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Abstract

This study evaluates osmophobia and taste abnormalities in relationship to sensitivity and specificity in the classification of migraine. Consecutive International Headache Society (IHS) classified patients (n = 1237) were evaluated. Symptoms were graded from 0 to 3. Osmophobia and taste abnormalities were tested for sensitivity and specificity in migraine diagnosis. The patients were 85.4% female and their mean age was 38.1 years. Of 673 patients 24.7% complained of osmophobia, and 24.6% of 505 complained of taste abnormalities. In the absence of nausea and vomiting the combinations of two symptoms gave the following sensitivity and specificity percentages, respectively: photophobia and phonophobia, 10.6 and 84.9; photophobia and osmophobia, 1.1 and 99.0; phonophobia and osmophobia, 1.1 and 98.6; photophobia and taste abnormality, 9.6 and 99.0; phono-phobia and taste abnormality, 9.6 and 98.8; and osmophobia and taste abnormality, 4.2 and 99.4. Osmophobia and taste abnormalities were demonstrated to be very specific in diagnosing migraine IHS 1.1-1.6, but very insensitive.

Keywords

Migraine headache classification osmophobia taste abnormalities

Introduction

The International Headache Society (IHS) Classification of Headaches in 1988 provided a monumental advance (1). It provided a firm basis for comparing patient groups in research and clinical practice. The system continues to be refined. One area of interest has been in the fine-tuning of the associated symptoms category (category D) of the operational criteria for the diagnosis of migraine. In the absence of nausea and vomiting, light and sound intolerance are required for the diagnosis of migraine. The issue has arisen whether osmophobia may play a useful role in defining migraine in this category. (Appendix to proposed International Headache Classification, 2nd Edn). Also neglected has been associated taste abnormality in migraine. The current study was performed for the purpose of defining the sensitivity and specificity of osmophobia and taste abnormalities in a large clinical sample of migraine patients in the diagnosis of migraine.

Patients and methods

Study population

The study population consisted of men, women, and children suffering from the full range of the IHS-defined migraine with or without aura. Patients were treated by the author in his clinical practice and the data accumulated in a database at the time of the visit.

Patients were excluded from the database if they had: (i) had no headache; (ii) headaches thought to be related to trauma or injuries; (iii) complicated neurological problems, i.e. underlying brain or systemic illness related to their headaches; (iv) recent onset headaches, i.e. less than 1 month prior to study; (v) significant legal issues related to their headaches; (vi) been seen prior to the initiation of the database; (vii) declined to, or were cognitively not able to participate in the database interview; and (viii) language or intellectual barriers. Patient data were recorded at the initial visit. Semistructured interviews were performed. This is a retrospective study and data were accumulated in the usual course of patient management. Many patients already used diaries and calendars, and some consulted the author's website for sampling the type of information required. If the patient was uncertain of the information, that variable was omitted. Institutional review board approval for use of the data without specific patient approval was obtained. Confidentiality was preserved by omitting the identification of patients when the data were downloaded to the statistical package.

Study design

Eligible headache patients at the author's clinic seen consecutively between July 2000 and May 2003 were included in a database. Patients were subjected to a headache evaluation, based on their past month typical headache characteristics, as well as a physical and neurological examination. A thorough medical history was also recorded. Osmophobia and taste abnormalities in particular, and other associated symptoms such as nausea, vomiting, photophobia, phonophobia, dizziness, diarrhoea, running of the nose or tearing of the eyes, were evaluated for sensitivity (positive finding of symptom(s) in patients with IHS migraine 1.1–1.6) and specificity (negative symptom(s) in patients who were not diagnosed with IHS migraine 1.1–1.6). Also included were other migraine features (not necessarily related to classification) such as headache waking patient from sleep, worsening of headache with activity, headache intensity (>3/10 and > 6/10), degree of unilateral headache, throbbing quality, and family members with headache, to provide a broader perspective of the associated symptoms findings.

Patient symptom rating

At the initial visit, patients were asked to rate their response to questions on a scale of 0 = never; 1 = occasional (1–33%); 2 = frequent (34–66%); 3 = very frequent (67–100%) in their typical headache.

Statistical analysis

Sensitivity was obtained by dividing the positive symptom(s) frequency in patients with a definitive diagnosis of IHS migraine 1.1–1.6 by the total number of patients with that diagnosis and expressed for patients with grades 1 through 3, grades 2 and 3, and grade 3. Specificity was obtained by dividing the negative symptom(s) frequency in patients who did not have a diagnosis of IHS migraine 1.1–1.6 by the total number of patients who did not have that diagnosis and expressed for patients with grades 1 through 3, grades 2 and 3, and grade 3. This analysis was performed in patients with no nausea or vomiting and also in patients without the restriction of no nausea or vomiting.

