Is uncertain diagnosis a more frequent reason for referring migraine patients to neurologist than other headache syndromes?

The objective was to assess whether the physician's uncertainty of diagnosis was a more frequent motivation for referring migraine patients than other headache patients to a neurologist. In this population based survey we included 846 consecutive patients referred to and examined at a specialist centre for headache during a period of 2 years. As primary outcome we compared cross-sectionally frequency of referring patients with migraine and other headaches to neurologist. According to the patients, uncertainty of diagnosis was the main reason for referral to a neurological specialist consultation, i.e. in 51% of cases. Thirty-nine per cent of patients classified as having migraine were referred because of an uncertain diagnosis, compared with 62% in patient with other headaches (95 CI 0.13–0.33), ( P  < 0.0001). Headache subtypes other than migraine and younger age were associated to more uncertainty of diagnosis. We conclude that diagnostic uncertainty was an important factor amongst half the headache patients seen by neurologists and uncertain diagnoses as reason for referral was more important amongst patients with non-migrainous headache.     

Headache in children's drawings

Headache is a common health problem in childhood. Children's drawings are helpful in the diagnosis of headache type. Children, especially younger ones, communicate better through pictures than verbally. The aim of the present study is to evaluate the usefulness of drawings of the child's headache in the diagnostic process carried out by a pediatrician and a pediatric neurologist. At the beginning of a visit in a neurological clinic, or on the first day of hospitalization, the child was asked, "Please draw your headache," or "How do you feel your headache?" without any additional explanations or suggestions. Clinical diagnosis of headache type was made on the basis of the standard diagnostic evaluation. For the purpose of this study, children's headaches were categorized as migraine, tension-type headache, or "the others." One hundred twenty-four drawings of children with headaches were analyzed by 8 pediatricians and 8 pediatric neurologists. The analysts were unaware of the clinical history, age, sex, and diagnosis of the patients. The clinical diagnosis was considered the "gold standard" to which the headache drawing diagnosis was compared. There were 68 girls 5-18 years of age and 56 boys 7-18 years of age. Of the 124 children, 40 were clinically diagnosed with migraine (32.2%), 47 with tension-type headache (37.9%), and 37 (29.8%) as the others. Children with migraine most frequently draw sharp elements. Children with tension-type headache mainly drew compression elements and pressing elements. In the group of "the other" headaches, 21 children were diagnosed with somatoform disorders. The most frequent element in this group's drawings was a whirl in the head. Colors used most frequently were black and red, which signify severe pain. There was no difference in sensitivity of diagnoses between neurologists and pediatricians. Because the evaluation of drawings by children with headaches done both by pediatricians and pediatric neurologists was correct for approximately half of the children, the authors decided to prepare a set of test pictures, including characteristic presentations of pain. Preparing a ready set of test drawings may facilitate differentiation for the inexperienced doctors and encourage those children who refuse to draw.     

Ability of a nurse specialist to diagnose simple headache disorders compared with consultant neurologists

OBJECTIVE: To compare the ability of a headache nurse specialist and consultant neurologists in diagnosing tension-type headache and migraine. METHODS: An experienced neurology ward sister was trained in the differential diagnosis of headache disorders. Over six months, patients with non-acute headache disorders and role players trained to present with benign or sinister headaches were seen by both the nurse and a consultant neurologist. Both reached independent diagnoses of various headache disorders. RESULTS: Consultants diagnosed 239 patients with tension-type headache (47%), migraine (39%), or other headache disorders (14%). The nurse agreed with the consultant in 92% of cases of tension-type headache, 91% of migraine, and 61% of other diagnoses. Where the nurse did not agree with the diagnosis, most would have been referred for a consultant opinion. Both the nurse and the doctors misdiagnosed the same three of 13 role players. The investigation rate of the consultants varied between 18% and 59%. Only one clinically relevant abnormality was found on head scans and this was strongly suspected clinically. CONCLUSIONS: A headache nurse specialist can be trained to diagnose tension-type headache and migraine. A nationwide nurse led diagnostic headache service could lead to substantial reduction in neurology waiting times.     

