New Headache Guidelines Published: ICHD-3 beta

It has come to light that there is a need to improve upon the way migraine headache is diagnosed. In a 2011 study of 250 people who were newly diagnosed with migraine, it was found that it took over 5 years for more than half of those people to be diagnosed.1 About one in three were diagnosed after 1 to 5 years. Only 17% got their diagnosis in less than 12 months! Fortunately, the guidelines for diagnosing migraine have been closely reviewed and updated to better meet the needs of those who suffer from this condition.

Last July, the third edition of the International Classification of Headache Disorders (ICHD-3 beta) was published.2 While the guidelines are ready for immediate use, the “beta” remains in the name for field testing and alignment with the International Classification of Disease edition 11 (ICD-11) of the World Health Organization (WHO), which will be published in the next couple of years.2-4 Many changes have been made to the previous version (ICHD-2), some of which we discuss below.

One significant update is the addition of chronic migraines that occur at least 15 days per month, for at least 3 months. As we know, migraines occur at different levels of severity. In the past, patients with these headaches were all diagnosed with migraine, regardless of how many migraine attacks they actually had.5 Diagnostic criteria for chronic migraine are as follows:

A. Headache (tension-type-like and/or migraine-like) on at least 15 days per month for >3 months and fulfilling criteria B and C
B. Occurring in a patient who has had at least 5 attacks fulfilling criteria B-D for migraine without aura and/or criteria B and C for migraine with aura
C. On at least 8 days per month for >3 months, fulfilling any of the following:

1. Criteria C and D for migraine without aura

2. Criteria B and C for migraine with aura

3. Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative

D. Not better accounted for by another ICHD-3 diagnosis.

The updated guidelines also recommend that patients who meet the criteria for chronic migraine and for medication-overuse headache should be given both diagnoses.2 We know that medication overuse is the most common cause of symptoms suggestive of chronic migraine. In fact, about half of patients with chronic migraine revert to a type of episodic migraine after stopping medication and are therefore wrongly diagnosed with chronic migraine. Additionally, we know that many people who appear to be overusing medication don’t get better after drug withdrawal. Therefore, in this case, the diagnosis of medication-overuse headache may actually be incorrect.

The criteria for secondary headaches were revised so that a diagnosis of secondary headache can actually be given the first time you go to see your doctor.2,3 Previously, a diagnosis could not be given until the you had recovered from whatever it was causing the headache, and from the secondary headache itself. The new guidelines state “when a new headache occurs for the first time in close temporal relation to another disorder that is known to cause headache, or fulfills other criteria for causation by that disorder, the new headache is coded as a secondary headache attributed to the causative disorder. This remains true even when the headache has the characteristics of a primary headache (migraine, tension-type headache, cluster headache or one of the other trigeminal autonomic cephalalgias)…”

Finally, migraine with aura is now subdivided into several categories: migraine with typical aura, typical aura with headache, migraine with brainstem aura, hemiplegic migraine, several types of familial hemiplegic migraine, sporadic hemiplegic migraine, and retinal migraine. 2,5 Of note, the term "migraine with brainstem aura" is a new term to the ICHD-3. Previously used terms were: basilar artery migraine, basilar migraine, and basilar-type migraine.

So, what does this mean for you? Generally, these updated guidelines are representative of the fact that research on migraine is ongoing. There remains a constant need to improve the way we diagnose migraines, and new research continues to uncover new information and highlights the fact that this is not a “one size fits all” condition.

It’s important that you talk to your doctor about all of your symptoms so you can get a proper diagnosis - including the type (or types) of migraine you experience. If you feel that it would benefit you, you may also consider seeing a headache specialist.

Note: This post was updated to include: further explanation for the use of the term "beta" in the guidelines, full diagnostic criteria for chronic migraine, and terms previously used for "migraine with brainstem aura" on May 16, 2014.

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