ORIGINAL RESEARCH article
Front. Neurol.
Sec. Headache and Neurogenic Pain
Diagnosis Through Differentiation: A Pilot Study on Improving the Diagnostic Efficiency of Primary Headaches in ICHD3
Provisionally accepted
- 1Harvard Medical School, Boston, United States
- 2Beth Israel Deaconess Medical Center, Boston, United States
- 3Rutgers Robert Wood Johnson Medical School, New Brunswick, United States
Select one of your emails
You have multiple emails registered with Frontiers:
Notify me on publication
Please enter your email address:
If you already have an account, please login
You don't have a Frontiers account ? You can register here
Background: What is the minimum number of questions necessary to diagnose any given primary headache disorder? The answer to this question may provide clinicians with a more efficient approach to history taking and lead to a more concise form of ICHD3. In this project, we attempt to address this problem mathematically. Methods: We defined a headache phenotype as a collection of characteristics, variables that can take on a Boolean (true/false) value and correspond to elements of the diagnostic criteria for each headache in ICHD3. There may be multiple phenotypes that fit a given diagnosis in the ICHD3. We extracted all characteristics used to describe primary headaches up to two levels deep in the hierarchy in the ICHD3. For each headache diagnosis, we determined its "necessary true" (NT) characteristics. We also generated a list of "necessary false" (NF) characteristics by identifying characteristics that logically contradict the NT for each given diagnosis. We then sought to algorithmically identify the smallest set of NT and NF needed to differentiate between all primary headache diagnoses. As a result, any primary ICHD3 headache phenotype can be diagnosed once both the NT and NF criteria are satisfied. We verified this by translating all the possible conditions described by the ICHD3 criteria to our phenotype encoding schema. Results: We were able to minimize the NT and NF criteria to a set of 22 and 6 characteristics, respectively, with 5 overlaps between the groups. Though an even smaller NT set may be possible, we are limited by computational power. These characteristics can be queried by using the following questions to generate a headache phenotype: duration, frequency sudden/rapid onset, laterality, clearly remembered onset, sharp contour, severity, relationship to sleep/awakening, reversibility of aura, stabbing quality, and whether the headache can be triggered by sex, compression, traction, cold, or exercise. Conclusion: Fifteen questions are necessary to differentiate the primary headache disorders in ICHD3. A smaller set may be possible, but we cannot prove its existence. Using this reduced set of questions, clinicians may be able to more efficiently arrive at ICHD3 diagnoses, but further research is required.
Keywords: Headache classification, Headache diagnosis, Migraine, Primary headache disorders, Tension-Type Headache
Received: 19 Oct 2025; Accepted: 04 Dec 2025.
Copyright: © 2025 Zhang and Cheng. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Pengfei Zhang
Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.