Experts' opinion about the primary headache diagnostic criteria of the ICHD-3rd edition beta in children and adolescents

BACKGROUND

The 2013 International Classification of Headache Disorders-3 (ICHD-3) was published in a beta version to allow the clinicians to confirm the validity of the criteria or to suggest improvements based on field studies. The aim of this work was to review the Primary Headache Disorders Section of ICHD-3 beta data on children and adolescents (age 0-18 years), and to suggest changes, additions, and amendments.

METHODS

Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the literature available on pediatric headache, they made observations and proposed suggestions for the primary headache disorders section of ICHD-3 beta data on children and adolescents.

RESULTS

Some headache disorders in children have specific features which are different from those seen in adults and which should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psycho-social basis in children and adolescents making primary headache disorders in children distinct from those in adults.

CONCLUSIONS

Several recommendations are presented in order to make ICHD-3 more appropriate for use with children.

Primary Stabbing Headache in A Headache Clinic

Primary stabbing headache (PSH) is a short-lasting but troublesome headache disorder which has been known for several decades. We surveyed and registered consecutive patients with PSH in a headache clinic in Taiwan. A total of 80 patients (24 M/56 F, 53.2 ± 16.2 years) were enrolled in our study. Migraine was reported in 20 (25%) patients and was less common in those with PSH onset at >50 years than those with onset at <50 years (14% vs. 38%, P = 0.02). The headache was unilateral in 59% of the patients and always in a fixed area in 36%. The head pain frequently involved extratrigeminal regions (70%) and in 30 patients (38%) was accompanied by jolts, i.e. head or body movements. Indomethacin was effective (74%) in patients who received it. Our study showed primary stabbing headache was a common and easily treated headache disorder in headache clinic. However, 70% of our patients could not fulfil criterion A ‘exclusively or predominantly in the distribution of the first division of the trigeminal nerve’ and 15% could not fulfil criterion C ‘no accompanying symptoms’ of the International Classification of Headache Disorders-II criteria proposed for PSH.

Nummular Headache: Three New Cases

Nummular headache is proposed as a distinct type of headache in the Appendix of the second edition of the International Classification of Headache Disorders (ICHD-II). It is a chronic condition, with the following characteristics: pain is felt on a small circumscribed cranial area; pain is of mild to moderate intensity; there is no evidence of a structural abnormality. Herein, three cases fulfilling the ICHDII proposed criteria (code A13.7.1) for nummular headache are reported.

Functional neuroimaging of primary headache disorders

Until recently, primary headache disorders, such as migraine and cluster headache were considered to be vascular in origin. However, advances in neuroimaging techniques, such as positron emission tomography, single photon emission computed tomography and functional magnetic resonance imaging have augmented the growing clinical evidence that these headaches are primarily driven from the brain. This review covers functional imaging studies in migraine, cluster headache, rarer headache syndromes and experimental head pain. Together with newer techniques, such as voxel-based morphometry and magnetic resonance spectrometry, functional imaging continues to play a role in elucidating and targeting the neural substrates in each of the primary headache syndromes.

Frequency of headache among the employees of a rubber company in the state of São Paulo, Brazil

CONTEXT AND OBJECTIVE

Primary headaches may be responsible for absenteeism and a fall in the yield and productivity of work. The aim of this study was to establish the presence and frequency of primary headache among employees of a rubber shoe sole company, and its link to absenteeism.

DESIGN AND SETTING

Cross-sectional study carried out with help from the staff of the medical and social department of a rubber factory located in the municipality of Franca, São Paulo.

METHOD

A questionnaire on headache characteristics was distributed to all employees. The returned and completed questionnaires were divided into two groups: with and without reports of headache. The headaches were classified into four main groups: migraine, tension-type headache (TTH), cluster headache and others. In terms of the reported frequency, headaches were also classified as chronic daily headache (CDH).

RESULTS

The number of valid questionnaires was 392 (59%); 80.9% were from male and 19.1% from female employees. Headaches were reported by 120 subjects (30.6%), with 17.4% belonging to the migraine group and 8.9% to the TTH group. Migraine was more frequent (p < 0.001) among all participants and also among the women (p < 0.05). TTH was more frequent among the men (p < 0.05). CDH was identified in 14 individuals (3.6%).

