1. AN OVERVIEW OF
INTERNATIONAL CLASSIFICATION OF
HEADACHE DISORDERS- ICHDII
Dr Prashant Makhija

2. NEED FOR CLASSIFICATION
 Uniformity – minimizing inter & intra observer variation among
professionals
 Communication
 Standardized approach to research
 Formulating treatment guidelines

3. HISTORY
 First recorded classification system ,Thomas Willis, in De
Cephalalgia in 1672
 1787, Christian Baur, divided headaches into idiopathic (primary
headaches) and symptomatic (secondary ones), and defined 84
categories
Wolff’s Headache. S Silberstein, R B Lipton, David W Dodick. 8th edition

4.  1960s, ad hoc committee of the World Federation of Neurology,
ad hoc committee of the US National Institutes of Health,
merely listed the few headache disorders recognized at that time,
gave short descriptions, no diagnostic criteria
 First internationally acceptable and clinically useful classification
system came in 1988- ICHD I(opinion of experts)
 2004, ICHD II, accepted by the WHO , incorporated in the
International Classification of Diseases 10 (evidence-based
revision) (ICD 10)
 ICHD III, expected January 2013
Wolff’s Headache. S Silberstein, R B Lipton, David W Dodick. 8th edition

5. ICHD II

8. OPERATIONAL RULES
 Classification is hierarchical- 4 digits for coding, diagnoses with
varying degrees of specificity
 1st digit- major diagnostic category
 2nd digit- subtype within that diagnostic category
 Subsequent digits- more specific diagnosis
The International Classification of Headache Disorders, 2nd Edition: Application to Practice. Jes Olesen. Functional Neurology 2005; 20(2): 61-68

9.  Clinical practice
 Diagnosis for each headache type they have experienced within
the past year
 Diagnoses should be listed in their order of importance to the
patient
 Provision is made for probable diagnoses
 headache types that are missing a single diagnostic feature
 do not fulfil the full criteria for another headache
The International Classification of Headache Disorders, 2nd Edition: Application to Practice. Jes Olesen. Functional Neurology 2005; 20(2): 61-68

10.  Primary headache- diagnosis of exclusion
 the history, physical and neurological examinations do not
suggest a secondary disorder
 a secondary disorder is suggested, but ruled out by appropriate
investigations
 a secondary disorder is present, but the primary headache attacks
did not occur for the first time in close temporal relation to the
causative disorder
The International Classification of Headache Disorders, 2nd Edition: Application to Practice. Jes Olesen. Functional Neurology 2005; 20(2): 61-68

11.  Secondary headache diagnoses
 new kind of headache for the first time in close temporal relation
to another disorder known to cause headache
 headache is attributed to that disorder
 Diagnosis of secondary headache in a patient with a pre-existing
primary headache
 it occurs in very close temporal relation to the potentially
causative disorder
 exacerbation of the headache is marked (or differs from the
primary disorder)
The International Classification of Headache Disorders, 2nd Edition: Application to Practice. Jes Olesen. Functional Neurology 2005; 20(2): 61-68

12.  the evidence that the potentially causative disorder can cause
headaches is strong
 there is improvement or disappearance of headache after relief
from the causative disorder
The International Classification of Headache Disorders, 2nd Edition: Application to Practice. Jes Olesen. Functional Neurology 2005; 20(2): 61-68

13. LIMITATIONS/ CRITISISMS
 Classification criteria are too detailed and impractical for use in
daily practice
 Addresses individual headache attacks only
 provides a snapshot of the situation at a given moment
 does not take into account the natural history of the headache or
the spectrum of headache in the person
1.
2.
3.
The “IHS” Classification (1988, 2004) – Contributions, Limitations and Suggestions. K Ravishankar. SUPPLEMENT OF JAPI • APRIL 2010 •
VOL. 58 7
Headache classification: criticism and suggestions. G.C. Manzoni , P. Torelli. Neurol Sci (2004) 25:S67–S69
Headache & Related Disorders. Debashish Chowdhury, Meena Gupta, Geeta A Khwaja, Amit Batla. Chpt r1. Shashikant S Seshia

