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

The burdens attributable to primary headache disorders in children and adolescents in Iran: estimates from a schools-based study

BACKGROUND

We recently found headache disorders to be highly prevalent among children (aged 6-11 years) and adolescents (aged 12-17) in Iran (gender- and age-adjusted 1-year prevalences: migraine 25.2%, tension-type headache 12.7%, undifferentiated headache [UdH] 22.1%, probable medication-overuse headache [pMOH] 1.1%, other headache on ≥ 15 days/month [H15+] 3.0%). Here we report on the headache-attributed burden, taking evidence from the same study.

METHODS

In a cross-sectional survey, following the generic protocol for the global schools-based study led by the Global Campaign against Headache, we administered the child and adolescent versions of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) structured questionnaire in 121 schools, purposively selected to reflect the country's diversities. Pupils self-completed these in class, under supervision. Headache diagnostic questions were based on ICHD-3 criteria but for the inclusion of UdH (defined as mild headache with usual duration < 1 h). Burden enquiry was across multiple domains.

RESULTS

The analysed sample (N = 3,244) included 1,308 (40.3%) children and 1,936 (59.7%) adolescents (1,531 [47.2%] male, 1,713 [52.8%] female). The non-participating proportion was 3.4%. Mean headache frequency was 3.9 days/4 weeks, and mean duration 1.8 h. Estimated mean proportion of time in ictal state was 1.1% (1.4% for migraine, 16.5% for pMOH). Symptomatic medication was consumed on a mean of 1.6 days/4 weeks. Lost school time averaged 0.4 days/4 weeks overall (2%, assuming a 5-day week), but was eleven-fold higher (4.3 days; 22%) for pMOH. For most headache types, days of reported limited activity were several-fold more than days lost from school (45% for pMOH, 25% for other H15+). Almost one in 12 parents (7.9%) missed work at least once in 4 weeks because of their son's or daughter's headache. Emotional impact and quality-of-life scores reflected these measures of burden.

CONCLUSIONS

Headache, common in children and adolescents in Iran, is associated with symptom burdens that may be onerous for some but not for most. However, there are substantial consequential burdens, particularly for the 1.1% with pMOH and the 3.0% with other H15+, who suffer educational disturbances and potentially major life impairments. These findings are of importance to educational and health policies in Iran.

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

BACKGROUND

The Global Burden of Disease (GBD) study is increasingly well informed with regard to headache disorders, but sub-Saharan Africa (SSA) remains one of the large regions of the world with limited data directly derived from population-based studies. The Global Campaign against Headache has conducted three studies in this region: Ethiopia in the east, Zambia in the south and Cameroon in Central SSA. Here we report a similar study in Benin, the first from West SSA.

METHODS

We used the same methods and questionnaire, applying cluster-randomized sampling in three regions of the country, randomly selecting households in each region, visiting these unannounced and randomly selecting one adult member (aged 18-65 years) of each household. The HARDSHIP structured questionnaire, translated into Central African French, was administered face-to-face by trained interviewers. Demographic enquiry was followed by diagnostic questions based on ICHD-3 criteria.

RESULTS

From 2,550 households with eligible members, we recruited 2,400 participants (participating proportion 94.1%). Headache ever was reported by almost all (95.2%), this being the lifetime prevalence. Headache in the last year was reported by 74.9%. Age-, gender- and habitation-adjusted estimates of 1-year prevalence were 72.9% for all headache, 21.2% for migraine (including definite and probable), 43.1% for TTH (also including definite and probable), 4.5% for probable medication-overuse (pMOH) and 3.1% for other headache on ≥ 15 days/month. One-day (point) prevalence of headache was 14.8% according to reported headache on the day preceding interview.

CONCLUSIONS

Overall, these findings are evidence that headache disorders are very common in Benin, a low-income country. The prevalence of pMOH, well above the estimated global mean of 1-2%, is evidence that poverty is not a bar to medication overuse. The findings are very much the same as those in a similar study in its near neighbour, Cameroon. With regard to migraine, they are reasonably in accord with two of three earlier studies in selected Beninese populations, which did not take account of probable migraine. This study adds to the hitherto limited knowledge of headache in SSA.

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.

Frequency and risk factors for headache disability: A population-based cross-sectional study in Egypt

BACKGROUND

A headache is a very common condition that can have a significant impact on one's quality of life. It is one of the leading causes of years lived with disability worldwide. The objective of the study was to determine the prevalence of primary headache disability, its characteristics, risk factors and its impact on daily life.

MATERIALS AND METHODS

A cross-sectional study was conducted in Fayoum governorate. The sample size was 1909 participants. A multistage random sample technique was used to select adults aged above 18 years. A self-structured questionnaire solicited information on sociodemographic characteristics, headache characteristics, and the headache disability index. SPSS v 22.0 was used for data analysis.

