Difficulties in work-related activities among migraineurs are scarcely collected: results from a literature review

Hallmarks of primary headache: part 1 - migraine

BACKGROUND AND AIM

Migraine is a common disabling conditions which, globally, affects 15.2% of the population. It is the second cause of health loss in terms of years lived with disability, the first among women. Despite being so common, it is poorly recognised and too often undertreated. Specialty centres and neurologists with specific expertise on headache disorders have the knowledge to provide specific care: however, those who do not regularly treat patients with migraine will benefit from a synopsis on the most relevant and updated information about this condition. This paper presents a comprehensive view on the hallmarks of migraine, from genetics and diagnostic markers, up to treatments and societal impact, and reports the elements that identify migraine specific features.

MAIN RESULTS

The most relevant hallmark of migraine is that it has common and individual features together. Besides the known clinical manifestations, migraine presentation is heterogeneous with regard to frequency of attacks, presence of aura, response to therapy, associated comorbidities or other symptoms, which likely reflect migraine heterogeneous genetic and molecular basis. The amount of therapies for acute and for prophylactic treatment is really wide, and one of the difficulties is with finding the best treatment for the single patient. In addition to this, patients carry out different daily life activities, and might show lifestyle habits which are not entirely adequate to manage migraine day by day. Education will be more and more important as a strategy of brain health promotion, because this will enable reducing the amount of subjects needing specialty care, thus leaving it to those who require it in reason of refractory condition or presence of comorbidities.

CONCLUSIONS

Recognizing the hallmarks of migraine and the features of single patients enables prescribing specific pharmacological and non-pharmacological treatments. Medical research on headaches today particularly suffers from the syndrome of single-disease approach, but it is important to have a cross-sectional and joint vision with other close specialties, in order to treat our patients with a comprehensive approach that a heterogeneous condition like migraine requires.

Societal and personal impact of migraine

Migraine is one of the main causes of years lived with disability (YLDs) worldwide, as showed in the Global Burden of Diseases Study. Its influence on patients' life is relevant and pervasive, with a specific impact on social, family, and work functioning, considering that migraine mainly affects adults under the age of 50. Several studies demonstrated that relations inside the family as well as in every social context are negatively influenced by migraine. According to the results of studies and surveys from different countries, patients' daily activities are often limited during migraine attacks, particularly in terms of performance in social and domestic activities and in terms of reduced productivity in work and school duties. Also an interictal burden is present. Migraineurs are conditioned by the fear of the next attack, often suffer from comorbid conditions such as anxiety and depression, and are subject to different forms of stigma. Consequently, migraine implies relevant costs for the individuals and for society, with higher figures for indirect costs (related to reduced participation and to limited productivity) than indirect costs (related to drugs, medical visits, examinations, and hospitalization).

Health Care Utilization and Costs in Patients With Migraine Who Have Failed Previous Preventive Treatments

Objective

To characterize health care utilization (HCU) and associated costs among patients with migraine categorized by the number of preventive treatment failures (TFs; 1 TF, 2 TFs, and 3+ TFs) using real-world data.

Methods

This retrospective analysis identified adults with incident migraine diagnosis in the IBM MarketScan Commercial and Medicare Supplemental database between January 1, 2011, and June 30, 2015. TF was defined in the 2 years after the first migraine diagnosis period. One TF, 2 TFs, and 3+ TFs were defined as patients who had received only 2 preventive treatments (PTs), 3 PTs, and 4+ PTs in the 2-year period, respectively. A negative binomial model was used to analyze HCU data, and a 2-part model was used for cost data controlling for the preindex Deyo-Charlson Comorbidity Index.

Results

Overall, 24,282 patients with incident migraine who had failed at least 1 PT were included in the analysis. Of these, 72.7% (n = 17,653) had 1 TF, 20.2% (n = 4,900) had 2 TFs, and 7.1% (n = 1,729) had 3+ TFs. Adjusted annualized rates of all-cause and migraine-specific HCU increased with an increase in the number of TFs (1.4-4 times higher; all p < 0.0001 vs 1 TF). The mean total all-cause health care costs were higher by $3,732 (95% confidence interval [CI]: $2,708-$4,588) in patients with 2 TFs and by $8,912 (95% CI: $7,141-$10,822) in patients with 3+ TFs vs those with 1 TF. Outpatient costs were the key drivers of differences in health care costs.

