Narrative Review

The IASP classification of chronic pain for ICD-11:

chronic secondary headache or orofacial pain
Rafael Benoliela, Peter Svenssonb, Stefan Eversc, Shuu-Jiun Wangd,e, Antonia Barkef, Beatrice Korwisif,
Winfried Rieff, Rolf-Detlef Treedeg,*, The IASP Taskforce for the Classification of Chronic Pain

Abstract
This article describes chronic secondary headache and chronic orofacial pain (OFP) disorders with respect to the new International
Classification of Diseases (ICD-11). The section refers extensively to the International Classification of Headache Disorders (ICHD-3)
of the International Headache Society that is implemented in the chapter on Neurology in ICD-11. The ICHD-3 differentiates between
primary (idiopathic) headache disorders, secondary (symptomatic) headache disorders, and OFP disorders including cranial
Downloaded from http://journals.lww.com/pain by BhDMf5ePHKbH4TTImqenVCDV3BItTVWTa4IF2YOwcCrYpM+BjVUsQs4lruxtg2MmOivNTQvoMps= on 01/22/2019

neuralgias. Chronic headache or OFP is defined as headache or OFP that occurs on at least 50% of the days during at least 3 months
and lasting at least 2 hours per day. Only chronic secondary headache and chronic secondary OFP disorders are included here;
chronic primary headache or OFP disorders are listed under chronic primary pain syndromes that have been described in
a companion publication. The subdivisions of chronic secondary OFP of ICHD-3 are complemented by the Diagnostic Criteria for
Temporomandibular Disorders and contributions from the International Association for the Study of Pain Special Interest Group on
Orofacial and Head Pain and include chronic dental pain. The ICD-11 codes described here are intended to be used in combination
with codes for the underlying diseases, to identify patients who require specialized pain management. In addition, these codes shall
enhance visibility of these disorders in morbidity statistics and motivate research into their mechanisms.
Keywords: Classification, ICD-11, ICHD-3, WHO, Chronic secondary headache, Chronic orofacial pain, TMD, Facial pain, Dental
pain, Diagnosis

1. Background on chronic headache and
orofacial pain
Headache and orofacial pain (OFP) disorders are among the most
prevalent pain disorders.26,47 Migraine is rated as the sixth most
disabling disorder as measured by years lost due to disability.18
Combined with medication-overuse headache, headaches rank
third (behind back pain and depression) among the disorders
leading to disability.18 Orofacial pain disorders affect over
Sponsorships or competing interests that may be relevant to content are disclosed
at the end of this article.
R. Benoliel, P. Svensson, S. Evers, S.-J. Wang, and A. Barke contributed equally to
the manuscript; R.-D. Treede and W. Rief also contributed equally.
a intracranial pressure). Research on OFP, both primary and
Rutgers School of Dental Medicine, The State University of New Jersey, Newark,
NJ, United States, b Department of Dentistry and Oral Health, Section of Orofacial
Pain and Jaw Function, Aarhus University, Aarhus, Denmark, c Faculty of Medicine,
University of Münster, Münster, Germany, d Faculty of Medicine and Brain Research
Center, National Yang-Ming University School of Medicine, Taipei, Taiwan,
e according to their temporal patterns.5,21 Although primary
Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, f Division
of Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-
University Marburg, Marburg, Germany, g Department of Neurophysiology, CBTM,
Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
*Corresponding author. Address: Department of Neurophysiology, Centre for
Biomedicine and Medical Technology Mannheim, Medical Faculty Mannheim,
Heidelberg University, Ludolf-Krehl-Str.13-17, 68167 Mannheim, Germany.
Tel.: 149 (0)621 383 71 400; fax: 149-(0)621 383 71 401. E-Mail address:
Rolf-Detlef.Treede@medma.uni-heidelberg.de (R.-D. Treede).
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article on
the journal’s Web site (www.painjournalonline.com).
PAIN 160 (2019) 60–68
© 2018 International Association for the Study of Pain
http://dx.doi.org/10.1097/j.pain.0000000000001435
a quarter of the population and induce significantly reduced
quality of life and disability.43 These data establish a clear
justification for a specific place of these disorders within the
International Classification of Diseases (ICD).
Headache and OFP disorders are separated into primary
(idiopathic) and secondary (symptomatic) types. Most research in
the past decades centred on primary headache disorders, in
particular on migraine. Only limited knowledge is available on the
epidemiology and pathophysiology of secondary headache
disorders. One reason for this may be that research has focused
on the underlying disorder but not on the headache itself, despite
the fact that some local or systemic disorders are mainly or
exclusively characterized by their headache (eg, changes in
secondary, has lagged behind headache research possibly also
due to a lack of a clear classification system.