CONCLUSIONS

Headache was a common problem among the employees of this company and was a cause of absenteeism for 8.7% of the respondents to the questionnaire.

[Interobserver reliability among neurology resident physicians in the diagnosis of primary headaches according to the 2004]

INTRODUCTION

We determine the interobserver reliability among neurology resident physicians when diagnosing primary headaches using the 2004 International Headache Classification (IHC) compared to that obtained when compared with these observers and those of a consensus group (CG) made up of investigators and observers.

PATIENTS AND METHODS

The study was performed in an adult and pediatric population from a 4th level Colombian hospital out-patient neurology clinic. After informed consent was obtained from each patient, a video was recorded, eliminating the facial images in order to prevent patient identification. Two same level residents (observer 1 and observer 2) with previous training in the international classification of headache disorders (IHD-2) examined the video. Each video was examined separately with the classification in hand, making the diagnoses. The diagnoses obtained were compared between the observers and with the CG.

RESULTS

We obtained a kappa index: 0.64 comparing residents, k: 0.66 comparing resident 1 to CG and kappa index 0.70 comparing resident 2 to CG in the level of groups. The kappa value obtained for the headache type level was 0.51 interobservers, 0.61 on comparing observer one with CG and 0.65 on comparing observer two with CG.

CONCLUSION

Our results indicate that there is adequate reliability in the application of the 2004 IHC classification in the diagnosis of primary headaches among neurology resident physicians.

Clinical spectrum of thunderclap headache

Headaches of the thunderclap variety become severe in intensity within seconds to a minute of onset. Patients with thunderclap headache are to be evaluated in an emergent fashion as many of the underlying causes are associated with significant morbidity and mortality. Although subarachnoid hemorrhage is usually the initial consideration, a multitude of other etiologies have been identified and are discussed herein. In accordance with the increased utilization of cerebral imaging, availability of noninvasive techniques to image the cerebral vasculature and interest in identifying causes of thunderclap headaches, the list of potential causes is growing rapidly. Included in this growth are the reversible cerebral vasoconstriction syndromes, terminology recently introduced to unify several disorders all presenting with thunderclap headache and similar diagnostic findings including reversible vasoconstriction of the intracranial arteries.

Cefaléias primárias: abordagem diagnóstica por médicos não-neurologistas

OBJETIVO: Avaliar o conhecimento do diagnóstico e conduta de médicos não-neurologistas quanto às cefaléias primárias. MÉTODO: 91 médicos foram solicitados a diagnosticar e estabelecer condutas em três histórias de pacientes com características clínicas de migrânea sem aura (MSA), cefaléia do tipo tensional crônica (CTTC) e migrânea com aura (MCA), elaboradas de acordo com a Classificação Internacional das Cefaléias - 2ª Edição (CIC-II). RESULTADOS: MSA: dois profissionais (2,2%) fizeram o diagnóstico correto, 54 (59,3%) diagnosticaram migrânea sem especificar o subtipo. CTTC: 15 médicos (16,5%) diagnosticaram cefaléia de tensão sem especificar o subtipo. MCA: 26 (28,6%) fizeram o diagnóstico de migrânea e apenas um médico (1,1%) fez o diagnóstico correto do subtipo. Dezesseis médicos (17,6%) afirmaram conhecer a CIC-II. CONCLUSÃO: A maioria dos médicos não-neurologistas desconhece os critérios utilizados para diagnóstico e classificação das formas mais freqüentes de cefaléias primárias.

Paroxysmal stabbing headache in the multiple dermatomes of the head and neck: a variant of primary stabbing headache or occipital neuralgia?