Recurrent headache in chinese children: any agreement between clinician diagnosis and symptom-based diagnoses using the International Classification of Headache Disorders (Second Edition)?

There has been a lack of published data on the pattern of recurrent headache in Chinese children. The validity of the International Classification of Headache Disorders criteria has not been evaluated in Chinese children. We performed a retrospective medical record review of 124 children aged <18 years with an International Classification of Diseases coding of headache followed up in a general outpatient clinic in a university-based hospital over a 3-year period (2000-2002). The aims of our study were to (1) study the pattern of recurrent headache in Chinese children and (2) study any agreement between clinical diagnoses made by our board-certified pediatricians and symptom-based diagnoses using the second edition of the International Classification of Headache Disorders (International Classification of Headache Disorders-II). The most common type was unclassified headache (70.2%), followed by infrequent episodic tension-type headache (24.2%) and migraine without aura (5.6%). A family history of headache or migraine was more commonly found in children with infrequent episodic tension-type headache or migraine without aura (P = .0109). The co-occurrence of abdominal pain with infrequent episodic tension-type headache was 30%; for unclassified headache, it was 19.5%. Dysmenorrhea occurred in 7.1% of girls with infrequent episodic tension-type headache and 8.6% of girls with unclassified headache. However, migraine without aura was not associated with abdominal pain or dysmenorrhea. Children with migraine without aura were more frequently referred to child neurologists (P = .0207) and admitted (P = .0000). Neurologic investigations, including electroencephalography, computed tomography, or magnetic resonance imaging of the brain, were performed in less than 30% of cases. Abnormal results were found in only seven cases; with two referred to a neurosurgeon and none requiring surgical intervention. Thus, by using the clinical diagnosis of our board-certified pediatricians as the standard, the sensitivity and specificity of International Classification of Headache Disorders-II-based definition of migraine without aura was 23.1% and 93.4%, respectively, and for infrequent episodic tension-type headache, it was 37.5% and 76%, respectively. The typical characteristics of migraine tend to emerge later and might have led to underdiagnosis of the younger age group, with a higher rate of referral and inpatient management. The new edition of the International Classification of Headache Disorders criteria is still restrictive in clinical practice and might not be able to reflect current pediatric practice. Further studies with a defined study period or recurrent headache might be more useful in analyzing the use of these new International Classification of Headache Disorders criteria in the diagnosis of recurrent headache in children.     

Migraine in Thai children: prevalence in junior high school students

A cross-sectional study to determine the prevalence of migraine in seventh grade Thai students in 4 junior high schools in Bangkok, Thailand, according to the diagnostic criteria of the second edition of the Classification of Headache of the International Headache Society was conducted in July 2004. The study included a screening self-administered questionnaire and face-to-face interview with physical examination. The diagnosis of migraine was made and confirmed by 2 pediatric neurologists. All of 1789 students in participating schools completed the questionnaire. After 2 interviews, 248 students (13.8%) were diagnosed with migraine. The prevalence in girls was higher than that in boys (16.2% vs 11.7%). Migraine as having aura was diagnosed in 34 students (13.7%). One student had sporadic hemiplegic migraine. Among 248 children, 176 (71%) reported the duration of headache between 1 and 2 hours. The leading precipitating factor of migraine was the stress related to daily school activities (17.7%). There were 32 students (12.9%) with frequent and intense headache who were referred to their primary physicians for further management. This study had disclosed a high prevalence of migraine in seventh grade Thai students in Bangkok City and reflected the existing burden of this illness in Thai students.     

The prevalence of migraine in neurologists

To assess the prevalence of migraine among neurologists and neurologist headache specialists, the authors performed a survey of neurologists who attended a headache review course. The 1-year and lifetime prevalences of migraine in the 220 respondents were as follows: male neurologists, 34.7%, 46.6%; male headache specialists, 59.3%, 71.9%; female neurologists, 58.1%, 62.8%; and female headache specialists, 74.1%, 81.5%. Migraine is much more prevalent among neurologists than in the general population.     