RESULTS

Headaches caused complete disability in 19.5% of the study group, and 76.8% developed severe disability. Participants who reported that they had a headache more than once a week were; 44.5% had moderate pain and 40.2% had more intense pain. About 55% complained of attacks rather than continuous headache and were more likely to have a degree of complete disability, (P = 0.001). A statistically significant association was found between living in urban areas, working in professional occupations, complaining of severe headache in the form of an attack and seeking medical advice, with high scores of headache disability.

CONCLUSION

Headache is a condition that affects the entire population in a way that causes high levels of disability. Good management is necessary for the reduction of the adverse effects of headaches on the health of the population. This should focus on raising public awareness by means of education and on the provision of basic healthcare.

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.

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.

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.

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

BACKGROUND

The Global Campaign against Headache collects data from children (6-11 years) and adolescents (12-17) to inform health and education policies and contribute to the Global Burden of Disease (GBD) study. This survey in Zambia, part of this global enquiry, was the second from sub-Saharan Africa (SSA).

METHODS

Following the generic protocol, this was a schools-based cross-sectional survey. We used the child and adolescent versions of the structured Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire, self-completed by pupils within classes, in a total of nine schools in Lusaka (urban) and Copperbelt (semi-rural). These two of Zambia's ten provinces were selected to represent the country's urban/rural divide. Headache diagnostic questions were based on ICHD-3 except for undifferentiated headache (UdH).

RESULTS

Of 2,759 potential participants, 2,089 (615 children [29.4%], 1,474 adolescents [70.6%]) completed questionnaires (participating proportion 75.7%). Children were therefore under-represented (mean age 13.1 ± 2.8 years), while gender distribution (1,128 [54.0%] male, 961 [46.0%] female) was close to expectation. Observed lifetime prevalence of headache was 97.5%. Gender- and age-adjusted 1-year prevalence estimates were 85.8% for all headache, 53.2% for migraine (definite 17.5%, probable 35.7%), 12.1% for tension-type headache (TTH), 14.8% for UdH, 3.3% for all headache on ≥ 15 days/month and 0.9% for probable medication-overuse headache. Headache durations were short: only 28.6% of participants with any headache, and only 10.5% of those diagnosed as probable migraine, reported usual durations of > 2 h (the threshold for definite migraine). Of the latter, 36.6% reported < 1 h, the duration criterion for UdH. There were weak associations of migraine (definite + probable) with female gender, and of TTH and headache on ≥ 15 days/month with adolescence. Headache yesterday was reported by 22.2% of the sample, 25.5% of those with headache.

CONCLUSIONS

Headache disorders among young people are prevalent in Zambia. Among them, migraine is the most common, with UdH also highly prevalent. In this study there were diagnostic uncertainties, which rested to a large extent on the distinction between migraine and UdH among the many participants reporting headache of < 2 h' duration. Similar uncertainties occurred in the first study in SSA, in Ethiopia. Because of these, we conclude only that migraine affects at least 17.5% of these age groups in Zambia, which is still a large proportion, adult prevalence in an earlier study being 22.9%. Supplementary estimates of attributed burden are needed to inform public-health and educational policies in Zambia.

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

BACKGROUND

While the Global Burden of Disease study reports headache disorders as the third-highest cause of disability worldwide, the headache data in this study largely come from adults. This national study in Iran, the first of its type in the Eastern Mediterranean Region, was part of a global schools-based programme within the Global Campaign against Headache contributing data from children (6-11 years) and adolescents (12-17 years).

METHODS

We followed the generic protocol for the global study. In a cross-sectional survey, self-completed structured questionnaires were administered to pupils within their classes in 121 schools selected from across the country to be representative of its diversities. Headache diagnostic questions were based on ICHD-3 criteria but for the inclusion of undifferentiated headache.

RESULTS

Of 3,357 potential participants, 3,244 (children 1,308 [40.3%], adolescents 1,936 [59.7%]; males 1,531 [47.2%], females 1,713 [52.8%]) satisfactorily completed the questionnaire. Children and males were therefore somewhat under-represented, with a participating proportion of 96.6%. Gender- and age-adjusted 1-year prevalence of any headache was 65.4%, of migraine 25.2%, of tension-type headache 12.7%, of undifferentiated headache 22.1%, of all headache on ≥15 days/month 4.1%, and of probable medication-overuse headache 1.1%. All headache types except undifferentiated headache were more prevalent among adolescents than children; probable medication-overuse headache increased five-fold between childhood and adolescence.

CONCLUSIONS

Headache disorders are common in children and adolescents in Iran, with undifferentiated headache accounting for over one third of cases. The increasing prevalence of probable medication-overuse headache with age is concerning. These findings are of importance to health and educational policies in Iran.

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.

Neurological disorders in Northern Tanzania: A 6-year prospective hospital-based case series

Background

The burden of neurological disorders is large and altered by the HIV epidemic.

Objectives

We describe the pattern of neurological disorders and their association with HIV infection in adult patients attending a consultant hospital in Northern Tanzania.

Methods

In this prospective cross-sectional study, we collected data on adult neurological referrals over a 6-year period between 2007-13. The odds of HIV infection, across neurological categories adjusted for age and sex, was calculated.

