American Headache Society members' assessment of headache diagnostic criteria

OBJECTIVE: We assessed the views of physicians interested in headache as to the diagnosis of the most commonly occurring and currently controversial headaches. BACKGROUND: The International Headache Society (IHS) classification system has received wide professional endorsement and considerable empirical support, but in the United States, their adoption by clinicians may be proceeding more slowly. Questions remain, including what diagnostic criteria for migraine and tension-type headache clinicians may continue to favor over those outlined by the IHS, to what extent is the "transformed migraine" diagnosis used in clinical practice, and how is analgesic rebound headache diagnosed with regard to the various quantitative measures of analgesic use. METHODS: Members of the American Headache Society rated the importance of IHS and non-IHS diagnostic criteria for migraine and tension-type headache and for analgesic rebound headache. Respondents also described their use of the proposed transformed migraine diagnosis. RESULTS: Two-thirds (67.3%) of the respondents reported use of the IHS criteria or the IHS criteria in conjunction with clinical judgment. For migraine and tension-type headache, IHS criteria were rated with high importance, but some respondents reported using additional non-IHS diagnostic criteria and de-emphasizing certain IHS criteria. For chronic headache, almost two-thirds (63%) of respondents reported using the transformed migraine diagnosis. For analgesic rebound headache, respondents preferred to make the diagnosis based on medication consumption that is lower than amounts stipulated in the IHS classification system. CONCLUSIONS: There remains a number of physicians interested in headache who do not use the IHS classification system, who modify the IHS criteria in practice, and who use the "transformed migraine" diagnosis for patients with chronic daily headache.     

Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study

CONTEXT: Headache experts have suggested that to improve the recognition of migraine, patients with a stable pattern of episodic, disabling headache and a normal physical exam should be considered to have migraine in the absence of contradictory evidence. The premise upon which this approach is based-that is, that episodic, recurrent primary headache in the clinic is usually migraine-has not been evaluated in prospective clinical studies. OBJECTIVES: To (1) evaluate the diagnoses of patients consulting their physician with primary episodic headache and (2) compare clinic diagnoses and patient self-diagnoses with International Headache Society (IHS) headache diagnoses assigned on the basis of longitudinal data from patient diaries. DESIGN: Prospective, open-label study. During the screening visit, patients self-reported a headache diagnosis and then were assigned a headache diagnosis by their physician following his or her customary practice. Patients with a new physician diagnosis of migraine or nonmigraine primary headache were given diaries to record headache symptoms for up to 3 months or 6 attacks. Members of an expert panel, unaware of the clinic diagnosis, used diary data to assign a headache diagnosis to each attack and to each patient. SETTING: One hundred twenty-eight (128) practices in 15 countries including the United States. PATIENTS: A total of 1203 male and female patients between 18 and 65 years of age who consulted their physician with headache as a primary or secondary complaint. RESULTS: Overall, 94% of patients with a physician diagnosis of nonmigraine primary headache or a new clinic diagnosis of migraine had IHS-defined migraine (76%) or probable migraine (migrainous) (18%) headache on the basis of longitudinal diary data. A new clinic diagnosis of migraine was almost always correct: 98% of patients with a clinic diagnosis of migraine had IHS-defined migraine (87% of patients) or probable migraine (11% of patients) headache on the basis of longitudinal diary data. On the other hand, review of diaries of patients with a clinic diagnosis of nonmigraine revealed that 82% of these patients had IHS-defined migraine (48%) or probable migraine (34%) headache. Altogether, one in four patients (25%) with IHS-defined migraine according to longitudinal diary data did not receive a clinic diagnosis of migraine. CONCLUSIONS: These findings support the diagnostic approach of considering episodic, disabling primary headaches with an otherwise normal physical exam to be migraine in the absence of contradictory evidence. If in doubt of diagnosis or when assigning a nonmigraine diagnosis, strong consideration should be given to the use of a diary to confirm primary headache diagnosis.     

