Open Access

European headache federation consensus on technical investigation for primary headache disorders

  • D. D. Mitsikostas1Email author,
  • M. Ashina2,
  • A. Craven3,
  • H. C. Diener4,
  • P. J. Goadsby5,
  • M. D. Ferrari6,
  • C. Lampl7,
  • K. Paemeleire8,
  • J. Pascual9,
  • A. Siva10,
  • J. Olesen11,
  • V. Osipova12,
  • P. Martelletti13 and
  • on behalf of EHF committee
The Journal of Headache and PainOfficial Journal of the "European Headache Federation" and of "Lifting The Burden - The Global Campaign against Headache"201617:5

https://doi.org/10.1186/s10194-016-0596-y

Received: 16 January 2016

Accepted: 2 February 2016

Published: 9 February 2016

Abstract

The diagnosis of primary headache disorders is clinical and based on the diagnostic criteria of the International Headache Society (ICHD-3-beta). However several brain conditions may mimic primary headache disorders and laboratory investigation may be needed. This necessity occurs when the treating physician doubts for the primary origin of headache. Features that represent a warning for a possible underlying disorder causing the headache are new onset headache, change in previously stable headache pattern, headache that abruptly reaches the peak level, headache that changes with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre, first onset of headache ≥50 years of age, neurological symptoms or signs, trauma, fever, seizures, history of malignancy, history of HIV or active infections, and prior history of stroke or intracranial bleeding. All national headache societies and the European Headache Alliance invited to review and comment the consensus before the final draft. The consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. Persistent aura without infarction and migrainous infarction require brain MRI, MRA and MRV. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all TACs. For primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required. Because there is little and no good evidence the committee constructed a consensus based on the opinion of experts, and should be treated as imperfect.

Keywords

Primary headache disorders Migraine Tension-type headache TACs Consensus Diagnostic tests Brain MRI

Main text

Headache is a symptom in the main rather a condition. Only when headache attacks fulfill specific diagnostic criteria consistently does a primary headache disorder occur [1]. Accompanying symptoms are important together with the particular headache characteristics including pain severity, duration, quality and location. In most cases headache is primary but secondary headache disorders may be related to life threatening conditions. They may respond to common analgesics and mimic primary ones a lot. Diagnostic tests are necessary therefore when the treating physician doubts for the primary origin of headache. Up-to-date there is no official recommendation for these tests, although headache remains the commonest presenting symptom in people asking medical consultation. To bridge this gap European Headache Federation (EHF) appointed an internal and external committee to prepare a consensus on the diagnostic testing that primary headache disorders may require. The procedure followed was consisted of three phases. In phase one members of the Executive Board of EHF (internal committee: DDM, AS, CL, KP, VO and PM) prepared the first draft that was send to all National European Headache Societies for review. Thirteen National Headache Societies replied (40 %) with comments. European Headache Alliance also participated in this review phase. Based on their comments and suggestions draft 2 was edited (phase 2) that was applied for review in a group of distinguished headache specialists that EHF appointed as the external subcommittee (MA, HCD, MDF, PJG, JP, and JO). After fulfilling all comments into one manuscript the final draft of the consensus was arranged (phase 3), which is presented in the Appendix. Table 1 summarizes the principles.
Table 1

Tests recommended for primary headache disorders

ICHD-IIIb code

Disorder

Tests

1

Migraine

 

1.1

Migraine without aura

None

 

Frequent episodic migraine

Brain MRIa

Carodit ultrasound or MRAa

ESRa

1.2

Migraine with aura

Brain MRIa

1.2.2

Migraine with brainstem aura

Brain MRI & MRA

EEGa

Carotid and vertebral arteries ultrasound/or CT or MRAa

Genetic evaluationa

1.3

Chronic migraine

Brain MRI Gd & MRVa

Fundoscopya

Lumbar puncturea

Polysomnographya

1.4

Complications of migraine

Brain MRI

1.4.1/2

Persistence of aura symptoms

Emergency brain CT or MRI

Carotid and vertebral arteries ultrasound/or CT or MRA

ESRa

1.4.3

Migrainous infarction

Emergency brain CT or MRI

Carotid and vertebral arteries ultrasound/or CT or MRAa

ESRa

1.4.3

Migraine aura-triggered seizures

Repetitive EEGs or video EEG

1.5

Probable migraine

Brain MRIa

1.6

Episodic syndromes that may be associated with migraine

Gastric work-up

2

TTH

 