Results

Of 2037 participants, 54.8% were male and 45.2% were female. The median age of participants was 43 years. The results for HIV screening were available for 992/2037 (48.7%) patients, of whom 306 (30.8%) were seropositive. The most frequent neurological disorders were cerebrovascular disease (19.9%), paraplegia (13.6%), and peripheral neuropathies (8%). Taken together CNS infection accounted for 278/2037 (13.6%). The adjusted odds (aOR) of HIV infection was highest amongst infections; brain abscesses (aOR 107, 95% CI 35.1-470.4) and meningitis/encephalitis (aOR 40.1, 95% CI 13.6-172.9), but also raised in cerebrovascular disease, paraplegia, peripheral neuropathies, cranial nerve palsies, seizures, cerebllar disorders, movement disorders, motor neuron disease and headache.

Conclusion

The main pattern of neurological disorders in Northern Tanzania is presented. The odds of HIV infection was highest in CNS infections and in a wide range of non-communicable neurological disorders.

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.

Headache service quality: the role of specialized headache centres within structured headache services, and suggested standards and criteria as centres of excellence

In joint initiatives, the European Headache Federation and Lifting The Burden have described a model of structured headache services (with their basis in primary care), defined service quality in this context, and developed practical methods for its evaluation.Here, in a continuation of the service quality evaluation programme, we set out ten suggested role- and performance-defining standards for specialized headache centres operating as an integral component of these services. Verifiable criteria for evaluation accompany each standard. The purposes are five-fold: (i) to inspire and promote, or stimulate the establishment of, specialized headache centres as centres of excellence; (ii) to define the role of such centres within optimally structured and organized national headache services; (iii) to set out criteria by which such centres may be recognized as exemplary in their fulfilment of this role; (iv) to provide the basis for, and to initiate and motivate, collaboration and networking between such centres both nationally and internationally; (v) ultimately to improve the delivery and quality of health care for headache.

Headache prevalence and its functional impact among HIV-infected adults in rural Rakai District, Uganda

Headache is common, but its prevalence and impact in sub-Saharan Africa and especially in HIV+ individuals is relatively unknown. We sought to determine the prevalence and functional impact of headache among HIV-infected (HIV+) adults in a cross-sectional observational cohort study in rural Rakai District, Uganda. Participants completed a sociodemographic survey, depression screen, functional status assessments, and answered the headache screening question, "Do you have headaches?" Participants responding affirmatively were assessed with the ID Migraine tool for diagnosis of migraine and Headache Impact Test-6 to determine functional impact of headache. Characteristics of participants with and without headaches and with and without functional impairment were compared using t tests for continuous variables, chi-square tests for categorical variables, and multivariate logistic regression. Of 333 participants, 51% were males, mean age was 37 (SD 9) years, 94% were on antiretroviral therapy (ART) and mean CD4 count was 403 (SD 198) cells/μL. Headache prevalence was 28%. Among those reporting headache, 19% met criteria for migraine, 55% reported functional impairment, and 37% reported substantial or severe impact of headache. In multivariate analyses, female sex (odds ratio (OR) 2.58) and depression (OR 2.49) were associated with increased odds and ART (OR 0.33) with decreased odds of headache. Participants with substantial/severe functional impact were more likely to meet criteria for depression (32% vs 9%). In conclusion, headache prevalence in HIV+ rural Ugandans was lower than global averages but still affected more than one quarter of participants and was associated with significant functional impairment.

Health-care utilization for headache disorders in Nepal: a population-based door-to-door survey

BACKGROUND

Headache disorders are an important global public-health problem, but under-diagnosed, undertreated and under-prioritized. Deficiencies in health care for headache, present everywhere, are likely to be greater in poorly-resourced countries. This study reports on health-care utilization for headache in Nepal, a low-income country with high headache burden.

METHODS

We took data from a cross-sectional, nationwide population-based door-to-door survey, with multistage cluster random sampling. Face-to-face structured interviews included enquiry into consultations with professional health-care providers (HCPs), and investigations and treatments for headache. Analysis included associations with sociodemographic variables and indices of symptom severity.

RESULTS

Of 2100 participants, 1794 reported headache during the preceding year (mean age 36.1 ± 12.6 years; male/female ratio 1:1.6). Of these, 58.4% (95% CI: 56.1-60.7%) had consulted at least once in the year with HCPs at any level, most commonly (25.0%) paramedical; 15.0% had consulted pharmacists, 10.8% general physicians and 7.6% specialists (of any type). Participants with probable medication-overuse headache consulted most (87.0%), followed by those with migraine (67.2%) and those with tension-type headache (48.6%; p < 0.001). A minority (11.9%) were investigated, mostly (8.9%) by eye tests. Half (50.8%) had used conventional medications for headache in the preceding month, paracetamol being by far the most common (38.0%), and 10.3% had used herbal therapies. Consultation was positively associated with rural habitation (AOR = 1.5; p < 0.001). Proportions consulting increased in line with all indices of symptom severity.

