Migraine assessment scales review

1. Migraine assessment- screening
instruments & scales

2. Overview
• Migraine is the most common headache disorder
• Diagnosis is by ICHD-2 criteria
• However, less than half of patients with migraine are properly
diagnosed
• Out of these, only one-third are properly treated, leading to
headache-related disability & health-related quality-of-
life(HRQoL)
• Migraine is often associated with psychiatric disorders,
including depression and anxiety
• Thus, proper treatment of comorbid psychiatric disorders is
crucial to the adequate treatment of migraines.

3. Impact of migraine
• Thus, migraine adversely affects daily functioning
• Not only does it affect the family life and
relationships but also has certain indirect costs
• These indirect costs can be enormous
• It is estimated that in the US, the indirect cost of
migraine to employers is approximately $12 billion
annually

4. Screening items & tools
• These help us to:
 Facilitate diagnosis
 Identify comorbid diseases
 Evaluate disability & HRQoL
 Assessment treatment response

5. Migraine diagnostic tools

6. ID Migraine
• Three-item migraine screener
• If the answer to any 2 questions is yes, then:
 Sensitivity = 0.82
 Specificity = 0.75
• Test reliability comparable to that of other screening
tools
• Sensitivity and specificity not influenced by gender ,
age, presence of comorbid headaches, or previous
diagnostic status

7. • However, the global application of ID Migraine needs
further validation due to the different prevalences of
migraine symptoms in different regions and racial
groups
• Eg. Asian populations show lesser prevalence of
photophobia compared to Western populations but
have a higher rate of Osmophobia
• Hence, validation or modification might be necessary
when applying a screening instrument in different
regions.

8. PCN screener
• It assess a combination of treatment and
diagnosis
• It is efficient in a primary care setting
• Has 4 questions which give good insight

10. Brief headache screen

11. Disease impact assessment tools

12. • Migraine attacks vary in severity from
moderate to severe pain with prolonged
incapacitation
• Assessing pain and disability is important in
determining the impact of disease
• Managing headache-related disability is a
challenge

13. MIDAS
• Migraine Disability Assessment Questionnaire
• It is a 5-item questionnaire designed to evaluate disability
within the most recent 3 months
• The patient needs to score the reduction in the performance,
in days, of work/school, household work, and family/social
activities.
• A score 0-270 is used to indicate the overall level of disability
• Due to its high internal consistency, validity, and good
correlation with clinical diagnoses and treatment, MIDAS has
been widely validated across countries and translated into
several languages
• In addition to disability assessment, MIDAS also serves as a
powerful instrument for the stratified care of patients with
migraine

15. Headache Impact Test(HIT-6)
• Widely validated instrument
• The HIT-6 comprises six items to evaluate the frequency of
severe headache
• Each of the six items is scored according to frequency,
generating an overall score of 36-78
• The impact scores can be classified as
 Little or no impact (grade 1: score 36-49),
 Moderate impact (grade 2: score 50-55),
 Substantial impact (grade 3: score 56-59), or
 Severe impact (grade 4: score 60e78)

16. • The HIT-6 score is obtained at baseline and at every 4
weeks of treatment and could be used as a good
surrogate marker of the response to treatment.
• A reduction of 2.3 points on the HIT-6 score
following treatment indicates a clinically significant
improvement in patients with chronic daily headache
• Furthermore, in a recent study, HIT-6 was found to
be useful for understanding the specific burden of
chronic daily headache compared with episodic
headache (i.e., chronic migraine vs. episodic
migraine)*
*Buse D, Manack A, Serrano D, Reed M, Varon S, Turkel C, et al. Headache impact of chronic and
episodic migraine: results from the american migraine prevalence and prevention study. Headache
2012;52(1):3e17.

