The “IHS” Classification (1988, 2004) –

Contributions, Limitations and Suggestions

K Ravishankar

Abstract
The first ‘International Classification of Headache Disorders’ by The International Headache Society (1988) (1) was a major
landmark document. It helped develop a common language for understanding headaches and advanced research in
this neglected field. It was found to be useful, but because it was complex and cumbersome, it remained underutilised
in practice. An evidence-based revised second edition was launched in 2004(2) This article analyses the Contributions
and Limitations of this Classification. The important changes that pertain to ‘Migraine’ in the revised 2004 Classification
have been listed. It is hoped that this Classification will be used more often in practice not only by Neurologists but by
all who see headache patients in their routine practice.

Introduction chapters for primary headaches, eight for secondary headaches

and two for cranial neuralgias, central and primary facial pain
C lassifications may seem complex and cumbersome but
they are essential to make order out of chaos. A consistent
classification system, which employs a set of scientifically
and other headache sub-types. The second edition identifies 45
primary and 120 secondary headache types and subtypes, and
includes 29 causes of cranial neuralgias and central causes of
derived diagnostic criteria induces comparable uniformity in facial pain (3). Within each group, diagnoses are arranged in a
clinical observations and conclusions. And so it is with headache hierarchical system using upto 4 digits. In general practice, for
diagnosis too! instance, doctors can classify to the first or second digit, whereas
Before early attempts at Classification, the taxonomy of in specialist practice, the third and sometimes the fourth digit can
headache was not uniform and there were no diagnostic criteria. be used. The outline of this Classification is given below (Table 1)
In 1962, an Ad Hoc committee of the National Institutes of (2)
and the Classification is also available online at www.i-h-s.org.
Health produced a classification of headache disorders which Revisions in ICHD-2
at that time represented a major step forward. Unfortunately its
definitions were open to differing interpretations. At around the There are many interesting changes in ICHD-2 (2004) and
same time, there were rapid advances in the understanding of the there is in addition an extensive appendix, which describes a
biologic basis for primary headaches. So in 1985, the International number of disorders that need validation and proposes a few
Headache Society (IHS) formed a Headache Classification alternative criteria that can be tested. There are major additions
Committee under the Chairmanship of Prof. Jes Olesen and to both Primary Headaches and Secondary Headaches. (Table
in 1988 published the First ‘ International Classification of 2)(2). Some diagnoses have been moved to other sections and
Headache Disorders’ which included specific diagnostic criteria some others have been renamed (Table 3) 2 reflecting changes
for all headache disorders(1). in our perception of their underlying pathophysiology. All
secondary headaches are now described as ‘attributed to’ instead
This Classification proved to be an enormous advance, of ‘associated with’. The Appendix includes headache disorders
promoted studies of the epidemiology of headache and for which there is limited evidence. It is the hope that the entities
facilitated drug trials which have formed the basis of current included in the appendix will be useful for future nosographic
treatment guidelines. It withstood the test of time and was found and epidemiologic research. The ICHD-2 is therefore a result of
to be particularly useful in headache research. Since the first the advances in the headache field over the last two decades.
edition was based largely upon personal opinions and general
consensus, the IHS in 2004, brought out an evidence-based Since this is a Special issue on Migraine, this article will
revision of the earlier classification and this is now popular detail only the changes to the ‘Migraine’ group in the revised
as The International Classification of Headache Disorder 2nd classification. Changes to the rest of the Classification will be
Edition (ICHD-2)(2). It provides operational diagnostic criteria for beyond the scope of this article.
all headache types and has become the standard for headache The Migraine group has been expanded to include many new
diagnosis and clinical research. It has now been accepted by the entities. Under the types of Migraine with Aura a new entity
WHO and has been used in the International Classification of of typical aura with non-migraine headache(1.2.2) has been
Diseases 10 (ICD 10). It is imperative today, for any publication added. Following recent advances in the genetics of migraine,
on the subject of headache to compulsorily use ICHD-2. It is hemiplegic migraine has now been subdivided into Familial
therefore important for all physicians who see headache patients (1.2.4) and Sporadic hemiplegic migraine (1.2.5). Basilar migraine
to become familiar with the revised classification and the criteria, has now been renamed basilar-type migraine (1.2.6). Amongst
as this will in future be the standard reference document for the childhood periodic syndromes, cyclic vomiting syndrome
headache diagnosis, treatment and research. Unfortunately even (1.3.1) and abdominal migraine (1.3.2) have been included while
20 years later, most of us are still not using this Classification! alternating hemiplegia of childhood has been moved to the
The revised 2004 Classification has 14 chapters. There are four appendix.. In terms of duration of the headache and location of
the pain, the criteria for pediatric migraine has been modified.
Consultant in-charge, The Headache and Migraine Clinic, Jaslok Under the heading complications of migraine(1.5), chronic
Hospital and Research Centre; Lilavati Hospital and Research Centre, migraine (1.5.1), persistent aura without infarction (1.5.3) and
Mumbai. migraine – triggered seizure (1.5.5) are new inclusions. There are

