Cost-effectiveness analysis of interventions for migraine in four low- and middle-income countries

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.

Advocacy for patients with headache disorders

Primary headache disorders are worldwide highly prevalent and burdensome and should be therefore considered as a global public health priority. However, too many patients with primary headache disorders still do not receive satisfying care. The most likely identified reasons for such a scenario - lack of public awareness, stigma, lack of trained professionals with inadequate healthcare systems and policies - are remediable. Despite the progresses that were made in headache advocacy, these efforts have not yielded substantial improvements in research funding or access to specialty care and even standards of care. The situation is more complex in Low and Middle Income Countries (LMICs) where headache advocacy is urgently needed given the magnitude of the difficulties that patients with primary headache disorders face in accessing care. The growing emergence of coordinated, collaborative, patient-centered advocacy efforts with improved patient-clinician partnership is an opportunity to enhance progress in advocacy for a satisfying life and optimal and equitable care for people with primary headache disorders. LMICs can benefit greatly from coordinating these efforts on a global scale. The recent organization of a training program on headache diagnosis and management for healthcare professionals in Africa is a concrete example.

The relationship between headache-attributed disability and lost productivity: 3 Attack frequency is the dominating variable

BACKGROUND

In an earlier paper, we examined the relationship between headache-attributed disability, measured as proportion of time in ictal state, and lost productivity. In a linear model, we found positive and significant associations with lost paid worktime, lost household worktime and total lost productivity (paid + household), but with high variance, which was increased when headache intensity was introduced as a factor. We speculated that analyses based on headache frequency alone as the independent variable, eliminating both the subjectivity of intensity estimates and the uncertainties of duration, might show stronger associations.

METHODS

Focusing on migraine, we used individual participant data from 16 countries surveyed either in population-based studies or in the Eurolight project. These data included frequency (headache days/month), usual attack duration (hours), usual headache intensity ("not bad", "quite bad", "very bad") and lost productivity from paid and household work according to enquiries using the Headache-Attributed Lost Time (HALT) questionnaire. We used multiple linear regressions, calculating regression equations along with unstandardized and standardized regression coefficients. We made line and bar charts to visualize relationships.

RESULTS

Both frequency and intensity were significant predictors of lost productivity in all multiple linear regressions, but duration was a non-significant predictor in several of the regressions. Predicted productivity in paid work decreased among males by 0.75-0.85 days/3 months for each increase of 1 headache day/month, and among females by 0.34-0.53 days/3 months. In household chores, decreases in productivity for each added day/month of headache were more similar (0.67-0.87 days/3 months among males, 0.83-0.89 days/3 months among females). Visualizations showed that the impact of duration varied little across the range of 2-24 h. The standardized regression coefficients demonstrated that frequency was a much better predictor of lost productivity than intensity or duration.

CONCLUSION

In the relationship between migraine-attributed impairment (symptom burden) and lost productivity, frequency (migraine days/month) is the dominating variable - more important than headache intensity and far more important than episode duration. This has major implications for current practice in headache care and for health policy and health-resource investment. Preventative drugs, grossly underutilized in current practice, offer a high prospect of economic benefit (cost-saving), but new preventative drugs are needed with better efficacy and/or tolerability.

Barriers to headache care in low- and middle-income countries

Headache disorders are a common cause of disability globally and lead not only to physical disability but also to financial strain, higher rates of mental health disorders such as depression and anxiety, and reduced economic productivity which negatively impacts gross domestic product (GDP) on a national scale. While data about headache are relatively scarce in low- and middle-income countries (LMICs), those available suggest that headache disorders occur on a similar scale in LMICs as they do in high-income countries. In this manuscript, we discuss common clinical, political, economic and social barriers to headache care for people living in LMICs. These barriers, affecting every aspect of headache care, begin with community perceptions and cultural beliefs about headache, include ineffective headache care delivery systems and poor headache care training for healthcare workers, and extend through fewer available diagnostic and management tools to limited therapeutic options for headache. Finally, we review potential solutions to these barriers, including educational interventions for healthcare workers, the introduction of a tiered system for headache care provision, creation of locally contextualized diagnostic and management algorithms, and implementation of a stepped approach to headache treatment.

Direct cost and healthcare resource utilization of patients with migraine before treatment initiation with calcitonin gene-related peptide monoclonal antibodies by the number of prior preventive migraine medication classes

OBJECTIVE

This study compared all-cause direct cost and healthcare resource utilization (HCRU) among preventive migraine medication (PMM)-naïve patients and patients with up to 3 PMM category switches before initiating calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs).

METHODS

This was a retrospective analysis of the IBM Marketscan database. Patients who initiated injectable CGRP mAbs between May 2018 and December 2019 (index period) were included in 4 groups based on the number of prior non-CGRP PMM classes used during the 24-month pre-index period: P0 = none; P1 = one; P2 = two; P3 ≥ three. All-cause direct cost and HCRU for groups were compared without adjustment and after generalized propensity score (GPS) matching.

