ICHD-3 is significantly more specific than ICHD-3 beta for diagnosis of migraine with aura and with typical aura

DOI: https://doi.org/10.1186/s10194- 019- 1072- 2

Abstract-Summary In the emergency room, distinguishing between a migraine with aura and a transient ischemic attack (TIA) is often not straightforward and mistakes can be harmful to both the patient and to society.

The new ICHD-3 diagnostic criteria for migraine with aura and migraine with typical aura display an excellent specificity (96 and 98% respectively), and are sig- nificantly more specific than the previous ICHD-3 beta classification system when it comes to diagnosing a first single attack (probable migraine with aura and prob- able migraine with typical aura).

The ICHD-3 is a highly useful tool for the clinical neurologist in order to distin- guish between a migraine with aura and a TIA, already at the first point of patient contact, such as in the emergency department or a TIA clinic.

Background One of the changes that was introduced from ICHD-2 via ICHD-3 beta to ICHD-3 was a change to the diagnostic criteria of migraine with aura (Sect. 1.2) and migraine with typical aura (Sect. 1.2.1), with the aim of being able to better differentiate migraines from transient ischemic attacks.

The aim of our study was to assess, whether these changes result in a higher

specificity when diagnosing migraine with aura and migraine with typical aura.

Methods The study was conducted on a total of 128 patients who presented to the emergency room of the University Hospital of Lübeck, Germany between August 2016 and January 2017 and were referred for suspected transient ischemic attack.

Patients were recruited at the time of presentation to the emergency room inter- viewed by a member of the study team, usually still in the emergency room, and at the latest within 8 h of presentation.

The patients received standard care during the subsequent hospital stay (all 128 participants that were recruited to the study were independently admitted as an

3.1 Classification

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inpatient) from physicians independent from the study team and blinded to the col- lected data.

We tested the specificity of: a. the diagnostic criteria for migraine with aura and migraine with typical aura of the ICHD-3 [10] and b. of the ICHD-3 beta [11] in our 128 patients with suspected TIA.

Results When looking at all 20 patients that neither received the diagnosis of a TIA nor that of an ischemic cerebral infarct, we found that their ABCD2 score was significantly lower at 2.15 (p < 0.001).

If we however look at the diagnosis of a single migraine attack (probable migraine with aura, whereby only one attack has occurred), the ICHD-3 beta results in a false-positive rate of 53.2% of our TIA patients (specificity of only 41%), while the ICHD-3 has a lower false-positive rate of only 24.2% (79% specificity).

The specificity of the ICHD-3 for single attack migraine with typical aura is thus significantly greater than that of the ICHD-3 beta (p  =  0.002, McNemar’s Chi- Square Test).

Patients with migraine were significantly younger than patients with a TIA (p = 0.0042) and also than their false positive counterparts of Group C (p = 0.0374), meaning that younger age is an important positive predictor of a true positive migraine diagnosis.

Discussion If the patient presents with a first episode, it becomes even more challenging to decide whether this is a migraine attack or a TIA (a previous similar episode makes the diagnosis of a migraine far more likely).

The low prevalence of migraine with aura (3.1% or 4 patients) in our study popu-

lation could lead to spurious specificity measurements.

Our study shows that the new ICHD-3 diagnostic criteria for migraine with aura and migraine with typical aura display a very good specificity, and are sig- nificantly more specific than the previous ICHD-3 beta classification system when it comes to diagnosing a single attack of migraine with aura and with typi- cal aura.

The ICHD-3 presents a useful tool for the clinical neurologist to distinguish between a migraine with aura and a TIA, already at the first point of patient contact, such as in the emergency department or a TIA clinic.

Conclusions Migraine with aura is difficult to distinguish from a transient ischemic attack, mis- takes are harmful to both patient and society.

Acknowledgement A machine generated summary based on the work of Göbel, Carl H.; Karstedt, Sarah C.; Münte, Thomas F.; Göbel, Hartmut; Wolfrum, Sebastian; Lebedeva, Elena R.; Olesen, Jes; Royl, Georg. 2020 in The Journal of Headache and Pain.

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3 Diagnosis

Primary Stabbing Headache