The International Classification of Headache Disorders 2nd Edition



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A7. Headache attributed to non-vascular intracranial disorder

A7.9.1 Post-radiosurgery headache

Diagnostic criteria:

A. Diffuse and/or holocranial headache fulfilling criteria C and D

B. Radiosurgery of the brain has been performed

C. Headache develops within 7 days after radiosurgery

D. Headache resolves within 3 months after radiosurgery



Comment:

Although de novo headache has been described after radiosurgery, most studies do not provide a detailed description of the clinical characteristics of the headache, nor is it usually clear whether headache occurring after radiosurgery represents an exacerbation of an underlying headache disorder or a new headache. In cases where a previous history of headache was not present, the headache syndrome was short-lived, occurred more than a year after the procedure, and resembled migraine or thunderclap headache. Therefore, the relationships between these headaches and the radiosurgical procedures preceding them are highly doubtful. Carefully controlled prospective studies are necessary to determine whether a unique headache disorder can occur after radiosurgery and, if so, how it is related to the type and location of lesion being irradiated and/or the dosage and radiation field employed.

A7.9.2 Post-electroconvulsive therapy (ECT) headache

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. Electroconvulsive therapy (ECT) has been given

C. Headache develops within 4 hours after ECT and after at least 50% of treatments

D. Headache resolves within 72 hours after ECT



Comments:

Clear descriptions of headache associated with ECT are sparse. Published data may not be adequate to define post-ECT headache operationally.

The characteristics of headache after ECT are noted in several case reports. Hawken et al (2001) reported on a patient who suffered from “mild migraine” every two to three days and “more severe” migraine every 7-10 days after ECT (the symptoms listed correspond with diagnostic criteria for 1.1 Migraine without aura). Headache developed immediately after the patient regained consciousness following sessions of ECT. On one of six occasions the headache was associated with nausea but other symptoms of migraine were not described in this report. The headache did not respond to sumatriptan but was alleviated by a combination of propranolol and naproxen, and appeared to be prevented by administration of propranolol prior to ECT. De Battista and Mueller (1995) described a patient who developed severe post-ECT unilateral headaches associated with nausea/vomiting and photophobia. The patient had a history of similar although less intense headaches. Prophylactic administration of sumatriptan appeared to prevent the headache whereas prophylactic administration of beta-blockers did not. Ghoname et al (1999) reported on five patients who experienced headaches immediately after sessions of ECT. The headaches were severe and bilateral in each case (pulsating in two), but no other symptoms of migraine were described. Several other letters and case reports have documented attacks of severe headache (associated with symptoms of migraine or described as being similar to migraine) triggered by ECT in patients with a history of migraine (eg, Folkerts, 1995; Oms et al, 1998). Markowitz et al (2001) reported that, of 13 moderate or severe attacks of headache after ECT, six were associated with sensitivity to light, four with sensitivity to noise, three with nausea and one with vomiting. All but one of the attacks decreased within 1.5 hours after intranasal administration of sumatriptan 20 mg.


A7.10 Chronic post-intracranial disorder headache

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. An intracranial disorder has been present but has been effectively treated or has remitted spontaneously

C. Headache has been attributed to the intracranial disorder

D. Headache persists for >3 months after effective treatment or spontaneous remission of the intracranial disorder


Bibliography and references

A7.9.1 Post-radiosurgery headache

Kondziolka D, Lundsford LD, Flickinger JC. Gamma knife stereotactic radiosurgery for cerebral vascular malformations. In: Alexander E III, Loeffler JS, Lundsford LD eds. Stereotactic Radiosurgery. New York: McGraw Hill Inc 1993:136-145.

Lundsford LD, Flickinger JC, Coffee RJ. Stereotactic gamma knife radiosurgery. Initial North American experience in 207 patients. Arch Neurol 1990;47:169-175.

Rozen TD, Swanson JW. Post-gamma knife headache: A new headache syndrome? Headache 1997;37:180-183.

A7.9.2 Post-electroconvulsive therapy (ECT) headache

DeBattista C, Mueller K. Sumatriptan prophylaxis for postelectroconvulsive therapy headaches. Headache 1995;35:502-503.

Folkerts H. Migraine after electroconvulsive therapy. Convulsive Therapy 1995;11:212-215.

Ghoname EA, Craig WF, White PF. The use of percutaneous electrical nerve stimulation (PENS) for treating ECT-induced headaches. Headache 1999;39:502-505.

Hawken ER, Delva NJ, Lawson JS. Successful use of propranolol in migraine associated with electroconvulsive therapy. Headache 2001;41:92-96.

Markowitz JS, Kellner CH, DeVane CL, Beale MD, Folk J, Burns C, Liston HL. Intranasal sumatriptan in post-ECT headache: results of an open-label trial. Journal of ECT 2001;17:280-283.

Oms A, Miro E, Rojo JE. Sumatriptan was effective in electroconvulsive therapy (ECT) headache. Anesthesiology 1998;89:1291-1292.



Weiner SJ, Ward TN, Ravaris CL. Headache and electroconvulsive therapy. Headache 1994;34:155-159.

