ICHD-II Criteria Research Articles

What clues are available for differential diagnosis of headaches in emergency settings?

The correct diagnosis of headache disorders in an emergency room is important for developing early management strategies and determining optimal emergency room activities. This prospective clinical based study was performed in order to determine demographic and clinical clues for differential diagnosis of primary and secondary headache disorders and also to obtain a classification plot for the emergency room practitioners. This study included 174 patients older than 15 years of age presenting in the emergency room with a chief complaint of headache. Definite headache diagnoses were made according to ICHD-II criteria. Classification and regression tree was used as new method for the statistical analysis of the differential diagnostic process. Our 174 patients with headache were diagnosed as basically primary (72.9%) and secondary (27.1%) headaches. Univariate analysis with cross tabs showed three important results. First, unilateral pain location caused 1.431-fold increase in the primary headache risk (p = 0.006). Second, having any triggers caused 1.440-fold increase in the primary headache risk (p = 0.001). Third, having associated co-morbid medical disorders caused 4.643-fold increase in the secondary headache risk (p < 0.001). It was concluded that the presence of comorbidity, the patient’s age, the existence of trigger and relaxing factors, the pain in other body parts that accompanies headache and the quality of pain in terms of location and duration were all important clues for physicians in making an accurate differentiation between primary and secondary headaches.

Investigation of the T3111C CLOCK gene polymorphism in cluster headache

Sirs: Cluster headache (CH) is a primary headache characterized by severe unilateral pain, ipsilateral autonomic symptoms and, in many cases, restlessness. The etiology of CH is still unclear, although clinical, endocrine and neuroimaging studies implicate the hypothalamus. Hypothalamic involvement is also supported by the efficacy of stereotactic deep brain stimulation of the posterior hypothalamic area in chronic drug resistant CH [1]. The increased familial risk of CH suggests a genetic liability with inheritance likely to be autosomal dominant with low penetrance, although autosomal recessive or multifactorial inheritance have also been suggested in some families [2]. A polymorphism of the hypocretin receptor 2 gene has recently been associated with CH [3], a remarkable association since hypocretin-containing cells are located exclusively in the posterolateral hypothalamus. A striking feature of CH is its diurnal and seasonal periodicity, suggesting that circadian and infradian rhythms regulate CH attacks. Polymorphisms in the CLOCK gene, a highly conserved circadian gene, influence the circadian phase in humans [4] and circadian mood fluctuations in bipolar patients [5]. We performed a genetic association study to evaluate whether the T3111C CLOCK polymorphism (also known as T3092C) might be related to CH susceptibility under the assumption of autosomal dominant inheritance. A total of 101 consecutive, unrelated Italian patients (79 men and 22 women) with CH (85 episodic and 16 chronic CH) gave informed consent to the study. All patients were diagnosed after direct interview by a neurologist expert in headache disorders and according to ICHD-II criteria [6]. Of the 101 patients, 87 described a clear circadian rhythmicity of the attacks. 100 healthy individuals, in whom CH and migraine were excluded by direct interview, served as controls. The control sample came from the same geographical region as the CH patients. We analyzed a single nucleotide polymorphism, T3111C, in the 3’ flanking region of the CLOCK gene [4]. DNA was extracted from whole blood by standard methods [7]. PCR primers and methods were those reported by Katzenberg et al. [4]. The T3111C polymorphism was detected by enzymatic digestion with Sdu I (Fermentas) and electrophoresed on MetaPhor agarose 2 % gel. The allelic and genotypic frequencies were compared by means of the Fisher’s exact test. The Hardy-Weinberg equilibrium was verified for all tested populations, and alleles were in Hardy-Weinberg equilibrium in both controls and patients. We found no significant difference in allelic and genotypic frequencies between the total CH patient group and the control subjects (χ2 = 1.261, p = 0.261; χ2 = 5.791, p = 0.055) (Table 1). Nor was a significant difference found when considering the 87 CH patients with circadian rhythmicity of the attacks alone. Our study does not support the hypothesis that the T3111C CLOCK polymorphism is associated with CH. It therefore strengthens the similar negative results reported previously by Rianero et al. [8]. Our analysis moreover resulted in nonsignificant differences when the 87 CH patients reporting a clear periodicity of the attacks were considered separately. It thus appears that CLOCK gene T3111C polymorphism does not influence CH, but our result of course cannot exclude that polymorphic variations at other biological rhythm genes LETTER TO THE EDITORS

