What are the ICHD-3 (International Classification of Headache Disorders, 3rd edition) criteria for diagnosing and treating headache disorders?

ICHD-3 Criteria for Diagnosing Headache Disorders

The International Classification of Headache Disorders, 3rd edition (ICHD-3) provides standardized diagnostic criteria for various headache disorders, with migraine, tension-type headache, and cluster headache being the most common primary headache types. 1

Migraine Without Aura

• Requires at least five attacks fulfilling the following criteria 1:

  • Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
  • Headache has at least two of these four characteristics:
    • Unilateral location
    • Pulsating quality
    • Moderate or severe pain intensity
    • Aggravation by or causing avoidance of routine physical activity
  • At least one of the following during headache:
    • Nausea and/or vomiting
    • Photophobia and phonophobia
  • Not better accounted for by another ICHD-3 diagnosis

• Special consideration for children and adolescents: attacks may last 2-72 hours 1

Migraine With Aura

• Requires at least two attacks fulfilling the following criteria 1:

  • One or more fully reversible aura symptoms:
    • Visual
    • Sensory
    • Speech and/or language
    • Motor
    • Brainstem
    • Retinal
  • At least three of these six characteristics:
    • At least one aura symptom spreads gradually over ≥5 minutes
    • Two or more aura symptoms occur in succession
    • Each individual aura symptom lasts 5-60 minutes
    • At least one aura symptom is unilateral
    • At least one aura symptom is positive
    • The aura is accompanied with or followed by headache within 60 minutes
  • Not better accounted for by another ICHD-3 diagnosis

• Important note: When multiple symptoms occur during an aura, the acceptable maximal duration is the sum of the individual durations (e.g., 3 symptoms = 3 × 60 minutes) 1

Chronic Migraine

• Requires 1:
  • Headache (migraine-like or tension-type-like) on ≥15 days/month for >3 months
  • Occurring in an individual who has had at least five attacks fulfilling criteria for migraine without aura and/or migraine with aura
  • On ≥8 days/month for >3 months, headache meets any of these criteria:
    • Criteria for migraine without aura
    • Criteria for migraine with aura
    • Believed by patient to be migraine at onset and relieved by triptan/ergot derivative
  • Not better accounted for by another ICHD-3 diagnosis

Medication-Overuse Headache

• Requires 1:
  • Headache on ≥15 days/month in a patient with pre-existing headache disorder
  • Regular overuse for >3 months of acute/symptomatic headache medication:
    • Non-opioid analgesics on ≥15 days/month for ≥3 months, OR
    • Any other acute medication or combination on ≥10 days/month for ≥3 months
  • Not better accounted for by another ICHD-3 diagnosis

Vestibular Migraine

• Requires 1:
  • At least 5 episodes with vestibular symptoms of moderate/severe intensity lasting 5 min to 72 hours
  • Current or previous history of migraine with/without aura according to ICHD criteria
  • One or more migraine features with at least 50% of vestibular episodes:
    • Headache with at least two migraine characteristics
    • Photophobia and phonophobia
    • Visual aura
  • Not better accounted for by another vestibular or ICHD diagnosis

Diagnostic Aids

• Headache diaries: Record pattern and frequency of headaches, accompanying symptoms, and medication use 1
• Headache calendars: Record temporal occurrence of headaches and related events (e.g., menstruation) 1
• Screening questionnaires 1:
  • ID-Migraine: Three questions about headache-associated nausea, photophobia, and disability
  • Migraine Screen Questionnaire (MS-Q): Five questions about headache frequency, intensity, length, associated symptoms, and disability

Clinical Considerations and Pitfalls

• Medical history is the mainstay of migraine diagnosis; physical examination is usually confirmatory 1
• ICHD-3 criteria prioritize specificity over sensitivity; "probable migraine" diagnosis is used when all criteria aren't met 1
• Migraine with aura and migraine without aura can coexist in the same patient 1
• Family history strengthens suspicion of migraine, especially with onset around puberty 1
• Chronic migraine is not static; patients may revert to episodic migraine or vice versa 1
• ICHD-3 criteria show limitations when applied to children under 6 years of age, particularly regarding attack duration 2
• Aura symptoms can be similar to transient ischemic attacks (TIAs) but differ in that aura symptoms typically spread gradually (≥5 min) and occur in succession, while TIA symptoms have sudden, simultaneous onset 1