Headache in young patients: Clinical characteristics of a series of 651 cases. / Cefalea en jóvenes: características clínicas en una serie de 651 casos.

INTRODUCTION: Headache has a negative impact on health-related quality of life in young patients. We aim to analyse the characteristics of a series of young patients visiting a headache clinic and estimate the burden of different types of headaches listed by the International Classification of Headache Disorders (ICHD). METHODS: We prospectively recruited patients aged 14 to 25 years who were treated at our clinic during a period of 6.5 years. We recorded each patient's sex, complementary test results, and previous treatment. We subsequently compared the characteristics of our sample to those of patients older than 25. RESULTS: During the study period, we treated 651 patients aged 14 to 25 years; 95.6% had received symptomatic treatment, and 30.1% had received preventive treatment. A total of 755 headaches were recorded. Only 80 were secondary headaches, most of which were included in Group 8; 77.2% were included in Group 1, 3.1% in Group 2, 1.2% in Group 3, 5% in Group 4, 0.6% in Group 13, and 0.9% in Group 14. According to Headache Impact Test (HIT-6) scores, headache had at least a moderate impact on the quality of life of 449 patients. CONCLUSION: Most headaches in young patients can be classified according to ICHD criteria. Migraine was the most frequent diagnosis in our sample. Although headache was commonly associated with a negative impact on quality of life, most patients had received little preventive treatment before being referred to our clinic.

The validation of the Hungarian version of the ID-migraine questionnaire.

BACKGROUND: Despite its high prevalence, migraine remains underdiagnosed and undertreated. ID-Migraine is a short, self-administrated questionnaire, originally developed in English by Lipton et al. and later validated in several languages. Our goal was to validate the Hungarian version of the ID-Migraine Questionnaire. METHODS: Patients visiting two headache specialty services were enrolled. Diagnoses were made by headache specialists according to the ICHD-3beta diagnostic criteria. There were 309 clinically diagnosed migraineurs among the 380 patients. Among the 309 migraineurs, 190 patients had only migraine, and 119 patients had other headache beside migraine, namely: 111 patients had tension type headache, 3 patients had cluster headache, 4 patients had medication overuse headache and one patient had headache associated with sexual activity also. Among the 380 patients, 257 had only a single type headache whereas 123 patients had multiple types of headache. Test-retest reliability of the ID-Migraine Questionnaire was studied in 40 patients. RESULTS: The validity features of the Hungarian version of the ID-Migraine questionnaire were the following: sensitivity 0.95 (95% CI, 0.92-0.97), specificity 0.42 (95% CI, 0.31-0.55), positive predictive value 0.88 (95% CI, 0.84-0.91), negative predictive value 0.65 (95% CI, 0.5-0.78), missclassification error 0.15 (95% CI, 0.12-0.19). The kappa coefficient of the questionnaire was 0.77. CONCLUSION: The Hungarian version of the ID-Migraine Questionnaire had adequate sensitivity, positive predictive value and misclassification error, but a low specificity and somewhat low negative predictive value.

A lost track in ICHD 3 beta: A comprehensive review on osmophobia.