History of childhood maltreatment is associated with comorbid depression in women with migraine

A bidirectional relationship between migraine and depression suggests a neurobiological link. Adverse experiences, particularly childhood maltreatment, may alter neurobiological systems, and predispose to a multiplicity of adult chronic disorders. Our objective is to determine, within a headache clinic population of women, if depression moderates the abuse-migraine relationship. At six headache specialty clinics, women with migraine were diagnosed using ICHD-II criteria, and frequency was recorded. A questionnaire regarding maltreatment history, headache characteristics, current depression, and somatic symptoms was completed. A total of 949 women with migraine completed the survey: 40% had chronic headache (> or =15 headache days/month) and 72% had "very severe" headache-related disability. Major depression was recorded in 18%. Physical or sexual abuse was reported in 38%, and 12% reported both physical and sexual abuse in the past. Migraineurs with current major depression reported physical (p < 0.001) and sexual (p < 0.001) abuse in higher frequencies compared to those without depression. Women with major depression were more likely to report sexual abuse occurring before age 12 years (OR = 2.30, 95% CI: 1.14 to 4.77), and the relationship was stronger when abuse occurred both before and after age 12 years (OR = 5.08, 95% CI: 2.15 to 11.99). Women with major depression were also twice as likely to report multiple types of maltreatment (OR = 2.07, 95% CI: 1.27 to 3.35) compared to those without depression. Childhood maltreatment was more common in women with migraine and concomitant major depression than in those with migraine alone. The association of childhood sexual abuse with migraine and depression is amplified if abuse also occurs at a later age.

Nummular headache: another case treated with gabapentin

Sir, Nummular headache (NH) is a chronic, mild-to-moderate head pain located in a small circumscribed area of the head in the absence of any lesion of cranial structures, first described by Pareja et al. [1]. It was coded as A13.7.1 in the Appendix of the ICHD-II Classification [2]. It was treated with NSAIDs, analgesics, botulinum toxin [3] and gabapentin (GBP) [4]. In a recent series of three cases [5], various drugs and local nerve blocks brought no relief. OF, a 26-year-old woman, reported, for about one year previous, a continuous pressure-like pain of mild intensity in a rounded area of 3–4 cm diameter of the left parietal region close to the midline. The pain tended to worsen in intensity during the evening hours, and was accompanied with discomfort and increased sensitivity to light touch within the same area. No nausea, vomiting, photophobia or phonophobia were reported. She had been suffering from mild head trauma for seven years before the onset of pain. She did not take any medication. Neurological examination was unremarkable. She underwent routine blood tests, EKG and EEG, all without abnormalities. Cerebral angio-MRI with CE was normal except for a cholesterol granuloma at the apex of right temporal pyramid. Roentgenogram of cervical spine showed only a minimal scoliosis and cervical hypolordosis. In accordance with ICHD-II criteria, a diagnosis of NH was made and treatment with GBP was prescribed, at the initial dose of 300 mg, reaching a final dose of 300 mg t.i.d. in two weeks. Full dose was not tolerated because of dizziness and restlessness. At the dose of 600 mg the patient experienced full remission of pain, while local cutaneous hypersensitivity persisted. She stopped spontaneously GBP after two months, without recurrence of pain until now (three further months of follow-up). In our opinion, this observation adds further evidence to the efficacy of GBP in NH. Received: 29 December 2006 Accepted in revised form: 23 January 2007 Published online: 11 May 2007

Headache and Recurrent Abdominal Pain: A Controlled Study by the Means Of The Child Behaviour Checklist (CBCL)

