoked meats Ham, turkey, hot dogs (with nitrates) All meats without nitrates
Desserts Any sweets containing chocolate or nuts Any sweets without chocolate or nuts
Miscellaneous Monosodium glutamate (MSG) (found in Chinese, Mexican, Seafood, and soups), Accent, meat tenderizer, seasoned salt, yeast, yeast extract Salt in moderation, lemon juice, butter or margarine, cooking oil, whipped cream, white vinegar, commercial salad dressings

*Diet information modified from Diamond S: Dietary factors in vascular headache. Neurol Forum 1991;2:2. Also from Shulman, KI et al: Dietary restrictions, tyramine, and the use of monoamine oxidase inhibitors. JClin Psychopharmacol 1989;9:397.

More information about Migraine Headaches:

“The Migraine Brain: Your Breakthrough Guide to Fewer Headaches, Better Health” by Carolyn Berstein

Meredith Mancuso DPTMeredith Mancuso, DPT

of MOSAIC Physical Therapy

Meredith grew up in Boston, MA. She attended Colby College in Waterville, ME and went on to get her Doctorate in Physical Therapy at Massachusetts General Hospital’s Institute of Health Profession, Boston, MA. She joined MOSAIC PT in March 2014.


Presentation information is not meant to be taken as medical advice.

Presentations posted online may include discussion notes, links, images, and other information added by Seattle Dizzy Group.

Download Presentation Handout PDF (original without notes):

(Join the Seattle Dizzy Group closed/secret Facebook group to download the presentation.  Send us your email address for invitation to join our Facebook group).



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