Acute headache and persistent headache attributed to cervical artery dissection: Field testing of ICHD-III beta

Abstract

The criteria for headache attributed to cervical artery dissection have been changed in the new third edition of the International Classification of Headache Disorders (ICHD-III beta). We have retrospectively investigated 19 patients diagnosed from 2001 to 2006 with cervical artery dissection at onset and followed them up six months after dissection.

At dissection onset 17/19 patients were classified as headache probably attributed to vascular disorder at the time of dissection using the ICHD second edition (ICHD-II) criteria. In contrast, 17/19 of patients fulfilled the ICHD-III beta criteria for Headache or facial or neck pain attributed to cervical carotid or vertebral artery dissection or Headache attributed to intracranial arterial dissection. Six months after dissection five of 19 patients still reported persistent headache attributed to dissection.

The study demonstrates that the ICHD-III beta criteria for cervical artery dissection are useful for classifying patients at the first encounter. We show for the first time that persistent headache attributed to arterial dissection is frequent.

Introduction

Headache or facial or neck pain as symptoms of cervical or vertebral artery dissection (VAD) have been reported in numerous studies (1–4) and are sensitive (5) but unspecific (6) symptoms. Pain resolution within one month was a necessary requirement in the International Classification of Headache Disorders, second edition (ICHD-II), 6.5.1 headache or facial or neck pain attributed to arterial dissection (7) (Table 1). This implied that a definite diagnosis could not be met until one month had elapsed. Therefore, headache or facial or neck pain following dissection could be applied only as headache probably attributed to vascular disorder (7) within the first month. This was unsatisfactory, as it is best to classify headache or pain at the first encounter. In the new ICHD third edition beta (ICHD-III beta), the requirements for headache attributed to dissection classification have been modified, and pain resolution is no more an absolute requirement (8) (Table 1). The secondary headaches are so far defined as resolving within one to three months with the exception of headache attributed to head injury which is divided into an acute and a persistent form (8). For other secondary headaches, including headache attributed to arterial dissection, a persistent form is described only in the appendix (8). There is a lack of studies investigating how often headache persists after arterial dissection. Based on these issues, we found it timely to field test the classification of headache or facial or neck pain attributed to dissection according to the new ICHD-III criteria in comparison with the ICHD-II. We retrospectively tested and classified headache and pain before, during and six months after dissection in 19 consecutive patients using both ICHD-II and III.

Table 1.

Comparison of criteria according to the International Classification of Headache Disorders second and third edition (ICHD-II and ICHD-III) (7,8).

ICHD-II	6.5.1 Headache or facial or neck pain attributed to arterial dissection	ICHD-III	6.5.1 Headache or facial or neck pain attributed to cervical carotid or vertebral artery dissection
A	Any new headache, facial pain or neck pain of acute onset, with or without other neurological symptoms or signs and fulfilling criteria C and D	A	Any new headache and/or facial or neck pain fulfilling criterion C
B	Dissection demonstrated by appropriate vascular and/or neuroimaging investigations	B	Cervical carotid or vertebral dissection has been diagnosed
C	Pain develops in close temporal relation to and on the same side as the dissection	C	Evidence of causation demonstrated by at least two of the following:
			1. pain has developed in close temporal relation to other local signs of cervical artery dissection, or has led to the diagnosis of cervical artery dissection
			2. either or both of the following:
			a. pain has significantly worsened in parallel with other signs of the cervical artery lesion
			b. pain has significantly improved or resolved within one month of its onset
			3. either or both of the following:
			a. pain is severe and continuous for days or longer
			b. pain precedes signs of acute retinal and/or cerebral ischemia
4. pain is unilateral and ipsilateral to the affected cervical artery
D	Pain resolves within one month	D	Not better accounted for by another ICHD-III diagnosis.

