# Presentation: 493986

## Headache Classification2007

- Stephen D. Silberstein, M.D., F.A.C.P.
- Director, Jefferson Headache Center,
- Professor of Neurology
- Thomas Jefferson University Hospital
- Philadelphia, Pennsylvania
- Past President American Headache Society

## Old Ad-hoc Headache Classification

- 1.	Migraine
- Migraine variants, vascular headaches, atypical facial neuralgia
- 2.	Tension headache (muscular contraction headache)
- 3.	Headache associated with intracranial disturbances
- Arteriosclerotic brain diseases, vascular  anomalies, aneurysms, tumor, infections
- 4.	Headache associated with extracranial disturbances
- Eye, ear, nose, bones of the skull and neck
- 5.	Headache associated with cranial trauma
- 6.	Hypertension, allergy, arteritis (temporal), fevers, infection
- 7.	Psychogenic headaches
- Conversion, tension headaches

## International Classificationof Headache Disorders2nd edition

- (ICHD-2)

## ICHD-2 Classification

**Part 1:**Primary headache disorders
**Part 2:**** **Secondary headache disorders
**Part 3: **Cranial neuralgias, central and primary facial pain and other headaches

## ICD-9: Problems

- Outmoded Terminology
- Based on ad-hoc criteria
- Classic and common migraine no longer used
- Did not allow characterization of disorders based on epidemiology and new science
- Many disorders misclassified or not classified
- Many new disorders described
- No relationship to ICHD-2
**Tension headache** misclassified as psychiatric disorder
- Occurs in over 50% of population

## ICD-9: New Categories

- 339 Other Headache Syndromes
- 346 Migraine
- Secondary Headaches

## ICD-9 Revisions:Tension-type headache not psychological

-  307    Special symptoms or syndromes, not elsewhere classified
-  		307.8 	Pain disorders related to psychological factors
- 			307.81      **Tension headache**
- 			 Excludes: headache:
- Add				syndromes (339.00-339.89)
- Add				**tension-type** (339.10-339.12)

## 339 Subcategories: Other Headache Syndromes

- 339.0  Cluster headaches and other TACS
- 339.1  Tension-type Headache (TTH)
- 339.2  Post-traumatic Headache (PTH)
- 339.3  Drug induced headache
- 339.4  Complicated headache syndromes
- 339.8  Other headache syndromes

## ‘Episodic versus Chronic’

- In pain, ***chronic*** denotes persistence > 3 months
- In headache, it has this meaning for secondary headache disorders
- For primary episodic headache disorders (*eg, *migraine), ***chronic*** is used whenever headache ***occurs on more days than not*** > 3 months
- Episodic means <15days/month
- Trigeminal autonomic cephalalgias exception
***Chronic*** not used until unremitting >1 year

## New subcategory 339.0 Cluster headaches and other trigeminal autonomic cephalgias (TACS)

- New code	339.00    Cluster headache syndrome, unspecified			     (Cluster headache NOS, Ciliary neuralgia, 				      Histamine cephalgia,  Lower half migraine, 				      Migrainous  Neuralgia)
- New code 	339.01	Episodic cluster headache
- New code	339.02	Chronic cluster headache
- New code 	339.03	Episodic paroxysmal hemicrania 						Paroxysmal hemicrania NOS
- New code	339.04	Chronic paroxysmal hemicrania
- New code	339.05	SUNCT
- New code	339.09	Other TACS

## New Subcategory 339.1 Tension-type Headache (TTH)

- Excludes:	tension headache due to psychological factors (307.81)
- New code   	339.10	TTH, unspecified
- New code	   	339.11	Episodic TTH
- New code	  	339.12	Chronic TTH

## New Subcategory 339.2 Post-traumatic Headache (PTH)

- New code  	339.20 	PTH, unspecified
- New code  	339.21	Acute PTH
- New code  	339.22	Chronic PTH
- PTH can be part of post-concussion syndrome
- But does not have to be

## New Subcategory 339.3

- Drug induced headache, not elsewhere classified
- Medication overuse headache
- Rebound headache

## New Subcategory	 339.4	Complicated Headache Syndromes

- New code   339.41  Hemicrania continua (HC)
- Unilateral CDH
- New code   339.42  New daily persistent headache  (NDPH)
- New onset CDH
- New code   339.43  Primary thunderclap headache
- New code   339.44  Other complicated headache syndrome

## New Subcategory	 339.8Other headache syndromes

- New code   339.81    Hypnic headache
- New code   339.82    Headache associated with sexual activity				 Orgasmic headache						 Preorgasmic headache
- New code   339.83    Primary cough headache
- New code   339.84    Primary exertional headache
- New code   339.85    Primary stabbing headache
- New code   339.89    Other headache syndromes

## 346 Migraine

- Following fifth-digit subclassification used with category 346:
- Revise	0   *without* mention of intractable migraine _*without*__ mention of status     _	     _migrainosus_
- Revise	1   *with* intractable migraine, so stated, _*without*__ mention of status _		     _migrainosus_
- Add       2   *without* mention of intractable migraine *with* status migrainosus
- Add       3   *with* intractable migraine, so stated, *with* status migrainosus

## Revise 346.0 Migraine with aura

- Add		Classic migraine
- Add		Basilar migraine
- Add 		Migraine triggered seizures (can use sz 			codes)
- Add		Migraine with acute-onset aura
- Add 		Migraine with aura without headache 				(Migraine equivalents)
- Add		Migraine with prolonged aura
- Add		Migraine with typical aura
- Add		Retinal migraine

## Revise 346.1 Migraine without Aura

- Add	       Common Migraine

## 346.2 Variants of migraine, Not Elsewhere Classified

- Add      Cyclical vomiting
- Add      Ophthalmoplegic migraine
- Add      Periodic headache syndromes in child 	    or adolescent

## New Codes

- 346.3	Hemiplegic migraine							Familial								Sporadic
- 346.4	Menstrual migraine					Menstrually related migraine
- 			Pure menstrual migraine

## New Codes

- 346.5	Persistent migraine aura without 		cerebral infarction							Persistent migraine aura NOS
- 346.6	Persistent migraine aura with 			cerebral infarction
- 				Can use stroke codes

## New Codes

- 346.7	Chronic migraine						Transformed migraine