Another way of subclassifying headache and OFP disorders is
headache disorders are chronic in the sense that they can occur
lifelong in an individual patient, another definition is needed for
chronic secondary headache or OFP disorders as intended in this
article. The term “chronic daily headache” was commonly used
for headache disorders that occurred (untreated) on at least 50%
of the days for at least 3 months and lasted at least 4 hours per
day. The criterion of a minimum duration per day (2h for other
conditions such as migraine in children) was used to exclude the
paroxysmal headache disorders (eg, cluster headache) because
these headache disorders are not really a chronic pain condition
but a disorder of recurrent brief pain paroxysms. To create
consistency across the classification, we now chose a minimum
duration of 2 hours for all chronic secondary headaches. This

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way, chronic headache and OFP disorders can be separated
from episodic (other terms would be paroxysmal or remitting)
disorders by their time pattern.
Facial pain has generally been separated from headache
because this type of pain is mostly musculoskeletal and
transmitted through the second and third trigeminal branches,
whereas headache disorders are transmitted through the first
trigeminal branch. The academic definition of headache vs
facial pain is anatomic. Headache is defined as pain occurring
only or mainly above the orbitomeatal and/or nuchal ridge,
whereas facial pain is defined as pain occurring mainly or
exclusively under the orbitomeatal line, anterior to the pinnae
and above the neck21; others include the forehead as part of the
face.38 Nevertheless, the complex pain referral patterns to
adjacent structures are so common that, in clinical practice,
headache and facial pain are most often intimately related. In
addition, we are specifically dealing with pain occurring within
the oral cavity and thus relate to oral and facial pain as an entity
termed OFP. Physicians typically have limited knowledge about
oral pathology because this field generally has been delegated
to dentistry. One of the aims of this article is to provide a chronic
pain classification that can be used by both professions for the
benefit of their patients.
2. The need for a classification system
The universally recognized International Classification of Diseases
describes itself as “the foundation for the identification of health
trends and statistics globally, and the international standard for
reporting diseases and health conditions.”52 The ICD has
established itself as the classification standard for clinicians and
researchers alike. The ICD comprehensively brings together,
under one hierarchical system, all known diseases, disorders,
injuries, and other related health conditions. It is largely designed
in a systems-based format that mostly disregards whether or not
pain is present. Headache is part of ICD-10 in the Neurology
chapter (G43 and G44), but acute and chronic as well as primary
and secondary headache are not differentiated systematically.
Orofacial pain is not represented in a separate chapter but mainly
attributed to the anatomic basis of the pain (eg, trigeminal
neuralgia is listed as subtype of trigeminal nerve disorders), and
temporomandibular disorders (TMDs) are coded in 2 separate
sections (G44.846 and K07.6). The diagnosis of headache has
been largely guided by the International Classification of
Headache Disorders (ICHD), which was established in 198820
and is now available in its third edition (ICHD-3).21 However,
although ICHD is very detailed with respect to headache
disorders, it fails to include some of the OFP disorders (including
dental pain).4
Thus, a complete and comprehensive structure for pain in
general, and headache and OFP in particular, is lacking. These
gaps are obstacles to the collection of accurate data on important
and common headache and OFP disorders. For pain clinicians
and researchers, the current ICD is a very complex system to
use and for this reason a new classification system was initiated.
3. The IASP task force ICD-11 initiative
To create a consistent classification of chronic pain, the
International Association for the Study of Pain (IASP) estab-
lished a task force that worked in close cooperation with World
Health Organization (WHO) representatives, the International
Headache Society (IHS), the IASP special interest group on
orofacial and head pain (OFHA-SIG), the American Academy of
Copyright Ó 2018 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
www.painjournalonline.com 61
Orofacial Pain, and the International Network for Orofacial Pain
and Related Disorders Methodology (previously International
RDC/TMD Consortium Network). This classification is dedi-
cated exclusively to chronic pain syndromes and excludes
acute pain. Chronic pain was defined as persistent or recurrent
pain lasting longer than 3 months.49 This definition was chosen
because it provides a clear operationalization that is in line with
widely used criteria and includes the majority of relevant
conditions. Applying this criterion to headache and OFP is
more challenging because many disorders are episodic but
recurrent in nature over long periods. For this reason, the
concept of chronicity in headache and OFP includes a measure
of attack frequency. Chronic headache is therefore defined as
occurring for at least 2 hours per day on at least 50% of the days
for more than 3 months and fulfilling criteria for the specific
headache or OFP. This concept has been tested in OFP5 but
has not yet been implemented fully.