Background Osmophobia (Os) has been reported to be much more prevalent in migraine (M) than in other primary headaches, and its high specificity in the differential diagnosis between M and tension-type headache (TTH) has been reported. Os was included in the ICHD II Appendix as a diagnostic criterion of M. It disappeared in ICHD-3 beta. To understand this choice, we reviewed the literature after 2004. Methods This was a systematic review. We searched in PubMed, MEDLINE and Cochrane library for "osmophobia", "odour/odorphobia AND headache", "odour/odor hypersensitivity AND headache" and "olfactory hypersensitivity AND headache". Results 112 papers cited Os as an accompanying symptom of headache; 16 focused on Os in M diagnosis. With the data from 40 articles, we calculated the pooled prevalence of Os in 14,360 patients (2281 pediatric) affected by M (n = 12,496) and TTH (n = 1864). In M, the prevalence was 48.5% (CI 95% 41.4 to 55.8%) in adults and 23.4% (CI 95% 15.7 to 33.4%) in pediatric patients; in TTH, the prevalence was 8.9% (CI 95% 4.6 to 13.5%) in adults and 7.9% (CI 95% 3.3 to 18.1%) in pediatric patients. Ten of these papers allowed us to calculate the sensibility and specificity of Os in differential diagnosis between M and TTH. In adults, the value of specificity was 94.1% (CI 95% 88.9 to 96.9%), and sensitivity was 51.4% (CI 95% 38.4 to 64.2%). In pediatric patients, specificity was 92.0% (CI 95% 81.9 to 96.7%), and sensitivity was 22.1% (CI 95% 10.1 to 41.8%). Conclusion The literature endorses the inclusion of Os among M diagnostic criteria. On this ground, the decision to remove Os from ICHD 3 beta appears unjustified and a revision of this choice is recommended.

Identification of subgroups of patients with tension type headache with higher widespread pressure pain hyperalgesia.

BACKGROUND: Identification of subgroups of patients with different levels of sensitization and clinical features can help to identify groups at risk and the development of better therapeutic strategies. The aim of this study was to identify subgroups of patients with tension type headache (TTH) with different levels of sensitization, clinical pain features, and psychological outcomes. METHODS: A total of 197 individuals with TTH participated. Headache intensity, frequency, and duration and medication intake were collected with a 4-weeks diary. Pressure pain thresholds were assessed bilaterally over the temporalis muscle, C5-C6 joint, second metacarpal and tibialis anterior muscle to determine widespread pressure pain hyperalgesia. The Hospital Anxiety and Depression Scale assessed anxiety and depression. The State-Trait Anxiety Inventory evaluated the state and trait levels of anxiety. The Headache Disability Inventory evaluated the burden of headache. Health-related quality of life was determined with the SF-36 questionnaire. Groups were considered as positive (three or more criteria) or negative (less than three criteria) on a clinical prediction rule: headache duration <8.5 h/day; headache frequency <5.5 days/week; bodily pain <47 and vitality <47.5. RESULTS: The ANCOVA revealed that subjects in group 1 (positive rule, n = 89) exhibited longer headache history, shorter headache duration, lower headache frequency, higher widespread pressure hyperalgesia, higher anxiety trait levels, and lower quality of life (all, P < 0.01) than those subjects within group 2 (negative rule, n = 108). Differences were similar between men and women. CONCLUSIONS: This study identified a subgroup of patients with TTH with higher sensitization, higher chronicity of headaches and worse quality of life but lower frequency and duration of headache episodes. This subgroup of individuals with TTH may need particular attention and specific therapeutic programs for avoiding potential chronification.

Comprehensive Application of the International Classification of Headache Disorders Third Edition, Beta Version.

The purpose of this study was to test the feasibility and usefulness of the International Classification of Headache Disorders, third edition, beta version (ICHD-3ß), and compare the differences with the International Classification of Headache Disorders, second edition (ICHD-2). Consecutive first-visit patients were recruited from 11 headache clinics in Korea. Headache classification was performed in accordance with ICHD-3ß. The characteristics of headaches were analyzed and the feasibility and usefulness of this version was assessed by the proportion of unclassified headache disorders compared with ICHD-2. A total of 1,627 patients were enrolled (mean age, 47.4±14.7 yr; 62.8% female). Classification by ICHD-3ß was achieved in 97.8% of headache patients, whereas 90.0% could be classified by ICHD-2. Primary headaches (n=1,429, 87.8%) were classified as follows: 697 migraines, 445 tension-type headaches, 22 cluster headaches, and 265 other primary headache disorders. Secondary headache or painful cranial neuropathies/other facial pains were diagnosed in 163 patients (10.0%). Only 2.2% were not classified by ICHD-3ß. The main reasons for missing classifications were insufficient information (1.6%) or absence of suitable classification (0.6%). The diagnoses differed from those using ICHD-2 in 243 patients (14.9%). Among them, 165 patients were newly classified from unclassified with ICHD-2 because of the relaxation of the previous strict criteria or the introduction of a new diagnostic category. ICHD-3ß would yield a higher classification rate than its previous version, ICHD-2. ICHD-3ß is applicable in clinical practice for first-visit headache patients of a referral hospital.

