The prevalence of primary headache disorders in Russia: a countrywide survey

Headache prevalence and demographic associations in the Delhi and National Capital Region of India: estimates from a cross-sectional nationwide population-based study

BACKGROUND

India is a large and populous country where reliable data on headache disorders are relatively scarce. This study in northern India (Delhi and National Capital Territory Region [NCR], including surrounding districts in the States of Haryana, Uttar Pradesh and Rajasthan) continues the series of population-based studies within the Global Campaign against Headache and follows an earlier study, using the same protocol and questionnaire, in the southern State of Karnataka.

METHODS

This cross-sectional study used the Global Campaign's established methodology. Biologically unrelated Indian nationals aged 18-65 years were included through multistage random sampling in both urban and rural areas of NCR. Interviews at unannounced household visits followed the structured Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire in its original English version or in the validated Hindi version. Demographic enquiry was followed by a neutral headache screening question and diagnostic questions based on the International Classification of Headache Disorders edition 3 (ICHD-3), which focused on each respondent's most bothersome headache. Questions about headache yesterday (HY) enabled estimation of 1-day prevalence. A diagnostic algorithm first identified participants reporting headache on ≥ 15 days/month (H15+), diagnosing probable medication-overuse headache (pMOH) in those also reporting acute medication use on ≥ 15 days/month, and "other H15+" in those not. To all others, the algorithm applied ICHD-3 criteria in the order definite migraine, definite tension-type headache (TTH), probable migraine, probable TTH. Definite and probable diagnoses were combined.

RESULTS

Adjusted for age, gender and habitation, 1-year prevalences were 26.3% for migraine, 34.1% for TTH, 3.0% for pMOH and 4.5% for other H15+. Female preponderance was seen in all headache types except TTH: migraine 35.7% vs. 15.1% (aOR = 3.3; p < 0.001); pMOH 4.3% vs. 0.7% (aOR = 5.1; p < 0.001); other H15 + 5.9% vs. 2.3% (aOR = 2.5; p = 0.08). One-day prevalence of (any) headache was 12.0%, based on reported HY. One-day prevalence predicted from 1-year prevalence and mean recalled headache frequency over 3 months was slightly lower (10.5%).

CONCLUSIONS

The prevalences of migraine and TTH in Delhi and NCR substantially exceed global means. They closely match those in the Karnataka study: migraine 25.2%, TTH 35.1%. We argue that these estimates can reasonably be extrapolated to all India.

Headache Attributed to a Substance or Its Withdrawal

Identification of substances that may cause or trigger headache is important to start effective treatment early to prevent unnecessary suffering, deterioration in quality of life, and the development of chronic pain. Treatment in case of medication overuse and other chronic headache should be decisive and effective. Drug withdrawal and introduction of effective prophylactic medication for the underlying headache disorder should be the primary treatment strategy. Typical headache-inducing substances are nitric oxide, phosphodiesterase, cocaine, alcohol, histamine, carbon oxide, and calcitonin gene-related peptide. The withdrawal of caffeine, estrogen, and opioids is most often associated with the development of headache.

The prevalence and demographic associations of headache in the adult population of Peru: a national cross-sectional population-based study

BACKGROUND

The Global Campaign against Headache is conducting a series of population-based studies to fill the large geographical gaps in knowledge of headache prevalence and attributable burden. One major region not until now included is South America. Here we present a study from Peru, a country of 32.4 million inhabitants located at the west coast of South America, notable for its high Andes mountains.

METHODS

The study was conducted in accordance with the standardized methodology used by the Global Campaign. It was a cross-sectional survey using cluster randomised sampling in five regions to derive a nationally representative sample, visiting households unannounced, and interviewing one randomly selected adult member (aged 18-65 years) of each using the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire translated into South American Spanish. The neutral screening question ("Have you had headache in the last year?") was followed by diagnostic questions based on ICHD-3 and demographic enquiry.

RESULTS

The study included 2,149 participants from 2,385 eligible households (participating proportion 90.1%): 1,065 males and 1,084 females, mean age 42.0 ± 13.7 years. The observed 1-year prevalence of all headache was 64.6% [95% CI: 62.5-66.6], with age-, gender- and habitation-adjusted prevalences of 22.8% [21.0-24.6] for migraine (definite + probable), 38.9% [36.8-41.0] for tension-type headache (TTH: also definite + probable), 1.2% [0.8-1.8] for probable medication-overuse headache (pMOH) and 2.7% [2.1-3.5] for other headache on ≥ 15 days/month (H15+). One-day prevalence of headache (reported headache yesterday) was 12.1%. Migraine was almost twice as prevalent among females (28.2%) as males (16.4%; aOR = 2.1; p < 0.001), and strongly associated with living at very high altitude (aOR = 2.5 for > 3,500 versus < 350 m).

CONCLUSION

The Global Campaign's first population-based study in South America found headache disorders to be common in Peru, with prevalence estimates for both migraine and TTH substantially exceeding global estimates. H15 + was also common, but with fewer than one third of cases diagnosed as pMOH. The association between migraine and altitude was confirmed, and found to be strengthened at very high altitude. This association demands further study.

The prevalence of headache in the adult population of Morocco: a cross-sectional population-based study

BACKGROUND

The series of population-based studies conducted by the Global Campaign against Headache has, so far, included Pakistan and Saudi Arabia from the Eastern Mediterranean Region. The Maghreb countries of North Africa, also part of this Region, are geographically apart and culturally very different from these countries. Here we report a study in Morocco.

METHODS

We applied the standardised methodology of Global Campaign studies, with cluster-randomized sampling in regions of Morocco selected to be representative of its diversities. In three of these regions, in accordance with this methodology, we made unannounced visits to randomly selected households and, from each, interviewed one randomly selected adult member (aged 18-65 years) using the HARDSHIP structured questionnaire translated into Moroccan Arabic and French. In a fourth region (Fès), because permission for such sampling was not given by the administrative authority, people were randomly stopped in streets and markets and, when willing, interviewed using the same questionnaire. This was a major protocol violation.

RESULTS

We included 3,474 participants, 1,074 (41.7%) from Agadir, 1,079 (41.9%) from Marrakech, 422 (16.4%) from Tétouan and 899 from Fès. In a second protocol violation, interviewers failed to record the non-participating proportion. In the main analysis, excluding Fès, observed 1-year prevalence of any headache was 80.1% among females, 68.2% among males. Observed 1-day prevalence (headache yesterday) was 17.8%. After adjustment for age and gender, migraine prevalence was 30.8% (higher among females [aOR = 1.6]) and TTH prevalence 32.1% (lower among females [aOR = 0.8]). Headache on ≥ 15 days/month (H15+) was very common (10.5%), and in more than half of cases (5.9%) associated with acute medication overuse (on ≥ 15 days/month) and accordingly diagnosed as probable medication-overuse headache (pMOH). Both pMOH (aOR = 2.6) and other H15+ (aOR = 1.9) were more common among females. In the Fès sample, adjusted prevalences were similar, numerically but not significantly higher except for other H15+.

CONCLUSIONS

While the 1-year prevalence of headache among adults in Morocco is similar to that of many other countries, migraine on the evidence here is at the upper end of the global range, but not outside it. H15 + and pMOH are very prevalent, contributing to the high one-day prevalence of headache.

Headache in the adult population of Cameroon: prevalence estimates and demographic associations from a cross-sectional nationwide population-based study

BACKGROUND

Knowledge of headache prevalence, and the burdens attributable to headache disorders, remains incomplete in sub-Saharan Africa (SSA): reliable studies have been conducted only in Zambia (southern SSA) and Ethiopia (eastern SSA). As part of the Global Campaign against Headache, we investigated the prevalence of headache in Cameroon, in Central SSA.

