International Headache Society Classification Research Articles

Headache attributed to airplane travel (‘airplane headache’): Clinical profile based on a large case series

The 'headache attributed to airplane travel', also named 'airplane headache' (AH), is a recently described headache disorder that appears exclusively in relation to airplane flights, in particular during the landing phase. Based on the stereotypical nature of the attacks in all reported cases, we proposed provisional diagnostic criteria for AH in a previously published paper. Up to now 37 cases have been described in the literature. After our paper was disseminated via the Internet, we received several email messages from subjects around the world who had experienced such a peculiar headache. Their cooperation, by completing a structured questionnaire and allowing the direct observation of three subjects, enabled us to carry out a study on a total of 75 patients suffering from AH. Our survey confirmed the stereotypical nature of the attacks, in particular with regard to the short duration of the pain (lasting less than 30 minutes in up to 95% of the cases), the clear relationship with the landing phase, the unilateral pain, the male preponderance, and the absence of accompanying signs and/or symptoms. It is conceivable to consider barotrauma as one of the main mechanisms involved in the pathophysiology of AH. The observation that the pain appears inconstantly in the majority of cases, without any evident disorder affecting the paranasal sinuses, could be consistent with a multimodal pathogenesis underlying this condition, possibly resulting in the interaction between anatomic, environmental and temporary concurrent factors. This is by far the largest AH case series ever reported in the literature. The diagnostic criteria that we previously proposed proved to be valid when applied to a large number of patients suffering from this condition. We support its recognition as a new form of headache, to be included in the forthcoming update of the International Headache Society Classification, within '10. Headache attributed to disorder of homoeostasis'. Its formal validation would favour further studies aimed at improving the understanding of its pathophysiology and implementing preventative measures.

Ophthalmoplegic migraine: Migraine variant or cranial neuralgia?

Ophthalmoplegic migraine (OM) is a rare headache disorder, which usually starts in childhood but sometimes first appears in adulthood. The typical clinical presentation is migraine-like headache accompanied or followed by transient extraocular muscle paresis, mostly involving the oculomotor nerve but sometimes the abducens or trochlear nerves. Ophthalmoplegia recovers spontaneously within weeks. OM was initially classified as a migraine variant in the International Classification of Headache Disorders, 1st edition (ICHD-1) (1). In 1992, Mark et al. (2) described the first OM patient with reversible gadolinium enhancement of the oculomotor nerve on magnetic resonance imaging (MRI). Thereafter, several case reports followed. Because of the self-limiting clinical characteristics, the disease was suspected to be related to recurrent demyelinating neuropathy. In 2004, the International Headache Society (IHS) Classification Committee moved this headache disorder to the group of ‘cranial neuralgias’ in the International Classification of Headache Disorders, 2nd edition (ICHD-2) (3); nonetheless, the terminology of ‘ophthalmoplegic migraine’ remained in use (Table 1). In this issue of Cephalalgia, Akimoto et al. (4) report on a 54-year-old man, who experienced attacks of OM for more than 45 years. The MRI examination in the acute phase showed an enhanced nodular lesion in the root exit zone (REZ) of the left oculomotor nerve. Because the clinical symptoms were progressive, a biopsy was performed. Intriguingly, the biopsy did not show inflammatory cell infiltration or demyelination but neuromuscular hamartoma. This finding obviously does not support a prior belief that the MRI findings imply demyelination as the underlying cause for OM. Even though enhancement of the cisternal portion of the oculomotor nerve is the most common MRI finding for OM, it is not specific. Certain causes can present similar pictures, such as trauma, inflammation, demyelination, small vessel ischemia, tumor (schwannoma, lymphoma, hemangioma and carcinomatous meningitis), postviral syndrome and systemic lupus erythematosus.

