Drug efficacy should not be used as a diagnostic criterion for headaches

Headache is a highly complex condition and thus cannot be explained by a single mechanism. There are no biomarkers for headache, and no effective diagnostic tests which are universally applicable.

For instance, the International Classification of Headache Disorders (ICHD) criteria for conditions such as chronic migraine (CM), hemicrania continua (HC) and Tolosa‐Hunt syndrome (THS) require diagnosis to include a detailed medical history and notification of potential sensitivity to treatment drugs.1,2

CM is the most common form of chronic headache in patients presenting to headache clinics.3,4 At present, however, there is no “gold standard” for diagnosis of CM in clinical practice. ICHD‐3β requires migraine‐specific medication as one of its criteria, as a previous study showed that patients in some countries were taking triptans prescribed by their headache clinics; this could, of course, increase the sensitivity of the criteria.5 Additionally, a survey in Italy showed that triptans were used by 46.4% of patients with a previous diagnosis of migraine.6 Data from Latin America showed that 70% of medication‐overuse headache (MOH) over‐used ergotamine, and most of these patients were migraine sufferers prior to MOH.7 However, in our previous studies, just one patient was found to have used triptans to alleviate migraine episodes; none of the patients we surveyed had tried to use ergot agents.4,8,9 Another study in China showed that only very few patients (0.9%) used triptans or ergot agents, for the treatment of headache.10 In other words, it is clear that migraine‐specific medications are still not available on a global scale. In part this may be because other types of analgesics are not only effective but also cheaper than triptans. Moreover, migraine‐specific medications can also be effective against other primary headaches, such as cluster headaches and some secondary headaches. Consequently, the ICHD‐3β for CM may be difficult to apply in clinic practice.

In an attempt to address this issue, we conducted a study which involved field‐testing the ICHD‐3β and expert opinion (EO) criteria for CM; this research showed that EO criteria were more applicable.9,11 EO criterions remove the criterion C3, stating “believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative” and replace the item with probable migraine.11

Absolute sensitivity to indomethacin is required as one of the diagnostic criteria for HC.1 However, a previous study reported numerous cases of secondary HC.12,13 Moreover, another type of primary headache, known as ‘paroxysmal hemicrania’ also shows extreme sensitivity to indomethacin. Research showed that indomethacin may also impact other types of headache, such as jabs and jolts syndrome, benign exertional headache and some cases of cluster headache.14

To diagnose THS, ICHD‐2 requires that pain and paresis resolve within 72 hours when treated adequately with corticosteroids, which is used as one of its criteria.2 However, the ICHD‐3β criteria for THS removed this criterion, and instead, commented that pain and paresis of THS resolve when treated adequately with corticosteroids.1 An Italian study evaluated the ICHD‐3β diagnostic criteria for THS and concluded that it was reasonable to delete this criterion but still retain the specific mention of corticosteroid treatments.15 This revision indicated that corticosteroid response remained meaningful for THS and that corticosteroid treatment could confirm the final diagnosis of THS, rather than diagnose THS. Consequently, downgrading the role of corticosteroid treatment is deemed to be reasonable.

In summary, diagnosis is flawed in some patients using the normal treatment criteria and can lead to incorrect diagnoses and treatment responses. Thus, the ICHD should remove treatment response as a criterion. Accurate diagnosis of headache must precede treatment, and consideration of drug efficacy should not be required as a diagnostic criterion for headache. Treatment response could help to confirm the final diagnosis of headache in cases where diagnosis is undefined.

Jiying Zhou (the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China)

Contact: Jiying Zhou, Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China. Email: [email protected]


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