INTERNATIONAL CLASSIFICATION

of
HEADACHE DISORDERS

3rd edition beta, ICHD-3beta

Jes Olesen, Danish Headach Center,

Dept of Neurology, Glostrup Hospital,
University of Copenhagen, Denmark

©International Headache Society 2013

 Membership 3rd International
Headache clasification committee
• Jes Olesen, chair • Julio Pasqual
• Lars Bendtsen • Michael B Russell
• David Dodick • Todd Schwedt
• Anne Ducros • Timothy Steiner
• Stefan Evers (honoary secretary)
• Michael First • Critina Tassorelli
• Peter J Goadsby • Gisela M Terwindt
• Andrew Hershey • Maurice Vincent
• Zaza Katsarava • Shuu-Jiun Wang
• Morris Levin
©International Headache Society 2013
 History
• ICHD-1 1988 and ICHD-2 in 2004
• Headache Classification Committee of
the International Headache Society
(IHS): The International Classification
of Headache Disorders, 3rd edition
(beta version) Cephalalgia 2013;33 629-
808
• ICHD-3 in 2016

©International Headache Society 2013

 Why a beta version?

• WHO wants field testing of ICD-11

• ICHD-3 should also be field tested
• An opportunity for broad input
and detection of errors
• Research opportunities
• Allows final version to bring final
WHO codes

©International Headache Society 2013

 Relation to WHO`s International
Classification of Diseases
11th edition (ICD-11)
• ICD-11 immensely important for
medical statistics and reimbursement
• Developed a bit after ICHD-3 but
otherwise in parallel
• Headache in ICD-11 greatly has its own
block
• All important headache diagnoses now
under neurology ©International Headache Society 2013
Use ICHD-3beta immediately

• Dont continue with ICHD-2

• Final ICHD-3 will not differ much
• Translate the beta version for
immediate use
• Remember to cite ICHD-3. More
relevant and benefits Cephalalgia

©International Headache Society 2013

 Classification

• The primary headaches

• The secondary headaches
• Cranial neuralgias, other facial
pain and other headaches

©International Headache Society 2013

 Structure

One chapter (1-13) per major group:

• introduction
• headache types, subtypes, subforms with:
– previously used terms
– disorders that are related but coded elsewhere
– short descriptions
– explicit diagnostic criteria
– notes and comments
• selected bibliography
©International Headache Society 2013
 Appendix for:

• research criteria for novel entities that have

not been sufficiently validated
• alternative diagnostic criteria that may be
preferable but for which the evidence is
insufficient
• a first step in eliminating disorders included
in previous editions but for which insufficient
evidence

©International Headache Society 2013

 Important general rule

1. Each distinct type of headache that a patient

has must be separately diagnosed and coded
– eg, a severely affected patient may receive three
diagnoses and codes:
1.1 Migraine without aura,
2.2 Frequent episodic tension-type headache and
8.2 Medication-overuse headache

©International Headache Society 2013

 Migraine classification

• 1.1 Migraine without aura

• 1.2 Migraine with aura
• 1.3 Chronic migraine
• 1.4 Complications of migraine
• 1.5 Probable migraine
• 1.6 Episodic syndromes that may be associated with
migraine

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 1.2 Migraine with aura
• 1.2.1 Migraine with typical aura
• 1.2.1.1 Typical aura with headache
• 1.2.1.2 Typical aura without headache
• 1.2.2 Migraine with brainstem aura
• 1.2.3 Hemiplegic migraine
• 1.2.3.1 Familial hemiplegic migraine (FHM)
• 1.2.3.1.1 Familial hemiplegic migraine type 1
• 1.2.3.1.2 Familial hemiplegic migraine type 2
• 1.2.3.1.3 Familial hemiplegic migraine type 3
• 1.2.3.1.4 Familial hemiplegic migraine, other loci
• 1.2.3.2 Sporadic hemiplegic migraine
• 1.2.4 Retinal migraine
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 Migraine with aura
• A. At least two attacks fulfilling criteria B and C
• B. One or more of the following fully reversible aura
symptoms: 1. visual 2. sensory 3. speech and/or language
4. motor 5. brainstem 6. retinal
• C. At least two of the following four characteristics:
1. at least one aura symptom spreads gradually
over 5 minutes, and/or two or more symptoms
occur in succession
2. each individual aura symptom lasts 5-60 minutes1
3. at least one aura symptom is unilateral2
4. the aura is accompanied, or followed within 60
minutes, by headache ©International Headache Society 2013
 Migraine with typical aura
• A. At least two attacks fulfilling criteria for 1.2
• B. Aura consisting of visual, sensory and/or speech/
language symptoms, each fully reversible, but no
motor, brainstem or retinal symptoms

