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Abstract
We prospectively assessed inter-observer agreement in the diagnosis of recurrent headaches in children. Clinical letters containing information on 40 children with headaches (age 4.3 to 17.8 years, median 10.4 years) were given to four Pediatric Neurologists. One or more headache types could be checked off on a data sheet that listed the main types recognized by the International Headache Society and an additional one, "combined migraine and tension-type headache".
There were six combinational pairs of neurologists. The six pairs yielded 240 sets of diagnoses. Percentage agreement ranged from 45% to 78%, Kappa values from 0.20 to 0.59, and weighted Kappa from 0.19 to 0.52 within the six pairs. Agreement was 76% when both neurologists in a pair assigned single headache types and 4% when one or both neurologists diagnosed multiple types.
The International Headache Society suggests that patients may have multiple types of headache and recommends that all types be classified. We suggest that the option of diagnosing more than one headache type from data in clinical letters may reduce inter-observer agreement.
Key words: Childhood headache, classification, inter-observer agreement.
Abstract
Roentgenographic studies were carried out on 372 patients with tension-type headache and 225 normal control subjects to determine relationships between straightened cervical spines, low-set shoulders, and cervical spine instability. A great majority of the patients with tension-type headache were found also to have straightened cervical spine. Patients with tension-type headache may have a restricted progression of the cervical spinal lordosis, which results in a straightened cervical spine. The flexor muscles of the head and neck prevent physiological lordosis of the cervical spine, and their sustained chronic contraction may be a principal cause of a straightened neck. The low-set shoulder was frequently seen in patients with tension-type headache, and it ma result in traction of the brachial plexus, which gives rise to pain in the neck and shoulders. Cervical spine instability, on the other hand, was rather infrequent in patients with tension-type headache. Its relationship to tension-type headache is unclear and warrants further study. Our results suggest that both a straightened cervical spine and low-set shoulders may play an important role in the pathogenesis of tension-type headache and its accessory symptoms.
Key words: Headache; Roentgenography; Cervical Spine; Straight neck; Low-set shoulder.
Abstract
Current classification systems for diagnosing headaches utilize sets of specific criteria. To determine the usefulness of these criteria in the practical application of diagnosing headache patients, 698 headache specialists were asked to review four case vignettes of headache patients and assign a diagnosis. They also ranked International Headache Society (IHS) criteria along with other features commonly used in the diagnosis of headaches in order of importance. There was no difference in ranked importance for the specific criteria posed by the IHS compared with commonly used criteria not included within the IHS system. A large majority of the respondents combined IHS features with other associated features not used in the IHS system as the basis of diagnostic assignment. These results raise a question about the acceptance and utilization of the IHS system as a basis for diagnoses. They also suggest that there is a need to educate health care providers about the appropriate use of the current IHS criteria to increase reliability of headache diagnosis.
Key words: migraine, tension-type, IHS criteria, diagnosis.
Abstract
Objective: Comparison of clinical headache diagnoses in primary care to algorithm diagnoses from a standardized headache interview.
Design: A sample of consecutive primary care headache patients (n=779) at the Group Health Cooperative of Puget Sound were interviewed and medical records abstracted.
Measurements: The medical record provided 'chart' diagnoses while a structured interview and diagnostic algorithm yielded the 'algorithm diagnosis'. The patients were also administered the depression sub-scale from the SCL 90-R, in addition to answering questions about pain intensity and disability used to grade the severity of chronic pain.
Results: Among persons diagnosed by the primary care physician as having migraine, 78% received an algorithm diagnosis of migraine. However, study patients were more likely to receive a diagnosis of migraine by algorithm (57%) than by clinical diagnosis (33%). While clinicians infrequently recorded a diagnosis of migraine and tension-type headache in the same patients, tension-type headache was identified among half of the algorithm diagnosed migraineurs. Among patients with algorithm-diagnosed migraine, female gender, increased disability, and the presence of aura increased the likelihood that the clinician would also diagnose migraine. Conversely, the presence of tension-type headache features, high levels of depression, high number of headache days and age over 65 years reduced the likelihood of the clinician diagnosing migraine among algorithm-diagnosed cases.
Conclusions: The co-occurrence of migraine and tension-type headache symptoms are commonly reported by patients, however, primary care physicians usually recorded a single diagnosis of either migraine or tension headache. Among patients reporting migrainous features, the presence of chronic headache, emotional distress and the absence of disability reduced the likelihood that the clinician would assign a diagnosis of migraine. These results suggest the need for diagnostic and management strategies appropriate for patients whose headaches combine tension-type and migrainous features.
Key words: algorithm-diagnosis, migraine, tension-type headache, primary care.
Abstract
The International Headache Society (IHS) headache classification, while a major advance, does not adequately classify the daily and near-daily headache disorders known as chronic daily headache (CDH). We believe that chronic daily headache is a group of disorders which includes chronic tension-type headache (CTTH), transformed migraine (TM), new daily persistent headache (NDPH), and hemicrania continue (HC). We propose specific criteria for transformed migraine, new daily persistent headache, and hemicrania continua, and have modified the criteria for chronic tension-type headache.
Key words: chronic daily headache, transformed migraine, hemicrania continua, tension-type Headache.