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vomiting, and prostration. The headache may last hours or at times days, and often leaves the
victim feeling drained.
2. Classic migraine: In classic migraine an aura precedes the headache by a number of minutes.
Visual auras of myriad description are common and may include flashing or sparkling lights,
coloured geometric patterns or whorls, zigzag patterns, or visual field compromise. Other focal
neurological symptoms such as numbness in the face and hand or expressive speech difficulty
may occur. The headache then follows.
3. Migraine Equivalent: In this condition, also known as migraine variant or acephalalgic migraine,
there is a classic aura but no after-coming headache.
Rarely, other forms of migraine occur including “complicated migraine” (hemiplegic migraine or other
form of stroke), ophthalmoplegic migraine with III nerve palsy, and basilar migraine with ataxia and
confusion.
ICAO Preliminary Unedited Version — October 2008 III-10-3
When determining medical fitness in migraine, the medical assessor should consider:
1. Prodrome: Some migraineurs experience an ill-defined uneasy, anxious, or unsettled feeling for a
day or more before headache onset, allowing avoidance measures.
2. Precipitating factors: Certain foods (especially cheese and chocolate), sleep deprivation,
exposure to sun, emotional stress, alcohol (especially red wine), and many other factors may be a
specific trigger of migraine in an individual. Identification of these may allow countermeasures.
3. Aura: The nature of the aura is important in aeromedical disposition. A tiny scintillating or
shimmering crescent in a small fraction of the visual field may be inconsequential, whereas
transient loss of half of the visual field would be unquestionably compromising.
4. Rapidity of onset: In some persons rapid onset leads to relative incapacitation within minutes,
whereas in others gradual onset over many hours affords ample time for avoidance while flying.
5. Frequency: Intervals between migraines may be years in some, and days or weeks in others.
6. Severity: Severe migraine may be essentially incapacitating due to pain, vomiting, and
prostration. However, there is a range of severity from this level to a mild throb or almost
imperceptible ache.
7. Therapy: Certain medications such as beta-adrenergic or calcium channel blocking agents may
be aeromedically acceptable for migraine prophylaxis, while central nervous system effects of
others (such as valproic acid, antidepressants, and narcotic analgesics) preclude their use in
aviators.
Operational implications:
A diagnosis of migraine is not compatible with any class of medical certification until a satisfactory
determination of potential compromise to aviation safety has been made and effective countermeasures
have been implemented.
Aeromedical considerations:
Applicants with migraine may be considered for medical certification if the disorder can be controlled.
In some, simple avoidance of precipitating factors may be sufficient. The aura must be assessed. Loss of
vision in one half of the visual field would not be acceptable, whereas in-flight occurrence of a minor
scintillation in the far periphery of the visual field might not cause significant functional impairment.
Slow onset over many hours might allow countermeasures, while rapid onset in minutes would be
unacceptable. A frequency of one or two migraines annually may not be disqualifying, whereas several
per month would bar certification. Severe migraine can be incapacitating, whereas mild migraine may be
inconsequential. Satisfactory documentation of successful treatment with acceptable medications may
allow medical certification. Beta-adrenergic and calcium channel blocking agents are among acceptable
medications, whereas antidepressants, anticonvulsants, narcotic analgesics and several others are
unacceptable.
Migraine may constitute an unacceptable risk in certain operations, such as single pilot operations
having the prospect of immediate deployment. Multicrew operations can provide a measure of risk
mitigation. The same might apply in air traffic control operations, where relief from a position is
possible. Additionally, non-safety-sensitive air traffic control duties might be an option during an
observation period.
An observation period of 6-12 months will often be appropriate to demonstrate effectiveness of avoidance
countermeasures and/or treatment.
ICAO Preliminary Unedited Version — October 2008 III-10-4
Cluster Headache
Cluster headache (Horton’s headache1, histamine headache) is an uncommonly encountered distinct entity
characterized by abrupt onset of severe intra-orbital, retro-orbital, or peri-orbital pain lasting 30-45
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Manual of Civil Aviation Medicine 2(24)
