Diagnosis of headache in childhood and adolescence: a study in 437 patients

We investigated whether the criteria for idiopathic headache published by the International Headache Society (IHS) are useful in childhood and adolescence and compared the diagnoses according to this classification with those of Vahlquist. We used a semi-structured questionnaire to examine a total of 437 children and adolescents referred consecutively to a headache outpatient clinic. Twenty-eight of 437 patients were excluded because of symptomatic or unclassifiable headache. Of 409 patients with idiopathic headache, 70.4% had definite migraine or tension-type headache (IHS 1.1, 1.2, 2.1, 2.2), 20.5% had a migrainous disorder (IHS 1.7) and 9.1% had headache of the tension-type not fulfilling the criteria (IHS 2.3). In the differential diagnosis of migraine and tension-type headache the intensity of pain, aggravation of headache by physical activity, nausea and vomiting were the most important features. The quality of pain, photo- and phonophobia were less helpful and location least important. The duration of migraine attacks was less than 2 h in 19.0% of the migraine patients. In general, the diagnostic criteria of migraine were highly specific but less sensitive, and those of tension-type headache highly sensitive but less specific. The agreement between IHS criteria and those of Vahlquist was marked (kappa = 0.57). We conclude that the IHS criteria are useful for classifying headache in children and adolescents referred to a headache outpatient clinic. A forthcoming modification of the IHS criteria should consider a reduction of the minimum duration of migraine attacks from 2 h to I h and should try to increase the sensitivity of the criteria for migraine and the specificity of the criteria for tension-type headache.     

Migrainous disorder and headache of the tension-type not fulfilling the criteria: a follow-up study in children and adolescents

In this follow-up study in children and adolescents with recurrent headaches classified as migrainous disorder (IHS 1.7) and headache of the tension-type not fulfilling the criteria (IHS 2.3), 28.6% were headache-free and 71.4% still had headaches 2-5 years after the first examination. The majority remained in the same one-digit IHS diagnosis, whereas 20% changed from migraine to tension-type headache or vice versa. The number of IHS criteria fulfilled increased significantly from the first to the second examination. The reason for diagnosing IHS 1.7 and IHS 2.3 most often was a short headache duration or headache characteristics not meeting the criteria. By reducing the minimum headache duration to 1 h, 11 of 58 patients could be diagnosed as migraine without aura. There was a remarkable overlap in the diagnostic criteria for migraine without aura and tension-type headache. In IHS 1.7 and IHS 2.3 this overlap exceeded 80%, with a trend to decrease at the second examination.     

Effect of age on the fulfilment of the IHS criteria for migraine in children at a headache clinic

In a headache clinic, 247 children suffering from severe recurrent headaches were studied in relation to the IHS criteria for migraine. Of the 247, 163 had migrainous headache, with 110 (67.5%) of these having migraine in accordance with the IHS criteria. The remaining 53 (32.5%) had headache attacks fulfilling all but one of the IHS criteria. Coverage of the IHS criteria for migraine was 93%. Symptoms of unilateral headache, aggravation by physical activity, and nausea showed the greatest differences in frequency between those with migraine and those with probable migraine. All children with aura fulfilled criteria for migraine. Children with migraine with aura (11.8, 95% CI: 11.0–12.6 years) were older than those without aura (10.1, 9.4–10.8 years; p = 0.001). Children with pulsating headache were slightly older than children without pulsating headache. No differences in age were detected for the other IHS criteria.     

Short migraine attacks of less than 2 h duration in children and adolescents

We studied the duration of migraine attacks among children and adolescents who reported headache attacks lasting <2 h. Among the 720 children who attended our specialist headache clinic, over a period of 6 years, 231 children had migraine with or without aura fulfilling the International Headache Society (IHS) criteria for the diagnosis of migraine. A further 15 children reported headache attacks typical of migraine, but of duration <2 h. They were asked to fill prospective headache diaries in order to determine with accuracy the duration of their headache attacks. Ten (67%) of these children provided prospective fully analysable headache diaries and recorded a total of 120 headache attacks, 66 attacks (55%) lasting for <1 h each, 30 attacks (25%) lasting between 1 and 2 h, and 24 attacks (20%) lasting >2 h. Patient-based analysis of the headache diaries showed that only three children consistently had headache attacks lasting <1 h. Seven children had some of their headache attacks lasting for at least 1 h and four had some of their headache attacks lasting at least 2 h. This study shows that headache attacks in children with migraine can be variable, and brief attacks are rare. A combination of short (<1 h) and long (>2 h) attacks of headache can coexist in the same patient. The IHS diagnostic criteria of 1988 for migraine in children should therefore acknowledge such variation and allow reduction of the duration of migraine attacks to 1 h.     

