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Published by: aquarossalinda on Feb 11, 2010
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Given the range of disorders that produce headache, a systematicapproach to classification and diagnosis is an essential for clinicalmanagement. For the past 15years, the first edition of the diagnosticcriteria of the International Headache Society, ICHD-1 (HeadacheClassification Committee of the International Headache Society 1988),has been the accepted standard for headache diagnosis. The secondedition of the International Classification of Headache Disorders, ICHD-2 (Headache Classification Subcommittee of the International HeadacheSociety 2004), reflects our improved understanding of some previouslyincluded disorders as well as the development of criteria for previouslyexcluded disorders.Like its predecessor, the ICHD-2 separates headache into primaryand secondary disorders. The four categories of primary headaches aremigraine, tension-type headache, cluster headache and other trigeminalautonomic cephalalgias, and other primary headaches. There are ninecategories of secondary headache. Important changes in the ICHD-2include a restructuring of the criteria for migraine, a new subclassifica-tion of tension-type headache, introduction of the concept of trigeminalautonomic cephalalgias, and addition of previously unclassified primaryheadaches. Several disorders were eliminated or reclassified. Herein wepresent an overview of the ICHD-2, highlighting the primary headachedisorders and their diagnostic criteria. We conclude by presenting anapproach to headache diagnosis based on these criteria.
Headache is one of the most common types of recurrent pain as wellas one of the most frequent symptoms in neurology (Scher et al1999). Although almost everyone gets occasional headaches, there arewell-defined headache disorders that vary in incidence, prevalenceand duration (Rasmussen 1995). These disorders are usually dividedinto two broad categories: primary headache and secondary headachedisorders. In secondary disorders, headaches are attributed to anothercondition, such as brain tumour or head injury; for the primarydisorders the headache is not due to another condition.Given the range of disorders that can produce headache, a syste-matic approach to headache classification and diagnosis is an essentialprelude to appropriate management. For the past 15years, the firstedition of the diagnostic criteria of the International Headache Society(ICHD-1) has been the accepted standard (Headache ClassificationCommittee of the International Headache Society 1988). The secondedition of the International Classification of Headache Disorders(ICHD-2) reflects our improved understanding of some disordersand the identification of new disorders (Headache ClassificationSubcommittee of the International Headache Society 2004). Likeits predecessor, the ICHD-2 separates headache into primary andsecondary disorders.The ICHD-1 and ICHD-2 have established uniform terminologyand consistent operational diagnostic criteria for the full range of headache disorders around the world. This has facilitated epidemi-ological studies and the multinational clinical trials that provide thebasis for the current research and treatment guidelines (Tfelt-Hansenet al 2000). In this chapter, we will first present an overview of theICHD-2 (Headache Classification Subcommittee of the InternationalHeadache Society 2004). We will discuss the classification of theprimary headache disorders. We will review the classification of dailyor near-daily primary headaches. Finally we will briefly discuss theclassification of the secondary headache disorders.
The ICHD-2: an overview
Table54.1 presents an overview of the ICHD-2. The four categoriesof primary headaches are 1.0, migraine; 2.0, tension-type headache;3.0, cluster headache and other trigeminal autonomic cephalalgias;and 4.0, other primary headaches. There are nine categories of sec-ondary headache (against eight in the ICHD-1), which are headacheattributed to 5.0, head and neck trauma; 6.0, cranial or cervical vascular disorders; 7.0, nonvascular intracranial disorders; 8.0, sub-stance or its withdrawn; 9.0, infection; 10.0, disorder of homeostasis;11.0, disorders of cranium, neck, eyes, ears, nose, sinuses, teeth,mouth, or other facial or cranial structures; 12.0, psychiatric disorders;and 13, cranial neuralgias and central causes of facial pain. Finally,there is a fourteenth category that includes headache not classifiableelsewhere.The ICHD-2 includes operational rules, some of which aresummarized and commented on here. These rules present the generalprinciples for headache classification and are quoted or paraphrasedfrom the criteria (Headache Classification Subcommittee of theInternational Headache Society 2004).The ICHD-2 provides a hierarchy of diagnoses with varyingdegrees of specificity. Headache disorders are identified with three-or sometimes four-digit codes. The first digit specifies the major diag-nostic categories indicated in Table54.1 (i.e. migraine, 1.0; tension-type headache, 2.0, etc.). The second digit indicates a disorder withinthe category, for example migraine without aura (1.1) (Table54.1).Subsequent digits permit more specific diagnosis for some typesof headache. For example, headaches in a patient with familial hemi-plegic migraine could be coded as migraine (1.0), migraine with aura(1.2), or most precisely as familial hemiplegic migraine (1.2.4). Inthis example, the three-digit code provides important informationabout aetiology, symptom profile, and treatment.In clinical practice, patients should receive a diagnosis for eachheadache type they have experienced within the last year. Thecriteria suggest that the 1-year period prevalence should be used inepidemiological studies, while the life prevalence should be usedin genetic studies.
