Folia Medica 2013; 55(3&4): 46-55
Copyright © 2013 Medical University Plovdiv
doi: 10.2478/folmed-2013-0027
DIAGNOSTIC VALUE OF COMBINATIONS OF SYMPTOMS OF MIGRAINE AND
TENSION-TYPE HEADACHE INCLUDED IN THE DIAGNOSTIC CRITERIA FOR
CHILDREN AND ADOLESCENTS IN THE INTERNATIONAL CLASSIFICATION OF
HEADACHE DISORDERS 2ND EDITION
Iliyana H. Pacheva1*, Ivan G. Milanov2, Ivan S. Ivanov1, Rumen S. Stefanov3
1Department
of Pediatrics and Medical Genetics, Medical University, Plovdiv, 2St. Naum Hospital of Neurology and Psychiatry, Medical University, Sofia, 3Department of Social Medicine and Public Health, Medical University, Plovdiv, Bulgaria
ABSTRACT
AIM: To suggest diagnostic combinations of symptoms for migraine and tension type headache (TTH), and for differentiation of overlapping headache (classified as either migraine
or TTH) through evaluation of the diagnostic value of combinations of characteristics included in the International Headache Society diagnostic criteria for migraine and TTH in
children and adolescents.
PATIENTS AND METHODS: The study comprised an epidemiological school-based study (412
of 1029 pupils with chronic / recurrent headache) and a clinical study conducted in the
Pediatric Neurology Ward and outpatient clinic at Plovdiv Medical University Hospital
(203 patients with chronic / recurrent headache). An inclusion criterion was at least two
episodes of headache during the last year. Exclusion criteria were: headache occurring only
during acute infections; withdrawal of informed consent. Headache was classified according to the International Classification of Headache Disorders 2nd edition (ICHD-II) The
diagnostic value of all combinations of items in criteria C and D for migraine and TTH was
measured by sensitivity, specificity, and odds ratio.
RESULTS: The combination “unilateral location, severe intensity, aggravation by physical activity” had 100% specificity for migraine. The combination “bilateral location, pressingtightening quality, mild intensity, no aggravation by physical activity” had 100% specificity
for TTH. The combinations: “migrainous location, severe intensity, aggravation by physical
activity”, “severe intensity, nausea”, “pulsating quality, nausea”, “pulsating quality, migrainous location, aggravation by physical activity” seemed to pose the greatest risk for developing migraine. These combinations - “no nausea, no photophobia”, “bilateral location, mild
intensity and either no aggravation by physical activity or pressing-tightening quality, or no
nausea or no photophobia” increased the most the TTH risk. Using these combinations as
additional criteria for overlapping headache we classified 50% of overlapping headache as
TTH and 8.3% as migraine.
CONCLUSIONS: Some combinations of symptoms clarify the diagnosis of migraine and TTH.
More than 50% of overlapping headache could be differentiated as TTH or MWA by the
proposed combinations.
Key words: migraine, tension type headache, overlapping headache, children and adolescents,
combinations of symptoms, ICHD-II
INTRODUCTION
Tension type headache (TTH) and migraine without aura (MWA) are the most frequent primary
types of headache in children and adolescents. The
precise diagnosis of the type of headache is very
important for adequate treatment but is hindered
by the overlap of the symptoms of these two entities.1-3 The overlapping characteristics of MWA
and episodic TTH (ETTH) led to the conclusion
that distinction between these two entities may be
difficult or even impossible.4-6 A number of primary
headaches could be classified as either MWA or
*Correspondence and reprint request to: I. Pacheva, Department of Pediatrics and Medical Genetics, Medical
University, Plovdiv; E-mail: [email protected]; Mob.: +359 887 948 644
15A Vassil Aprilov St., 4002 Plovdiv, Bulgaria
Unauthenticated
Received 11 March 2013; Accepted for publication 11
November 2013
46
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Diagnostic Value of Combinations of Symptoms of Migraine and Tension-Type Headache Included in the Diagnostic Criteria for
Children and Adolescents in the International Classification of Headache Disorders 2nd Edition
TTH, the so called “overlapping headache“.2,7,8 This
stems from the presence of similar items in some
of the diagnostic criteria for migraine and TTH in
children in the ICHD-II. For example, bifrontal
and bitemporal location and moderate intensity in
criterion C and only one of either phonophobia or
photophobia in criterion D are valid for MWA as
well as for ETTH.9,10
In cases with overlapping criteria for both
headache types additional criteria are needed to
determine the correct diagnosis – migraine or TTH.
