UCNS Course A Review of ICHD-3b

Transcription

1 UCNS Course A Review of ICHD-3b Andrew D. Hershey, M.D., Ph.D., FAHS Endowed Chair and Director of Neurology Director, Cincinnati Children s Headache Center Professor of Neurology and Pediatrics University of Cincinnati

2 Disclosures Support grants, contracts, honoraria - NIH, CHRF research foundation, Allergan, Amgen, Curelator, Depomed, and Lilly American Headache Society Board Member NIH Advisory Board, Common Data Elements American Migraine Foundation Advisory Board Assoc Ed Headache, Cephalalgia, The Journal of Headache Pain

3 Objectives Understand basic concepts of ICHD Discuss changes and implications To explore where things go from here

4 Headache Classification History

5 History of Migraine 3000 BC, Sumeria the sick headache The sick-eyed says not - I am sick-eyed The sick-headed not - I am sick-headed

6 History of Migraine 400 BC, Hippocrates Shining light followed by violent pain in the temples

7 History of Migraine 2nd Century AD, Aretaeus of Cappadocia Heterocrania (one-sided headache with blackness before the eyes, nausea, vomiting, photophobia and osmophobia 200 AD, Galen Migraine is Greek for hemicrania

8 History of Childhood Migraine 1949, Vahlquist and Hackzell Attacks separated by Sx free intervals Two of: nausea, flimmer scotoma, hemicrania, FHx

9 Classification of Headache Ad Hoc Committee, 1962 Vascular headache of migraine type Muscle-contraction headache Combined headache 12 other headache syndromes

10 Classification of Headache Ad Hoc Committee, 1962 Vascular headache of migraine type Classic migraine Common migraine Cluster headache Hemiplegic and ophthalmoplegic migraine Lower-half headache

11 History of Childhood Migraine Prensky, Ped Cl N Amer, , Prensky Recurrent with symptom free intervals Three our of six features Abdominal pain, nausea, or vomiting Localized unilateral/hemicrania Throbbing, pulsatile quality Complete relief after a brief period of sleep Aura - visual, sensory, or motor Family history

12 History of Childhood Migraine Prensky, Ped Cl N Amer, , Prensky Abrupt or slow worsening Vary greatly in severity Do not need to interrupt activity Occur at any time of day Abdominal pain/nausea/vomiting without headache

13 ICHD 1988 International Classification of Headache Disorders 3 years to develop, 12 subcommittees, expert opinion based nd Edition Research testing of ICHD led to changes Revision later of Medication overuse Website development rd Edition (beta) Beta for testing and to synchronize with ICD-11

14 ICHD Organizational structure Primary Headaches Secondary Headaches Painful Cranial Neuropathies Appendix

15 ICHD Organizational structure Primary Headaches Migraine Tension-type Headaches Trigeminal Autonomic Cephalagias Other Primary Headaches Secondary Headaches Painful Cranial Neuropathies Appendix

16 ICHD Organizational structure Primary Headaches Secondary Headaches Posttraumatic Vascular Disease Other Intracranial Pathology Substances CNS infection Homeostatic disorders Cranium, Neck, Eyes, ENT, Sinuses, Mouth, Teeth, TMJ Psychiatric Painful Cranial Neuropathies Appendix

17 Classification of Headache International Classification of Headache Disorders 3 rd Edition (beta version), Cephalalgia, 2013 Basic Concepts Hierarchical Diagnosis for current headache or within the past year (genetics is lifetime) Diagnosis each distinct type 1.1 Migraine without aura 1.2 Migraine with aura 8.2 Medication-overuse headache

18 Classification of Headache International Classification of Headache Disorders 3 rd Edition (beta version), Cephalalgia, 2013 Basic Concepts Hierarchical Diagnosis for current headache or within the past year (genetics is lifetime) Diagnosis each distinct type In order of importance Sometimes a minimum number of attacks to meet criteria, but frequency not typically required

19 Classification of Headache International Classification of Headache Disorders 3 rd Edition (beta version), Cephalalgia, 2013 Basic Concepts Primary vs. secondary vs. both If new headache first occurs in close temporal relation, with causation = secondary disorder Even if primary headache characteristics When a pre-existing primary becomes chronic or significantly worsens in close temporal relation Diagnose both primary and secondary headache

