Abstract
Professor Olesen berates himself as previous Chairman of the Headache Classification Committee for only recently noticing “a flaw in ICHD-3” (1).
He need not do so.
His concern is that no sets of diagnostic criteria exist for 1.0 Migraine and for 2.0 Tension-type headache, and he points to the contrast with 3.1 Cluster headache, “which is coded at the second digit level (and) has a set of diagnostic criteria”.
ICHD-3 recognises four groups (or chapters) of primary headache disorders (2), each group including multiple headache types that are in some manner related. None of these groups (1. Migraine, 2. Tension-type headache, 3. Trigeminal autonomic cephalalgias, 4. Other primary headache disorders) is associated with a set of diagnostic criteria because, strictly, they are not diagnoses.
Nevertheless, for reasons of pragmatism, we do speak of and write about migraine and tension-type headache as though these were headache types, especially in epidemiological studies (3) and in estimates of prevalence and headache-attributed burden (4). Arguably, therefore, sets of overarching criteria are needed for each, embracing all the types, subtypes and subforms within their respective hierarchies.
But Professor Olesen’s proposals for 1.0 Migraine will not work. His criterion A (At least five attacks fulfilling B) immediately excludes those cases of 1.2 Migraine with aura that are diagnosed on the basis of at least two but fewer than five attacks (2). It also is not entirely compatible with 1.3 Chronic migraine, the criteria for which do not specify attacks, other than with reference in criterion B to 1.1 Migraine without aura and 1.2 Migraine with aura, either or both of which must feature in the patient’s history (2). Finally, there is circular conflict in criterion B (Attacks fulfilling diagnostic criteria for one or more of the diagnoses 1.1–1.5) since attacks themselves cannot be considered to fulfil criterion A for these types (2).
The solution for 1.0 Migraine may be simpler:
Recurrent headache and/or other symptoms fulfilling criteria for 1.1 Migraine without aura, 1.2 Migraine with aura and/or 1.3 Chronic migraine Not better accounted for by another ICHD-3 diagnosis.
Deliberately excluded are 1.4 Complications of migraine and 1.5 Probable migraine, which are what their names imply (i.e., not migraine per se).
Epidemiological studies adopting such criteria should recognise that, among the subtypes of 1.2 Migraine with aura, only 1.2.1.1 Typical aura with headache may be included, and, unless these studies find a reliable way to diagnose aura (4), this only when the headache has migraine characteristics.
Professor Olesen’s proposals for 2.0 Tension-type headache run into trouble with criterion D1 (No nausea or vomiting), since criterion D1 for 2.3 Chronic tension-type headache allows “no more than one of photophobia, phonophobia or mild nausea” (2). Adopting the same approach, the solution may again be simpler:
Headache fulfilling criteria for 2.1 Infrequent episodic tension-type headache, 2.2 Frequent episodic tension-type headache or 2.3 Chronic tension-type headache Not better accounted for by another ICHD-3 diagnosis.
Footnotes
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.