©International Headache Society 2013

Migraine with typical aura appendix
C. At least three of the following six characteristics:
1. at least one aura symptom spreads gradually
over 5 minutes
2. two or more aura symptoms occur in succession
3. each individual aura symptom lasts 5–60
minutes
4. at least one aura symptom is unilateral
5. at least one aura symptom is positive
6. the aura is accompanied, or followed within 60
minutes, by headache

©International Headache Society 2013

 Chronic migraine

A. Headache (tension-type-like and/or migraine-like)

on 15 days per month for >3 months2 and fulfilling
criteria B and C
B. Occurring in a patient who has had at least five
attacks fulfilling criteria B-D for 1.1 Migraine without
aura and/or criteria B and C for 1.2 Migraine
with aura
C. On 8 days per month for >3 months, fulfilling any
of the following :
1. criteria C and D for 1.1 Migraine without aura
2. criteria B and C for 1.2 Migraine with aura
3. believed by the patient to be migraine at onset
and relieved by a triptan or ergot derivative
D. Not better accounted for by another ICHD-III
diagnosis.
©International Headache Society 2013
 Important general rule

• If a primary headache gets chronic or

significantly worse (doubling or more)
in relation to a causative disorder, code
for both

©International Headache Society 2013

 Chronic migraine appendix

A. Headache (tension-type-like and/or migraine-like)

on 15 days per month for >3 months and fulfilling
criteria B and C
B. Occurring in a patient who has had at least five
attacks fulfilling criteria B–D for 1.1 Migraine without
aura and/or criteria B and C for 1.2 Migraine
with aura
C. On 8 days per month for >3 months fulfilling any
of the following:
1. criteria C and D for 1.1 Migraine without aura
2. criteria B and C for 1.2 Migraine with aura
3. criteria A and B for 1.5 Probable migraine
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A1.3.1 Chronic migraine with
pain-free periods

A. Headache fulfilling criteria for 1.3 Chronic migraine

and criterion B below
B. Interrupted by pain-free periods of >3 hours on ≥5
days per month which are not attributed to drug
treatment.

©International Headache Society 2013

1.6 Episodic syndromes that may be
associated with migraine
• 1.6.1 Recurrent gastrointestinal
disturbance
• 1.6.1.1 Cyclical vomiting syndrome
• 1.6.1.2 Abdominal migraine
• 1.6.2 Benign paroxysmal vertigo
• 1.6.3 Benign paroxysmal torticollis
• A 1.6.6 Vestibular migraine

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 A1.6.5 Vestibular migraine
• A. At least five episodes fulfilling criteria C and D
• B. A current or past history of 1.1 Migraine without
aura or 1.2 Migraine with aura1
• C. Vestibular symptoms of moderate or severe intensity,
lasting between 5 minutes and 72 hours
• D. At least 50% of episodes are associated with at least
one of the following three migrainous features:
1. headache with at least two of the following four:
a)unilateral location b) pulsating quality c) moderate or
severe intensity d) aggravation by routine physical activity
2. photophobia and phonophobia
3. visual aura
©International Headache Society 2013
 Conclusions

• ICHD-3 beta is published, use it

immediately
• Translate it
• Find mistakes and report to
relevant chapter chairperson
• Participate in Field testing

©International Headache Society 2013