Headache and recurrent abdominal pain (RAP) are common disorders in children and adolescents, frequently referred to paediatricians. Both disorders show similarities in trigger and comorbid factors, their burden on family and individual life, and a paroxysmal trend with risks of chronicization over time. However, very few studies have compared directly headache and RAP. The main aim of this study was to compare the psychological profile of headache and RAP patients vs. healthy controls. A total of 210 children and adolescents [99 boys, 111 girls; age range 4-18 years; mean age (m.a.) = 11.04, SD 4.05] were assessed: 70 headache patients (m.a. 12.4 years; SD 2.9; F = 35, M = 35), 70 RAP patients (m.a. 9 years; SD 3.6; F = 30, M = 40) and 70 controls (m.a. 11.7 years; SD 4.6; F = 46, M = 24). The diagnoses had been made according to international systems of classification both for headache (ICHD-II criteria) and RAP (Rome II criteria). The psychological profile had been made according to the Child Behaviour Checklist 4-18 (CBCL). anova one-way analysis was used to compare CBCL scales and subscales between groups. Headache and RAP showed a very similar trend vs. control for the main scales of the CBCL, with a statistically significant tendency to show problems in the Internalizing scale (anxiety, mood and somatic complaints) and no problems in the Externalizing (behavioural) scale. Only for the Attention Problems subscale migraineurs showed a significant difference compared with RAP. In conclusion, headache and RAP show a very similar psychological profile that should be considered not only for diagnostic and therapeutic purposes, but also from the aetiological aspect.

The Burden of Headache in a Patient Population from a Specialized Headache Centre

The aim was to characterize the individual and socio-economic impact of headache in a patient population from The Danish Headache Centre. This was a cross-sectional study using a structured interview, prospective headache diaries and standardized self-administered questionnaires using the ICHD-II criteria. Fifty-five subjects (12 male and 43 female) with a median age of 41 years and a median headache frequency of 15 days/month participated. Very high utilization of the healthcare system and a high absence rate due to headache of 12 days/year were reported. Eighty-one percent experienced a marked decrease in work effectiveness. Overall, 91% felt hampered by their headache on a daily basis and 98% had had expenses for headache medication. Frequent headache disorders are highly costly, especially due to indirect costs. Prevention, early intervention or effective treatment strategies for headache disorders may therefore be highly cost effective, not only for the individual but also for society.

Prevalence and features of migraine in Japanese junior high school students aged 12–15 yr

Migraine is the most common cause of recurrent headache among children and adolescents resulting in missing of school and disabling their daily life. The purpose of this study is to determine the prevalence and clinical features of headache in junior high school children in Japan. In December 2004, questionnaires were sent to 14 junior high schools. There were multiple-choice type questions on headache, mainly migraine. The questionnaires were given during school hours, and 6472 answers were obtained. One thousand four hundred seventy-eight (22.8%) students experienced severe headache and 476 (7.4%) had consulted physicians. Three hundred thirteen (4.8%) were identified as having migraine based on the ICHD-II criteria, consisting of 110/3346 boys (3.3%) and 203/3126 girls (6.5%): 91 (29.1%) with aura and 222 (70.9%) without aura. In about half of the children the migraine attacks were of short duration, ranging from 1 to 3 h. There were 36 boys (1.1%) and 45 girls (1.4%) who had shorter attacks of less than 1 h, whom we did not diagnose as having migraine according to the ICHD-II criteria. Although migraine is common among schoolchildren, it is often under- or miss-diagnosed since the clinical figure for childhood migraine differs from that for adults.