Psychological Interventions for Headache in Children and Adolescents

Headache in children and adolescents represents a number of complex and multifaceted pain syndromes that can benefit from psychological intervention. There is good evidence for the efficacy of cognitive behavioral therapy, relaxation training, and biofeedback. The choice of intervention is influenced by patients' age, sex, family and cultural background, as well as the nature of stressors and comorbid psychiatric symptoms. Management must always be family-centered. Psychological treatments are essential elements of the multidisciplinary, biopsychosocial management of primary headache disorders, particularly for those with frequent or chronic headache, a high level of headache-related disability, medication overuse, or comorbid psychiatric symptoms. Future studies of efficacy and effectiveness of psychological treatment should use the International Headache Society's definition and classification of headache disorders, and stratify results by headache type, associated conditions, and treatment modality.

Treatment of refractory chronic cluster headache by chronic occipital nerve stimulation

Greater occipital nerve stimulation (ONS) has been recently proposed to treat severe chronic cluster headache patients (CCH) refractory to medical treatment. We report the results of a French multidisciplinary cohort study. Thirteen CCH patients were operated and data were collected prospectively. All of them suffered from CCH according to the International Headache Society classification, lasting for more than 2 years, refractory to pharmacological prophylactic treatment with adequate trials, with at least one daily attack. Chronic ONS was delivered through a subcutaneous occipital electrode connected to an implanted generator, in order to induce paraesthesias perceived locally in the lower occipital region. After surgery (mean follow-up 14,6 months), the mean attack frequency and intensity decreased by 68% and 49%, respectively. At last follow-up, 10/13 patients were considered as responders (improvement >50%). Prophylactic treatment could be stopped or reduced in 8/13 cases. Local infection occurred in one patient, leading to hardware removal. Our data confirmed the results of the 36 similar cases reported in the literature, suggesting that ONS may act as a prophylactic treatment in chronic CH. Considering their respective risks, ONS should be proposed before deep brain stimulation in severe refractory CCH patients.

Migraine and Vertigo

Migraine and vertigo are common disorders in medicine, affecting about 14–16% and 7–10%, respectively, of the general population. Recent epidemiologic studies indicate that 3.2% of the population have both migraine and vertigo. Vertigo may occur in up to 25% of patients with migraine. Migraine is the most frequent vascular disorder causing vertigo in all age groups. Migraine leads to various central or peripheral vestibular syndromes with vertigo such as migrainous vertigo, basilar-type migraine, benign paroxysmal vertigo of childhood, and other vertigo syndromes related to migraine. Migrainous vertigo is the most common cause of spontaneous recurrent vertigo. Diagnostic criteria for migrainous vertigo have been proposed but are not included in the most recent International Headache Society classification of migraine. On the other hand, there are statistical associations between migraine and vertigo syndromes including benign paroxysmal positional vertigo, Meniere's disease, persistent cerebellar symptoms, anxiety-related dizziness, and motion sickness. Vertigo can also act as a migraine trigger. Although some mutations in the CACNA1A gene have been identified in some familial cases, the mechanism of migraine-associated vertigo is still obscure. Treatment includes vestibular suppressants for acute attacks and migraine prophylaxis for patients with frequent attacks.

Intravenous sodium valproate aborts migraine headaches rapidly

This preliminary study was designed to evaluate the efficacy and safety of intravenous sodium valproate in managing severe migraine headache. In a preliminary prospective open-label study, we treated patients with severe migraine headache using intravenous sodium valproate, after obtaining written informed consent. Thirty-six patients, hospitalized with acute established migraine, were infused with sodium valproate. The diagnosis of migraine was based on the International Headache Society classification criteria. Severity of headache was reported on 10-point visual analog. Disability was assessed on a five-point scale. Primary and secondary endpoints were measured as sustained pain relief and symptoms improvement at 2 h, respectively. The study participants had a mean±SD age of 35.7±9.3 years. The loading dose of sodium valproate was 900-1200 mg, and the average time to best response for headache severity was 50 min. A reduction in pain from severe or moderate to mild or no pain in 60 min was reported in 75% of patients [OR=7.187 (95% confidence intervals: 1.32-38.95)]. After treatment with sodium valproate, headache severity was significantly decreased (P<0.0001). No serious adverse events were reported. Intravenous Sodium Valproate (iVPA) seems to be safe and rapidly effective for intractable migraine attack. Randomized, double-blinded, controlled studies are warranted.