Aim: To evaluate the diagnostic value of combinations of symptoms included in the International
Headache Society diagnostic criteria for migraine
and TTH in children and adolescents.
To suggest diagnostic combinations of symptoms for migraine and TTH, and to differentiate
overlapping headache (which could be classified as
either probable MWA or probable ETTH) through
evaluation of the diagnostic value of combinations
of characteristics included in the International
Headache Society diagnostic criteria for migraine
and TTH in children and adolescents.
PATIENTS AND METHODS
The present study consisted of two subsets – an
epidemiological survey and a clinical study.
EPIDEMIOLOGICAL SURVEY
The epidemiological study was a school-based study
among 7 to 17 year-old students in the schools
of the Plovdiv region of Bulgaria. Plovdiv is the
second largest city of Bulgaria. Random sampling
was made among the public schools from urban
and rural districts of Plovdiv. A total of 1063 pupils
aged 7-17 years were randomly selected from three
different schools.
An inclusion criterion was at least two episodes
of headache during the last year. Exclusion criteria
were: 1. Headache occurring only during acute
infections; 2. Withdrawal of informed consent.
The study was approved by the Ethics Committee of Plovdiv Medical University and by the
school authorities. Confidentiality was ensured for
all pupils and their parents.
A total of 1029 pupils (96.8% of the selected
pupils) completed the study.
The epidemiological survey was conducted in
four steps.
Step 1: Questionnaire. All selected students
received a specially designed questionnaire from
their teachers or the school nurse / physician. It
contained 21 questions inquiring into all the charFolia Medica 2013; 55(3&4): 46-55
© 2013 Medical University Plovdiv
acteristic features of headache syndromes according
to the ICHD-II diagnostic criteria. It was also used
to collect information about additional factors like
headache frequency, family history, possible triggering factors, associated conditions or diseases,
etc. Students above the age of 10 completed the
questionnaire on their own. The others did it at
home with their parents and then returned it to
their teacher.
Step 2: Clinical interview, physical and neurological examination. Step 2 was performed by
a team of three headache experts headed by a
pediatric neurologist in the month after step 1. The
interview followed the structure of the questionnaire
and gave additional explanation of the questions,
which had been misunderstood. In the case of a
discrepancy between the answers in the questionnaire
and during the interview the latter was accepted
as correct. Physical examination focused on height,
weight, head circumference, rash, pigmentations
and depigmentations; nasal obstruction, palpable
pain over nasal sinuses, auscultation for murmurs
over the neck and temporal bone, heart auscultation, blood pressure. Neurological examination
included evaluation of muscle tone and strength,
reflexes, sensation, coordination, gait, and cranial
nerves examination.
Step 3: Additional consultations and investigations. Ophthalmologic, otorhinolaringologic, EEG,
Doppler sonography, imaging (CT or MRI) studies
and laboratory investigations, such as CBC, electrolytes, hormones, were performed in cases where
secondary headache was suspected.
Step 4: Classification. Each case with a headache
was classified according to the diagnostic criteria
of ICHD-II – 2004.
CLINICAL STUDY
The clinical study included 203 newly diagnosed
patients with chronic or recurrent headache from the
2509 children that were admitted to the Pediatric
Neurology Ward at Plovdiv Medical University
Hospital, or treated as outpatients between 2002 and
2006. The clinical study used the same inclusion
and exclusion criteria as the epidemiological study.
It started from step 2 and progressed to step 4 of
the previously described study design.
After classification of the headache by type,
patients from the epidemiological and clinical studies with identical headache types were analyzed.
The study design is presented in Fig. 1. The
definitions of headache characteristics and the differentiation of clinical characteristics are listed in
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47
I. Pacheva et al
Appendix 1.
According to the existing methodological problem when using the diagnostic criteria for migraine
or TTH (the necessity to cover at least two of
four items in criterion C and also in criterion D)
we evaluated the diagnostic value of all possible
combinations between the items in each criterion.
The value of combinations between the items of
criterion C and D with high OR was also studied.
Combinations in criterion C for migraine were constructed as:
Combinations of two symptoms
migrainous (unilateral / bifrontal / bitemporal) location
pulsating quality
moderate / severe intensity
pain aggravation by daily physical activity
Combinations of three symptoms
migrainous (unilateral / bifrontal / bitemporal ) location
pulsating quality
moderate / severe intensity
pain aggravation by daily physical activity
Combinations of all four symptoms
Combinations in criterion D for migraine were constructed as:
Combinations of two symptoms
nausea
photophobia
vomiting
phonophobia
Combinations of three symptoms
nausea
photophobia
vomiting
phonophobia
Combinations of all four symptoms
Combinations between items of criterion C and criterion D were made similarly.