High prevalence of somatic symptoms and depression in women with disabling chronic headache

To better define, in women with headache, the relationship of depression and somatic symptoms to headache, characterized by diagnoses, frequency, and disability. At six headache specialty clinics, women with headache were classified using ICHD-II criteria, and frequency was recorded. A questionnaire addressing demographics, age at onset of headache, headache-related disability, somatic symptom, and depression severity was completed. Logistic regression was performed to measure the associations of headache frequency and headache-related disability with somatic symptom and depression severity. A total of 1,032 women with headache completed the survey, 593 with episodic (96% with migraine) and 439 with chronic headache (87% with migraine). Low education and household income was more common in chronic headache sufferers and in persons with severe headache disability. Somatic symptom prevalence and severity was greater in persons with chronic headache and with severe headache-related disability. Significant correlation was observed between PHQ-9 and PHQ-15 scores (r = 0.62). Chronic headache, severe disability, and high somatic symptom severity were associated with major depressive disorder (OR = 25.1, 95% CI: 10.9 to 57.9), and this relationship was stronger in the subgroup with a diagnosis of migraine (OR = 31.8, 95% CI: 12.9 to 78.5). High somatic symptom severity is prevalent in women with chronic and severely disabling headaches. Synergistic relationship to major depression exists for high somatic symptom severity, chronic headache, and disabling headache, suggesting a psychobiological underpinning of these associations.

Occipital Neuralgia Evoked by Facial Herpes Zoster Infection

Occipital neuralgia is a pain syndrome which may usually be induced by spasms of the cervical muscles or trauma to the greater or lesser occipital nerves. We report a patient with occipital neuralgia followed by facial herpes lesion. A 74-year-old male experienced sudden-onset severe headache in the occipital area. The pain was localized to the distribution of the right side of the greater occipital nerve, and palpation of the right greater occipital nerve reproduces the pain. He was diagnosed with occipital neuralgia according to ICHD-II criteria. A few days later, the occipital pain was followed by reddening of the skin and the appearance, of varying size, of vesicles on the right side of his face (the maxillary nerve and the mandibular nerve region). This was diagnosed as herpes zoster. This case represents a combination of facial herpes lesions and pain in the C2 and C3 regions. The pain syndromes can be confusing, and the classic herpes zoster infection should be considered even when no skin lesions are established.

Chronic daily headache: classification, stress and impact on the quality of life

Chronic daily headache (CDH) is a heterogeneousgroup of headaches that occurs 15 or more days permonth, lasting more than four hours, including thoseassociated with medication overuse. The objectives ofthis study were: to classify CDH; to assess the quality oflife and level of stress of the patients with this type ofheadache.A hundred patients, from both sexes, with minimumage of 18 years old were prospectively studied. The in-clusion criterion was the presence of primary headachewith more than 4-hour duration, a frequency of 15 daysor more monthly, in the last three months. The diagno-sis was according to the second edition of the Interna-tional Classification of Headache Disorders (ICHD-II) cri-teria. The SF-36 questionnaire to observe quality of lifeand Lipp´s Inventory of Stress Symptoms to diagnosestress were used. Patients with chronic organic diseasewere not included.The patients´ mean age was 38.8 years. The majori-ty (87%) was women. CDH mean duration was 4.0 years.Applying the ICHD-II criteria, 17 different types of diag-nosis were necessary to classify CDH of these patients.Among these types of diagnosis, 11 presented migraine(80% of the patients). The types with migraine had low-er scores according to SF-36 either in physical function

Clinical Features, Classification and Prognosis of Migraine and Tension-Type Headache in Children and Adolescents: A Long-Term Follow-Up Study

We performed a long-term follow-up examination in children and adolescents with migraine and tension-type headache (TTH) in order to investigate the evolution of clinical features and headache diagnoses, to compare International Classification of Headache Disorders (ICHD)-I and ICHD-II criteria and to identify prognostic factors. We re-examined 227 patients (52.4% female, age 17.6 +/- 3.1 years) 6.6 +/- 1.6 years after their first presentation to a headache centre using identical semistructured questionnaires. Of 140 patients initially diagnosed with migraine, 25.7% were headache free, 48.6% still had migraine and 25.7% had TTH at follow-up. Of 87 patients with TTH, 37.9% were headache free, 41.4% still had TTH and 20.7% had migraine. The number of subjects with definite migraine was higher in ICHD-II than in ICHD-I at baseline and at follow-up. The likelihood of a decrease in headache frequency decreased with a changing headache location at baseline (P < 0.0001), with the time between baseline and follow-up (P = 0.0019), and with an initial diagnosis of migraine (P = 0.014). Female gender and a longer time between headache onset and first examination tended to have an unfavourable impact. In conclusion, 30% of the children and adolescents presenting to a headache centre because of migraine or TTH become headache-free in the long-term. Another 20-25% shift from migraine to TTH or vice versa. ICHD-II criteria are superior to those of ICHD-I in identifying definite migraine in children and adolescents presenting to a headache centre. The prognosis is adversely affected by an initial diagnosis of migraine and by changing headache location, and it tends to be affected by an increasing time between headache onset and first presentation.

