Headache Medicine, v.5, n.2, p.39-45, Apr./May/Jun. 2014 39

A multiaxial evaluation of the headache patient

Uma avaliação multiaxial de paciente com cefaleia

ORIGINAL ARTICLE

ABSTRACTABSTRACT

ABSTRACT

Background: Background:

Background: Primary headaches are considered a complex

medical problem. They usually appear as isolated episodes

but can progress into chronic headaches entailing significant

functional disability for the patient. With the objective of

upgrading the quality of care given to headache patients,

there have been several proposals to integrate the wide array

of variables which influence headache experiences into a

systemized evaluation model. Such a system should prevent

key elements from being overlooked, aid diagnosis and facilitate

treatment plans. However, as of yet, no such model has been

widely adopted.

Method:Method:

Method: In the present paper, we propose

integrating The International Classification of Headache

Disorders (ICDH) into a multiaxial assessment system similar

to the Diagnostic and Statistical Manual of Mental Disorders

(DSM-IV) which is used in psychiatry. The contents of the

different axes found in the DSM cover many of the fundamental

clinical variables which have been supported by the medical

literature for the past twenty years. Our discussion focuses

mainly on chronic headache and migraine since they are

clinically relevant to this form of evaluation. We believe our

proposed model could be applied generally to all headache

types.

Conclusion:Conclusion:

Conclusion: Headache disorders require an evaluation

method flexible enough to reflect the multiple dimensions

influencing the course of the disease. In order to achieve a

systemized, widely accessible evaluation, we propose a

headache patient evaluation structure that is familiar and

generally accepted by the medical community. Implementing

such a system would be beneficial as it could lead towards

building a more uniform evaluation system, facilitate student

learning and communication among practitioners, all of which

are important steps for improving patient care.

KeywordsKeywords

Keywords: Migraine; Headache; Multiaxial; Evaluation;

Classification

Eric Magnoux

, Gregorio Zlotnik

, LaFerrière Justine

Montreal Migraine Clinic, Montreal, Québec, Canada

B.A., McGill University

Magnoux E, Zlotnik G, Justine L A multiaxial evaluation of the headache patient.

Headache Medicine. 2014;5(2):39-45

INTRODUCTION

Over the past 20 years, major efforts have been

made to further our understanding of headache

disorders. An internationally accepted headache

classification was published by the International

Headache Society in 1988

(1)

and revised in 2004,

(2)

new abortive and preventive medication has been

developed and practical guidelines have been drafted

to structure treatment options.

(3-5)

Despite these advances,

migraine, one of the most frequent and disabling

headaches, is still under-diagnosed and under-treated.

Patients often do not consult a physician for their

migraines, those who do are not always correctly

diagnosed and those who are given a correct diagnosis

do not always receive optimal treatment. Some efforts

have been made to address these issues. The MIDAS

(6)

questionnaire and migraine diagnosis screeners,

(7,8)

are

examples of tools developed for primary care physicians

to measure the debilitative effects of migraines on

patients' daily functions, improve diagnosis and promote

better healthcare management. However, such tools are

not widely used and, consequently, migraines are still

associated with severe disability in 53.7% of patients.

(9)

One important complication related to episodic

migraines is their potential to progress into chronic

headaches. This risk, coupled with the challenge of

identifying patients in whom this potential exists, only

reinforces the need to optimize migraine diagnosis and

treatment. From an interventional perspective, Bigal and

Lipton

(10)

examined the process of migraine chronification

by dividing the associated factors into two categories,

40 Headache Medicine, v.5, n.2, p.39-45, Apr./May/Jun. 2014

MAGNOUX E, ZLOTNIK G, JUSTINE L

non-modifiable and modifiable. The former includes

genetics, gender, age, being of Caucasian ancestry,

socioeconomic status, and educational level; the latter

includes high headache frequency, obesity, medication

overuse, caffeine, snoring and apnea, psychiatric

comorbidities and stress. Comorbidities particularly

contribute to headache-related disability,

(11,12)

and the

authors stress the importance of screening for them. In

all, it is clear from these authors' work that several

variables influence migraine experiences and that, even

if the correct diagnosis is made, one still risks overlooking

key elements that contribute to the development of the

patient's symptoms. Hence there is an evident need for

an evaluation tool that goes beyond simple headache

diagnosis.

