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Current RMA Instruments
|Reasonable Hypothesis SOP||7 of 2018|
|Balance of Probabilities SOP||8 of 2018|
Changes from previous Instruments
- ICD-9-CM Codes: 346.0, 364.1, 346.8, 346.9
- ICD-10-AM Codes: G43
Migraine is an episodic headache disorder, usually manifesting as a severe, unilateral, throbbing headache, generally associated with nausea and/or light and sound sensitivity.
Confirming the diagnosis
The diagnosis is made clinically, based on the patient history. There are no specific diagnostic tests.
The relevant medical specialist is a neurologist.
Additional diagnoses covered by SOP
- Atypical migraine
- Basilar migraine
- Classical migraine
- Complicated migraine
- Common migraine
- Familial hemiplegic migraine
- Migraine equivalent
- Migraine with aura
- Migraine without aura
- Ophthalmoplegic migraine
- Retinal migraine
- Vestibular migraine
Related conditions that may be covered by SOP
- “Post-traumatic headache” (see comments)
Conditions not covered by SOP
- Cluster headache*
- Chronic paroxysmal hemicrania* - cluster headache SOP
- Histamine cephalgia* - cluster headache SOP
- Horton’s neuralgia* - cluster headache SOP
- Headaches due to intracranial inflammatory or neoplastic disorders or structural abnormalities – code to underlying disease
* another SOP applies
Migraines that are claimed to have commenced or worsened in association with head or neck trauma come under the migraine SOP. A diagnosis of post-traumatic headaches/migraines should not be made.
The RMA has formally investigated whether head or neck trauma is a cause of headache. They have not issued separate SOPs for “post-traumatic headaches” and they have concluded that head or neck trauma is not a cause of migraine or tension-type headache.
Claims for “post-traumatic headache” should be determined using the tension-type headache, migraine or cluster headache SOP, depending on the clinical presentation. The exception is if the headaches are due to a demonstrable structural abnormality (eg. subdural haematoma), in which case that abnormality should be diagnosed.
Clinical onset will be based on the history and date from the first episode that meets appropriate criteria for migraine, as determined by a medical practitioner.
Clinical worsening has been defined in the migraine SOP. It is still necessary when determining claims to consider whether there has been worsening of the condition, over and above the normal course of the disease, and arising due to relevant service rendered after the onset of the condition.