Chronically evolving headaches: classification and terminology

Chronic migraine appeared for the first time in the second edition of the International Classification of Headache Disorders (ICHD-II) in 2004, listed among the complications of migraine. Unfortunately, the diagnostic criteria of ICHD-II for this headache form tend to equate it with a migraine with a high frequency of attacks, rather than with an unfavourable evolution of migraine with loss of symptom-free intervals between attacks. On the other hand, the latter occurrence has increasingly been described in the last few years with the term "transformed migraine". Therefore, it seems advisable to carry out a revision of the ICHD-II in order to: (a) subdivide migraine at the three-digit level into infrequent episodic, frequent episodic and chronic migraine; and (b) introduce transformed migraine among the complications of migraine.

Endocrine Function Is Altered in Chronic Migraine Patients with Medication‐Overuse

To evaluate the effects of analgesic overuse on endocrine function in patients with chronic migraine and medication-overuse headache (CM-MOH). Chronic migraine is frequently associated with an overuse of symptomatic medications. Drugs currently used in acute migraine attacks are associated with several endocrine effects. At present, the endocrine effects of medication overuse in chronic migraine patients are unknown. Eighteen patients with CM-MOH, diagnosed according to the ICHD-II criteria, and 18 healthy controls received an intravenous administration of GHRH, hCRH, and TRH. Plasma concentrations of GH, TSH, ACTH, and cortisol were measured for a 90-minute period after administration of the specific releasing hormones. Hormonal basal concentrations were similar in both groups. GH response to GHRH was significantly reduced in patients with CM-MOH in comparison with controls. TRH induced a reduction of TSH concentrations only at the end of the test. After hCRH administration, ACTH and cortisol concentrations were significantly higher in cases than in controls. A significant correlation between duration of the disease and altered hormonal response was found. Our study shows that both corticotropic and somatotropic functions are significantly impaired in CM-MOH patients and suggests a role for hormones in the development of chronic migraine.

Facial Pain and the Second Edition of the International Classification of Headache Disorders

Recurrent or chronic facial pain may be a diagnostic challenge. Applying the diagnostic criteria of the second edition of the International Classification of Headache Disorders (ICHD-II) leaves a considerable number of patients unclassifiable. The aim of this study was to establish and evaluate revised criteria of trigeminal neuralgia and persistent idiopathic facial pain. Based on the diagnostic value of 12 clinical features of trigeminal neuralgia and 15 features of persistent idiopathic facial in 97 patients referred for facial pain to a neurological tertiary care centre we established revised criteria for persistent idiopathic facial pain and additional criteria for probable trigeminal neuralgia and probable idiopathic facial pain. Applying the newly proposed criteria reduced the number of patients with facial pain not classifiable by more than 50%. The new criteria improved the sensitivity, particularly in idiopathic facial pain and did not cause a relevant decrease in specificity compared to ICHD-II. This study suggests that amendments to the ICHD-II criteria improve the diagnostic classification of facial pain.

HLA-DRB1 genotyping in Italian migraine patients

We examined the distribution of HLA-DRB1 alleles in a cohort 255 Italian migraine patients and in a control group of 325 healthy subjects. 214 patients fulfilled the ICHD-II criteria for migraine without aura and 41 patients the criteria for migraine with aura. The frequency of DRB1 *16 allele was found to be significantly increased in migraine without aura patients ( p = 0.02; OR 1.97, 95% CI: 1.10–3.54) than in healthy controls. The frequencies of HLA-DRB1 alleles were not significantly different between migraine with aura patients and controls. We did not detect any effect of DRB1 alleles on age at onset, duration of the disease, frequency and duration of migraine attacks. Our data suggest the presence of a genetic susceptibility factor for migraine without aura within the HLA region.