The third edition of ICHD21 served as the starting point for
the present classification and is extensively referenced for its
definitions. ICHD-3 relies on a well-researched collection of
pain-related data (location, severity, quality, referral etc.) and
the selective use of special tests (neurophysiology, imaging
etc.) to define specific disorders. However, some OFP
disorders are still not specifically described, notably dental
pain, different types of TMDs, and isolated facial presentations
of resembling migraines and trigeminal autonomic cephalal-
gias (TACs).4,53 For TMD, the Diagnostic Criteria for Tempo-
romandibular Disorders (DC-TMD) were adopted.41 The
current proposal for chronic secondary headache and OFP
disorders strives to close some of the gaps outlined above by
adopting, together with ICHD-3, the DC-TMD and the
proposals from the OFHA-SIG. The proposed classification
underwent initial field testing in Australia, Germany, Japan,
and Norway in 2016. Revised models were subjected to further
testing through the website. We will report the results of these
field tests separately.
The proposed classification is now part of the so-called
“foundation layer” of ICD-11, which contains all diagnostic
entities (diseases, disorder, signs, symptoms, etc.) with defi-
nitions as well as inclusion and exclusion criteria. These entities
are hierarchically interconnected as a network of “parents” and
“children”. In contrast to previous editions, ICD-11 allows
“multiple parenting”, ie, any given entity (“child” or “subordinate”)
may belong to more than one major section (“parent”). This is
exemplified by trigeminal neuralgia (child/subordinate) being
assigned to both the peripheral neuropathic pain and the
headache/OFP categories (parents).
In the proposed classification of chronic pain, extension codes
will allow to specify the time course and severity of the pain as well
as the presence of psychological and social factors.48 Pain
severity is a combined score of pain intensity, pain-related
distress, and functional impairment that are quantified using
standardized rating scales; functioning properties will, in addition,
be specified according to the International Classification of
Functioning, Disability and Health (ICF).35
For the actual diagnostic coding, the WHO prepares
subsets from the foundation, the so-called “linearizations.”
The most important linearization is the Mortality and Morbidity
(MMS) Linearization. It is the basis of the statistical reporting of
mortality data by WHO member states; it is also used for
reimbursement purposes in many health systems worldwide
and for morbidity statistics. The current version was “frozen”
(June 18, 2018) in preparation for its implementation by the
member states from 2022 onwards.
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4. Classification of chronic secondary headache or
orofacial pain
4.1. General structure of the chronic pain classification:
chronic primary and secondary headache or orofacial
pain disorders
Chronic headache or OFP was split into 2 main domains: (1)
chronic primary headache or OFP and (2) chronic secondary
headache or OFP. A similar distinction was made for chronic
visceral pain and for chronic musculoskeletal pain.2,36 The
term “primary” was preferred over “idiopathic” because we
often understand the pathophysiological events underlying
some of these disorders. Chronic secondary headache or OFP
is defined as headache or OFP that occurs on at least 50% of
the days during at least 3 months and lasting at least 2 hours
per day, and is clearly associated with the effects of disease
(regional or systemic), trauma (physical, chemical, radiation),
infection, or a host of other factors. The entities covered are
shown in Table 1 together with ICD-10 counterparts, where
those exist. In this article, we highlight the more novel aspects
of the classification and the reader is referred to the existing
and widely accepted classifications for all other entities (ICHD-
3 and DC-TMD).
Chronic primary headache and OFP disorders are described
separately in a different article published by the same working group.34
However, to give an insight into the primary headache and OFP
disorders, these conditions are briefly described as follows.
4.1.1. Chronic primary headache
Chronic primary headache is defined as headache that occurs on
at least 15 days per month for more than two hours per headache
day for more than 3 months. Chronic primary headache disorders
are mostly a continuation of their episodic counterparts such as
chronic migraine, chronic tension-type headache, and new daily
persistent headache. The chronic counterparts of the TACs
include chronic cluster headache, chronic paroxysmal hemi-
crania, and short-lasting unilateral neuralgiform headache
attacks. Of note, chronicity in TACs is defined as headache
attacks occurring for more than 1 year without remission, or with
remission periods lasting less than 3 months. Hemicrania
continua, one of the TACs, is a chronic disorder by definition.
4.1.2. Chronic primary orofacial pain
Orofacial pain, of which about 10% is chronic, affects around
a quarter of the general population.28,31,33 This is in agreement with
the 2009 National Health Interview Survey that found that 5% of
adults reported pain in the face or jaw over a 3-month period.39 The
incidence ratio of persistent facial pain was reported at 38.7 per

Table 1
List of primary and secondary headache and orofacial pain disorders with their ICD-10 code if applicable.