Results

Demographic characteristics

Of the 1237 patients seen by the author at the initial visit, 85.4% were females. The mean (± SD) age of patients was 38.1 (11.84) years (range 12.9–80.5).

Headache diagnosis (Fig. 1)

Based on headache characteristics on initial evaluation, 727 patients were diagnosed with IHS 1.1–1.6 migraine (99% IHS 1.1–1.2), 330 as migraine 1.7, 93 as tension-type headache 2.1–2.2, and 87 as ‘other’ which were patients not diagnosed in one of the former groups (31% cluster IHS 3.1–3.3; 16% trigeminal neuralgia IHS 12.2; 53% headache not classifiable IHS 13). Of the IHS 1.1–1.6 patients, 36% reported aura varying from 1% to 100% of migraine attacks.

Figure 1

Population studied.

Osmophobia and taste frequencies

Of the data available, 166 of 673 patients (24.7%) complained of osmophobia during migraine headaches (12.5% mild, 7% moderate, and 5.2% severe). One hundred and twenty-four of 505 (24.6%) complained of taste abnormalities (13.5% mild, 6.1% moderate, and 5.0% severe).

Associated symptoms, sensitivity and specificity in the diagnosis of migraine IHS 1.1–1.6 (Table 1)

In diagnosing migraine in the absence of nausea and vomiting the combination of two of the associated symptoms gave the following sensitivity and specificity percentages, respectively: photophobia and phonophobia, 10.6 and 84.9; photophobia and osmophobia, 1.1 and 99.0; phonophobia and osmophobia, 1.1 and 100; photophobia and taste abnormality, 9.6 and 99.0; phonophobia and taste abnormality, 9.6 and 98.8; osmophobia and taste abnormality, 4.2 and 99.4. Surprisingly, in the absence of nausea and vomiting either osmophobia or taste abnormality alone gave a specificity of 98.4%. Vomiting alone (grade 3) gave a specificity of 97.5% and any running of the nose/tearing of the eyes, without nausea or vomiting, 92.2%. Increasing grades of symptom severity decreased sensitivity and increased specificity across all associated symptoms. In patients when nausea and vomiting were not excluded, sensitivity increased markedly but specificity decreased. In all situations, increasing the grade of symptom impacted significantly on the findings. (See Tables 2–6.)

Table 1

Sensitivity and specificity of two of photophobia, phonophobia, osmophobia, or taste abnormality in migraine IHS 1.1–1.6 – no nausea or vomiting

Grade	Not IHS 1.1–1.6		IHS 1.1–1.6		Sensitivity %∗	Specificity %†
Grade	With symptom	Total	With symptom	Total	Sensitivity %∗	Specificity %†
Photophobia and phonophobia
>0	77	510	65	727	8.9	84.9
>1	21	510	36	727	5.0	95.9
>2	6	510	14	727	1.9	98.8
Photophobia and osmophobia
>0	5	510	8	727	1.1	99.0
>1	3	510	2	727	0.3	99.4
>2	1	510	0	727	0	99.8
Phonophobia and osmophobia
>0	7	510	8	727	1.1	98.6
>1	6	510	2	727	0.3	98.8
>2	5	510	0	727	0	99.0
Osmophobia and taste abnormality
>0	3	510	3	727	0.4	99.4
>1	1	510	0	727	0	99.8
>2	0	510	0	727	0	100
Photophobia and taste abnormality
>0	5	510	7	727	1.0	99.0
>1	0	510	2	727	0.3	100
>2	0	510	1	727	0.1	100
Phonophobia and taste abnormality
>0	6	510	7	727	1.0	98.8
>1	1	510	2	727	0.3	99.8
>2	0	510	2	727	0.3	100

∗Sensitivity = number of patients with symptom/total IHS 1.1–1.6.

†Specificity = 100 minus (number of patients with symptom/total not IHS 1.1–1.6).