A paroxysmal stabbing or icepick-like headache in the multiple nerve dermatomes, especially involving both trigeminal and cervical nerves, has not been fully explained or classified by the International Classification of Headache Disorder, 2(nd) Edition (ICHD-II). Of patients with acute-onset paroxysmal stabbing headache who had visited the Hallym University Medical Center during the last four years, 28 subjects with a repeated stabbing headache involving multiple dermatomes at the initial presentation or during the course were prospectively enrolled. All patients were neurologically and otologically symptom free. A coincidental involvement of both trigeminal and cervical nerve dermatomes included seven cases. Six cases involved initially the trigeminal and then cervical nerve dermatomes. Five cases showed an involvement of the cervical and then trigeminal nerve dermatomes. The remaining patients involved multiple cervical nerve branches (the lesser occipital, greater occipital and greater auricular). Pain lasted very shortly and a previous history of headache with the same nature was reported in 13 cases. Preceding symptom of an infection and physical and/or mental stress were manifested in seven and six subjects, respectively. All patients showed a self-limited benign course and completely recovered within a few hours to 30 days. Interestingly, a seasonal gradient in occurrence of a stabbing headache was found in this study. A paroxysmal stabbing headache manifested on multiple dermatomes can be explained by the characteristics of pain referral, and may be considered to be a variant of primary stabbing headache or occipital neuralgia.

375 childhood primary headache: clinical features, the agreement between clinical diagnosis and diagnoses using the international classification of headache disorders in Thai children

OBJECTIVE

To study the clinical features of patients with headache and agreement between clinical diagnoses and ICHD II criteria diagnosis in primary headaches in Thai children.

MATERIAL AND METHOD

Patients with headache who, over a 4-year period, consulted the neurological clinic, were interviewed by questionnaire, examined, diagnosed, treated, and followed up by pediatric neurologists. The result from the questionnaire was used to define the type of headache according to the ICHD II criteria. The clinical features were analyzed and clinical diagnosis was compared with diagnoses using the International Classification of Headache disorders.

RESULTS

Three hundred and seventy-five primary headache patients were defined by ICHD II criteria. One hundred twenty eight (35.2%) were migraine, 47 (12.5%) were tension-type, 123 (33.3%) were probable migraine, 31 (8.3%) were probable tension-type, and 40 (10.7%) cannot be classified because the symptoms were not compatible with diagnosed criteria. Using clinical diagnosis as the standard, the sensitivity of the ICHD-based definition of migraine without aura and probable migraine was 89.96% whereas the specific was 65.09%. On the other hand, the sensitivity of the International Classification of Headache disorders-based definition of infrequent episodic tension-type and probable infrequent episodic tension-type was 56.34% whereas the specific was 87.50%.

CONCLUSION

The present study shows the increase of sensitivity but decrease of the specificity of ICHD II criteria in diagnosed pediatric migraine headache. However, the duration of attack and quality of headache are still the limitation of diagnosis for pediatric headache. Therefore, the diagnosis criteria in pediatric headache should be developed distinctly from adults.

The Convergence Hypothesis

The Convergence Hypothesis postulates a single pathophysiological mechanism to explain the clinical spectrum of primary headaches seen in patients with migraine. The history and the scientific underpinnings of the Convergence Hypothesis are presented. Extrapolations from the Convergence Hypothesis are used to explore the evolution of episodic to chronic migraine and the development of common migraine co-morbidities as a consequence of frequent migraine. A patient staging system is presented to illustrate this transformation process in migraine patients.

Recurrent primary thunderclap headache and benign CNS angiopathy: spectra of the same disorder?

OBJECTIVES

To investigate the clinical pictures of patients with recurrent thunderclap headaches of unknown etiology and to field-test two relevant International Classification of Headache Disorders, 2nd edition (ICHD-II) criteria, i.e., primary thunderclap headache (Code 4.6) and benign (or reversible) angiopathy of the CNS (Code 6.7.3).

METHODS

We prospectively recruited patients presenting with idiopathic recurrent thunderclap headaches from a hospital-based headache clinic. Detailed histories, neurologic examinations, and MRIs and magnetic resonance angiographies (MRAs) were performed in all patients to exclude secondary causes. Patients with cerebral vasoconstriction received serial MRA follow-up.

RESULTS

Fifty-six consecutive patients (51 female/5 male, mean age 49.6 +/- 9.8 [range 22 to 76] years) were enrolled. Segmental vasoconstriction (or benign CNS angiopathy) was found in 22 patients (39%). Thunderclap headache recurred in all patients with a median frequency of 0.7 times per day for a median period of 14 days (range 6 to 86 days). The median duration for each single attack was 3 hours. Most patients (84%) reported at least one trigger. Nimodipine effectively aborted further attacks in 83% of the treated patients. Headache attacks subsided within 3 months. Four patients (7%) developed ischemic complications. Patients with and without vasoconstriction based on MRA images were similar regarding demographics and headache profile. Except for the duration criterion, our patients generally mapped well into the proposed ICHD-II criteria.