The IHS Classification Criteria for Migraine Headaches in Adolescents Need Minor Modifications

The operational and diagnostic criteria for migraine and all other headache disorders released in 1988 by the International Headache Society are universally considered reliable and exhaustive. These criteria, however, cannot be considered as satisfactory for population-based studies on migraine prevalence, especially if adolescents are the subjects of the study.
Using these diagnostic criteria, we conducted an epidemiological study in order to assess the prevalence of migraine headache in a student population aged 11 to 14 years. Our survey made it possible to code IHS 1.1 (migraine without aura) in 2.35%, IHS 1.2 (migraine with aura) in 0.62%, IHS 1.7 (migrainous disorders not fulfilling migraine criteria) in 1.52%, and IHS 13 (headache not classifiable) in 1.38% of the examined pupils.
In adolescents, the low prevalence estimates of migraine headache coded IHS 1.1 and the relatively high prevalence estimates of headaches coded IHS 1.7 and IHS 13 have appeared to be a consequence of the rigidity of some operational diagnostic criteria of the recent IHS classification rather than of the geographical, environmental, or socioeconomical pecularities of the cohort.
Therefore, in order to improve the reliability and the exhaustiveness of the IHS classification by increasing its sensitivity, we believe that minor modifications of the diagnostic criteria are necessary. Within these revised criteria, the subitem "moderate or severe intensity" of pain headache should become mandatory, whereas the lower limit of the criterion "duration of pain" should be reduced to 1 hour.     

Prevalence of menstrually related migraine and nonmigraine primary headache in female students of Belgrade University

OBJECTIVES: To determine prevalence and characteristics of menstrually related migraine and nonmigraine headache in female students of Belgrade University. METHODS: A questionnaire was administered to female students during randomly selected classes of the Schools of Medicine and Pharmacy. Diagnoses were assigned according to the criteria of the International Headache Society and MacGregor's stricter definition of "menstrual" migraine. RESULTS: Of 1943 female students (18 to 28 years old), 1298 (66.8%) had primary headaches. Among 1298 students with headache, 245 (12.6%) had migraine and 1053 (54.2%) had nonmigraine headache. The prevalence rates of migraine versus nonmigraine headache in relation to the menstrual cycle were: premenstrual, 0.9% versus 4.4%; menstrual, 1.5% versus 1.5%; menstrually associated, 6.1% versus 10.1%; menstrually unchanged, 2.7% versus 19.2%; and menstrually unrelated, 1.4% versus 18.9%. Female students with migraine had menstrually related attacks more frequently than students with nonmigraine headache (67.7% versus 29.5%). This difference was most prominent among students with menstrual migraine compared with students with menstrual nonmigraine headache (12.2% versus 2.7%). Exacerbation of migraine during menstruation was slightly more severe and more complex than exacerbation of nonmigraine headache. Female students with migraine versus nonmigraine headache did not differ significantly in age, age at onset of menarche, or age at onset of headache. Female students with migraine were significantly more likely to report a positive family history for migraine and menstrual migraine, severe attacks, reduced work activity, and aura. CONCLUSION: The results obtained are in accord with the prevailing opinion that there is a relationship between migraine and female sex hormones, and suggest that women with nonmigraine headache are also susceptible to hormonal fluctuations.     

Quality of Life and Productivity in Nurses Reporting Migraine

A random sample survey was conducted to determine the prevalence of migraine in nurses and to study its effect on quality of life and productivity. Of the 10 000 nurses sampled, 2949 returned the questionnaire for a response rate of 29.5%. The majority (99%) of respondents were employed and worked in hospitals (60%). According to the International Headache Society (IHS) criteria, 17% of the sample (n=495) were classified as having migraine. An additional 25% (n=750) suffered severe headaches but did not meet IHS criteria for migraine, and the remaining 58% (n=1704) were classified as not having either migraine or severe headaches. The migraineurs had significantly reduced work productivity and quality of life compared to both the severe headache and the nonmigraine nonsevere headache groups. This study will increase awareness and sensitivity of the profession to its colleagues who are migraine sufferers.     

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.     

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.     

