Limited Utility of ICHD 3 Criteria in Children 6 Years or Younger

International Classification of Headache Disorders 3rd edition criteria may not be useful in diagnosing children 6 years of age or younger.

The International Classification of Headache Disorders, 3rd edition (ICHD 3) criteria, which can be used to diagnose varying headache disorders including chronic migraine, chronic tension-type headache, and new daily persistent headache, may have limited utility in children <6 years of age.

Additionally, amitriptyline and topiramate may be the optimal treatment strategies for pediatric patients, regardless of chronic primary headache (CPH) type. This is according to a study published in Frontiers in Neurology.

Researchers reviewed the medical charts of pediatric patients who were admitted to 2 hospitals in Italy between 2010 and 2016 (n=377). Patients included in the retrospective medical chart review were up to 18 years of age and were diagnosed with CPH during the studied time interval. The investigators also looked for patients with medication overuse headache (MOH). Correlations between CPH and demographic data, CPH and headache qualitative features, CPH and MOH risk, and CPH and response to prophylactic therapies were examined. The researchers also compared the ICHD 3 vs. ICHD 2 criteria in terms of diagnoses.

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A diagnosis of CPH was made less frequently in children <6 years of age (0.8%; P <.05). After age 15 years, the risk for MOH was higher than at previous ages (P <.05). A higher proportion of undefined diagnoses were made with the ICHD 3 criteria compared with the ICHD 2 criteria (7.9% vs 2.6%, respectively; P <.05). The use of only the ICHD 2 criteria was helpful for making a probable diagnosis of chronic migraine (11.9%; P <.05). A headache attack duration of <2 hours was the primary criterion that did not result in satisfying a definitive diagnosis in 70% of patients <6 years of age (P <.005). The most effective drugs for treating these patients included amitriptyline and topiramate (P <.05), with no difference between the 2 agents (P >.05).

Limitations of the study include its retrospective design, its relatively small sample size, and the lack of placebo-controlled study regarding the prophylactic treatments administered in the patients.

“In our patients the [chronic migraine] prevalence did not largely change passing from the second to the third version of the ICHD,” the researchers explained. “This is probably due to the fact that most our chronic patients with undefined diagnosis did not receive such a diagnosis for the qualitative characteristics of their headache, but for the duration of their attacks.”


Papetti L, Salfa I, Battan B, et al. Features of primary chronic headache in children and adolescents and validity of ICHD 3 criteria. Front Neurol. 2019;10:92.