CONCLUSIONS

This study suggests that the two diagnostic entities proposed by the ICHD-II may present different spectra of the same disorder. The distinct headache profile may help physicians quickly recognize this disabling headache disorder with risk of stroke and provide timely treatment.

Uncommon primary headaches

PURPOSE OF REVIEW

The new International Classification of Headache Disorders was recently published by the International Headache Society. Several uncommon primary headaches, including some new clinical entities (e.g. hypnic headache), were included in the section on 'Cluster headache and other trigeminal autonomic neuralgias' and 'Other primary headaches'. The recent classification offers an interesting opportunity to evaluate the clinical role and to discuss the mechanisms of some of the more relevant uncommon primary headaches.

RECENT FINDINGS

Due to the low incidence of these uncommon headache forms, their diagnostic criteria, pathogenetic mechanisms and therapy are still debated. Differential diagnosis versus secondary headaches is also a crucial issue. In this review, some of the most important uncommon primary headaches are discussed in light of the most recent contributions to the literature.

SUMMARY

The review focuses on the update of the main uncommon primary headaches, intending to clarify some controversial points and to indicate some headlines for further research.

[Rare primary headache syndromes]

Primary headaches include common forms such as migraine, tension-type headache, and the less frequent cluster headache. Besides, several uncommon primary headaches were included in the section on 'Cluster headache and other trigeminal autonomic neuralgias' (section 3) and 'Other primary headaches' (section 4) in the second edition of the International Classification of Headache Disorders (ICHD-II, 2004). Since the prevalences of these uncommon headaches are quite low, datas related to clinical features, physiopathology and management are still controversial. While paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) are listed in the third section, hemicrania continua (HC) with not prominent autonomical signs are classified in the fourth section in the ICHD-II classification. The fourth section also includes other rare primary headache syndromes. In this review, some of the uncommon primary types of headache will be discussed. Even though these headaches are reported seldomly, the prevalences are possibly higher than known. It is of importance to recognize these uncommon disorders, since their management differs from common primary headaches.

Optimising primary headache management

Despite the fact that headache is one of the commonest of medical complaints seen in practice, most headache patients continue to be suboptimally managed. Probably because recent advances in the field of headache are written about more in specialty journals, many physicians even today feel that nothing much can be done for their headache patients! And, since more than 90% of headaches seen in practice are primary headaches, we need to realize that there is enough evidence now to show that primary headaches are a potentially treatable biological problem. It is therefore important that we do not err in the diagnosis and choice of the right drug options. This article discusses some of the reasons for suboptimal management of primary headaches and suggests measures to avoid these 'Pitfalls'. Secondary headaches where there is an underlying cause identifiable on examination or investigation are outside the scope of this review.

[The prevalence of primary headaches in the working population at a psychiatric hospital in Zimbabwe]

AIM

To determine the rate of prevalence and the clinical-epidemiological and therapeutic characteristics of primary headaches in Zimbabwe.

SUBJECTS AND METHODS

A descriptive study was carried out on the working population at the National Psychiatric Hospital in Zimbabwe. The International Headache Society classification was used. Sample size, which was calculated by means of the program EpiInfo 2002, was 175 workers, who were selected by simple random sampling.

RESULTS

The rate of prevalence of primary headaches was 37.1%. 66.1% of cases were between 20 and 39 years old. 29.2% had a family history of headaches. Tension-type headaches (47.7%) and common migraine (30.8%) were the predominant types. Onset of headaches occurred before the age of 15 years in 46.12% of patients. The most frequent location was cervical, which was found in 40% of cases. The most frequent precipitating factors were menstruation (24.6%) and stress (21.5%). The most frequent accompanying symptom was tearing (27.7%). 40% suffered headaches three or more times a month. The predominant symptomatic treatment was paracetamol (83.1%) and non-steroidal anti-inflammatory drugs (52.3%). Beta blockers and amitriptyline were used as prophylactic therapy for the episodes of headache in 18.5% and 13.8% of cases, respectively.

CONCLUSIONS

The prevalence of primary headaches is high among the working population under study.