Psychiatric disorders and pain location in unilateral migraineurs

To explore the relationship between the side of pain during attacks and psychopathological features in strictly unilateral migraine, we recruited 35 patients affected by migraine with and/or without aura diagnosed according to the revised ICHD–II criteria. Seventeen patients had right side–locked pain (R–SUM), 11 had left side–locked (L–SUM) and 7 had side–shifting pain (SSM). Patients were administered the Hamilton Anxiety Scale, the State and Trait Anxiety Inventory–State Anxiety, the Beck Depression Inventory and the 20–item Toronto Alexithymia Scale. Statistical analyses showed that the L–SUM group was significantly more anxious and depressed than the other two groups of patients. Our preliminary data suggest that strictly left unilateral migraine is associated with more severe anxiety and depression. This finding appears to be consistent with studies that reported a higher degree of these disorders in patients with left cerebral hemispheric damage.

Idiopathic Headache in Children Under Six Years of Age: A Follow‐Up Study

To assess the evolution of idiopathic headache with early onset and to investigate the influence of early somatic disorders, "life events," and psychiatric disorders on the onset and the course of headache. We also studied the possible prognostic role of gender, headache diagnosis at onset, and history of headache in family members on the course of headache. We also investigated the applicability of the ICHD-II criteria to idiopathic headache in preschool children. Prospective evaluation of 25 consecutive headache patients referred before the age of 6 years. Headache diagnosis was based on the IHS 1988 criteria, on the ICHD-II criteria, and on "alternative" clinical criteria [eg, duration less than 1 hour in migraine without aura (MWA), less than 30 minutes in tension-type headache (TTH)]. All patients were assessed by a structured interview to detect early developmental disorders (eg, feeding difficulties or sleep disorders) and "life events" (eg, parents' separation and others according to DSM-IV). All patients underwent clinical observations and assessment of psychiatric comorbidity (ICD-10) by means of interviews and the Child Behaviour Check List. All the above-mentioned evaluations were performed at recruitment (T0) and at the end of the follow-up period (T1). A total of 25 children with headache (12 males; 13 females) were monitored through long-term clinical follow-up (mean duration: 4.2 years; range: 2.8 to 6.6 years). The "definite" diagnosis of migraine without aura or TTH at T0 was possible in only 6/25 (24%) and 9/25 patients (36%) applying the IHS 1988 criteria and the ICHD-II criteria respectively, but in 20/25 (80%) applying the "alternative" clinical criteria. Evaluation of headache at T1 revealed: remission in 16/25 (64%) patients and persistence in 9/25 (36%). At T1, the ICHD-II diagnosis was possible in 100% of the children with headache persistence (1/9 migraine without aura and 8/9 TTH) and these diagnoses were found to be perfectly concordant with those obtained applying the "alternative criteria." Early developmental disorders were present in 11/25 children, with a significantly higher prevalence in children with headache persistence compared to children showing headache remission (78% vs. 25%; P < .05). No significant differences were found between patients with headache persistence and patients with headache remission with regard to gender, history of headache in family members, headache diagnosis at onset, psychiatric comorbidity at T0, and with regard to "life events" at both T0 and T1. Conversely, the children presenting psychiatric disorders at T1 were more frequently affected by headache than those without psychiatric disorders (59% vs. 15%; P < .05). Our results suggest that the ICHD-II criteria are too restrictive to allow the classification of migraine without aura and TTH in preschool children. Nevertheless, a diagnosis based on these criteria was possible in all the patients with headache persistence at the end of several years' follow-up. We found a significant association between early somatic disorders and persistence of headache and also between the presence of psychiatric disorders at the end of follow-up and the persistence of headache. "Life events," on the other hand, while not showing a statistically significant association with the evolution of the headache, may nevertheless influence the course of the headache in some patients. Our results suggest that environmental and psychological factors play an important role in idiopathic headache with onset in preschool age, and thus that the diagnostic-therapeutic approach must take these factors into account.