METHODS

We used the same methodology as the studies in Zambia and Ethiopia, employing cluster-randomized sampling in four regions of Cameroon, selected to reflect the country's geographic, ethnic and cultural diversities. We visited, unannounced, randomly selected households in each region, and randomly selected one adult member (aged 18-65 years) of each. Trained interviewers administered the Headache-Attributed Restriction, Disability and Impaired Participation (HARDSHIP) structured questionnaire, developed by an international expert consensus group and translated into Central African French. Demographic enquiry was followed by diagnostic questions based on ICHD-3 criteria.

RESULTS

Headache was a near-universal experience in Cameroon (lifetime prevalence: 94.8%). Observed 1-year prevalence of headache was 77.1%. Age- and gender-adjusted estimates were 76.4% (95% confidence interval: 74.9-77.9) for any headache, 17.9% (16.6-19.3) for migraine (definite + probable), 44.4% (42.6-46.2) for tension-type headache (TTH; also definite + probable), 6.5% (5.7-7.4) for probable medication-overuse headache (pMOH) and 6.6% (5.8-7.6) for other headache on ≥ 15 days/month (H15 +). One-day prevalence ("headache yesterday") was 15.3%. Gender differentials were as expected (more migraine and pMOH among females, and rather more TTH among males). pMOH increased in prevalence until age 55 years, then declined somewhat. Migraine and TTH were both associated with urban dwelling, pMOH, in contrast, with rural dwelling.

CONCLUSIONS

Headache disorders are prevalent in Cameroon. As in Zambia and Ethiopia, estimates for both migraine and TTH exceed global mean estimates. Attributable burden is yet to be reported, but these findings must lead to further research, and measures to develop and implement headache services in Cameroon, with appropriate management and preventative strategies.

The burden of headache disorders in North India: methodology, and validation of a Hindi version of the HARDSHIP questionnaire, for a community-based survey in Delhi and national capital territory region

BACKGROUND

Knowledge of the prevalence and attributable burden of headache disorders in India is sparse, with only two recent population-based studies from South and East India. These produced conflicting results. A study in North India is needed. We report the methodology of such a study using, and validating, a Hindi translation of the Headache-Attributed Restriction, Disability, Social Handicap, and Impaired Participation (HARDSHIP) questionnaire developed by Lifting The Burden (LTB). Almost half of the Indian population speak Hindi or one of its dialects.

METHODS

The study adopted LTB's standardized protocol for population-based studies in a cross-sectional survey using multistage random sampling conducted in urban Delhi and a surrounding rural area. Trained interviewers visited households unannounced, randomly selected one adult member from each and applied the Hindi version of HARDSHIP in face-to-face interviews. The most bothersome headache reported by participants was classified algorithmically into headache on ≥ 15 days/month (H15 +), migraine (including definite and probable) or tension-type headache (including definite and probable). These diagnoses were mutually exclusive. All participants diagnosed with H15 + and a 10% subsample of all others were additionally assessed by headache specialists and classified as above. We estimated the sensitivity and specificity of HARDSHIP diagnoses by comparison with the specialists' diagnoses.

RESULTS

From 3,040 eligible households, 2,066 participants were interviewed. The participating proportions were 98.3% in rural areas but 52.9% in urban Delhi. In the validation subsample of 291 participants (149 rural, 142 urban), 61 did not report any headache (seven of those assessed by HARDSHIP, eight by headache specialists and 46 by both) [kappa = 0.83; 95% CI: 0.74-0.91]. In the remaining 230 participants who reported headache in the preceding year, sensitivity, specificity and kappa with (95% CI) were 0.73 (0.65-0.79), 0.80 (0.67-0.90) and 0.43 (0.34-0.58) for migraine; 0.71 (0.56-0.83), 0.80 (0.730.85) and 0.43 (0.37-0.62) for TTH and 0.75 (0.47-0.94), 0.93 (0.89-0.96) and 0.46 (0.34-0.58) for H15 + respectively.

CONCLUSION

This study validates the Hindi version of HARDSHIP, finding its performance similar to those of other versions. It can be used to conduct population surveys in other Hindi-speaking regions of India.

Health equity, care access and quality in headache - part 1

Current definitions of migraine that are based mainly on clinical characteristics do not account for other patient's features such as those related to an impaired quality of life, due to loss of social life and productivity, and the differences related to the geographical distribution of the disease and cultural misconceptions which tend to underestimate migraine as a psychosocial rather than neurobiological disorder.Global differences definition, care access, and health equity for headache disorders, especially migraine are reported in this paper from a collaborative group of the editorial board members of the Journal of Headache and Pain. Other components that affect patients with migraine, in addition to the impact promoted by the migraine symptoms such as stigma and social determinants, are also reported.

[Mental disorders, social and demographic characteristics of patients with chronic and episodic migraine]

OBJECTIVE

To compare socio-demographic, clinical and psychological characteristics and comorbid mental disorders in patients with chronic migraine (CM) and episodic migraine (EM).

MATERIAL AND METHODS

Eighty patients with migraine (40 with CM (16 men and 24 women, mean age 33.5±6.1 years) and 40 with EM (9 men and 31 women, mean age 31.4±5.7 years) were examined. All patients were interviewed and tested with psychometric methods. Socio-demographic and clinical-psychological characteristics were determined in all patients. The psychiatrist assessed the mental status of patients and diagnosed comorbid mental disorders according to the ICD-10 criteria.

RESULTS

Symptoms of depression, high levels of trait and state anxiety, and a tendency to emotional inadequacy of response were more common in CM patients than in EM patients (p<0.05). Mental disorders, predominantly of the anxiety-depressive spectrum, were more common in CM patients than EM patients (OR (95% CI)=2.54 (2.03 to 2.98, p<0.001). Seventy-five percent of CM patients had more than one psychiatric diagnosis, almost a quarter of CM patients had schizotypal disorder, which is significantly higher than in EM patients (OR (95% CI)=1.99; 1.03 to 2.42, p<0.001). There were more unmarried, single (without constant partner), unemployed, high-education patients in the CM group than in the EM group. The negative impact of headache on the daily activity of patients was significantly higher in the CM group than in the EM group (p<0.05).

CONCLUSION

Mental disorders and psychological features (anxiety, depression symptoms, a tendency to emotional inadequacy of response) are more common in CM patients than in EM patients. The presence of these factors may contribute to the chronification of migraine.

Medication overuse headache: a review of current evidence and management strategies

The third edition of the International Classification of Headache Disorders (ICHD-3) defines medication-overuse headache (MOH) as a headache that develops when a person regularly uses acute or symptomatic headache medications excessively (10 or more, or 15 or more days per month, depending on the medication) for a period of time longer than 3 months. Even though it may not be reported as frequently as it actually is, it affects about 5% of the general population on average. It typically happens following repeated anti-pain medication use for pre-existing headache disorders, such as migraines. Anti-pains can also be used frequently in patients with pre-existing headache disorders for reasons other than treating headaches, such as psychological drug attachment. MOH is linked to a number of illnesses, such as anxiety, depression, and obsessive compulsive disorder (OCD). Both simple and complex types are possible. Additionally, there is no universal consensus on how to treat MOH, but drug discontinuation is the best course of action. Using the medical subject headings "Medication Overuse Headache," "Migraine Headache," "Tension Headache," "Chronification of Headache," and "Antipains," an all-language literature search was done on PubMed, Google Scholar, and Medline up until March 2023. We looked into the epidemiology, risk factors, pathophysiology, clinical characteristics, comorbidities, diagnosis, management, and preventative measures of MOH in the literature. This article focuses on the MOH research themes.

