The Dawn of a New Era in Headache Classification

Abstract

DEAR EDITOR Among the many things the COVID pandemic taught humanity, a prominent one is that medical knowledge is ultra-rapidly changing. Changes are driven by need and the world saw long strides in new knowledge to defeat a common enemy. This was also the time some radically new approaches to medical publications were made. One eye-catching format was that of living systematic reviews. Even with rapid publication, it has been noted that there is a lag by months or years in cumulative evidence. Living reviews allowed authors to update previously vetted and peer reviewed literature (1). The World Headache Society Multiaxial Classification of Headache Disorders First Edition (WHS-MCH1) is a clinician-focused classification of head, neck, and face pains. It is a game changer for several reasons. It is perhaps the first living medical classification that has been published and therefore we also decided to call it a ‘version’ in the electronic publishing saga, to reflect how rapidly we would update and create further versions. It also reflects the strides made in understanding the mechanism of disease genetics, neural structures and networks, radiological and other biomarkers. Similar advances paved the way for multiaxial classifications in epilepsy (2) and dystonia (3), although multiaxial classifications have been around from the 18th century (4). WHS-MCH1 is also designed to be used effectively by clinicians of all levels of experience to be able to classify and action complex headache management. Headache specialists would find how fascinating it is to classify based on both mechanisms and a multiaxial approach. This is also perhaps the world’s first classification where an entire axis is devoted to the patient narrative. This is aimed to reduce the gap between an objective assessment of individual burden and disability and the subjective perception of the impact of pain and associated symptoms in an individual patient. WHS-MCH1 is a bedside and desktop clinical tool which can be applied at every patient visit. This will update the changes in the patient and disease characteristic every time and functions as a compass to ascertain whether the navigation of a labyrinth of complex clinical pathways is in the correct direction or not. It guides investigations and treatment based on deductive reasoning (5) and algorithms, making it attractive for all healthcare workers who can use this for appropriate triage and referral, thereby reducing precious time lost in emergencies or a busy outpatient practice. If you ask me who are the greatest beneficiaries of this classification system, it is the patients. It is heavily scientific, as much as it is patient-centric. This is also a landmark facelift to the archaic method of classification based on opinions from cloistered rooms to that of a natural evolution from the battlefield, that is, from near the suffering patient in a wider, multicultural, and inclusive environment that the World Headache Society is founded upon. The longer-term goal is that this classification be used to generate national and regional headache registries which will guide the formulation of management paradigms, guidelines, and policies. Although any new classification is likely to meet resistance from the inertia and ramrod of long-held beliefs and post truth, it is hoped that the spirit of science and inquiry prevails.