RESULTS

Of the 23,288 patients included (mean age ± standard deviation [SD] 45.4 ± 12.0 years), 85.6% were females, and the mean Charlson Comorbidity Index was 0.69 ± 1.2. P3 group had the highest average annual unadjusted total healthcare costs per patient ($50,274±$76,629); the highest costs attributed to procedure/imaging-related expenses ($20,105±$36,401) and pharmacy ($11,633±$29,763). P0 group had the lowest cost ($25,288±$41,427). Pairwise comparison of GPS matched costs showed significantly greater average annual direct costs per patient in the P3 group vs. P0 (p = .003), P1 (p = .014), and P2 (p = .021) groups. GPS matched HCRU also increased with the number of prior PMM classes used. Anti-epileptics (48.9%) were the most commonly used PMM class, with triptans (75.2%) being the most common acute medication class.

CONCLUSIONS

Total direct healthcare cost and HCRU increased significantly with increasing use of PMM classes with the greatest cost difference existing between the P0 and the P3 groups.

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.

The relationship between headache-attributed disability and lost productivity: 2. Empirical evidence from population-based studies in nine disparate countries

Background

Headache disorders are disabling, with major consequences for productivity, yet the literature is silent on the relationship between headache-attributed disability and lost productivity, often erroneously regarding the two as synonymous. We evaluated the relationship empirically, having earlier found that investment in structured headache services would be cost saving, not merely cost-effective, if reductions in headache-attributed disability led to > 20% pro rata recovery of lost productivity.

Methods

We used individual participant data from Global Campaign population-based studies conducted in China, Ethiopia, India, Nepal, Pakistan and Russia, and from Eurolight in Lithuania, Luxembourg and Spain. We assessed relationships in migraine and probable medication-overuse headache (pMOH), the most disabling common headache disorders. Available symptom data included headache frequency, usual duration and usual intensity. We used frequency and duration to estimate proportion of time in ictal state (pTIS). Disability, in the sense used by the Global Burden of Disease study, was measured as the product of pTIS and disability weight for the ictal state. Impairment was measured as pTIS * intensity. Lost productivity was measured as lost days (absence or < 50% productivity) from paid work and corresponding losses from household work over the preceding 3 months. We used Spearman correlation and linear regression analyses.

Results

For migraine, in a linear model, we found positive associations with lost paid worktime, significant (p < 0.05) in many countries and highly significant (p < 0.001) in some despite low values of R² (0–0.16) due to high variance. With lost household worktime and total lost productivity (paid + household), associations were highly significant in almost all countries, although still with low R² (0.04–0.22). Applying the regression equations for each country to the population mean migraine-attributed disability, we found pro rata recoveries of lost productivity in the range 16–56% (> 20% in all countries but Pakistan). Analysing impairment rather than disability increased variability. For pMOH, with smaller numbers, associations were generally weaker, occasionally negative and mostly not significant.

Conclusion

Relief of disability through effective treatment of migraine is expected, in most countries, to recover > 20% pro rata of lost productivity, above the threshold for investment in structured headache services to be cost saving.

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.

Structured headache services as the solution to the ill-health burden of headache: 1. Rationale and description

In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the "patient journey") with perplexing obstacles.High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary.The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded.It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses.

The relationship between headache-attributed disability and lost productivity: 1. A review of the literature

BACKGROUND

Headache disorders are disabling and have a significant impact on productivity. The relationship between these two consequences is of considerable economic and political interest. We enquired into it through a systematic search of the English-language literature.

METHODS

We followed PRISMA guidelines in specifying search terms and syntax and in article selection. We used the term "disability" in the search, accepting any meaning that authors attached to it, but this proved problematic. Accordingly, we adopted the definition used in the Global Burden of Disease study. In article selection, we included only those that purported to measure disability as so defined and lost productivity. We reviewed the full texts of those selected. We included further articles identified from review of the bibliographies of selected articles.

RESULTS

The literature search found 598 studies, of which 21 warranted further review. Their bibliographies identified another four of possible relevance. On full-text reading of these 25, all were rejected. Ten applied incompatible definitions of disability and/or lost productivity. Two did not measure both. Four reported lost productivity but not disability. Eight studies reported and measured both but did not assess the association between them or provide the means of doing so. One was purely methodological.

CONCLUSIONS

The literature is silent on the relationship between headache-attributed disability and lost productivity. In view of its health economic and political importance, empirical studies are required to remedy this. A prerequisite is to clarify what is meant by "disability" in this context.

A universal outcome measure for headache treatments, care-delivery systems and economic analysis

BACKGROUND

The first manuscript in this series delineated a model of structured headache services, potentially cost-effective but requiring formal cost-effectiveness analysis (CEA). We envisaged a need for a new outcome measure for this purpose, applicable to all forms of treatment, care and care-delivery systems as opposed to comparisons of single-modality treatments.

CONCEPTION AND DELINEATION

A literature review confirmed the lack of any suitable established measure. We prioritised construct validity, simplicity, comprehensiveness and expression in intuitive units. We noted that pain was the key burdensome symptom of migraine and episodic tension-type headache (TTH), that pain above a certain level was disabling, that it was difficult to put economic value to pain but relatively easy to do this for time, a casualty of headache leading to lost productivity. Alleviation of pain to a non-disabling level would be expected to bring restoration of function. We therefore based the measure on time spent in the ictal state (TIS) of migraine or TTH, either as total TIS or proportion of all time. We expressed impact on health, in units of time, as TIS*DW, where DW was the disability weight for the ictal state supplied by the Global Burden of Disease (GBD) studies. If the time unit was hours, TIS*DW yielded hours lived with (or lost to) disability (HLDs), in analogy with GBD's years lived with disability (YLDs).

