Headache ISSN 0017-8748


C 2007 the Authors doi: 10.1111/j.1526-4610.2007.00758.x
Journal compilation 
C 2007 American Headache Society Published by Blackwell Publishing

Research Submission
Validation of a German Language Questionnaire
for Screening for Migraine, Tension-Type Headache,
and Trigeminal Autonomic Cephalgias
Guenther Fritsche, PhD; Michael Hueppe, PhD; M. Kukava; A. Dzagnidze, MD;
Markus Schuerks, MD; M.-S. Yoon, MD; Hans-Christoph Diener, MD, PhD; Zaza Katsarava, MD

Background.—To develop a German language questionnaire for screening for migraine, tension-type headache,
and trigeminal autonomic cephalgias.
Objective.—Aim of the study was to develop a German language self-administered headache questionnaire for
screening for migraine (MIG), tension-type headache (TTH), and trigeminal-autonomic cephalgias (TAC).
Methods.—Questionnaire-based diagnoses were blindly compared with those of headache experts.
Results.—Overall 278 headache patients (MIG = 97, TTH = 60, TAC = 98, MIG plus TTH = 23) as well as
42 patients with low back pain without headache and 47 healthy subjects were studied. The Cohen’s kappa for 7
headache syndromes including all combination diagnoses was 0.64 (95% CI 0.58-0.70). Sensitivity and specificity
for migraine were 0.73 and 0.96, for TTH 0.85 and 0.98, for TAC 0.63 and 0.99, and for MIG plus TTH 0.62 and
0.97, respectively. Ignoring all combination diagnoses, the kappa-coefficient for the monodiagnoses MIG, TTH, and
TAC (193 out of 278 patients) was 0.93 (CI 0.83-1.0). The retest-reliability (4 weeks later) was 0.95.
Conclusion.—We present the first questionnaire in German language including 3 most common primary
headaches for use in epidemiological research.
Key words: headache, questionnaire, migraine, tension-type headache, trigemino-autonomic cephalgias, validity,
reliability

(Headache 2007;47:546-551)

The current diagnosis of idiopathic headache syn-
dromes by headache specialists is based on the cri-
teria from the International Headache Society.1 Epi-
demiological studies on headache (eg, reference 2)
collect data from thousands of individuals and, there-
From the Department of Neurology, University Hospital Essen,
Germany (Drs. Fritsche, Kukava, Dzagnidze, Schuerks, Yoon,
Diener, and Katsarava); Department of Anaesthesiology, Uni-
versity of Luebeck, Germany (Dr. Hueppe).
Address all correspondence to Dr. Guenther Fritsche, Depart-
ment of Neurology, University Hospital Essen, University of
Essen, Hufelandstr. 55, 45122 Essen, Germany.
Accepted for publication September 5, 2006.
fore, exclude the possibility of a face-to-face exami-
nation. Screening questionnaires represent an attrac-
tive and inexpensive alternative. This kind of ques-
tionnaire should be abbreviated and simple. On the
other hand, the requirements to the questionnaire are
to record sensitivity, specificity, and positive and neg-
ative predictive values as highly as possible. Therefore
the validity of a questionnaire usually has to be proved
by comparing results with clinical face-to-face exami-
nations.
Currently only one German language question-
naire exists to diagnose migraine and tension-type
headache.3 It has never been used, however, in epi-
demiological studies.

