doi:10.1111/j.1468-2982.2008.01560.

Population-based validation of a German-language

self-administered headache questionnaire
M-S Yoon, M Obermann, G Fritsche, M Slomke, P Dommes, C Schilf, H-C Diener & Z Katsarava
Department of Neurology, University of Essen, Hufelandstrasse 55, Essen, Germany

Yoon M-S, Obermann M, Fritsche G, Slomke M, Dommes P, Schilf C, Diener H-C,

Katsarava Z. Population-based validation of a German-language self-
administered headache questionnaire. Cephalalgia 2008; 605–608. London. ISSN
0333-1024
We validated a German-language self-administered headache questionnaire for
migraine (M), tension-type headache (TTH) and trigeminal autonomic cephala-
lgia (TAC) in a general population sample of people with headache. Randomly
selected subjects (n = 240) diagnosed by the questionnaire as M (n = 60), TTH
(n = 60), a combination of M and TTH (M+TTH, n = 60) and TAC (n = 60) were
invited for examination by headache specialists. One hundred and ninety-three
subjects (80%) were studied. Sensitivity and specificity for M were 0.85 and 0.85,
for TTH 0.6 and 0.88, for M+TTH 0.82 and 0.87, respectively. Cohen’s k was 0.6
(95% confidence interval 0.50, 0.71). Of 45 patients with TAC according to the
questionnaire, physicians diagnosed cluster headache in two patients only. We
conclude: (i) the questionnaire can be used to diagnose M, TTH and M+TTH, but
not TAC; (ii) screening questionnaires for epidemiological research should be
validated in a general population sample but not in a tertiary headache clinic.
䊐Headache, migraine, questionnaire, tension-type headache, trigeminal autonomic ceph-
alalgias, validity
Zaza Katsarava, MD, PhD, MSc, Department of Neurology, University Hospital
Essen, University of Essen, Hufelandstr. 55, 45122 Essen, Germany. Tel. + 49 20
1723 2467, fax + 49 20 1723 5919, e-mail zaza.katsarava@uni-due.de Received 20
March 2007, accepted 30 November 2007

research. For the purpose of validation we recruited

Introduction
Large-scale population-based studies on headache
are important to gain information on prevalence
and distribution of different headache syndromes.
These investigations collect data from thousands of
individuals and therefore exclude the possibility of
a face-to-face examination. Self-administered ques-
tionnaires represent an attractive and inexpensive
alternative. These kinds of questionnaires should be
short and simple, while the requirements of the
questionnaire are to achieve maximum sensitivity,
specificity, and positive and negative values.
We recently introduced a self-administered ques-
tionnaire for the diagnosis of migraine (M), tension-
type headache (TTH) and trigeminal autonomic
cephalalgia (TAC) to employ in epidemiological
278 patients with idiopathic headache syndromes
[M, TTH, a combination of M and TTH (M+TTH),
and TAC] from our headache out-patient clinic and
compared the questionnaire’s diagnoses with neu-
rological examination results of headache experts.
We found fairly high sensitivity and specificity
values for all four headache syndromes (1). We
were aware, however, that patients recruited from a
tertiary headache centre introduced a selection bias,
and therefore findings could not be extrapolated to
the general population.
In our recent study, we investigated people with
headache in a general population sample to
re-validate the screening questionnaire, comparing
the diagnoses results with those of neurologists
experienced in headache.

