Background.
WHO proposed that migraine, together with tetraplegia, mental disorders and dementia, have become the most serious chronic dysfunctional diseases. The prevalence of migraine in Europe and the United States is 1500-2000/100,000 people with an incidence rate of 10%-15%; in China, the prevalence is 732.1/100,000 people with an incidence rate of 0.06%. Such a low prevalence of migraine in China seems to be a cause for celebration. However, Professor Yu Shengyuan of the Department of Neurology of the PLA General Hospital pointed out that some hospitals, especially the primary hospitals, often have “neurovascular headache” and “neurogenic headache” in their medical records, which do not exist in the international headache classification standards. Professor Li Shunwei of the Department of Neurology of Peking Union Medical College Hospital said that many cases cannot be included in the statistics because many physicians still use unstandardized terms for headache classification. According to neurologists in clinical practice, the number of headache cases in China would never be so different from that in Europe and the United States. In January 2004, after 15 years of using the first edition of the International Classification of Headache Disorders, the International Headache Classification Committee released the second edition of the International Classification of Headache Disorders, which took 3.5 years to revise.
In order to make the clinicians in China to be in line with the international standard in diagnosis and treatment of headache, and to make the relevant scientific research results in China to be recognized by the foreign counterparts, and to let the medical personnel understand the new International Classification of Headache Disorders (hereinafter referred to as Headache Classification), Beijing Neurology Academic Salon recently invited Professor Yu Shengyuan from the Department of Neurology of the PLA General Hospital to give a partial interpretation of the Headache Classification.
Features of the Headache Classification.
1. It adopts a step-by-step classification method, dividing all headaches into 14 categories, and each category is divided into subtypes and derived forms. For example, migraine is a major category of headache, and there are six subtypes under the migraine category: migraine without aura, migraine with aura, childhood cycle syndrome that may be a precursor to migraine, retinal migraine, migraine complications, and likely migraine, and six derived forms under the migraine with aura subtype.
2. In determining diagnostic criteria, the Headache Classification Committee relies fully on evidence from clinical symptoms, follow-up studies of patient populations, epidemiological studies, treatment outcomes, genetics, neuroimaging, and pathophysiology. Considerable detailed and important changes were made to the diagnostic criteria in the original classification based on the new evidence. For example, chronic migraine is included as a new diagnosis for those patients who meet the diagnostic criteria for migraine and do not have substance abuse and have an attack of 15 days or more per month.
3. Many new elements have been added, such as the addition of “headache attributable to psychiatric disorders” to the major categories, in order to encourage physicians to conduct research on the relationship between psychiatric disorders and headache. A new subtype of “likely migraine” has been added to the migraine category.
Interpretation of the International Classification of Headache Disorders.
1. The International Classification of Headache Disorders is divided into three major parts and 14 categories. The first part is primary headache: migraine, tension-type headache, cluster headache and primary trigeminal neuralgia, and other primary headaches.
The second part is secondary headache: headache attributed to head and/or neck trauma, headache attributed to cranial or cervical vascular disease, headache attributed to non-vascular intracranial disease, headache attributed to certain substances or withdrawal of certain substances, headache attributed to infection, headache attributed to metabolic disease, headache attributed to diseases of the head, neck, eyes, ears, nose, sinuses, teeth, mouth or other head and facial structures, headache attributed to psychiatric disorders, and headache attributed to other diseases. headache, and headache attributed to mental disorders.
The third part is cranial nerve, central and primary facial pain and other headaches: there are cranial nerve pain and facial pain related to central diseases, other types of headache, cranial nerve pain, central or primary facial pain.
2.In the category of migraine, there are two new subtypes of migraine with aura: “headache without typical migraine aura” and “disseminated hemiplegic migraine”.
3. Oculomotor paralysis migraine is included in cranial neuralgia and facial pain related to central diseases. What are the diagnostic criteria?
A. At least 2 episodes meeting B.
B. Migraine-like headache attacks occur simultaneously or within 4 days with mild paralysis of one or more of the 3rd, 4th, and/or 6th cerebral nerves.
C. Appropriate examination to exclude damage to the fossa oculi and posterior cranial fossa tissue.
4. The diagnostic criteria for aura migraine are changed to
A. At least 2 attacks are consistent with B.
B. Migraine aura meets one of all the aura of the 6 derived forms.
C. Not attributable to other disorders.
5. The absence of motor disturbance is emphasized in the diagnostic criteria for headache with a typical migraine aura.
A. At least 2 attacks meet criteria B to D.
B. The aura includes at least one of the following, but no motor disturbance.
(i) fully recoverable visual symptoms, including positive symptoms (such as punctate chromatophoresis or linear flash hallucinations) and/or negative symptoms (such as visual field defects); (ii) fully recoverable sensory symptoms, including positive symptoms such as pins and needles and/or negative symptoms such as numbness; and (iii) fully recoverable speech difficulties.