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 Table 1 : Revised IHS Classification of Headache – ICHD2 (2004) (2)
A. Primary headache disorders 2.4 Probable tension-type headache
1. Migraine 2.4.1 Probable infrequent episodic tension type headache
1.1 Migraine without aura 2.4.2 Probable frequent episodic tension type headache
1.2 Migraine with aura 2.4.3 Probable chronic tension-type headache
1.2.1 Typical aura with migraine headache 3. Cluster headache and other trigeminal autonomic cephalalgias
1.2.2 Typical aura with non-migraine headache 3.1 Cluster headache
1.2.3 Typical aura without headache 3.1.1 Episodic cluster headache
1.2.4 Familial hemiplegic migraine (FHM) 3.1.2 Chronic cluster headache
1.2.5 Sporadic hemiplegic migraine 3.2 Paroxysmal hemicrania
1.2.6 Basilar-type migraine 3.2.1 Episodic paraoxysmal hemicrania
1.3 Childhood periodic syndromes that are commonly 3.2.2 Chronic paroxysmal hemicrania (CPH)
precursors of migraine 3.3 Short-lasting Unilateral Neuralgiform headache attacks
1.3.1 Cyclic vomiting with conjunctival injection and Tearing (SUNCT)
1.3.2 Abdominal migraine 3.4 Probable trigeminal autonomic cephalalgia
1.3.3 Benign paroxysmal vertigo of childhood 3.4.1 Probable cluster headache
1.4 Retinal migraine 3.4.2 Probable paroxysmal hemicrania
1.5 Complications of migraine 3.4.3 Probable SUNCT
1.5.1 Chronic migraine 4. Other primary headaches
1.5.2 Status migrainosus 4.1 Primary stabbing headache
1.5.3 Persistent aura without infraction 4.2 Primary cough headache
1.5.4 Migrainous infraction 4.3 Primary exertional headache
1.5.5 Migraine-triggered seizure 4.4 Primary headache associated with sexual activity
1.6 Probable migraine 4.4.1 Preorgasmic headache
1.6.1 Probable migraine without aura 4.4.2 Orgasmic headache
1.6.2 Probable migraine with aura 4.5 Hypnic headache
1.6.5 Probable chronic migraine 4.6 Primary thunderclap headache
2. Tension-type headache (TTH) 4.7 Hemicrania continua
2.1 Infrequent episodic tension-type headache 4.8 New daily-persistent headache (NDPH)
2.1.1 Infrequent episodic tension- type headache associated B. Secondary headache disorders
with pericranial tenderness 5. Headache attributed to head and/or neck trauma
2.1.2 Infrequent episodic tension-type headache not 6. Headache attributed to cranial or cervical vascular disorder
associated with pericranial tenderness
7. Headache attributed to non-vascular intracranial disorder
2.2 Frequent episodic tension-type headache
8. Headache attributed to a substance or its withdrawal
2.2.1 Frequent episodic tension-type headache associated
9. Headache attributed to infection
with pericranial tenderness
10. Headache attributed to disorder of homeoeostasis
2.2.2 Frequent episodic tension-type headache not
associated with pericranial tenderness 11. Headache or facial pain attributed to disorder of cranium, neck,
eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial
2.3 Chronic tension-type headache
structures
2.3.1 Chronic tension-type headache associated with
12. Headache attributed to psychiatric disorder
pericranial tenderness
13. Cranial neuralgias and central causes of facial pain
2.3.2 Chronic tension-type headache not associated with
pericranial tenderness 14. Other headache, cranial neuralgia central or primary facial pain.