© Blackwell Publishing Ltd Cephalalgia, 2008, 28, 605–608 605

606 M-S Yoon et al.
Methods
The study was approved by the ethics committee of
the University Duisburg-Essen, Germany. Informed
written consent was obtained from all subjects.
Construction of questionnaire
A detailed description of the questionnaire has
been provided previously (1). Briefly, the question-
naire was based on the second version of the clas-
sification criteria of the International Headache
Society [International Classification of Headache
Disorders (ICHD)-2] (2). It first explained the prin-
ciples and general rules for answering, followed
by specific questions regarding M (seven items),
TTH (seven items) and TAC (six items). The ques-
tions were to be answered with ‘yes’ or ‘no’. Fur-
thermore, subjects were interviewed about the
number of days associated with the different
headache types and the number of intake days of
acute pain or migraine drugs per month. The
analysis algorithm corresponded to the ICHD-2
criteria as well.
Subjects
Subjects with headache were recruited during the
first phase of a population-based survey of the
German Headache Consortium, which aims to
investigate the prevalence of idiopathic headache
syndromes in the general population of Germany.
One part of the study population comprised a
random sample of 6000 inhabitants of the city of
Essen, a town in the Region of North Rhine-
Westphalia in the western part of Germany. The city
covers an area of 210 360 km2 and has 585 481
inhabitants, 305 726 female and 279 755 male. Inclu-
sion criteria were: age 18–65 years and German
citizenship (to ensure proper knowledge of the
German language). Subjects received a question-
naire via postal mail and in a case of non-response
a reminder 2 weeks later. Individuals who did not
respond were called and asked for an interview per
phone performed by trained medical students
based on the same questionnaire. After eight unsuc-
cessful calls subjects were considered as non-
responders. Individuals who refused the interview
either by postal response or by phone were also
considered as non-responders.
The population-based validation was performed
during the first phase of the survey. The response
rate was 69%. We selected a random sample of
240 responders who were diagnosed by the
questionnaire as M (n = 60), TTH (n = 60), a combi-
nation of M and TTH (M+TTH, n = 60) and TAC
(n = 60). These subjects were asked to undergo a
neurological examination performed by one of
authors (M-S.Y., M.O. or M.S.). Neurologists were
blinded to the questionnaire’s diagnosis.
Statistics
Sensitivity, specificity, positive and negative predic-
tive values were calculated for M, TTH, M+TTH
and TAC using physician medical diagnoses as a
gold standard. Cohen’s k with 95% confidence
interval (CI) was calculated for the overall agree-
ment of physician and questionnaire diagnoses.
Data analysis was performed by SPSS 13.0 (SPSS
Inc., Chicago, IL, USA) and BiAS 8.0 (3).
Results
Of 240 invited subjects, 47 refused and therefore 193
subjects (80%) were studied, of whom 132 (68%)
were women. Mean age was 45.5 ⫾ 12.4 years.
Validity of all questionnaire diagnoses
The questionnaire had diagnosed M in 49 subjects,
TTH in 46, M+TTH in 53, and TAC in 45 subjects.
Headache experts diagnosed M in 71 cases, TTH in
68, M+TTH in 49, and cluster headache in two
cases. In three subjects neurologists diagnosed post-
traumatic headache. Table 1 shows the demo-
graphic characteristics and distribution of headache
syndromes. Table 2 demonstrates the agreement
between questionnaire and physician diagnoses for
the entire study population as well as for patients
with M, TTH and M+TTH, ignoring 45 subjects
with the questionnaire diagnosis of TAC.
An important finding was that of 45 question-
naire diagnoses of TAC, the headache experts con-
firmed only two. This fact clearly demonstrated that
the questionnaire cannot be used for the diagnosis
of TAC. We therefore performed a post hoc analysis
ignoring 45 subjects with the questionnaire diagno-
sis of TAC.
Table 3 summarizes the sensitivity, specificity,
positive and negative predictive values as well as
the corresponding likelihood ratios. The sensitivi-
ties and specificities for M, TTH and M+TTH were
fairly high. The Cohen’s k coefficient was 0.60 (95%
CI 0.50, 0.71).
© Blackwell Publishing Ltd Cephalalgia, 2008, 28, 605–608
 Headache screening questionnaire 607

Table 1 A and B: demographic and clinical characteristics of the study population

1A: Distribution of headache syndromes according to the questionnaire

Total (n = 193) M (n = 49) TTH (n = 46) TAC (n = 45) M+TTH (n = 53)

Years: mean (SD) 45.4 (12.4) 46.2 (12.6) 45.5 (13.8) 43.8 (13.6) 46.5 (10.8)
Gender: M/W 61/132 12/37 18/28 21/24 10/43

1B: Distribution of headache syndromes as diagnosed by neurologists

Post-traumatic
Total (n = 193) M (n = 71) TTH (n = 68) TAC (n = 2) M+TTH (n = 49) headache (n = 3)

Years: mean (SD) 45.4 (12.4) 45.5 (12.9) 45.7 (12.9) 39; 59 44.9 (10.4) 23; 56; 65
Gender: M/W 61/132 24/47 24/44 2/0 9/40 2/1

M, migraine; TAC, trigeminal autonomic cephalalgia; TTH, tension-type headache.

