Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The tragic migraine classification and diagnosis fiasco

Dr. Elliot Shevel
Conditions
August 31, 2024
Share
Tweet
Share

The first classification of primary headaches was developed in 1962 by the Ad Hoc Committee, a group of neurologists with a special interest in migraine. They correctly classified primary headaches, as per the published data, into:

  1. Vascular headache of the migraine type
  2. Muscle contraction headache
  3. Mixed muscular/vascular headache

The different types of primary headaches were classified according to the anatomical structure from which the pain originates. Therefore, one had to examine the patient to determine where the pain originated, and one could then direct the treatment at the pain source, whether it be the arteries, the muscles, or, as is frequently necessary, both.

In 1985, however, the International Headache Society decided to improve on the Ad Hoc Committee’s classification. They appointed a panel of headache specialists, led by Professor Jes Olesen, to compile a new classification.

This classification, called the International Classification of Headache Disorders (ICHD), is now accepted worldwide as the “gold standard.” Specialist headache journals only accept papers if the cohorts have been selected according to the ICHD criteria. As a result, not only is all migraine treatment based on the ICHD, but all migraine research is also based on it.

In this communication, I expose the fatal flaws in the ICHD, which is a tragic fiasco—tragic because since the adoption of this classification in 1988, it has severely retarded migraine research. As a result, countless millions of migraine sufferers have received the wrong or inadequate treatment, continuing to suffer unnecessarily.

According to the ICHD, the following criteria must be used to diagnose migraine:

A. Number of attacks: At least five attacks
B. Duration of attacks: Should last between 4-72 hours
C. Pain characteristics: At least two of the following should be present

  1. Pain should be pulsating or throbbing
  2. Pain should be unilateral
  3. Moderate to severe pain intensity
  4. Aggravation of pain by routine physical activity, such as walking up stairs

D. Associated symptoms: At least one of the following is required

  1. Nausea and/or vomiting
  2. Photophobia plus phonophobia

There is, however, no evidence to support the inclusion of any of these criteria for the diagnosis of migraine. The ICHD-3 bibliography contains 13 references, 12 of which have absolutely nothing to do with the diagnostic criteria for migraine.

Only one pertinent reference relates to unilateral headache. This paper, written by Professor Olesen, the chairman of the Classification Committee from 1985 until after the publication of the ICHD-3 in 2018, reported that the pain was unilateral in 56 percent and bilateral in 44 percent of migraineurs.

A major concern, however, is that one of the criteria used to choose the 750 migraineurs in Professor Olesen’s study was unilateral pain. This means there was a built-in bias favoring unilaterality in the sample, and even despite this violation of the principle of random selection, only slightly more patients had unilateral pain than bilateral pain.

Several other studies, conducted before the ICHD was first published, also presented measurable, repeatable, independently verifiable data showing that unilaterality is not a reliable criterion for diagnosing migraine.

The data, therefore, diametrically oppose the inclusion of unilaterality as a diagnostic criterion for migraine.

ADVERTISEMENT

A second major concern is the inclusion of “pulsation” as a criterion for migraine. “Pulsating” is defined in the ICHD-2 as “throbbing or varying with the heartbeat,” but in 2010, it was shown that the rate of throbbing in migraine does not correlate to the pulse rate. Inexplicably, throbbing headache correlating with the pulse rate is still a criterion for migraine diagnosis in the ICHD-II.

In the preface to the ICHD-1, it actually stated, “It should be pointed out that many parts of the document are based on the experience of the experts of the committees in the absence of published evidence.”

Professor Olesen himself admitted in a paper published in 1994 that the IHS diagnostic criteria are “based on opinions” and are “not based on empiric data.”

Professor Olesen also wrote, “The IHS headache classification system emphasizes headache diagnosis, which is ideally related to the underlying biology of these disorders.” In the ICHD, the criteria for diagnosing migraine are based entirely on symptoms and are not related in any way to the underlying biology. The underlying biology is never mentioned.

To sum up, for most of the criteria used to diagnose migraine—i.e., number of attacks, duration of attacks, pain intensity, aggravation of pain with mild exercise, photophobia, phonophobia, and nausea and vomiting—the ICHD-3 provides no supporting data. For those criteria where data do exist—i.e., unilateral pain and pulsatile pain—the data actually contradict their inclusion as diagnostic criteria for migraine.

The ICHD is no more than an extension of Galen’s original description of migraine, which is purely a description of the symptoms. This may have been acceptable in 100 AD, but in the 21st century, it is an anachronism that has retarded our understanding not only of migraine but also of other primary headaches.

Research into new migraine medications since 1988 has been severely compromised, as they are frequently being tested on the wrong people. The result has been that the effectiveness of migraine medications has been compromised, and countless millions of sufferers continue to have their quality of life tragically and unnecessarily destroyed.

The first, second, and third editions of the ICHD combined contain many references in the migraine section. The significance of these references is not clear, though, as they are not, as in any scientific publication, numerically correlated with the text. In addition, the references in the bibliography are devoid of any data supporting the selection of the classification criteria.

For the sake of the countless migraineurs, the ICHD must be discarded as soon as possible!

Elliot Shevel is an oral maxillofacial surgeon and headache specialist.

Prev

Pandemic lessons: How better staffing and communication can save health care

August 31, 2024 Kevin 0
…
Next

Balancing residency and pregnancy [PODCAST]

August 31, 2024 Kevin 0
…

Tagged as: Neurology

Post navigation

< Previous Post
Pandemic lessons: How better staffing and communication can save health care
Next Post >
Balancing residency and pregnancy [PODCAST]

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

Related Posts

  • Big pharma ignores low-cost migraine solution

    John C. Hagan III, MD
  • A manifesto for the next revolution in nocebo and placebo studies

    Jeremy Howick, PhD
  • Diagnosis: malformation of a health care system

    Jeffrey Fraser, MD
  • Tragic optimism in the time of COVID-19

    Alexa Mason
  • Getting a terminal diagnosis for my baby

    Sophia Zilber
  • Retrospective refusal of payment based upon final diagnosis compromises patients’ welfare

    David Hoke, MD, MBE, Kenneth V. Iserson, MD, MBA, and Jesse Basford, MD

More in Conditions

  • Finding healing in narrative medicine: When words replace silence

    Michele Luckenbaugh
  • Why coaching is not a substitute for psychotherapy

    Maire Daugharty, MD
  • Why doctors stay silent about preventable harm

    Jenny Shields, PhD
  • Why gambling addiction is America’s next health crisis

    Safina Adatia, MD
  • How robotics are reshaping the future of vascular procedures

    David Fischel
  • How the shingles vaccine could help prevent dementia

    Marc Arginteanu, MD
  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician
    • Why doctors stay silent about preventable harm

      Jenny Shields, PhD | Conditions
    • Why interoperability is key to achieving the quintuple aim in health care

      Steven Lane, MD | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician
    • Why doctors stay silent about preventable harm

      Jenny Shields, PhD | Conditions
    • Why interoperability is key to achieving the quintuple aim in health care

      Steven Lane, MD | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...