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ICHD classification and diagnosis of migraine

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The classification of all headaches, including migraines, is organized by the International Headache Society, and published in the International Classification of Headache Disorders (ICHD). The current version, the ICHD-2, was published in 2004.

The first category within the ICHD is Migraine. Migraines in general are considered to be a neurological syndrome. It is estimated that 11% (303 million) of the global population,[1][2][3] including 43 million Europeans[4] and 28 million Americans,[5] experience migraines.

Organization of migraine subclasses

The ICHD-2 categorization includes 6 subclasses of migraine (formerly 7), most of which are further subdivided. The following table outlines these classes and their ICHD-1, -2, and ICD-10 codes.

ICHD-2[6] ICHD-1[7] ICD-10[6][8] ICHD-2 Diagnosis
1.1 1.1 G43.0 Migraine without aura
1.2 1.2 G43.1 Migraine with aura
1.3 1.5 G43.82 Childhood periodic syndromes that are commonly precursors of migraine
1.4 1.4 G43.81 Retinal migraine
1.5 1.6 G43.3 Complications of migraine
1.6 n/a G43.3
(G40;
G41) 		Migraine-triggered seizure
1.7 n/a G43.83 Probable migraine
n/a 1.3 Opthalmoplegic migraine
n/a 1.7 Migrainous disorder not fulfilling above criteria

Migraine without aura (common migraine)

In the common form of migraine, the patient primarily suffers from migraine without aura, and may also sometimes suffer migraine with aura. The International Classification of Headache Disorders[9] definition is:

Description: Recurrent headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.

Diagnostic criteria:
A. At least five attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours [when untreated]
C. Headache has at least two of the following characteristics:

1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity

D. During the headache at least one of the following:

1. Nausea and/or vomiting
2. Photophobia and phonophobia
E. Not attributed to another disorder
— International Classification of Headache Disorders[9]

When these criteria are partially fulfilled, there are alternative diagnoses, i.e. "probable migraine without aura" or "episodic tension-type headache".

Migraine with aura

The second-most common form of migraine headache: the patient primarily suffers migraine with aura, and might also suffer migraine without aura. The International Classification of Headache Disorders[9] definition is:

Description: Recurrent disorder manifesting in attacks of reversible focal neurological symptoms that usually develop gradually over 5–20 minutes and last for less than 60 minutes. Headache with the features of "migraine without aura" usually follows the aura symptoms. Less commonly, headache lacks migrainous feature or is completely absent [i.e., the aura may occur without any subsequent headache].

Diagnostic criteria:
A. At least two attacks fulfilling criterion B
B. Migraine aura fulfilling criteria [described below]
C. Not attributed to another disorder.

...[Criteria for "Typical aura":]
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
[Aura also has] at least two of the following:
1. Homonymous visual symptoms [i.e., affecting just one side of the field of vision] and/or unilateral sensory symptoms [i.e., affecting just one side of the body]
2. At least one aura symptom develops gradually over [at least] 5 minutes and/or different aura symptoms occur [one after the other] over [at least] 5 minutes
3. Each symptom lasts [from] 5 [to] 60 minutes

...[Other potential aura criteria:]

  • Fully reversible motor weakness...
  • Each aura symptom lasts [from] 5 minutes [to] 24 hours...
  • [In the case of a "Basilar-type" migraine], Dysarthria [difficulty speaking], vertigo [dizziness], tinnitus [ringing in the ears], [and other symptoms].
    — International Classification of Headache Disorders[9]

Basilar type migraine

Basilar type migraine (BTM) (previously basilar artery migraine [BAM] and basilar migraine [BM]) is an uncommon, complicated migraine with symptoms caused by brainstem dysfunction. Serious episodes of BTM can lead to stroke, coma, and death. Using triptans and other vasoconstrictors as abortive treatments for BTM is contraindicated. Abortive treatments for BTM address vasodilation and restoration of normal blood flow to the vertebrobasilar territory to restore normal brainstem function.

Familial and sporadic hemiplegic migraine

Main article: Familial hemiplegic migraine

Familial hemiplegic migraine (FHM) is migraine with a possible polygenetic cause—in fact, FHM can only be diagnosed when at least one close relative has it too.[9] The patient experiences typical migraine with aura headache either preceded or accompanied with one-sided, reversible limb weakness and/or sensory difficulties and/or speech difficulties. FHM is associated with ion channel mutations.