Similar combinations in the diagnostic criteria for TTH were constructed as well.
Combinations of items with a high OR for migraine and for TTH were used as additional diagnostic criteria
for reclassification of overlapping headache as migraine or TTH.
48
Folia Medica 2013; 55(3&4): 46-55
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Diagnostic Value of Combinations of Symptoms of Migraine and Tension-Type Headache Included in the Diagnostic Criteria for
Children and Adolescents in the International Classification of Headache Disorders 2nd Edition
Figure 1. Study design.
STATISTICAL METHODS
Descriptive statistics, percentage distributions, nonparametric tests, ANOVA and correlation analyses
were used. Different tests of statistical significance
were applied as appropriate: t-test, Fisher exact test,
chi-square, Kolmogorov-Smirnov test and KruskalWallis H test. Statistical analyses were done with the
SPSS software (version 11.5; SPSS, Inc., Chicago,
IL). The diagnostic value of the combinations of
symptoms was measured by sensitivity (Se), specificity (Sp), and odds ratio (OR). The group of migraine
was compared with the remaining headache patients
(TTH and other headache). The group of TTH was
compared correspondingly with the patients with
migraine and other headache.
Folia Medica 2013; 55(3&4): 46-55
© 2013 Medical University Plovdiv
RESULTS
Four hundred and twelve children with chronic or
recurrent headache were found in the epidemiological
study - 132 of them with migraine only, 175 with
TTH only and 89 with other type of headache. Two
hundred and three children with chronic or recurrent
headache were found in the clinical study - 95 of
them with migraine only, 60 with TTH only and 33
with other headache. Forty eight out of 122 patients
with other headache had an overlapping headache.
EVALUATION OF COMBINATIONS OF SYMPTOMS FOR MIGRAINE
The evaluation of different combinations of symptoms for the diagnosis of migraine is presented in
Table 1.
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Table 1. Evaluation of combinations of symptoms for diagnosing migraine by statistical parameters: Se, Sp, ОR
(arranged in descending order by OR)
Combinations of symptoms
Se
Sp
Unilateral location, severe intensity, aggravation by physical activity
Unilateral location, severe intensity, aggravation by physical activity,
pulsating quality
Migrainous location, severe intensity, aggravation by physical activity
0.11
1
0.07
1.00
0.31
0.99
39.71 (14.26-110.58)
Severe intensity and nausea
0.42
0.97
24.93 (12.62-49.25)
Pulsating quality, nausea and vomiting
0.16
0.99
21.67 (6.59-71.29)
Unilateral location, pulsating quality, aggravation by physical activity
0.11
0.99
21.44 (5.03-91.43)
Migrainous location, pulsating quality, aggravation by physical activity
0.31
0.98
20.03 (9.43-42.56)
Pulsating quality and nausea
0.36
0.97
19.69 (9.94-39.00)
Severe intensity and photophobia
0.38
0.97
19.48 (10.16-37.73)
Pulsating quality, photo- and phonophobia
0.31
0.98
19.24 (9.05-40.91)
Aggravation by physical activity and nausea
Pulsating quality, moderate to severe intensity, aggravation by physical
activity
Unilateral location and nausea
0.47
0.96
18.89 (10.75-33.19)
0.39
0.97
18.55 (9.85-34.95)
0.17
0.99
18.39 (6.48-52.16)
Migrainous location, pulsating quality, severe intensity
0.31
0.97
17.75 (8.66-36.38)
Pulsating quality and aggravation by physical activity
0.41
0.96
16.94 (9.34-30.71)
Severe intensity, nausea and vomiting
0.22
0.98
16.48 (6.94-39.14)
Pulsating quality, severe intensity, aggravation by physical activity
0.25
0.98
16.29 (7.28-36.45)
Pulsating quality, photophobia
0.40
0.96
14.98 (8.39-26.76)
Unilateral location, pulsating quality, severe intensity
0.14
0.99
14.12 (4.92-40.50)
Migrainous location, severe intensity, aggravation by physical activity
0.47
0.94
13.94 (8.36-23.23)
Severe intensity, photo- and phonophobia