Comprehensive Application of the International Classification of Headache Disorders Third Edition, Beta Version

The purpose of this study was to test the feasibility and usefulness of the International Classification of Headache Disorders, third edition, beta version (ICHD-3beta), and compare the differences with the International Classification of Headache Disorders, second edition (ICHD-2). Consecutive first-visit patients were recruited from 11 headache clinics in Korea. Headache classification was performed in accordance with ICHD-3beta. The characteristics of headaches were analyzed and the feasibility and usefulness of this version was assessed by the proportion of unclassified headache disorders compared with ICHD-2. A total of 1,627 patients were enrolled (mean age, 47.4±14.7 yr; 62.8% female). Classification by ICHD-3beta was achieved in 97.8% of headache patients, whereas 90.0% could be classified by ICHD-2. Primary headaches (n=1,429, 87.8%) were classified as follows: 697 migraines, 445 tension-type headaches, 22 cluster headaches, and 265 other primary headache disorders. Secondary headache or painful cranial neuropathies/other facial pains were diagnosed in 163 patients (10.0%). Only 2.2% were not classified by ICHD-3beta. The main reasons for missing classifications were insufficient information (1.6%) or absence of suitable classification (0.6%). The diagnoses differed from those using ICHD-2 in 243 patients (14.9%). Among them, 165 patients were newly classified from unclassified with ICHD-2 because of the relaxation of the previous strict criteria or the introduction of a new diagnostic category. ICHD-3beta would yield a higher classification rate than its previous version, ICHD-2. ICHD-3beta is applicable in clinical practice for first-visit headache patients of a referral hospital.

Are migraine and tension-type headache diagnostic types or points on a severity continuum? An exploration of the latent taxometric structure of headache.

The objective of this study was to assess whether migraine and tension-type headache (TTH) are best viewed as discrete entities or points on a severity continuum using taxometric analysis. Historically, classification systems have conceptualized the primary headache disorders of migraine and TTH as fundamentally different disorders that are differentiated by their characteristic symptom profiles and, as such, imply differing pathophysiologies and required treatments. Despite this categorical nosology, findings continue to emerge suggesting that migraine and TTH instead reflect dimensions of severity within the same headache construct. However, few studies have assessed this issue using taxometric statistical analyses or investigated how this taxonomic structure varies as a function of age and headache frequency. We conducted a latent-mode factor analysis of headache symptomatology obtained from 3449 individuals with headache from 2 previous, large-scale cross-sectional studies of primary headache sufferers (Martin et al., 2005, and Smitherman and Kolivas, 2013). Stratified taxometric analyses suggest that the validity of a categorical vs dimensional classification varies as a function of sample characteristics. Specifically, graphical results revealed that high headache frequency (>15 d/mo) and younger age (<24 years old) were associated with unimodal distributions suggestive of a dimensional construct of primary headache, whereas lower headache frequency and older age were associated with bimodal distributions characteristic of discrete diagnostic entities. Conceptualizing primary headache as a severity continuum was supported for young adults and those with frequent headaches. The distinctions of a categorical classification system were supported for adults (>24 years old) and those with infrequent headache.

Field testing the alternative criteria for tension-type headache proposed in the third beta edition of the international classification of headache disorders: results from the Korean headache-sleep study.

