1. Field testing ICHD classifications
Jes Olesen, professor of neurology
Danish Headache Center, dept of neurology
Rigshospitalet Glostrup
Denmark
Conflicts of interest: None

2. Improving criteria for a primary headache
1.2 Migraine with aura
1.2 and A 1.2

3. 1.2 Migraine with aura
2716 patients with 1.2 MA, MTA, FHM, SHM and basilar-type migraine according to ICHD-2 were prospectively collected in a cross sectional study design

4. Results – Criteria for 1.2 MA
All patients fulfilled the criteria for 1.2 MA in ICHD-3 beta. The new ICHD-3 beta criteria for 1.2 MA were thus 100% sensitive.
The specificity for 1.2 MA in ICHD-3 beta compared to patients diagnosed with 1.1 MO was 89,3%.

5. Main body- and appendix criteria for MA. Differentiation from TIA
TIA in anterior circulation 88%
TIA in posterior circulation 12%
Recurrent TIA 6%
Duration of TIA:
42 patients (35%) less than 60 minutes
18 patients (15%) from 1 hour to 3 hours
60 patients (50 %) from 3 hours to 24 hours

6. Specificity for migraine with aura criteria
1.2 Migraine with aura main body specificity 0.73 A1.2 Migraine with aura alternative criteria specificity Migraine with typical aura main body specificity 0.88 A1.2.1 Migraine with typical aura alternative criteria specificity 1.0

7. Developing criteria for a new kind of primary headache
4.8 Nummular headache

8. Pareja JA, Caminero AB, Serra J, Barriga FJ, Dobato JL, Barón M, Vela L, Sánchez del Río M. Numular headache: a coin-shaped cephalgia. Neurology 2002; 58:
Guerrero AL, Cortijo E, Herrero-Velázquez S, Mulero P, Miranda S, Peñas ML, Pedraza MI, Fernández R. Nummular headache with and without exacerbations: comparative characteristics in a series of 72 patients. Cephalalgia 2012; 32:

9. Nummular headache
A. Continuous or intermittent head pain fulfilling criterion B
B. Felt exclusively in an area of the scalp, with all of the following four characteristics:
1.sharply-contoured
2.fixed in size and shape
3.round or elliptical
4.1-6 cm in diameter
C. Not better accounted for by another ICHD-3 diagnosis1.

10. Further testing desireable
How well do the criteria perform tested against a migraine material, a TTH material etc. (specificity)
In a mixed material of patients with localized headache, should the criteria be tightened or loosened?
Is pain after minor localized trauma excluded or not?

11. Improving criteria for a secondary headache
6.1.2 Headache attributed to TIA
7.1.1 Headache attributed to Idiopathic Intracranial Hypertension

12. Headache Attributed to TIA according to ICHD-3
Any new headache fulfilling criterion C
Transient ischemic attack (TIA) has been diagnosed
Evidence of causation demonstrated by both of the following:
Headache has developed simultaneously with other symptoms and/or clinical signs of TIA
Headache resolves within 24 hours
D. Not better accounted for by another ICHD-3 diagnosis

13. Test of criteria in 120 patients with TIA
Extensive physician conducted validated semistructured interviews
Characterisation of the TIA
Characterisation of previous headache disorders
Characterisation of headache occurring around the time of TIA
A new type of headache
A previous type with altered characteristics
A previous type unaltered
Many occurred hours after TIA and several lasted longer than 24 hours
Lebedeva E.R. et al in preparation

14. Proposed diagnostic criteria for Headache Attributed to TIA
Headache fulfilling criterion C
Transient ischemic attack (TIA) has been diagnosed
Evidence of causation demonstrated by one of the following:
Any type of headache occurring within one hour of TIA onset
Any new type of headache occurring within 24 hours of TIA onset
D. Not better accounted for by another ICHD-3 diagnosis
Lebedeva E.R. et al in preparation

15. Yri HM and Jensen RH: Cephalalgia 2015; 35: 553-562
Patient material

16. Distinguishing clinical features

18. Developing criteria for a new kind of secondary headache
Headache attributed to airoplane travel
A 6.10 Persistent headache attributed to arterial dissection

19. Clinical picture of Aeroplane Headache
Median age at diagnosis is 28.7 ± 4.8 years
148 males and 127 females
Onset: Exclusively during take-off or landing – mainly during landing
Duration: AH:10-30 min.
Severity: very severe with a rating of 8-10/10
Quality: stabbing, jabbing or pulsating in the fronto-orbital region.
Berlingen et al 2006, 2011, Mainardi et al 2012

20. Mainardi et al 2012

21. Headache attributed to aerplane travel
A. At least two episodes of headache fulfilling criterion C
B. The patient is travelling by aeroplane
C. Evidence of causation demonstrated by at least two of the following:
1.headache has developed during the aeroplane flight
2.either or both of the following:
a)headache has worsened in temporal relation to ascent following take-off and/or descent prior to landing of the aeroplane
b)headache has spontaneously improved within 30 minutes after the ascent or descent of the aeroplane is completed
3.headache is severe, with at least two of the following three characteristics:
a)unilateral location1
b)orbitofrontal location2
c)jabbing or stabbing quality3
D.Not better accounted for by another ICHD-3 diagnosis4.

22. ICHD-II at time of dissection
A6.10 Persistent headache attributed to past cranial or cervical vascular disorder
ICHD-II at time of dissection
17/19 patients were classified as having: 
6.5.1 Headache or facial or neck pain attributed to cervical carotid or vertebral or intracranial artery dissection 
2/19 patients were classified as having:
usual primary headache triggered by dissection.
ICHD-III six months after dissection
5/17 patients were classified as having:
A6.10 Persistent headache attributed to past cranial or cervical vascular disorder (appendix criteria)
Table of dissection, headache characteristics and headache classification of 19 patients with cervical carotid or vertebral artery dissection.
Schytz et al. Cephalalgia 2014

23. Improving criteria for a cranial neuralgia
Classical trigeminal neuralgia

25. Field-testing of diagnostic criteria in classical trigeminal neuralgia
 Sensitivity
 Specificity
ICHD 2
76.2%
89.2%
ICHD 3 beta
74.3%
97.3%
Author´s first proposed criteria caused large decrease in specificity*
76.7%
64.9%
Authors final proposed criteria
96.1%
83.8%
Firstly, we evaluated the sensitivity and specificity of ICHD-3 beta when the monothetic criterion B that excludes pain radiating outside the trigeminal distribution was removed. This caused a small insignificant increase in sensitivity to 76.7% (p = compared to ICHD-3 beta) but the specificity dropped from 97.3% (ICHD-3 beta) to 64.9% (p = 0.002). We considered this modification unfavorable due to decreased specificity and no yield in sensitivity.
Maarbjerg et al 2015

26. Conclusions
ICHD-3 emminently suited for field testing of diagnostic criteria
Good case series with prospective systematic recording of symptoms and sometimes laboratory investigations are necessary
Claims based on studies labelled field testing are not necessarily correct. It has to be done right
Many changes have already been based on good field testing
There is much more to do, particularly for the secondary headaches

27. Classical trigeminal neuralgia, proposed criteria

28. Why field testing? ICHD classifications more and more evidence based
ICHD classifications have explicit (operational) diagnostic criteria
They are suited for field testing and modification
ICHD-3beta to ICHD-3 entirely based on field testing studies
All future changes to headache classification should be based exclusively on new scientific evidence (field testing)

29. Types of field testing Improving criteria for a primary headache
Developing criteria for a new type of primary headache
Improving criteria for a secondary headache
Developing criteria for a new type of secondary headache
Improving criteria for a cranial neuralgia