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How new headache criteria will affect GP diagnosis

Dr Andrew Dowson identifies key aspects of the new IHS headache classification

When published in 1988, the classification criteria of the International Headache Society gave physicians their first definitive means of diagnosing patients in their surgeries. They have proved invaluable, especially in research. The criteria, however, were lengthy and complex. Now, 16 years later, we have a second, even longer, edition1. Of most importance to the GP is what has not changed: the classification of migraine and tension-type headache (TTH) remain essentially the same. The main innovations relate to the classification of chronic headaches, which were poorly delineated.

Chronic headache

Chronic migraine and chronic TTH are defined, respectively, as migraine or TTH-like headaches occurring on 15 days per month for more than three months in the absence of medication overdose. It is well recognised that some patients present with features of both chronic migraine and chronic TTH. Diagnosis can be problematic in these cases, although migraine is given precedence when choosing between them.

New daily persistent headache (NDPH)

This additional form of chronic headache is classified as headaches with features typical of TTH that are daily and unremitting from very soon (three days) after onset.

Medication overuse headache (MOH)

A particularly common and insidious type of chronic headache associated with the overuse of symptomatic headache medications. The new classification criteria defines probable MOH as headache present on >15 days per month that has developed or worsened following the regular use of symptomatic headache medications (ergots, triptans, analgesics, opioids or combination medications).

The contribution of the triptans to MOH development has only been fully recognised in recent years2. MOH is only confirmed if the headache resolves or reverts to its previous episodic pattern within two months of medication being discontinued.

Several other headache syndromes are defined in the new IHS criteria, but these are rarer forms seldom seen in primary care.

Implications for primary care

Migraine is still classified as repeated episodes of headache lasting four to 72 hours, accompanied by one or more of nausea, vomiting and photophobia, or phonophobia. The headache is typically unilateral, pulsating, moderate or severe and aggravated by physical activity. Aura symptoms may or may not be present.

Recent evidence has indicated a simpler way of identifying migraine. Patients who consult with episodic headaches that interfere significantly with their normal daily activities almost always have migraine3. They can be given a default diagnosis of migraine, which can be confirmed with further questioning if necessary4.

Tension-type headache TTH is classified as episodic or chronic headaches that last for minutes to days and characterised by bilateral, mild-to-moderate pain that is pressing or tightening in quality and not exacerbated by physical activity. Photophobia or phonophobia, but not nausea, may be present. Studies and clinical experience demonstrate that patients with episodic TTH hardly ever go to their GP for care, although chronic cases may be seen.

Chronic headaches happen on >15 days per month and usually present with a mixed pattern of daily headaches typical of TTH, with episodic exacerbations of migraine-like headaches. At one end of the scale, patients experience TTH only (chronic TTH in the new criteria). At the other end, patients may have daily, or near-daily, migraine attacks without significant TTH ('chronic migraine' in the new criteria). Those with migraine and TTH will be classified as chronic migraine.

Any of these patients may be overusing headache medications and so have MOH. Management of these chronic headaches follows the same basic principles: withdrawal of the offending medications, introduction of headache prophylaxis and strictly limited use of acute medications in exacerbations (see box)5.

Conclusion

The new criteria are an improvement, although the definition of mixed-pattern headaches still falls short of the ideal6. The main interest will come from neurologists and headache specialists, but there is information of use to the GP.

Management of chronic migraine

and medication overuse headache

lIntroduce prophylaxis to reduce the frequency of the headaches. Amitriptyline and sodium valproate can be very useful as prophylaxis for chronic headaches, and botulinum toxin is a promising therapy for

the future.

lPatients with a history of head injury and/or those with neck stiffness or restricted neck movement usually benefit from physical therapy and exercises for the neck.

lUse acute medications to treat breakthrough headache attacks and manage the original episodic primary headaches. A triptan is the logical medication for patients with chronic migraine. Use should be strictly limited, to no more than 12 doses per month5.

l(MOH only) Withdraw the medications being overused, but beware of withdrawal symptoms. These can be minimised with a six-day course of prednisolone 20mg.

Sinister headaches

Warning signs:

lThe patient is very young (50 years)

lThe headache is new onset (

lThe headache is very acute

lThe patient has atypical or non-reproducible (isolated) symptoms or an abnormal (focal) neurological exam

lSuspicious symptoms include rash, non-resolving neurological deficit, vomiting, pain or tenderness, accident or head injury, infection and hypertension

When to refer

GPs should be able to manage most patients with migraine and episodic TTH in their practices4, but referral to a specialist neurology or headache service may be necessary when:

lA sinister headache is suspected

lThe patient has 'atypical' migraine symptoms, possibly indicating one of the rare migraine variants

lThe patient is refractory to repeated acute and/or prophylactic medications

lThe frequency of the patient's headaches increases, despite intervention

lChronic migraine/TTH or cluster headache is suspected7

Further information

For GPs

Migraine in Primary Care Advisers: www.mipca.org.uk

Medscape: www.neurology.medscape.com

Doctor's Guide migraine site: www.pslgroup.com/migraine.htm

MIDAS website: www.migraine-disability.net

Migraine Trust: www.migrainetrust.org

For patients

Migraine Action Association: www.migraine.org.uk

Headache test: www.headachetest.co.uk

References

1 Headache Classification Sub-Committee of the International Headache Society. The international classification of headache disorders.

Cephalalgia 2004;24 (Suppl 1):1-160

2 Katsarava Z et al. Medication overuse headache: a focus on analgesics, ergot alkaloids and triptans. Drug Saf 2001;24:921-7

3 Dowson AJ et al. The prevalence and diagnosis of migraine in a primary care setting: insights from the Landmark Study. Headache Care 2004;1: in press

4 Dowson AJ et al. New guidelines for the management of migraine in primary care. Curr Med Res Opin 2002;18:414-39

5 Dowson AJ et al. Managing chronic headaches in the clinic.

Int J Clin Pract 2004; in press

6 Peatfield R. A revised classification of headache disorders.

BMJ 2004;328:119-20

7 Sender J et al. Setting up a specialist headache clinic in primary care: General Practitioners with a Special Interest (GPwSI) in headache. Headache Care 2004;1: in press

Andrew Dowson is director of the King's Headache Service, King's College Hospital, London

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