MIDAS and HIT-6 — Administering Disability and Impact Instruments in Primary Care
MIDAS counts lost days; HIT-6 measures impact. Both take under two minutes chairside and function as objective anchors in PA submissions, referral letters, and specialist communication — more defensible than narrative self-assessment.
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PA impact: This card directly affects prior authorization outcomes. Documentation language from this card can be used in PA letters and appeals.
Two instruments, two different things they measure. The Migraine Disability Assessment (MIDAS) and the Headache Impact Test (HIT-6) are the two validated instruments most commonly referenced in headache disorder PA documentation, referral letters, and specialist communication. They are not interchangeable. MIDAS counts days — it quantifies lost or significantly impaired days across work, household, and social activities over a three-month window. HIT-6 measures impact — it captures the experiential burden of headache disorders across six dimensions including pain severity, functional limitation, cognitive interference, and emotional consequences. A patient with ten lost workdays (high MIDAS) and a patient who never misses work but cannot function normally during attacks (high HIT-6, moderate MIDAS) have different clinical pictures that require different documentation. Both instruments take under two minutes to administer chairside. Neither requires specialist training.
Administering MIDAS. MIDAS consists of five questions covering the past three months. Ask each question directly and record the patient's answer as a number of days. The five questions are: (1) On how many days in the last three months did you miss work or school because of your headaches? (2) On how many days in the last three months was your productivity at work or school reduced by half or more because of your headaches? (3) On how many days in the last three months did you not do household work because of your headaches? (4) On how many days in the last three months was your productivity in household work reduced by half or more because of your headaches? (5) On how many days in the last three months did you miss family, social, or leisure activities because of your headaches? Add the five responses. The total is the MIDAS score. Grade I: 0–5 (little or no disability); Grade II: 6–10 (mild disability); Grade III: 11–20 (moderate disability); Grade IV: 21 or higher (severe disability). Document in the chart as: "MIDAS [score], Grade [X], clinician-administered [date]." Patients who have been tracking with the Headache Vault will have longitudinal diary data available before the visit — this context makes the three-month recall more accurate, not redundant.
Administering HIT-6. HIT-6 consists of six questions, each answered on a five-point scale: Never (6 points), Rarely (8 points), Sometimes (10 points), Very Often (11 points), Always (13 points). The questions ask how often, in the past four weeks, the patient experienced: severe headache pain; headache limiting daily activities; wanting to lie down; fatigue; difficulty concentrating; and feeling fed up or irritated. Sum all six responses. Total score range is 36–78. Score interpretation: below 50 (little or no impact); 50–55 (some impact); 56–59 (substantial impact); 60 or higher (severe impact). The HIT-6 questionnaire is available free at headachetest.com and can be completed in the waiting room before the visit. Document as: "HIT-6 [score], [impact band], clinician-administered [date]."
What these scores do in a PA submission. MIDAS and HIT-6 scores function as objective anchors in PA documentation that distinguish a medically supported request from a narrative one. "Patient reports significant functional impairment" is challengeable. "MIDAS 16, Grade III, corroborated by 90-day prospective diary" is not. For CGRP preventive PAs, many payers do not explicitly require MIDAS or HIT-6, but their presence in a PA letter substantially narrows the grounds for denial. For appeals, a validated instrument score with a collection date is the difference between a supportable clinical argument and a clinician's assertion. Document scores with the instrument name, score, grade or band, date of administration, and who administered it.
What these scores do in a specialist referral. A headache specialist receiving a referral with MIDAS and HIT-6 scores has immediately actionable clinical context. Without them, the specialist starts from scratch at the first visit. The Headache Vault referral letter specification includes both scores when collected; the Visit Ready Report presents them with 30-to-90-day diary corroboration. A MIDAS score administered in primary care, documented in the chart, and referenced in the referral letter is the single most useful piece of information a specialist receives before seeing a new headache patient.
When the Vault prompts you to administer. The Visit Ready Report displays a MIDAS Status indicator based on the patient's tracking history. When sufficient data is available, the report will prompt: "MIDAS: Ready for formal administration — recommend collecting at this visit." This is not a suggestion to re-administer an instrument the patient has already completed — it is a prompt that the patient has enough longitudinal diary data to make a chairside MIDAS the most accurate and well-supported score they have ever submitted. The diary corroborates the recall; it does not replace the instrument. After administering, enter the score in the Vault patient record — it will appear in the next report and in all subsequent PA documentation.
A note on patient-reported functional impact and normalization. Patients with chronic headache disorders systematically underreport disability. They have restructured their lives around their condition — declining commitments they anticipate being unable to keep, working through attacks they have learned to manage, defining "a normal day" as a day with manageable pain. A patient who describes their headaches as "not that bad" may present with a MIDAS Grade III or higher when asked the five questions directly. Ask the questions; record the answers. The instrument produces the score regardless of how the patient frames their experience in conversation. This is clinically and documentarily significant: the score is objective in a way that narrative self-assessment is not.
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Run a PA — free →Citations: Stewart WF et al., Cephalalgia 1999;19 Suppl 25:20-28 (MIDAS development and validation) | Lipton RB et al., Headache 2000;40(7):528-535 (MIDAS Grade system) | Kosinski M et al., Quality of Life Research 2003;12(8):963-974 (HIT-6 development) | Yang M et al., Cephalalgia 2011;31(3):357-367 (HIT-6 psychometric properties) | Buse DC et al., Headache 2012;52(5):702-715 (disability underreporting in chronic migraine).