0.30
0.97
13.59 (7.01-26.36)
Unilateral location, aggravation by physical activity
0.16
0.99
13.36 (5.17-34.54)
Severe intensity, aggravation by physical activity
0.41
0.95
13.29 (7.74-22.84)
Unilateral localization and severe intensity
0.19
0.98
11.70 (5.17-26.49)
Pulsating quality and severe intensity
0.38
0.95
11.51 (6.69-19.81)
Vomiting and phonophobia
0.18
0.98
11.05 (4.87-25.08)
Vomiting and photophobia
0.18
0.98
10.73 (4.72-24.39)
Aggravation by physical activity and photophobia
0.42
0.93
9.97 (6.11-16.27)
Nausea and photophobia
0.36
0.95
9.91 (5.81-16.91)
Migrainous location, pulsating quality, moderate to severe intensity
0.49
0.90
9.02 (5.83-13.97)
Nausea and phonophobia
0.40
0.93
8.73 (5.38-14.16)
Nausea, photo- and phonophobia
0.29
0.96
8.65 (4.86-15.40)
Aggravation by physical activity, photo- and phonophobia
0.34
0.94
8.42 (5.02-14.13)
Unilateral location, pulsating quality, moderate to severe intensity
0.19
0.97
8.35 (4.11-16.95)
Vomiting, photo- and phonophobia
0.14
0.98
8.00 (3.47-18.46)
Nausea, vomiting, photo- and phonophobia
0.13
0.98
7.71 (3.33-17.83)
Unilateral location, photophobia
0.19
0.97
7.36 (3.71-14.59)
Unilateral location, pulsating quality
0.20
0.97
7.30 (3.78-14.11)
Unilateral location, photo- and phonophobia
0.12
0.98
5.99 (2.68-13.39)
Photo- and phonophobia
0.49
0.85
5.57 (3.77-8.23)
50
OR (95% CI)
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Diagnostic Value of Combinations of Symptoms of Migraine and Tension-Type Headache Included in the Diagnostic Criteria for
Children and Adolescents in the International Classification of Headache Disorders 2nd Edition
Table 2. Evaluation of combinations of symptoms for diagnosing TTH by statistical parameters: Se, Sp, ОR
(in descending order according to OR)
Combinations of symptoms
Se
Sp
Bilateral location, mild intensity, pressing-tightening quality, no aggravation by
physical activity
0.11
1.00
No nausea, no photophobia
0.94
0.75
47.72 (26.41-86.21)
0.35
0.99
46.90 (130.24-130.24)
0.37
0.99
40.29 (16.03-101.28)
0.14
0.99
27.74 (116.98-116.98)
0.37
0.98
25.89 (12.24-54.76)
No vomiting, no photophobia
0.93
0.66
24.69 (14.39-42.38)
Non-pulsating quality, mild intensity, no photophobia
0.32
0.98
23.69 (10.68-52.55)
Mild intensity, no aggravation by physical activity, no nausea
0.36
0.97
19.14 (9.67-37.89)
Non-pulsating quality, mild or moderate intensity, no photophobia
0.68
0.90
18.84 (12.13-29.27)
Non-pulsating quality, mild intensity, no nausea
0.32
0.97
18.32 (8.95-37.49)
Mild intensity, no aggravation by physical activity, no photophobia
0.37
0.97
18.00 (9.34-34.70)
Mild or moderate intensity, no aggravation by physical activity, no photophobia
0.72
0.87
17.96 (11.76-27.43)
Bilateral location, pressing-tightening quality, mild or moderate intensity,
no aggravation by physical activity
0.26
0.98
17.00 (37.96-37.96)
Bilateral location, mild intensity
0.41
0.96
15.89 (8.91-28.33)
Mild intensity, no aggravation by physical activity
0.37
0.96
15.70 (29.01-29.01)
Non-pulsating quality, mild or moderate intensity, no nausea
0.70
0.87
15.47 (10.20-23.46)
no aggravation by physical activity
Bilateral location, + mild no nausea
intensity
pressing-tightening quality
no photophobia
OR (95%CI)
Non-pulsating quality, mild or moderate intensity, no aggravation by physical activity
0.63
0.90
15.03 (9.73-23.21)
Mild or moderate intensity, no aggravation by physical activity, no nausea
0.74
0.84
14.56 (9.71-21.83)
Bilateral location, mild or moderate intensity, no aggravation by physical activity
0.71
0.85
13.97 (20.98-20.98)
Pressing-tightening quality, mild intensity
0.14
0.99
13.79 (4.81-39.56)
Non-pulsating quality, mild intensity
0.34
0.96
13.28 (7.17-24.61)
Mild or moderate intensity, no aggravation by physical activity
0.78
0.77
12.05 (17.91-17.91)
Non-pulsating quality, no aggravation by physical activity
0.72
0.82