Chronic primary headache or orofacial pain
Chronic migraine without or with aura (G43.3)
Chronic tension-type headache (G44.22)
Chronic trigeminal autonomic cephalalgias (TACs):
Chronic cluster headache (G44.02)
Chronic paroxysmal hemicranias (G44.04)
Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) (G44.05)
Hemicrania continua (G44.51)
Chronic primary temporomandibular disorder pains
Myalgia (M79.1)
Myofascial pain with referral
Arthralgia (M26.62)
Chronic burning mouth
Glossodynia (K14.6)
Chronic primary orofacial pain
Orofacial pain as a presentation of primary headaches
Persistent idiopathic dentoalveolar pain
Atypical facial pain (persistent idiopathic facial pain) (G50.1)
Chronic secondary headache or orofacial pain
Chronic headache/orofacial pain attributed to trauma or injury to the head and/or neck
Chronic headache/orofacial pain attributed to cranial or cervical vascular disorder
Chronic headache/orofacial pain attributed to nonvascular intracranial disorder
Chronic headache attributed to a substance or its withdrawal
Chronic headache/orofacial pain attributed to infection
Chronic headache/orofacial pain attributed to disorders of homeostasis or their nonpharmacological treatment
Chronic headache/orofacial pain attributed to disorder of the cranium, neck, eyes, ears, sinuses, salivary glands, and oral mucosa
Chronic dental pain
Diseases of pulp and periapical tissues (K04)
Other diseases of hard tissues of teeth (K03)
Chronic neuropathic orofacial pain
Pain attributed to a lesion or disease of the trigeminal nerve including trigeminal neuralgia (primary parent: chronic peripheral neuropathic pain)
Other cranial and regional neuralgias and neuropathies
Chronic secondary temporomandibular disorder pain
Chronic secondary orofacial muscle pain
Systemic disorders or trauma
Chronic secondary temporomandibular joint pain
Systemic disorders, trauma, or infection

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100,000 person years, is more common in women, and increased
with age.26 Most chronic primary OFP is associated with a painful
TMD, which is quite prevalent. Almost 5% of the population report this
type of pain (6.3% in women, 2.8% in men).22 Other diagnoses in this
section include burning mouth syndrome and atypical facial pain.
4.2. Chronic secondary headache or orofacial pain
In ICHD-3, secondary (or symptomatic) headache disorders are
the consequence of an underlying disorder or dysfunction.
Causation is mainly established by a temporal link and by typical
patterns of headache. Causation is not always indisputable; so,
the term “attributed to” is used to explain the link between the
underlying disorder and headache. The same logic is applied here
to chronic secondary OFP disorders.
The secondary headache and OFP disorders are listed in the
order of ICHD-3 and explained using the terminology of ICHD-3. This
means that every chapter of the ICHD-3 relating to chronic
secondary headache disorders is represented in the ICD-11
classification. Chapter 12 of ICHD-3 (headache attributed to
psychiatric disorders) was omitted because there is not enough
evidence that a specific chronic secondary headache exists that is
caused by psychiatric disorders. Chapter 13 of ICHD-3 was
modified so that individual sections are now assigned to chronic
dental pain and to facial pain and/or headache attributed to TMD.
The remaining sections in chapter 13 of ICHD-3 comprise the
neuropathic OFP disorders, in particular trigeminal neuralgia and
other disorders of the trigeminal nerve. The organisation of chronic
secondary headache or OFP is presented in Figure 1.
4.2.1. Chronic headache or orofacial pain attributed to
trauma or injury to the head and/or neck
Posttraumatic headache and OFP are common secondary pain
disorders. As per accepted definition, “acute” refers to those
occurring during the first 3 months after such a traumatic event.
“Chronic or persistent posttraumatic headache/OFP” is used if the
pain continues beyond that time. Most often, posttraumatic
headache/OFP resembles the primary version such as tension-
type headache or migraine. The diagnosis, therefore, depends on
the establishment of an association between the trauma or injury and
the headache/OFP onset. To establish a strict diagnosis of
posttraumatic headache/OFP pain, it must manifest itself within
7 days after trauma or injury, or within 7 days after regaining
consciousness, and/or within 7 days after recovering the ability to
sense and report pain. The 7-day interval is somewhat random, with
some experts proposing that the onset of posttraumatic headache
may occur after a longer interval. However, this longer interval is
observed only in a minority of patients and there are insufficient
published data to change this criterion.3
Headache and OFP may occur as the sole complaint after trauma
or injury. In some patients, pain is accompanied by further symptoms,
such as dizziness, fatigue, reduced ability to concentrate, psycho-
motor slowing, mild memory problems, insomnia, anxiety, personality
changes, and irritability. A patient presenting with this constellation of
symptoms after head injury would receive the diagnosis “post-
concussion syndrome.”50 Depending on the location of the initiating
trauma, OFP may be comorbid or the leading symptom.6
4.2.2. Chronic headache or orofacial pain attributed to
cranial or cervical vascular disorder
Relevant cranial or cervical vascular disorders that can cause
chronic headache include ischemic stroke, nontraumatic
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www.painjournalonline.com 63
intracranial hemorrhage, unruptured vascular malformation,
arteritis, cervical carotid or vertebral artery disorder, other
acute intracranial arterial disorders, genetic vasculopathy, and
pituitary apoplexy. Cervical artery dissections most commonly
present with head, face, or neck pain that is sometimes
accompanied by other signs. This presentation occurs in up to
95% of internal carotid artery dissections and in 70% of
vertebral artery dissections.8,9,14,19,32,45 In internal carotid
artery dissections, a unilateral headache may be the single
symptom in 45% of cases. It is ipsilateral to dissection with
a steady or throbbing quality.17,32 A typical case is shown in
Case vignette 1 (chronic headache after subarachnoid
hemorrhage).24 Here, the chronic headache appeared despite
successful surgical management of the hemorrhage; it had
different characteristics than the initial “thunderclap” head-
ache and was resistant to treatment.