UTILITY ASSESSMENT

Acute treatments would reduce TIS by shortening attack duration, preventative treatments by reducing attack frequency; health-care systems such as structured headache services would have these effects by delivering these treatments. These benefits were all measurable as HLDs-averted. Population-level estimates would be derived by factoring in prevalence, but also taking treatment coverage and adherence into account. For health-care systems, additional gains from provider-training (promoting adherence to guidelines and, therefore, enhancing coverage) and consumer-education (improving adherence to care plans), increasing numbers within populations gaining the benefits of treatments, would be measurable by the same metric.

CONCLUSIONS

The new outcome measure expressed in intuitive units of time is applicable to treatments of all modalities and to system-level interventions for multiple headache types, with utility for CEA and for informing health policy.

Burden, Disability and Public Health Importance of Headache Disorders in India

Headache disorders, characterized by recurrent headache, are among the most common disorders of the nervous system. The aim of this study was to document epidemiological and economic burden due to headache globally and in India and suggest a public health approach to address headache disorders for India. We reviewed the available literature on burden due to headache, its management using a primary health care approach and health system barriers, with special emphasis on India. Globally, it has been estimated that prevalence of current headache disorder (symptomatic within last year) among adults is about 50%, around 30% report migraine and headache on 15 or more days every month affects 1.7-4% people. The Global Burden of Disease Study 2016 estimated that migraine caused 45·1 million (95% UI 29·0-62·8) and tension-type headache 7·2 million (95% UI 4·6-10·5) years of life lived with disability. Limited data available in India support such high burden. These studies also indicate high diagnostic and treatment gaps for headache disorders in India. Major challenges in addressing headache disorders effectively in India are low perceived severity, absence of burden data, lack of standard treatment protocols for headache disorders and primary care models for neurological disorders in developing country context. There needs to be a better appreciation of the burden and a public health approach among all stakeholders, if burden of headache disorders is to be addressed effectively in India.

Effectiveness of Acceptance and Commitment Therapy in Central Pain Sensitization Syndromes: A Systematic Review

OBJECTIVES

Acceptance and commitment therapy (ACT) is considered by the American Psychological Association as an evidence-based treatment for a variety of disorders, including chronic pain. The main objective of the present systematic review was to determine the effectiveness of ACT in patients with central pain sensitization syndromes (CPSS).

METHODS

This systematic review was conducted according to the guidelines of the Cochrane Collaboration and PRISMA statements. The protocol was registered in advance in the Prospective Register of Systematic Reviews (PROSPERO) international database. The selected articles were evaluated using the Cochrane risk of bias (ROB) assessment tool. The PubMed, Scopus, and Web of Science databases were searched.

RESULTS

The literature search identified 21 studies (including investigations of fibromyalgia syndrome, irritable bowel syndrome, and migraine) eligible for the systematic review. There were no studies regarding the effectiveness of ACT for chronic tension-type headache (CTTH), interstitial cystitis (IC), or temporomandibular disorder (TMD). The evaluation of ROB showed that 12 of the selected studies were of low quality, 5 were of moderate quality, and 4 were high quality. ACT reduces some clinical symptoms, such as anxiety, depression, and pain. This positive effect of ACT might be mediated by pain acceptance, psychological flexibility, optimism, self-efficacy, or adherence to values. ACT showed better results in comparison to non-intervention (e.g., "waiting list") conditions, as well as pharmacological and psychoeducational interventions. It is not entirely clear whether extended ACT treatments are more advantageous than briefer interventions.

CONCLUSIONS

There are few studies about the effectiveness of ACT on CPSS. However, ACT seems to reduce subjective CPSS symptoms and improve the health-related quality of life of these patients. The absence of studies on the effectiveness of ACT in CTTH, IC, and TMD, indicate the pressing need for further ACT studies in these CPSS.

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.

Cost analysis of migraine pharmacotherapy with selective 5HT1 receptor agonists in Ukraine

The cost analysis for the relief of migraine attack using selective 5HT1-receptor agonists (frovatriptan, zolmitriptan, risatriptan, sumatriptan) of domestic and imported manufacturers in various dosages and forms of production in the proposed resource online pharmacy chains of Lviv for their efficient and cost effective applications. Among the registered drugs, most dosage forms and trade names are presented for sumatriptan; slightly less for risatriptan and zolmitriptan; for frovatriptan is only one trade name. It has been found that to relieve migraine attack with domestic drugs will be cheaper for patients than imported. Packaging with the same dosage of active ingredient, but with more tablets in the blister is more cost effective for patients. It`s the most economical to stop the migraine attack with Stopmigren (sumatriptan) at a dosage of 50 mg, packing 6 tablets in a blister, and the most valuable drug is Rapimig (zolmitriptan) at a dosage of 50 mg, packing 6 tablets in a blister.

Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

Background

Through the Global Burden of Diseases, Injuries, and Risk Factors (GBD) studies, headache has emerged as a major global public health concern. We aimed to use data from the GBD 2016 study to provide new estimates for prevalence and years of life lived with disability (YLDs) for migraine and tension-type headache and to present the methods and results in an accessible way for clinicians and researchers of headache disorders.