Novel therapeutic targets

The need for novel therapeutic strategies for the treatment of migraine and other primary headaches is well recognised. Although the underlying mechanism(s) and the molecular targets that should be tackled by novel medicines are still uncertain, significant improvements have been made in the last decade in the treatment of migraine. Strong evidence in experimental animal models and clinical investigation focus on drugs that limit the phenomena promoted by activation of neurons of the trigeminal ganglion at the level of both their central and peripheral perivascular endings. Identification of compounds that abort the migraine attack by precisely targeting different mechanisms should also help to recompose the puzzle of migraine pathogenesis.

[Headache Classification, new edition]

Headache is extremely prevalent and experienced by almost everyone. A clinical test for the diagnosis of headache is still lacking, and a detailed clinical description is therefore essential for a precise diagnosis. The second edition of the International Headache Classification is presented, along with a translation into Danish. The major changes from the first edition are a detailed description of several subtypes of migraine, three subdivisions of tension-type headache according to frequency of headache and a major extension of the chapter concerning secondary headaches due to medication overuse. General knowledge of the major subforms of primary and secondary headaches is a very important tool for diagnosis and treatment.

Application of ICHD 2nd edition criteria for primary headaches with the aid of a computerised, structured medical record for the specialist

We tested the computerised, structured medical record by entering and analysing the consecutive clinical sheets of primary headaches in the episodic forms (200) and chronic headache (200) and the corresponding output diagnoses of patients attending our Headache Centre. A diagnosis of one of the primary headache forms was obtained in 67.9% of cases. A certain diagnosis of primary headache plus that of a probable form was obtained in 24.4% of cases (12.7% represented by chronic migraine (CM) or chronic tension–type headache (CTTH)+probable medicationoveruse headache). Only probable forms were diagnosed in the remaining 7.3% (as single probable diagnosis in 5.8% of cases or multiple diagnoses of probable forms in the remaining ones). The percentage of certain diagnoses mainly in the chronic headache group (28.4%), and to a lesser extent tension–type headache (6.5%), were obtained in 34.9% of cases. A certain diagnosis of one chronic form plus that of a probable form was obtained in 50.8% of cases (26.9% represented by probable medication–overuse headache). Only probable forms were diagnosed in 13.46% (as single probable diagnosis in 8.73% of cases or multiple diagnoses of probable forms in the remaining ones). In the other cases, the ICHD–II classification does not allow the diagnoses of CM, CTTH or probable forms and medicationoveruse headache because the mandatory criteria for the diagnoses are too stringent and do not reflect modifications of the headache pattern in relation to its chronicity. These preliminary results underscore the usefulness of a computerised device based on the ICHD 2nd edition for diagnostic purposes in tertiary centres dedicated to headaches in clinical practice as well as its relevance for research. This computerised device may help to validate the new diagnostic criteria and to answer some emerging questions from the application of the new classification version, the relevance of which should be verified in clinical practice.

[Other primary headaches]

Most primary headaches are classified into a few categories, such as migraine or muscle contraction headache, and patients suffering from these headaches are common. On the other hand, other primary headaches are very rare. In this section entitled "Other primary headaches", eight headaches, including primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua, and new daily-persistent headache, are described. Some characteristics of other primary headaches are common in symptomatic headaches, such as subarachnoid hemorrhage or arterial dissection. Therefore, careful evaluations including neuroimaging are necessary to exclude organic diseases.

[The prevalence and character of primary headache in Japanese high school students]

We investigated prevalence and character of primary headache for 2,462 examples of high school student. An overall headache prevalence was 41.0 in boys, 55.3% in girls, and average of the headache onset was 12.7 in boys, 12.9 in girls years old. A prevalence of migraine is 5.5 in boys, 6.1% in girls according to ICHD-I and 13.7 in boys, 17.5% in girls according to modified ICHD-II diagnosis criteria. For the tension type headache, it was 23.0 in boys, 30.6% in girls according to modified ICHD-I diagnosis criteria. High school students with primary headache tend take painkillers easily, but are much less likely visit physicians (only 15.0%). Our data showed that the prevalence of headache especially migraine in Japanese high school student was almost similar to past world wide findings, and suggest that its impact on the quality of life can not be ignored. Therefore, headache education must be important and necessary in a high school.