• 
• 

Three Part Question

In [children who present to the emergency department] is the [international classification of headache disorders] useful in the [diagnosis of migraine].

Clinical Scenario

A 9 year old child comes to the emergency department accompanied by her mother. The child complains of a bilateral severe throbbing headache which started an hour ago but is still present. She has also vomited once. She complains that noise makes the headache worse. She has had this headache once before last week but did not attend the emergency department as it was relieved after sleeping. After taking the history and clinical examination your clinical impression is migraine. You wonder whether the ICHD is useful to support your diagnosis.

Search Strategy

Medline 1950-June 2007 using Ovid Interface
Embase 1980 to 2007 Week 23 using Ovid Interface
[(exp headache OR exp migraine disorders OR exp migraine OR exp migraine without aura OR exp migraine with aura OR exp migraine aura ) AND (exp international classification of headache disorders Or international classification of headache disorders.mp. OR ICHD.mp. OR disease classification.mp. ) AND (diagnosis.mp.) AND (LIMIT to children AND english)]

Search Outcome

4 papers were identified on Medline of which 1was relevant and 10 papers were identified on Embase of which 4 were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
C Kienbacher et al, 2006 Austria	Average age of 140 patients with migraine was 17.6 years.	Long term follow up	Diagnosis of definite migraine	Higher in ICHD II than ICHD I at baseline and at follow up.	Drop out rate was 44.5%. Study was done in a headache center therefore does not allow conclusions to be made about children and adolescents with migraine from the general population
Chan TY, Wong V 2006, China	124 chineese children <18 years of age	Retrospective medical review and follow up over 3 years.	Sensitivity and specificity of ICHD II in the diagnosis of migraine without aura	Sensitivity 23.1%, Specificity 93.4%	Study was retrospective. Clinicians diagnosed headache on clinical features and may not have used ICHD I/II.
Andrew D. Hershey et al 2005 Cincinnati OH	260 patients aged 18 and under diagnosed with migraine	Questionnaire	% of patients who met criteria for migraine	70.4% according to ICHD I (if headache duration was 4-72 hours). 71.9% according to ICHD II (if headache duration was 2-72 hours). 73.9% according to ICHD II (if headache duration was 1-72 hours).	Pain was rated as mild/moderate/severe. This criteria is vague and lacks validity. A 0-10 scale should have been used as it has been validated and has a high reliability.
			Sensitivity	ICHD II 84.4%
			Headache location	Unilateral (ICHD I) 27.7%. Bilateral (ICHD II) 82.7%.
			Associated symptoms	88.1% of patients according to ICHD II.
Nesrin Senbil et al, 2006 Turkey	132 children, but 61 children with migraine without aura. Average age was 10.8 years old.	Prospective study.	Migraine without aura	Sensitivity of ICHD I 36.1%, Specificity of ICHD I 93.5%, Sensitivity of ICHD II 78.7%, Specificity of ICHD II 90.3%	Sample size was small. All subjects were not accounted for.
			High sensitive and specific factors for migraine without aura	Lying in dark and quiet room. Not included in ICHD I or ICHD II.
			Number of cases of true positives.	ICHD I 22, ICHD II 48
			Number of cases of true negatives.	ICHD I 29, ICHD II 28
			Number of cases of false positives.	ICHD I 2, ICHD II 3
			Number of cases of false negatives.	ICHD I 39, ICHD II 13
MMF Lima et al, 2005 Brazil	496 children aged 2-15 years.	Retrospective study from 1992-2002	Sensitivity of ICHD I	Migraine with aura 27%. Migraine without aura 21%.	The study was based on patients who were referred to a headache clinic with chronic or recurrent headaches. The description of the duration of the aura in children is unclear.
			Sensitivity of ICHD II	Migraine with aura 71%. Migraine without aura 53%.
			Specificity of ICHD I	Migraine with aura 100%. Migraine without aura 100%.
			Specificity of ICHD II	Migraine with aura 99%. Migraine without aura 100%.
			% diagnosed as migraine with aura	5.2 % according to ICHD I. 14.5% according to ICHD II
			% diagnosed as migraine without aura	11% according to ICHD I. 28% according to ICHD II.
			All criteria of migraine met except one	Migrainous disorder ICHD I 57%. Probable migraine ICHD II 30%.
			Positive predictive value of migraine without aura.	ICHD I 100%. ICHD II 100%.
			Positive predictive value of migraine with aura.	ICHD I 100%. ICHD II 99%.
			Negative predictive value of migraine without aura.	ICHD I 53%. ICHD II 66%
			Negative predictive value of migraine with aura.	ICHD I 85%. ICHD II 93%.

Comment(s)

In one of the studies the drop out rate was high, and the study population was less than 100 patients.

Clinical Bottom Line

From the studies it can be seen that ICHD II is superior over ICHD I in diagnosing migraines in children. Sensitivity of ICHD II in diagnosing migraine without aura varied from 23.1% to 78.7%. Wide variations are also seen in ICHD I. This maybe because of the numbers of children used in the studies. ICHD II has a higher sensitivity in the diagnosis of migraine with/without migraine compared to ICHD I. Specificity of ICHD I and II is both high. From these results it is implicated that ICHD II should be used for diagnosing pediatric migraines.

References

1. C Kienbacher, C Wöber, HE Zesch, A Hafferl-Gattermayer, M Posch, A Karwautz, A Zormann, G Berger, K Zebenholzer, A Konrad, Ç Wöber-Bingöl. Clinical features, classification and prognosis of migraine and tension-type headache in children and adolescents: a long-term follow-up study. Cephalalgia 820-830, 2006 July
2. Chan TY, Wong V. Recurrent headache in Chinese children: Any agreement between clinician diagnosis and symptom-based diagnoses using the international classification of headache disorders (second edition)? Child neurology 132-138, 2006.
3. Andrew D. Hershey, Paul Winner DO, Marielle A. Kabbouche, Jack Gladstein , Marcy Yonker, Don Lewis, Eric Pearlman, Steven L. Linder, A. David Rothner MD, Scott W. Powers. Use of the ICHD-II Criteria in the Diagnosis of Pediatric Migraine. Headache 1288-1297, 2005 November.
4. Nesrin Senbil, Yahya Kemal Yavuz Gürer, Ömer Faruk Aydýn, Bengü Rezaki, Levent Ýnan Diagnostic criteria of pediatric migraine without aura. Turkish journal of pediatrics 31-37, 2006.
5. MMF Lima, NAMR Padula, LCA Santos, LDB Oliveira, S Agapejev, C Padovani. Critical analysis of the international classification of headache disorders diagnostic criteria (ICHD I-1988) and (ICHD II-2004), for migraine in children and adolescents Cephalalgia 1042-1047, 2005 November