Table 6

Summary of sensitivity and specificity study in migraine IHS 1.1–1.6 in decreasing order of specificity (grades > 0), without restriction of nausea or vomiting

	Sensitivity %	Specificity %
Photophobia and taste abnormality	16.8	100
Phonophobia and taste abnormality	16.4	100
Osmophobia and taste abnormality	10.2	100
Taste abnormality	17.1	90.2
Phonophobia and osmophobia	21.9	87.8
Photophobia and osmophobia	22.4	87.7
Osmophobia	22.8	86.7
Diarrhoea	28.6	81.0
Vomiting	52.1	75.5
Running of nose/tearing of eye	44.2	68.6
Photophobia and phonophobia	88.8	50.4
Nausea	90.5	49.2
Dizziness	73.7	46.7
Photophobia	93.8	42.9
Phonophobia	91.3	40.2

Table 2

Sensitivity and specificity of single associated symptoms in migraine IHS 1.1–1.6 in patients with no nausea or vomiting

Grade	Not IHS 1.1–1.6		IHS 1.1–1.6		Sensitivity %∗	Specificity %†
Grade	With symptom	Total	With symptom	Total	Sensitivity %∗	Specificity %†
Photophobia
>0	71	510	65	727	8.9	86.1
>1	40	510	38	727	5.2	92.2
>2	16	510	19	727	2.6	96.9
Phonophobia
>0	80	510	65	727	8.9	84.3
>1	41	510	44	727	6.1	92.0
>2	15	510	25	727	3.4	97.1
Dizziness
>0	67	510	35	727	4.8	86.9
>1	18	510	16	727	2.2	96.5
>2	4	510	5	727	0.7	99.2
Diarrhoea
>0	15	510	4	727	0.6	97.1
>1	5	510	1	727	0.1	99.0
>2	4	510	0	727	0	99.2
Running of nose or tearing of eyes
>0	40	510	24	727	3.3	92.2
>1	20	510	7	727	1.0	96.1
>2	7	510	1	727	0.1	98.6
Osmophobia
>0	8	510	8	727	1.1	98.4
>1	5	510	2	727	0.3	99.0
>2	3	510	0	727	0	99.4
Taste abnormality
>0	8	510	7	727	1.0	98.4
>1	1	510	2	727	0.3	99.8
>2	0	510	2	727	0.3	100.0

∗Sensitivity = number of patients with symptom/total IHS 1.1–1.6.

†Specificity = 100 minus (number of patients with symptom/total not IHS 1.1–1.6).

Table 3

Sensitivity and specificity of single associated symptoms in migraine IHS 1.1–1.6 in patients without restriction of nausea or vomiting

Grade	Not IHS 1.1–1.6		IHS 1.1–1.6		Sensitivity %∗	Specificity %†
Grade	With symptom	Total	With symptom	Total	Sensitivity %∗	Specificity %†
Nausea
>0	259	510	658	727	90.5	49.2
>1	143	510	389	727	53.5	72.0
>2	60	510	186	727	25.6	88.2
Vomiting
>0	125	510	379	727	52.1	75.5
>1	45	510	156	727	21.5	91.2
>2	13	510	56	727	7.7	97.5
Photophobia
>0	291	510	682	727	93.8	42.9
>1	205	510	514	727	70.7	59.8
>2	112	510	326	727	44.8	78.0
Diarrhoea
>0	15	510	4	727	0.6	97.1
>1	5	510	1	727	0.1	99.0
>2	4	510	0	727	0	99.2
Running of the nose or tearing of the eyes
>0	40	510	24	727	3.3	92.2
>1	20	510	7	727	1.0	96.1
>2	7	510	1	727	0.1	98.6
Osmophobia
>0	8	510	8	727	1.1	98.4
>1	5	510	2	727	0.3	99.0
>2	3	510	0	727	0	99.4
Taste abnormality
>0	8	510	7	727	1.0	98.4
>1	1	510	2	727	0.3	99.8
>2	0	510	2	727	0.3	100.0

∗Sensitivity = number of patients with symptom/total IHS 1.1–1.6.

†Specificity = 100 minus (number of patients with symptom/total not IHS 1.1–1.6).

Table 4

Sensitivity and specificity of single features in migraine IHS 1.1–1.6 in patients without restriction of nausea or vomiting

Grade	Not IHS 1.1–1.6		IHS 1.1–1.6		Sensitivity %∗	Specificity %†
Grade	With symptom	Total	With symptom	Total	Sensitivity %∗	Specificity %†
Headache wakes from sleep
>0	267	510	515	727	70.8	47.7
>1	114	510	267	727	36.7	77.7
>2	42	510	93	727	12.8	91.8
Headache worse with activity
>0	310	510	654	727	90.0	39.2
>1	229	510	558	727	76.8	55.1
>2	118	510	341	727	46.9	76.9
Headache intensity > 3/10
	355	510	416	727	57.2	30.4
Headache intensity > 6/10
	221	510	294	727	40.4	43.4
Headache side of head
>0	336	510	579	727	79.6	34.0
>1	240	510	435	727	59.8	52.9
>2	139	510	264	727	36.3	72.8
Headache throbbing
>0	355	510	667	727	91.8	30.4
>1	264	510	537	727	73.9	48.2
>2	119	510	305	727	50.0	76.7
Family history of headache
Any	280	510	519	727	71.4	45.1
>1	123	510	265	727	36.5	75.9
>2	47	510	108	727	14.9	90.8

∗Sensitivity = number of patients with symptom/total IHS 1.1–1.6.