C. At least 2 of the following were met.
(i) bilateral visual symptoms and/or unilateral sensory symptoms; (ii) at least one aura symptom gradually progressing for ≥ 5 minutes and/or different aura symptoms occurring in succession for ≥ 5 minutes; (iii) each symptom for ≥ 5 minutes and ≤ 60 minutes.
D. Headache meeting criteria B to D for migraine without aura occurred during the aura period or within the next 60 minutes of the presence of aura symptoms.
E. Not attributed to other disorders.
6. Sporadic hemiplegic migraine is a new addition to the subtype of “migraine with aura”, and its diagnostic criteria are
A. At least 2 attacks meet criteria B to C.
B. The aura should include at least one of the following, in addition to fully recoverable weakness in mobility.
(i) fully recoverable visual symptoms, including positive symptoms (such as punctate chromatophoresis or linear flash hallucinations) and/or negative symptoms (such as visual field defects); (ii) fully recoverable sensory symptoms, including positive symptoms (such as pins and needles) and/or negative symptoms (such as numbness); and (iii) fully recoverable speech difficulties.
C. At least 2 of the following are met.
(i) gradual development of at least one aura symptom for ≥ 5 minutes and/or different aura symptoms occurring back-to-back for ≥ 5 minutes; (ii) each symptom for ≥ 5 minutes and ≤ 24 hours; (iii) headache meeting criteria B to D for migraine without aura occurring during the aura phase or within the next 60 minutes of having aura symptoms.
D. Episodes meeting criteria A to E without first- or second-degree correlation.
E. Not attributed to other diseases.
7. Periodic vomiting is a new subtype of “childhood periodic syndrome that may be a precursor to migraine”, which is usually seen in children under 2 years old. The diagnostic criteria are
A. At least 5 episodes meeting criteria B and C.
B. Periodic episodes, individually stereotyped, with intense nausea and vomiting lasting from 1 hour to 5 days.
C. Vomiting for at least 4 episodes/hour or at least 1 hour during the attack.
D. Complete resolution of symptoms between episodes.
E. Not attributed to other diseases.
8. Abdominal migraine is also a new subtype of “childhood cyclic syndrome with possible migraine precursors”, and the diagnostic criteria are
A. At least 5 episodes meeting criteria B to D.
B. Abdominal pain episodes lasting 1 to 72 hours (untreated or unsuccessfully treated).
C. The abdominal pain has all of the following characteristics.
(i) located in the midline, around the umbilicus, or difficult to locate; (ii) dull or “mild” in nature; and (iii) moderate or severe in degree.
D. At least two of the following are present during abdominal pain: ① loss of appetite; ② nausea; ③ vomiting; ④ pallor.
E. It cannot be attributed to another disease.
9. The diagnostic criteria for benign paroxysmal vertigo in children require at least 5 episodes of “severe vertigo without aura, relieved by itself after several minutes to several hours”. The interictal neurological examination, hearing and vestibular function should be normal, and the EEG should be normal.
10. It is difficult to distinguish from transient ischemic attack (TIA) without infarctive persistent aura. The diagnosis can be considered when one or more aura symptoms of the current attack persist for more than 1 week in patients with aura migraine and are the same as the typical previous attacks. However, Prof. Chen Shengyuan said that in clinical practice, TIA should be considered first if it is difficult to distinguish, so as not to delay the rescue treatment.
11.Ecasional episodic tension-type headache is a subtype of the tension-type headache category, which is more common in clinical practice. The difference of its diagnostic criteria is that the duration and number of attacks are limited.
A. The average number of attacks is less than 1 day per month, but at least 10 attacks per year (less than 12 days per year), and meets diagnostic criteria B to D.
B. The headache lasts from 30 minutes to 7 days.
C. The headache has at least 2 of the following characteristics.
(i) bilateral headache; (ii) pressure or tightness-like (non-pulsating) in nature; (iii) mild to moderate headache; and (iv) daily activities such as walking or going up stairs do not aggravate the headache.
D. Two of the following are met.
(i) no nausea and vomiting (may be anorexic); (ii) no more than one of photophobia or phonophobia.
E. Cannot be attributed to other diseases.
12. Frequent paroxysmal tension-type headache is the same as “episodic tension-type headache” except that “the average monthly attack is greater than 1 day and less than 15 days, but at least 10 attacks (≥12 times per year and <180 days) for at least 3 months". B to D of the diagnostic criteria.
13.The classical diagnosis of trigeminal neuralgia emphasizes the importance of pain characteristics, and the diagnostic criteria are
A. Sudden onset of the disease, lasting 1 to 3 seconds, affecting one or more branches of the trigeminal nerve, satisfying criteria B and C.
B. The pain is characterized by at least one of the following.
(i) intense, sharp, superficial or stabbing; (ii) in the trigger area or triggered by a trigger factor.
C. The attack is stereotyped for the individual patient.
D. There is no clinical evidence of a neurological deficit.
E. There is no other etiology.
The International Headache Classification Committee requires an international classification of headache, with a primary classification (i.e., 14 major categories) for general community physicians, a secondary classification for general hospital internists, and a tertiary classification for use by neurologists and related researchers.