Vascular conditions causing headache/OFP have an acute
presentation, typically display neurological signs, and often remit
rapidly.21 A close temporal relationship between the manifesta-
tion of the headache/OFP and the neurological signs is central to
establish causation. If it is present, a diagnosis can be relatively
straightforward.
Many of the vascular conditions such as ischemic or
hemorrhagic stroke present with dramatic symptomatology,
such as disorders of consciousness and severe focal
neurological signs that overshadow the headache. Con-
versely, headache is the prominent presenting symptom in
other conditions such as subarachnoid hemorrhage. Acute-
onset headache may be an initial warning sign in ominous, and
often life-threatening, conditions such as dissections, cerebral
venous thrombosis, giant cell arteritis, and central nervous
system angiitis. Clearly, early diagnosis of such presentations
is crucial and allows for appropriate interventions aimed at the
underlying vascular disease that may prevent devastating
neurological consequences.
Because primary headaches are extremely common, these
conditions often occur in patients who report a history of
headache. Nevertheless, headache associated with vascular
conditions is characterized by a sudden onset of a novel type of
headache, usually not familiar to the patient. In these
situations, the presence of vascular conditions should be
suspected.21
4.2.3. Chronic headache or orofacial pain attributed to
nonvascular intracranial disorder
Relevant nonvascular intracranial disorders include increased
cerebrospinal fluid pressure, low cerebrospinal fluid pressure,
noninfectious inflammatory intracranial disease, intracranial neo-
plasms, intrathecal injection, epileptic seizure, Chiari malforma-
tion type I, and other nonvascular intracranial disorders.16
Compared to those on primary headaches, there are few
epidemiological studies of these headache types. Controlled
trials of therapy are almost nonexistent. Similarly, chronic OFP,
usually with neurological signs, will result from nonvascular
intracranial disorders such as neoplasms.7,11,27,37,40
4.2.4. Chronic headache attributed to a substance or its
withdrawal
Potential etiologies include exposure to a substance as in
medication overuse headache (ergotamine, triptans, simple
analgesics, compound analgesics, opioids, and others) or
substance withdrawal (caffeine, estrogen, and other substances
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Figure 1. Organization of chronic secondary headache or orofacial pain disorders (ICD-11 diagnoses). Levels 1 and 2 are part of the 2018 frozen version of ICD-11;
level 3 has been entered into the foundation layer. According to the new concept of multiple parenting in ICD-11, an entity may belong to more than one group of
diagnoses. attrib., attributed; Chron., chronic; HA/OFP, headache or orofacial pain; symptom., symptomatic.

with long-term use). Migraineurs seem to be physiologically
hypersensitive to a variety of stimuli. Alcohol, certain foods and
additives, chemical and drug ingestion and their withdrawal have
been implicated in the provocation of a migraine attack in
predisposed individuals.12,29 There is also a suspicion that
migraneurs are psychologically hyperresponsive to relevant
stimuli and challenges such as stress and anxiety.
Associations between headache and substance use or
withdrawal are often anecdotal, many based on reports of
adverse drug reactions. The association of a substance with
headache does not establish causation; so, the clinician must
consider other etiologies. Headache onset and substance
exposure may be merely coincidental, particularly regarding
substances that are consumed extremely commonly (eg,
cheese). In addition, headache may be the symptom of a systemic
disease that necessitates pharmacotherapy and the drugs may
be mistakenly blamed for the headache. Furthermore, drug trials,
in particular for episodic migraine, list adverse drug reactions that

Case vignette 1: chronic secondary headache disorder: chronic headache attributed to subarachnoid hemorrhage
A 59-year-old woman complains of bilateral frontotemporal headache. The pain is dull and pressing and is present every day for at least 6 hours. Pain severity is largely
moderate (visual analogue scale 5-6 on a 0-10 scale) but exacerbations occur by psychosocial stress and by Valsalva’s maneuver. There are no accompanying symptoms with
this headache.