Conclusions

TF in patients with migraine was associated with a substantial resource and cost burden, which increased with the number of TFs.

Patient-Reported Outcomes for Migraine in the US and Europe: Burden Associated with Multiple Preventive Treatment Failures

Purpose

To evaluate patient-reported outcomes (PROs) among patients with migraine, including those who were preventive-naïve and preventive-treated.

Methods

This was a point-in-time, real-world study of patients with migraine in the US and EU5 (France, Germany, Spain, Italy, and UK) and their physicians using data from the Adelphi Migraine Disease Specific Programme (DSP™). Physicians completed patient record forms (PRFs) for the next nine consulting patients with migraine plus a tenth patient, who did not need to be consecutive, for whom prior preventive migraine treatments had failed at least once, in order to achieve oversampling of such patients. Patients were given self-completion (PSC) forms that included the Migraine-Specific Quality of Life Questionnaire v2.1 (MSQ), Migraine Disability Assessment Scale (MIDAS), and Work Productivity and Activity Impairment (WPAI) questionnaire. Populations of interest included preventive-naïve and preventive-treated patients defined by the number of treatment lines (1–2 or 3+ preventive regimens). Continuous variables were compared using t-test or ANOVA if normally distributed and Mann–Whitney if not. Chi-squared was used for categorical variables.

Results

During August–December 2017, 615 physicians (359 PCPs, 256 neurologists) completed PRFs for 5785 patients (71% female; mean age 40 (±14) years; 65% in full- or part-time employment). Of these, 2798 completed a PSC (preventive-naïve/1–2/3+ preventive lines, n=1707/1034/57). Preventive-treated patients had a greater patient-reported burden across multiple measures versus preventive-naïve patients. Preventive-treated patients had lower MSQ scores indicating greater functional impairment, higher MIDAS scores indicating greater migraine-associated disability, and higher WPAI scores indicating greater overall work and activity impairment than preventive-naïve patients. The magnitude of difference was greatest for the 3+ preventive-treatments cohort. Patterns were similar in the US and EU5.

Conclusion

Among patients with migraine who are preventive-treated, including those with multiple lines of therapy, there remain considerable unmet needs in terms of restoring patient function.

Mapping Assessments Instruments for Headache Disorders against the ICF Biopsychosocial Model of Health and Disability

Headache disorders have a strong impact on sufferers’ lives. However, the “content” of assessment instruments addressing concepts, such as disability and quality of life (QoL), has not comprehensively been addressed. We searched SCOPUS for research papers in which outcome measures were used in adult populations of patients with migraine, tension-type headache (TTH), and cluster headache (CH). The content of single instruments was then mapped against the International Classification of Functioning, Disability, and Health. A total of 150 papers and 26 instruments were included: 15 addressed disability or impact, two addressed work-related difficulties, and nine addressed QoL. Few instruments were commonly used across the conditions and covered domains of functioning were impact on daily life activities, homework, school, and work-related tasks, leisure time, informal and family relations, pain, emotional difficulties, energy level, and impulse control. Most of the research is based on instruments that were developed for migraine, which is critical for CH, and the impact of headache disorders on work-related activities is poorly acknowledged. Further research is needed to expand the scope of headaches impact on daily life activities, and on environmental factors relevant to headache disorders to raise knowledge on the less represented areas, e.g., TTH impact.

Identification of work accommodations and interventions associated with work productivity in adults with migraine: A scoping review

OBJECTIVE

To identify factors associated with work productivity in adults with migraine, and accommodations or interventions to improve productivity or the workplace environment for them.

METHODS

We conducted a scoping review by searching MEDLINE, Embase, PsycINFO, Cumulative Index of Nursing and Allied Heath Literature, and Web of Science from their inception to 14 October 2019 for studies of any design that assessed workplace productivity in adults with migraine.

