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Current RMA Instruments
|Reasonable Hypothesis SOP||7 of 2018 as amended|
|Balance of Probabilities SOP||8 of 2018 as amended|
Changes from previous Instruments
- ICD-9-CM Codes: 346.0, 364.1, 346.8, 346.9
- ICD-10-AM Codes: G43
Typically, migraine is an episodic headache disorder, usually manifesting as a severe, unilateral, throbbing headache, generally associated with nausea and/or light and sound sensitivity. There are a number of variants of migraine and a headache is not always present.
Confirming the diagnosis
The diagnosis is made clinically, based on the patient history, and can be made by a GP. There are no specific diagnostic tests.
The relevant medical specialist is a neurologist.
Additional diagnoses covered by SOP
- Basilar migraine
- Classical migraine
- Chronic migraine
- Common migraine
- Migraine with aura
- Migraine with brainstem aura
- Migraine without aura
- Sporadic hemiplegic migraine
- Retinal migraine
- Vestibular migraine
Related conditions that may be covered by SOP
- “Post-traumatic headache” (see comments)
Conditions not covered by SOP
- Abdominal migraine#
- Amaurosis fugax (partly covered by retinal vascular occlusion SOP)
- Cluster headache*
- Chronic paroxysmal hemicrania* - cluster headache SOP
- Familial hemiplegic migraine#
- Histamine cephalgia* - cluster headache SOP
- Horton’s neuralgia* - cluster headache SOP
- Headaches due to intracranial or cervical inflammatory or neoplastic disorders or structural abnormalities – code to underlying disease
- Migrainous infarction#
- Ophthalmoplegic migraine#
- Tension-type headache*
* another SOP applies
# non-SOP condition
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”. They have concluded that head trauma is a cause of migraine, at the RH level only.
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 is consistent with having migraine.
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.