546
Headache
The aim of the study was to develop and vali-
date a self-administered questionnaire for diagnosis of
migraine (MIG), tension-type headache (TTH), and
trigeminal autonomic cephalgias (TAC), which could
be used for epidemiological research.
METHODS
The study was approved by the ethics committee
of the University of Essen, Germany. Written consent
was obtained from all patients and controls.
Construction of Questionnaire.—The question-
naire was based on the second version of the classifi-
cation criteria of the International Headache Society
(ICHD-2).1 It firstly explained the principles and gen-
eral rules for answering followed by specific questions
regarding MIG (7 items), TTH (7 items), and TAC
(6 items). The questions were to be answered with
“Yes” or “No.” Subjects were interviewed further
about the number of days with the different headache
types and the number of intake days of acute pain or
migraine drugs per month. In several preliminary tests
the questionnaire was presented to headache sufferers
to enhance the clarity of item formulations.
The analysis algorithm corresponded to the
ICHD-2 criteria. According to the algorithm the fol-
lowing outcomes were possible: MIG, TTH, TAC,
combination of MIG and TTH (MIG plus TTH, com-
bination of MIG and TAC (MIG plus TAC), combi-
nation of TTH and TAC (TTH plus TAC), and “non-
classifiable” headache.
Subjects.—Overall 278 patients were investigated.
We studied 180 consecutive patients seen between
November 2004 and April 2005 in the outpatient
headache clinic of the University of Essen, Germany
suffering from migraine (n = 97), TTH (n = 60), or
a combination of migraine and TTH (n = 23). Pa-
Table 1.—Demographic and Clinical Characteristics of the Study Population
Total (N = 278) MIG (N = 97)
Years: Mean (Range) 43.9 (16–79) 40.4 (16–73)
Gender: m/w 136/142 24/73
MIG = migraine; TTH = tension-type headache; TAC = trigeminal-autonomic cephalgias.
547
tients with TAC (n = 98) were recruited from a special
consultation of the same university clinic. Forty-seven
healthy subjects not suffering from headache and
42 patients with back pain not having headache served
as controls.
Study Flow.—On a visit day patients were asked to
fill out the questionnaire. Afterwards face-to-face in-
terviews were performed by 3 headache-experienced
neurologists blinded to the questionnaire diagnoses.
Symptomatic headaches were ruled out by clinical ex-
amination, Doppler and duplex sonography and as far
as necessary by computer tomography or magnetic res-
onance imagine of the brain. To determine the retest
reliability, the questionnaire was sent to all patients
4 weeks later.
Statistics.—Sensitivity, specificity, positive and
negative predictive values were calculated for all pos-
sible combinations including MIG, TTH, TAC, MIG
plus TTH, MIG plus TAC, TTH plus TAC using physi-
cian medical diagnoses as a gold standard. Cohen’s
kappa with 95% confidence interval (CI) was cal-
culated for the overall agreement of physician and
questionnaire diagnoses. The same procedure was per-
formed for the monodiagnoses, including MIG, TTH,
and TAC ignoring all combination diagnoses. Retest
reliability was calculated by Pearson’s Confidence Co-
efficient. Data analysis was performed by SPSS 13.0
and BiAS 8.0.4
RESULTS
A total of 278 headache patients participated in
the study. The demographic and clinical features of
the studied population are shown in the Table 1. The
gender distribution in subpopulations of patients with
migraine and TAC corresponded to the known epi-
demiological ratios.
TTH (N = 60) TAC (N = 98) MIG/TTH (N = 23)
39.5 (17–79) 49.4 (29–75) 43.8 (16–65)
24/36 77/21 9/14
548 April 2007

Table 2.—Agreement Between Physician and Questionnaire Diagnoses

Physician
Questionnaire MIG TTH TAC MIG + TTH MIG+ TAC TTH+ TAC NC Total

MIG 71 3 – 4 – – – 78
TTH 3 51 1 – – – – 55
TAC 1 1 62 – – – – 64
MIG + TTH 8 3 – 18 – – – 29
MIG + TAC 13 – 25 1 – – – 39
TTH + TAC – – 10 – – – – 10
NC 1 2 – – – – – 3
Total 97 60 98 23 – – – 278

MIG = migraine; TTH = tension-type headache; TAC = trigeminal-autonomic cephalgias; NC = not classifiable.

