11/2/2012

ICHDIII
Rebecca Burch, MD
Elizabeth Loder, MD, MPH
Graham Headache Center Boston, MA

Disclosures and competing

interests
Dr. Burch has no disclosures
Dr. Loder receives salary support from the
British Medical Journal in exchange for
services as an editor

Objectives
Describe the history of headache classification
and the first two iterations of the International
Classification of Headache Disorders (ICHD).
Discuss shortcomings in ICHD-II and IIR, and
provide specific case examples that demonstrate
these deficiencies
Identify likely areas of change in ICHD III

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Definitions
Classification
Grouping disorders into
categories

Diagnosis
Identification of
disease in an
individual person

A political and
philosophical act

Schwartz LM, Woloshin S. Changing disease definitions: implications for disease prevalence. Analysis of the
Third National Health and Nutrition Examination Survey, 1988-1994. Eff Clin Pract. 1999; 2:76-85.

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Ad Hoc Committee
1. Vascular Headache
A. Classic Migraine
B. Common Migraine
C. Cluster
D. Hemiplegic, Ophthalmoplegic migraine
E. Lower-half headache

2.
3.
4.
5.

Muscle Contraction Headache

Combined Headache: Vascular and MCH
Headache of Nasal Vasomotor Reaction
Headache of Delusional, Conversion, or
Hypochondriacal states
6. Nonmigrainous Vascular Headaches
7. Traction Headache
8. Headache due to overt Cranial Inflammation
9-13. Headache due to Diseases of Ear, Nose, Sinus, Teeth
14. Cranial Neuritides
15. Cranial Neuralgias

Before ICHD
There was surprisingly little disagreement about
the classification of headache. Consensus was
achieved by the fourth meetingOur chairman,
Arnold Friedman, MD, always provided each
committee member with exactly 25 sheets of lined
paper and 4 pencils sharpened to exactly the same
length.
Ostfeld A. The Ad Hoc
Committee on Headache
Classification. Cephalalgia
1993;13(Suppl. 12):11-12.

An example of their handiwork

Migraine
Recurrent attacks of headache, widely
varied in intensity, frequency, and
duration. The attacks are commonly
unilateral in onset; are usually associated
with anorexia, and sometimes with
nausea and vomiting; and are often
familial

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Proficiency
Proficiency in disease
management depends
primarily upon our ability to
place patients within diagnostic
groups of a size sufficient to
allow systematic research.

Olesen, J. (2008), The International Classification of Headache Disorders.

Headache: The Journal of Head and Face Pain, 48: 691693.
doi: 10.1111/j.1526-4610.2008.01121.x
.

Headache Diagnosis
Codified in the International Classification
of Headache Disorders
ICHD-III is in the works!

2006-2010
1985

ICHD-IIR
Classification
committee
formed

minor revisions

1980 1985 1990 1995 2000 2005 2010 2015

1982
IHS
formed

1989
ICHD-1

2003 ICHD-II

2013
ICHD-III beta

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The Structure of ICHD-II

Part 1: Primary headaches

Part 2: Secondary headaches
Part 3: Cranial Neuralgias, etc.
The Appendix

ICHD II
Part I
Primary Headaches
1. Migraine
2. Tension-type Headache
3. TACs and cluster
4. Other primary headaches:
hypnic headache, hemicrania
continua, etc.

ICHD II: Part II

Secondary Headaches
5. Posttraumatic
6. Vascular disease
7. Other intracranial pathology
8. Substance induced headache
9. CNS infection
10. Disorders of homeostasis
11. Neck, ENT, TMJ
12. Psychiatric causes

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ICHD II: Part 3

Cranial neuralgias, facial pain
13. Neuralgias and neuropathy
14. Other Headaches

ICHD II: The Appendix

Possible new disorders
A1.1 Menstrual migraine
A3.3 SUNA
Alternative criteria
e.g. for pediatric migraine

Disorder on the way out

e.g. basilar-type migraine

ICHD is hierarchical
1
1.2
1.2.4

Migraine (group)
Migraine with aura (type)
Familial hemiplegic
migraine (subtype)
(CACNA1 mutation)
(subform)

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ICHD: Good, not perfect

Tradeoff between sensitivity and
specificity not ideal for clinical practice
They do not incorporate important
features
Osmophobia
Prodromal features
Activating and relieving factors

Unclear if all will map onto biology

ICHD II

Terminology
Probable REPLACED terms such as
Migrainous headache
Used to mean that all but one criterion
has been met for a diagnosis.