Headaches and sleep problems among adults in the United States: Findings from the National Comorbidity Survey–Replication Study

Several studies have demonstrated an association between headache and disturbed sleep. None have examined this association across the headache spectrum. Our goal was to determine whether migraine and migraine with aura differ from nonmigraine headache in terms of associated insomnia complaints or severity of sleep problems. A probability sample of US adults was used. A structured interview administered by trained interviewers was used. Diagnostic criteria for migraine and migraine with aura were based on the International Headache Society classification. The presence or absence of four forms of sleep disturbance associated with an insomnia diagnosis was ascertained. There was a significant association between frequent severe headache, including migraine with and without aura, and disordered sleep. Adults with headache reported more frequently difficulty initiating sleep (odds ratio [confidence interval] = 2.0 [1.6-2.5]), difficulty staying asleep (2.5 [2.1-3]), early morning awakening (2.0 [1.7-2.5]) and daytime fatigue (2.6 [2.2-3.2]) and also were more than twice as likely to report three or more of these symptoms(2.5 [2-3.1]) compared to the individuals without headache. Adults with severe headache are at significantly higher risk of also suffering from sleep problems, when compared with the general population, regardless of specific headache type. Optimal treatment of headache must include investigation for sleep disorders and vice versa.

New Daily Persistent Headache: Controversy in the Diagnostic Criteria

New daily-persistent headache is a relatively uncommon type of chronic daily headache. The critical features of the original description and the subsequent Silberstein-Lipton description was the onset: daily headache starts abruptly without a background of frequent or worsening headache. In 2004, the International Headache Society classification committee excluded an abundance of migrainous features. The exclusion of patients with too many migrainous features from the International Headache Society classification was contentious from the onset and is a source of consternation for many headache experts. Many contend that the sudden onset of a daily headache raises the same issue of what turned on the headache, irrespective of the headache features. Switch-related questions about predisposing factors or precipitating events are equally valid regardless of how many migrainous features the patient has. The differential diagnosis, treatment response, or prognoses do not vary by the number of migrainous features. The current International Headache Society definition excludes more than half of patients with new onset of daily headache. This exclusion due to migrainous features could have adverse scientific, diagnostic, and treatment consequences.

A case of strictly unilateral migraine without aura transformed in an episodic hemicrania continua

According to the diagnostic criteria of International Headache Society classification, hemicrania continua is a strictly unilateral continuous headache of moderate intensity with painful exacerbations associated with ipsilateral autonomic signs without pain-free periods. We report a case of a 42-year-old woman suffered of a remitting form of hemicrania continua evolved from a strictly unilateral migraine without aura.

Effect of preventive (β blocker) treatment, behavioural migraine management, or their combination on outcomes of optimised acute treatment in frequent migraine: randomised controlled trial

Objective To determine if the addition of preventive drug treatment (β blocker), brief behavioural migraine management, or their combination improves the outcome of optimised acute treatment in the management of...

Paroxysmal Hemicrania in Children—Symptoms, Diagnostic Criteria, Therapy and Outcome

Whereas paroxysmal hemicrania (PH) is studied extensively in adults, even case reports of PH in children are rare. We present the first prospective follow-up study on PH in children. Our aim was to investigate whether differences exist between paediatric and adult patients. We assessed all children with chronic headache who were referred to our paediatric out-patient pain clinic within 3 years based on interviews and validated questionnaires. Among 628 patients we found five children with PH (0.8%) and three with probable PH (0.5%), in total 1.3%. Pain characteristics, autonomic symptoms and treatment response to indomethacin were similar to adult PH patients. Our results demonstrate that the International Headache Society classification of PH is also applicable to children. We suspect that PH has been underdiagnosed in children and therefore suboptimally treated thus far.