BACKGROUND: According to the third beta edition of the International Classification of Headache Disorder (ICHD-3 beta), the diagnostic criteria for tension-type headache (TTH) might lead to the inclusion of individuals with headaches showing migrainous features. To better define TTH, the alternative diagnostic criteria were proposed in the appendix of ICHD-3 beta. This study attempted to test the alternative criteria for diagnosis of TTH proposed in ICHD-3 beta in a population-based sample from Korea. METHODS: We selected participants from the Korean population aged 19-69 years using stratified random sampling and evaluated them by interview using a questionnaire designed to identify headache type, headache characteristics, and psychiatric comorbidities. RESULTS: Of the 2,762 participants, 586 (21.3%) were diagnosed as having TTH using the standard criteria. Among these, 238 (40.6%) were also classified as having TTH using the alternative criteria. All 238 TTH subjects first diagnosed as having TTH by the alternative criteria were also classified as having TTH by the standard criteria. If the standard criteria were not applied, the remaining 348 patients were subclassified as having probable migraine (115, 19.6%) and unclassified headache (233, 39.7%). Compared with subjects diagnosed with TTH using the standard criteria, those diagnosed using the alternative criteria were less likely to demonstrate unilateral, pulsating headache, which is aggravated by movement, photophobia, phonophobia, and osmophobia. CONCLUSION: Using the alternative criteria, less than half of the subjects with TTH according to the standard criteria were classified as having TTH. All the subjects with TTH by the alternative criteria were classified as having TTH by the standard criteria. This study also demonstrated that subjects diagnosed with TTH using the standard criteria could include people with headaches showing migrainous features.

Diagnosing and understanding adult headache.

Primary headaches are the most common headache disorders. The most common forms are tension-type headaches, migraine, and cluster headache. Knowing the clinical presentation coupled with taking a thorough history taking and performing a thorough physical examination usually helps in arriving at a correct diagnosis. Special attention should be paid to unusual clinical presentations. Further diagnostic work-up should be performed in the presence of atypical and worrisome signs.

Evaluation and management of "sinus headache" in the otolaryngology practice.

Patients, primary care doctors, neurologists and otolaryngologists often have differing views on what is truly causing headache in the sinonasal region. This review discusses common primary headache diagnoses that can masquerade as "sinus headache" or "rhinogenic headache," such as migraine, trigeminal neuralgia, tension-type headache, temporomandibular joint dysfunction, giant cell arteritis (also known as temporal arteritis) and medication overuse headache, as well as the trigeminal autonomic cephalalgias, including cluster headache, paroxysmal hemicrania, and hemicrania continua. Diagnostic criteria are discussed and evidence outlined that allows physicians to make better clinical diagnoses and point patients toward better treatment options.

Reliability and validity of the migraine disability assessment scale among migraine and tension type headache in Iranian patients.

INTRODUCTION: MIDAS is a valid and reliable short questionnaire for assessment of headache related disability. Linguistic validation of Persian MIDAS and assessment of psychometric properties between tension type headache (TTH) and migraine were the aims of this study. METHODS: Patients with migraine or TTH were included. At the first visit, we administered a headache symptom questionnaire, MIDAS, and SF-36. Patients filled out MIDAS in second and third visit within three and eight weeks after base line visit. Internal consistency (Cronbach α ) and test-retest reproducibility (Spearman correlation coefficient) were used to assess reliability. Convergent validity and MIDAS capability to differentiate between chronic and episodic headaches (migraine and TTH) were also assessed. RESULTS: The 267 participants had episodic migraine (EM-64%), chronic migraine (CM-13.5%), episodic TTH (ETTH-13.5%), and chronic TTH (CTTH-9). Internal consistency reliability was 0.8 for the entire sample, 0.72 for TTH, and 0.82 for migraine. Test-retest reliability for all questions between visit 1 and visit 2 varied from 0.54 to 0.71. Convergent validity was assessed using SF-36 as an external referent. Patients with episodic headaches (EM and ETTH) had significantly lower MIDAS scores than chronic headaches (CM and CTTH). CONCLUSION: Persian MIDAS is a valid and reliable questionnaire for migraine and TTH that can differentiate between episodic headache and chronic headache.