CONCLUSIONS

Although over half of participants with headache had consulted professional HCPs, this reflects demand, not quality of care. Although 7.6% had seen specialists, very few would have been headache specialists in any sense of this term. High persistent burden, with only half of participants with headache using conventional medications, and these not best chosen, suggests these consultations fell far short of meeting need. Health policy in Nepal should recognise this, since the consequences otherwise are costly: lost health, diminished productivity and damaged national economy. On a positive note, the proportions consulting suggest that capacity exists at multiple levels within the Nepalese health system. With this to build upon, structured headache services in line with international recommendations appear achievable in Nepal. Educational programmes are the essential requirement.

Medication-overuse headache: a widely recognized entity amidst ongoing debate

Medication overuse in primary headache disorders is a worldwide phenomenon and has a role in the chronification of headache disorders. The burden of disease on individuals and societies is significant due to high costs and comorbidities. In the Third Edition of the International Classification of Headache Disorders, medication-overuse headache is recognized as a separate secondary entity next to mostly primary headache disorders, although many clinicians see the disease as a sole complication of primary headache disorders. In this review, we explore the historical background of medication-overuse headache, its epidemiology, phenomenology, pathophysiology and treatment options. The review explores relevant unanswered questions and summarizes the current debates in medication-overuse headache.

Chronic Headache Due to Overuse of Analgesics and Anti-Migraine Agents

BACKGROUND

The frequent or regular use of analgesics and anti-migraine drugs can make headache more frequent and induce the transformation of episodic to chronic headache. Chronic headache due to medication overuse is defined as headache that is present on ≥ 15 days per month for at least three months in a patient who previously suffered from primary headaches, and who takes analgesics on ≥ 15 days per month or anti-migraine drugs (triptans or ergot alkaloids), opioid drugs, or combined analgesics on ≥ 10 days per month.

METHODS

This review is based on pertinent articles published up to December 2017 that were retrieved by a selective search in PubMed employing the terms "medication overuse AND headache" and "medication overuse headache."

RESULTS

The prevalence of medication overuse headache in the general population in Germany is 0.7% -1%. This disorder is more common in women and in persons suffering from comorbid mental disorders or other painful conditions. The treatment of medication overuse headache consists of three steps. Patient education and counseling are given with the goal of reducing the intake of medication for acute headache treatment. The ensuing headache prophylaxis is with topiramate, amitriptyline, or onabotulinum toxin A. If these treatment strategies fail, a drug holiday is recommended. This can be in the outpatient, day clinic, or inpatient setting, depending on the severity of the condition and its comorbidities.

CONCLUSION

Patients who frequently take acute medication to treat headache episodes must be identified early in order to avoid headache chronification and medication overuse headache. The suggested treatment algorithm is still in need of validation by randomized trials.

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.

Burden of migraine in a Kuwaiti population: a door-to-door survey

Background

Migraine prevalence and disability imprints on Kuwaiti population are underreported. We aimed to measure the prevalence of migraine and to assess its burden in Kuwait.

Methods

A cross-sectional community-based study was conducted which included biologically unrelated Kuwaiti adult population aged 18–65 years. They were randomly recruited from all six governments of Kuwait using stratified multistage cluster sampling. Trained interviewers visited the samples in door-to-door approach. The Headache-Attributed Restriction, Disability, and Social Handicap and Impaired Participation (HARDSHIP) questionnaire was used to collect the data. Demographic enquires were followed by diagnostic and disability questions.

Results

A total of 15,523 subjects were identified; of whom 3588 (23%) were diagnosed as episodic migraine and 845 (5.4%) as chronic headache. Prevalence of episodic migraine was 31.71% in female versus 14.88% in males (P < 0.01) with a mean age of 34.56 ± 10.17 years. Most of migraine cohort (64.4%) sought medical advice with respect to their migraine headaches and the majority (62.4%) were seen by general practitioners (GPs) while 17.2% were assessed by neurologists and 3.7% was seen by other specialties. Tension type headache and sinus-related headaches were diagnosed in 8.9% and 2.1% of migraine subjects respectively. The majority (94.6%) of migraine subjects used symptomatic drugs for headache attacks, whereas 39.9% were taking preventive medication. In the preceding 3 months to the survey, subjects with episodic migraine had lost a mean of 1.97 days from their paid work or school attendance compared to 6.62 days in chronic headache sufferers (P < 0.001). Additionally, subjects with episodic migraine lost a mean of 1.40 days from household work compared to 5.35 days in subjects with chronic headache (P < 0.001). Participants with episodic migraine and chronic headache missed a mean of 2.81 and 3.85 days on social occasions, in the preceding 3 months (P < 0.001).

Conclusions

Migraine in Kuwait is highly prevalent and it has a significant impact on activity of daily living, schooling/ employment and social occasions of patients. Accurate diagnosis, effective abortive and preventive treatments of migraine are paramount to improve quality of life and as well as cost saving.