2.1

Infrequent TTH

None

2.2 and 3

Frequent TTH and Chronic TTH

Brain MRI MRI Gd & MRVa

Fundoscopya

Lumbar puncturea

Polysomnographya

3

TACs (all)

Brain MRI

Brain MRA and Carotid and vertebral arteries ultrasound/or CT or MRAa

Pituitary function testinga

3.1

Cluster headache

+Polysomnographya

3.2

Paraxysmal Hemicrania

Brain MRI and MRA and Carotid and vertebral arteries ultrasound/or CT or MRAa

3.3

Suna & Sunct

+ High resolution MRI of brainstem

3.4

Hemicrania Continua

Brain MRI

Brain MRA and Carotid and vertebral arteries ultrasound/or CT or MRAa

4

Other primary headache disorders

 

4.1

Primary cough headache

Brain MRI

Cranio-cervical and brain MRAa

4.2

Primary exercise headache

Brain MRI and MRA/MRV

Lumbar puncturea

Carotid & vertebral ultrasound, or CT or MRA

Cardiological evaluation a

4.3

Primary headache associated with sexual activity

Brain MRI, MRA/MRV

Carotid and vertebral arteries ultrasound/or CT or MRA

Lumbar puncturea

ESR, CRPa

4.4

Primary thunderclap headache

Brain MRI, MRA/MRV

Carotid and vertebral arteries ultrasound/or CT or MRA

Lumbar puncturea

ESR, CRPa

4.5

Cold-stimulus headache

None

4.6

External-pressure headache

None

4.7

Primary stabbing headache

Brain MRI, MRA/MRV

Carotid and vertebral arteries ultrasound/or CT or MRA

Lumbar puncturea

ESR, CRPa

4.8

Nummular headache

Brain MRI, ESR, ANF and RF

4.9

Hypnic headache

Brain MRI, ESR, CRP

Polysomnography

24-hour blood pressure monitoring

4.10

New daily persistent headache

Brain MRI, MRA

Lumbar puncturea

aIndicates specific conditions

Declarations

EHF committee

1. Bendtsen, Lars (Danish Headache Society);

2. Bicakci, Sebnem (Turkish Neurological Society Headache Chapter and Headache and Pain Research Society);

3. Braschinsky, Mark (Estonian Headache Society);

4. Brossner, Gregor (Austrian Headache Society);

5. Constantinidis, Theodoros (Hellenic Headache Society);

6. Costa, Cinzia (Italian Headache Society);

7. Edvinsson, Lars (Swedish Migraine Society);

8. Freimane, Aija (Latvian Association for the Study of Pain);

9. Gantenbein, Andy (Swiss Headache Society);

10. Gouveia, Raquel Gil (Portuguese Headache Society);

11. Groseva, Veselina (Bulgarian Headache Society);

12. Hristova, Sonya (Bulgarian Headache Society);

13. Karli, Necdet (Turkish Neurological Society Headache Chapter and Headache and Pain Research Society);

14. Latysheva, Nina (Russian Headache Society);

15. Ljubisavljevic, Srdjan (Serbian Headache Society);

16. Logina, Inara (Latvian Association for the Study of Pain);

17. Milanov, Ivan (Bulgarian Headache Society);

18. Obelleniene, Diana (Lithuanian Headache Association);

19. Palavra, Filipe (Portuguese Headache Society);

20. Parreira, Elsa (Portuguese Headache Society);

21. Riederer, Franz (Austrian Headache Society);

22. Sacco, Simona (Italian Headache Society);

23. Schytz, Henrik (Danish Headache Society);

24. Sergeev, Alexey (Russian Headache Society);

25. Steinber, Anna (Swedish Migraine Society);

26. Toom, Kati (Estonian Headache Society);

27. Vikelis, Michail (Hellenic Headache Society);

28. Zebenholzer, Karin (Austrian Headache Society);

29. Zidvec-Trajkovic, Jasna (Serbian Headache Society).

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Authors’ Affiliations

(1)
Neurology Department, Athens Naval Hospital
(2)
Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen
(3)
European Headache Alliance, President
(4)
Department of Neurology, University Hospital Essen, University Duisburg-Essen
(5)
Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, and King’s Clinical Research Facility, Kings College London, Wellcome Foundation Building, King’s College Hospital
(6)
Center for Proteomics and Metabolomics, Leiden University Medical Center
(7)
Medical Headache Center, Hospital Sisters of Mercy
(8)
Department of Neurology, Ghent University Hospital
(9)
University Hospital Marqués de Valdecilla and IDIVAL
(10)
Department of Neurology, Cerrahpasa School of Medicine, Istanbul University
(11)
Danish Headache Centre and Department of Neurology, Rigshospitalet, Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen
(12)
Department of Neurology, First Moscow State Medical University
(13)
Department of Clinical and Molecular Medicine, Sapienza University