Methods

Data were derived from population-based cross-sectional surveys on migraine and tension-type headache. Prevalence for each sex and 5-year age group interval (ie, age 5 years to ≥95 years) at different time points from 1990 and 2016 in all countries and GBD regions were estimated using a Bayesian meta-regression model. Disease burden measured in YLDs was calculated from prevalence and average time spent with headache multiplied by disability weights (a measure of the relative severity of the disabling consequence of a disease). The burden stemming from medication overuse headache, which was included in earlier iterations of GBD as a separate cause, was subsumed as a sequela of either migraine or tension-type headache. Because no deaths were assigned to headaches as the underlying cause, YLDs equate to disability-adjusted life-years (DALYs). We also analysed results on the basis of the Socio-demographic Index (SDI), a compound measure of income per capita, education, and fertility.

Findings

Almost three billion individuals were estimated to have a migraine or tension-type headache in 2016: 1·89 billion (95% uncertainty interval [UI] 1·71–2·10) with tension-type headache and 1·04 billion (95% UI 1·00–1·09) with migraine. However, because migraine had a much higher disability weight than tension-type headache, migraine caused 45·1 million (95% UI 29·0–62·8) and tension-type headache only 7·2 million (95% UI 4·6–10·5) YLDs globally in 2016. The headaches were most burdensome in women between ages 15 and 49 years, with migraine causing 20·3 million (95% UI 12·9–28·5) and tension-type headache 2·9 million (95% UI 1·8–4·2) YLDs in 2016, which was 11·2% of all YLDs in this age group and sex. Age-standardised DALYs for each headache type showed a small increase as SDI increased.

Interpretation

Although current estimates are based on limited data, our study shows that headache disorders, and migraine in particular, are important causes of disability worldwide, and deserve greater attention in health policy debates and research resource allocation. Future iterations of this study, based on sources from additional countries and with less methodological heterogeneity, should help to provide stronger evidence of the need for action.

Funding

Bill & Melinda Gates Foundation.

[Real-world migraine burden: clinical and economic aspects]

AIM

To evaluate the rationale for different approaches to preventive chronic migraine (CM) treatment by comparing clinical outcomes and financial burden of the disease in the real-world practice.

MATERIAL AND METHODS

Sixty-six patients with CM were enrolled at the Alexander Vein Headache Clinic (60 women and 6 men, aged 28-51). All patients were divided into 3 groups: group 1 (n=22) received oral preventative treatment with topiramate, up to 100 mg daily, for three months; group 2 (n=20) received 12 acupuncture sessions (3 sessions a week); group 3 (n=24) received 155-195 units of botulinum toxin type A (botox, BTA). The follow-up period in all groups was 3 months. Efficacy was evaluated by clinical examination, the Headache Impact Test (HIT-6) and questionnaires to assess subjective patient satisfaction and treatment tolerability.

RESULTS

BTA demonstrated the highest efficacy in this study. Compared to the oral preventative treatment and acupuncture, BTA reduced the frequency of headache faster and more significantly facilitating CM transformation into episodic migraine (headache frequency was 16.1±0.1; 18.0±0.02; and 13.9±0.3 in groups 1, 2 and 3, respectively, after one month of treatment). BTA also improved the quality of life faster and more significantly and was better tolerated (good - 51%, 75% and 85% in groups 1, 2 and 3, respectively; satisfactory - 35%, 25% and 15% in groups 1, 2 and 3, respectively; bad 14% in the oral prevention group). In the BTA group, the majority of patients demonstrated earlier treatment satisfaction. Despite higher (compared to topiramate) direct costs in the BTA group (RUB 29 931.51 and RUB 32 085.87, respectively), the predicted cost of a headache-free day was the smallest and totaled RUB 652.15 (compared to RUB 692.86 and RUB 1017.60 in the topiramate and acupuncture groups, respectively).

CONCLUSION

The data on the efficacy and costs of different CM prevention strategies would facilitate optimal treatment choice for neurologists and patients.

Economic Studies on Non-Communicable Diseases and Injuries in India: A Systematic Review

BACKGROUND

The burden from non-communicable diseases and injuries (NCDI) in India is increasing rapidly. With low public sector investment in the health sector generally, and a high financial burden on households for treatment, it is important that economic evidence is used to set priorities in the context of NCDI.

OBJECTIVE

Our objective was to understand the extent to which economic analysis has been used in India to (1) analyze the impact of NCDI and (2) evaluate prevention and treatment interventions. Specifically, this analysis focused on the type of economic analysis used, disease categories, funding patterns, authorship, and author characteristics.

METHODS

We conducted a systematic review based on economic keywords to identify studies on NCDI in India published in English between January 2006 and November 2016. In all, 96 studies were included in the review. The analysis used descriptive statistics, including frequencies and percentages.

RESULTS

A majority of the studies were economic impact studies, followed by economic evaluation studies, especially cost-effectiveness analysis. In the costing/partial economic evaluation category, most were cost-description and cost-analysis studies. Under the economic impact/economic burden category, most studies investigated out-of-pocket spending. The studies were mostly on cardiovascular disease, diabetes, and neoplasms. Slightly over half of the studies were funded, with funding coming mainly from outside of India. Half of the studies were led by domestic authors. In most of the studies, the lead author was a clinician or a public health professional; however, most of the economist-led studies were by authors from outside India.