The headache started after a subarachnoid hemorrhage (SAH) that she had in the age of 57. The SAH started with an extreme thunderclap headache, after which the patient
had amnesia for about 2 weeks. An intracranial bleeding due to a large aneurysm was detected, and a craniotomy was performed for clipping of the aneurysm. The patient was
in coma for 10 days. After awakening from the coma, the patient experienced a dull headache, which she never had before. There were no other sequelae from the SAH.
Treatment with amitriptyline 25 mg in the evening had a positive impact on headache intensity but the headache is not cured. The headache cannot be modulated by any other
therapies such as physiotherapy or biofeedback.

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include typical signs and symptoms of the disorder itself. In the
case of migraine trials, these include headache, nausea, and
other associated symptoms. Some disorders may predispose to
drug-related headache: alone, neither the drug nor the condition
would produce headache.21
4.2.5. Chronic headache or orofacial pain attributed to
infection
Intracranial infections that can cause chronic headache or OFP
include bacterial meningitis or meningoencephalitis, viral menin-
gitis or encephalitis, intracranial fungal or other parasitic
infections, and brain abscess or subdural empyema.1 Relevant
systemic infections may be caused by bacteria, viruses, or other
organisms.15 Headache is usually the consequence of active
infection, resolving within 3 months of eradication of the infection,
and therefore would not be considered a chronic headache.
When the infection cannot be eliminated and remains active,
headache may persist, and if it continues for 3 months or longer, it
is considered chronic. More rarely, the infection resolves or is
eradicated but headache persists nevertheless. Then, similarly, it
is considered chronic if it lasts longer than 3 months.
Headache is the first and most commonly encountered
symptom in patients with intracranial infections. Report of a novel
diffuse headache associated with a variable combination of the
following symptoms should direct attention towards an in-
tracranial infection even in the absence of neck stiffness: focal
neurological signs and/or an altered mental state and a general
malaise and/or pyrexia.46
4.2.6. Chronic headache or orofacial pain attributed to
disorders of homeostasis or their nonpharmacological
treatment
This comprises all chronic headache disorders caused by
disorders of homoeostasis including hypoxia and/or hypercapnia
(ie, high altitude, aeroplane travel, diving, and sleep apnea),
dialysis, arterial hypertension, hypothyroidism, fasting, and
cardiac cephalalgia. The diagnosis is also appropriate when
chronic pain is attributed to their nonpharmacological treatment;
if it is attributed to pharmacological treatment, the section 4.2.4.
applies. Orofacial pain may occur together with such headaches
or in isolation. Cardiac cephalgia that accompanies chest
symptoms has been reported in 5.2% of one series of patients
with myocardial infarction (MI).4,13 More rarely, MI pain may be
“isolated,” presenting primarily as headache (3.4%), jaw pain
(3.6%), or neck pain (8.4%).4 Interestingly, there seems to be an
anatomical correlate between pain location and site of infarct,
with inferior MI associated with OFP (8.3%) and cardiac cephalgia
more frequently reported (7.3%) in anterior MI.4,13
4.2.7. Chronic headache or orofacial pain attributed to
disorders of cranium, neck, eyes, ears, nose, sinuses, teeth,
mouth, or other facial or cervical structures
The cervical spine and other neck structures have been
associated with chronic headache or OFP. Clinically, many
headaches and OFP seem to refer from cervical, nuchal, or
occipital regions. Many of these have been attributed to cervical
osteodegenerative changes. However, virtually all people older
than 40 years have some degree of cervical degenerative
pathology.30,44 Large-scale controlled studies clearly show that
people with and without headache or OFP have similar
prevalences of cervical degenerative changes. Spondylosis or
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www.painjournalonline.com 65
osteochondrosis are therefore not conclusively the explanation of
associated headache or OFP. Other widespread disorders
suspected to underlie chronic headaches and OFP, such as
chronic sinusitis, TMDs, and refractive errors of the eyes, have
also been shown to be equally prevalent in patient and control
populations.
In establishing the diagnosis of chronic secondary headache or
OFP, the rules for causation need to be more rigorously applied.
These include the establishment of the strength, consistency,
specificity, and temporal sequence of the association in addition
to its biological coherence, gradient, and plausibility within
current medical knowledge.10 Experimentation with the treat-
ment of the suspected disease and observation of outcomes are
essential. With these, better classification criteria may emerge.
4.2.8. Chronic dental pain
Chronic dental pain results from a disorder involving the teeth or
associated tissues (pulpal, periodontal, or gingival pain). The
typical causative factor will be caries or trauma to a tooth or teeth
or associated tissues. In addition to clinical examination, imaging
(intraoral x-rays, computed tomography scans etc.) may facilitate
the correct diagnosis.