Several attempts have been made along these lines:

since 1992, five papers from three groups have been

published

(13-17)

stating that primary headaches represent

a complex disease that requires a clear diagnosis, global

clinical profile and adapted treatment to improve the quality

of care. The authors included many of the modifiable

factors listed above, (headache frequency, medication

overuse, comorbidities, stress and disability) into a

systemized evaluation system. However, the proposals

have not been widely accepted, as their novel and varied

structures have limited their use among headache

specialists. We believe that this could be remedied by the

use of a headache evaluation system that is more uniform

and constructed from standardized and reliable medical

knowledge.

Therefore we propose in the present paper a pilot

multiaxial evaluation tool. We believe that a systemized

multiaxial evaluation system for patients suffering from

all types of headaches could improve diagnosis by

ensuring that all relevant information concerning the

patient is included in the final evaluation. This would

render treatment and care management much more

effective as all contributive factors would be addressed.

We believe that with a few modifications, the DSM-IV

evaluation framework could be used as an ideal

template for designing such an evaluation tool not only

because it integrates all the variables considered relevant

when evaluating headache patients but because its

structure will aid its spread and acceptance within the

medical community. Indeed, by drawing from previous

models – namely from the International Headache

Society and the DSM – we hope that the familiarity of

our model's structure will facilitate accessibility and enable

any type of practitioner (from specialists to medical

students) to provide a more thorough, in depth, and

reliable medical evaluation. We favor the DSM model

over other multiaxial systems since it is an accepted

reference supported by the prevailing biopsychosocial

model.

METHODS

In the sections below we present an overview of the

multiaxial psychiatric methods as found in the DSM (section

A) as well as the headache classification scheme proposed

by the IHS (section B). We then propose our own synthesis.

A. The multiaxial psychiatric evaluation model:A. The multiaxial psychiatric evaluation model:

A. The multiaxial psychiatric evaluation model:

the DSMthe DSM

the DSM

(18-20)(18-20)

(18-20)

The classification of mental illnesses that preceded

the DSM-III was based on a psychosocial and

psychodynamic etiological view. Inter-evaluator diagnostic

reliability was poor, so a scientific approach to these

illnesses was not possible. Framed within a scientific

perspective and with increased communication among

physicians in mind, a diagnostic revision was undertaken

to create the DSM-III. The authors adopted a purely

descriptive approach to symptoms, eliminating any

reference to etiology; precise criteria were established for

making reliable diagnoses. In addition to this diagnostic

component and because of the difficulty involved when

evaluating patients with psychiatric problems, the authors

created a multiaxial evaluation framework for identifying,

from the most important clinical variables, those that were

the most useful for psychiatric cases. Five axes were defined.

The first draft of the DSM-III was developed by expert

consensus and validation studies were used to prepare

the DSM-IV.

(21)

• Axis I describes the clinical symptoms, defined by

precise criteria and a clinical course over time.

• Axis II describes personality disorders and traits

and, in the DSM IV, maladaptive personality features and

defense mechanisms. This axis is relevant because the

clinical presentation, the response to treatment and the

clinical course of the disease are also influenced by

personality traits. It is distinct from Axis I and warrants special

attention, as it is often neglected in favor of the clinical

syndrome. This axis underscores the importance of

personality disorders in relation to the diagnosis in Axis I.

• Axis III describes current medical conditions. It adds

information to the overall clinical picture and can be useful

for understanding or managing the case.

Headache Medicine, v.5, n.2, p.39-45, Apr./May/Jun. 2014 41

• Axis IV identifies the psychological stressors that

can affect the diagnosis, treatment and prognosis of the

mental disorders established in Axes I and II. These

stressors can contribute to the exacerbation or onset of

an illness or can be the consequence of a mental illness,

hence the importance of taking them into account.

• Axis V assesses the patient's global functioning

level based on three dimensions: psychological, social

and occupational. Using a percentage scale to quantify

these three dimensions, Axis V is used to assess the impact

of the mental illness. The process can also be repeated

over time to evaluate continually the patient's clinical

course.