CONCLUSIONS

The results indicate the lack of engagement of economists generally and health economists in particular in research on NCDI in India. Demand from health policy makers for evidence-based decision making appears to be lacking, which in turn solidifies the divergence between economics and health policy, and highlights the need to prioritize scarce resources based on evidence regarding what works. Capacity building in health economics needs focus, and the government's support in this is recommended.

The headache under-response to treatment (HURT) questionnaire, an outcome measure to guide follow-up in primary care: development, psychometric evaluation and assessment of utility

Background

Headache disorders are both common and burdensome but, given the many people affected, provision of health care to all is challenging. Structured headache services based in primary care are the most efficient, equitable and cost-effective solution but place responsibility for managing most patients on health-care providers with limited training in headache care. The development of practical management aids for primary care is therefore a purpose of the Global Campaign against Headache. This manuscript presents an outcome measure, the Headache Under-Response to Treatment (HURT) questionnaire, describing its purpose, development, psychometric evaluation and assessment for clinical utility. The objective was a simple-to-use instrument that would both assess outcome and provide guidance to improving outcome, having utility across the range of headache disorders, across clinical settings and across countries and cultures.

Methods

After literature review, an expert consensus group drawn from all six world regions formulated HURT through item development and item reduction using item-response theory. Using the American Migraine Prevalence and Prevention Study’s general-population respondent panel, two mailed surveys assessed the psychometric properties of HURT, comparing it with other instruments as external validators. Reliability was assessed in patients in two culturally-contrasting clinical settings: headache specialist centres in Europe (n = 159) and primary-care centres in Saudi Arabia (n = 40). Clinical utility was assessed in similar settings (Europe n = 201; Saudi Arabia n = 342).

Results

The final instrument, an 8-item self-administered questionnaire, addressed headache frequency, disability, medication use and effect, patients’ perceptions of headache “control” and their understanding of their diagnoses. Psychometric evaluation revealed a two-factor model (headache frequency, disability and medication use; and medication efficacy and headache control), with scale properties apparently stable across disorders and correlating well and in the expected directions with external validators. The literature review found few instruments linking assessment to clinical advice or suggested actions: HURT appeared to fill this gap. In European specialist care, it showed utility as an outcome measure across headache disorders. In Saudi Arabian primary care, HURT (translated into Arabic) was reliable and responsive to clinical change.

Conclusions

With demonstrated validity and clinical utility across disorders, cultures and settings, HURT is available for clinical and research purposes.

Electronic supplementary material

The online version of this article (10.1186/s10194-018-0842-6) contains supplementary material, which is available to authorized users.

The burden of headache disorders in Ethiopia: national estimates from a population-based door-to-door survey

BACKGROUND

Headache disorders are the third-highest cause of disability worldwide, with migraine and medication-overuse headache (MOH) the major contributors. In Ethiopia we have shown these disorders to be highly prevalent: migraine 17.7%, TTH 20.6%, probable MOH (pMOH) 0.7%, any headache yesterday (HY) 6.4%. To inform local health policy, we now estimate disability and other burdens attributable to headache in this country.

METHODS

In a cross-sectional survey using cluster-randomized sampling, we visited households unannounced in four diverse regions (urban and rural) of Ethiopia. We interviewed one member (18-65 years old) of each household using the HARDSHIP structured questionnaire. Screening and diagnostic questions based on ICHD-II were followed by burden enquiry in multiple domains. We estimated disability using disability weights (DWs) from the Global Burden of Disease 2013 study.

RESULTS

We interviewed 2385 participants (1064 [44.7%] male, 596 [25.0%] urban; participating proportion 99.8%). Reported mean intensity of migraine was 2.6 (scale 1-3). People with migraine spent 11.7% of their time in the ictal state (DW: 0.441); they were therefore 5.2% disabled overall. Pain and disability from TTH were much lower. Mean intensity of pMOH was 2.95. People with pMOH spent 60.2% of time with headache (DW: 0.223), and were 13.4% disabled. Average proportions of per-person lost productive time were, for migraine, 4.5% from paid work, 5.3% from household work; for pMOH they were 29.2% and 16.0%. There were highly-disabled minorities, and large gender differences, males losing more paid workdays, females more household workdays. All headache types were associated with impairments in quality of life. Across the population aged 18-65 years (effectively the working population), disability from headache was 1.4%, with 1.6% of workdays lost (half from migraine). Estimates from HY, eliminating recall error, were highly compatible.

CONCLUSIONS

Ethiopia is a low-income country, and cannot afford these losses - including, perhaps, 1.6% of GDP. Political action is necessary, aimed at mitigating both the economic burden and the associated ill health. WHO has recommended structured headache services with their basis in primary care as the most efficient, effective, affordable and equitable solution, potentially cost-saving. We believe they can be implemented within Ethiopia's existing health-care infrastructure.