Development and validation of an Arabic-language headache questionnaire for population-based surveys

Background

The reported prevalence of headache disorders in Arab regions varies considerably between countries. This may be due to a lack of standardized survey instruments that capture the prevalence.

Purpose of the study

Our goal was to construct and validate a structured headache questionnaire for Arabic-speaking headache patients to be used as an epidemiological survey instrument.

Methods

We developed a culturally adapted interviewer-administered questionnaire in Arabic language comprising two sets of questions. The first set included personal and sociodemographic data together with a screening question regarding the presence of headaches over the last year. The second set was designed to define the type and pattern of headaches according to the International Classification of Headache Disorders criteria (for subjects with “yes” answers on the screening question). Validation process took place in two phases through probability random sampling selected from 1,221 headache subjects collected in an epidemiological survey 3 (n=70) and 6 months (n=232) later. A detailed assessment of patients’ headaches was performed by neurologists (blinded from the questionnaire diagnosis) who clinically assessed the patients’ headache.

Results

The validity of the questionnaire was tested in 232 subjects with a mean age of 41.2±10.9 years, 72.8% of whom were females. The mean time to complete the questionnaire was 8.4±1.7 minutes. The intraclass correlation coefficient was 0.903 (95% confidence interval: 0.875–0.925), the Cronbach κ coefficient was 0.775 (95% confidence interval: 0.682–0.837), and the percentage of agreement was 84.5%.

Conclusion

Our results support the use of this comprehensive questionnaire as a valid tool for headache assessment among Arabic-speaking patients.

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.

Prevalence and incidence of neurological disorders among adult Ugandans in rural and urban Mukono district; a cross-sectional study

Background

The burden of neurological diseases is increasing in developing countries. However, there is a prominent scarcity of literature on the incidence of neurological diseases in sub-Saharan Africa. This study was therefore undertaken to determine the prevalence and incidence of neurological diseases in this setting to serve as a baseline for planning and care for neurological disorders in Uganda.

Methods

The study was conducted within rural and urban Mukono district, east of Kampala city of Uganda, central region. Over a period of six months, a cross sectional survey was conducted and screening was performed using a standardized questionnaire. All subjects with neurological symptoms and signs were reviewed by a team of neurologists and neurological diagnoses made.

Results

Of the 3000 study subjects, 50.3% (1510/3000) were from the rural setting. Out of the participants screened, 67.4% were female, with a median age of 33 years. Among the 98 subjects with confirmed neurological disorders, the frequency of diseases was as follows; peripheral neuropathy (46.2%), chronic headaches (26.4%), and epilepsy (8.5%), followed by pain syndromes (7.5%), stroke (6.6%) and tremors/Parkinson disease (3.8%). The crude prevalence rates of these disorders (95% CI) were 14.3% (8.5–24.1); 13.3% (7.7–22.8); 33.7% (23.9–47.4) for stroke, epilepsy and peripheral neuropathy respectively. Peripheral neuropathy followed by chronic headaches had the highest estimated incidence/1000 years. Stroke had an estimated incidence of 3.6 new cases with 95% CI of (2.1–6.1)/1000 years.

Conclusion

Peripheral neuropathy, chronic headaches and epilepsy disorders are major causes of morbidity in Sub-Saharan settings. There is an urgent need of more robust and powered studies to determine the incidence of these diseases.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0732-y) contains supplementary material, which is available to authorized users.

Ketoprofen for episodic tension-type headache in adults

BACKGROUND

Tension-type headache (TTH) affects about 1 person in 5 worldwide. It is divided into infrequent episodic TTH (fewer than one headache day per month), frequent episodic TTH (2 to 14 headache days per month), and chronic TTH (15 headache days a month or more). Ketoprofen is one of a number of analgesics suggested for acute treatment of headaches in frequent episodic TTH.

OBJECTIVES

To assess the efficacy and safety of ketoprofen for treatment of episodic TTH in adults compared with placebo or any active comparator.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and the Oxford Pain Relief Database up to May 2016, and also reference lists of relevant published studies and reviews. We sought unpublished studies by asking personal contacts and searching online clinical trial registers and manufacturers' websites.

SELECTION CRITERIA

We included randomised, double-blind, placebo-controlled studies (parallel-group or cross-over) using oral ketoprofen for symptomatic relief of an acute episode of TTH. Studies had to be prospective, with participants aged 18 years or over, and include at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and extracted data. We used the numbers of participants achieving each outcome to calculate the risk ratio (RR) and number needed to treat for one additional beneficial outcome (NNT) or one additional harmful outcome (NNH) for oral ketoprofen compared to placebo or an active intervention for a range of outcomes, predominantly those recommended by the International Headache Society (IHS).We assessed the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