Variability of reported headache symptoms and diagnosis of migraine at 12 months

Assignment of a diagnosis of migraine has been formalized in diagnostic criteria proposed by the International Headache Society. The objective of the present study is to determine the reproductibility of the formal diagnosis of migraine in a cohort of headache sufferers over a one-year period. The study was performed in a community cohort taking part in a long-term prospective health survey, the GAZEL study. Two thousand five hundred individuals reporting headache in the GAZEL cohort were sent two postal questionnaires concerning headache symptoms and features at 12-monthly intervals. Replies to the questions allowed a migraine diagnosis to be attributed retrospectively using an algorithm based on the IHS classification scheme. The response rate was 82% for the first questionnaire and 69% for both questionnaires. Of the 1733 subjects providing information at both time-points, the agreement rate for the diagnosis of strict migraine (IHS categories 1.1 or 1.2) was 77.7% (kappa = 0.48), with 62.2% of the patients with this diagnosis (IHS categories 1.1 or 1.2) at Month 0 retaining the same diagnosis at Month 12. When diagnostic criteria were widened to include IHS category 1.7 (migrainous disorder), the agreement rate of the diagnosis was similar at 77.6% (kappa = 0.52), but 82% of the patients with this diagnosis (IHS categories 1.1 or 1.2 or 1.7) at Month 0 now retained the same diagnosis at Month 12. In conclusion, the one-year reproducibility of reporting of migraine headache symptoms is only moderate, varies between symptoms, and leads to instability in the formal assignment of a migraine headache diagnosis and to diagnostic drift between headache types. This finding is compatible with the continuum model of headache, where headache attacks can vary along a severity continuum from episodic tension-type headaches to full-blown migraine attacks.     

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.     

A structural representation of migraine diagnostic criteria: the experts' view

OBJECTIVE: To generate an empirically derived structural representation of migraine diagnostic criteria in a group of international headache experts using the Pathfinder network scaling algorithm in order to evaluate the validity of the migraine criteria used in the International Headache Society (IHS) classification system. BACKGROUND: Because it is a disease entity that lacks objective defining markers, developing valid diagnostic criteria for migraine is a challenge. The IHS committee relied on expert consensus to develop their classification system in 1988. Expert consensus also was used to evaluate the validity of the IHS classification system, but further studies employing alternative methods still are needed. METHODS: Headache experts representing the Executive Committee of the IHS and the Board of Directors of the American Headache Society analyzed 14 criteria (7 IHS and 7 non-IHS) considered relevant in diagnosing migraine. Their ratings were submitted to the Pathfinder algorithm to generate a network structure reflecting the experts' conceptualization of migraine diagnostic criteria. RESULTS: The expert network had 3 groupings: headache characteristics (eg, phonophobia, unilateral pain, throbbing pain), biological contributing factors (eg, family history, hormonal relationship, relief with sleep), and triggering factors (eg, worse with stress, food triggers). The IHS criteria were clustered together in the center portion of the network. A t test showed that each IHS criterion was closer conceptually to other IHS criteria than to non-IHS criteria. Graph theory indices revealed that the most central criteria were unilateral pain, moderate/severe intensity, and nausea/vomiting. CONCLUSION: The structural representation of migraine diagnostic criteria from these international headache experts is consistent with the migraine diagnostic criteria set forth in the IHS classification system and thus provides further support for the validity of migraine criteria in the IHS system.     

CT观察中鼻甲气化及其与慢性前组鼻窦炎的关系

目的 探讨中鼻甲气化的CT表现、诊断标准及分类,评价中鼻甲气化与慢性前组鼻窦炎的关系。 方法 回顾性分析248侧中鼻甲气化的CT图像,观察冠状位图像中鼻甲气化表现特征,尝试界定中鼻甲垂直部气化标准及垂直部高位与低位气化的标准。分析中鼻甲气化与慢性前组鼻窦炎的关系。 结果 不同类型中鼻甲气化具有不同的CT表现。鼻窦炎与无鼻窦炎者的中鼻甲气化数量差异有统计学意义。不同中鼻甲气化类型之间慢性额窦炎的数量差异无统计学意义,慢性前组筛窦炎及上颌窦炎的数量差异有统计学意义。鼻窦炎程度积分与中鼻甲垂直部低位气化的大小之间无相关性。 结论 鼻窦冠状位CT对于中鼻甲气化观察分析有重要价值。中鼻甲气化很可能是慢性前组鼻窦炎的潜在危险因素,而且不同气化类型引起鼻窦炎的危险性不尽相同。     

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.     