Clinical Characteristics of Migraine and Episodic Tension-Type Headache in Relation to Old and New Diagnostic Criteria

Eighty-one patients were diagnosed as having migraine, tension headache or both according to previously used criteria. Then we performed a standardized interview to determine the frequency and severity of headache characteristics used in the new operational diagnostic criteria of the International Headache Society (IHS). In every patient the original diagnosis fulfilled also the IHS criteria, but in 9 patients the criteria were only fulfilled in half or less of the attacks, and applying the IHS criteria they also achieved an additional diagnosis. In one patient these attacks did not fulfill the pain criteria and in 8 (4 migraine, 4 tension headache) they did not fulfill the criteria for accompanying symptoms. Overall the IHS criteria are sensitive and specific, but they may possibly be improved with regard to accompanying symptoms. The present study suggests that recording of frequency and graded severity of characteristics using a headache diary may further improve the distinction between the different types of headache.     

Migraine without aura and migrainous disorder in children; International Headache Society (IHS) and revised IHS criteria

The widely used criteria of the IHS to define migraine without aura in children are highly specific but show poor sensitivity, with a large percentage of headaches being classified as migrainous disorder (MD). The objective of this study was to assess how many headache patients in a series of children met the diagnostic criteria of the IHS for migraine without aura or MD and to determine the changes required to convert the greatest number of MD into migraine without aura, without affecting classification of the remaining headache types. A prospective study was undertaken of 131 patients under 15 years old referred to our centre for headache. Patients were classified according to the IHS criteria and according to a modification of these criteria consisting of: (1) reduction of minimum time required for classification into migraine without aura from 2 h to 1 h; (2) acceptance of bifrontal location in addition to hemicranial; (3) acceptance of either phonophobia or photophobia as valid criteria instead of requiring presence of both. Using the IHS criteria, 51 (39%) children were diagnosed as having migraine without aura and 26 (20%) as having MD. According to our revised IHS criteria, 68 (52%) were diagnosed as migraine without aura and nine (7%) as MD. When the three modified criteria were applied, three tension headaches and one unclassifiable headache changed category. When only reduced duration and bifrontal location were applied, none of the headaches other than MD changed category. Application of two modifications to the IHS criteria--reduction in duration of headache to 1 h and acceptance of bifrontal location--increased sensitivity without reducing specificity in classifying migraine without aura in children.     

Responsiveness of non-IHS migraine and tension-type headache to sumatriptan

In a long-term efficacy and satiety study, 424 patients were treated with sumatriptan (6 mg sc) for 1,904 migraine attacks. The patients were diagnosed with migraine based on IHS criteria but individual migraine attacks treated in the study were physician diagnosed; not necessarily required to meet IHS criteria. A re-analysis of the treatment response to open label sumatriptan (6 mg sc) indicated that 43 patients had treated at least one migraine that fulfilled IHS criteria for tension-type headache. Analysis of this population revealed they treated 232 headaches. Of these headaches, 114 were classified per IHS criteria as migraine; 76 as tension-type; and 42 as. non-IHS migraine (not classifiable as IHS migraine or IHS tension-type headache). Of the 114 migraines a positive response to sumatriptan occurred in 109 (96%) cases; of the 76 tension-types, 73 responded to sumatriptan (97%); of the 42 non-IHS migraine, 40 (95%) responded to sumatriptan. An equivalent response to sumatriptan among three diagnostic groups of headache supports the concept of a common biologic mechanism involving 5HT₁ receptors that spans a range of clinical presentations.     