Adult-Onset Neuroepidemiology in Finland: Lessons to Learn and Work to Do

Finland is a relatively small genetic isolate with a genetically non-homogenous population. Available Finnish data on neuroepidemiology of adult-onset disorders are limited, and this paper describes the conclusions that can be drawn and their implications. Apparently, Finnish people have a (relatively) high risk of developing Unverricht-Lundborg disease (EPM1), Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS), Spinal muscular atrophy, Jokela type (SMAJ) and adult-onset dystonia. On the other hand, some disorders, such as Friedreich's ataxia (FRDA) and Wilson's disease (WD), are almost absent or completely absent in the population. Valid and timely data concerning even many common disorders, such as stroke, migraine, neuropathy, Alzheimer's disease and Parkinson's disease, are unavailable, and there are virtually no data on many less-common neurological disorders, such as neurosarcoidosis or autoimmune encephalitides. There also appear to be marked regional differences in the incidence and prevalence of many diseases, suggesting that non-granular nationwide data may be misleading in many cases. Concentrated efforts to advance neuroepidemiological research in the country would be of clinical, administrative and scientific benefit, but currently, all progress is blocked by administrative and financial obstacles.

Assessment of the Prevalence and Level of Awareness of Medication Overuse Headache Among the General Population in Makkah City, Saudi Arabia

BACKGROUND

Medication overuse headache (MOH) is a secondary headache condition caused by consistently using more medication than necessary to treat headache symptoms. MOH is defined as a headache that occurs for 15 or more days per month in a patient with a pre-existing primary headache, and it develops as a result of regular overuse of symptomatic headache medication for more than three months. Patients with headaches often use simple pain medication for 15 or more days per month (e.g., non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol) and 10 or more days per month of opioids, triptans, and combination analgesics, but when there is no relief from these medications, the headache progression can lead to a cycle of consuming more medication with increased pain, which can lead to MOH.

OBJECTIVE

This study aimed to assess the prevalence and awareness of MOH among the general population of Makkah, Saudi Arabia.

METHODS

A cross-sectional study was conducted between December 2022 and March 2023 using a self-administered online questionnaire disseminated through social media. Data were collected from females and males 18 years of age and older living in Makkah, Saudi Arabia.

RESULTS

Overall, 715 individuals completed the questionnaire, 497 of whom were female (69.5%). The average age of the participants was 32.9 years (±13.3 years). The prevalence of MOH among those who reported having experienced headaches throughout their lifetimes was estimated to be 4.5%. Only 134 people (18.7%) were determined to be aware of MOH.

CONCLUSION

This study demonstrated that the general population of Makkah has a high prevalence of MOH and low levels of MOH awareness.

The HARDSHIP databases: a forthcoming free good from the Global Campaign against Headache

In order to pursue its purpose of reducing the global burden of headache, the Global Campaign against Headache has gathered data on headache-attributed burden from countries worldwide. These data, from the individual participants in adult population-based studies and child and adolescent schools-based studies, are being collated in two databases, which will be powerful resources for research and teaching and rich information sources for health policy.Here we briefly describe the structure and content of these databases, and announce the intention to make them available in due course as a free good.

Medication overuse headache

Medication overuse headache (MOH) is a secondary headache disorder attributed to overuse of acute headache medications by a person with an underlying headache disorder, usually migraine or tension-type headache. MOH is common among individuals with 15 or more headache days per month. Although MOH is associated with substantial disability and reductions in quality of life, this condition is often under-recognized. As MOH is both preventable and treatable, it warrants greater attention and awareness. The diagnosis of MOH is based on the history and an unremarkable neurological examination, and is made according to the diagnostic criteria of the International Classification of Headache Disorders third edition (ICHD-3). Pathophysiological mechanisms of MOH include altered descending pain modulation, central sensitization and biobehavioural factors. Treatment of MOH includes the use of headache preventive therapies, but essential to success is eliminating the cause, by reducing the frequency of use of acute headache medication, and perhaps withdrawing the overused medication altogether. Appropriate treatment is usually highly effective, leading to reduced headache burden and acute medication consumption.

Global epidemiology of migraine and its implications for public health and health policy

Migraine is one of more than 200 headache disorders but stands out among these as a major cause of population ill health. In migraine epidemiology, the key variable is prevalence, but, from the perspective of public health, prevalence is uninformative without burden estimates. Here, we discuss how migraine epidemiology, from a quite recent start, has evolved into the respectable though imperfect science of today, but with the legacy that much of the large corpus of older literature is of questionable reliability. Newer studies have benefited from a universally accepted definition of migraine, while methodological developments have broadened the scope of migraine caseness, and published guidelines address important methodological issues. In the light of these developments, we question the apparent increase in migraine prevalence over time, offering explanations as to why this may be illusory. We suggest that the current best estimates are that global migraine prevalence is 14-15%, and that migraine accounts for 4.9% of global population ill health quantified in years lived with disability (YLDs). These evaluations are probably under-quantified rather than over-quantified, and YLDs are not a comprehensive measure of migraine-attributed burden. Despite these uncertainties, such high estimates of population ill health have clear implications for health policy.

[Botulinum toxin type A (Relatox) in transition from medication overuse to non-overuse status in patients with chronic migraine: a subgroup analysis of phase IIIb randomized single-blind multicenter active-controlled parallel-group trial]

OBJECTIVE

To access the effect of Relatox, the first Russian botulinum toxin type A, in patients with chronic migraine (CM) and medication overuse (MO).

MATERIAL AND METHODS

In phase IIIb single-blind randomized multicenter active-controlled parallel-group study, patients with CM were randomized to once intramuscular injections of Relatox (n=101) or onabotulinumtoxin A injections - Botox (n=108). This subgroup analysis evaluated the percentage of patients who transition from medication overuse to non overuse status from baseline; mean changes in the number of headache days, migraine headache days, acute headache medication intakes days, headache intensity, proportion of patients who had a ≥50% reduction in headache days, proportion of the patients with severe (≥60) Headache Impact Test-6 score and with a severe (≥21) MIDAS score in a 28-day periods in each treatment among patients with baseline acute medication overuse via repeated measures.

RESULTS

Of 209 patients with CM, 100% met medication overuse criteria. Relatox and Botox demonstrated significant improvement for overall least squares mean change in headache days, migraine headache days, headache intensity; and headache-related disability and quality of life in CM patients with baseline MO, without differences between the groups. 75% and 70% patients in the Relatox and Botox groups, respectively, achieved ≥50% reduction in headache days from baseline (OR 1.58, CI 95% 0.84; 3.02, p=0.155). Furthermore, Relatox and Botox significant reduced average medication overuse rates in patient with CM and MO at baseline. 62% of patients in the Relatox group and 48% of patients in the Botox group transitioned from medication overuse to non overuse status compared from baseline (OR 2.07, CI 95% 0.91; 4.62, p=0.044). Relatox group had greater reductions than the Botox group in the percentage of patients with acute migraine-specific medication (triptan) overuse (p=0.050).

CONCLUSION

The results demonstrate highly prevalent of medication overuse among individuals with CM. This analysis provides evidence that the Russian botulinum toxin type A Relatox significantly improves measures of headache symptoms, quality of life and headache-related disability, and also significantly greater, compared to Botox, reduces migraine-specific medication consumption in patients with chronic migraine who overuse acute medications.

