Migraine — atypical clinical presentations and the most common diagnostic challenges

INTRODUCTION: Migraine is the most common neurological disorder worldwide. However, despite its high prevalence and clear diagnostic criteria, migraine is frequently underdiagnosed or misidentified as other primary or secondary conditions. STATE OF THE ART: Migraine remains one of the greatest diagnostic challenges due to its remarkable clinical diversity and tendency to mask other conditions. One major challenge in diagnosing primary headaches is the lack of available biomarkers, and diagnosis is largely based on criteria and patient self-reporting. CLINICAL IMPLICATIONS: This article discusses different and often atypical clinical presentations of migraine and the most common diagnostic challenges encountered in clinical practice. The diagnostic difficulties of migraine with aura will be discussed, with particular emphasis on retinal migraine, migraine aura without headache, and vestibular migraine, as well as the most common misdiagnoses, including sinus headache, facial pain, neuralgias, and other primary headaches. FUTURE DIRECTIONS: Future directions in headache medicine will include the accurate clinical characterization of primary headaches and facial pain. This will require detailed clinical observation, the identification of migraine-specific biomarkers, and precise phenotyping using the latest technologies.