Headache: classification
 Marcelo E. Bigal & Richard B. Lipton
SECTION 6: Headache and facial pain
 The ICHD-2 classificationClassDescriptionClassDescription
8Headache attributed to a substance or its withdrawal
8.1Headache induced by acute substance use or exposure8.2Medication overuse headache8.3Headache as an adverse event attributed to chronic medication8.4Headache attributed to substance withdrawal
9Headache attributed to infection
9.1Headache attributed to intracranial infection9.2Headache attributed to systemic infection9.3Headache attributed to HIV/AIDS9.4Chronic postinfection headache
10Headache attributed to disorder of homoeostasis
10.1Headache attributed to hypoxia and/or hypercapnia10.2Dialysis headache10.3Headache attributed to arterial hypertension10.4Headache attributed to hypothyroidism10.5Headache attributed to fasting10.6Cardiac cephalalgia10.7Headache attributed to other disorder of homoeostasis
11Headache or facial pain attributed to disorder of cranium,neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial orcranial structures
11.1Headache attributed to disorder of cranial bone11.2Headache attributed to disorder of neck11.3Headache attributed to disorder of eyes11.4Headache attributed to disorder of ears11.5Headache attributed to rhinosinusitis11.6Headache attributed to disorder of teeth, jaws, or related structures11.7Headache or facial pain attributed to temporomandibular jointdisorder11.8Headache attributed to other disorder of cranium, neck, eyes, ears,nose, sinuses, teeth, mouth, or other facial or cervical structures
12Headache attributed to psychiatric disorder
12.1Headache attributed to somatization disorder12.2Headache attributed to psychotic disorder
13Cranial neuralgias and central causes of facial pain
13.1Trigeminal neuralgia13.2Glossopharyngeal neuralgia13.3Nervus intermedius neuralgia13.4Superior laryngeal neuralgia13.5Nasociliary neuralgia13.6Supraorbital neuralgia13.7Other terminal branch neuralgias13.8Occipital neuralgia13.9Neck–tongue syndrome13.10External compression headache13.11Cold stimulus headache13.12Constant pain caused by compression, irritation or distortion of cranial nerves or upper cervical roots by structural lesions13.13Optic neuritis13.14Ocular diabetic neuropathy13.15Head or facial pain attributable to herpes zoster13.16Tolosa–Hunt syndrome13.17Ophthalmoplegic ‘migraine’13.18Central causes of facial pain13.19Other cranial neuralgia or other centrally mediated facial pain
14Other headache, cranial neuralgia, central or primary facial pain1Migraine
1.1Migraine without aura1.2Migraine with aura1.3Childhood periodic syndromes that are commonly precursors of migraine1.4Retinal migraine1.5Complications of migraine1.6Probable migraine
2Tension-type headache
2.1Infrequent episodic tension-type headache2.2Frequent episodic tension-type headache2.3Chronic tension-type headache2.4Probable tension-type headache
3Cluster headache and other trigeminal autonomic cephalalgias
3.1Cluster headache3.2Paroxysmal hemicrania3.3Short-lasting unilateral neuralgiform headache attacks withconjunctival injection and tearing (SUNCT)3.4Probable trigeminal autonomic cephalalgia
4Other primary headaches
4.1Primary stabbing headache4.2Primary cough headache4.3Primary exertional headache4.4Primary headache associated with sexual activity4.5Hypnic headache4.6Primary thunderclap headache4.7Hemicrania continua4.8New daily-persistent headache
5Headache attributed to head and/or neck trauma
5.1Acute post-traumatic headache5.2Chronic post-traumatic headache5.3Acute headache attributed to whiplash injury5.4Chronic headache attributed to whiplash injury5.5Headache attributed to traumatic intracranial haematoma5.6Headache attributed to other head and/or neck trauma5.7Postcraniotomy headache
6Headache attributed to cranial or cervical vascular disorders
6.1Headache attributed to ischaemic stroke and transientischaemic attack6.2Headache attributed to non-traumatic intracranial haemorrhage6.3Headache attributed to unruptured vascular malformations6.4Headache attributed to arteritis6.5Carotid or vertebral artery pain6.6Headache attributed to cerebral venous thrombosis6.7Headache attributed to other intracranial vascular disorders
7Headache attributed to non-vascular intracranial disorder
7.1Headache attributed to high cerebrospinal fluid pressure7.2Headache attributed to low cerebrospinal fluid pressure7.3Headache attributed to non-infectious inflammatory disease7.4Headache attributed to intracranial neoplasm7.5Headache attributed to intrathecal injection7.6Headache attributed to epileptic seizure7.7Headache attributed to Chiari malformation type17.8Syndrome of transient headache and neurological deficits withcerebrospinal fluid lymphocytosis7.9Headache attributed to other non-vascular intracranial disorder