Table 2 Agreement between physician and questionnaire diagnoses for the entire study population

Physician
Symptomatic
Questionnaire M TTH TAC M+TTH headache Total

M 33 11 0 4 1 49
TTH 5 35 0 5 1 46
TAC 32 10 2 0 1 45
M+TTH 1 12 0 40 0 53
Total 71 68 2 49 3 193

M, migraine; TAC, trigeminal autonomic cephalalgia; TTH, tension-type headache.

Table 3 Sensitivity, specificity, positive and negative predictive values for migraine, TTH, and M+TTH

Sensitivity (95% CI) Specificity (95% CI) PPV (95% CI) NPV (95% CI)

M 0.85 (0.73, 0.96) 0.85 (0.77, 0.92) 0.67 (0.54, 0.8) 0.94 (0.89, 0.98)
TTH 0.6 (0.48, 0.73) 0.88 (0.81, 0.95) 0.76 (0.64, 0.88) 0.77 (0.69, 0.86)
M+TTH 0.82 (0.71, 0.92) 0.87 (0.80, 0.94) 0.75 (0.64, 0.87) 0.90 (0.85, 0.96)

CI, confidence interval; NPV, negative predictive value; PPV, positive predictive value; M, migraine; TTH, tension-type
headache.

Overall, the quality of our questionnaire is com-

Discussion
We re-validated a self-administered questionnaire
as a screening instrument for M, TTH and TAC in
a population-based sample of patients.
The values for sensitivity, specificity, positive and
negative prediction were fairly high for M and
TTH, as well as for a combination of M and TTH.
The values were quite similar to those observed in
the first validation (1). The overall agreement
between the questionnaire and physician diagnoses
was 0.60, which should be considered as a ‘strong’
agreement level (4).
parable to the international literature (5–13). The
values of sensitivity and specificity were usually
higher if the instrument focused on migraine only.
Lipton et al. presented a very short screening ques-
tionnaire for migraine with only three items and
were able to achieve a sensitivity of 0.81 and speci-
ficity of 0.75 as well as a k agreement of 0.68 (9).
More detailed migraine questionnaires have been
presented by Kallela et al. (7). This migraine-specific
instrument obtained a sensitivity of 0.99 and a
specificity of 0.96. The k value for the comparison
‘telephone interview’ vs. ‘clinical examination’ was

© Blackwell Publishing Ltd Cephalalgia, 2008, 28, 605–608

608 M-S Yoon et al.
0.85. Questionnaires seeking more than one diag-
nosis resulted in considerably lower agreement
levels. Hagen et al. differentiated between migraine,
non-migraine headache and chronic headache. k
agreements were 0.59, 0.43 and 0.44, respectively
(14). The questionnaire suggested by Rasmussen
et al. covered migraine, episodic and chronic TTH.
Relatively low k agreements of 0.43, 0.30 and 0.24,
respectively, were reported (4).
Another important finding of the study has been
the fact that in a population-based setting the ques-
tionnaire revealed a very low specificity in diagnos-
ing TAC. The majority of misdiagnosed patients
suffered from migraine with one or more cluster-
like autonomic symptoms, which is not unusual
(15). Some others had TTH. Future studies will
have to show whether the questionnaire could be
used as a first screening step to confine the scope on
suspected headache cases to be followed by neuro-
logical examination. This approach has recently
been used by an Italian group (16). The authors
reported a high sensitivity of 100%, but a quite low
specificity of 34%, and therefore examined all sus-
pected cases personally.
Hence, we consider that the main goal of the
study, to re-validate the questionnaire in a
population-based setting, was achieved. The results
clearly demonstrate that the self-administered ques-
tionnaire of the German Headache Consortium can
be used in population-based epidemiological
studies to assess the prevalence of M, TTH and a
combination of M and TTH. At present, the ques-
tionnaire is used in a population-based epidemio-
logical study on the prevalence of headache in
Germany. Referring data will follow.
Finally, this study has clearly demonstrated that
the validation of a self-administered headache
questionnaire in patients of tertiary headache
centres could be misleading, overestimating the
questionnaire’s quality even though this first vali-
dation step might be necessary for other reasons.
The final validation should, however, be done in a
population-based sample of headache patients.
Acknowledgement
The study was supported by the German Ministry for Edu-
cation and Research, Heinemannstrasse 2, 53175 Bonn,
Germany.
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© Blackwell Publishing Ltd Cephalalgia, 2008, 28, 605–608