[Modern principles of primary headaches prevention in children and adolescents]

Headaches in children and adolescents are an actual problem of modern medicine. In most cases, headaches are regarded as a manifestation of vertebrogenic or cerebrovascular pathology, or as a manifestation of autonomic dystonia syndrome which leads to an erroneous diagnosis and treatment. The review considers the factors of occurrence and chronicity of primary headaches (hypodynamia, postural disorders, magnesium and vitamin D deficiency, anxiety and depression, central sensitization, alexithymia), methods for their diagnosis and treatment.

Epidemiology of migraine

Migraine affects over a billion people worldwide and brings with it a huge burden of disability. It is a disease which disproportionally affects the working age population which heightens its economic impact, both at the individual family level and the societal level. Women are significantly more affected by migraine at every age and in all social and geographical groups. At the most severe end of the spectrum, chronic migraine is associated with poorer overall physical and mental health as well as increased risk of unemployment and lower household income. Estimates of the incidence and prevalence of migraine vary with sex, race, ethnicity, geography, socioeconomic, and educational status, suggesting there are many factors at play. In many cases, it is not clear whether these factors are causative of migraine, the effects of migraine, or (as is most likely) a combination of both. Future studies should aim to clarify these links, so that modifiable factors can be addressed where possible and those at risk of developing chronic migraine might receive targeted treatment at an early stage.

[Comparative clinical study of pharmacokinetics and bioequivalence of Relonova and Maxalt]

OBJECTIVE

Evaluation of the bioequivalence of the tested Relonova, tablets, 10 mg and Maxalt, tablets, 10 mg drugs on an empty stomach in healthy volunteers.

MATERIAL AND METHODS

The pharmacokinetic analysis population included 40 volunteers, the safety analysis population included 40 volunteers. The average age of randomized volunteers (men - 20, women - 20) was 29.3±8.9 years, height 1.71±0.09 m, body weight 70.86±11.66 kg, mean BMI 24.18±2.81 kg/m2. The method used high performance liquid chromatography with tandem mass spectrometric detection. Statistical analysis of the obtained data was performed based on the assumption of a log-normal distribution of the parameters AUC0-72 and Cmax.

RESULTS

The ratio of geometric means for the key pharmacokinetic parameters (AUC0-t, AUC0-inf and Cmax) of rizatriptan is close to 90%, CI is within the acceptable range for bioequivalent drugs (80-125%). The intrasubject variability (CVintra) for rizatriptan was 23.74% (Cmax), 10.94% (AUC0-t). The average profiles of the pharmacokinetic curves of rizatriptan when taking the test and reference drugs have similar shapes. Relonova and reference Maxalt are bioequivalent.

CONCLUSION

The results of the study make it possible to recommend Relonova for further clinical study and wide practical application.

[Botulinum toxin type A (Relatox) in the treatment of chronic migraine in adults: results of phase IIIb, randomized, one-blind, multicenter, active-controlled, parallel-group trial]

OBJECTIVE

To access the efficacy and safety of the first Russian botulinum toxin type A (Relatox) as a headache prophylaxis in adult with chronic migraine (CM).

MATERIAL AND METHODS

The randomized, one-blind, multicenter, active-controlled, parallel-group trial study involved 209 patients with CM aged from 19 to 65 years. The patients were randomized to injections of the Russian botulinum toxin type A - Relatox (n=101) or onabotulinumtoxinA injections - Botox (n=108). The duration of the study was 16 weeks, which included five visits of patients every 4 weeks. Relatox and Botox were injected once into seven muscle groups of the head and neck at a dose of 155-195 units. Primary efficacy variable was mean change from baseline in frequency of headache days after 12 weeks. Secondary efficacy variables were mean changes from the baseline to week 12 in frequency of migraine days, acute headache pain medication intakes days; headache intensity; proportion of patients achieving ≥50% reduction from baseline in headache days, the proportion of the patients with medication overuse, the proportion of the patients with severe (≥60) Headache Impact Test-6 score and with a severe (≥21) MIDAS score.

RESULTS

Analyses demonstrated a large mean decrease from baseline in frequency of headache days, without statistically significant between-group differences Relatox vs Botox at week 12 (-10.89 vs -10.06; p=0.365) and at other time points. Significant differences from baseline were also observed for all secondary efficacy variables at all time points without differences between the groups. The proportion of patients achieving ≥50% reduction from baseline in headache days was 75.0% and 70% in the Relatox and Botox groups, respectively (OR, CI 95% 1.58 [0.84; 3.02], p=0.155). Adverse events (AE) occurred in 15.8% of Relatox patients and 15.7% of Botox patients (p=1.000). No unexpected AE were identified.

CONCLUSION

The results demonstrate that the first Russian botulinum toxin type A (Relatox) is an effective prophylactic treatment for CM in adult patients. Relatox led to significant improvements from baseline in multiple measures of headache symptoms, headache-related disability and quality of life. For the first time, a comparative analysis of two botulinum toxin type A products in parallel groups showed no less (not inferior) efficacy and safety of Relatox relative to Botox in the treatment of CM in adults.

The Global Campaign turns 18: a brief review of its activities and achievements

The Global Campaign against Headache, as a collaborative activity with the World Health Organization (WHO), was formally launched in Copenhagen in March 2004. In the month it turns 18, we review its activities and achievements, from initial determination of its strategic objectives, through partnerships and project management, knowledge acquisition and awareness generation, to evidence-based proposals for change justified by cost-effectiveness analysis.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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Efficacy and safety of anti-CGRP(r) monoclonal antibodies in real clinical practice: preliminary analysis after three months of therapy

Monoclonal antibodies inhibiting calcitonin gene related peptide (CGRP) or its receptor have been widely used for migraine prophylactic therapy for the past three years. Evaluation of their efficacy and safety of therapy in real clinical practice is needed.Objective: to evaluate the efficacy and safety of Erenumab, a monoclonal antibody inhibiting the CGRP receptor during three months of therapy.Patients and methods. Sixty-eight patients (58 women and 10 men, mean age 37±10.4 years) with episodic or chronic migraine who were treated with Erenumab were observed. Patients were assessed with MIDAS, WPAI, and HADS scales; the presence of cutaneous allodynia was evaluated with ASC-12 questionnaire. Patients kept a headache diary and marked adverse events during the whole treatment period.Results and discussion. 47 patients (69%) had chronic migraine and 32 (71.9%) had medication overuse headache. In 48 patients (70%) after 3 injections of Erenumab the number of days with migraine decreased by 50% or more. In 7 patients (10%), the reduction in headache days was more than 75%; 20 (29%) did not experience sufficient effect after three months of therapy. Nineteen adverse events were noted in 15 (22%) patients. Severe constipation led to discontinuation of treatment in two patients (3%).Conclusion. The study showed the efficacy and safety of Erenumab for migraine prophylaxis in both patients with episodic and chronic migraine.

Medication overuse headache and awareness

BACKGROUND

Medication overuse headache (MOH) is the worsening of an underlying headache due to the overuse of its acute treatment. Unintentionally, healthcare professionals may contribute to this condition. Health professionals play an important role in preventing this increasingly frequent and difficult-to-treat condition.

OBJECTIVE

To investigate MOH awareness among physicians with headache through a survey conducted among medical doctors on our university campus.

METHODS

This was an observational cross-sectional study about MOH awareness. The total number of medical doctors working in the Dokuz Eylül University Health Campus was provided by the administrative unit. A total of 18 questions were prepared and administered on a voluntary basis to obtain information about MOH awareness.

