For clinicians

Clinical references

Last updated: April 29, 2026

Contents
  1. Migraine and headache classification
  2. Disability scoring (MIDAS)
  3. Medication-overuse thresholds
  4. OnabotulinumtoxinA (Botox) for chronic migraine
  5. CGRP-targeted preventives
  6. Hormonal pattern flag
  7. Treatment-response separation
  8. What Ember does not do
  9. Audit invitation
Ember organizes what patients log and leaves interpretation to the clinician. This page lists the published sources behind Ember’s rules and scores, and marks where Ember uses its own method. If you find an inconsistency or think a decision is wrong, tell us at hello@cascadeheadache.com.

Migraine and headache classification

Each logged day is classified by fixed rules built on the diagnostic criteria in the International Classification of Headache Disorders, 3rd edition (ICHD‑3). Ember does not propose a diagnosis.

Ember also records a migraine day without head pain when symptoms limited the day. That rule is Ember’s own.

Source: International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38(1):1–211. Available at ichd-3.org.

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Disability scoring (MIDAS)

Disability is summarized using the Migraine Disability Assessment (MIDAS) questionnaire. Ember calculates the MIDAS score from the days the patient has reported, then reports the corresponding grade (I–IV).

Source: Stewart WF, Lipton RB, Dowson AJ, Sawyer J. Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability. Neurology. 2001; 56(suppl 1):S20–S28.

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Medication-overuse thresholds

Acute medication use is tracked against the criteria in ICHD‑3 Section 8.2 (Medication-overuse headache).

ICHD‑3 sets the overuse thresholds at ≥10 days/month for more than 3 months for triptans, ergots, opioids, and combination analgesics, and at ≥15 days/month for more than 3 months for simple analgesics (e.g., NSAIDs, acetaminophen). Ember’s default monthly limits sit one day below them, at 9 and 14 days. Patients are warned at the limit and nudged earlier, at 80% of it.

Patients can dismiss the monthly warning for a medicine or mute the earlier nudge for 30 days. The counts still appear in the chart note.

Gepants (e.g., ubrogepant, rimegepant) are not currently included in ICHD‑3 medication-overuse criteria and Ember does not count them toward an overuse threshold.

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OnabotulinumtoxinA (Botox) for chronic migraine

Ember reports Botox interval, onset, and wear-off relative to the PREEMPT 1 and 2 protocol (155 units across 31 sites every 12 weeks, with up to 40 additional units allowed).

Sources: Aurora SK, Dodick DW, Turkel CC, et al. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 2010; 30(7):793–803. Diener HC, Dodick DW, Aurora SK, et al. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 2010; 30(7):804–814.

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CGRP-targeted preventives

For monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) and oral CGRP antagonists, Ember reports the patient-reported response and tracks the timing of starts and switches. Indications and place-in-therapy follow current guidance from the American Headache Society.

Source: Charles AC, Digre KB, Goadsby PJ, Robbins MS, Hershey A. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: an American Headache Society position statement update. Headache. 2024; 64(4):333–341.

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Hormonal pattern flag

Ember compares how often migraine days fall within two days of a recorded period start (day 1 ± 2) with how often they fall on other recorded days. The five-day window follows ICHD‑3 Appendix A1.1.1 (Pure menstrual migraine without aura) and A1.1.2 (Menstrually-related migraine without aura).

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Treatment-response separation

When a patient is on overlapping preventives, Ember compares the current 90-day migraine-day rate with the rate before each treatment started. It also lists the treatments already active at each start. Treatments started together are reported as one group. Cascade Headache developed this method.

The methodology is internal and is not yet published. We invite specialists to review it. To examine it with bundled demo data, open the app and tap the version line in Profile seven times to flip between your data and a demo dataset.

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What Ember does not do

  • Make treatment recommendations
  • Flag drug interactions
  • Decide what counts as a rebound headache
  • Replace clinical judgment
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Audit invitation

We are a small team and we want this to be right. If you spot an inconsistency, an inaccuracy, or a citation that needs updating, email hello@cascadeheadache.com.

Citations on this page point to the primary literature and to the latest published criteria. As guidelines update, this page updates with them. The date at the top reflects the most recent revision.

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