Untreated dental decay has been reported as the most
important reason for toothache, which can impact routine daily
activities. Toothache is a common problem and, depending on
geographic location, may be highly prevalent.23 However, it is
unclear what proportion of reported toothache is truly chronic and
more data are needed.25 From currently available data, duration
of constant toothache is present for 27.6 days up to seeking
care.25 A similar study estimated 55.2 days of tooth pain before
presenting for treatment to an emergency dental clinic.51
However, as the above epidemiology suggests, truly chronic (ie,
lasting .3 months) dental pain may be extremely rare and caution
should be exercised when diagnosing such cases. If the etiology
is vague and examination/testing is inconclusive, consider
whether diagnoses in the section of chronic primary pain may
be more suitable.34
4.2.9. Chronic neuropathic orofacial pain
This chapter comprises painful lesions or diseases of the
cranial nerves and is also part of the section on chronic
neuropathic pain.42 The existing nosology of cranial nerve
pains is not totally satisfactory as discussed in the respective
companion paper.42 Many long-established diagnostic terms,
which may be strictly inaccurate, have been retained (tri-
geminal neuralgia and other less frequent cranial neuralgias).
ICHD-3 presents detailed definitions, subtypes, and
subforms.21
4.2.10. Chronic secondary temporomandibular disorder
pain
Chronic secondary TMD is chronic pain in the temporomandib-
ular joint(s) or masseter or temporalis muscle(s) attributed to
persistent inflammation (due to eg, infection, crystal deposition or
autoimmune disorders), structural changes (such as osteoarthri-
tis or spondylosis), injury, or diseases of the nervous system. It
occurs for at least 2 hours per day on at least 50% of the days
during at least 3 months. If the etiology is vague, consider using
codes in the section of chronic primary pain.34 Chronic secondary
TMD pain should be subtyped as myofascial TMD pain or
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R. Benoliel et al. 160 (2019) 60–68 PAIN®

temporomandibular joint arthralgia, or both. A typical case is
illustrated in Case vignette 2.
4.2.11. Other specified and unspecified chronic secondary
headache or orofacial pain
Diseases not explicitly listed in the classification may be captured
in a residual category for “Other specified chronic headache or
orofacial pain”; an additional category for unspecified conditions
will provide for the classification of disorders for which insufficient
information is available to assign a more precise diagnosis. These
residual categories are automatically added by WHO.
5. Discussion
The systematic classification of chronic secondary headache and
OFP disorders as presented in this article is intended both for
clinical and for research purposes. These chronic secondary pain
codes should be used when the headache or OFP can be
attributed to an underlying cause; the underlying cause should be
coded as well.48 In combination with the extension code for pain
severity, this will serve the purpose of identifying those patients
whose pain needs specialist care. As demonstrated in the Case
vignette 1, chronic pain may outlast the initiating event and may
become the leading cause for continuing treatment need. This
pattern is also known for other chronic secondary pain
syndromes, eg, in chronic osteoarthritis.36
Within the classification of chronic pain for ICD-11, di-
agnostic categories are relatively broad. For further differen-
tiation of chronic secondary headache disorders, ICHD-3
provides more sophisticated and detailed classification criteria
that can be used if necessary. However, the present
classification is more detailed in orofacial and dental pain
disorders as some of these disorders are not considered or
only mentioned briefly (eg, TMD) in ICHD-3. Thus, chronic
secondary OFP syndromes are categorized here for the first
time in a systematic manner.
For research purposes, this classification is aimed to stimulate
clinical studies on the characteristics and on the treatment of
chronic secondary headache disorders and OFP. These disor-
ders have been neglected in clinical research in the past, mainly
due to a low interest of the major research groups. If distinct
subgroups of chronic secondary headache and OFP disorders
are enrolled in studies or clinical trials, this classification is
recommended. Furthermore, this classification system is
intended to create awareness of chronic secondary headache
and OFP syndromes. In many cases, the clinical picture of the
pain in the disorders presented in this article is similar to that of
chronic primary headache disorders. This often leads to a mis-
diagnosis of secondary headaches, which are then simply
diagnosed as chronic tension-type headache.
This classification is mainly based on the clinical phenotype of
the underlying disorder causing the headache or OFP. In the future,
other principles may be the basis for a new classification. For
example, the pathophysiological mechanisms of the pain signaling
itself are poorly understood in secondary (symptomatic) headache
or OFP. New knowledge of these mechanisms could lead to
a novel systematic classification. Another example for a future
classification could be differential responses to multimodal pain
treatment. Although it is natural to treat the chronic secondary
headache or OFP by treating the underlying disorder, this is not
possible in all cases. So, the response to different pharmacological
treatments or nonpharmacological procedures could help in
grouping these headache and OFP disorders. This would be
a pragmatic approach to determine the level of granularity required
in diagnostics: if all chronic secondary headaches and OFP
disorders were responsive to the same (combination) therapy,
further subclassification would only serve academic and epidemi-
ological purposes. Given the diverse nature of the underlying
conditions, we find this highly unlikely and anticipate that with
research progress, individual patients also will benefit from more
sophisticated treatment algorithms.
