Migraine without aura is the most common migraine subtype — roughly 70% of all migraine cases. It’s the textbook presentation: moderate-to-severe pulsing pain on one side of the head, lasting hours to days, accompanied by nausea and sensitivity to light and sound. No visual or sensory aura precedes the attack.
This page covers the ICHD-3 criteria, how it differs from migraine with aura, and what the diagnosis means clinically.
The full ICHD-3 1.1 criteria
For a formal diagnosis of migraine without aura, ICHD-3 requires:
- A. At least 5 attacks meeting criteria B–D.
- B. Headache attacks lasting 4–72 hours (untreated or unsuccessfully treated).
- C. Headache has at least 2 of these 4 characteristics:
- Unilateral (one-sided) location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by, or causing avoidance of, routine physical activity (e.g., walking or climbing stairs)
- D. During headache, at least 1 of:
- Nausea and/or vomiting
- Photophobia (light sensitivity) AND phonophobia (sound sensitivity)
- E. Not better accounted for by another ICHD-3 diagnosis.
The 5-attack minimum exists because a single attack — even one that meets all the other criteria — could be many things. Migraine is a recurrent disorder, and the diagnosis requires the recurrent pattern.
What the criteria actually capture
Three things to notice about the criteria:
“At least 2 of 4” gives flexibility
Not every migraine attack is one-sided pulsing severe pain that worsens with activity. The 2-of-4 rule means an attack can be bilateral and pulsing and severe and qualify. Or one-sided and moderate and worsened by activity. The flexibility reflects the real variability in individual attack patterns.
Light and sound sensitivity counts together
Criterion D needs either nausea OR (photophobia AND phonophobia). Light sensitivity alone, or sound sensitivity alone, doesn’t trigger D unless you also have nausea. Most migraine attacks have both — and the patient who retreats to a dark, quiet room is implicitly demonstrating both even when not explicitly stated.
”Routine physical activity” is the disambiguator from tension-type
Tension-type headache typically isn’t worsened by activity. Migraine is. The “I can climb stairs without it getting worse” distinction is one of the more reliable bedside clues.
The typical attack arc
A migraine without aura attack often follows this rough pattern, though every patient’s experience differs:
- Prodrome (sometimes, hours to days before) — see prodrome.
- Attack onset — pain develops, usually over 30 minutes to 2 hours from mild to peak.
- Peak attack — moderate-to-severe pain with full accompanying symptoms. This phase can be hours.
- Resolution — pain gradually declines, usually over 4–12 hours.
- Postdrome — recovery phase, hours to a day or more. See postdrome.
The headache phase itself rarely lasts the full 72 hours — average is more like 12–24 hours, with most patients aborting attacks earlier with medication.
How it differs from migraine with aura
The two subtypes share most clinical features but differ in:
| Feature | Without aura | With aura |
|---|---|---|
| Prevalence among migraine | ~70% | ~25–30% |
| Aura phase | None | 5–60 min visual / sensory / language symptoms |
| Stroke risk | Baseline population risk | Modestly elevated (small absolute) |
| Hormonal contraceptive considerations | Generally permissible | Combined hormonal contraceptives contraindicated due to stroke risk |
| Acute treatment | Same options | Same options |
| Preventive treatment | Same options | Same options |
The treatment overlap is large. The main clinical differences are the stroke-risk-related considerations and the diagnostic clarity that aura provides (the visual symptoms are very specific to migraine, making misdiagnosis less likely).
The diagnostic process
Migraine without aura is diagnosed clinically — no blood test, no imaging study confirms it. The process:
- History — pattern, duration, associated symptoms, family history, what triggers attacks, what relieves them.
- Physical and neurological exam — usually normal between attacks; this is reassuring.
- Rule out secondary causes — particularly for atypical features (sudden onset, new pattern after 50, focal deficits, etc.). Imaging may be ordered here.
- Apply ICHD-3 criteria to confirm the diagnosis.
Most patients with migraine have a normal neurological exam between attacks. The diagnosis comes from the pattern, not from any test result.
When imaging is warranted
Most patients with established migraine without aura don’t need imaging. The American Headache Society guidelines reserve imaging for patients with:
- New or different headache pattern.
- Headache with abnormal neurological exam.
- Headache associated with seizures, syncope, or focal deficits.
- New headache after age 50.
- Sudden severe (“thunderclap”) headache.
- Headache changed by position (suggesting CSF pressure issues).
- Headache with fever, weight loss, or systemic symptoms.
Routine MRI of every migraine patient adds cost without clinical benefit for the typical case.
What this means for Hermly
Hermly’s prediction model is trained on data from people with recurrent episodic migraine — predominantly the without-aura subtype, which is the majority pattern. The model works the same way for both subtypes — the aura phase isn’t itself a feature the model reads (it’s a brief phase preceding pain, not a forecast input).
If your attacks include aura, the patterns Hermly forecasts — sleep, weather, cycle, recent attack history — apply equally. The model doesn’t distinguish between subtypes because the underlying physiology that drives risk is similar.
What this isn’t
Not a diagnostic checklist for self-diagnosis. The ICHD-3 criteria are necessary but not sufficient — ruling out secondary causes is the part that needs clinical judgment. If you suspect you have migraine but haven’t been formally evaluated, a neurologist or headache specialist is the right next step.