The use of questions to determine the presence of photophobia and phonophobia during migraine.
ABSTRACT To investigate whether the use of more detailed close-ended questions as part of the routine headache history is helpful when patients initially deny that they are sensitive to light and noise during migraine headaches.
According to the International Headache Society 2004 criteria, the diagnosis of migraine requires the presence of at least one of the following during a headache: (1) nausea and/or vomiting, (2) photophobia and phonophobia. Evans anecdotally noted that many patients answer the question, "does light or noise bother you during a headache," with a "no" when the answer is really "yes" if they are asked more detailed close-ended questions.
Consecutive patients fulfilling International Headache Society 2004 criteria for migraine or probable migraine presenting to a headache clinic and a neurology clinic were asked the following questions: "does light bother you during a headache?" If "no," they were then asked, "during a headache, would you prefer to be in bright sunlight or in a dark room?"does noise bother you during a headache?" If "no," they were then asked, "during a headache, would you prefer to be in a room with loud music or in a quiet room?"
Eighty-five consecutive patients with migraine or probable migraine were questioned, 71 females (83.5%) and 14 males (16.5%). There was denial of light and sound sensitivity in 24% of patients with routine questioning and then awareness of sensitivity in 93% with the further questioning. A total of 7.1% of the patients were diagnosed with probable migraine. However, if the additional questions were not asked, 8% more of the patients with definite migraine would have been incorrectly diagnosed as probable migraine.
When patients initially deny light and noise sensitivity during migraine headaches, additional questions should be asked to ensure that their answer is accurate. Not asking the additional questions may result in the over-diagnosis of probable migraine.
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ABSTRACT: Photophobia is an important criterion for the diagnosis of migraine. However, several Asian epidemiological surveys about migraine have shown lesser prevalence of photophobia than that of Western studies. This discrepancy is probably caused by underestimation of photophobia due to inappropriate questioning of patients by physicians. To investigate this issue, we developed a questionnaire about photophobia and evaluated its usefulness in 103 patients with migraine. In phase 1 of the study, we found good repeatability of the questionnaire with a 0.826 kappa coefficient. In phase 2, the prevalence of photophobia from interviews and that from the questionnaire were compared. The prevalence of interview-documented photophobia was 51.5% and of questionnaire-documented photophobia 82.5% (P < 0.001). In phase 3, we attempted to make a short-form questionnaire with the same detection power of the questionnaire study. Two short-form questionnaires were identified as a useful method for detecting photophobia. The prevalence of photophobia could be underreported via interview, especially in Asian migraineurs. Using this questionnaire to test for photophobia, the diagnostic rate of photophobia and migraine could be improved.Cephalalgia 02/2009; 29(9):953-9. · 3.49 Impact Factor
Article: Migraine: pitfalls in the diagnosis.[Show abstract] [Hide abstract]
ABSTRACT: Although the understanding of the pathophysiology and the pharmacology of migraine has exploded there are still many pitfalls that may occur in the clinical assessment and management of migraine. This may prevent the patient from receiving optimal treatment. A diagnosis of migraine may be missed in the presence of other headache types that occur more frequently than migraine. Also, migraine may be misdiagnosed when treating physicians inappropriately interpret specific symptoms and co-morbid conditions as indicators of the presence of a non-migraine headache type such as sinus headache or tension headache. Migraine and tension-type headache share common triggers and this also contributes to the difficulty in their differential diagnosis. The non-availability of any diagnostic laboratory investigation only makes this job further difficult.The Journal of the Association of Physicians of India 04/2010; 58 Suppl:10-3.
The Use of Questions to Determine the Presence of
Photophobia and Phonophobia During Migraine
Randolph W. Evans, MD; Tad Seifert, MD; Jayasree Kailasam, MD; Ninan T. Mathew, MD
Objective.—To investigate whether the use of more detailed close-ended questions as part of the routine headache history
is helpful when patients initially deny that they are sensitive to light and noise during migraine headaches.
Background.—According to the International Headache Society 2004 criteria, the diagnosis of migraine requires the pres-
ence of at least one of the following during a headache: (1) nausea and/or vomiting, (2) photophobia and phonophobia. Evans
the answer is really “yes” if they are asked more detailed close-ended questions.
Methods.—Consecutive patients fulfilling International Headache Society 2004 criteria for migraine or probable migraine
presenting to a headache clinic and a neurology clinic were asked the following questions: “does light bother you during a
headache?” If “no,” they were then asked, “during a headache, would you prefer to be in bright sunlight or in a dark room?”
“does noise bother you during a headache?” If “no,” they were then asked, “during a headache, would you prefer to be in a
room with loud music or in a quiet room?”
Results.—Eighty-five consecutive patients with migraine or probable migraine were questioned,71 females (83.5%) and 14
males (16.5%).There was denial of light and sound sensitivity in 24% of patients with routine questioning and then awareness of
sensitivity in 93% with the further questioning.A total of 7.1% of the patients were diagnosed with probable migraine.However,
as probable migraine.
be asked to ensure that their answer is accurate.Not asking the additional questions may result in the over-diagnosis of probable
Key words: migraine, probable migraine, light and noise sensitivity, photophobia and phonophobia
According to the International Headache Socie-
ty 2004 criteria,the diagnosis of migraine requires the
presence of at least one of the following during a
headache: (1) nausea and/or vomiting, (2) photopho-
bia and phonophobia.1Evans anecdotally noted that
bother you during a headache,” with a “no” when the
answer is really “yes” if they are asked more detailed
close-ended questions.2We performed a prospective
study to investigate whether the use of more detailed
deny that they are sensitive to light and noise during
From the Baylor College of Medicine – Neurology, Houston,
TX (Dr. Evans); and Houston Headache Clinic, Houston, TX
(Drs. Seifert, Kailasam, and Mathew).