RESULTS

We included 26 articles describing 24 studies after screening 4139 records. Five prospective cohort studies showed that education on managing migraine in the workplace was associated with an increase in productivity of 29-36%. Two studies showed that migraine education and management in the workplace were associated with increased productivity (absenteeism decreased by 50% in one study). One prospective cohort study showed that occupational health referrals were associated with more than 50% reduction in absenteeism. Autonomy, social support, and job satisfaction were positively associated with productivity, while quantitative demands, emotional demands, job instability, and non-conducive work environment triggers are negatively associated with productivity in workers with migraine.

CONCLUSION

Despite migraine being the second leading cause of disability worldwide, there is a paucity of strong data on migraine-related work factors associated with productivity.Registration: None (scoping review).

Assessment of Work Productivity and Activity Impairment (WPAI) questionnaire for migraine with the help of a smartphone app

BACKGROUND

Migraine is a major cause of disability, which affects many areas of life, including productivity at work. Measuring absenteeism and presenteeism resulting from migraine with the use of appropriate tools is essential for better understanding the impact of this disease.

OBJECTIVE

The aim of the present study was to assess the work impact of migraine using the Brazilian Portuguese version of Work Productivity and Activity Impairment (WPAI) questionnaire.

METHODS

This survey was carried out with the aid of a smartphone app (Dr Cefaleia for Doctors) containing the questionnaires: ID-Migraine, Headache Impact Test (HIT-6), and WPAI. The data were collected during a headache awareness event. Correlations were assessed between migraine impact (HIT-6) with WPAI parameters: a) work time missed (absenteeism), b) impairment at work (presenteeism), c) overall work productivity loss (absenteeism+presenteeism), and d) activity impairment outside work.

RESULTS

Overall, 305 subjects with headache were interviewed and 167 were classified as having migraine. No significant differences in migraine impact according to sex (p=0.8) and modality of work were registered (p=0.8). Females had significantly higher absenteeism score (p<0.001), but presenteeism score was not significantly different between genders (p=0.3). WPAI absenteeism and presenteeism scores significantly correlated with migraine impact (HIT-6).

CONCLUSIONS

The results suggest WPAI Brazilian Portuguese version was efficient in assessing migraine related work impact. The use of an app with validated questionnaires facilitates the conduction of migraine impact research in different populations, allowing a better understanding of the burden of this disease.

Inpatient Management of Migraine

Migraine is a frequently disabling neurologic condition which can be complicated by medication overuse headache and comorbid medical disorders, including obesity, anxiety and depression. Although most migraine management takes place in outpatient clinics, inpatient treatment is indicated for migraine refractory to multiple outpatient treatments, with intractable nausea or vomiting, need for detoxification from medication overuse (such as opioids and barbiturates), and significant medical and psychiatric disease. The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life.

HEADWORK Questionnaire: Why Do We Need a New Tool to Assess Work-Related Disability in Patients With Migraine?

OBJECTIVE

This article reviews current headache disability measures and clinical need, as well as presenting the rationale for a new measure addressing work-related disability in migraine patients and the steps devoted to this aim.

BACKGROUND

Episodic and chronic migraine (EM and CM) constitute an enormous economic burden to societies, and the vast majority of this burden is attributable to indirect costs, ie those associated with productivity loss. A measure of work-related disability is therefore needed to quantify the impact of EM and CM on patients' ability to carry out work tasks.

METHODS

We briefly present the advantages and disadvantages of the disability measures that have been most commonly used for this purpose and the rationale for developing a new measure.

RESULTS

The entire process of development of HEADWORK, a questionnaire designed to assess work-related disability, is presented together with short-term sensitivity to change.

CONCLUSIONS

Current headache disability measures need improvement. HEADWORK is a valid, reliable, and sensitive questionnaire to address the amount and severity of work-related difficulties and of the factors contributing to such difficulties. HEADWORK is suitable for daily clinical practice, epidemiological research and for clinical trials, and potentially to define work-related disability weights for the calculation of migraine indirect costs.

Effect of Migraine Headache on Productivity of Patients According to Migraine Disability Assessment Score: A Cross-Sectional Study

Introduction

Migraine, a primary headache disorder, is usually recurrent with moderate to severe intensity. Migraine is the third most common cause of disability under the age of 50. There are various scoring systems for assessing this disability, one of which is MIDAS; the Migraine Disability Assessment Score. The objective of our study was to determine the extent of disability among migraine patients, patterns of prophylaxis, and their healthcare-seeking behaviors.