RESULTS

A total of 312 medical doctors were surveyed, including 198 (63.5%) from internal medical sciences, 81 (26%) from surgical medical sciences, and 33 (10.5%) from basic medical sciences. Half of the physicians in our sample were unaware of MOH. Our results showed that awareness of MOH, was quite low even among medical doctors.

CONCLUSIONS

MOH causes both labor and financial losses to countries and impairs the quality of life of patients. Preventing excessive use of medications by raising awareness among doctors is an important step to prevent the development of MOH.

Treatment of chronic migraine and neck pain with cognitive-behavioral therapy. Case report

The article presents a case of a patient with chronic migraine, neck pain, drug-induced headache and generalized anxiety disorder. We analyzed the relationship between migraines and neck pain. The article discusses the interdisciplinary treatment of chronic migraine, which included educational conversation, detoxification therapy, rational relief of migraine attacks, preventive pharmacotherapy and cognitive-behavioral therapy. The latter allowed to change the patient's perception of the disease, reduce anxiety and catastrophization of pain, cope with fears, stop taking benzodiazepines, reduce the intake of pain relievers, and increase daily activity and productivity at work. Clinical efficacy (reduction in the frequency of headaches per month by 50% or more) was achieved after 3 months of treatment. Long-term (12 months) follow-up of the patient showed long-term clinical effect of the interdisciplinary treatment.

Abuse of medications for the treatment of migraines: results of an online survey

Background. The abuse of headache medications is an important factor in the formation of drug-induced headache. Aim. To determine the prevalence and nature of drug use among patients with migraine and chronic cephalgic syndrome. Materials and methods. An Internet survey was conducted among 1598 Internet users, as well as through social networks (Instagram, Facebook, VK) using Google Forms. Results. 60% of respondents with chronic headache and migraine symptoms did not have a reliable diagnosis. More than 70% of patients choose a drug for pain relief on their own and 62.7% take the drug in every headache attack. Conclusion. Among patients with chronic headaches and migraines, there is a high percentage of people abusing symptomatic drugs, which indicates a high risk of drug-induced headache formation.

Structured headache services as the solution to the ill-health burden of headache. 2. Modelling effectiveness and cost-effectiveness of implementation in Europe: methodology

BACKGROUND

Health economic evaluations support health-care decision-making by providing information on the costs and consequences of health interventions. No universally accepted methodology exists for modelling effectiveness and cost-effectiveness of interventions designed to close treatment gaps for headache disorders in countries of Europe (or elsewhere). Our aim here, within the European Brain Council's Value-of-Treatment project, was to develop headache-type-specific analytical models to be applied to implementation of structured headache services in Europe as the health-care solution to headache.

METHODS

We developed three headache-type-specific decision-analytical models using the WHO-CHOICE framework and adapted these for three European Region country settings (Luxembourg, Russia and Spain), diverse in geographical location, population size, income level and health-care systems and for which we had population-based data. Each model compared current (suboptimal) care vs target care (delivered in accordance with the structured headache services model). Epidemiological and economic data were drawn from studies conducted by the Global Campaign against Headache; data on efficacy of treatments were taken from published randomized controlled trials; assumptions on uptake of treatments, and those made for Healthy Life Year (HLY) calculations and target-care benefits, were agreed with experts. We made annual and 5-year cost estimates from health-care provider (main analyses) and societal (secondary analyses) perspectives (2020 figures, euros).

RESULTS

The analytical models were successfully developed and applied to each country setting. Headache-related costs (including use of health-care resources and lost productivity) and health outcomes (HLYs) were mapped across populations. The same calculations were repeated for each alternative (current vs target care). Analyses of the differences in costs and health outcomes between alternatives and the incremental cost-effectiveness ratios are presented elsewhere.

CONCLUSIONS

This study presents the first headache-type-specific analytical models to evaluate effectiveness and cost-effectiveness of implementing structured headache services in countries in the European Region. The models are robust, and can assist policy makers in allocating health budgets between interventions to maximize the health of populations.

Candidate Genes and Proteomic Biomarkers of Serum and Urine in Medication-Overuse Headache

Chronic headache is a topical problem of neurology, psychiatry and general practice. The medication-overuse headache (MOH) is one of the leading pathologies in the structure of chronic headache. However, early diagnosis of the MOH is challenging. We analyzed potential proteomic biomarkers of serum and urine in patients with MOH.

METHODS

We searched PubMed, Springer, Scopus, Web of Science, ClinicalKey, and Google Scholar databases for English publications over the past 10 years using keywords and their combinations.

RESULTS

We found and analyzed seven studies that met the search criteria for the purpose of the review, including 24 serum proteomic biomarkers and 25 urine proteomic biomarkers of MOH. Moreover, the candidate genes and locus of the studied serum (vitamin D-binding protein, lipocalin-type prostaglandin D2 synthase, apolipoprotein E, etc.) and urine proteomic biomarkers (uromodulin, alpha-1-microglobulin, zinc-alpha-2-glycoprotein, etc.) of MOH are presented in this review.

CONCLUSIONS

The serum and urine proteomic biomarkers of MOH can potentially help with the identification of patients with MOH development. Due to the relevance of the problem, the authors believe that further investigation of the MOH proteomic biomarkers in different ethnic and racial groups of patients with primary headache is necessary. In addition, it is important to investigate whether medications of different drug classes influence the levels of serum and urine proteomic biomarkers.

Structured headache services as the solution to the ill-health burden of headache. 3. Modelling effectiveness and cost-effectiveness of implementation in Europe: findings and conclusions

BACKGROUND

There have been several calls for estimations of costs and consequences of headache interventions to inform European public-health policies. In a previous paper, in the absence of universally accepted methodology, we developed headache-type-specific analytical models to be applied to implementation of structured headache services in Europe as the health-care solution to headache. Here we apply this methodology and present the findings.

METHODS

Data sources were published evidence and expert opinions, including those from an earlier economic evaluation framework using the WHO-CHOICE model. We used three headache-type-specific analytical models, for migraine, tension-type-headache (TTH) and medication-overuse-headache (MOH). We considered three European Region case studies, from Luxembourg, Russia and Spain to include a range of health-care systems, comparing current (suboptimal) care versus target care (structured services implemented, with provider-training and consumer-education). We made annual and 5-year cost estimates from health-care provider and societal perspectives (2020 figures, euros). We expressed effectiveness as healthy life years (HLYs) gained, and cost-effectiveness as incremental cost-effectiveness-ratios (ICERs; cost to be invested/HLY gained). We applied WHO thresholds for cost-effectiveness.

RESULTS

The models demonstrated increased effectiveness, and cost-effectiveness (migraine) or cost saving (TTH, MOH) from the provider perspective over one and 5 years and consistently across the health-care systems and settings. From the societal perspective, we found structured headache services would be economically successful, not only delivering increased effectiveness but also cost saving across headache types and over time. The predicted magnitude of cost saving correlated positively with country wage levels. Lost productivity had a major impact on these estimates, but sensitivity analyses showed the intervention remained cost-effective across all models when we assumed that remedying disability would recover only 20% of lost productivity.

CONCLUSIONS

This is the first study to propose a health-care solution for headache, in the form of structured headache services, and evaluate it economically in multiple settings. Despite numerous challenges, we demonstrated that economic evaluation of headache services, in terms of outcomes and costs, is feasible as well as necessary. Furthermore, it is strongly supportive of the proposed intervention, while its framework is general enough to be easily adapted and implemented across Europe.

The first prevalence study of primary headaches in adults in a post-conflict area of Serbia

AIM

The aim of the present study was to establish annual prevalence of primary headaches, migraine, and tension-type headache among adults in a post-conflict area of Serbia.

