International classification of diseases-11 chronic primary headache diagnoses: data-based adaptations of criteria for the pediatric population

Lisa-Marie Rau, Antonia Barke, Beatrice Korwisi, Eva-Christina Becker-Emden, Michael Frosch,
Boris Zernikow, Julia Wager

Juli, 2026

Abstract

Many children present with chronic primary headache (CPH), yet classification within the International Classification of Diseases (ICD-11) is difficult, potentially impeding treatment pathways. The ICD-11 includes adult criteria, but it lacks coding notes addressing pediatric neurodevelopmental differences, and it stipulates inconsistent time criteria. The current study thus proposes optimized diagnostic criteria for CPH, chronic tension-type headache (TTH), and chronic migraine to better fit the observed symptoms among pediatric patients with CPH. Symptoms of N 5 231 pediatric patients presenting at a tertiary care center with migraine-like and/or TTH-like headache who met the ICD-11 chronic primary pain criteria were analyzed. Data-informed adjustments to diagnostic criteria were evaluated using grid search and receiver operating characteristic (ROC) analyses to identify the best criteria combination for CPH, chronic TTH, and chronic migraine. For all 3 diagnoses, the best approach was to align the time criteria with the definition of chronic primary pain—requiring at least 3 months of headache without further specification of hours or days per month. For chronic TTH, additionally allowing moderate nausea and up to 2 migraine-like symptoms yielded the best combination of sensitivity and specificity relative to migraine-like headache. The current study indicates that the diagnostic criteria included in the ICD-11 are ill-suited for diagnosing pediatric patients with CPH. To facilitate appropriate treatment for pediatric patients with headache, we strongly recommend implementing the proposed pediatric coding notes within the ICD-11.