Implementation of effective, self-sustaining headache services in the Republic of Georgia: Evaluation of their impact on headache-related disability and quality of life of people with headache

Background Headache disorders are widespread and disabling. They are common in Georgia, especially headache on ≥15 days/month (HA ≥ 15), but there are no headache services. Objective We established headache services meeting local needs, investigating feasibility, consumer uptake and satisfaction, and cost, with an exit strategy bequeathing effective, self-sustaining services that could be rolled out nationwide. Methods We created headache centres in Tbilisi and Gori offering free expert care for three visits over three months, and affordable medication thereafter. The primary outcome measure was the percentage of patients using the service beyond the free period - a measure of both satisfaction and sustainability. Results Of 1,445 patients (age 43.7 ± 12.4 years; 10.5% male), 49.8% had episodic migraine, 22.5% episodic tension-type headache, 25.7% HA ≥ 15 (24.5% overusing medication) and 2.0% trigeminal autonomic cephalalgias. Only 454 (31.4%) and 51 (3.5%) returned for second and third visits; in these, headache improved and treatment costs decreased. As information about the service spread, five other headache clinics opened in Tbilisi and Kutaisi (western Georgia). Pharmaceutical companies reduced prices (sumatriptan 100 mg from US$7 to US$1). Conclusion The study failed to achieve its primary outcome, but sustainable headache services operating to international standards were successfully implemented nonetheless, with demand increasing.

The prevalence of primary headache disorders in Ethiopia

BACKGROUND

Knowledge of the epidemiology of primary headache disorders in sub-Saharan Africa (SSA) remains very limited. We performed a population-based survey in rural and urban areas of Ethiopia, using methods similar to those of an earlier study in Zambia and tested in multiple other countries by Lifting The Burden.

METHODS

In a cross-sectional survey we visited households unannounced in four regions of Ethiopia: the mostly urban populations in Addis Ababa and its environs and rural populations of selected districts in Oromia, Amhara and South Nations Nationalities and People's Regions States (SNNPRS). We used cluster-randomized sampling: within clusters we randomly selected households, and one adult member (18-65 years old) of each household. The HARDSHIP structured questionnaire, translated into the local languages, was administered face-to-face by trained interviewers. Demographic enquiry was followed by diagnostic questions based on ICHD-II criteria.

RESULTS

From 2,528 households approached, 2,385 of 2,391 eligible members (1,064 [44.7%] male, 596 [25.0%] urban) consented to interview (participating proportion 99.8%). Headache in the preceding year was reported by 1,071 participants (44.9% [95% CI: 42.4-46.3]; males 37.7%, females 49.9%), and headache yesterday by 170 (7.1% [6.2-8.2]; males 45 [4.1%], females 125 [9.2%]). Adjusted for gender, age and habitation (urban/rural), 1-year prevalence of migraine was 17.7%, of tension-type headache (TTH) 20.6%, of all headache on ≥15 days/month 3.2%, and of probable medication-overuse headache (pMOH) 0.7%. The adjusted prevalence of headache yesterday was 6.4%. Very few cases (1.6%) were unclassifiable. All headache disorders were more common in females. TTH was less common in urban areas (OR: 0.3; p < 0.0001), but pMOH was very strongly associated (OR: 6.1; p < 0.0001) with urban dwelling. Education was negatively associated with migraine (OR: 0.5-0.7; p < 0.05) but (at university level) positively with pMOH (OR: 2.9; p = 0.067). Income above ETB 500/month showed similar associations: negatively with migraine (OR: 0.8; p = 0.035), positively with pMOH (OR: 2.1; p = 0.164).

CONCLUSIONS

Findings for migraine and TTH in Ethiopia were quite similar to those from Zambia, another SSA country; pMOH was much less prevalent but, as in Zambia, essentially an urban problem. Primary headache disorders are at least as prevalent in SSA as in high-income western countries.

Headache yesterday in Karnataka state, India: prevalence, impact and cost

BACKGROUND

The Global Campaign against Headache has pioneered evaluation of the prevalence and impact of headache on the preceding day ("headache yesterday") as a new approach to the estimation of headache-attributed burden, avoiding recall error. We report its application in Karnataka State, southern India.

METHODS

In a door-to-door survey, biologically unrelated adults (aged 18-65 years) were randomly sampled from urban and rural areas in and around Bengaluru and interviewed by trained researchers using a validated, structured questionnaire. Enquiry into headache applied ICHD-II diagnostic criteria and included questions about headache on the day preceding the interview (headache yesterday [HY]).

RESULTS

There were 2329 participants (participation proportion 92.6 %; males 1141 [49.0 %], females 1188 [51.0 %]; mean age 38.0 [±12.7] years; 1103 [47.4 %] from rural areas, 1226 [52.6 %] urban). HY was reported by 138 participants (males 33 [2.9 %], females 105 [8.8 %]): the 1-day prevalence of headache was 5.9 %. Mean duration of HY was 7.0 ± 8.5 h, so that 1.7 % of the population (5.9 % * 7.0/24), on average, had headache at any moment in time yesterday. Mean intensity on a scale of 1-3 was 2.0 [±0.8]. Lost productivity due to HY was reported by 83.3 % of participants with HY: 37.7 % able to do less than half of what they had planned and 13.0 % able to do nothing. Productivity loss at population level (being the productivity loss within the entire adult population, every single day, attributable to headache) was 3.0 %.

CONCLUSIONS

This method of enquiry, free from recall error, confirmed a very high level of headache-attributed burden in Karnataka: previous estimates based on 3-month recall may even have been too low. Until another study is done in the country, these are the best data for all India. They demonstrate need for action nationwide to mitigate this burden, and correct action will ultimately almost certainly be cost-saving.