METHODS

The data for this cross-sectional study was obtained via face-to-face interviews using questionnaires specifically designed for this purpose, in line with the available guidelines. The study sample included adults aged 18-65 years whose native language is Serbian with residence in six predominantly Serbian communities in Kosovo and Metohija. Relevant diagnoses were established according to the diagnostic criteria of the International Classification of Headache Disorders, 3rd edition.

RESULTS

The study included 1062 adults. Analyses indicated 47.7% prevalence of primary headaches. The 1-year prevalence of migraine (with aura and without aura) and tension-type headache was established at 15.2% (3.3% and 11.9%), and 32.2%, respectively. One-year prevalence of chronic headache was calculated at 3.5%, while the prevalence of medication overuse headache was slightly lower at 2.9%. Primary headaches were more prevalent among women, participants residing south of the river Ibar, married or cohabiting individuals, as well as among interviewees (persons) who reported feeling unsafe in Kosovo and Metohija. This is the first study of the prevalence of primary headache disorders in Serbia. The obtained data is comparable to the data available for other countries, especially those in the Balkan region.

Migraine: epidemiology and systems of care

Migraine is a neurovascular disorder that affects over 1 billion people worldwide. Its widespread prevalence, and associated disability, have a range of negative and substantial effects not only on those immediately affected but also on their families, colleagues, employers, and society. To reduce this global burden, concerted efforts are needed to implement and improve migraine care that is supported by informed health-care policies. In this Series paper, we summarise the data on migraine epidemiology, including estimates of its very considerable burden on the global economy. First, we present the challenges that continue to obstruct provision of adequate care worldwide. Second, we outline the advantages of integrated and coordinated systems of care, in which primary and specialist care complement and support each other; the use of comprehensive referral and linkage protocols should enable continuity of care between these systems levels. Finally, we describe challenges in low and middle-income countries, including countries with poor public health education, inadequate access to medication, and insufficient formal education and training of health-care professionals resulting in misdiagnosis, mismanagement, and wastage of resources.

[Cognitive and emotional disorders in patients with migraine and signs of leukoencephalopathy]

OBJECTIVE

To identify cognitive and emotional disorders and their correlation with neuroimaging parameters in patients with chronic migraine.

MATERIAL AND METHODS

We examined 50 patients (8 men and 42 women, mean age 41.9±11.9 years) with migraine, including 31 with chronic migraine, and signs of leukoencephalopathy according to magnetic resonance imaging (MRI). A control group comprised 40 healthy individuals (13 men and 27 women) aged 20 to 64 years (mean 42.6±12.0 years). A number of tests for neuropsychological examination and assessment of the emotional state, including a 12-word test, literal and categorical associations, Benton Test, the Montreal cognitive scale (MOCA), the Hospital Depression Scale, the Beck Depression Scale, the Center for Epidemiological Research scale, the Hospital Anxiety Scale and the Spielberger-Khanin scale, were administered at baseline and after 3 and 6 month of preventive therapy.

RESULTS

Patients with migraine had lower scores (p=0.004) on MOCA, memorization of 12 words (p=0.0003), test for literal (p=0.001) and categorical associations (p=0.0002) compared with the control group. No significant correlations were found between the volume of white matter lesions according to MRI and the severity of cognitive impairment. An inverse correlation of average strength was noted (correlation coefficient R=-0.41) between the number of days with headache per month and the MOCA score (p<0.05). In patients with migraine, signs of depression were found on the Hospital Depression Scale (p=0.04), Beck Depression Scale (p=0.003), the Center for Epidemiological Research scale (p=0.0001), and increased anxiety on the Hospital Anxiety Scale (p=0.0001) and the Spielberger-Khanin scale (p=0.0001). A significant relationship was found between the degree of depression and the MOCA score (p=0.007). The frequency of headaches decreased from 19.4±2.9 to 12.6±4.4 days per month (p<0.05).

CONCLUSION

There were a significant decrease of emotional disorders and improvement of cognitive functions compared with baseline scores during the 6 month therapy. Preventive treatment of migraine and concomitant emotional disorders seems to be the most effective way to improve cognitive functions.

A population-based survey for disabling headaches in Greece: Prevalence, burden and treatment preferences

OBJECTIVE

To estimate the prevalence, burden and current treatment of disabling primary headaches in a large sample of the Greek population aged 18-70 years old.

METHODS

This is an observational descriptive study, with cross-sectional design performed by quantitative computer-assisted telephone interviews, using a validated 37-item questionnaire for headaches. The prevalence, burden, and current treatment of primary headaches (ICHD-3) were recorded along with participants' treatment preferences.

RESULTS

Out of 10,008 interviewed participants, 1197 (12.0%) reported headaches affecting performance. The annual prevalence of migraine was 8.1% (95% confidence interval, 7.6-8.7, corresponding to 0.6 million Greeks), of chronic migraine 1.0% (95% confidence interval, 0.8-1.2, corresponding to 0.1 million), and of tension-type headache 3.8% (95% confidence interval, 3.4-4.2, corresponding to 0.3 million). The participants with headaches reported 0.5 headache-induced lost workdays per month (corresponding to 5.8 million lost workdays annually) and reductions in performance on 2.8 workdays per month (corresponding to 30.9 million workdays annually). In all, 43.4% of headache participants felt bad/ashamed because of headaches and 21.9% sought professional treatment, most often from a private neurologist. 83.8% of headache participants had never taken pharmacological prophylaxis, and only 5.5% were currently under preventative treatment. For both prophylactic and acute treatment, headache participants prefer oral medication to injection or stimulation devices.

CONCLUSION

More than 10% of the Greek adult population up to 70 years old experience disabling headaches, causing a dramatic work loss. More than 80% of these have never taken pharmacological prophylaxis. Thus, enriching the quality of life of people with headaches relies crucially on expanding awareness about headaches and their treatment.

Diagnosis and treatment of migraine: Russian experts' recommendations

Migraine is one of the most common types of headache, which can lead to a significant decrease in quality of life. Researchers identify migraine with aura, migraine without aura, and chronic migraine that substantially reduces the ability of patients to work and is frequently concurrent with mental disorders and drug-induced headache. The complications of migraine include status migrainosus, persistent aura without infarction, migrainous infarction (stroke), and a migraine aura-induced seizure. The diagnosis of migraine is based on complaints, past medical history, objective examination data, and the diagnostic criteria as laid down in the International Classification of Headache Disorders, 3 rd edition. Add-on trials are recommended only in the presence of red flags, such as the symptoms warning about the secondary nature of headache. Migraine treatment is aimed at reducing the frequency and intensity of attacks and the amount of analgesics taken. It includes three main approaches: behavioral therapy, seizure relief therapy, and preventive therapy. Behavioral therapy focuses on lifestyle modification. Nonsteroidal anti-inflammatory drugs, simple and combined analgesics, triptans, and antiemetic drugs for severe nausea or vomiting are recommended for seizure relief. Preventive therapy which includes antidepressants, anticonvulsants, beta-blockers, angiotensin II receptor antagonists, botulinum toxin type A-hemagglutinin complex and monoclonal antibodies to calcitonin gene-related peptide or its receptors, is indicated for frequent or severe migraine attacks and for chronic migraine. Pharmacotherapy is recommended to be combined with non-drug methods that involves cognitive behavioral therapy; progressive muscle relaxation; mindfulness; biofeedback; post-isometric relaxation; acupuncture; therapeutic exercises; greater occipital nerve block; non-invasive high-frequency repetitive transcranial magnetic stimulation; external stimulation of first trigeminal branch; and electrical stimulation of the occipital nerves (neurostimulation).