17. Evaluation of comorbid psychiatric
disorders

18. • Migraine is known to be associated with a variety of
psychiatric disorders.
• Certain personality traits are associated with a higher
prevalence of migraine, especially chronic migraine
and medication overuse
• Patients with primary headache disorders are prone
to have a higher incidence of the neurotic triad of
hypochondriasis, depression, and hysteria, but are
still within two standard deviations compared with
the control group

19. MMPI
• Minnesota Multiphasic Personality Inventory
• Was originally designed to identify personality
structure and psychopathology
• Consists of ten different scales that are used to
identify nine major different personality traits
• MMPI (original edition) and MMPI-2 (revised in
1989)44 are commonly used in headache studies

20. Hospital Anxiety and Depression Scale
(HADS)
• Designed for screening patients with potential anxiety and
depression rather than grading the severity of the anxiety and
depression.
• There are 14 items on the HADS questionnaire, seven of
which measure anxiety (HADS-A) and seven of which measure
depression (HADS-D).
• Each item is scored in a scale of 0e3, resulting in an overall
score of 0e21 for both HADS-A and HADS-D
• A subscale of 3-9 on HADS-A yields a sensitivity of 0.66-0.86
and a specificity of 0.83-0.93 for anxiety,
• Whereas a subscale of 7-9 on HADS-D yields a sensitivity of
0.66-0.91 and a specificity of 0.87-0.97 for depression

21. Beck Depression Inventory (BDI)
• BDI is commonly used as a tool to grade depression.
• BDI consists of 21 questions, each scored on a scale of 0-3.
• The questions covers most of the diagnostic criteria of the
major depressive disorders in(DSM IV) including
hypochondriasis, perception of body image, and changes in
sleep, appetite, etc
 A score of 0-9 indicates minimal depression,
 10-18 indicates mild depression,
 Score of 19-29 indicates moderate depression, and
 Score of >30 indicates severe depression

22. Patient Health Questionnaire (PHQ-9)
• PHQ-9, a 9-item questionnaire with each item
corresponding to one criterion of the DSM-IV
diagnostic criteria of major depressive disorder,
serves as both a screening tool and a grading
instrument for depression
• Each of the nine items is scored on a scale of 0e3
depending on the frequency of symptoms. An overall
score 10 provides a sensitivity of 88% and specificity
of 88%
• PHQ-4, a simplified edition of PHQ-9, has been
developed to rapidly screen depression and anxiety

23. Assessing HRQoL

24. Migraine-Specific Quality of Life
Questionnaire version 2.1 (MSQ v2.1)
• A 14-item questionnaire used to assess the limitations in daily
performance due to migraine
• MSQ v2.1 is composed of three domains: role function-
restrictive (RR), role function-preventive (RP), and emotional
function (EF).
• The first two of these domains are used to access the
reduction and prevention of daily social- and work-related
activities
• The last domain is used to evaluate emotions associated with
migraine.

25. European Quality of Life-5
Dimensions (EQ-5D)
• A self-reported health status that covers five
dimensions (mobility, self-care, usual activities,
pain/discomfort, and anxiety/depression) and
general health status
• EQ-5D is widely used to evaluate the HRQoL of
different diseases, including psychiatric diseases,
medical diseases, surgical outcomes, etc.73
• In addition, in patients with migraines, EQ-5D scores
are even worse during frequent attacks compared
with the baseline condition of the patient

26. Short-form 36 (SF-36)
• A multidimensional questionnaire used to assess the impact
of disease on eight health domains, such as:
 Physical functioning,
 Role limitations due to physical problems,
 Bodily pain,
 General health perceptions,
 Vitality,
 Social functioning,
 Role limitations due to emotional problems, and
 Mental health
• A score of 0-100 on each subscale is generated, with higher
scores indicating better HRQoL

27. References
• Peng KP, Wang SJ. Migraine diagnosis: screening
items, instruments, and scales. Acta Anaesthesiol
Taiwan. 2012 Jun;50(2):69-73
• Buse DC, Rupnow MF, Lipton RB. Assessing and
managing all aspects of migraine: migraine attacks,
migraine-related functional impairment, common
comorbidities, and quality of life. Mayo Clin Proc.
2009 May;84(5):422-35
• http://www.medscape.org/viewarticle/552933

28. Thank You