Author: Jiying Zhou

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]

References

  1. Headache Classification Committee of the International Headache Society (IHS) (2013) The international classification of headache disorders (beta version). Cephalalgia 33(9): 629-808.
  2. Headache Classification Subcommittee of the International Headache Society (2004) The International Classification of Headache Disorders: 2nd Edition. Cephalalgia 24 Suppl 1: 9-160.
  3. Sancisi E., Cevoli S., Vignatelli L., Nicodemo M., Pierangeli G., Zanigni S., & Montagna P. (2010). Increased prevalence of sleep disorders in chronic headache: a case–control study. Headache: The Journal of Head and Face Pain,50(9), 1464-1472.
  4. Huang, Q., Li, W., Li, N., Wang, J., Tan, G., Chen, L., & Zhou, J. (2013). Elevated blood pressure and analgesic overuse in chronic daily headache: an outpatient clinic-based study from China. The journal of headache and pain,14(1), 51.
  5. Bigal ME, Rapoport AM, Sheftell FD, Tepper SJ, Lipton RB (2007) The International Classification of Headache Disorders revised criteria for chronic migraine—field testing in a headache specialty clinic. Cephalalgia 27(3): 230-234.
  6. Cevoli S, D’Amico D, Martelletti P, Valguarnera F, Del Bene E et al (2009) Underdiagnosis and undertreatment of migraine in Italy: a survey of patients attending for the first time 10 headache centres. Cephalalgia 29(12): 1285-1293.
  7. Bigal ME, Rapoport AM, Sheftell FD, Tepper SJ, Lipton RB (2007) The International Classification of Headache Disorders revised criteria for chronic migraine—field testing in a headache specialty clinic. Cephalalgia 27(3): 230-234.
  8. Wang, Y., Zhou, J., Fan, X., Li, X., Ran, L., Tan, G., & Liu, B. (2011). Classification and clinical features of headache patients: an outpatient clinic study from China. The journal of headache and pain,12(5), 561-567.
  9. Jiang, H., Deng, Y., Zhang, Y., Jin, J., Kong, X., Zhu, Q., & Zhou, J. (2016). Field testing of the ICHD-3β and expert opinion criteria for chronic migraine. The Journal of Headache and Pain,17(1), 85.
  10. Dong Z., Chen, X., Steiner TJ., Hou, L., Di, H., He, M., & Yu, S. (2015). Medication-overuse headache in China: Clinical profile, and an evaluation of the ICHD-3 beta diagnostic criteria. Cephalalgia,35(8), 644-651.
  11. Silberstein SD, Lipton RB, Dodick DW (2014) Operational diagnostic criteria for chronic migraine: expert opinion. Headache 54(7): 1258-1266.
  12. Zhang, Y., Wang, D., He, Z., Wu, Q. Zhou J (2016) Hemicrania continua-like headache secondary to nasopharyngeal carcinoma: A case report. Cephalalgia 0333102416654884.
  13. Favier I, van Vliet JA, Roon KI, Witteveen RJ, Verschuuren JJ et al. (2007) Trigeminal autonomic cephalgias due to structural lesions: a review of 31 cases. Archives of Neurology 64(1): 25-31.
  14. Sjaastad O, Spierings EL (1984) “Hemicrania continua”: another headache absolutely responsive to indomethacin. Cephalalgia 4(1): 65-70.
  15. Hao R, He Y, Zhang H, Zhang W, Li, X et al. (2015) The evaluation of ICHD-3 beta diagnostic criteria for Tolosa–Hunt syndrome: a study of 22 cases of Tolosa–Hunt syndrome. Neurological Sciences 36(6): 899-905.