Medication-Overuse Headache: Differences between Daily and Near-Daily Headache Patients

Medication-overuse headache (MOH) is a challenging neurological disease, which brings frustration for sufferers and treating physicians. The patient's lack of adherence and limited treatment evidence are frequent. The aim of this study was to compare the outcome and treatment strategies between consecutive MOH patients with daily and near-daily headache from a tertiary center.

METHODS

Every consecutive patient seen between January and December 2014 with the diagnosis of MOH was included. Psychiatric comorbidities, inability to inform baseline headache frequency, current or previous two-month use of preventive medications, and refusal to sign informed consent were exclusion criteria. The patients were evaluated in thorough initial consultations and divided in two groups based on their baseline headache frequency. The diagnosis and treatment strategies were clearly explained. The filling out of a detailed headache diary was requested from all patients. Endpoints compared headache frequency and adherence after two, four, and eight months between the two study groups.

RESULTS

One-hundred sixty-eight patients (31 male, 137 female) met the inclusion criteria. Nineteen patients (11.3%) were excluded. All patients had migraine or chronic migraine as primary headaches. Eighty had daily (DH), and 69 near-daily headache (NDH), at baseline consultation. Mean baseline frequency was 24.8 headache days/month (18.9 days/month for the near-daily group), average headache history was 20.6 years and mean time with >15 headache days/month was 4.8 years. Outpatient withdrawal, starting prevention, and enforcing the correct use of rescue therapy was carried out with all patients. After two months, 88% of the DH and 71% of the NDH groups adhered to treatment (p = 0.0002). The HF decreased to 12 and 9 headache days/month, respectively in DH and NDH groups (p > 0.05, non-significant) (Intention-to-treat (ITT) 14 DH; 12 NDH; p > 0.05). After four and eight months, 86.3% and 83.7% of the DH patients, and 59.4% and 55% of the NDH patients were still under treatment (p = 0.0003 and p = 0.0001). The HF decreased, respectively, to nine and nine headache days/month in the DH patients compared to 6 and 7 headache days/month in the NDH group (p > 0.05) (ITT, 12; 12; DH; 10; 11; NDH; p > 0.05).

CONCLUSIONS

Although open studies provide limited conclusions, withdrawing overused medications and starting prevention may have helped the favorable outcomes. However, daily headache patients had a significantly higher adherence and lower relapse rates than near-daily headache patients, despite a considerable reduced headache frequency in both groups. Additionally, real-world patient studies are scarce and the comparison between these two subsets of patients may be useful to guide clinicians in approaching their patients. Controlled studies are necessary to confirm these observations.

The challenge of managing headache disorders in a tertiary referral neurology clinic in Rwanda

OBJECTIVE

To determine the pattern, management, and outcome of headaches among patients treated at Outpatient Neurology Clinic.

METHODS

A retrospective study was conducted at the Out-Patient Neurology Clinic of the Butare University Teaching Hospital, University of Rwanda, Butare, Rwanda between February and May 2015. We extracted the demographic data, headache characteristics, and associated conditions, prior pain-relieving medication use, waiting time before consultation, the results of paraclinical investigations, final diagnosis according to the International Classification of Headache Disorders, management, and 3-month clinical outcome from the medical records of all patients who consulted for headache over 36-month period. Epi Data and Statistical package for Social sciences software version 21.0 (SPSS Inc, Chicago, IL, USA) software were used for data processing.

RESULTS

Headache disorders represent a quarter of all neurological consultations. Patients were predominantly female (67%) and young (78% <45 years old). One-third (34%) presented with chronic tension-type headache. Neuroimaging demonstrated an abnormality in a significant minority (14%). Amitriptyline was the most commonly used drug (60%) in management. Forty percent of those patients followed for 3 months did not experience any clinical improvement.

CONCLUSION

Headache is among the most common medical complaints in the Outpatient Neurology Clinic, with a wide array of underlying diagnoses, and a significant yield on neuroimaging. A significant proportion of those suffering from headache disorders have poor short-term outcomes. Novel approaches, such as headache support groups and alternative pharmacological agents, should be investigated for these patients.

The burden of headache disorders in Nepal: estimates from a population-based survey

BACKGROUND

Headache disorders, particularly migraine and tension-type headache (TTH), are among the most prevalent global public-health problems. Medication-overuse headache (MOH) is a common sequela of mismanagement of these. Migraine and MOH are highly disabling. Formulation of responsive health policy requires reliable, locally-derived, population-based data describing both individual and societal impact of headache disorders. South-East Asia is the only one of WHO's six world regions in which no such national data have yet been gathered.

METHODS

In a nationwide population-based cross-sectional study, a representative sample of Nepalese-speaking adults (18-65 years) were randomly selected by stratified multistage cluster sampling. Trained interviewers made unannounced door-to-door visits and enquired into headache and its attributable burden using a culturally-adapted and validated Nepalese translation of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire.