11.85 (7.99-17.57)
Non-pulsating quality, mild or moderate intensity
0.73
0.80
10.69 (7.26-15.76)
Bilateral location, pressing-tightening quality, no aggravation by physical activity
0.29
0.96
10.46 (19.49-19.49)
Bilateral location, mild or moderate intensity
0.86
0.64
10.31 (6.75-15.74)
No nausea, no vomiting, no photophobia, no phonophobia
0.61
0.87
10.15 (15.20-15.20)
Bilateral location, pressing-tightening quality, mild or moderate intensity
0.31
0.95
9.33 (16.55-16.55)
Pressing-tightening quality, mild or moderate intensity, no aggravation by physical activity
0.26
0.96
9.20 (4.92-17.20)
No nausea, no photophobia, no phonophobia
0.62
0.85
9.15 (6.18-13.55)
No vomiting, no photophobia, no phonophobia
0.64
0.82
7.85 (5.37-11.46)
Pressing-tightening quality, no aggravation by physical activity
0.29
0.95
7.18 (12.34-12.34)
No nausea, no phonophobia
0.64
0.80
6.91 (4.77-10.02)
Pressing-tightening quality, mild or moderate intensity
0.32
0.93
6.45 (3.92-10.59)
No vomiting, no phonophobia
0.66
0.73
5.36 (3.74-7.67)
No photophobia, no phonophobia
0.65
0.73
5.16 (3.61-7.38)
Pressing-tightening, bilateral location
0.34
0.89
4.09 (6.28-6,28)
Bilateral location, no aggravation by physical activity
0.56
0.72
3.25 (4.46-4,46)
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I. Pacheva et al
The combination “unilateral location, severe
intensity, pain aggravation by physical activity with
or without pulsating quality” had 100% specificity.
The combinations: “migrainous location, severe
intensity, pain aggravation by physical activity”,
“severe intensity, nausea”, “pulsating quality, nausea
with or without vomiting”, “migrainous location,
pulsating quality, pain aggravation by physical
activity” increased the most the risk of migraine.
EVALUATION OF COMBINATIONS OF SYMPTOMS FOR TTH
The evaluation of different combinations of symptoms for TTH is presented in Table 2.
The combination “bilateral location, pressingtightening quality, mild intensity, no aggravation by
physical activity” had 100% specificity. The combinations: “no nausea, no photophobia”, “bilateral
location and mild intensity, combined with one of
the following: no aggravation by physical activity
or tightening - pressing quality or no nausea or
no photophobia” made the risk for TTH increase
the most.
RECLASSIFICATION OF OVERLAPPING HEADACHE BY PROPOSED
ADDITIONAL DIAGNOSTIC CRITERIA
The combinations that made the risk of developing
migraine and TTH increase the most (with high
OR) were used as additional criteria to differenti-
Figure 2. Differentiation of the overlapping headache
by our recommended additional criteria.
ate the group of overlapping headache. Thus 50%
of these children were classified as TTH and 8.3%
as MWA (Fig. 2).
DISCUSSION
The overlap in criteria C and D for MWA and ETTH
is under constant discussion.4,8,11 Several solutions
have been suggested to improve the differentiation
of migraine and TTH. Rasmussen et al. recommended the item intensity to be a separate criterion
52
and associated symptoms to be evaluated according to their severity.4 Messinger et al. suggested
all items of the diagnostic criteria to be separate
criteria.8 Zebenholzer et al. found 80% of overlap
between the diagnoses probable migraine and probable TTH, using diagnostic criteria of the ICHD-I.
Their findings were confirmed by other authors.2,3,8,9
The problem with overlapping headache is more
prominent for children and adolescents because of
some accepted revisions in the criteria for migraine
in ICHD-II.10 The revisions include shorter duration
of migraine attack in children - 1 hour (instead of
4 hours for adults); either unilateral or bifrontal
or bitemporal location (instead of only unilateral
location for adults); photo- or phonophobia (instead
of photo- and phonophobia for adults). Therefore,
more items in the diagnostic criteria overlapped for
migraine and TTH.