Table 2 : New additions to the ‘Migraine’ group(2) Table 3 : Migraine disorders which have been renamed in
• Typical aura without headache [1.2.3] the new classification criteria(2)
• Cyclical vomiting [1.3.1] Earlier Terminology and Current Terminology
• Abdominal migraine [1.3.2] • Hemiplegic migraine - Familial hemiplegic migraine [1.2.4] and
• Chronic migraine [1.5.1] Sporadic hemiplegic migraine [1.2.5]
• Persistent aura without infarction [1.5.3] • Basilar migraine - Basilar-type migraine [1.2.6]
• Migraine-triggered seizure [1.5.5] • Migrainous disorder - Probable migraine without and with aura
[1.6.1., 1.6.2]
• Probable chronic migraine [1.6.5]

some changes in the diagnostic criteria for status migrainosus Contributions of the Classification
(1.5.2) and migrainous infarction(1.5.4). The criteria for chronic
The 1988 monograph ‘Classification and Diagnostic Criteria
migraine has been modified subsequently and these have been
for Headache disorders, Cranial Neuralgias and Facial Pain’(1) by
discussed in the editorial. Section 1.6 includes headaches that
the International Headache Society was a landmark document
closely but not completely resemble migraine and are now called
in the headache field. It clearly defined headache disorders
probable migraine instead of migrainous disorder.
and increased the interest levels in migraine and other related
disorders. Vague terminologies were for the first time replaced
by uniform international headache language. Clinical trials

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were conducted using the IHS criteria and this led to rational, The educated proactive migraineur in developed countries,
evidence-based treatment strategies. The reproducibility who maintains a headache diary definitely contributes to the
of epidemiologic studies on primary headaches in diverse ease with which doctors can use the Classification in the Western
practice settings suggested that the criteria were generalizable. world.
It was therefore a positive development that contributed to a There are many additional reasons why this classification
uniform diagnostic system and led to greater focus on research is not easy to use in India.(4) Headache as a sub-speciality has
in headache. still not caught on. Clinics are overcrowded, there are major
problems like stroke and epilepsy that force headache medicine
Limitations of the Classification into the back-seat. Not all patients are literate, recall is poor,
No doubt, the Classification has had a major positive impact headache diaries are not maintained. Most clinicians find that the
but like with most Classifications, there are still some issues that classification is time consuming to use and the benefit obtained
need debate. There has been criticism and suggestions regarding is not proportionate as it is not a guide to specific treatment. We
the need for revised criteria for individual headache types. There need a more user- friendly version.
is not much controversy regarding the secondary headaches
but there are still issues in the primary headache category. Conclusion
Some argue that the classification criteria are too detailed and The IHS classification has contributed positively to progress
impractical for use in daily practice. Without going into the in the headache field. It is now universally employed and is
details category-wise, one may broadly state that there are some a standard document to be followed for publication in the
areas which need to be addressed in future revisions. The IHS headache field. The present classification does have certain
Classification addresses individual headache attacks only. It does drawbacks but it is only through feedback, opinions and
not take into account the natural history of the headache or the arguments that future editions of the Classification will be
spectrum of headache in the person. It does not recognise the more complete and practically relevant. So it is up to all of us
inter-relationship between migraine and tension-type headache. to use it and produce evidence pertaining to difficulties using
A consistent criticism has been that the diagnostic criteria for the classification. A shorter, more portable classification that
migraine are not applicable to children and adolescents with employs a more comprehensive clinic-based approach would of
migraine. For most patients with chronic daily headache the course be a great improvement. But given the heterogeneity of
classification is extremely challenging to use. Correspondingly, the headache field and the myriad clinical presentations, until
several revised criteria have been proposed and field-tested. the day when we will have biological markers, I wonder if it will
There is therefore a need for future changes to address childhood be possible to have THAT perfect classification which satisfies
headache syndromes, chronic headaches, menstrual migraine clinicians and researchers alike !
and headaches with overlapping features.
References
Suggestions for Future Classifications 1. Headache Classification Subcommittee of the International
The difficulty in using the Classification is largely because Headache Society. The International Classification of Headache
of atypical episodes and recall bias. This apart, there may be a Disorders.2nd ed. Cephalalgia 1988;
genuine problem using the Classification at different levels of 2. Headache Classification Subcommittee of the International
practice in developing countries (where 80 per cent of the world Headache Society. The International Classification of Headache
population lives !). In many areas of Asia and Africa, other Disorders.2nd ed. Cephalalgia 2004; 24 (Suppl. 1): 1–160.
pressing health priorities confront the clinician, literacy levels 3. Gladstone JP, Dodick DW. From hemicrania lunaris to hemicrania
among patients are low, clinics are overcrowded and there is continua: an overview of the revised International Classification of
less importance given to the functional quality of life. In these Headache Disorders. Headache. 2004; 44(7): 692-705.
settings, even neurologists might find it a dilemma to use the 4. Ravishankar K. Barriers to headache care in India and efforts to
Classification. improve the situation. Lancet Neurol. 2004 Sep; 3(9): 564-7.

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