Vestibuläre Migräne

Vestibular migraine (VM) presents with attacks of spontaneous or positional vertigo lasting seconds to days. Headaches are often absent during acute attacks, but other symptoms of migraine, such as photophobia or auras may be present. Like migraine headaches VM triggers may include stress, sleep deprivation and hormonal changes. During acute attacks there may be central spontaneous or positional nystagmus and, less commonly, unilateral vestibular hypofunction. In the symptom-free interval vestibular testing shows mostly minor and non-specific findings. The pathogenesis of VM is uncertain but migraine mechanisms may interfere with the vestibular system at the level of the labyrinth, brainstem and cerebral cortex. Treatment includes vestibular suppressants for acute attacks and migraine prophylaxis for patients with frequent recurrences. Avoidance of triggers, stress management and biofeedback may also play a role. However, treatment efficacy has not been validated by properly controlled clinical trials. VM is not included in the 2004 International Headache Society Classification, where basilar-type migraine must have at least two posterior circulation manifestations so that isolated vertigo would not satisfy this criterion.

Prevalence of chronic migraine and medication overuse headache in Germany—the German DMKG headache study

Population-based epidemiological studies about the prevalence of chronic migraine using the 2004 International Headache Society (IHS) classification definition are rare. We analysed the data of the Deutsche Migräne und Kopfschmerz Gesellschaft headache study, which included 7417 adults in three regions of Germany, with respect to their headache. Additionally, body mass index, alcohol consumption and smoking behaviour were recorded. Using the IHS definition from 2004, chronic migraine was diagnosed in 0.2% of the population. Half of these patients also fulfilled the criteria of medication overuse headache (MOH). The distribution of migraine attacks per subject was highly skewed, with only 14% of all migraine patients having more than six migraine attacks per month. Patients with chronic migraine or MOH seem more often to be active smokers than controls without headache. A body mass index of ≥ 30 was present significantly more often in patients with MOH than in controls or in patients with episodic migraine. The skewed distribution of the numbers of attacks per patient supports the recommendation to differentiate between episodic migraine with low and high attack frequency, as is done in the classification of tension-type headache. It further suggests that migraine with high attack frequency might be biologically different. The higher prevalence of smokers and of patients with a body mass index ≥ 30 in chronic migraine or MOH supports the idea of a frontal dysfunction in these patients.

Vertigo as a Symptom of Migraine

Migraine and vertigo are common disorders, affecting about 14% and 10%, respectively, of the general population. If migraine and vertigo were unrelated, the expected comorbidity would be 1%, whereas recent epidemiological studies indicate that 3.2% of the population have both migraine and vertigo. The excess comorbidity may be attributed to two factors: 1) vertigo syndromes (including Menière's disease, benign paroxysmal positional vertigo, and anxiety-related dizziness) that are more common in migraineurs than in controls and 2) vestibular migraine (VM) (vertigo as a symptom of migraine.) VM presents with attacks of spontaneous or positional vertigo lasting seconds to days. Headaches are often absent during acute attacks, but other migrainous features such as photophobia or auras, may be present. Like migraine headaches, VM triggers include stress, sleep deprivation, and hormonal changes. During acute attacks, there may be central spontaneous or positional nystagmus and, less commonly, unilateral vestibular hypofunction. In the symptom-free interval, vestibular testing shows mostly minor and nonspecific findings. The pathogenesis of VM is uncertain, but migraine mechanisms may interfere with the vestibular system at the labyrinth, brainstem, and cerebral cortex. Treatment includes vestibular suppressants for acute attacks and migraine prophylaxis for patients with frequent recurrences. However, treatment efficacy has not been validated by properly controlled clinical trials. VM does not fit into the 2004 International Headache Society Classification, in which "basilar-type migraine" must have at least two posterior circulation manifestations; isolated vertigo would not satisfy this criterion.