There also exists the "sporadic hemiplegic migraine" (SHM), which is the same as FHM but with no close family members showing the symptoms.

Effecting a differential diagnosis between basilar migraine and hemiplegic migraine is difficult. Often, the decisive symptom is either motor weakness or unilateral paralysis, which occur in FHM and SHM. Basilar migraine can present tingling and numbness, but true motor weakness and paralysis occur only in hemiplegic migraine.

Abdominal migraine

Abdominal migraine is a recurrent disorder of unknown origin, principally affecting children. Sometimes early on, it can be misdiagnosed in an ER setting as appendicitis. Episodes feature nausea, vomiting, and moderate-to-severe central, abdominal pain. The child is well between episodes. The International Classification of Headache Disorders[9] definition is:

Diagnostic criteria:

A. At least 5 attacks fulfilling criteria B-D.
B. Attacks of abdominal pain lasting 1-72 hours (untreated or unsuccessfully treated)
C. Abdominal pain has all of the following characteristics:
1. midline location, periumbilical or poorly localized
2. dull or "just sore" quality
3. moderate or severe intensity
D. During abdominal pain at least 2 of the following:
1. anorexia
2. nausea
3. vomiting
4. pallor
E. Not attributed to another disorder
— International Classification of Headache Disorders[9]

Most children suffering abdominal migraine will develop propensity to migraine headache in adult life; the two propensities might co-exist during the child's adolescence.

Treating an abdominal migraine can often be difficult;[10] medications used to treat other forms of migraines are usually employed.[11] These include Elavil (75-150 mg),[12] Wellbutrin SR (400 mg),[13] and Topamax (200-400 mg).[14]

In some cases, the abdominal migraine is a symptom linked to cyclic vomiting syndrome (CVS).[15] There may be a history of migraines in the family of the sufferer.[16]

Retinal migraine

Main article: Retinal migraine

Retinal migraines are a subclass of optical migraines. Sufferers will experience a scotoma—a patch of vision loss in one eye surrounded by normal vision—for less than one hour before vision returns to normal. Retinal migraines may be accompanied by a throbbing unilateral headache, nausea, or photophobia.

Not classified in the ICHD-2

Acephalgic migraine

Acephalic migraine is a neurological syndrome. It is a variant of migraine in which the patient may experience aura symptoms such as scintillating scotoma, nausea, photophobia, hemiparesis and other migraine symptoms but does not experience headache. Acephalic migraine is also referred to as amigrainous migraine, ocular migraine, ophthalmic migraine or optical migraine.

Sufferers of acephalgic migraine are more likely than the general population to develop classical migraine with headache.

The prevention and treatment of acephalgic migraine is broadly the same as for classical migraine. However, because of the absence of "headache", diagnosis of acephalic migraine is apt to be significantly delayed and the risk of misdiagnosis significantly increased.

Visual snow might be a form of acephalic migraine.

If symptoms are primarily visual, it may be necessary to consult an ophthalmologist or optometrist to rule out potential eye disease before considering this diagnosis.

Menstrual migraine

Menstrual migraine is distinct from other migraines. Approximately 21 million women in the US suffer from migraines,[17] and about 60% of them suffer from menstrual migraines.[18]

  • There are two types of menstrual migraine – Menstrually Related Migraine (MRM) and Pure Menstrual Migraine (PMM)
  • MRM is a headache of moderate-to-severe pain intensity that happens around the time of a woman’s period and at other times of the month as well.
  • PMM is similar in every respect but only occurs around the time of a woman’s period.[19]
  • The exact causes of menstrual migraine are uncertain but evidence suggests there may be a link between menstruation and migraine due to the drop in estrogen levels that normally occurs right before the period starts.[20]
  • Menstrual migraine has been reported to be more likely to occur during a five-day window, from two days before to two days after menstruation.[21]

When compared with migraines that occur at other times of the month, menstrual migraines have been reported to

  • Last longer—up to 72 hours[22]
  • Occur more often with nausea and vomiting[18]
  • Be more difficult to treat—occur more frequently[24]