Change in intraindividual ICHD-II headache diagnosis over time: a follow-up of the DMKG headache study.

BACKGROUND: Change in headache diagnoses over time within the same individual is not well studied in the adult population. In this study, we prospectively examined the individual variation of migraine and tension-type headache (TTH) diagnoses over time. METHODS: As part of the epidemiological Deutsche Migräne und Kopfschmerzgesellschaft (DMKG) headache study, 1312 participants were personally interviewed and 1122 responded to a second mailed questionnaire 2.2 years later. Headaches were assigned to migraine or TTH at two different points in time using the International Headache Classification, ICHD-II. We used broad (definite and probable subtypes) and strict (only definite type) definitions of migraine and TTH. RESULTS: Using the broad definition increased the reproducibility of migraine diagnosis from 48.0% to 62.0% and of TTH from 59.0% to 65.0%. A constant TTH diagnosis was related to a higher social status (OR 2.81; 95% CI 1.43-5.53) a higher level of education (OR 1.96; 95% CI 1.00-3.85) and physical inactivity (OR 2.28; 95% CI 1.16-4.49). A constant diagnosis of definite migraine was associated with severe headache (OR 2.64; 95% CI 0.97-7.21) and frequent use of headache medication (OR 4.73; 95% CI 0.95-23.60). The result that coexisting TTH decreased the likelihood of a constant migraine (OR 0.29; 95% CI 0.10-0.85) is assumed to indicate response variability. CONCLUSIONS: In epidemiological studies, definite and probable subtypes should be included in the diagnosis to increase the diagnostic accuracy.

Diagnostic value of combinations of symptoms of migraine and tension-type headache included in the diagnostic criteria for children and adolescents in the International Classification of Headache Disorders 2nd Edition.

AIM: To suggest diagnostic combinations of symptoms for migraine and tension type headache (TTH), and for differentiation of overlapping headache (classified as either migraine or TTH) through evaluation of the diagnostic value of combinations of characteristics included in the International Headache Society diagnostic criteria for migraine and TTH in children and adolescents. PATIENTS AND METHODS: The study comprised an epidemiological school-based study (412 of 1029 pupils with chronic/recurrent headache) and a clinical study conducted in the Pediatric Neurology Ward and outpatient clinic at Plovdiv Medical University Hospital (203 patients with chronic/recurrent headache). An inclusion criterion was at least two episodes of headache during the last year. Exclusion criteria were: headache occurring only during acute infections; withdrawal of informed consent. Headache was classified according to the International Classification of Headache Disorders 2nd edition (ICHD-II) The diagnostic value of all combinations of items in criteria C and D for migraine and TTH was measured by sensitivity, specificity, and odds ratio. RESULTS: The combination "unilateral location, severe intensity, aggravation by physical activity" had 100% specificity for migraine. The combination "bilateral location, pressing-tightening quality, mild intensity, no aggravation by physical activity" had 100% specificity for TTH. The combinations: "migrainous location, severe intensity, aggravation by physical activity", "severe intensity, nausea", "pulsating quality, nausea", "pulsating quality, migrainous location, aggravation by physical activity" seemed to pose the greatest risk for developing migraine. These combinations--"no nausea, no photophobia", "bilateral location, mild intensity and either no aggravation by physical activity or pressing-tightening quality, or no nausea or no photophobia" increased the most the TTH risk. Using these combinations as additional criteria for overlapping headache we classified 50% of overlapping headache as TTH and 8.3% as migraine. CONCLUSIONS: Some combinations of symptoms clarify the diagnosis of migraine and TTH. More than 50% of overlapping headache could be differentiated as TTH or MWA by the proposed combinations.

Evaluation of diagnostic and prognostic value of clinical characteristics of migraine and tension type headache included in the diagnostic criteria for children and adolescents in International Classification of Headache Disorders--second edition.