The Future of Migraine: Beyond Just Another Pill

The Future of Migraine: Beyond Just Another Pill

Headache made fascinating, not frustrating

Headache medicine is a rapidly growing subspecialty of neurology. This discipline is vast and varied, with many advances in the past two decades, and several monographs are available. So when you come across another headache book, the first thought that comes to your mind is “and how is this book going to be different from the others?” By use of a case-based approach that highlights dilemmas faced in practice, Newman and Levin have combined their years of clinical experience and hours of teaching expertise to bring out this excellent book that looks at headache from a practical viewpoint. The topics are well chosen, difficult and uncommon clinical presentations are included, ways to investigate headache are logically outlined, and the differential diagnosis is discussed in accordance with the second edition of the International Headache Society Classification of Headache Disorders. A total of 33 chapters are grouped under three headings to cover diagnostic dilemmas, treatment issues, and prognostic problems. In the section on diagnosis, the chapters on white-matter abnormalities visualised on imaging, giant-cell arteritis, carotid dissection, spontaneous intracranial hypotension, vasculitis headache, migrainous vertigo, and nummular headache are outstanding. In the section on treatment, many practice pearls can be picked up from the chapters that discuss headache in pregnancy, inpatient management, and problems with headache recurrence. The final section in this text includes topics that are generally skipped in other headache books, such as serotonin syndrome, school problems, transient global amnesia, and migraine with patent foramen ovale. The tables, key points, and carefully selected references at the end of each chapter are a unique feature of the text. This book thereby provides readers the opportunity for rapid revision or, by going through the listed references, detailed understanding about each topic. With so many underlying causes of headache, any pocket-sized book on the topic cannot be all inclusive. By way of suggestion, more tables and some flow charts would have been welcome. An introductory chapter on the pitfalls of headache history-taking and a concluding chapter highlighting recent advances, current controversies, and future directions in the headache specialty would have made the book more interesting. The contents of Headache and Facial Pain can best be summarised as distilled wisdom from two experts in the headache field who have seen it all. This book is strongly recommended for clinicians who regularly see patients with headache in their practice. The authors have shown that headache disorders need not always be frustrating; indeed they can even be fascinating when you know what to do and how to treat the next patient. Different headaches have different treatments, and that is what this book is all about.

Increased Affinity of Platelet Dopamine-Binding to D 2 -Receptors in Migraineurs: Implications of the Dopaminergic System in Migraine

Evaluation of: Shukla R, Kanna VK, Vinod P, Sankhwar ML, Yadav RS: Platelet dopamine: D2-receptor binding in patients with migraine. Cephalalgia DOI: 10.1111/j.1468-2982.2008.01760.X (2009) (Epub ahead of print). This study aimed to measure the level of platelet dopamine binding to the dopamine D2 receptor in migraineurs, using 3H-spiperone as a radioligand, and compared samples with control subjects. Patients adhering to the International Headache Society classification of migraine were shown to have significantly reduced dissociation constant (Kd: 1.71 ± 0.19 nM) for D2-receptor binding compared with controls. There was no relationship between Kd and other specific clinical features, such as migraine type, frequency and vomiting. The findings point to a relationship between dopamine binding and migraine, however further studies with larger patient groups are necessary to evaluate the exact role of dopamine and specific clinical features.