14.  Ignores diagnostic elements that may be very important and
significant
 family history
 age at onset
 recurrence
 patterns of attacks
 clinical course in relation to reproductive events in women of
childbearing age
 lifestyle and co morbidity
( requirement of a multi-axial classification system)
1.
2.
3.
The “IHS” Classification (1988, 2004) – Contributions, Limitations and Suggestions. K Ravishankar. SUPPLEMENT OF JAPI • APRIL 2010 •
VOL. 58 7
Headache classification: criticism and suggestions. G.C. Manzoni , P. Torelli. Neurol Sci (2004) 25:S67–S69
Headache & Related Disorders. Debashish Chowdhury, Meena Gupta, Geeta A Khwaja, Amit Batla. Chpt r1. Shashikant S Seshia

15.  Chronic migraine- criteria not representative of those migraine
forms that over the years evolve to a daily chronic course
 Interpretation of the relationship between chronic migraine and
symptomatic drug overuse headache that seems too
complicated and hardly applicable in practice
 SUNCT - doubts are raised by its inclusion in Group 3
alongside cluster headache instead of Group 13 (cranial
neuralgias and central causes of facial pain) alongside trigeminal
neuralgia
1.
2.
3.
The “IHS” Classification (1988, 2004) – Contributions, Limitations and Suggestions. K Ravishankar. SUPPLEMENT OF JAPI • APRIL 2010 • VOL.
58 7
Headache classification: criticism and suggestions. G.C. Manzoni , P. Torelli. Neurol Sci (2004) 25:S67–S69
Headache & Related Disorders. Debashish Chowdhury, Meena Gupta, Geeta A Khwaja, Amit Batla. Chpt r1. Shashikant S Seshia

16.  Cluster headache- failure to make the distinction between
chronic from the onset and cluster headache evolved from
episodic
 New daily persistent headache (NDPH)- Group 4 of other
primary headaches, lack of evidence in the literature to support
its existence as a separate clinical entity, more appropriate to
include NDPH in the Appendix to ICHD-II, until further research
helps clarify its still undefined clinical picture
1.
2.
3.
The “IHS” Classification (1988, 2004) – Contributions, Limitations and Suggestions. K Ravishankar. SUPPLEMENT OF JAPI • APRIL
2010 • VOL. 58 7
Headache classification: criticism and suggestions. G.C. Manzoni , P. Torelli. Neurol Sci (2004) 25:S67–S69
Headache & Related Disorders. Debashish Chowdhury, Meena Gupta, Geeta A Khwaja, Amit Batla. Chpt r1. Shashikant S Seshia

17. PROPOSALS FOR ICHD III
 Chronic migraine will move from the appendix into the main body
of the classification
 Simplification of the classification of migraine with aura
 Introduce so-called ‘‘specifiers’’ in the migraine chapter,
treatment-responsive and treatment refractory migraine
Jes Olesen. New plans for headache classification: ICHD-3. Cephalalgia 2011 31: 4

18.  Substantial changes, Other Primary Headaches, in response to
important nosographic studies of some of these disorders
 Extensive changes will be made regarding the secondary
headaches, contrary to the existing criteria, the diagnosis of a
secondary headache before it is treated
 Already-published criteria for medication overuse headache into
the main body of the classification
Jes Olesen. New plans for headache classification: ICHD-3. Cephalalgia 2011 31: 4

19. CONCLUSION
 Contributed positively to progress in the headache field
 Present classification does have certain drawbacks
 Feedback, opinions and arguments - more complete and
practically relevant future editions of the Classification
 A shorter, more portable classification which satisfies clinicians
and researchers alike is the need of the hour

20. THANK YOU