UNLABELLED: Data about the sensitivity and the specificity of the items included in the diagnostic criteria for migraine and tension type headache (TTH) in children is limited and sometimes controversial. AIM: To evaluate the diagnostic value of characteristics of migraine and TTH included in the diagnostic criteria of ICHD-II and according to results to suggest additional criteria for diagnostic differentiation of primary paediatric headache. PATIENTS AND METHODS: The investigation consisted of an epidemiological school-based study (1029 pupils completed the study and 412 had chronic or recurrent headache) and a clinical study conducted in Paediatric Neurology Ward and outpatient clinic (203 patients with chronic or recurrent headache). Inclusion criterion was at least two episodes of headache during the last year. Exclusion criteria were: headache occurring only during acute infections; withdrawal of informed consent. ICHD - II was used to classify headache. The diagnostic value of characteristics of migraine and TTH was measured using sensitivity, specificity, odds ratio and area under receiver operating characteristic curve (AUC). RESULTS: Regarding the AUC, the best diagnostic items for migraine are: moderate or severe intensity or only severe intensity, pain aggravation by physical activity, pulsating quality, respectively, for TTH - no photophobia, no nausea, no aggravation by physical activity, mild or moderate intensity and non-pulsating quality. The most significant symptom for increasing the migraine risk was pulsating pain and the most significant items for TTH risk were no photophobia, bilateral location and no nausea. Family history of migraine also increased migraine risk and could be either included in the diagnostic criteria for migraine or recommended as additional item in differentiating migraine and TTH with overlapping diagnostic criteria. According to AUC, we could recommend changing the content of the item of intensity for migraine as only severe intensity.

Migraine and migraine subtypes in preadolescent children: association with school performance.

OBJECTIVES: To conduct a population-based study describing school performance in children with episodic migraine (EM), chronic migraine (CM), and probable migraine (PM), relative to controls. METHODS: Children (n = 5,671) from 87 cities and 18 Brazilian states were interviewed by their teachers (n = 124). First, teachers were asked to provide information on the performance of the students while at school, which consisted of the same information provided to the educational board, with measurements of the overall achievement of competencies for the school year. The MTA-SNAP-IV scale was then used to capture symptoms of attention-deficit/hyperactivity disorder, and to provide objective information on the performance of the students. Parents were interviewed using a validated headache questionnaire and the Strengths and Difficulties Questionnaire, which measures behavior in 5 domains. Multivariate models estimated determinants of school performance as a function of headache status. RESULTS: EM occurred in 9% of the children, PM in 17.6%, and CM in 0.6%. Poor performance at school was significantly more likely in children with EM and CM, relative to children without headaches, and was significantly influenced by severity (p < 0.001) and duration (p < 0.001) of headache attacks, by abnormal scores of mental health (p < 0.001), and by nausea (p < 0.001), as well as by headache frequency, use of analgesics, and gender. CONCLUSION: Children with migraine are at an increased risk of having impairments in their school performance and factors associated with impairment have been mapped. Future studies should address the directionality of the association and putative mechanisms to explain it.

Psychological issues in the evaluation and treatment of tension-type headache.

Tension-type headache is the most common headache disorder, affecting approximately 40 % of Americans within a one-year span. Although the most common form, episodic tension-type headache, is rarely impairing, more frequent tension-type headache can occur with significant disability and psychological comorbidity. Appreciating the psychological impact, assessing the associated biopsychosocial issues, and understanding patients' coping styles are important in forming an appropriate treatment plan and maximizing treatment outcomes. A range of psychological therapies including relaxation training, cognitive behavioral therapy, biofeedback and mindfulness have demonstrated utility in treating chronic pain conditions and reducing the associated disability. This may be particularly applicable to special populations, including pediatric patients, pregnant patients and geriatric. Psychological assessment and treatment may be done conjointly with medication management and expands treatment options. There is great need to continue researching the effects of psychological treatments, standardizing interventions and making them available to the wider population.