We did not find authors that evaluated and
compared the significance of different combinations
of symptoms included in the diagnostic criteria of
ICHD-II for migraine or TTH. Accordingly, the
combinations of symptoms have not been used
in the diagnostic differentiation of both headache
types up to now.
According to our results, the combinations of
items in criterion D (associated symptoms) for
migraine were less significant for increasing the
migraine risk than the combinations of symptoms
in criterion С (pain characteristics).
The combination “unilateral location, severe
intensity, pain aggravation by physical activity with
or without pulsating pain” which had 100% specificity for migraine made the diagnosis of migraine
certain. That is why our suggestion is to diagnose
migraine whenever this combination of symptoms
occurs, independently of the other headache characteristics. According to the literature unilateral
location and severe intensity are the symptoms
with high specificity for migraine.11-13 This fact
could explain their existence in the combination,
which made the diagnosis of migraine certain.
The diagnostic role of the other symptom in this
combination - pain aggravation by physical activity
is controversial.6,14-16 However, there are authors
who consider it as an important differential factor
between migraine and TTH in children.12,15,16
The combinations: “migrainous location, severe
intensity, pain aggravation by physical activity”,
“severe intensity, nausea”, “pulsating quality, nausea” and “migrainous location, pulsating quality,
pain aggravation by physical activity” increased the
most the migraine risk and could be recommended
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Diagnostic Value of Combinations of Symptoms of Migraine and Tension-Type Headache Included in the Diagnostic Criteria for
Children and Adolescents in the International Classification of Headache Disorders 2nd Edition
as additional criteria for differentiating overlapping
headache when criteria for both headache types
(MWA and ETTH) are covered.
Most of these combinations included the pain
characteristics. Of all associated symptoms, only
nausea was included in combinations that significantly increased migraine risk. These results did
not confirm the reports of some authors that differentiating the headache should be based mainly
on the associated symptoms but not on the characteristics of headache different from intensity.6,17
Unlike combinations in criterion C, the combinations in criterion D increased migraine risk
much less (maximum 9-fold). These combinations
included symptoms nausea or vomiting. Nausea was
reported to be a symptom with good sensitivity and
specificity by other authors and they considered
it as an important differential diagnostic feature
between migraine and TTH.11,12 “Photophobia and
phonophobia” increased the risk only 5 1/2-fold.
Therefore the new content of this item in ICHD - II
- photophobia and/or phonophobia is more reliable.
The second combination “severe intensity and
nausea” confirmed the Wober - Bingol et al.‘s suggestion to diagnose migraine when severe headache
and nausea presented independently of the other
symptoms.11
The analysis of the different combinations of the
items included in the diagnostic criteria C and D
for TTH showed that the combination in criterion С
“bilateral location, pressing-tightening quality, mild
intensity, no pain aggravation by physical activity”
had 100% specificity and made the diagnosis TTH
certain. That is why we could recommend this
combination of symptoms as diagnostic for TTH,
independently of the other headache characteristics.
Mild intensity and pressing-tightening quality are
symptoms with high specificity for TTH.12,15,18,19
Gallai et al. considered that the symptom mild to
moderate intensity should be an obligatory criterion for TTH, while moderate to severe intensity
– obligatory for migraine.19 The item no pain
aggravation by routine physical activity had high
sensitivity and high specificity for TTH according
to most of the existing data in the literature.1,11,12,16
Similarly to migraine, the combination for certain diagnosis of TTH was a combination of pain
characteristics, not of associated symptoms. Among
the items considering associated symptoms the
combination “no nausea, no photophobia“ increased
at highest extent TTH risk. The next combinations
which increased the most (at least 25-fold) the TTH
risk were “bilateral location and mild intensity,
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combined with one of the following: no aggravation
by physical activity or pressing-tightening quality
or no nausea or no photophobia”. They could
be recommended as additional diagnostic criteria
for TTH used to differentiate it from overlapping
headache.
The combinations which included the lack of
phonophobia had less significance as risk items
for TTH, in comparison with combinations that
included the lack of other associated symptoms
such as photophobia, nausea and vomiting. Ozge
et al. also found phonophobia as the most common
of the associated symptoms in TTH in children.18
Applying our recommended combinations for
differentiation of overlapping headache more than
50% of this headache group could be differentiated
as TTH or MWA, as most of it was classified as
TTH. Therefore the recommended combinations of
symptoms will lead to substantial reduction of the
percentage of overlapping headache.
