Transcript INTERNATIONAL CLASSIFICATION OF HEADACHE DISORDERS …

Objectives
• Describe how to diagnose migraine
with/without aura
• Give examples for each of secondary
headache disorders (5-12)
• Give examples for each of cranial
neuralgias and facial pains (13-14)
INTERNATIONAL CLASSIFICATION
of
HEADACHE DISORDERS
2nd Edition
(ICHD-II)
Classification
Part 1:
Primary headache disorders
Part 2:
Secondary headache disorders
Part 3:
Cranial neuralgias, central and primary
facial pain and other headaches
Primary or Secondary Headache?
Primary
• No other causative disorder
Primary or Secondary Headache?
Secondary
• Caused by another disorder
• New headache occurring in close
temporal relation to another disorder
that is a known cause of headache
Part 1: Primary Headaches
1. Migraine
2. Tension-type headache
3. Cluster headache and other trigeminal
autonomic cephalalgias
4. Other primary headaches
Cephalalgia = headache
Part 2: Secondary Headaches
5. Headache attributed to head and/or
neck trauma
6. Headache attributed to cranial or
cervical vascular disorder
7. Headache attributed to non-vascular
intracranial disorder
8. Headache attributed to a substance or
its withdrawal
9. Headache attributed to infection
10.Headache attributed to disorder of
homeostasis
11. Headache or facial pain attributed to
disorder of cranium, neck, eyes, ears,
nose, sinuses, teeth, mouth and other
facial or cranial structures
12.Headache attributed to psychiatric
disorder
Part 3
Cranial neuralgias, central and peripheral
facial pain and other headaches
13.Cranial neuralgias and central causes
of facial pain
14.Other headache, cranial neuralgia,
central or peripheral facial pain
Neuralgia = pain extending along the course of one or more nerves
(any cause)
nd
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Headache Red Flags, Positive Imaging
Reason for Imaging Request (111 Patients)
Onset of new or different headache
Nausea or vomiting
Worst headache ever experience
Progressive visual or neurological changes (5)
Paralysis (3)
Weakness, ataxia or loss of co-ordination
Impaired consciousness (2)
Onset of headache after age of 50 years
Papilloedema (1)
Stiff neck
Onset of headache with exertion
Systemic illness
Numbness
Asymmetry of pupillary response (4)
Sensory loss
Signs of meningeal irritation
%
57.7
29.7
28.8
18.0
13.5
12.6
11.7
10.8
9.0
5.4
5.4
4.5
3.6
1.8
0.9
0.9
From these reasons for imaging request, only 5 show correlation with positive findings on imaging
Sobri et al. The British Journal of Radiology, 76 (2003), 532–535
What Questions to Ask Your
Patients
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Pattern
Onset
Location
Frequency
Duration
Severity
Prodrome/aura
Associated symptoms
Sleep habits
Precipitating factors
Emotional factors
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Relationship profile
Family history
Seasonal relationship
Menstruation
Medical history
Surgical history
Allergy
Previous investigation
Past treatment and
responses
• Present medication
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1.1 Migraine without Aura (Common Migraine)
Diagnostic Criteria:
A. At least 5 attacks fulfilling B-D
B. Headache attacks lasting 4-72 hours
C. Headache has at least two of the following:
D.
E.
1.
2.
3.
4.
Unilateral location
Pulsating quality
Moderate or severe intensity
Aggravation by exertion
During headache at least one of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
Not attributed to another disorder
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Migraine with Aura
A.
B.
At least 2 attacks fulfilling B-D.
Aura consisting of at least one of the following, but
no motor weakness:
1. fully reversible visual symptoms including positive
features (e.g., flickering lights, spots or lines)
and/or negative features (i.e., loss of vision)
2. fully reversible sensory symptoms including
positive features (i.e., pins and needles) and/or
negative features (i.e., numbness)
3. fully reversible dysphasic speech disturbance
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Migraine with Aura
C.
D.
E.
At least two of the following:
1. homonymous visual symptoms and/or unilateral
sensory symptoms
2. at least one aura symptom develops gradually
over ≥5 minutes and/or different aura symptoms
occur in succession over ≥5 minutes
3. each symptom lasts ≥5 and <60 minutes
Headache fulfilling criteria B–D for 1.1 Migraine
without aura begins during the aura or follows aura
within 60 minutes
Not attributed to another disorder
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Aura
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Aura
A.
B.
C.
D.
E.
F.
G.
H.
I.
Takes many forms
Migraine with aura = 1/3 total migraine cases
In Migraine with Aura, first attack associated with aura = 40%,
aura with every attack = 20%
57% has aura before headache
Most auras last less than 30 minutes
Most headache follows within 30 minutes
75% has single aura but combinations do occur
Small blind dots > flashes of light > blind spot > foggy vision
No association between headache side and aura side
Queiroz LP, Rapoport AM, Weeks RE et al. Headache. 1997 Mar; 37(3): 137-41.
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Differential Diagnoses
Transient Neurological Deficit:
A.
B.
C.
D.
E.
Transient Ischemic Attack
Seizure
Hypoglycemia
Syncope
Etc.
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Case Study
1. 19-year-old man, unilateral throbbing and at
times non-throbbing headache, onset at age 12.
Duration of headache 6-12 hours, very severe
with aura of twinkling lights, worsening when
straining or working. Associated symptoms
include nausea, vomiting, phonophobia and
photophobia. Sleep may result in free of
headache when waking up. Precipitating factors
include chocolate, cheese.
2. Frequency of 4-6 times a year.
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Case Study
1. Does he have a migraine headache?
2. What is your plan of treatment?
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Case Study
1. 22-year-old woman, bilateral non-throbbing
headache, onset at age 18. Duration of
headache 6-12 hours, activity must stop when
under attack, worsening if working continues.
Associated symptoms include nausea only.
Sleep does not result in free of headache when
waking up. Precipitating factors include white
wine and smoked salmon.
2. Frequency of 10-12 times a year.
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Case Study
1. Does she have a migraine headache?
2. What is your plan of treatment?
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