ICHD II: Major changes

All secondary headaches structured in same way:

A. Headache characteristics
B. Presence of secondary disorder
C. Defines the causal relationship
D. Headache greatly improves or disappears after
remission of causative condition. (If missing diagnose
probably attributed to)

Attributed to used instead of associated with

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ICHD II: Major changes

Drug-induced headache
overuse headache
New entities:

medication

Hypnic headache
Hemicrania continua
New daily persistent headache
Primary thunderclap headache

- Explosive coital headache

renamed Orgasmic
headache 4.4.2
- Dull coital headache
renamed Pre-orgasmic
headache 4.4.1
- Coital headache with

postural features moved

to low pressure headache
category

Ophthalmoplegic
migraine sent to
cranial neuralgias
Revised criteria
for childhood
migraine

ICHD II: Pediatric headache

ICHD-I criticized for lack of sensitivity in
diagnosis of pediatric migraine
ICHD-II shortened minimum duration from
4 to 2 hours for those under 15.
Footnote mentions bilateral nature of pain
Alternative appendix criteria

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Field Testing
Pediatric headache clinics
Evaluated sensitivity of ICHD-I, II,
appendix criteria
Gold standard: The clinical impression
based on the clinical experience of the
examiners
Use of the ICHD-II criteria in the diagnosis of pediatric
migraine. Hershey AD, Winner P, Kabbouche MA,
Gladstein J, Yonker M, Lewis D, Pearlman E, Linder SL,
Rothner AD, Powers SW. Headache. 2005 NovDec;45(10):1288-97.

Proposed criteria with highest

sensitivity
Duration of 72 hours or less
2/4 features: focal location, pulsating, moderate or
severe, worsening or limiting physical activity AND
Associated symptoms of nausea and/or vomiting OR 2/5
photo, phono, difficulty thinking, lightheadedness or
fatigue
88.1% met these criteria
still a gap of 15% who clinically have migraine.

ICHD II: Problems

23 year old woman who meets criteria for
migraine
Before 60% of her headaches she
experiences typical visual aura lasting 45
minutes

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Aura

Aura

Focal neurologic event(s)visual, sensory,

motor
Usually precedes headachebut not always
Positive, negative, spreading and reversible

ARS #1
On 2 occasions, however, she has onset of her usual
visual aura symptoms but they last for 6 days before
remitting. There is no evidence of infarction on
imaging.

What is the diagnosis according to ICHD-II?

A. Migraine with aura
B. Migraine with prolonged aura
C. Persistent migraine aura without infarction
D. Complicated migraine
E. Migraine aura status

ARS #2
On 2 occasions, however, she has onset of her usual
visual aura symptoms but they last for 8 days before
remitting. There is no evidence of infarction on
imaging.

What is the diagnosis according to ICHD-II?

A. Migraine with aura
B. Migraine with prolonged aura
C. Persistent migraine aura without infarction
D. Complicated migraine
E. Migraine aura status

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ICHD II: Problems

What should be required for a diagnosis of
secondary headaches?
Does the cause have to be treated and the
headache improve in order to infer causation?
If disorders are untreatable how can the
diagnosis be made?
Is it helpful to make a diagnosis after the
headache goes away?