Secondary headache attributed to exposure to or overuse of a substance

BACKGROUND

Secondary headaches attributed to exposure to or the overuse of a substance are classified under chapter eight in the International Classification of Headache Disorders 3rd edition. Three distinct sub-chapters consider: 1. Headache attributed to exposure to a substance, 2. Medication overuse headache, and 3. Headache attributed to substance withdrawal. Headache attributed to exposure to a substance refers to a headache with onset immediately or within hours after the exposure, while medication overuse headache is a headache occurring on 15 or more days per month that has developed as a consequence of regular usage of acute headache medication(s) for more than three consecutive months in a patient with a pre-existing primary headache disorder. The withdrawal of caffeine, oestrogen, and opioids is most often associated with the development of headache.

DISCUSSION

Despite the current headache classification, there is no certainty of a causal relationship between the use of any substance and the development of headache. Some substances are likely to provoke headache in patients that suffer from a primary headache disorder like migraine, tension-type headache or cluster headache, while others were described to cause headache even in people that generally do not get headaches. Toxic agents, such as carbon monoxide (CO) are difficult to investigate systematically, while other substances such as nitric oxide (NO) were specifically used to induce headache experimentally. If a patient with an underlying primary headache disorder develops a headache, in temporal relation to exposure to a substance, which is significantly worse than the usual headache it is considered secondary. This is even more the case if the headache phenotype is different from the usually experienced headache characteristics. Medication overuse headache is a well-described, distinct disease entity with only marginally understood pathophysiology and associated psychological factors. Managing medication overuse headache patients includes education, detoxification, prophylactic treatments and treating comorbidities, which is reflected in available guidelines. Viewing medication overuse headache as a separate entity helps clinicians and researchers better recognise, treat and study the disorder.

CONCLUSION

Identification of substances that may cause or trigger secondary headache is important in order to educate patients and health care professionals about potential effects of these substances and prevent unnecessary suffering, as well as deterioration in quality of life. Treatment in case of medication overuse and other chronic headache should be decisive and effective.

The prevalence of headache disorders in children and adolescents in Lithuania: a schools-based study

BACKGROUND

While the Global Burden of Disease (GBD) study reports headache disorders as the second-highest cause of disability worldwide, the headache data in GBD come very largely from adults. This national study in Lithuania was part of a global schools-based programme within the Global Campaign against Headache contributing data from children (7-11 years) and adolescents (12-17 years).

METHODS

The methods followed the generic protocol for the global study. The basic study design was a cross-sectional survey. Self-completed structured questionnaires were administered, within classes, in 24 schools selected from seven regions of Lithuania to be nationally representative. Headache diagnostic questions were based on ICHD-3 beta criteria but for the inclusion of undifferentiated headache (UdH).

RESULTS

Of 3714 potential participants, 2505 (children 1382 [55.2%], adolescents 1123 [44.8%]; males 1169 [46.7%], females 1336 [53.3%]) completed the questionnaire. Adolescents and males were therefore relatively under-represented, with non-participation (32.6%) due in most cases to lack of parental consent. Observed lifetime prevalence of headache was 92.2%. Gender- and age-adjusted 1-year prevalence was 76.6% (migraine: 21.4%; tension-type headache [TTH]: 25.6%; UdH: 24.0%; all headache on ≥15 days/month: 3.9%; probable medication-overuse headache: 0.8%). All headache types except UdH were more prevalent among females than males, and among adolescents than children. UdH showed a complex relationship with age, but represented 38.0% of all reported headache in children, 27.4% in adolescents. Headache yesterday (HY) was reported by 17.5%, almost double the 9.8% predicted from prevalence and headache frequency to have headache on any day. The reason was unclear.

CONCLUSIONS

Findings were not very different from those reported in Turkey and Austria, but with more TTH. Headache has, therefore, again been shown to be common in children and adolescents, and UdH confirmed as a headache type that must be recognised and included in accounts of headache in these age groups.

Pain rates in general population for the period 1991-2015 and 10-years prediction: results from a multi-continent age-period-cohort analysis

Background

Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people. The aims of this study are to evaluate the temporal variations of pain rates among general populations for the period 1991–2015 and to project 10-year pain rates.

Methods

We used the harmonized dataset of ATHLOS project, which included 660,028 valid observations in the period 1990–2015 and we applied Bayesian age–period–cohort modeling to perform projections up to 2025. The harmonized Pain variable covers the content “self-reported pain experienced at the time of the interview”, with a dichotomous (yes or no) modality.

Results

Pain rates were higher among females, older subjects, in recent periods, and among observations referred to cohorts of subjects born between the 20s and the 60s. The 10-year projections indicate a noteworthy increase in pain rates in both genders and particularly among subjects aged 66 or over, for whom a 10–20% increase in pain rate is foreseen; among females only, a 10–15% increase in pain rates is foreseen for those aged 36–50.

Conclusions

Projected increase in pain rates will require specific interventions by health and welfare systems, as pain is responsible for limited quality of subjective well-being, reduced employment rates and hampered work performance. Worksite and lifestyle interventions will therefore be needed to limit the impact of projected higher pain rates.

Cognitive impairment in chronic migraine: a cross-sectional study in a clinic-based sample

Cognitive impairment has been described in all phases of a migraine attack and interictally. However, the prevalence and phenotype of such impairment in chronic migraine (CM) have not yet been studied.

OBJECTIVES

The aim of this study was to evaluate both the prevalence of the objective cognitive deficit in patients with CM and the factors underlying its etiology.

METHODS

144 patients with CM and 44 age-matched patients with low-frequency episodic migraine (EM) (a maximum of 4 headache days per month) participated in this study. Neuropsychiatric characteristics were measured with the HADS Hospital Anxiety and Depression Scale. Cognitive function was assessed with the Montreal Cognitive Assessment (MoCA), Digit Symbol Substitution Test (DSST), Rey Auditory Verbal Learning Test (RAVLT), and the Perceived Deficits Questionnaire (PDQ-20).

RESULTS

Compared to EM, CM subjects demonstrated higher subjective and objective cognitive impairment across all tests. CM patients had 4 times higher odds of achieving a RAVLT score in the lower quartile range compared to EM (Odds Ratio [OR] 3.8; 95% confidence interval [95%CI] 1.5‒9.6; р=0.005). In the MoCA, CM patients demonstrated the most striking impairment in memory/delayed recall (65.3%), attention (46.5%), abstraction (30.6%), and language (27.1%). Chronic headache and level of education, but not gender, depression or anxiety, were independent predictors of cognitive impairment.

CONCLUSIONS

Cognitive impairment is prevalent in the CM population during their mildest possible pain and may be caused by a central sensitization. Timely preventive treatment of EM is warranted.

[Migraine burden and clinical inertia: what can we do?]

AIM

To study the compliance of neurologists and headache specialists to chronic headache and chronic migraine (CM) diagnosis and treatment guidelines.

MATERIAL AND METHODS

The survey included 634 neurologists from all regions of the Russian Federation. Mean age of respondents was 40.7±8.5 years, mean years of experience 14.2±7.8 years.

RESULTS

Most doctors work in outpatient or hospital settings (49% and 24%, respectively), 7% were headache specialists. Tension-type headache (TTH) was diagnosed in 30% and CM in 17% of patients while 44% of patients were presumed to have a mixed headache disorder (TTH+CM). Only 10% of physicians do not use instrumental diagnostic methods in chronic headache. This study has shown sufficient attention to comorbid conditions and frequent prescription of headache preventative treatment. Botox prescription data is equivocal: 35% of physicians recommend such treatment, 27% do not, while other doctors prescribe it for off-label indications.