Classification of primary headaches

Given the range of disorders that produce headache, a systematic approach to classification and diagnosis is an essential prelude to clinical management. For the last 15 years, the diagnostic criteria of the International Headache Society (IHS) have been the accepted standard. The second edition of The International Classification of Headache Disorders (January 2004) reflects our improved understanding of some disorders and the identification of new disorders. Neurologists who treat headache should become familiar with the revised criteria. Like its predecessor, the second edition of the IHS classification separates headache into primary and secondary disorders. The four categories of primary headaches include migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalalgias, and other primary headaches. There are eight categories of secondary headache. Important changes in the second edition include a restructuring of these criteria for migraine, a new subclassification of tension-type headache, introduction of the concept of trigeminal autonomic cephalalgias, and addition of previously unclassified primary headaches. Several disorders were eliminated or reclassified. In this article, the authors present an overview of the revised IHS classification, highlighting the primary headache disorders and their diagnostic criteria. They conclude by presenting an approach to headache diagnosis based upon these criteria.     

Increasing incidence of medically recognized migraine headache in a United States population.

OBJECTIVE: To investigate trends in the incidence of medically recognized migraine in Olmsted County, Minnesota over approximately a decade. METHODS: The authors used the records-linkage system of the Rochester Epidemiology Project to identify individuals whose records included any diagnostic rubric related to headache for the 3-year period 1979 through 1981 and the 2-year period 1989 through 1990. A nurse abstracter and a neurologist (J.W.S.) reviewed the complete history of each potential case and assigned a diagnosis using the International Headache Society classification (IHS, modified). Only patients who consulted a doctor for their headache and had their initial visit for migraine within the study years were considered as incident cases. RESULTS: The incidence of medically recognized migraine increased in female subjects between the 1979-through-1981 period and the 1989-through-1990 period for all ages, but particularly among those who were aged 10 to 49 years. The peak incidence rate at age 20 to 29 years increased from 634.5 new cases per 100,000 person-years in 1979 through 1981 to 986.4 in the 1989-through-1990 period (absolute increase 351.9; relative increase 56%). The rise in incidence in female subjects was most sizable for migrainous disorder (IHS code 1.7); smaller increases were noted for migraine without aura and with typical aura. Only a slight absolute increase in migraine incidence rates was observed in male subjects, restricted to those 10 to 19 years of age (absolute increase 174.7; relative increase 89%). CONCLUSIONS: Although the incidence rates reported here are restricted to patients who consulted a doctor for their headache, the authors suggest that the incidence of migraine has increased over time in female subjects, especially those of reproductive age. The increase was most pronounced for migrainous disorder. Incidence rates were more stable in male subjects over time.     

Migraine with aura in patients over 50?years of age: the Marseille’s registry

The goal of this study was to describe specifically the clinical characteristics of migraine with aura in patients over the age of 50. During 1?year, three neurologists working in a tertiary headache center included all patients aged 50?years and over presenting migraine with aura in a prospective registry. Fifty-seven patients with migraine with aura aged 50?years and over were interviewed using a standardized questionnaire during a consultation. Auras were visual for all the patients, paresthesic for 16 patients, and aphasic for 16. One patient had a sporadic hemiplegic migraine. The headache followed the aura in a large majority of patients and fulfilled the International Headache Society criteria for migraine headache for 38 patients. Typical aura without headache was described in 26 patients and was the only expression of the disease for five patients. Two groups can be defined: in the first one, migraine with aura began before 50?years (39 patients). Thirty-one patients had typical aura with migraine headache and 15 complained of typical aura without headache. The second group (18 patients) included patients who developed migraine with aura over 50 for the first time. Among them, patients may have typical aura with migraine headache (seven patients), typical aura with non-migraine headache (eight patients) and/or typical aura without headache (11 patients). Late-life onset transient visual phenomena are not rare. These symptoms may occur for the first time after 50, in the absence of headache. When migraine with aura began after 50?years, headache has more often the characteristics of typical aura with non-migraine headache, or migraine may have the presentation of typical migraine without headache.     