CONCLUSIONS
Some combinations of symptoms make diagnosis
of migraine certain (“unilateral location, severe
intensity, pain aggravation by physical activity“),
other combinations make the TTH diagnosis certain
(“bilateral location, pressing-tightening quality, mild
intensity, no aggravation by physical activity”).
Most of the overlapping headache could be
differentiated as ETTH or MWA by applying our
recommended combinations: “migrainous location,
severe intensity, aggravation by physical activity”,
“severe intensity, nausea”, “pulsating quality, nausea”, “migrainous location, pulsating quality, pain
aggravation by physical activity” for migraine and
“no nausea, no photophobia”, “bilateral location,
mild intensity and either no aggravation by physical activity or pressing-tightening quality or no
nausea or no photophobia” for TTH.
APPENDIX 1
Definition and categorization of headache characteristics:
Localization of headache was differentiated as
unilateral, bifrontal, bitemporal, diffuse, occipital,
and other.
“Migrainous location” included unilateral, bifrontal or bitemporal location.
Pain intensity was defined as mild, moderate,
severe and different.
The quality of pain was differentiated as pulsating, pressing-tightening, stabbing, undetermined,
and different. Non pulsating quality included all
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I. Pacheva et al
qualities different from pulsating.
The aggravation of pain by daily physical activity was coded as “yes”, “no” or “sometimes”.
“Yes” and “sometimes” were summarized as a
positive answer.
Associated symptoms such as nausea, vomiting,
photophobia, phonophobia, vertigo/light-headedness
were coded separately as “yes”, “no” or “sometimes”. “Yes” and “sometimes” were summarized
as a positive answer.
Positive first or second line family history of
migraine was noted as “yes” or “no”.
REFERENCES
1. Turkdogan D, Cagirici S, Soylemez D, et al. Characteristic and overlapping features of migraine and
tension-type headache. Headache 2006;46:461-8.
2. Karli N, Akgoz S, Zarifoglu M, , et al. Clinical characteristics of tension type headache and migraine
in adolescents: a student based study. Headache
2006;46:399-412.
3. Anttila P, Metsahonkala L, Aromaa M, et al. Determinants of tension type headache in children.
Cephalalgia 2002;22:401-9.
4. Rasmussen B, Jensen J, Olesen J. A population-based
analysis of the diagnostic criteria of the International
Headache Society. Cephalalgia 1991;11:129-34.
5. Hockaday JM. Headache in children. British Journal
of Hospital medicine. 1982;27:383-90.
6. Rossi L, Cortinovis I, Menegazzo L, et al. Classification criteria and distinction between migraine and
tension type headache in children. Dev Med Child
Neurol 2001;43:45-51.
7. Zebenholzer K, Wober C, Kienbacher C, WoberBingol C. Migrainous disorder and headache of the
tension type not fulfilling the criteria: a follow-up
study in children and adolescents. Cephalalgia
2000;20:611-6.
8. Messinger H, Spierings E, Vincent A. Overlap of
migraine and tension-type headache in the International Headache Society classification. Cephalalgia
1991;11:233-7.
9. Headache Classification Committee of the International Headache Society. Classification and diagnos-
54
tic criteria for headache disorders, cranial neuralgias
and facial pain. Cephalalgia 1988;8s7:1-96.
10. Headache classification Subcommittee of International Headache Society, The international Classification of Headache disorders-second edition.
Cephalalgia 2004;24(s1):1-160.
11. Wober-Bingol С, Wober C, Wagner-Ennsgraber C,
et al. IHS criteria for migraine and tension-type
headache in children and adolescents. Headache
1996;36:231-8.
12. Pacheva I, Milanov I, Ivanov I, Stefanov R. Evaluation of diagnostic and prognostic value of clinical
characteristics of migraine and tension type headache included in the diagnostic criteria for children
and adolescents in international classification of
headache disorders – second edition. Int J Clin Pract
2012;66(12):1168-77.
13. Pajaron E, Lainez J, Monzon M, et al. The validity of the classification criteria of the International
Headache Society for migraine, episodic tension
headache and chronic tension headache. Neurologia
1999;14:283-8.
14. Seshia S, Wolstein J. International Headache Society
classification and diagnostic criteria in children:
a proposal for revision. Dev Med Child Neurol
1995;37:879-82.
15. Smetana G. The diagnostic value of historical features in primary headache syndromes: a comprehensive review. Arch Intern Med 2000;160:2729-37.
16. Kroner-Herwig B, Heinrich M, Morris L. Headache in German children and adolescents: a population-based epidemiological study. Cephalalgia
2007;27:519-27.