A8. Headache attributed to a substance or its withdrawal

8.1.10 Headache as an acute adverse event attributed to medication used for other indications


Table 1: Drugs that may induce headache or worsen pre-existing headache


Acetazolamide

Codeine

Interferons

Ondansetron

Ajmaline

Didanosine

Isoniazid

Paroxetine

Amantadine

Dihydralazine

Meprobamate

Pentoxifylline

Antihistaminics

Dihydroergotamine

Methaqualone

Perhexiline

Barbiturates

Dipyridamole

Metronidazole

Primidone

Beta-interferon

Disopyramide

Morphine and derivatives

Prostacyclines

Bromocriptine

Disulfiram

Nalidixic acid

Ranitidine

Caffeine

Ergotamine

Nifedipine

Rifampicin

Calcium antagonists

Etofibrate

Nitrofurantoin

Sildenafil

Carbimazol

Gestagens

Nitrates

Theophylline and derivatives

Chinidine

Glycosides

Non-steroidal anti-inflammatory drugs

Thiamazole

Chloroquine

Griseofulvin

Octreotide

Trimethoprim + sulfamethoxazole

Cimetidine

Guanethidine

Oestrogens

Triptans

Clofibrate

Immunoglobulins

Omeprazole

Vitamin A


A8.5 Chronic post-substance exposure headache

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. Exposure to a substance has been present but has ceased

C. Headache has been attributed to exposure to the substance

D. Headache persists for >3 months after exposure to the substance ceased


A9. Headache attributed to infection

A9.1.6 Headache attributed to space-occupying intracranial infectious lesion or infestation

Comment:

There are space-occupying intracranial infectious lesions causing headache other than brain abscess or subdural empyema. Since the pathophysiology is miscellaneous and the systematic studies to classify these headaches are inadequate, tentative diagnostic criteria are given here in the appendix.

Diagnostic criteria:

  1. Headache with at least one of the following characteristics and fulfilling criteria C and D:

1. diffuse continuous pain

2. aggravated by straining

3. accompanied by nausea and/or focal neurological symptoms and/or signs


  1. Evidence of a space-occupying intracranial infectious lesion or infestation from neuroimaging and/or laboratory investigations

  2. Headache develops during the space-occupying intracranial infection or infestation

  3. Headache resolves within 3 months1 after successful treatment of the lesion



Note:

1. Headache usually resolves within 1 month.
Comments:

A direct space-occupying effect leading to raised intracranial pressure and/or irritation of the meningeal or arterial structures are the mechanisms for causing headache of this subtype.

The most common organisms causing space occupying granulomatous or cystic central nervous system diseases are mycobacteria, fungi (eg, Cryptococcus neoformans and others), Toxoplasma gondii, free living amoebae, cestodes (eg, Cysticercus cellulosae, Coenurus cerebralis, Sparganum species), nematodes (eg, Toxocara canis, lymphatic filariae, Onchocerca volvulus, Anisakis species) and trematodes (eg, Schistosoma species, in particular Schistosoma japonicum, and Paragonimus species).


A9.1.7 Headache attributed to intracranial parasitic infestation

Coded elsewhere:

Headache attributed to space occupation by rather than to a direct effect of an intracranial parasitic infestation is coded as A9.1.6 Headache attributed to space-occupying intracranial infectious lesion or infestation.
Comment:

Parasitic infestations are characterised by an acute stage and a chronic stage. Headache in the acute stage is usually due to meningitis while headache in the chronic stage is believed to be due to encephalitic changes or secondary to neuropsychological deterioration. Systematic studies of the headaches caused by these disorders are lacking and therefore diagnostic criteria can only be proposed with great uncertainty.
Diagnostic criteria:

  1. Headache with one or other of the following characteristics, with or without focal neurological symptoms and/or signs and fulfilling criteria C and D:

1. headache, with acute onset, resembling 9.1.1 Headache attributed to bacterial meningitis

2. headache with more insidious onset and characteristic of chronic meningoencephalitis



  1. Evidence of an intracranial parasitic infestation from CSF examination, blood serology and/or neuroimaging

  2. Headache develops during the parasitic infestation

  3. Headache resolves within 3 months after successful treatment of the infestation



Comments:

Headache is a common and frequently the first symptom of intracranial parasitic infestation. A wide variety of parasitic organisms may infest the central nervous system, directly or indirectly. Whereas Trypanosoma cruzi (American trypanosomiasis, Chagas’ disease) may cause acute meningitis, T. brucei gambiense (West African trypanosomiasis, Gambian sleeping sickness) and T. brucei rhodesiense (East African trypanosomiasis, East African sleeping sickness) cause a chronic meningoencephalitis.

Predisposing factors include exposure to parasites in tropical and/or subtropical areas of prevalence and, in a few instances, immunocompromised status.


A9.4.2 Chronic post-non-bacterial infection headache

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C and D

B. A non-bacterial infection has been present but has been effectively treated or has remitted spontaneously

C. Headache has been attributed to the infection

D. Headache persists for >3 months after effective treatment or spontaneous remission of the infection


Comment:

There is little evidence for the existence of chronic headache attributed to non-bacterial infections. More research is needed.

Bibliography


Westerink MA, Amsterdam D, Petell RJ, Stram MN, Apricella MA. Septicemia due to DF-2. Cause of a false-positive cryptococcal latex agglutination result. Am J Med 1987;83:155-158.
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