B. The International Classification of HeadacheB. The International Classification of Headache

B. The International Classification of Headache

Disorders (ICHD)Disorders (ICHD)

Disorders (ICHD)

The International Classification of Headache

Disorders is considered the main medical reference for

headache disorders. It was published in 1988 in response

to criticisms that the existing model published in 1962

(22)

was unreliable due to its lack of strict operational

diagnostic guidelines. Just as was the case for the DSM,

this problem was remedied by referencing to precise

diagnostic criteria defined by expert consensus. It was

revised in 2004 through the use of validation studies.

Although the ICHD model did not adopt a multiaxial

evaluation system like the DSM, its strict operational

guidelines ensure diagnostic reliability, which in turn

facilitates research by promoting further communication

among experts.

Given that the methodology used when assessing a

psychiatric patient – that is achieving a diagnosis by select

criteria with added dimensions to factor in – overlap with

ones used for the headache patient, it seems reasonable

to ask whether it would be beneficial to have a similar

system for headache patients. The ICHD could provide

consistency and reliability for the diagnosis while the

contents of the five axes styled from the multiaxial

psychiatric evaluation used in the DSM could help extract

the vital information needed by any clinician to ensure a

global assessment of the patient. Some of the potential

benefits are immediately apparent, including cases in

which there is medication overuse, medical and

psychiatric comorbidities, behavioral characteristics, stress

and disability. Our following discussion focuses mainly

on chronic headache and migraine because they are

clinically relevant to this form of evaluation. However,

we believe that our proposed model could be applied

generally to all headache types.

A MULTIAXIAL EVALUATION OF THE HEADACHE PATIENT

Axis IAxis I

Axis I describes the diagnosis of headache disorders

according to the existing ICHD criteria. It serves to establish

that headaches are the primary reason for the consultation.

It can involve more than one diagnosis as the clinical course

of the headaches progresses.

Axis II,Axis II,

Axis II, which we refer to as the "complications" axis,

pertains to the presence of chronic migraine and to

medication overuse. Because of their clinical importance

and because they are closely linked, we propose that a

separate axis be devoted to each of these factors, especially

since only 20.2% of chronic migraineurs are diagnosed.

(23)

The IHS does, in fact, grant special status to chronic migraine,

as a complication of episodic migraine.

Axis IIIAxis III

Axis III describes associated conditions or

comorbidities, both medical and psychiatric.

They may or not be associated with the headaches.

(24)

However, from a medical perspective, these comorbidities

are essential to include as they greatly affect treatment

options, e.g., asthma and beta-blockers or vasculitis and

triptans, bipolar disorder and preventive medication.

Painful comorbidities can also complicate the patient's

clinical course, e.g., fibromyalgia and irritable bowel

syndrome and other comorbidities, such as obesity, snoring

and apnea that are associated with chronification.

Axis III also includes personality disorders and traits

as comorbidities, as these can modulate the patient's

coping strategies for his or her headaches, medication

use and relationship with the health care professional; such

considerations are especially important if the patient is at

risk for medication overuse. For further explanation of

patients with type II

(25)

medication overuse, we refer to the

works of Saper et al.

(16)

Figure 1. Our proposed model which integrates diagnostic criteria from the ICDH

and the multiaxial structure from the DSM-IV

Our Proposal for a Multiaxial Headache Evaluation

Axis I. IHS Classification (primary/secondary headache)

Axis II. Complications

a) Chronic migraine

b) Medications overuse

Axis III. Comorbidities

a) Medical

b) Psychiatric

1) Clinical disorders

2) Clinical disorders, including headache coping

strategies

Axis IV. Psychosocial and environmental problems (DSM-IV Axis IV)

Axis V. Disability

42 Headache Medicine, v.5, n.2, p.39-45, Apr./May/Jun. 2014

Axis IVAxis IV

Axis IV covers environmental and psychosocial

stressors because the link between stress as a trigger for

headaches/migraine attacks and the progression to

chronic headaches has been well established.