We included four studies, all of which enrolled adults with frequent episodic TTH. They all specified using the IHS diagnostic criteria and reported mean baseline pain of at least moderate intensity. While 1253 people with TTH participated in these studies, the numbers available for any analysis were lower than this because outcomes were inconsistently reported and because many participants received active comparators.None of the included studies were at low risk of bias across all domains considered, although for most studies and domains this was likely to be due to inadequate reporting rather than poor methods. We judged one study to be at high risk of bias due to small size.Useful information was available only for ketoprofen 25 mg. For the IHS preferred outcome of being pain-free at two hours the NNT for ketoprofen 25 mg compared with placebo was 9.0 (95% confidence interval (CI) 4.8 to 72) in two studies (272 participants; low quality evidence). The NNT was 3.7 (95% CI 2.6 to 6.3) for pain-free or mild pain at two hours in two studies (272 participants; moderate quality evidence). Fewer people needed rescue medication with ketoprofen 25 mg than with placebo, with a number needed to treat to prevent one event (NNTp) of 6.2 (95% CI 4.3 to 11) in three studies (605 participants; moderate quality evidence). The number of participants reporting any adverse event was higher with ketoprofen 25 mg than placebo (NNH 15, (95% CI 8.7 to 45)) in three studies (651 participants with 66 events; low quality evidence). Most events were of mild to moderate intensity.Ketoprofen 25 mg was not different from paracetamol 1000 mg in two studies with 276 participants for any efficacy outcomes (low to moderate quality evidence); the RR for pain-free at two hours was 1.3 (95% CI 0.9 to 2.0). The number of participants reporting any adverse event was higher with ketoprofen 25 mg than with paracetamol (NNH 17, 95% CI 8.9 to 130)) in two studies (582 participants, 68 events; low quality evidence).Studies reported no serious adverse events.We judged the quality of the evidence comparing ketoprofen 25 mg with placebo or paracetamol 1000 mg as moderate to very low. Where evidence was downgraded it was because of the small number of studies and events.

AUTHORS' CONCLUSIONS

Ketoprofen 25 mg provided a small benefit compared with placebo in terms of being pain-free at two hours or having mild or no pain at two hours for people with frequent episodic TTH who have an acute headache of moderate or severe intensity. Its use was associated with more people experiencing adverse events. Ketoprofen 25 mg was not superior to paracetamol 1000 mg for any efficacy outcome.

Prevalence of primary headache disorders in a population aged 60 years and older in a rural area of Northern China

BACKGROUND

Primary headache disorders are among the most common neurological complaints worldwide, and are significant causes of disability. Data are limited on the prevalence of primary headaches among individuals aged 60 years and older in China. The purpose of our study was to investigate the prevalence and characteristics of primary headaches among people aged 60 years and older in a rural area of northern China.

METHODS

A door-to-door survey was conducted in Ji County of Tianjin Province. A total of 5248 residents aged 60 years and older were visited from 2014 to 2015, unannounced, and basic sociodemographic and headache diagnostic information was collected via a questionnaire. Primary headache was classified tension-type headaches, migraines, chronic headache, and unclassified headache.

RESULTS

The 1-year prevalence for primary headaches in Ji county is 10.30 %. The 1-year prevalence of tension-type headaches, migraines, chronic headache, and unclassified headache is 2.02 %, 0.85 %, 3.79 %, and 3.63 %. The 1-year prevalence of primary headache was higher in women than in men. The 1-year prevalence of primary headache was decreased with increasing age. The 1-year prevalence of tension-type headaches and chronic headache were decreased with higher education. Headache in the elderly was mild to moderate and not serious.

CONCLUSIONS

In a population older than 60 years of age in rural, northern China, we found the 1-year prevalence of primary headache was 10.30 %, of tension-type headaches was 2.02 %, of migraines was 0.85 %, of chronic headache was 3.79 %, and of unclassified headache was 3.63 %. The prevalence of all of these was much lower than those observed in previous studies examining prevalence rates in the general population. The results of our study also indicated that women are more likely to have primary headache than men. We also found that chronic headache was frequent among the elderly. Participants with higher education levels were more predisposed than healthy participants to tension-type headaches. We also found that respondents who did not participate in social activities had a decreased predisposition for primary headache in general, as well as for unclassified headache. Lastly, we found that participants who had heart disease were more likely than healthy participants to experience primary headache, tension-type headache, chronic headache, and unclassified headache.

Medication-overuse headache: a perspective review

Medication-overuse headache (MOH) is a debilitating condition in which frequent and prolonged use of medication for the acute treatment of pain results in the worsening of the headache. The purpose of this paper is to review the most recent literature on MOH and discuss future avenues for research. MOH accounts for a substantial share of the global burden of disease. Prevalence is often reported as 1-2% but can be as high as 7% overall, with higher proportions among women and in those with a low socioeconomic position. Management consists of withdrawing pain medication, focusing on prophylactic and nonmedical treatments, and limiting acute symptomatic medication. Stress reduction and lifestyle interventions may support the change towards rational pain medication use. Support, follow up, and education are needed to help patients through the detoxification period. There is fertile ground for research in MOH epidemiology, pathophysiology, and neuroimaging. Randomized and long-term follow-up studies on MOH treatment protocols are needed. Further focused research could be of major importance for global health.