Migraine in childhood and adolescence. A critical study of the diagnostic criteria and of the influence of age on clinical findings

We studied 253 children aged <15 years. Phase 1 included 193 children with migraine (1.1 and 1.2) divided into two groups (<10 and ≥ 10 years). We studied the relationship between age and migraine type, headache characteristics, and associated symptoms of the International Headache Society (IHS) definition. A higher frequency of migraine with aura, pulsatile quality, and unilateral location was observed in older children. In phase 2 we studied 176 children with headache (excluding migraine with aura), comparing diagnostic criteria, definition items, sensitivity, and specificity. The results showed that item B of the definition was the most frequent cause of exclusion in the 1.7 diagnostic group. Compared with Vahlquist and the IHS, the Prensky criteria were the most sensitive. Sensitivity was >70% for pain of moderate/severe intensity, duration between 2 and 48 h, isolated photophobia, isolated phonophobia, and aggravation with physical activity. Specificity was >70%, for nausea, vomiting, phonophobia and photophobia, isolated photophobia, aggravation with physical activity, and isolated phonophobia. Based on three alternative definitions, each modifying one item of the IHS definition, the sensitivity and specificity of these alternative definitions were compared with the "extended" criteria (children with migraine without aura and migrainous disturbance, according to the IHS criteria, grouped together). Exclusion of headache duration increased sensitivity by 10%, compared to restrictive IHS criteria, without decreasing specificity.     

IHS Criteria for Migraine and Tension-Type Headache in Children and Adolescents

We investigated the influence of age on the IHS criteria for migraine and tension-type headache in 437 consecutive children and adolescents and found the following age-associated statistically significant differences: migraine duration, occurrence of migraine aura, and bilateral location of tension-type headache were more often fulfilled by adolescents, whereas aggravation of headache by physical activity (in migrainous disorder) and photophobia (in migraine with aura) were more often fulfilled by children, Accordingly, there are only a few, differences concerning the fulfillment of the IHS criteria for migraine and tension-type headache in children and adolescents. Independent of age, the intensity of headache and the presence or absence of nausea are most important for differentiating the two major types of idiopathic headache. The sensitivity of the IHS criteria for migraine could be increased by reducing the minimum duration of migraine and by allowing the diagnosis of migraine when severe headache is associated with nausea, even though the criteria of location, quality, and aggravation by physical activity are not fulfilled.     

One-year prevalence of migraine in Sweden: a population-based study in adults

A randomly selected sample of 1668 individuals (782 women and 886 men) aged 18-74 years was interviewed by telephone using a standardized questionnaire including the International Headache Society (IHS) criteria for migraine. The survey was performed by SIFO, the national public opinion poll agency. The results obtained demonstrate that 21% of the Swedish population had suffered from severe headaches during the past year. A majority of these headache sufferers (61%) fulfilled the IHS-criteria for migraine. The 1-year prevalence of migraine in Sweden was found to be 13.2 +/- 1.9% (16.7% among women and 9.5% among men). The prevalence of migraine in this Swedish population did not differ between the northern, middle and southern part of Sweden, or between urban and rural areas or different income groups. Only about half (49%) of the migraineurs had been diagnosed by a physician. Among the individuals who fulfilled the IHS criteria for migraine the mean attack-frequency was 1.3 per month and the mean attack-duration was 19 h. If the duration of the attack was disregarded as a strict criterion for migraine (attacks < 4 h and > 72 h were included), the prevalence increased to 17.0 +/- 1.9% without affecting the sex distribution. With this amendment, 92% of those who considered their headaches to be migraine or migraine-like in fact fulfilled the alternative criteria for migraine. However, only 76% of those who believed that they had migraine or migraine-like headaches fulfilled the strict IHS criteria for migraine. An extension of the time window from 4 to 72 h may be reasonable both from a pragmatic and from a rational clinical point of view.     