(26,27)

Identifying the different stressors and determining their

importance in a patient provides guidance for the course

of care which should emphasize psychological (Cognitive

Behavioral Therapy) or psychophysiological (relaxation,

biofeedback) treatment.

Axis V Axis V

Axis V is devoted to the disability assessment. In

the field of headache medicine, a structured evaluation

including this axis should incite the clinician to examine

the impact of the patients' headaches, as patients

seldom report functional disability or emotional

repercussions spontaneously.

(28)

The type of

questionnaire used is less important, it is the act of

evaluating disability which needs to be the focus.

Headache specialists could use MIDAS or other scales

like HIT-6 while primary care physicians could use

global assessment functioning (GAF) found in the DSM.

Primary care clinicians whose practice cannot bear the

burden of an additional questionnaire could conduct

a less formal disability assessment, which could consist

simply in asking the patient about any missed or

disrupted work days or social activities.

EXAMPLES

Reformulating Clinical VignettesReformulating Clinical Vignettes

Reformulating Clinical Vignettes

(29)(29)

(29)

These vignettes, originally published by Sun-Edelstein

et al.,

(29)

were designed to illustrate which headache

diagnoses are reached when using the ICHD criteria. They

describe a fictional woman of 38 years suffering from

chronic headache for the past 3 years. The goal was to

demonstrate how, notwithstanding the nearly identical

profiles, these patients can still be given differing headache

diagnoses when following ICHD diagnostic criteria. We

have taken the same vignettes and have applied our

proposed multiaxial headache patient evaluation to reveal

how seemingly uniform profiles can turn into unique,

complex cases.

TIENT A.TIENT A.

TIENT A. "38F with mild-moderate headache

every day for 3 years. Prior to daily headache, had

migraines 1-5 days/month. Now has a migraine 10 days/

month. Previously used sumatriptan every other day but

has been using it only twice per week for the last 6 months.

Does not use any other acute-care medication".

Axis I: Migraine without aura.

Axis II: Chronic migraine.

Axis III: Asthma, primary Raynaud's syndrome.

Major depression in remission; generalized

anxiety disorder.

No presumed or diagnosed personalitydisorders.

Axis IV: Son died 3 years ago as a result of a skiing

accident. Troubled marital relationship ever

since.

Axis V: Misses 1 day of work per month and regularly

cancels family activities. MIDAS grade III.

TIENT BTIENT B

TIENT B

. .

. "38F with mild-moderate headaches

every day for 3 years. Prior to daily headache, had

migraines 1-5 days/month. Now has a migraine 10

days/month. Has been using sumatriptan every other

day for 2 years. Does not use any other acute-care

medication."

Axis I: Migraine without aura.

Axis II: Medication overuse headache.

Axis III: obesity (Body Mass Index: 35), Glucose

Tolerance Test positive, snoring, obsessive

personality disorder.

Axis IV: Disagreement with coworkers and boss over

work, which she feels is botched by the others.

Axis V: Misses 3 days of work per month and does

not go out for fear of a migraine attack. MIDAS

grade IV-A.

TIENT CTIENT C

TIENT C. "38F with mild-moderate headaches

every day for 3 years. Prior to daily headache, had

migraines 1-5 days/month. Now has a migraine 4 days/

month. She previously used sumatriptan every other day

but has been using it once per week for the last 6 months.

Does not use any other acute medication."

Axis I: Chronic Tension Type Headache, migraine

without aura.

Axis II: Nil.

Axis III: Nil.

Axis IV: Family problems because of limitations in

activities.

Axis V: Misses work occasionally. Occasional limitation

in family activities. MIDAS grade II.

TIENT DTIENT D

TIENT D. "38F with mild-moderate headache

every day for 3 years. Prior to daily headaches, had

migraines 1-5 days/month. Now has migraine 4 days/

month. Has been using sumatriptan every other day for 2

years. Does not use any other acute-care medication."

MAGNOUX E, ZLOTNIK G, JUSTINE L

Headache Medicine, v.5, n.2, p.39-45, Apr./May/Jun. 2014 43

Axis I: Migraine without aura.

Axis II: Medication overuse headache.

Axis III: No medical comorbidity.

Drug abuse, cocaine, alcohol, cannabis.