†Specificity = 100 minus (number of patients with symptom/total not IHS 1.1–1.6).

Table 5

Summary of sensitivity and specificity study in migraine IHS 1.1–1.6 in decreasing order of specificity (grades > 0), no nausea or vomiting

	Sensitivity %	Specificity %
Osmophobia and taste abnormality	0.4	99.4
Photophobia and taste abnormality	1.0	99.0
Photophobia and osmophobia	1.1	99.0
Phonophobia and taste abnormality	1.0	98.8
Phonophobia and osmophobia	1.1	98.6
Osmophobia	1.1	98.4
Taste abnormality	1.0	98.4
Diarrhoea	0.6	97.1
Running of nose/tearing of eye	3.2	92.2
Dizziness	4.8	86.9
Photophobia	8.9	86.1
Photophobia and phonophobia	10.6	84.9
Phonophobia	8.9	84.3

Discussion

This study evaluates osmophobia and taste abnormalities during migraine attacks in a large sample of IHS 1.1–1.6 diagnosed patients in migraine classification.

Overall, osmophobia and taste abnormalities are sparsely mentioned in current headache texts (2, 3), and even less so is migraine mentioned in the authoritative olfaction and gustation text (4). There are limited reported studies of osmophobia and taste pertaining to migraine in the literature. Strong odours are described as a trigger of migraine (5, 6). Sensitivity to odours and olfactory hallucinations are described in migraine (7–11). Olfactory or taste symptoms during migraine were described in 13% of 64 patients) and 10.9% of 46 women reported olfactory hallucinations (12). Blau documented a frequency of osmophobia in 25 of 50 ‘migraine’ patients (13). The current study shows a lower percentage of patients having osmophobia. Taste is very similar to osmophobia in the current study. This is hardly surprising. Anosmic patients complain of abnormal taste, but it is primarily flavour that is affected. However, they may also complain of less sensitive sweet and salt taste (14). The absence of osmophobia in the current study had less effect on taste abnormalities (40% of the original numbers) than the absence of taste abnormalities had on osmophobia (28.3%).

The IHS 1988 classification is a unique document. It has provided an operational guideline for the working diagnosis of most headache types and situations, and provided standardization for comparing populations of patients in clinical and drug studies. Almost more important has been the huge outpouring of literature, thought, and research that the classification has evoked (15–33). Not all reports have been favourable but, as in any system, improvements can and will be made over the years. The ultimate classification will depend on biological data combined with clinical data.

The area of interest in this study is the classification of patients using osmophobia and/or taste abnormalities in category D of the IHS 1988 classification in the absence of nausea and vomiting. Do these symptoms have a place in the diagnosis of migraine? Clearly, this study demonstrates the remarkable specificity of both osmophobia and taste abnormalities either alone or combined with one another or with other associated symptoms (always above 98% and contrasted with other associated symptoms and also other features of migraine not necessarily related to classification). However, they do not add any extra patients that would not have been already diagnosed by the current 1988 IHS classification. This reflects on the basic strength of the current classification. This analysis needs to be replicated using a different population of patients.

This study explores the phenomena of osmophobia and taste abnormalities with particular reference to classification of migraine. Osmophobia and taste abnormalities were demonstrated in this study to be very specific in diagnosing migraine IHS 1.1–1.6, but very insensitive. Few, if any, additional patients would be diagnosed as having migraine who would not normally be diagnosed under the current 1988 IHS classification.

References

1. Headache Classification Committee of the International Headache Society . Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988; 8 (Suppl. 7):1–96.

Silberstein

Lipton

Dalessio

DJ.

Wolff's headache. 7th edn. New York: Oxford University Press, 2001.

Olesen

Tfelt-Hansen

Welch

KMA.

The headaches. 2nd edn. Philadelphia: Lippincott Williams and Wilkins, 2000.

4. Doty

RL.

, editor Handbook of olfaction and gustation. 2nd edn. New York: Marcell Dekker, 2003.

Scharff

Turk

Marcus

DA.

Triggers of headache episodes and coping responses of headache diagnostic groups. Headache 1995; 35: 397–403.

Raffaelli

Martins

A role for anticonvulsants in migraine. Funct Neurol 1986; 1: 495–8.

Lance

JW.

Mechanism and management of headaches. 4th edn. London: Butterworths, 1982.

Wolfberg

Ziegler

DK.