Chronic tension-type headache in children and adolescents

In this study, the causes, predisposing factors and clinical features of chronic daily headache in children and adolescents were studied within the population of patients attending a specialist headache. The International Headache Society's (IHS) criteria for the diagnosis of chronic tension type headache (CTTH) were assessed for their applicability in the paediatric age group. Over a period of three years, demographic and clinical data were collected prospectively on all children who attended the clinic and suffered from daily attacks of headache. One hundred and fifteen children and adolescents (32% of all clinic population) had chronic daily headache, of whom 93 patients (81%) fulfilled the IHS criteria for the diagnosis of CTTH. They were between 3-15 years of age (mean: 11.1, SD: 2.3) and their female to male ratio was 1.2 : 1. Around one third of the patients also suffered from migraine (mainly migraine without aura). The headache was described as mild in 60.9%, moderate 36.5% and severe 2.6%. Headache was located at the forehead in 53% or over the whole of the head in 29.6%. Pain was described as 'just sore' or dull by 73.9%. During attacks of headache, at least half the patients reported light intolerance, noise intolerance, anorexia or nausea. Thirty-two percent of patients had at least one underlying chronic disease that may have contributed to the pathogenesis of the CTTH. Eleven percent had serious stressful events related to family illnesses and in four patients headaches were triggered by family bereavement. Fourteen percent were investigated with neuroimaging and 22% were referred for clinical psychology assessment and management. In conclusion, CTTH is a common cause of headache in children attending a specialist headache clinic. The clinical features closely match those of adult population and the IHS criteria for the diagnosis of CTTH can be adapted for use in children. Predisposing stressful risk factors, physical or emotional, are present in a large proportion.     

Diagnosis of migraine in children attending a pediatric headache clinic

The International Headache Society (IHS) criteria for migraine are not sufficient to diagnose migraine in children. Specifically, the duration and localization of the headache are different in children and adults with migraine. This study compared the formal IHS criteria with pediatric-amended IHS criteria and IHS criteria with the duration factor removed in children younger than 18 years. In addition, the older criteria by Vahlquist and by Prensky and Sommer were also compared. Finally, clinical diagnosis of migraine was compared with IHS criteria with the duration factor removed. The study showed that many children with a shorter duration headache have migraine and also that a number of children with a very long duration of headaches still fit the diagnosis of migraine. Unilateral headache is quite uncommon. The majority of children with migraine complained of bilateral headaches. It is concluded that the IHS criteria for pediatric migraine should be revised. We suggest making the duration factor a minor criteria for migraine in children or to exclude headaches lasting longer than 72 hours only in children younger than 15 years.     

A nationwide survey of migraine in France: prevalence and clinical features in adults

In November 1990 a nationwide survey of migraine was conducted in France on a representative sample of residents aged 15 years and older. The diagnosis of migraine was based on the International Headache Society (IHS) classification. In a previous study, we validated a diagnostic algorithm which classifies headache sufferers as IHS migraine, "borderline" migraine, possible migraine and non-migrainous headache. The overall prevalence of migraine patients with the IHS criteria in the present study was 8.1%; another 4% were classified as "borderline" migraine, which we in fact considered as definite migraine. Age, gender and occupation were found to be risk factors for migraine. Neither frequency and duration of attacks nor length of time of disease differed with gender. Expressed intensity of attacks, however, was greater in females.     

A nationwide survey of migraine in France: prevalence and clinical features in adults. GRIM.

In November 1990 a nationwide survey of migraine was conducted in France on a representative sample of residents aged 15 years and older. The diagnosis of migraine was based on the International Headache Society (IHS) classification. In a previous study, we validated a diagnostic algorithm which classifies headache sufferers as IHS migraine, "borderline" migraine, possible migraine and non-migrainous headache. The overall prevalence of migraine patients with the IHS criteria in the present study was 8.1%; another 4% were classified as "borderline" migraine, which we in fact considered as definite migraine. Age, gender and occupation were found to be risk factors for migraine. Neither frequency and duration of attacks nor length of time of disease differed with gender. Expressed intensity of attacks, however, was greater in females.     