Borderline personality disorder.

Axis IV: Has separated twice in the past year. Conflict

with immediate family. Has moved recently.

Axis V: Totally disabled, stopped working on her

physician's advice. MIDAS grade IV-B.

COMMENTS ON VIGNETTES

The headache histories presented in these four

vignettes are practically identical, except for the ICHD

diagnosis. However, by using the multiaxial evaluation, a

very different, more nuanced picture emerges which can

entail significant implications for treatment options and

overall patient prognosis.

In the case of patient A, medical comorbidities interfere

with preventive and abortive treatment. The patient's disability

is significant. Marital difficulties and bereavement are

significant and should be addressed using psychotherapy

since these issues have remained problematic for years.

While the patient's depression is in remission, her general

anxiety disorder must still be pharmacologically and

psychotherapeutically addressed since these factors have

been proven to have an impact on headaches and

disability. However, the absence of a personality disorder

should influence the prognosis positively.

In the case of patient B, evaluation show major

medical comorbidities (obesity, snoring) that interfere

directly with the patient's headache experiences; they

should be treated first. The patient's obsessive personality

disorder, coupled with interpersonal conflicts, is a source

of stress at work. The issues are likely to have a significant

impact on the course of care and should be addressed

using psychotherapy if possible.

In the case of patient C, the data do not indicate any

comorbidities or problem situations. Her disability is easily

manageable.

In the final case, there is a potential challenge in terms

of management. The patient does not have any medical

comorbidity, but her psychiatric comorbidities as well as

the presence of psycho-environmental stressors are

significant for her evaluation. Her disability is severe and

of mixed origin as it is due both to her headaches and to

her psychiatric problems. These must be addressed first.

Limits and expectations must be clearly defined as goals

of treatment.

DISCUSSION

The headache classification published in 1988 by

the International Headache Society was motivated by the

unreliability inherent in earlier classifications. The notion

of disability and tools designed to assess it such as the

MIDAS questionnaire were developed to obtain more

information about the patient but could still not present

an adequate global clinical picture; consequently,

treatment was rarely optimal.

To address these problems, Saper and colleagues

(16)

identified key variables to consider in order to fully

comprehend the complexity of each case and integrated

them into an original staging system. Their proposed

system is primarily addressed to headache specialists to

help them triage patients according to the case's complexity

and to help establish the corresponding intensity of

treatment.

Cady et al.,

(15)

drawing from Blau's phase model and

their convergence model, proposed another classification

of patients which proved to be clinically insightful, but was

difficult to use as its complexity limited its usage to highly

specialized headache experts.

Seshia et al.

(17)

suggested an original mutiaxial

classification for chronic headache which they believed could

be used for any other type of headache as well. They

defined six axes inspired from the axes styled in the DSM-

IV. However, as with many of the previous propositions,

Seshia et al.'s classification required in-depth knowledge

of headaches, again making its usage limited to specialists.

Furthermore, because they used six axes rather than five,

the structure of their evaluation diverges from that of the

DSM and makes it unfamiliar, thus harder to teach.

We believe that the lack of a standardized method

to guide headache patient evaluation is problematic as it

risks lessening the effectiveness of subsequent treatment

and impedes discussion among experts. Therefore, in

contrast to the preceding proposals, we do not suggest a

staging or a classification system, but a global evaluation

model for headache patients, structured in the form of a

multiaxial system similar to the DSM-IV. Our evaluation

system integrates the ICHD criteria to ensure diagnostic

reliability, but its real strength lies in its similarity to the

DSM-IV. We consider our proposed system to be much

more accessible to clinicians than the previously proposed

models because the multiaxial evaluation structure found

in the DSM-IV is taught during the formative years of

medical students and it is widely integrated within the

primary care sector.

A MULTIAXIAL EVALUATION OF THE HEADACHE PATIENT

44 Headache Medicine, v.5, n.2, p.39-45, Apr./May/Jun. 2014

It should be noted that Axis II of our proposed model

differs from that of the DSM-IV. We determined that this

axis should emphasize two clinically problematic, yet too

often omitted situations: medication-overuse headache

and chronic migraine. Axes III, IV and V include elements

which incorporate what the authors mentioned above

have identified, such as comorbidities, environmental

stressors and headache-related disability not

spontaneously reported by patients. We did not include

headache frequency because the widespread use of

calendars or headache agendas is enough to assess

this variable.