Finally, it should be acknowledged that this classification
system of chronic secondary headache and OFP disorders has
been developed and accepted in close cooperation of the 2 major
scientific societies that are focused (among others) on these
disorders, namely IASP and IHS. This is the first cooperation of its
kind and will help to increase acceptance and use of this
classification.
6. Summary and conclusions
This article presents a novel classification of chronic secondary
headache and OFP disorders as agreed by the 2 major scientific
societies in this field (IASP and IHS). It is part of the project to
classify chronic pain syndromes for the upcoming ICD-11.
Although most of the chronic secondary headache syndromes
are grouped and classified according to ICHD-3, the OFP
syndromes as presented here are grouped by different systems
including ICHD-3, DC-TMD, and proposals by OFHA-SIG. This
classification should help to better diagnose these disorders and
to stimulate research.
Conflict of interest statement
R. Benoliel has nothing to disclose. P. Svensson has nothing to
disclose. S. Evers has nothing to disclose. S.-J. Wang reports
personal fees from Eli-Lilly, personal fees from Daiichi-Sankyo,
grants and personal fees from Pfizer, Taiwan, personal fees from
Eisai, personal fees from Bayer, and personal fees from
Boehringer Ingelheim, outside the submitted work. A. Barke
reports personal fees from IASP, during the conduct of the study.

Case vignette 2: chronic secondary orofacial pain disorder: secondary temporomandibular joint disorder
A 45-year-old woman complains of bilateral pain around the temporomandibular joints (TMJs) during chewing and yawning. The pain is sharp and shooting with spread to the
temporal region and ear. The pain is present more than 2 hours per day and has lasted for more than 6 months. During the jaw movements, pain intensity is rated high with
a visual analogue scale score of 7 to 8 (on a 0-10 scale) and at rest intensity is mild with a visual analogue scale score of 2 to 3. The TMJ is painful on standardized palpation at
and around the lateral pole of the TMJ. Furthermore, there is crepitus in the TMJ during open–close movements. In addition, the masseter and temporalis muscles are painful
on palpation. Intraoral examination reveals an anterior open bite and tooth contacts only at the molar teeth. A computed tomography scan reveals severe degenerative changes
on the condyle and fossa with resorption, osteophyte formation, and subchondral cysts. The patient reports several previous episodes of significant TMJ pain lasting up to 1
year. She also has an underlying diagnosis of rheumatoid arthritis (7 years) and is currently being treated with methotrexate. For her flare up of TMJ pain, she is treated with
arthrocentesis, which results in significantly decreased TMJ pain. Additional therapy includes a hard occlusal splint and physiotherapy.

Copyright Ó 2018 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
 January 2019
· Volume 160
· Number 1
B. Korwisi has nothing to disclose. W. Rief reports grants from
IASP, during the conduct of the study; personal fees from Heel
and personal fees from Berlin Chemie, outside the submitted
work. R.-D. Treede reports grants from Boehringer Ingelheim,
Astellas, AbbVie, and Bayer, personal fees from Astellas,
Grünenthal, Bauerfeind, Hydra, and Bayer, and grants from EU,
DFG, and BMBF, outside the submitted work.
Acknowledgements
The authors gratefully acknowledge the financial support by the
International Association for the Study of Pain (IASP) and the
excellent discussions with Dr Robert Jakob of WHO.
Members of the Taskforce: Rolf-Detlef Treede (Chair), Winfried
Rief (Co-chair), Antonia Barke, Qasim Aziz, Michael I. Bennett,
Rafael Benoliel, Milton Cohen, Stefan Evers, Nanna B. Finnerup,
Michael First, Maria Adele Giamberardino, Stein Kaasa, Beatrice
Korwisi, Eva Kosek, Patricia Lavand’homme, Michael Nicholas,
Serge Perrot, Joachim Scholz, Stephan Schug, Blair H. Smith,
Peter Svensson, Johannes Vlaeyen, Shuu-Jiun Wang.
Appendix A. Supplemental digital content
Supplemental digital content associated with this article can be
found at http://links.lww.com/PAIN/A658. SDC includes a com-
plete reference list of the diagnoses entered into the foundation
with the foundation IDs as well as the extension codes (specifier).
Since the complete list is contained, the material is identical for all
papers of the series.
Article history:
Received 7 June 2018
Received in revised form 26 October 2018
Accepted 26 October 2018
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