CGRP may play a causative role in migraine

Calcitonin gene-related peptide (CGRP) has been detected in increased amounts in external jugular venous blood during migraine attacks. However, it is unknown whether this is secondary to migraine or whether CGRP may cause headache. In a double-blind crossover study, the effect of human alphaCGRP (2 microg/min) or placebo infused intravenously for 20 min was studied in 12 patients suffering from migraine without aura. Headache intensity was scored on a scale from 0 to 10. Two patients were excluded due to severe hypotension and one because she had an infection. In the first hour median peak headache score was 1.0 in the halphaCGRP group vs. 0 in the placebo group (P < 0.01). During the following 11 h all patients experienced headaches after halphaCGRP vs. one patient after placebo (P = 0.0004). The median maximal headache score was 4 after CGRP and 0 after placebo (P = 0.006). In three patients after halphaCGRP, but in no patients after placebo, the delayed headache fulfilled the IHS criteria for migraine without aura. As intravenous administration of halphaCGRP causes headache and migraine in migraineurs, our study suggests that the increase in CGRP observed during spontaneous migraine attacks may play a causative role.     

Outcome of juvenile headache in outpatients attending 23 Italian headache clinics. Italian Collaborative Study Group on Juvenile Headache (Società Italiana Neuropsichiatria Infantile [SINPI])

A multicenter 3-year follow-up study was carried out on young patients with headache referred to tertiary headache centers or pediatric clinics. Three years after the first examination in 1993, 442 (of an original sample of 719) young outpatients with headache (226 females and 216 males) were re-examined. The diagnostic criteria of the International Headache Society (IHS) and those modified for migraine without aura by Winner et al were applied at both the baseline evaluation and the 3-year re-examination. At the follow-up, 290 children still had headache, 101 were in clinical remission, and 51 had dropped out. Using the current diagnostic criteria, only 46.2% of patients having migraine without aura, 50% of those having migraine with aura, and 35.3% of those suffering from migraine disorders which do not fulfill IHS criteria for migraine received the same diagnosis at the time of follow-up. The percentage of patients receiving a diagnosis of migraine without aura rose significantly when new modified criteria were used (60.5%), whereas a drop in the frequency of migraine disorders not fulfilling IHS criteria was observed at follow-up, both in patients with the diagnosis of migraine without aura at the first examination (4.6%) and in patients with migraine not always fulfilling IHS criteria at the first examination (6.2%). Among all patients who received this latter diagnosis at the first examination, it was possible to make a diagnosis of migraine with aura at the follow-up in 8.8% of cases and that of migraine without aura in 26.5%. No significant variations in the frequency of either episodic tension-type headache or chronic tension-type headache were found, with the exception of a slight decrease in the percentage of tension-type headache which did not fulfill IHS criteria, but the difference between the first examination and the follow-up values does not reach the level of statistical significance (5% versus 12%). As far as the evolution of migraine is concerned, 17.4% of patients with migraine were headache-free at the 3-year follow-up. In tension-type headache, the percentage of patients who were headache-free was particularly high in those with the episodic form (32.9%) and in those suffering from tension-type headache not fulfilling IHS criteria (29.1%). The majority of patients who had been diagnosed as having unclassifiable headache at the first examination received a correct diagnosis at the follow-up with the exception of one patient. As observed in adult patients, variations in the headache characteristics were also observed in children and adolescents (that is, migraine with aura can change to migraine without aura, or the latter can transform into episodic tension-type headache or chronic tension-type headache can change into the episodic form). This follow-up study was aimed at reaching a better understanding of headache disturbances in children and adolescents, examining, in particular, variations of headache with time in this stage of life.     

Diagnosis of migraine: empirical analysis of a large clinical sample of atypical migraine (IHS 1.7) patients and proposed revision of the IHS criteria

The International Headache Society (IHS) diagnostic criteria for headache improved the accuracy of primary headache diagnoses, including migraine. However, many migraineurs receive an 'atypical migraine' diagnosis according to the IHS nosology (IHS 1.7), indicating that they approximate but do not fully meet all IHS criteria. This study characterized and sub-classified patients with atypical migraine. Within a clinical sample of 382 headache sufferers, 83 patients met IHS criteria for 'atypical migraine'. Patients receiving the IHS 1.7 designation did not converge to form a homogeneous group. Rather, distinct and clinically relevant subgroups were empirically derived (e.g. migraine with atypical pain parameters, brief migraine, chronic migraine). The results call for revisions of the IHS diagnostic criteria for migraine that would minimize the number of patients receiving an atypical diagnosis. Revisions would include decreasing the minimum headache duration criteria from 4 h to 2 h, and developing a classification for 'chronic migraine' for migraine greater than 15 days per month. The proposed revision provides a means of diagnosing the daily and near-daily headache commonly observed in clinical populations.     

