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.

View References
  1. Viticchi G, Silvestrini M, Falsetti L, et al. Time delay from onset to diagnosis of migraine. Headache: 2011;51:232–236.
  2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629-808.
  3. Olesen J. ICHD-3 beta is published. Use it immediately. Cephalalgia. 2013;33:627-628.
  4. The Lancet Neurology. 2013;12(8):727.
  5. Anderson P. New headache classification system published. Medscape Medical News. July 3, 2013. http://www.medscape.com/viewarticle/807334.

Comments

View Comments (3)
  • Ellen Schnakenberg
    5 years ago

    ICHD-3 is what the writer is referring to here. It should be added that the beta status was discussed at the Scottsdale conference in November, and specialists told that there will be no further changes and to consider this edition final.

    Second, it’s important that it be mentioned that a diagnosis of chronic Migraine doesn’t mean Migraine for 15 or more days per month as eluded here, but a combination of Migraine and tension headache is also permitted. This can be seen by clicking the link provided, but the article may seem misleading without checking all the links, which most people tend to avoid.

    Thirdly, what is now termed Migraine with brainstem aura was previously termed Basilar Type Migraine, a term which no longer exists in ICHD-3. Those with this diagnosis will want to know that the title of their Migraine has changed to avoid confusion.

    Having and maintaining a universal method to diagnosing headaches doesn’t mean that what’s going on in our bodies suddenly changes when a diagnosis changes, but as stated here, it does help us have a cleaner understanding of what’s happening. Additionally, the importance of clear diagnostic criteria is key to the performance of research. The closer we get to getting it right and being consistent, the more accurate and more applicable our research will be, leading to better treatments for patients.

    ~Ellen

  • janenez
    5 years ago

    I am wondering if chronic migraine can have a similar pattern as Relapsing-Remitting MS? I have had migraines since I was a child. They’ve become progressively worse over the years. (I’m 49 yo) I am presently diagnosed as “chronic” and have been this way for about 5 months. I had the same “season of chronic migraine” in 2011, 2009, 2007, 2005 that I can remember. In between these 5 to 6 month “relapses” I have a more stable 4 to 5 migraines a month that are not quite so physically debilitating. After each “time of relapse” I always feel like I don’t return all the way back to as healthy as I was before. My friends say it is “old age” since my problems are such things as muscle weakness and aching, lack of strength, memory loss, vision going downhill, etc. I feel as though it is all migraine related and more severe than “just getting older”. Has anyone heard of anything like this or had something similar diagnosed in some manner? Did anything help?

  • Ellen Schnakenberg
    5 years ago

    janenez

    This is a really good question.

    Yes, our Migraine patterns can change, for several reasons. The most common are a change in triggers, medications and comorbid health conditions.

    Keeping a journal may be of great help to you, and I would really like to encourage you to try that through at least 2-3 of your cycles. Here is the Migraine.com journal for you to try http://migraine.com/migraine-meter/

    As to the progression of your condition, most specialists and researchers agree that for many patients, Migraine is a progressive disease. This means it can continue to get worse with time. Many patients find this is true. Additionally, some of the meds we take can have a detrimental effect on us as well, and need to be taken into consideration, as well as other health conditions and their effects. Migraine is tricky because it is so multifaceted and difficult to pigeonhole neatly. Many patients complain of progression of cognition issues in particular. I don’t think there has been anything that tells us this is necessarily related to their Migraines, but research continues and we learn more every day.

    A long time ago, doctors used to mistakenly think that there was a type of Migraine called Cluster Migraines, but we know that these don’t actually exist as a diagnosis. In other words, it’s not a different Migraine type. What you’re experiencing may have been diagnosed as such many years ago however. Now we know to look for triggers and changes that have created the increased likelihood for transformation from chronic to episodic and back again. It is common for chronics to become episodics, and you may not be well managed as an episodic and relapsing occasionally.

    As to MS = MS patients do sometimes have Migraines that follow the same pattern as their remissions and flares, so having that diagnosis would be important in figuring out your particular puzzle.

    I suggest you see a Migraine and headache specialist to get down to the meat of what’s going on so you can get better control of your Migraines more consistently. Here is a link that may be of some help for you: http://migraine.com/blog/looking-for-a-migraine-specialist/

    ~Ellen

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