54Headache: classification
The ICHD-2 requires that all distinct types of headache that thepatient experiences should be diagnosed. A patient with a compli-cated headache may receive several separate diagnoses, for examplemigraine without aura (1.1) plus episodic tension-type headache(2.2) plus medication overuse (8.2). Also, for patients with more thanone diagnosis, diagnoses should be listed in their order of importanceto the patient.Probable diagnostic categories, such as probable migraine, probabletension-type headache, and probable cluster headache, are appliedto patients missing one of the features necessary for a diagnosis. If a headache fulfils both the full criteria for one disorder and also thecriteria for a probable diagnosis, the full should be coded. Forexample, if a patient has a headache that fulfils criteria for probablemigraine (1.6) and for frequent episodic tension-type headache (2.2),the patient should be diagnosed with frequent episodic tension-typeheadache (2.2). Although some headache types include frequency in their diagnosticcriteria (i.e. chronic migraine and chronic tension-type headache), theICHD-2 does not specifically code frequency or severity. Frequencyand severity may be specified parenthetically at the discretion of theexaminer.If a patient experiences a new kind of headache for the first timein close temporal relation to another disorder known to cause headacheand the headache is attributed to that disorder, the headache shouldbe coded as a secondary headache. Secondary headaches are classifiedbased on aetiology, not on symptom profile.Patients with pre-existing primary headaches sometimes experi-ence exacerbations in close temporal relation to a known cause of headache. In this circumstance, the known cause of headache mayhave worsened the pre-existing primary headache. Alternatively, itmay have caused a new type of secondary headache. A secondaryheadache is more likely if:1.there is a very close temporal relation to the potentially causaldisorder;2.there is a marked exacerbation of the primary headache;3.the evidence that the causal disorder can cause headaches isstrong; or4.there is improvement or disappearance of headache after relief from the causal disorder.Headache diaries are recommended, particularly in patients withmore than one headache type, to determine the symptom profiles of each type over a period of time.
Classification of the primary headaches
The ICHD-2 divides the primary headaches into four major categories,discussed in sequence below.
Migraine (1.0)
Migraine is a chronic neurological disorder characterized by episodicattacks of headache and associated symptoms. In western countries,the condition affects 12% of the adult population (Scher et al 1999).Migraine is a heterogeneous condition that results in a range of symp-tom profiles both within and among different individuals (Stewartet al 1994). Migraine is divided into six major categories, the twomost important of which are migraine without aura (1.1) and migrainewith aura (1.2) (Table54.2).
Migraine without aura (1.1)
Migraine without aura is a clinical syndrome characterized by headachefeatures and associated symptoms (Box54.1; Headache ClassificationSubcommittee of the International Headache Society 2004). According to the ICHD-2, if a patient fulfils criteria for more thanone type of migraine, each type should be diagnosed. Criteria formigraine without aura can be met by various combinations of features;no single feature is required. Because two of four pain features arerequired, a patient with unilateral, throbbing pain may meet thecriteria, but so does a patient with bilateral pressure pain if the painis moderate and aggravated by physical activity. Similarly, only oneof two possible associated symptom combinations is required.
 The ICHD-2 classification of migraineClassDescription1.1Migraine without aura1.2Migraine with aura1.2.1Typical aura with migraine headache1.2.2Typical aura with non-migraine headache1.2.3Typical aura without headache1.2.4Familial hemiplegic migraine1.2.5Sporadic hemiplegic migraine1.2.6Basilar-type migraine1.3Childhood periodic syndromes that are commonlyprecursors of migraine1.3.1Cyclical vomiting1.3.2Abdominal migraine1.3.3Benign paroxysmal vertigo of childhood1.4Retinal migraine1.5Complications of migraine1.5.1Chronic migraine1.5.2Status migrainosus1.5.3Persistent aura without infarction1.5.4Migrainous infarction1.5.5Migraine-triggered seizures1.6Probable migraine1.6.1Probable migraine without aura1.6.2Probable migraine with aura

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