Olfactory hallucination in migraine. Arch Neurol 1982; 39: 382.

Crosley

Dhamoon

Migrainous olfactory aura in a family. Arch Neurol 1983; 40: 459.

10.

Morrison

Price

WH.

The prevalence of psychiatric disorder among female new referrals to a migraine clinical. Psychol Med 1989; 19: 919–25.

11.

Ardila

Sanchez

Neuropsychological symptoms in the migraine syndrome. Cephalalgia 1988; 8: 67–70.

12.

Morrison

DP.

Abnormal perceptual experiences in migraine. Cephalalgia 1990; 10: 273–7.

13.

Blau

Solomon

Smell and other sensory disturbances in migraine. J Neurol 1985; 232: 275–6.

14.

Henkin

Levy

LM.

Functional MRI of congenital hyposmia. Brain activation to odors and imagination of odors and tastes. J Comp Assist Tomog 2002; 26: 39–61.

15.

Nash

JM.

A structural representation of migraine diagnostic criteria: the experts’ view. Headache 2003; 43: 322–9.

16.

Gallai

Sarchielli

Alberti

Pedini

Gallai

Rossi

Cittadini

Application of the International Headache Society diagnostic criteria in nine Italian headache centers using a computerized structured record. Headache 2002; 42: 1016–24.

17.

Rains

Penzien

Lipchik

Pedini

Ramadan

NM.

Diagnosis of migraine: empirical analysis of a large clinical sample of atypical migraine (IHS 1.7) patients and proposed revision of the IHS criteria. Cephalalgia 2001; 21: 584–95.

18.

Gobel

Classification of headaches. Cephalalgia 2001; 21: 770–3.

19.

Rokicki

Semenchuk

Bruehl

Lofland

Houle

TT.

An examination of the validity of the IHS classification system for migraine and tension-type headache in the college student population. Headache 1999; 39: 720–7.

20.

Olesen

Rasmussen

BK.

The International Headache Society classification of chronic daily and near-daily headaches: a critique of the criticism. Cephalalgia 1996; 16: 407–11.

21.

Silberstein

Lipton

Sliwinski

Classification of daily and near-daily headaches: field trial of revised IHS criteria. Neurology 1996; 47: 871–5.

22.

Olesen

The International Headache Society classification and diagnostic criteria are valid and extremely useful. Cephalalgia 1996; 16: 294–6.

23.

Pearce

JMS.

Are the International Headache Society criteria for headache useful?

Cephalalgia 1996; 16: 289–93.

24.

Tietjen

GE.

The International Headache Society classification: to use or not to use?

Cephalalgia 1996; 16: 296.

25.

Merikangas

Dartigues

Whitaker

Angst

Diagnostic criteria for migraine. A validity study. Neurology 1994; 44 (6 Suppl. 4): S11–6.

26.

Granella

D’Alessandro

Manzoni

Cerbo

Colucci

D’Amato C

Pini

International Headache Society classification: interobserver reliability in the diagnosis of primary headaches. Cephalalgia 1994; 14: 16–20.

27.

Sjaastad

Stovner

LJ.

The IHS classification for common migraine. Is it ideal?

Headache 1993; 33: 372–5.

28.

Merikangas

Pfaffenrath

Summary and recommendations for classification of headache. Cephalalgia 1993; 13 (Suppl. 12) 91–3.

29.

Merikangas

KR.

Classification of headache: methods and empirical data. Background and introduction. Cephalalgia 1993; 13 (Suppl. 12) 5–6.

30.

Merikangas

Frances

Development of diagnostic criteria for headache syndromes: lessons from psychiatry. Cephalalgia 1993; 13 (Suppl. 12) 34–8.

31.

Bruyn

GW.

Headache classification: status praesens. Cephalalgia 1993; 13 (Suppl. 12) 13–7.

32.

Messinger

Spierings

Vincent

AJ.

Overlap of migraine and tension-type headache in the International Headache Society classification. Cephalalgia 1991; 11: 233–7.

33.

Rasmussen

Jensen

Olesen

A population-based analysis of the diagnostic criteria of the International Headache Society. Cephalalgia 1991; 11: 129–34.

The Place of Osmophobia and Taste Abnormalities in Migraine Classification: A Tertiary Care Study of 1237 Patients

Abstract

Keywords

Introduction

Patients and methods

Study population

Study design

Patient symptom rating

Statistical analysis

Results

Demographic characteristics

Headache diagnosis (Fig. 1)

Osmophobia and taste frequencies

Associated symptoms, sensitivity and specificity in the diagnosis of migraine IHS 1.1–1.6 (Table 1)

Discussion

References