Methods

We identified 23 patients diagnosed with cervical artery dissection from 2001 to 2006 at the Stroke Unit at Glostrup Hospital in Denmark using a computerized hospital-based registry. Of these, it was possible to contact 19 by phone. Thus, a total of 19 patients were included. All patients had been evaluated by a staff neurologist, and the diagnosis of dissection was confirmed by computer tomography angiography (CTA) or magnetic resonance angiography (MRA) evaluated by an experienced neuroradiologist who was provided the patients’ clinical history. Images were evaluated for the presence of vessel stenosis or occlusion, and vessel wall abnormalities, including irregularity, intimal flap, pseudoaneurysm, and intramural hematoma. This latter finding was evaluated as enlargement of the outer diameter of the vessel together with a wall thickening representing the wall hematoma on CTA. The intramural hematoma was identified as a methemoglobin crescent on axial T1-weighted fat-suppressed MR images. Only images with vessel stenosis or occlusion and clear vessel wall abnormalities pathogenic of dissection were included. Medical and radiographic records were available for all patients and were evaluated by MM. Six months after onset a structured telephone interview was performed using a standardized questionnaire. Data of previous and present headache were registered and the headaches were then classified according to the ICHD-III criteria (8) and ICHD-II criteria (7).

Results

Nineteen patients were included. The median age was 43 years; range 34–63 years and 11/19 were men. Two patients had a pre-existing history of migraine with aura and one with migraine without aura. Sixteen patients had internal carotid artery dissection (ICAD), two patients had VAD and one patient had combined ICAD and VAD (Table 2).

Table 2.

Table of dissection, headache characteristics and headache classification of 19 patients with cervical carotid or vertebral artery dissection.

Patient nr.	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19
Dissection	Arteries involved	IC	IC	VA	IC	IC	IC	IC	IC	IC	IC	IC	IC	IC	IC/ VA	IC	IC	IC	IC	VA
Segment	C1	C1–4	V1–4	C1	C1	C1	C1	C2–3	C1–6	C1	C1–2	C1–5	C4–5	C1–2/V2	C1	C1	C1–2	C1	V3–4
Dissection side	L	L	R	R	L	R	L	L	L	R	L	B	L	B	L	R	R	L	B
Pain side	L	L	B	R	L	R	L	L	L	R	L	L	L	L	L	R	R	L	B
Pain	≤ 2 days
duration	> 2 days	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x
Pain onset	Sudden	x	x	x	x	x	x	x	x	x
Gradual	x
Unspecified	x	x	x	x	x	x	x	x	x
Pain	Unilateral	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x
localization	Bilateral	x	x
Intensity	Mild	x	a	x
Moderate	x	x	x	x	x
Severe	x	x	x	x	x	x	x	x	x	x	x
Neck pain	x	x	x	x	x	x	x	x
Facial pain	x	x	x
Findings	Horner’s syndrome	x	x	x	x	x	x	x	x	x	x
Ischemia symptoms	x	x	x	x	x	x	x	x
ICHD-II	Headache probably attributed to vascular disorder	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x
Migraine with aura	x
Tension-type headache	x
ICHD-III	Headache or facial or neck pain attributed to cervical carotid or vertebral artery dissection	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x
Headache attributed to intracranial dissection	x
Migraine with aura	x
Tension-type headache	x

IC: internal carotid artery; VA: vertebral artery; L: left; R: right; B: bilateral; ICHD-II and ICHD-III: International Classification of Headache Disorders, second and third editions. ^aNot specified.

In total, 18/19 reported headache and one of 19 had neck pain in close temporal relation to dissection. Of the 18 patients reporting headache, two patients reported headache characteristics during dissection that resembled their pre-existing primary headache (migraine aura and tension-type headache), which were classified according to both IHCD-II and ICHD-III. The dissection diagnosis was reached as one had a change in aura frequency, and the tension-type headache patient had ischemia symptoms.

ICHD-II at time of dissection

At the time of dissection, no patients could be clearly defined as having 6.5.1 headache or facial or neck pain attributed to arterial dissection (7), and instead headache probably attributed to vascular disorder (7) had to be applied in 17/19 patients. Two of 19 patients were classified as having their usual primary headache triggered by dissection.

ICHD-II six months after dissection

Upon evaluation six months after dissection, five of 17 patients, previously classified with headache probably attributed to vascular disorder at the time of dissection, were now classified as having A6.8 chronic post-vascular disorder headache according to the ICHD-II appendix criteria (7). One of 17 was classified as having usual primary headache, 10/17 patients had no headache and one of 17 had data missing.