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.

Impact of headache disorders in Italy and the public-health and policy implications: a population-based study within the Eurolight Project

BACKGROUND

Migraine, tension-type headache (TTH) and medication-overuse headache (MOH) are disabling lifelong illnesses. The Eurolight project, a partnership activity within the Global Campaign against Headache, assessed the impact of headache disorders in ten countries in Europe using a structured questionnaire coupled with various sampling methods. Here we present the findings from the Italian population.

METHODS

Questionnaires were distributed to a stratified sample (N = 3500) of the adult (18-65 years) inhabitants of Pavia province (1.05 % of the general population), randomly selected in cooperation with the local health service. Questions included demographic and diagnostic enquries, and assessment of various aspects of impact and health-care utilisation.

RESULTS

Altogether 500 questionnaires were returned of which 487 were adequately completed for analysis (58 % female, 42 % male). Among these, gender-adjusted lifetime prevalence of headache was 82.5 %, higher in females than in males (91.2 % vs 72.4 %; p < 0.0001). Gender-adjusted 1-year prevalence was 74.2 % (females 87.7 %, males 61.1 %; p < 0.0001). The most prevalent headache type was migraine (gender-adjusted 1-year prevalence 42.9 %; females 54.6 %, males 32.5 %; p < 0.0001), followed by TTH (28.6 %; no gender-related difference); all causes of headache on ≥15 days/month were reported by 7.0 % of participants (females 10.6 %, males 2.0 %; p = 0.0002), of whom 2.1 %,, all female (p = 0.0064) concomitantly overused acute medications (therefore probable MOH). Only 16.6 % of responders reporting headache had received a diagnosis from a doctor, and very few (2.4 %) were taking preventative medications. Headache had negative impacts on different aspects of life: education, career and earnings, family and social life. Each person with headache had lost, on average, 2.3 days from paid work and 2.4 days from household work, and missed social occasions on 1.2 days, in the preceding 3 months. An increasing gradient for impact was observed from episodic to chronic forms of headache.

CONCLUSIONS

Our study reveals that in Italy, as in other countries, migraine, TTH and MOH are highly prevalent and are associated with significant personal impact. These findings have important implications for health policy in Italy.

The prevalence of primary headache disorders in Nepal: a nationwide population-based study

Background

Headache disorders are among the most prevalent and burdensome global public-health problems. Within countries, health policy depends upon knowledge of health within the local populations, but the South-East Asia Region (SEAR), among WHO’s six world regions, is the only one for which no national headache prevalence data are available.

Methods

In a cross-sectional population-based study, adults representative of the Nepali-speaking population aged 18–65 years and living in Nepal were randomly recruited using stratified multistage cluster sampling. They were visited unannounced at home by trained interviewers who used a culturally-adapted Nepali translation of the structured Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire.

Results

There were 2,100 participants (1,239 females [59.0 %], 861 males [41.0 %]; mean age 36.4 ± 12.8 years) with 9 refusals (participation rate 99.6 %). Over half (1,100; 52.4 %) were resident above 1,000 m and almost one quarter (470; 22.4 %) lived at or above 2,000 m. The 1-year prevalence of any headache was 85.4 ± 1.5 % (gender- and age-adjusted 84.9 %), of migraine 34.7 ± 2.0 % (34.1 %), of tension-type headache (TTH) 41.1 ± 2.1 % (41.5 %), of headache on ≥15 days/month 7.7 ± 1.1 % (7.4 %) and of probable medication-overuse headache (pMOH) 2.2 ± 0.63 % (2.1 %).

There was a strong association between migraine and living at altitude ≥1,000 m (AOR = 1.6 [95 % CI: 1.3-2.0]; p < 0.001). There was a less strong association between TTH and urban dwelling (AOR = 1.3 [95 % CI: 1.1-1.6]; p = 0.003), and a possibly artefactual negative association between TTH and living above 1,000 m (AOR = 0.7 [95 % CI: 0.6-0.8]; p < 0.001).

Conclusion

Headache disorders are very common in Nepal. Migraine is unusually so, and strongly associated with living at altitude, which in very large part accounts for the high national prevalence: the age- and gender- standardised prevalence in the low-lying Terai is 27.9 %. Headache occurring on ≥15 days/month is also common. This new evidence will inform national health policy and provide a basis for health-care needs assessment. However, research is needed to explain the association between migraine and altitude, since it may be relevant to health-care interventions.

Prevalence of primary headache disorders in Fayoum Governorate, Egypt

Background

There is abundance of epidemiological studies of headache in developed and western countries; however, data in developing countries and in Egypt are still lacking. This study aims to detect the prevalence of primary headache disorders in both urban and rural sectors in Fayoum governorate, Egypt.