RESULTS

Among 2100 participants, 1794 (85.4 %) reported headache during the preceding year (male: 689 [38.4 %], female 1105 [61.6 %]; mean age 36.1 ± 12.6 years). Mean headache frequency was 3.8 ± 6.2 days/month, mean headache intensity 2.1 ± 0.7 on a 0-3 scale, and mean attack duration 41.9 ± 108.5 h. All aspects of symptom burden (frequency, intensity and duration) were greater among females (p < 0.001). Participants with headache had poorer quality of life (QoL) than those without (p < 0.001); QoL was worst among those with probable MOH (pMOH). Mean proportions of total available time spent in the ictal state were 5.4 % among participants with migraine, 3.9 % among those with TTH and 44.7 % among those with pMOH, with headache-related disabilities of 2.4, 0.15 and 9.7 % respectively. At population level, these disorders were responsible for reduced functional capacities of 0.81, 0.06 and 0.20 %. Total lost productive time due to headache was 6.8 % for the 85 % of the population with headache. Males lost more paid worktime than females (p < 0.001); the reverse was so for household worktime (p < 0.001).

CONCLUSIONS

Headache disorders, very common in Nepal, are also highly burdensome at both individual and population levels. There is a substantial penalty in lost production. The remedy lies in better health care for headache; structured headache-care services are urgently needed in the country, and likely to be cost-saving.

The burden attributable to headache disorders in India: estimates from a community-based study in Karnataka State

BACKGROUND

Headache disorders are common worldwide, causing pain and disability. India appears to have a very high prevalence of migraine, and of other headache disorders in line with global averages. Our objective was to estimate the burdens attributable to these disorders in order to inform health policy.

METHODS

In a door-to-door survey, biologically unrelated adults (18-65 years) were randomly sampled from urban and rural areas of Bangalore and interviewed by trained researchers. The validated structured questionnaire enquired into several aspects of burden.

RESULTS

Of 2,329 participants (non-participation rate 7.4 %), 1,488 (63.9 %; 621 male, 867 female) reported headache in the preceding year. Symptom burden was high. Migraine (1-year prevalence 25.2 %) occurred on average on 28 days/year but, in 38.0 % of cases (ie, 9.6 % of adults), on ≥3 days/month (≥10 % of days). All causes of headache on ≥15 days/month (prevalence 3.0 %) occurred on a mean of 245 days/year. Both these and migraine were rated severe in intensity. Participants with headache lost 4.3 % of productive time; those with migraine lost 5.8 % (equating to 1.5 % from the adult population). Lost paid worktime accounted for 40 % of this, probably detracting directly from GDP. We estimated population-level disability attributable to migraine using the disability weight from GBD2010 for the ictal state (0.433). Mean disability per person with migraine was 1.8 %, reducing the functional capacity of the entire adult population by 0.46 %. Fewer than one quarter of participants with headache had engaged with health-care services for headache in the last year. Actual expenditure on headache care was greatest among those with headache on ≥15 days/month (especially probable medication-overuse headache), but otherwise not high. Expressed willingness to pay for effective treatment for headache was higher, signalling dissatisfaction with current treatments.

CONCLUSIONS

In Karnataka State, southern India, prevalent headache disorders, especially migraine, give rise to commensurately heavy burdens. Limited access to health care fails to alleviate these. Structured headache services, with their basis in primary care, are the most efficient, effective, affordable and equitable solution. They could be implemented within the health-care infrastructure of India and are likely to be cost-saving. This solution requires political will, itself dependent on awareness.

The epidemiology of primary headache disorders in Zambia: a population-based door-to-door survey

Background

Little is known of the epidemiology of primary headache disorders in sub-Saharan Africa. We performed a population-based survey in Zambia using methods previously tested in multiple other countries.

Methods

This cross-sectional survey was conducted by visiting households unannounced, using cluster-randomized sampling, in the mostly urban Lusaka Province and mostly rural Southern Province. Within clusters, households were selected randomly, as was one adult member (18-65 years old) of each selected household. A structured questionnaire, translated into the local languages, was administered face-to-face by trained interviewers. Demographic enquiry was followed by diagnostic questions based on ICHD-II criteria. A random sub-sample of participants were invited for subsequent physician-interview to validate the diagnostic part of the questionnaire.

Results

Of 1,134 eligible household members contacted, 1,085 (450 male, 887 urban) consented to interview (refusal rate 4.3%). Others who had been selected but remained unavailable on three visits were not counted as refusals since their reasons were unknown, but gave rise to gender biases, being mostly male in urban areas and mostly female in rural areas. Statistical correction was applied. Adjusted for gender and habitation (urban/rural), the 1-year prevalence of any headache was 61.6%, of migraine 22.9%, of tension-type headache (TTH) 22.8%, of headache on ≥15 days/month 11.5% and of probable medication-overuse headache (pMOH) 7.1%. The adjusted point-prevalence of any headache (headache yesterday) was 19.1%. There was a small proportion (5.3%) of unclassified headache, some of which may have been secondary. The overwhelmingly strong association was between urban dwelling and pMOH (OR: 8.6; P=0.0001), with an urban prevalence of 14.5% (gender-adjusted). Validation of the questionnaire was limited by participants’ reluctance to present for physician review, substantial delays in doing so and major self-selection bias among those who did. These were unavoidable problems in resource-limited Zambia.

Conclusions

Primary headache disorders, common in high-income countries, are at least as prevalent in Zambia, a sub-Saharan African country. The selectively urban problem of pMOH seems likely to reflect ready availability of non-prescription analgesics, without easy access to professional health care for headache or any focused public-health education regarding correct usage of analgesics or the dangers of their overuse.