ICHD-III at time of dissection

At the time of dissection, 16/19 patients could be clearly defined as having 6.5.1 Headache or facial or neck pain attributed to cervical carotid or vertebral artery dissection (8), and one of 19 as having 6.7.4 Headache attributed to intracranial arterial dissection (8). Six of 19 patients had combined extracranial and intracranial dissection (Table 2), and were classified as having 6.5.1. Two of 19 were classified as having their usual primary headache triggered by dissection. In the ICHD-III criteria for 6.5.1 Headache or facial or neck pain attributed to cervical carotid or vertebral artery dissection, there are six requirements under level C (one for subcriteria 4 and two for subcriteria 1, 2 and 3) and at least two subcriteria should be present (Table 1). In the present study, all patients fulfilled the C1 criterion: (pain) “has led to the diagnosis of dissection.” Seventeen patients fulfilled the C4 criteria: pain was “unilateral and ipsilateral to the affected cervical artery” (Table 1). The other two patients had bilateral pain that fulfilled the C3a criteria: pain that was severe and continuous for days or longer. Our data were not adequate to determine if criteria C2 or C3b were fulfilled.

ICHD-III six months after dissection

Upon evaluation six months after dissection, five of 17 patients, previously classified with 6.5.1 Headache or facial or neck pain attributed to cervical carotid or vertebral artery dissection (8) or 6.7.4 Headache attributed to intracranial arterial dissection at the time of dissection (8), were now classified as having A6.10 Persistent headache attributed to past cranial or cervical vascular disorder according to the ICHD-III appendix criteria (8). Of these one had a previous history (before dissection) of migraine with aura. One of 17 was classified as having usual primary headache, 10/17 patients had no headache and one of 17 had data missing.

Discussion

The first major finding of the present field study was that using the new ICHD-III criteria 17/19 patients could be diagnosed with headache or facial or neck pain attributed to ICAD or VAD or intracranial artery dissection at the first encounter, which was in contrast to none according to the ICHD-II criteria. The second major finding was that follow-up interviews revealed that five of 19 still had persistent headache six months following dissection.

Headache criteria arterial dissection

In the present study, patients with headache attributed to intracranial arterial dissection according to the ICHD-III all fulfilled the C1 criteria, 17 patients the C4 criteria and the other two patients the C3a criteria. Thus, in our series these requirements were all that was needed to fulfill the C criterion. However, the other C criteria are likely to be equally sensitive, even though they require more detailed data, which highlights the importance of a proper patient history and exam.

The new ICHD-III beta classifies two types of dissection headache or pain, 6.5.1 describing ICAD or VAD and 6.7.4 intracranial dissection. However, the 6.5.1 diagnosis does not exclude intracranial dissection, as long as the dissected artery is cervical. This results in the 6.5.1 and 6.7.4 diagnosis not being mutually exclusive, as illustrated in six of 19 of patients in our study. At present, there are no clinical data on differences in pain quality or other features distinguishing intra- versus extracranial dissection headache or pain, and only intracranial dissection in patients without affection of the vertebral artery or ICAD cannot be given the 6.5.1 diagnosis. Thus, further clinical studies are needed to investigate possible differences between 6.5.1 and 6.7.4.

Persistent headache after dissection

In the five of 19 patients with persistent headache six months after dissection, there is an apparent classification gap for these patients, who seem to be only probably classified according to the appendix criteria in both the ICHD-II and beta version of the ICHD-III. Thus, this study supports changing the appendix criteria of persistent headache attributed to past cranial or cervical vascular disorder to a secondary headache type. However, future larger studies are needed to support this proposal.

Caveats and conclusions of the study

We acknowledge some methodological shortcomings of this report. The data were retrospective and based on medical records, which do not include all primary headache characteristics and a detailed description of headache debut. However, the interview at six months was performed using a standardized validated semistructured questionnaire. It would also have been desirable if the patients after admission had filled out headache diaries. The 19 subjects had fewer patients with VAD and migraine than in previous studies (2,9,10), which may limit the generalizability of our findings.

In conclusion, the present study showed that using the new ICHD-III beta criteria for patients with arterial dissection, a definite diagnosis can be reached at the first encounter. The study also showed that five of 19 patients report persistent headache following arterial dissection, which suggests that persistent headache following arterial dissection should be included in the main body of ICHD-III. However, the mechanisms behind persistent headache after dissection are not clear and need to be investigated in prospective future studies.

Clinical implications

We investigated 19 consecutive patients with carotid or vertebral artery dissection at onset, obtained their previous headache history and followed them up six months after dissection.

Headache was classified according to the International Classification of Headache Disorders second edition (ICHD-II) and third edition beta (ICHD-III beta).

The study demonstrates that the ICHD-III criteria for carotid or vertebral artery dissection are useful for classifying patients at the first encounter.

Persistent headache attributed to arterial dissection is frequent.