The ultimate objective of classification schemes such

as those presented by Saper et al.,

(16)

Cady et al,

(15)

Seshia et al.

(17)

is to improve patient care. However, as

most headache patients are firstly assessed by primary

care physicians, these classification schemes are unlikely

to be used because their structure and content targets

specialists in headache medicine. Our model can aid any

practitioner to evaluate a patient and offer a global picture

which can not only aid diagnosis but can also aid in

structuring an adapted treatment and follow-up plan.

CONCLUSION

Headache diagnosis has been facilitated since the

introduction of the International headache classification.

However, the evaluation of patients with headaches is a

complicated task and presents many of the same

dimensions encountered in psychiatric disorders. It

requires a clinician to consider confounding variables

that could be systematized. In order to devise an optimal

treatment, one must follow a thorough evaluation

structured so that all dimensions relevant to headache

treatment can be accounted for and key factors

contributing to the patient's unique situation identified.

However, as the goal of the present proposal is to create

both a reliable and user-friendly tool, we realize that this

evaluation tool needs to be simple and easily accessible

to all levels of physicians, from experienced clinician to

medical student. Therefore, this headache multiaxial

evaluation structure is an attempt to integrate established

diagnostic tools (the DSM and the IHCD) with some

aspects of classification schemes proposed by others in

order to achieve such an objective. We suggest that

combining the diagnosis criteria provided by the IHCD

with the in-depth, multilaxial DSM-style evaluation will

provide a tool to establish a reliable evaluation. By

including the most important dimensions relevant to

headache medicine into a medical evaluation, the

clinician can provide a treatment plan that is more likely

to be effective. Because our multiaxial evaluation system

proposal draws from reliable models, we believe it will

easily be accepted and integrated within clinical practice.

We hope that further contributions are made to this

model, for instance, to move towards integrating a proper

staging system that would guide treatment options more

effectively. If such a multiaxial evaluation could become

standardized within headache medicine, not only is

communication facilitated, but much-needed research

focused on patient care is encouraged.

REFERENCES

1. Headache classification committee of the International Headache

Society. Classification and diagnostic criteria for headache

disorders, cranial neuralgias and facial pain. Cephalalgia.

1988;8(suppl 7):1-96.

2. Headache Classification Subcommittee of the International

Headache Society. The International Classification of Headache

Disorders 2nd Edition. Cephalalgia. 2004;24 (suppl 1):1-160.

3. Pryse-Phillips WE, Dodick DW, Edmeads JG, Gawel MJ, Nelson

RF, Purdy RA, et al. Guidelines for the management of migraine

in clinical practice. CMAJ. 1997;156(9):1273-87. Erratum in

CMAJ 1997;157(10):1354.

4. Silberstein SD et al.Practice parameter: evidence-based

guidelines for migraine headache (an evidence-based review):

report of the Quality Standards Subcommittee of the American

Academy of Neurology. Neurology 2000;55(6):754-62. Erratum

in Neurology 2000;56(1):142.

5. Agence Nationale d'Accréditation et d'Évaluation en Santé. Prise

en charge diagnostique et thérapeutique de la migraine chez

l'adulte et chez l'enfant: aspects cliniques et économiques. La

Lettre du Neurologue. 2000;no3 vol. VII (suppl) :1-14.

6. Stewart WF, Lipton RB, Kolodner K, Liberman J, Sawyer J.

Reliability of the migraine disability assessment score I a

population-based sample of headache sufferers. Cephalalgia.

1999;19(2):107-14.

7.Lipton RB, Dodick D, Sadovsky R Kolodner K, Endicott J,

Hettiarachchi J, Harrison W; ID Migraine validation study. A

self-administered screener for migraine in primary care: The ID

Migraine validation study. Neurology. 2003; 61(3): 375-82.

8. Pryse-Phillips W, Aubé M, Gawel M, Nelson R, Purdy A,

Wilson K. A headache diagnosis project. Headache 2002;

42(8):728-37.

9. Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart

WF; AMPP Advisory Group. Migraine prevalence, disease

burden, and the need for preventive therapy. Neurology 2007;

68(5):342-9.

10. Bigal ME, Lipton RB. Clinical course in migraine: conceptualizing

migraine transformation. Neurology. 2008;71(11) :848-55.

11. Lantéri-Minet M, Radat F, Chautard MH, Lucas C. Anxiety and

depression associated with migraine : influence on migraine

subjets' disability and quality of life, and acute migraine

management. Pain. 2005;118(3):319-26.

MAGNOUX E, ZLOTNIK G, JUSTINE L

Headache Medicine, v.5, n.2, p.39-45, Apr./May/Jun. 2014 45

12. Saunders K, Merikangas K, Low NC, Von Korff M, Kessler RC.

Impact of comorbidity on headache-related disability. Neurology.

2008;70(7):538-47.

13. Saper JR, Hamel RL, Sell L, Winters M. A staging system for

primary headache disorders. Headache. 1992;32:257.

14. Lake AE, Saper JR, Hamel R, Kreeger C. Proposal for a multiaxial

diagnostic system for headache. Headache. 1995;35:285-6.

15. Cady RK, Schreiber CP, Farmer KU. Understanding the patient

with migraine: the evolution from episodic headache to chronic

neurologic disease. A proposed classification of patients with

headache. Headache. 2004;44(5):426-35.

16. Saper J, Lake A 3rd, Lipton R. Staging headache cases: reconciling

the complexity of a case with the required intensity of treatment.

Headache. 2007;47(1):90-3.

17. Seshia SS, Wöber-Bingöl Ç, Guidetti V. The classification of

chronic headache: Room for further improvement? Cephalalgia.

2010;30(10):1268-70.

18. American Psychiatric Association: Diagnostic and Statistical

Manual of Mental Disorders, Third Edition, Washington, D.C.,

APA, 1980.

19. Wilson M. DSM-III and the transformation of American psychiatry:

a history. Am J Psychiatry 1993;150 (3):399-410.

20. Williams JB. The multiaxial system of DSM-III: Where did it

come from and where should it go? Arch Gen Psychiatry 1985;

42(2):175-80.

21. American Psychiatric Association: Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition. Washington, DC,

American Psychiatric Association, 1994.

22. Ad Hoc committee on classification of headache. JAMA 1962;

179:127-8.

23. Bigal ME, Serrano D, Reed M, Lipton RB. Chronic migraine in

the population: burden, diagnosis, and satisfaction with

treatment. Neurology. 2008;71(8):559-66.

A MULTIAXIAL EVALUATION OF THE HEADACHE PATIENT

Corresponding author

Eric Magnoux MDEric Magnoux MD

Eric Magnoux MD

1600 Henri-Bourassa west # 420

Montreal, Québec, Canada, H3M 3E2

Email: cephalee@videotron.ca

Recieved: June 20, 2014

Accepted: June 27, 2014

24. Lipton RB, Silberstein SD. Why study the comorbidity of migraine?

Neurology. 1994;44(suppl 7):S4-S5.

25. Saper JR, Lake AE 3rd. Medication overuse headache: type I and

type II. Cephalalgia. 2006;26(10):1262.

26. Scher AL, Stewart WF, Buse D, Krantz DS, Lipton RB. Major life

changes before and after the onset of chronic daily headache: a

population-based study. Cephalalgia. 2008;28(8):868-78.

27. Fernandez E, Sheffield J. Relative contributions of life events

versus daily hassles to the frequency and intensity of headaches.

Headache. 1996;36(10):595-602.

28. Buse DC, Rupnow MF, Lipton RB. Assessing and managing all

aspects of migraine: migraine attacks, migraine-related functional

impairment, common comorbidities, and quality of life. Mayo

Clin Proc. 2009;84(5):422-35.

29. Sun-Edelstein C, Bigal ME, Rapoport AM. Chronic migraine

and medication overuse headache: clarifying the current

International Headache Society classification criteria.

Cephalalgia. 2009;29(4):445-52.