Cephalic venous congestion aggravates only migraine-type headaches

We performed the Queckenstedt's (Q)-test (compression over bilateral internal jugular veins) and a sham test on 33 patients with migraine attacks (coded as 1.1 based on headache classification proposed by International Headache Society (IHS)), 15 with migrainous attacks (IHS code 1.7), and 15 with tension-type headache (IHS code 2.1) in both supine and sitting positions. 'Migrainous headache' (code 1.7) was defined if the headache characteristics fulfilled all but one criteria for 'migraine without aura'. Migraine sufferers reported a marked increase in headache intensity after a 30-second Q-test in both supine and sitting positions. Aggravation was greater in the supine position. The intensity increase was not demonstrated in the sham test, or in patients with migrainous attacks or tension-type headaches after the Q-test. Patients with acute migraine thus appear more sensitive to increased cerebral venous pressure or intracranial pressure. The discrepancy of intensity changes between supine and sitting positions may reflect different amount of venous return through the internal jugular veins.     

Characteristics,impact and treatment of 6000 headache attacks: The PAMINA study

The aim of this study was to prospectively evaluate the characteristics of headache attacks, their impact on daily activities as well as the type and efficacy of acute medication in patients with migraine. We included 281 patients with episodic migraine (87% females, aged 41.2±12.1). All patients kept a headache diary for 3 months covering headache characteristics, therapy and questions adopted from the Headache Impact Test (HIT‐6) for rating the impact of each single headache attack (HIT‐6 s). For evaluating the efficacy of acute medication we compared triptans with other compounds using headache duration as outcome parameter. Of 6051 headache attacks 52.8% fulfilled the ICHD‐II criteria of migraine. The HIT‐6 s score was 2.4±2.2 (range 0–6). It was lowest in untreated headaches (2.0±2.1) and highest in those treated with a combination of triptans and other compounds (4.1±2.0, p <0.001). Patients used triptans on 8.0% of all headache days, other compounds on 33.1%, a combination of both on 1.5% and no medication on 57.3% of the headache days. Migraine attacks of moderate or severe intensity treated with triptans alone lasted significantly shorter than those treated with other compounds (5.1±3.6 vs. 6.9±5.3 h, p <0.001). In conclusion, almost 50% of the headaches occurring in patients with migraine do not fulfill migraine criteria. Use of triptans is associated with a shorter duration of moderate and severe migraine attacks compared to use of other compounds.     

Clinical characteristics of tension-type headache and migraine in adolescents: a student-based study

BACKGROUND AND OBJECTIVES: Adolescent headaches, particularly migraine, might present with different features from adult headaches. The objectives of this study were to investigate the characteristics of tension-type headache and migraine, to find the sensitivity and specificity of the diagnostic criteria of the IHS classification according to age and gender. METHODS: A multistep, stratified, cluster sampling method was used for subject selection. The estimated sample size was 2387. The study was conducted in two phases: the questionnaire and the face to face interview phases. During the semistructured interview, a clinical diagnosis has been made and clinical characteristics have been recorded. RESULTS: All headaches fulfilled the criteria of duration. The most common feature of migraine was moderate to severe (92.4%), pulsating pain (79.2%). For ETTH, bilateral localization (91.3%) and mild to moderate pain intensity (90.6%) were the most common features. Younger adolescents showed mixed headache characteristics. Highest sensitivities for migraine were duration (100%), moderate to severe pain (92.4%), and pulsating quality of pain (79.2%). Vomiting, trigger factors food and alcohol had a high specificity for migraine. CONCLUSIONS: Our data strongly support continuum hypothesis. In early adolescence headaches might present with mixed headache characteristics. Age and gender have some influence on headache characteristics, particularly on migraine. The sensitivity and specificity of case definition criteria of ICHD-2 for adolescent migraine is moderate and need to be reconsidered.