Headache syndromes amongst schoolchildren in Riyadh,Saudi Arabia

We evaluated 1,400 randomly selected Saudi children in grades 1 through 9 to determine the prevalence of migraine and tension-type headache. Of the 1400 distributed questionnaires, 1,181 (84.3%) were completed properly and so served as the basis for analysis. There were 573 boys (48.5%) and 608 girls (51.5%). Ages ranged from 6 to 18 years. Five hundred eighty-eight children (49.8%; 272 boys and 316 girls) had recurrent headache episodes not related to febrile illness in the year preceding the survey. Eighty-four children (7.1%; 37 boys and 47 girls) had recurrent episodes of migraine, and 504 (42.7%; 232 boys and 272 girls) had recurrent episodes of nonmigraine headache. For both boys and girls, the age-specific prevalence rate for nonmigraine headache rose steadily from around 15% at aged 6 to 7 years to nearly 60% after aged 15. For migraine, there was a sharp increase in the prevalence rate (from around 2% to around 9%) at aged 10 to 11, also in both boys and girls. Age-adjusted prevalence for migraine between aged 6 and 15 was 6.2%. Due to the relatively poor sensitivity of some of the IHS criteria in children, this figure may underestimate the true magnitude of migraine in the population studied.     

Assessment of International Headache Society diagnostic criteria: a reliability study

In 1988 the International Headache Society (IHS) introduced new diagnostic criteria for headaches and craniofacial pain. Since headaches can be diagnosed solely on the basis of information provided by the patient, it is essential that the criteria are reproducible and consistent. Two neurologists evaluated the clinical records of 100 consecutive outpatients and transferred the data on headache and associated phenomena to a form designed to reflect the IHS criteria. Interobserver concordance (kappa statistics) in the application of the diagnostic criteria of primary headaches was: (i) "perfect" to "substantial" for the first IHS digit, being kappa = 1.0 for cluster headache and paroxysmal hemicrania; kappa = 0.88 for migraine; kappa = 0.75 for tension-type headache; (ii) "almost perfect" to "substantial" for the second digit (kappa = 0.94 for cluster headache; kappa = 0.90 for migraine with aura; kappa = 0.81 for episodic tension-type headache; kappa = 0.78 for migraine without aura; kappa = 0.71 for chronic tension-type headache; kappa = 0.66 for cluster headache-like disorder not fulfilling the criteria; (iii) "moderate" for migrainous disorder (kappa = 0.48) and headache of the tension-type (kappa = 0.43) not fulfilling the criteria. These results show that the IHS diagnostic criteria are satisfactorily applicable to high quality medical records abstracted by experienced neurologists.     

"Symptomatic Migraine": Intracranial Lesions Mimicking Migrainous Headache -A Report of Three Cases

Case reports of three headache patients, two with intracerebral meningioma and one with hydrocephalus are presented, in whom the clinical picture fulfilled the criteria of the International Headache Society (IHS) for the diagnosis of migraine. The symptomatic (ie, lesional) nature of the headaches could be detected by neither clinical neurological examination nor routine investigations such as EEG and skull x-ray. On the other hand, brain imaging techniques (CT, MRI) were found to be of particular in value diagnosing the lesions. Our cases indicate that neuroimaging with CT or MRI in the assessment of headache patients should not be handled too restrictively. Compared to CT, however, the additional diagnostic value of MRI in headache seems to be limited.     

Chronic daily headache. How should it be included in the IHS classification?

A number of patients attending specialty headache centers complain of very frequent, almost continuous or continuous headaches, which are usually grouped together under the term chronic daily headache , a category which does not appear in the International Headache Society (IHS) classification. On the basis of the IHS criteria, these patients can only be classified as having a chronic tension-type headache with the possible addition of migraine, if migrainous attacks are superimposed on the "background" headache. However, several studies have demonstrated that most patients with chronic daily headache originally suffered from migraine and that their migraine has transformed, in the course of time, into a chronic headache picture in which isolated migraine attacks may or may not persist. Despite some differences in the personal opinions of authors involved in the care of patients with chronic daily headache, some views seem to be generally accepted: (1) the great majority of chronic daily headaches are transformations of an original episodic migraine and cannot be included in the chronic tension-type headache category, (2) the current IHS classification does not allow many patients presenting with chronic daily headache to be classified correctly, (3) an important nosological category (transformed migraine) has emerged from all the studies on this subject, (4) it is impossible to diagnose transformed migraine merely by "photographing" the picture of single attacks. Although some theoretical problems remain unresolved, it seems to us that the next revision of the IHS classification can no longer ignore the existence of chronic daily 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.