ARS #3
A 28 year old woman with a history of episodic migraine
has developed daily headache. For the last 4 months
she has 20 days of migraine a month with low grade
headache on other days. She takes 4 triptan+ 8
aspirin/acetaminophen/caffeine tablets daily.
According to ICHD-II how should she be diagnosed?
A. Probable medication overuse headache
B. Medication overuse headache
C. Probable chronic migraine
D. Medication overuse headache and probable
chronic migraine
E. Probable medication overuse headache and
probable chronic migraine

Doctors need to diagnose

patients at the time they
present, not retrospectively
after their treatment is
successful, at which point the
correct diagnoses may be
merely of academic
interestthis serves the
purpose of science but not
clinical medicine.

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According to the original published version

of ICHD-II, MOH could not be definitively
diagnosed until the putative cause
medication overusehad been
discontinued.
Discontinuation had to be followed by
clinical improvement within 2 months.
Thus the diagnosis could only be made
after the headache disappeared.

ARS #4
A 28 year old woman with a history of episodic migraine
has developed daily headache. For the last 4 months
she has 20 days of migraine a month with low grade
headache on other days. She takes 4 triptan+ 8
aspirin/acetaminophen/caffeine tablets daily.
According to ICHD-IIR how should she be diagnosed?
A. Probable medication overuse headache
B. Medication overuse headache
C. Probable chronic migraine
D. Medication overuse headache and probable
chronic migraine
E. Probable medication overuse headache and
probable chronic migraine

Medication Overuse Headache: Still tricky

When medication overuse is present, this is the most
likely cause of chronic symptoms
Call it probable chronic migraine or probable chronic
TTH until you have accomplished medication
withdrawal.
THEN, call it chronic migraine if headaches persist
for more than 2 months after withdrawal
Or call it medication overuse headache plus episodic
TTH or Migraine if improvement occurs

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ARS #5

A 46 year old woman has had constant pain in the right temple for the last two years.
Her background level of pain is rated 3/10 on a 0-10 scale, with periodic
exacerbations that can be 9/10. These are associated with mild nausea, right sided
nasal congestion and tearing of the right eye. She had gastric bypass surgery four
months ago and post-operatively had a DVT, for which she is on coumadin. She has
been forbidden to use any NSAIDs.
What is the diagnosis according to ICHD-II?

A. Hemicrania continua
B. Probable hemicrania continua
C. Cluster headache
D. Probable cluster headache
E. A diagnosis cannot be assigned

What we will see in ICHD-III

As a general rule, we now propose that headache persisting for 3

months after cure or spontaneous remission of the causative
disorder should be called chronic post-X headache.
However, since little evidence exists for most chronic post-X
headaches, this should be mentioned in the appendix and
introduced in the body of the classification only after evidence
emerges for the existence of such post-X headache for each
individual cause of secondary headache.
This means that we shall not distinguish between acute and chronic
post-X headache but simply call secondary headaches: headache
attributed to X until 3 months after cure of the causative disorder. If
headache then continues, the term chronic post-X headache shall
be applied.

Proposed general diagnostic

criteria for secondary headaches

Headache of any type, fulfilling criteria C and D

Another disorder scientifically documented to be able to cause headache
has been diagnosed1
Evidence of causation shown by at least two of the following:2
Headache has occurred in temporal relation to the onset of the
presumed causative disorder
Headache has occurred or has significantly worsened in temporal
relation to worsening of the presumed causative disorder
Headache has improved in temporal relation to improvement of the
presumed causative disorder
Headache has characteristics typical of the causative disorder3
Other evidence exists of causation4
The headache is not better accounted for by another headache diagnosis

Olesen J, et al. Proposals for new standardized general diagnostic criteria for secondary
headache disorders. Cephalalgia December 2009 vol. 29 no. 12 1331-1336

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Fig 3 Combinations of headache subtypes across 30 years among participants who met
criteria for migraine (with or without aura) or tension-type headache at 1 interview and were
interviewed 4 times across follow-up (n=346).

Merikangas K R et al. BMJ 2011;343:bmj.d5076

2011 by British Medical Journal Publishing Group

Thanks!
eloder@partners.org
rburch@partners.org

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