Address all correspondence to Randolph W. Evans, MD, 1200
Binz #1370, Houston, TX 77004.
Accepted for publication June 24, 2007.
Conflict of Interest: None
Published by Blackwell Publishing
© 2008 the Authors
Journal compilation © 2008 American Headache Society
Consecutive patients presenting to both a
headache clinic and a private practice general neu-
rology clinic were interviewed. As part of the usual
headache history, they were asked the following
1. “Does light bother you during a headache?”
If “no,” they were then asked, “During a
headache, would you prefer to be in bright sun-
light or in a dark room?”
2. “Does noise bother you during a headache?”
If “no,” they were then asked, “During a
headache, would you prefer to be in a room with
loud music or in a quiet room?”
All patients who fulfilled International Headache
or probable migraine were included in the study.
In January and February 2005,85 consecutive pa-
tients with migraine or probable migraine were ques-
tioned, 71 females (83.5%) and 14 males (16.5%).
Twenty-two patients (26%) reported light did not
bother them during headache. Of these 22 patients,
20 preferred a dark room upon further closed-ended
bother them during headache. Of these 22 patients,
21 preferred a quiet room upon additional closed-
ended questioning (95.5%). Thirteen patients (15%)
reported having no light and sound sensitivity as well
as no nausea and/or vomiting during a headache. Of
these 13 patients without nausea, 7 preferred a quiet
The terms “photophobia and phonophobia” are
somewhat misnomers since they are derived from
Greek and mean “dread or fear of light and sound”
when migraineurs more often have a hypersensitiv-
ity to the stimuli which may even be present interic-
tally.3,4For example,between attacks,migraineurs are
controls.In a recent large study asking subjects about
the presence of symptoms in most attacks, photopho-
bia and phonophobia decreased in occurrence with
older age, respectively, as follows: ages 18-38, 79%,
and 77%;and ages 60+,75% and 67%.7The substrate
of photophobia may be similar to the cause of visual
aura with abnormal occipital cortical or neuronal hy-
perexcitability.8The hypersensitivity to sound may be
migraine hypo-functioning serotonergic state causing
This study reveals that there is underreporting of
discussion about behaviors and sensitivities during a
migraine episode such as wearing sunglasses or go-
ing into a dark room or turning down the volume of
the music,radio,or television,which may not have oc-
curred to the patient when only asked the “does light
or noise bother you”question.
One potential shortcoming of the study is that
we did not record whether patients had a migraine
headache at the time of the interview (as a minority
probably did) and compare their responses to those
without acute headaches. It is possible although un-
likely that they were more accurate in answering the
tive of patients usually without acute headaches seen
in headache and general neurology clinics.
Probable migraine fulfills all but one criterion
for migraine with or without aura. A recent very
large self-administered survey in the United States
of 4.5%.11The authors suggest that they may have
underreported probable migraine because the ques-
tionnaire was applied in just those with a self-defined
severe headache. Another large self-administered
survey in France reported a 1-year prevalence of
probable migraine of 10.1%.12Our survey diag-
nosed probable migraine in 7.1%. However, if we
did not ask the further questions, 8% would have
been misdiagnosed as probable migraine rather than
If health care providers are only using the rou-
tine questions to assess light and noise sensitivity, the
use of these additional closed-ended questions will in-
crease the number of migraine diagnoses using Inter-
national Headache Society criteria in some of the pa-
tients who might be diagnosed as probable migraine
if they did not have nausea.Although we suspect that
many health care providers are already using similar
questions be routinely used as part of the headache
history when the responses to the initial questions are
The 2004 migraine criteria do not specify how to
determine whether the patient has photophobia and
phonophobia.1The International Headache Society
of a short discussion under the“notes”section for the
third edition criteria.
Acknowledgment: Presented in abstract form at
the 2005 American Headache Society Annual Scientific
1. Headache Classification Subcommittee of the Inter-
national Headache Society.The international classi-
3. Main A, Dowson A, Gross M. Photophobia
and phonophobia in migraineurs between attacks.
4. Vingen JV, Pareja JA, StÃren O, White LR,
Stovner LJ. Phonophobia in migraine. Cephalalgia.
5. Mulleners WM, Aurora SK, Chronicle EP, Stew-
ard R,Gopal S,Koehler PJ. Self-reported photophic
symptoms in migraineurs and controls are reliable
6. Evans RW. Female migraineurs are much more
likely to blink in a flash photograph than controls.
7. Bigal ME,Liberman JN,Lipton RB. Age-dependent
prevalence and clinical features of migraine.Neurol-
8. Aurora SK,Cao Y,Bowyer SM,Welch KM. The oc-
cipital cortex is hyperexcitable in migraine: Experi-
mental evidence. Headache. 1999;39:469-476.
9. Wang W, Timsit-Berthier M, Shoenen J. Intensity
dependence of auditory evoked potentials is pro-
nounced in migraine: An indication of cortical po-
10. Sand T,Vingen JV. Visual,long-latency auditory and
brainstem auditory evoked potentials in migraine:
Relation to pattern size, stimulus intensity, sound
and light discomfort thresholds and pre-attack state.
11. Silberstein S, Loder E, Diamond S, Reed ML, Bigal
migraine in the United States:Results of theAmeri-
can Migraine Prevalence and Prevention (AMPP)
12. Lanteri-Minet M, Valade D, Geraud G, Chautard
MH, Lucas C. Migraine and probable migraine—
results of FRAMIG 3, a French nationwide survey
carried out according to the 2004 IHS classification.