References

  1. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1016/j.cpr.2009.05.002, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1016/j.cpr.2009.05.002 instead.
  2. ^ Leonardi, Matilde; Mathers, Colin (2000). "Global burden of migraine in the Year 2000: summary of methods and data sources" (PDF). Global Burden of Disease 2000. World Health Organization. Retrieved 4 September 2009.
  3. ^ "The Global Burden of Disease: A response to the need for comprehensive, consistent and comparable global information on diseases and injuries" (PDF). Epidemiology and Burden of Disease. World Health Organization. 2003. Retrieved 4 September 2009.
  4. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1111/j.1468-2982.2008.01837.x, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1111/j.1468-2982.2008.01837.x instead.
  5. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1212/WNL.0b013e3181b7c1d8, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1212/WNL.0b013e3181b7c1d8 instead.
  6. ^ a b Headache Classification Subcommittee of the International Headache Society (2004). "The International Classification of Headache Disorders, 2nd Edition" (PDF). Cephalagia. 24 (Supplement 1). Oxford, England, UK: Blackwell Publishing. ISSN 0333-1024. Retrieved 4 September 2009.
  7. ^ "ICHD-1" (PDF). International Headache Society. 1988. Retrieved 4 September 2009.
  8. ^ "G43". International Statistical Classification of Diseases and Related Health Problems 10th Revision Version for 2007. World Health Organization & the German Institute of Medical Documentation and Information. 2007. Retrieved 4 September 2009.
  9. ^ a b c d e f g Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 14979299, please use {{cite journal}} with |pmid=14979299 instead.
  10. ^ http://headaches.about.com/cs/asktheclinian/f/122203_1f.htm
  11. ^ http://headaches.about.com/od/migrainediseas1/a/what_abdom_mx.htm
  12. ^ http://www.answers.com/topic/amitriptyline
  13. ^ http://www.webmd.com/migraines-headaches/abdominal-migraines-children-adults?page=2
  14. ^ http://www.medicinenet.com/topiramate/article.htm
  15. ^ http://digestive.niddk.nih.gov/ddiseases/pubs/cvs/index.htm#migraine
  16. ^ http://dictionary.webmd.com/terms/abdominal-migraine
  17. ^ Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M (2001). "Prevalence and burden of migraine in the United States: data from the American Migraine Study II". Headache. 41 (7): 646–57. doi:10.1046/j.1526-4610.2001.041007646.x. PMID 11554952.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  18. ^ a b Granella F, Sances G, Zanferrari C, Costa A, Martignoni E, Manzoni GC (1993). "Migraine without aura and reproductive life events: a clinical epidemiological study in 1300 women". Headache. 33 (7): 385–9. doi:10.1111/j.1526-4610.1993.hed3307385.x. PMID 8376100.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ (2004) "The International Classification of Headache Disorders: 2nd edition". Cephalalgia 24 Suppl 1: 9–160.
  20. ^ Brandes JL (2006). "The influence of estrogen on migraine: a systematic review". JAMA. 295 (15): 1824–30. doi:10.1001/jama.295.15.1824. PMID 16622144.
  21. ^ a b MacGregor EA, Hackshaw A (2004). "Prevalence of migraine on each day of the natural menstrual cycle". Neurology. 63 (2): 351–3. PMID 15277635.
  22. ^ Granella F, Sances G, Allais G; et al. (2004). "Characteristics of menstrual and nonmenstrual attacks in women with menstrually related migraine referred to headache centres". Cephalalgia. 24 (9): 707–16. doi:10.1111/j.1468-2982.2004.00741.x. PMID 15315526. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  23. ^ Couturier EG, Bomhof MA, Neven AK, van Duijn NP (2003). "Menstrual migraine in a representative Dutch population sample: prevalence, disability and treatment". Cephalalgia. 23 (4): 302–8. doi:10.1046/j.1468-2982.2003.00516.x. PMID 12716349.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ^ Martin VT, Wernke S, Mandell K; et al. (2005). "Defining the relationship between ovarian hormones and migraine headache". Headache. 45 (9): 1190–201. doi:10.1111/j.1526-4610.2005.00242.x. PMID 16178949. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
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