Methods

This survey was done in 50 migraine patients at Jinnah postgraduate medical Centre from April to May 2018. The questionnaire inquired about the demographic information, management of migraine, and effect of this condition on their sleep, and the last part had assessment to know about their functional disability.

Results

The majority of the patients were females with a mean age of 31 ± 10 years. Acetaminophen was the most common medication used during a migraine attack, followed by nonsteroidal anti-inflammatory drugs. Only 54% of subjects admitted using prophylaxis, out of which 94% had stopped taking it after some time, with the most common reason being their side effects. β-blockers were the most common prophylaxis used. Only 32% had a regular follow-up visit with their doctors. Patients were graded according to the MIDAS score as: little or no disability, 22%; mild disability, 14%; moderate disability, 24%; and severe disability, 40%.

Conclusions

The majority of migraine patients were found to have severe disability, which affected their daily work and social activities. Despite an increase in disability rate due to migraine, people do not seek regular medical care for this type of headache in Pakistan.

A narrative review on the burden of migraine: when the burden is the impact on people's life

Background

The burden of headache disorders, and of migraine in particular, is multifaceted and fragmented. The aim of this narrative review is to provide a description the main topics underlying the concepts of burden and impact of migraine disorders.

Main results

MedLine has been searched for publications covering the period 1990–2018 dealing with the terms burden or impact of migraine, including both episodic and chronic migraine. The main results and themes are reported in a descriptive way, and were grouped by similarity of content into overarching categories. A total of 49 papers, published over 25 years (1994–2018), were retained for the qualitative analysis. Six main themes were identified: prevalence of migraine disorders, overall impact of migraine disorders, impact on work or school activities, family impact, interictal burden, and disease costs. Majority of included studies concluded that patients with migraine reported an higher burden or impact in one or more of the six main themes herein identified, compared to non-headache patients or to patients with tension-type headache, with a tendency towards worse outcomes consistently with higher headache frequency.

Conclusions

The results of this narrative review show that the meaning of a sentence like “migraine is a burdensome condition” is not univocal: rather, it may refer to different concepts and meanings. In our opinion, future research should focus on understanding and facing the impact of migraine on work-related activities and on everyday life activities, as these aspects are highly connected to some tangible (i.e. cost) and less tangible (i.e. interictal burden and reduced quality of life) facets of migraine burden. Disease-specific measures have been implemented and should be exploited to enhance our understanding of migraine burden. This approach would allow to better understand the real impact on people’s life of such a burdensome disease.

Validation of a self-reported instrument to assess work-related difficulties in patients with migraine: the HEADWORK questionnaire

Background

The degree to which work-related difficulties are recognized in headache research is poor and often carried out with inadequate information such as “reduced ability to work as usual”, which do not capture at all the variety of difficulties and the factors that impact over them. The aim of this paper is to present the validation of the HEADWORK questionnaire, which addresses the amount and severity of difficulties in work-related tasks and the factors that impact over them.

Methods

We developed a set of items based on a previous literature review and patients’ focus groups and tested it on a wide set of patients with episodic and chronic migraine attending eight different Italian headache centers. HEADWORK factor structure was assessed with exploratory and confirmatory factor analysis; internal consistency and construct validity were addressed as well.

Results

The validation sample (N = 373) was mostly composed of patients with episodic migraine without aura (64.3%) and of females (81%). Factor analysis retrieved two different scales: “Work-related difficulties”, composed of eleven items which explain 67.1% of the total variance, and “Factors contributing to work difficulties”, composed of six items which explain 52.1% of the total variance. Both HEADWORK subscales have good measurement properties, with higher scores being associated to higher disability, lower quality of life, lower productivity, higher headache frequency and pain intensity.

Conclusions

HEADWORK is a 17-item, two-scale questionnaire addressing the impact of migraine on work-related difficulties in terms of difficulties in general or specific skills, and the factors contributing to these difficulties, defined as negative impact on work tasks. It can be used to address disability weights for the purpose of calculating the burden of migraine, and to assess the balance between therapeutic and side effects of medication on productivity.