Validation of a Questionnaire for the Detection of Cluster Headache

In the absence of biological markers, the diagnosis of cluster headache (CH) rests on clinical evidence as reported through ad-hoc interviews. The aim of this study was to validate a 16-item self-administered questionnaire designed to screen CH cases. The questions were based on the second edition of the International Headache Society classification (ICHD-II) criteria for CH (n = 12) and on specific disease features (n = 3). Answers to each question were either "Yes,""No," or "Don't know." The validity of this screening tool was assessed using a two-step procedure. In Step 1, the 16 questions were submitted to 30 healthy subjects with different cultural backgrounds to verify content clarity. In Step 2, the questionnaire was given to 71 patients (32 women and 39 men) aged 15 to 78 years (mean 37.5 years), who were seen at the University of Parma Headache Center with a diagnosis of CH (episodic, 17; chronic, 13), migraine (without aura, 18; with aura, 3), and tension-type headache (episodic, 16; chronic, 4) according to the ICHD-II criteria. Sensitivity, specificity, and the positive and negative predictive values were calculated for each question as measures of validity. Severity, unilaterality, and location of pain had the highest sensitivity (100%), but low (34.1%) or fairly low specificity (61.0% and 58.5%, respectively). In contrast, a positive response to lithium or verapamil had a 66.7% sensitivity and a 97.6% specificity. Sensitivity and specificity were 100% and 90.2% for duration of attacks (<180 to 240 minutes), and 90.0% and 92.7% for compulsory movements, respectively. The best discriminatory pattern for symptom detection was unilaterality of pain and the presence of at least five of the following seven features: pain severity and location, duration, frequency and daily recurrence of attacks, rhinorrhea and restlessness as accompanying symptoms. Our findings confirm that this questionnaire is a useful method for CH screening in epidemiological studies.

Conversion from migraine without aura to typical aura without headache after irbesartan

arterial hypertension and her family physician prescribed irbesartan 150 mg daily. In the following months, the patient perceived a significant reduction of headache attacks. However, in January 2003 the patient developed an attack of migraine aura without headache. She reported symptoms of a scintillating scotoma, gradually expanding across the right visual field and lasting for approximately 30 min. The aura was not followed by headache. The patient had seven additional attacks in a two-year period, with the same clinical features. All the attacks fulfilled the ICHD-II criteria for ‘Typical aura without headache’ (code 1.2.3). Magnetic resonance imaging scan of the brain did not reveal any abnormalities. Extensive blood testing was normal. Factor V Leiden (R506Q) and prothrombin (G20210A) gene mutations were absent. This is the first case, to our knowledge, describing the conversion of MO into typical aura without headache after antihypertensive therapy. Mammalian brain harbours a renin-angiotensin system [3] and angiotensin receptors (AT1, AT2 and AT4) are plentiful in human brain. Our case report suggests a possible Conversion from migraine without aura to typical aura without headache after irbesartan

Decreasing the minimal duration of the attack to 1 hour: is this sufficient to increase the sensitivity of the ICHD-II diagnostic criteria for migraine in childhood?

We applied the second edition of the International Classification of Headache Disorders (ICHD-II) in 417 children (age range, 2–12 years) with chronic headaches attending a pediatric headache clinic. The initial diagnosis was made according to the ICHD-II while the final diagnosis was, based on the longitudinal intuitive clinical diagnosis (LICD), deemed to be the gold standard. The diagnosis of migraine without aura had a sensitivity of 52%, a specificity of 100% and a positive predictive value of 100%; for the diagnosis of migraine (at the one-digit level) these values were 87%, 100% and 100%, respectively. The ICHD-II criteria for migraine without aura have high specificity but low sensitivity in childhood, even considering the minimal duration of the attacks to be 1 hour. Other factors, such as the existence of subgroup 2.4 (probable tension-type headache), are responsible for the low sensitivity of ICHD-II criteria for the diagnosis of migraine without aura in patients of this age group.