CONCLUSION

To overcome clinical inertia, further education in chronic headaches and their optimal treatment is warranted.

The prevalence of primary headache disorders in Saudi Arabia: a cross-sectional population-based study

BACKGROUND

The large geographical gaps in our knowledge of the prevalence and burden of headache disorders include most of Eastern Mediterranean Region (EMR). Following a nationwide population-based study in Pakistan, we present here a similar study from Kingdom of Saudi Arabia (KSA). Both were conducted as projects within the Global Campaign against Headache The two purposes of this study were to inform national health policy and contribute to global knowledge of headache disorders.

METHODS

We surveyed Arabic-speaking adults aged 18-65 years in all 13 regions of KSA. While previous Global Campaign studies have engaged participants by calling at randomly selected households, the culture of KSA made this unacceptable. Participants were, instead, contacted by cell-phone (since cell-phone coverage exceeded 100% in KSA), using random-digit dialling. Trained interviewers used a culturally adapted version of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire, with diagnostic enquiry based on ICHD-II. We estimated 1-year prevalences of the headache disorders of public-health importance (migraine, tension-type headache [TTH] and probable medication-overuse headache [pMOH]) and examined their associations with demographic variables.

RESULTS

A total of 2316 participants (mean age of 32.2 ± 10.7 years; 62.3% male; 37.7% female) were included (participation proportion 86.5%). Gender and age distributions imperfectly matched those of the national population, requiring adjustments for these to prevalence estimates. Observed 1-year prevalence of all headache was 77.2%, reducing to 65.8% when adjusted. For headache types, adjusted 1-year prevalences were migraine 25.0%, TTH 34.1%, pMOH 2.0% and other headache on ≥15 days/month 2.3%. Adjusted 1-day prevalence of any headache was 11.5%. Migraine and pMOH were associated with female gender (ORs: 1.7 and 4.7; p < 0.0001). Migraine was negatively associated with age > 45 years (OR: 0.4; p = 0.0143) while pMOH was most prevalent in those aged 46-55 years (OR: 2.7; p = 0.0415). TTH reportedly became more common with increasing level of education.

CONCLUSION

Prevalences of migraine and TTH in KSA are considerably higher than global averages (which may be underestimated), and not very different from those in Pakistan. There is more pMOH in KSA than in Pakistan, reflecting, probably, its higher-income status and greater urbanisation (facilitating access to medication).

Primary headache disorders among the adult population of Mongolia: prevalences and associations from a population-based survey

BACKGROUND

In the ongoing Global Campaign endeavour to improve knowledge and awareness of headache prevalence worldwide, Mongolia is a country of interest. It sits between Russia and China, in which prevalence is, respectively, much higher and much lower than the estimated global mean. We conducted a population-based study in Mongolia both to add to knowledge and to inform local health policy.

METHODS

Using standardized methodology with cluster random sampling, we selected Mongolian adults (aged 18-65 years) from five regions reflecting the country's diversities. They were interviewed by trained researchers, cold-calling at their homes, using the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) structured questionnaire following pilot-testing. ICHD-3 beta diagnostic criteria were applied.

RESULTS

N = 2043 (mean age 38.0 [±13.4] years, 40% urban-dwelling and 60% rural), with a non-participation proportion of 1.7%. Males were somewhat underrepresented, for which corrections were made. The crude 1-year prevalence of any headache was 66.1% (95% CI: 64.0-68.2%), with a strong female preponderance (OR: 2.2; p < 0.0001). Age- and gender-adjusted prevalences were: migraine 23.1% (for females, OR = 2.2; p < 0.0001); tension-type headache (TTH) 29.1% (no gender difference); probable medication-overuse headache (pMOH) 5.7% (trending towards higher in females); other headache on ≥15 days/month 5.0% (for females, OR = 2.2; p = 0.0008). Unclassified cases were only 35 (1.7%). Any headache yesterday was reported by 410 (20.1%; for females, OR = 2.4; p < 0.0001). Only pMOH showed a strong association with age, peaking in middle years with a 5-fold increase in prevalence. Migraine showed a consistent association with educational level, while pMOH showed the reverse, and was also more common among other groups than among participants who were single (never married). Migraine was less common among rural participants than urban (OR: 0.80; p = 0.0326), while pMOH again showed the reverse (OR: 2.4; p < 0.0001). Finally, pMOH (but not migraine or TTH) was significantly associated with obesity (OR: 1.8; p = 0.0214).

CONCLUSION

Headache disorders are common in Mongolia, with, most notably, a very high prevalence of headache on ≥15 days/month corroborated by the high prevalence of headache yesterday. The picture is very like that in Russia, and dissimilar to China. There are messages for national health policy.

Hormonal contraceptives and the risk of ischemic stroke in women with migraine: a new international consensus

The paper is devoted to the safe use of hormonal contraception in women with migraine, an urgent interdisciplinary problem daily faced by gynecologists, neurologists, and specialists in headache diagnosis and treatment. It gives information on the prevalence of migraine, the risk of ischemic stroke and other cardiovascular disorders in women with different types of migraine, including those receiving contraception and hormone replacement therapy. The paper presents the main provisions of the new interdisciplinary consensus «Hormonal contraceptives and the risk of ischemic stroke in women who have migraine», which are recommended to be taken into account by specialists of any profile when prescribing hormonal therapy to women with migraine in order to avoid cardiovascular events.

Monitoring chronic headache and medication-overuse headache prevalence in Denmark

Objectives

To study chronic headache and medication-overuse headache (MOH) prevalence; to identify groups with high prevalence of these conditions; and to identify the most frequently used pain medications among respondents with chronic headache.

Background

Chronic headache and MOH prevalence in Denmark were last estimated in 2010.

Methods

In this cross-sectional study, 104,950 individuals aged ≥16 years were randomly sampled for the 2017 Danish Capital Region Health Survey. Responses to questions about headache and use of acute pain medications were linked to demographic registries. MOH was defined as headache ≥15 days/month plus self-report of use of pain medications ≥10 or 15 days/month, in the last three months. Weighted prevalence proportions were calculated.

Results

Among 55,185 respondents, chronic headache prevalence was 3.0% (95% CI: 2.3–3.2) and MOH prevalence was 2.0% (95% CI: 1.8–2.1). Both conditions were more common among females and the middle-aged. Respondents on social welfare or receiving early retirement pensions had the highest prevalences. Among those with chronic headache, 44.7% overused over-the-counter analgesics for headache; paracetamol 41.5%; a combination of different pain relievers 25.3%; ibuprofen 21.9%; opioids 17.0%; combination preparations 14.3%; and triptans 9.1%.

Conclusions

The highest prevalence of chronic headache and MOH was seen among people with low socioeconomic position. Overuse of paracetamol was most common. Reported opioid use was higher than expected. Groups with high prevalence of MOH should be the focus of public health interventions on rational use of OTC and prescription pain medications.

The organizations of specialized medical care for patients with headache

Primary headaches are common diseases in the clinical practice. Affecting the active, able-bodied population, impairing the quality of life and causing social maladjustment, they are of immense social significance. The medical care for patients with headaches ought to be complex and include a patient’s educational program, rational pharmaceutical therapy, detection and correction of comorbid functional disorders, nonpharmaceutical therapy. Despite an adequate therapy, the treatment satisfaction remains low and stimulates development of individualized treatment algorithms, that take into account the patient’s personal characteristics. They should be applicable both for the self treatment and for the use in the neurological and general practice.