References

  1. Headache Classification Committee of the International Headache Society (IHS) (2014) The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 33:629–808View ArticleGoogle Scholar
  2. Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E (2012) Quality standards subcommittee of the american academy of neurology and the american headache society. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the quality standards subcommittee of the american academy of neurology and the american headache society. Neurology 78:1337–1345PubMed CentralView ArticlePubMedGoogle Scholar
  3. Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sándor PS (2009) European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine-revised report of an EFNS task force. Eur J Neurol 16:968–981View ArticlePubMedGoogle Scholar
  4. Metso TM, Tatlisumak T, Debette S, Dallongeville J, Engelter ST, Lyrer PA, Thijs V, Bersano A, Abboud S, Leys D, Grond Ginsbach C, Kloss M, Touzé E, Pezzini A, Metso AJ, CADISP group (2012) Migraine in cervical artery dissection and ischemic stroke patients. Neurology 78:1221–1228View ArticlePubMedGoogle Scholar
  5. Cianchetti C, Pruna D, Ledda M (2013) Epileptic seizures and headache/migraine: a review of types of association and terminology. Seizure 22:679–685View ArticlePubMedGoogle Scholar
  6. Panayiotopoulos CP (1999) Elementary visual hallucinations, blindness, and headache in idiopathic occipital epilepsy: differentiation from migraine. J Neurol Neurosurg Psychiatry 66:536–540PubMed CentralView ArticlePubMedGoogle Scholar
  7. Pelzer N, Stam AH, Haan J, Ferrari MD, Terwindt GM (2013) Familial and sporadic hemiplegic migraine: diagnosis and treatment. Curr Treat Options Neurol 15:13–27View ArticlePubMedGoogle Scholar
  8. Chai NC, Scher AI, Moghekar A, Bond DS, Peterlin BL (2014) Obesity and headache: part I-a systematic review of the epidemiology of obesity and headache. Headache 54:219–234PubMed CentralView ArticlePubMedGoogle Scholar
  9. De Simone R, Ranieri A (2015) The role of intracranial hypertension in the chronification of migraine. Neurol Sci 36(Suppl 1):23–28View ArticlePubMedGoogle Scholar
  10. Russell MB, Kristiansen HA, Kværner KJ (2014) Headache in sleep apnea syndrome: epidemiology and pathophysiology. Cephalalgia 34:752–755View ArticlePubMedGoogle Scholar
  11. Kahya Eren N, Bülbül NG, Yakar Tülüce S, Nazlı C, Beckmann Y (2015) To Be or Not to Be patent: the relationship between migraine and patent foramen ovale. Headache 55:934–942View ArticlePubMedGoogle Scholar
  12. Bendtsen L, Evers S, Linde M, Mitsikostas DD, Sandrini G, Schoenen J (2010) EFNS. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol 17:1318–1325PubMedGoogle Scholar
  13. Mitsikostas DD, Edvinsson L, Jensen RH, Katsarava Z, Lampl C, Negro A, Osipova V, Paemeleire K, Siva A, Valade D, Martelletti P (2014) Refractory chronic cluster headache: a consensus statement on clinical definition from the European Headache Federation. J Headache Pain 15:79PubMed CentralView ArticlePubMedGoogle Scholar
  14. Levy MJ, Matharu MS, Meeran K, Powell M, Goadsby PJ (2005) The clinical characteristics of headache in patients with pituitary tumours. Brain 128:1921–1930View ArticlePubMedGoogle Scholar
  15. Mitsikostas DD, Vikelis M, Viskos A (2008) Refractory chronic headache associated with obstructive sleep apnoea syndrome. Cephalalgia 28(2):139–143PubMedGoogle Scholar
  16. Barloese M, Lund N, Jensen R (2014) Sleep in trigeminal autonomic cephalagias: a review. Cephalalgia 34:813–822View ArticlePubMedGoogle Scholar
  17. Rozen TD, Fishman RS (2012) Cluster headache in the United States of America: demographics, clinical characteristics, triggers, suicidality, and personal burden. Headache 52:99–113View ArticlePubMedGoogle Scholar