Validity of all Questionnaire Diagnoses.—Four
headache syndromes were diagnosed by headache ex-
perts: MIG, TTH, TAC, and MIG plus TTH (Table 2).
The questionnaire provided 3 further diagnoses in 52
patients: MIG plus TAC, TTH plus TAC, and a diag-
nosis “not classifiable headache.” Table 2 shows the
agreement between physician and questionnaire diag-
noses. Forty-nine patients with a questionnaire’s di-
agnosis of MIG plus TAC and TTH plus TAC were
identified by the physicians as 35 cases of TAC alone,
13 cases of MIG, and 1 case of MIG plus TTH. Two of
3 cases with the questionnaire diagnosis “not classifi-
able” were diagnosed by physicians to have TTH and
1 to have MIG.
A Cohen’s kappa of 0.64 indicated the agreement
for the 7 × 7 cross-tab. The 95% confidence interval
constitutes 0.58 and 0.70.
Sensitivity, Specificity, Positive and Negative Pre-
dictive Values.—Table 3 summarizes the sensitivity,
specificity, positive and negative predictive values as
well as the corresponding likelihood ratios. The sensi-
tivity was the largest for TTH and the lowest for MIG
plus TTH. The specificity was more than 90% in all 4
syndromes. The positive and negative predictive val-
ues ranged between 78% (PPV for MIG plus TTH)
and 96% (PPV for TAC).
Validity of Questionnaire for Monodiagnoses
of MIG, TTH, and TAC.—In a post hoc analy-
sis we calculated the agreement coefficient (Kappa)
for the 3 monodiagnoses of MIG (74 cases), TTH
(55 cases), and TAC (64 cases) ignoring combina-
tion diagnoses. Table 4 shows agreement of diagnoses
in 184 cases and disagreement in 9 cases. Only in 3
patients with migraine, 4 patients with TTH, and 2
patients with TAC the questionnaire diagnoses de-
viated from the physician’s diagnosis. The Cohen’s
Kappa-coefficient was 0.93 and 95% CI (0.83 and
1.00).

Table 3.—Sensitivity, Specificity, Positive and Negative Predictive Values for Migraine, TTH, TAC, and MIG plus TTH

N (T) Sensitivity % (CI) Specificity % (CI) PPV % (CI) NPV % (CI) Likelihood-ratio

MIG (CI) 71 (97) 73.2 (63.2; 81.7) 96.1 (92.2; 98.4) 91.0 (82.4; 96.3) 87.0 (81.5; 91.3) 18.9
TTH (CI) 51 (60) 85.0 (73.4; 92.9) 98.2 (95.4; 99.5) 92.7 (82.4; 97.9) 95.9 (92.5; 98.1) 46.3
TAC (CI) 62 (98) 63.3 (52.9; 72.7) 98.8 (96.0; 99.8) 96.9 (89.2; 99.6) 83.2 (77.5; 87.9) 56.9
MIG/TTH (CI) 18 (23) 62.1 (42.3; 79.3) 97.8 (94.9; 99.3) 78.3 (56.3; 92.5) 95.3 (91.8; 97.6) 28.4

N = number of correct diagnoses by questionnaire; T = number of physician diagnoses; PPV = positive predictive value; NPV =
negative predictive value; CI = 95% confidence interval.
Headache 549