Sinus headaches: avoiding over- and mis-diagnosis

‘Sinus headache’ is a term used by many patients and primary-care physicians and, contrary to popular belief, sinus headaches are uncommon. Headaches that are due to sinusitis are confined to a minority of patients who have acute frontal sinusitis or sphenoiditis. The International Headache Society classification is robust in qualifying the term sinus headache and says that “chronic sinusitis is not validated as a cause of headache and facial pain unless relapsing into an acute stage”. The vast majority of people who present with a symmetrical frontal or temporal headache, sometimes with an occipital component, have tension-type headache. Unilateral, episodic headaches are often vascular in origin. The idea that sinusitis can trigger migraine is misplaced, as the whole symptom complex is vascular and coexisting nasal congestion is due to vasodilation of the nasal mucosa that is sometimes part of the vascular event. The use of nasal endoscopy and imaging of the paranasal sinuses have advanced our appreciation that these patients are suffering from a vascular event. When these patients are asked to attend a clinic when they are symptomatic, the vast majority are found not to have a sinus infection. Sinusitis rarely causes headache, let alone facial pain, except when there is an acute bacterial infection when the sinus in question cannot drain, and it is usually unilateral due to increased pressure and inflammation caused by pus trapped within the sinus cavity. These patients usually have a history of a viral upper respiratory infection immediately before this and they have pyrexia with unilateral nasal obstruction. The vast majority of patients with acute sinusitis respond to antibiotics. Recurrent bacterial sinusitis is rare and anyone with more than two episodes of genuine bacterial sinusitis in 1 year should be investigated for evidence of poor immunity. Patients with chronic bacterial sinusitis rarely have any pain unless the sinus ostia are blocked and their symptoms are then the same as in acute sinusitis. Within the medical literature, there are texts that report that sphenoid sinusitis can cause headaches and, as with other acute sinus infections, intracranial or ophthalmolgical complications can occur. First, acute sphenoid sinusitis is rare and second, most of these patients respond to antibiotics. Batotrauma can cause short-lived pain in the sinus involved but there is always a clear history associated with diving or flying and, as the pressure within the sinus equalizes, the pain resolves within a few hours. Headaches are rarely due to sinusitis.

Post-traumatic headache

The onset of post-traumatic headache (PTC) occurs in the first seven days after trauma, according to the International Headache Society (IHS) classification. The objective of this study was to evaluate the several forms of headache that appear after mild head injury (HI) and time interval between the HI and the onset of pain. We evaluated 41 patients with diagnosis of mild HI following the IHS criteria. Migraine without aura and the chronic tension-type headache were the most prevalent groups, occurring in 16 (39%) and 14 (34.1%) patients respectively. The time interval between HI and the onset of headache was less than seven days in 20 patients (48.7%) and longer than 30 days in 10 (24.3%) patients. The results suggest that PTC may arise after a period longer than is accepted at the present by the IHS.

Migrainous Vertigo: Results of Caloric Testing and Stabilometric Findings

Association between migraine and vertigo has been widely studied during the last years. A central or peripheral vestibular damage may occur in patients with migrainous vertigo. Despite much evidence, at present the International Headache Society classification does not include a specific category for migrainous vertigo. To assess the prevalence of central and peripheral vestibular disorders and postural abnormalities in patients diagnosed as affected by definite migrainous vertigo according to Neuhauser. Thirty patients with migraine and acute vertigo lasting from minutes to hours underwent a full otoneurological screening for spontaneous, positional, and positioning nystagmus with head-shaking and head-thrust (Halmagyi) tests, an audiometric examination, and videonystagmography with bithermal stimulation according to Freyss. Videonystagmographic findings were compared with those of 15 migraineurs without lifetime vertigo (group M). Next day, a static posturography was performed; posturographic results have been compared with those of a second control group of 30 healthy patients matched for age and sex (group C). In total, 14 subjects with migrainous vertigo showed otovestibular disorders; 6 subjects showed impaired vestibulo-oculomotor reflexes (20%). Five more patients had bilateral increased responses (16.6%). Five patients showed signs of central brainstem or cerebellar disorders for altered pursuit or saccades or positional direction changing nystagmus. Stabilometric results returned higher values of Length and Surface above all when testing was performed in eyes closed conditions compared with the normal control group. The subgroup of 14 subjects with migrainous vertigo and vestibular abnormalities performed poorly in stabilometric exams and seemed to rely more on visual cues in balance control than the subgroup of 16 subjects with migrainous vertigo but without abnormalities. Our results indicate that vestibular functional damage may occur in all vestibular pathways; central and peripheral signs are equally represented. Our data are not inconsistent with the hypothesis that a vestibulo-spinal dysfunction is the causal factor for the posturographic results. Moreover, the Visual Romberg Index is significant for increased visual cue dependence in migraineurs.