17. Viswanathan V, Bridges S, Whitehouse W, Newton R.
Childhood headache: discrete entities or continuum?
Dev Med Child Neurol 1998;40:544-50.
18. Ozge A, Bugdayci R, Sasmaz T, et al. The sensitivity and specificity of the case definition criteria of
headache: a school-based epidemiological study of
5562 children in Mersin. Cephalalgia 2002;22:791-8.
19. Gallai V, Sarchielli P, Carboni F, et al. Applicability
of the 1988 IHS criteria to headache patients under
the age of 18 years attending 21 Italian headache
clinics. Headache 1995;35:146-53.
Folia Medica 2013; 55(3&4): 46-55
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Diagnostic Value of Combinations of Symptoms of Migraine and Tension-Type Headache Included in the Diagnostic Criteria for
Children and Adolescents in the International Classification of Headache Disorders 2nd Edition
ДИАГНОСТИЧЕСКАЯ СТОИМОСТЬ КОМБИНАЦИЙ СИМПТОМОВ, ВКЛЮЧЕННЫХ
В ДИАГНОСТИЧЕСКИЕ КРИТЕРИИ МЕЖДУНАРОДНОЙ КЛАССИФИКАЦИИ ГОЛОВНОЙ БОЛИ - 2004 Г. ПО ВОПРОСАМ
МИГРЕНИ И ТЕНЗИОННОГО ТИПА ГОЛОВНОЙ БОЛИ В ДЕТСКОМ И В ЮНОШЕСКОМ ВОЗРАСТЕ
И. Пачева, И. Миланов, И. Иванов, Р. Стефанов
РЕЗЮМЕ
ЦЕЛЬ: Работа ставит себе целью предложить диагностические комбинации симптомов по вопросам
мигрени, тензионного типа головной боли /ТТГБ/ и
дифференциации припокрывающей головной боли, сопоставляя диагностическую стоимость комбинаций
и характеристики, включенные в диагностические
критерии мигрени и ТТГБ в детском возрасте.
ПАЦИЕНТЫ И МЕТОДЫ: Исследование включает
эпидемиологическую головную боль - 412 пациентов
с хронической/рецидивирующей головной болью среди
1029 учеников в возрасте 7 – 17 лет - и клиническую
головную боль - 203 пациента с хронической/рецидивирующей головной болью. Все пациенты лечились
в детском неврологическом стационаре и амбулатории УМБАЛ им. „Святого Георгия”. Критерий
включения – минимум два приступа головной боли
за последний год; критерий выключения – приступы
головной боли проявляются только во время острой
инфекции или из-за нежелания пополнения анкеты.
Головная боль типизирована по Международной
классификации головной боли II с использованием
анкетного метода, клинического интервью, соматического и неврологического статусов, а также
и дополнительных исследований. Диагностическая
Folia Medica 2013; 55(3&4): 46-55
© 2013 Medical University Plovdiv
стоимость всех комбинаций симптомов /критерии
С и D мигрени и соответственно ТТГБ/ оценена с
помощью чувствительности, специфичности и ОR.
Р ЕЗУЛЬТАТЫ : Комбинация „односторонняя
локализация, сильный интенситет и усиление
боли от физической активности” показывает
100-процентную специфичность наличия мигрени, соответственно „двусторонняя локализация,
небольшой интенситет, сжимающий характер,
неусиление боли от физической активности”
говорит о ТТГБ. Комбинации „сильный интенситет, локализация мигрени, усиление боли
от физической активности”, „сильный интенситет, тошнота”, „пульсирующий характер,
тошнота”, „пульсирующий характер, локализация мигрени, усиление боли от физической актиности” в самой высокой степени увеличивают
риск мигрени, соответственно „отсутствие
тошноты и фотофобии”, „двусторонняя локализация, небольшой интенситет и каждый
из следующих показателей: неусиление боли от
физической активности, сжимающий характер,
отсутствие тошноты, отсутствие фотофобии” увеличивают риск ТТГБ. Применяя эти
комбинации дифференциации припокрывающей
головной боли в 50% случаев речь идет о ТТГБ,
а в 8.3% - о мигрени.
ЗАКЛЮЧЕНИЕ: Использование существующих
комбинаций приводит к тому, что делает
диагнозы „мигрень и ТТГБ” достоверными.
Свыше 50% припокрывающей головной боли
можно классифицировать как ТТГБ или как
мигрень благодаря предложенным авторами
дифференцирующим комбинациям.
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