Table 4.—Agreement Between Physician and Questionnaire
Diagnoses for Monodiagnoses
Physician
Questionnaire MIG TTH TAC
MIG 71 3 –
TTH 3 51 1 55
TAC 1 1 62
Total 75 55 63
MIG = migraine; TTH = tension-type headache; TAC =
trigeminal-autonomic cephalgias.
Sensitivity, Specificity, Positive and Negative Pre-
dictive Value for the Questionnaire Monodiagnoses.—
Sensitivity was highest for TAC (98.4%) and low-
est for migraine (91.2%). Specificity was highest for
TAC (98.5%) and the lowest for TTH (95.1%). PPV
and NPV ranged between 88.1% (PPV for TTH) and
99.2% (NPV for TAC) (see Table 5).
Patients With Back Pain and Headache-Free
Persons.—All 42 patients with low back pain with-
out headache were negative according to the ques-
tionnaire as there were 40 out of 47 healthy controls.
Seven controls who were headache free according to
the questionnaire were later diagnosed as TTH by
physicians during a face-to-face interview.
Retest-Reliability of the Questionnaire.—Table 6
shows the agreement of questionnaire diagnoses at
baseline and 4 weeks later. Overall in 9 cases we found
a deviation between the first and second evaluation.
Two migraine patients were diagnosed as migraine at
baseline and as “not classifiable” 4 weeks later. Four
patients with MIG plus TTH at baseline were diag-
nosed as migraine and 3 patients with MIG plus TAC
were diagnosed as MIG 4 weeks later. The Pearson’s
correlation coefficient was 0.948.
Total DISCUSSION
We achieved the main goal of the study: to con-
74 struct a self-administered questionnaire for screen-
ing for MIG, TTH, and TAC. The overall agreement
64
between the questionnaire and physician diagnoses
193
including all possible (7) headache syndromes, and
therefore a large chance correction, was 0.64, which
should be considered as a “strong” agreement level.5
The questionnaire allowed combination of headache
syndromes, which in some cases produced diagnosis
of combinations of migraine and TAC or TTH and
TAC. Three cases were diagnosed as nonclassifiable.
Hence, in 18% of patients the questionnaire diag-
noses were not correct. Exclusion of combination di-
agnoses significantly improved the sensitivity, speci-
ficity as well as positive and negative predictive values
achieving an excellent Kappa of 0.93. This indicates
that the questionnaire is quite valid in identifying pa-
tients with monodiagnoses and less valid in patients
with more than one headache syndrome. A very good
retest reliability with a Pearson’s coefficient of 0.95 was
observed. Four weeks after the first evaluation only
9 patients made deviating statements.
Overall the quality of our questionnaire is compa-
rable with the international literature. At present, sev-
eral validated headache questionnaires do exist. Most
of them are constructed as screening instruments for
migraine6-15 and usually consist of 3 to 8 items, which
are based on the IHS-criteria.
Lipton et al presented a very short screening ques-
tionnaire for migraine with only 3 items and were able

Table 5.—Sensitivity, Specificity, Positive and Negative Predictive Value for Migraine-, TTH-, and TAC-Monodiagnoses

N Sensitivity % (CI) Specificity % (CI) PPV % (CI) NPV % (CI) Likelihood-ratio

MIG (CI) 74 91.2 (82.8; 96.4) 97.4 (92.8; 99.4) 95.0 (88.8; 99.1) 94.3 (90.9; 97.5) 36.2
TTH (CI) 55 92.8 (82.7; 98.0) 95.1 (90.1; 98.0) 88.1 (77.0; 95.0) 97.1 (92.8; 99.2) 18.9
TAC (CI) 64 98.4 (91.4; 99.96) 98.5 (94.7; 99.8) 96.88 (89.1; 99.6) 99.2 (95.9; 99.9) 66.9

N = number of correct diagnoses by questionnaire; PPV = positive predictive value; NPV = negative predictive value; CI = 95 % -
confidence interval.
550 April 2007

Table 6.—Number of Agreement of Questionnaire Diagnoses our study may be slightly overestimated. Validation
at First Measuring Time (T-1) and 4 Weeks Later (T-2)
studies, which are strongly based on population instead
of clinical samples, eventually will produce more au-
T-2 thentic data. At present the questionnaire is used in a
Questionnaire Agreeing Disagreeing population based epidemiological study on the preva-
Diagnoses T-1 Diagnoses Diagnoses lence of headache in Germany. Referring data will be
reported next.
MIG 78 75 2 NC
TTH 55 55 –
TAC 64 64 –
CONCLUSION
MIG + TTH 29 25 4 MIG We present a new headache questionnaire which
MIG + TAC 39 31 3 MIG could be recommended for use as a screening instru-
TTH + TAC 10 10 –
NC 3 3 – ment for epidemiological research in German lan-
Total 278 269 9 guage.
Acknowledgments: Supported by the German Min-
MIG = migraine; TTH = tension-type headache; TAC = istry for Education and Research.
trigeminal-autonomic cephalgias; NC = not classifiable; T-1 =
measurement 1; T-2 = measurement 2 four weeks later. Conflict of Interest: None

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