20 Classification of Headache International Classification of Headache Disorders 3 rd Edition (beta version), Cephalalgia, 2013 Basic Concepts Primary vs. secondary vs. both Not all headaches required to meet criteria to make diagnosis May be due to treatment Inability to recall Can ask for typical or untreated headache

21 Classification of Headache International Classification of Headache Disorders 3 rd Edition (beta version), Cephalalgia, 2013 Basic Concepts Primary vs. secondary vs. both Not all headaches required to meet criteria to make diagnosis Diary can help diagnosis and separation of multiple types Secondary headache does not require remission/substantial improvement Medication overuse can be diagnosed before recovery from MOH

22 Classification of Headache International Classification of Headache Disorders 3 rd Edition (beta version), Cephalalgia, 2013 Basic Concepts Primary vs. secondary vs. both Not all headaches required to meet criteria to make diagnosis Diary can help diagnosis and separation of multiple types Secondary headache does not require remission/substantial improvement Appendix for research

23 ICHD I to II to 3b General evolution of diagnosis through testing and validation Consistent Structure (although with some variability) Primary Headaches A. Number of required attacks B. Time duration C. Headache Characteristics D. Associated features E. Rule out other causes Secondary Headaches A. Presence of Headache B. Presence of causative disorder C. Evidence of causation

24 Changes in ICHD-3b Migraine Migraine without aura Pediatric Note - Duration 2-72 hours (vs with diary) Sleep included in duration Pediatric specific notes eliminated and in comments Pediatric and adolescents (<18 years old) Evolutionary change in location Migraine with aura ICHD-3b changed to 6 auras (visual, sensory, speech and/or language, motor, brainstem, and retinal) Basilar-type migraine is now an aura (Migraine with Brainstem Aura)

25 Changes in ICHD-3b Migraine Chronic migraine Added in ICHD-II, modified in ICHD-2R ICHD-3b Majority of headaches meet criteria for migraine or respond to migraine treatment Episodic syndromes that may be associated with migraine Formerly Childhood periodic syndromes Recognizes may occur in adults

26 Changes in ICHD-3b Tension-type Headaches 3 subtypes by frequency Infrequent (10 episodes, < 1/month) Frequent (10 episodes, 1-14 days/month) Chronic (>15 days/month, >3 months)

27 Changes in ICHD-3b Trigeminal Autonomic Cephalagias Cluster headache moved under this category Paroxysmal Hemicrania SUNCT and SUNA Common TAC features Brief duration headaches Autonomic abnormalities Divided into episodic and chronic Hemicrania continua moved into this category

28 Changes in ICHD-3b Other primary Headaches associated with exertion Headaches associated with external stimuli Epicrania Miscellaneous NDPH

29 Changes in ICHD-3b Secondary headaches General criteria A. Any headache fulfilling criterion C B. Another disorder scientifically documented to be able to cause headaches has been diagnosed C. Evidence of causation (2 of 4) 1. Headache developed in temporal relation 2. One or both a. Headache significantly worsened with causative disorder b. Headache significantly improved with treatment of causative disorder 3. Headache characteristics typical for causative disorder 4. Other evidence of causation D. Rule out other causes

30 Changes in ICHD-3b Secondary headaches basic concepts Cause and effect reduced, just needs to be consistent Causative disorder can cause a primary headache phenotype or worsen and existing primary phenotype

31 Changes in ICHD-3b Secondary headaches specific highlights Post-traumatic headache within 7 days from head injury or awakening from head injury ICH Pressure required to be >250 mmcsf, but with comment that up to 280 mmcsf may be normal in children MOH (should it just be Medication overuse?) Example of transition to a relatively established criteria Removed specific agent requirement Removed requirement to resolve after cessation Can have both CM and MOH

32 Conclusions ICHD-3b is beta Intended to be tested before finalization in 1-2 years ICHD revisions a continuing process Evidence and validation is continuing Genetics and biomarkers may be included in future Recommended reading ICHD 3b (Cephalagia, 2013) ICHD-III Changes and Challenges (M. Levin, Headache Currents, 2013: 1383-