Electronic supplementary material

The online version of this article (10.1186/s10194-018-0914-7) contains supplementary material, which is available to authorized users.

Migraine: incorrect self-management for a disabling disease

Migraine is an economically and socially relevant pathology but patients' consciousness and consequently a proper management is often unsatisfactory. In this study, we aimed to evaluate the disease awareness, the general approach and the impact on working activity in a population of headache-affected hospital workers. During an 18-month period, hospital workers responded to a questionnaire investigating headache presence, characteristics and awareness. Specific attention was paid to define headache impact on working activities. 1774 consecutive subjects were enrolled. Headache was documented in 45.7% of the sample, migraine in 16.6%. 40.6% of the patients with headache and 50.7% of the migraneous subjects had a specialist medical evaluation. Triptans use was significantly lower than non-steroidal anti-inflammatory drugs use. 39.5% of migraneous complained of attacks during working time, 60.2% acknowledged a negative influence on work quality. 25.5% of migraneous patients reported a loss of working days attributable to the disease. Migraine is disabling for workers with negative consequences on job capacity and quality. Efforts should be made to improve disease awareness to stimulate a better diagnostic and therapeutic approach.

Long working hours directly and indirectly (via short sleep duration) induce headache even in healthy white-collar men: cross-sectional and 1-year follow-up analyses

OBJECTIVE

Headache in employees may be linked with both overwork and sleep restriction induced by long working hours. Inter-relationships among working hours, sleep duration and headache were investigated.

METHODS

Cross-sectional analyses for prevalent headache (n = 35,908) and 1-year follow-up analyses for incident headache (n = 19,788) were conducted in apparently healthy white-collar men aged 25-59 years. Headache (yes/no), working hours and sleep duration were based on self-administered questionnaire. After determination of relationships between working hours and sleep duration, logistic regression analysis estimated odds ratio (OR) and 95% confidence interval for prevalent and incident headache according to working hours (35-44, 45-49, 50-59 and ≥60 h/week) and sleep duration (≥7, 6-6.9, 5-5.9 and <5 h/day), and tested linear trends in OR. Additionally, interactive effects of working hours and sleep duration on OR were checked. Covariates in the analyses were age, body mass index, drinking, smoking and exercise.

RESULTS

Prevalent and incident headache was found in 1979 (5.5%) men and 707 (3.6%) men, respectively. Working hours were inversely associated with sleep duration. OR for prevalent and incident headache rose with increasing working hours and with reducing sleep duration, regardless of influences of the covariates. Working hours and sleep duration had no interactive effects on OR for prevalent or incident headache.

CONCLUSIONS

The results indicate that long working hours directly and indirectly (via short sleep duration) induce headache even in apparently healthy white-collar men. Headache in employees may be useful for early detection of adverse health effects by long working hours.

Staying in service with posttraumatic headache

Objective:

To predict the probability of a military outcome (medical discharge/retirement) in patients with mild traumatic brain injury from a clinical analysis of predetermined patient and headache characteristics.

Methods:

This retrospective cohort study sampled all new patients referred for headache evaluation at the Brain Injury Clinic of the Womack Army Medical Center, Ft. Bragg, NC (August 2008–January 2010). Headache characteristics were extracted and analyzed. Multivariable binary logistic regressions were conducted to predict probability of medical discharge/retirement.

Results:

Ninety-five soldiers (age 31.3 ± 7.4 years, male 93.7%) reported 166 headaches. The most common injury cited was a blast (53.7%). Patients with a continuous headache have almost 4 times the odds of a medically related discharge/retirement compared to patients without such a headache (continuous headache regression coefficient estimate: p < 0.042, odds ratio 3.98, 95% Wald confidence interval 1.05–15.07). Results suggest that, compared to service members who did not have a continuous headache, patients with headache histories with severe holocephalic pain who medicate to keep functioning had the highest probability of medical discharge/retirement.

Conclusions:

Certain headache characteristics may be predictive of military outcomes after mild traumatic brain injury, and we propose a profile that may be useful in that prediction. These data could be useful in future attempts to assess and treat patients with posttraumatic headache and to advise longer-term planning for return to duty or discharge.