Methods

A total of 2600 subjects were included using multi-stage stratified systematic random sampling, with respondent rate of 91.3 %. A pre-designed Arabic version, interviewer-administered, pilot tested structured questionnaire was developed according to The International Classification of Headache Disorders, 3rd edition (beta version), and this questionnaire was validated and the strength of agreement in headache diagnosis was good.

Results

The 1-year headache prevalence was 51.4 %, which was more prevalent in urban dwellers. The most common primary headache type was episodic tension type headache (prevalence; 24.5 %), followed by episodic migraine (prevalence; 17.3 %), both types peaked in midlife. Headache disorders were more common in females with exception of cluster headache that showed the expected male dominance. The risk of chronic headache increased more than one fold and half when the participants were females, married, and in those with high education. More than 60 % of our participants did not seek medical advice for their headaches problem; this percentage was higher in rural areas.

Conclusions

Primary headache disorders are common in Egypt; prevalence rate was comparable with western countries with exception of episodic tension headache. Still headache is under-estimated and under-recognized in Egypt and this problem should be targeted by health care providers.

Headache disorders and public ill-health in India: prevalence estimates in Karnataka State

BACKGROUND

Primary headache disorders are among the commonest disorders, affecting people in all countries. India appears to be no exception, although reliable epidemiological data on headache in this highly populous country are not available. Such information is needed for health-policy purposes. Our aim was to estimate the prevalence of each of the headache disorders of public-health importance, and examine their sociodemographic associations, in urban and rural populations of Karnataka, south India.

METHODS

In a door-to-door survey, 2,329 biologically unrelated adults (aged 18-65 years) were randomly sampled from urban (n = 1,226) and rural (n = 1,103) areas in and around Bangalore and interviewed by trained researchers using a pilot-tested, validated, structured questionnaire. ICHD-II diagnostic criteria were applied.

RESULTS

The observed 1-year prevalence of any headache was 63.9 %, with a female preponderance of 4:3. The age-standardised 1 year prevalence of migraine was 25.2%; prevalence was higher among females than males (OR: 2.1 [1.7-2.6]) and among those from rural areas than urban (OR = 1.5 [1.3-1.8]). The age-standardized 1 year prevalence of TTH was 35.1%, higher among younger people. The estimated prevalence of all headache on ≥15 days/month was 3.0%; that of pMOH was 1.2%, five-times greater among females than males and with a rural preponderance.

CONCLUSIONS

There is a very high 1 year prevalence of migraine in south India (the mean global prevalence is estimated at 14.7%). Explanations probably lie in cultural, lifestyle and/or environmental factors, although the observed associations with female gender and rural dwelling are usual. Levels of TTH, pMOH and other headache on ≥15 days/month are similar to global averages, while the very strong association of pMOH with female gender requires explanation. Until another study is conducted in the north of the country, these are the best data available for health policy in a population of over 1.2 billion people.

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

BACKGROUND

Three headache disorders - migraine, tension-type headache (TTH) and medication-overuse headache (MOH) - are major contributors to population ill-health. Policy-makers need local knowledge of these to guide priority-setting. Earlier we reported the prevalence of these disorders in Zambia; here we describe the burdens attributable to them.

METHODS

This was a cross-sectional population-based survey of adults aged 18-65 years, selected by cluster-randomized sampling in the mostly urban Lusaka Province and mostly rural Southern Province. Interviewers visiting households used a structured questionnaire. Diagnoses made algorithmically applied ICHD-II criteria. Burden enquiry focused on the previous 3 months and the day before interview. Disability was estimated by applying disability weights (DWs) from the Global Burden of Disease Survey 2010.

RESULTS

From 1,134 households, 1,085 unrelated adults (450 male, 635 female) were interviewed (refusal rate 4.3%). The gender- and habitation-adjusted 1-year prevalence of migraine was 22.9%, of TTH 22.8%, of headache on ≥15 days/month 11.5%, of probable MOH (pMOH) 7.1%. Reported mean intensity of migraine attacks was 2.7, representing severe pain. People with migraine spent 10.0% of their time in the ictal state (DW: 0.433); they were therefore 4.3% disabled overall. Disability from TTH was much lower. People with pMOH (time with headache: 37.5%; DW: 0.220) were 8.3% disabled overall. Average lost productive time in the preceding 3 months for migraine was 4.1 days from work (6.3% loss) and 4.2 days (4.7% loss) from household work. Losses for pMOH were 4.8 days (7.4% loss) from work and 4.5 days (5.0% loss) from household work. In the population aged 18-65 years (effectively the working population), estimated disability from migraine was 0.98%, with 1.4% of workdays lost, and from pMOH was 0.59%, with 0.53% of workdays lost. Headache yesterday was reported by 28.3% of participants, whose average productivity yesterday was 55.9% of expectation.

CONCLUSIONS

Zambia loses 1.93% of GDP to headache, and action is required to mitigate this loss and the associated suffering. Structured headache services with their basis in primary care are the most efficient, effective, affordable and equitable solution. They could be implemented within the existing health-care infrastructure of Zambia. These matters require urgent political attention.