Implementation and evaluation of existing guidelines on the use of neurophysiological tests in non-acute migraine patients: a questionnaire survey of neurologists and primary care physicians

Background and purpose:  The main aims of this study were to evaluate: the diffusion, use and perception of the usefulness of the 2004 EFNS guidelines on neurophysiological testing in non-acute headache patients; the frequency with which the different neurophysiological tests were recommended in non-acute migraine patients by physicians aware or unaware of the guidelines; and the appropriateness of the reasons given for recommending neurophysiological tests.
Methods:  One hundred and fifty physicians selected amongst the members of the Italian societies of general practitioner (GPs), neurologists and headache specialists were contacted via e-mail and invited to fill in a questionnaire specially created for the study.
Results:  Ninety-two percent of the headache specialists, 8.6% of the neurologists and 0% of the GPs were already aware of the EFNS guidelines. A significantly higher proportion of headache specialists had not recommended any neurophysiological tests to the migraine patients they had seen in the previous 3 months, whereas these tests had frequently been prescribed by the GPs and neurologists. Overall, 80%, 42% and 42.6% of the reasons given by headache specialists, neurologists and GPs, respectively, for recommending neurophysiological testing in their migraine patients were appropriate ( P  < 0.01).
Conclusions:  The diffusion of the EFNS guidelines on neurophysiological tests and neuroimaging procedures was found to be very limited amongst neurologists and GPs. The physicians aware of the EFNS guidelines recommended neurophysiological tests to migraine patients less frequently and more appropriately than physicians who were not aware of them. The most frequent misconceptions regarding neurophysiological tests concerned their perceived capacity to discriminate between migraine and secondary headaches or between migraine and other primary headaches.     

Recurrent Gastrointestinal Disturbance: Abdominal Migraine and Cyclic Vomiting Syndrome

Primary headache disorders, including migraine, are some of the most common neurological disorders presenting to hospital. Episodic syndromes that may be associated with migraine, including recurrent gastrointestinal disturbances such as abdominal migraine and cyclic vomiting, often pre-date or co-occur with the onset of migraine in a child who is at risk of developing the headache condition. The purpose of this review is to evaluate the two most common episodic syndromes, abdominal migraine and cyclic vomiting syndrome, including their pathophysiology, common presentations, and diagnostic criteria. Differential diagnosis and “red flag” features are outlined, and an approach to diagnostic work-up is offered. Finally, we provide an evidence-based review of management options and long-term prognosis. Future research should include randomized trials for the acute and preventive treatment of these disorders, as well as research as to whether early intervention can prevent progression to migraine and/or mitigate migraine severity.     

Headache in children with brain tumors

To study the criteria for early differential diagnosis between migraine and headache due to brain tumors, we analyzed the symptoms and signs of two groups of children. The first group consisted of 67 children in whom a brain tumor had been diagnosed. The second group was composed of 600 children who had been diagnosed as migraine cases. Among the features of headache that are considered to be alarming symptoms of a brain tumor, the following were found to indicate a brain tumor with the greatest sensitivity: nocturnal headache or headache present on arising, both associated with vomiting, and increased frequency of headache. Nocturnal headache or headache present on arising, associated with vomiting, and/or progressive neurological symptoms or signs occurred in 65 of 67 children with brain tumor within 2 months of the onset of their headaches and in all 67 within 6 months.     

Migraine-related strokes. Clinical profile and prognosis in 20 patients

We reviewed the records of 4874 patients, aged 50 years and younger, who were seen at the Mayo Clinic, Rochester, Minn, from 1976 to 1980, and had received a diagnosis of migraine, migraine equivalent, or vascular headache. Twenty patients (16 females and four males) who had migraine-associated brain infarctions are described. The areas of infarction and corresponding angiographic abnormalities were most frequently in the distribution of the posterior cerebral artery. During a mean follow-up period of seven years, two patients had a second brain infarction. At last follow-up examination, 18 of the 20 patients had minimal or no functional impairment. For the period 1976 to 1979, we reviewed the available data on cerebral infarction for the Rochester, Minn, population aged 50 years or younger; 25% of all incidence cases of cerebral infarction were migraine associated.     

Multimedia education in headache: the European Neurological Network.