  18. Cohen AS, Matharu MS, Goadsby PJ (2006) Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or cranial autonomic features (SUNA)-a prospective clinical study of SUNCT and SUNA. Brain 129:2746–2760View ArticlePubMedGoogle Scholar
  19. Bogorad I, Blum S, Green M (2010) A case of MS presenting with SUNCT status. Headache 50:141–143View ArticlePubMedGoogle Scholar
  20. Vilisaar J, Constantinescu CS (2006) SUNCT in multiple sclerosis. Cephalalgia 26:891–893View ArticlePubMedGoogle Scholar
  21. Charlson RW, Robbins MS (2014) Hemicrania continua. Curr Neurol Neurosci Rep 14:436View ArticlePubMedGoogle Scholar
  22. Allena M, Rossi P, Tassorelli C, Ferrante E, Lisotto C, Nappi G (2010) Focus on therapy of the Chapter IV headaches provoked by exertional factors: primary cough headache, primary exertional headache and primary headache associated with sexual activity. J Headache Pain 11:525–530PubMed CentralView ArticlePubMedGoogle Scholar
  23. Blok KM, Rinkel GJ, Majoie CB, Hendrikse J, Braaksma M, Tijssen CC, Wong YY, Hofmeijer J, Extercatte J, Kerklaan B, Schreuder TH, ten Holter S, Verheul F, Harlaar L, Pruissen DM, Kwa VI, Brouwers PJ, Remmers MJ, Schonewille WJ, Kruyt ND, Vergouwen MD (2015) CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals. Neurology 84:1927–1932View ArticlePubMedGoogle Scholar
  24. Halker RB, Vargas BB (2013) Primary exertional headache: updates in the literature. Curr Pain Headache Rep 17:337View ArticlePubMedGoogle Scholar
  25. Schwartz DP, Robbins MS, Grosberg BM (2013) Nummular headache update. Curr Pain Headache Rep 17:340View ArticlePubMedGoogle Scholar
  26. Gil-Gouveia R, Goadsby PJ (2007) Secondary “hypnic headache”. J Neurol 254:646–654View ArticlePubMedGoogle Scholar
  27. Holle D, Naegel S, Obermann M (2013) Hypnic headache. Cephalalgia 33:1349–1357View ArticlePubMedGoogle Scholar
  28. Goadsby PJ (2011) New daily persistent headache: a syndrome, not a discrete disorder. Headache 51:650–653View ArticlePubMedGoogle Scholar
  29. Yri HM, Rönnbäck C, Wegener M, Hamann S, Jensen RH (2014) The course of headache in idiopathic intracranial hypertension: a 12-month prospective follow-up study. Eur J Neurol 21(12):1458–1464View ArticlePubMedGoogle Scholar
  30. Perez-Barcena J, Llompart-Pou JA, O’Phelan KH (2014) Intracranial pressure monitoring and management of intracranial hypertension. Crit Care Clin 30:735–750View ArticlePubMedGoogle Scholar
  31. Debette S, Grond-Ginsbach C, Bodenant M, Kloss M, Engelter S, Metso T, Pezzini A, Brandt T, Caso V, Touzé E, Metso A, Canaple S, Abboud S, Giacalone G, Lyrer P, Del Zotto E, Giroud M, Samson Y, Dallongeville J, Tatlisumak T, Leys D, Martin JJ (2011) Cervical Artery Dissection Ischemic Stroke Patients (CADISP) Group. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology 77:1174–1181View ArticlePubMedGoogle Scholar
  32. Seidel S, Lieba-Samal D, Vigl M, Wöber C (2011) Clinical features of unilateral headaches beyond migraine and cluster headache and their response to indomethacin. Wien Klin Wochenschr 123(17-18):536–541View ArticlePubMedGoogle Scholar
  33. Sandrini G, Friberg L, Coppola G, Jänig W, Jensen R, Kruit M, Rossi P, Russell D, Sanchez Del Rìo M, Sand T, Schoenen J (2011) European Federation of Neurological Sciences. Neurophysiological tests and neuroimaging procedures in non-acute headache (2nd edition). Eur J Neurol 18:373–381View ArticlePubMedGoogle Scholar
  34. Tremolizzo L, Ferrario S, Pellegrini A, Fumagalli L, Ferrarese C, Appollonio I (2015) Neurological soft signs in primary headache patients. Neurosci Lett 595:41–44View ArticlePubMedGoogle Scholar

Copyright

© Mitsikostas et al. 2016