The European Neurological Network is a European Economic Community supported project. The purpose of the project was to develop a multimedia educational tool for general practitioners in order to improve their management of sleep disorders, epilepsy and headache. The project involves approximately one hundred engineers and physicians from Belgium, Denmark, England, Finland, France, Germany, Italy, Portugal and Spain. This paper concerns the multimedia educational tool on headache. The system consists of five different modules, i.e. classification, clinical data, headache tutorial, diagnostic headache diary and nomenclature. It is possible to move between the modules both vertically and horizontally. The headache classification of the International Headache Society is provided in full text as a work of reference. This classification is used world wide and has been adopted by International Classification of Diseases 10 Neurological Adaptation (ICD-10 NA) and the World Health Organisation. The clinical data concentrate on migraine and tension-type headache, the two most common headache disorders, but data on familial hemiplegic migraine, cluster headache, drug-induced headache and secondary headaches are also available. The headache tutorial consists of case records that the user can test their diagnostic abilities on. The diagnostic headache diary is an expert system on headache diagnostics. It can be filled in during a consultation in order to provide the headache diagnosis or it can be printed and used by the headache patient to record headache attacks and medicine consumption. The nomenclature module provides an explanation of words and expressions used in the system.     

Incidence of migraine headache: a population-based study in Olmsted County, Minnesota.

To determine the incidence of clinically detected migraine headache in the defined population of Olmsted County, MN, 1979-1981, we screened over 6,400 patient records from several diagnostic rubrics using the unique resources of the Rochester Epidemiology Project for population-based studies. We identified 629 Olmsted County residents who fulfilled the International Headache Society's 1988 criteria for newly diagnosed migraine headache between 1979 and 1981. The overall age-adjusted incidence was 137 per 100,000 person-years for males and 294 per 100,000 person-years for females. The highest incidence in females was among those aged 20 to 24 years (689 per 100,000 person-years), and in males, the highest incidence was among those aged 10 to 14 years (246 per 100,000 person-years). From 1979 to 1981, there was a striking increase in the age-adjusted incidence in those under 45 years of age: the incidence increased 34% in women and 100% for men. This is the first population-based study of migraine incidence across all ages.     

Coexistence of cervicogenic headache and migraine without aura (?)

It is well known that migraine with aura may coexist with various unilateral headaches, like cluster headache and chronic paroxysmal hemicrania. It may also coexist with cervicogenic headache. The diagnosis of migraine without aura ("common migraine") poses greater problems than the diagnosis of migraine with aura. Cervicogenic headache diagnosis also poses problems when these two headaches coexist, since they have symptoms in common. Therefore, the scientific demonstration of coexistence of migraine without aura and cervicogenic headache is bound to be a difficult task. In the present study, migraine without aura and cervicogenic headache seemed to coexist in 4 patients (3 F and 1 M, mean age 50). Attacks with migraine characteristics fulfilled the IHS and IASP migraine criteria. Out of a maximum of 13 migraine characteristics based on the IHS/IASP migraine criteria, such as unilaterality, aggravation on minor physical activity, etc., none of the patients presented less than 11, as opposed to a mean of < or = 4 of these criteria in the cervicogenic type attacks. A similar system, based on criteria such as: reduction of range of motion in the neck, mechanical precipitation of attacks, etc., was also developed for cervicogenic headache. The mean number of cervicogenic headache criteria was 4.3 (out of a total of 5) in the "cervicogenic part of the picture", as opposed to 1.5 (1.8 if laterality is considered, see text) in the "migraine part of the picture". Drug regimens and anaesthetic blocks also showed different results in the two different headaches in the same patient. All in all, this study seems to support a coexistence of the two headache types.     

Commentary: development and validation of the Asian Migraine Criteria (AMC)

Precise and manageable diagnostic criteria are vital for researchers and clinicians dealing with headache. The lack of clear and accessible markers of the biological distinctions between different types of headache means that criteria are determined by expert consensus. The International Classification of Headache Disorders (ICHD) criteria are the current benchmark and are evolving. They are effective for research as they exclude questionable cases from consideration, but in clinical practice they are used inconsistently by neurologists, and rarely by general practitioners, because of complexity. In this issue of the Journal of Clinical Neuroscience, Ghandehari et al. have proposed a new set of criteria, the Asian Migraine Criteria (AMC). These criteria perform well against the gold-standard ICHD, but are almost as complex. They do not have the simplicity of the ID Migraine tool. Nevertheless, they are welcome: any tool that general practitioners may be attracted to use that increases the accuracy of headache diagnosis is to be applauded.     

Most cases labeled as "retinal migraine" are not migraine.

BACKGROUND: Monocular visual loss has often been labeled "retinal migraine." Yet there is reason to believe that many such cases do not meet the criteria set out by the International Headache Society (IHS), which defines "retinal migraine" as attacks of fully reversible monocular visual disturbance associated with migraine headache and a normal neuro-ophthalmic examination between attacks. METHODS: We performed a literature search of articles mentioning "retinal migraine," "anterior visual pathway migraine," "monocular migraine," "ocular migraine," "retinal vasospasm," "transient monocular visual loss," and "retinal spreading depression" using Medline and older textbooks. We applied the IHS criteria for retinal migraine to all cases so labeled. To be included as definite retinal migraine, patients were required to have had at least two episodes of transient monocular visual loss associated with, or followed by, a headache with migrainous features. RESULTS: Only 16 patients with transient monocular visual loss had clinical manifestations consistent with retinal migraine. Only 5 of these patients met the IHS criteria for definite retinal migraine. No patient with permanent visual loss met the IHS criteria for retinal migraine. CONCLUSIONS: Definite retinal migraine, as defined by the IHS criteria, is an exceedingly rare cause of transient monocular visual loss. There are no convincing reports of permanent monocular visual loss associated with migraine. Most cases of transient monocular visual loss diagnosed as retinal migraine would more properly be diagnosed as "presumed retinal vasospasm."     

Influence of general practitioners' personal knowledge on migraine in medical attitudes towards their patients suffering from migraine

The subjective aspects of the doctor-patient relationship may impact disease management methods applied to migraine patients. This prospective study compared the medical attitudes of doctors towards migraine headache in relationship to their personal sensitivity to this disease. The study concerned data on the health care management of migraine headache by 711 general practitioners, 325 of whom suffer from migraine headache themselves, 227 who do not suffer from migraines, but who have a close family member that does, and 159 who neither suffer from migraine headache, nor have anyone close who does. Each doctor filled out a medical practice questionnaire concerning this pathology and included one migraine patient in the survey. Each patient answered a specific quality of life questionnaire. It was shown that doctors suffering from migraine headache themselves declared having more migraine patients in their practices than the other doctors. Nonetheless, the doctor's sensitivity to migraine headache does not seem to have an impact on the diagnosis and therapeutic care of patients; diagnosis criteria are the same within the three groups and correspond to international headache society criteria. Furthermore, the therapeutic means applied, whether acute first or second intention treatment, or long-term treatment, do not differ amongst the three groups. Quality of life and patients' feelings about medical support were significantly related to the doctor's level of sensitivity towards the disease: they were highest amongst patients treated by doctors suffering from migraines themselves, and lowest amongst patients treated by doctors with no close family members suffering from migraines. Although therapeutical attitudes do not vary, the quality of life perceived by patients is better when the doctors themselves are concerned by the disease.     

Magnetic resonance angiography of the circle of Willis in migraine patients

We analysed records of 244 consecutive adult outpatients who presented at our neurological polyclinic between 1996 and 2001 with migraine and who underwent a MRA of the circle of Willis. In 80 cases, a definitive migraine diagnosis according to the International Headache Society criteria (1988) could be retrieved from the patient records. Of these, 63 patients had migraine without aura and 17 patients had migraine with aura. Two MRA procedures were abrupted because of claustrophobia and another two MRA studies were unreliable because of movement artefacts. In only one patient of the remaining 240, an aneurysm was suspected with MRA. However, a conventional angiography did not confirm any cerebrovascular abnormality. All other exams were considered normal. This retrospective study argues against a systematic screening of migraine patients with MRA.