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

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.

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 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.

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.

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

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

Assessment of Headache Characteristics, Impact, and Managing Techniques among Pharmacy and Nursing Undergraduates-An Observational Study

Background and Objectives: Many different forms of headaches can change or impact daily activity and quality of life, which increases the financial burden on society over time. Undergraduates who get headaches may be absent from attending lectures, perform less well on their daily tasks and academic achievement, as well as struggle to build and maintain relationships with peers and mentors. Therefore, this study aimed to assess the headache-related characteristics and managing approaches among Saudi pharmacy and nursing students at a Saudi university, in Riyadh, Saudi Arabia. Materials and Methods: A survey questionnaire was administered in this cross-sectional study to participants at a Saudi university, in Riyadh, Saudi Arabia. Participants included males. The sample size was calculated with Raosoft® software. Data analysis was executed using IBM Statistic SPSS, and the level of statistical significance was set at p < 0.05. Results: A total of 236 participants completed the questionnaires. The majority, i.e., 218 (92.4%) of them, were male; in addition, 124 (52.5%) were aged between 26 and 30, 124 (52.5%) were pharmacy students, 112 (47.5%) were nursing students, and 134 (56.8%) were smokers. When asked about ever having at least one episode of headache during the week, 66.1% (n = 156) agreed that they had one episode of headache, although 57 (24.2%) of the students had a headache for five days during a week. With regard to the impact of headaches on everyday activities, only 34.7% of the students said that headache disrupted their regular activities. Almost 41% of the students agreed that headache impacted their academic performance. Nearly 34% of students (n = 79) who had headaches considered napping, while 33% (n = 64) took painkillers and anti-inflammatory medicines, and 25% (n = 59) considered taking caffeine. In this study, the participants’ ages and headache severity were strongly associated (p = 0.0001). More pharmacy students (66.1%) reported having severe headaches than nursing students (14.3%) (p = 0.0001). Conclusions: The current findings revealed that most of the undergraduates suffered from headaches, and the intensity of the pain was moderate; furthermore, one in four undergraduates reported that headaches impacted their academic performance. Caffeine and simple analgesics and anti-inflammatories were used for headache relief.

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 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.

Burden of headache in a HIV-positive population of sub-Saharan Africa

BACKGROUND

About 26 million people are living with HIV in sub-Saharan Africa. The DREAM programme in sub-Saharan Africa provides free healthcare for HIV/AIDS and a range of chronic non-communicable diseases. HIV is a risk factor for neurological non-communicable diseases including stroke and epilepsy, which themselves are associated with headache, and HIV may be a direct risk factor for headache. We investigated the prevalence and burden of headache in a HIV+ population in sub-Saharan Africa.

METHODS

At the DREAM Centre in Blantyre, Malawi, a low-income country with a population of 19 million and 9.2% HIV prevalence, a structured questionnaire was administered by a trained lay interviewer to consecutively attending HIV+ patients aged 6-65 years. All were monitored with regular viral load detection.

RESULTS

Of 513 eligible patients invited, 498 were included (mean age 34.1 ± 12.8 years; 72% females; 15 declined). All were on antiretroviral treatment, with viral load undetectable in 83.9%. The 1-year prevalence of headache was 80.3% (females 83.6%, males 71.9%); 3.8% had ≥15 headache days/month, 1.4% had probable medication-overuse headache. Mean overall headache frequency was 4.4 ± 5.4 days/month. Those reporting headache lost means of 2.3% of paid workdays and 3.3% of household workdays because of headache. Only one third had sought advice for their headache.

CONCLUSIONS

Headache is very prevalent among HIV+ patients in Malawi, imposing additional burden and costs on individuals and the community. Management of headache disorders should be implemented in HIV centres, as it is for other chronic non-communicable diseases.

The burden and health care use of patients with migraine and tension-type headache in post-conflict area of Serbia

PURPOSE

The aim of the present study was to assess the burden and health care use of adult patients with migraine and tension type headache in a post-conflict area of Serbia.

METHODS

This cross-sectional study was conducted on a representative sample of adults, living in predominantly Serb communities on the Kosovo and Metohija territory. The required data was obtained through a survey, utilizing a culturally-adapted questionnaire. The study sample comprised of 1,062 adults.

RESULTS

In the year preceding the study, 49.7% of included subjects suffering from migraines and 27.5% of those experiencing tension type headache sought medical assistance for their condition. The majority (88.5%) of the respondents utilized non steroid antiinfammatory drugs as analgesic, while 14.2% used prophylactic treatment. Migraine sufferers reported losing on average 11.1 days in a 3-month period, while those experiencing tension type headache lost 4.7 days (p < 0.001) due to headaches, preventing them from partaking in professional, family and social activities. On headache-free days, 24.5% of the respondents were anxious or tense in anticipation of a headache onset, while 30% did not feel that the headache had completely resolved. Moreover, 11.5% of the sample reported never or rarely feeling in control of the headache, while 20% of the respondents were of view that their headaches were not taken seriously by their employer and co-workers and rarely discuss them. Adverse effect of headaches on education is more frequently noted by migraine sufferers than those experiencing tension type headache (p = 0.001), and this disparity persists in relation to career (p < 0.001) and family planning (p = 0.001).

CONCLUSIONS

In Kosovo and Metohija, primary headaches exert a profound influence on the affected individuals and their community, and thus require recognition as one of the priorities of social initiatives aimed at the enhancement of public health.

[The indirect costs of tension type headache. A systematic literature review]

OBJECTIVE

The objective of this work was to systematically review the published literature in relation to the estimated indirect costs associated with TTH.

DESIGN

This systematic review followed the Preferred Reporting Items Statement for Systematic Reviews and Meta-analyzes (PRISMA).

DATA SOURCES

The review was performed in two main databases, PubMed and EconLit, and was completed with the gray literature search.

STUDY SELECTION

The basic criterion for the inclusion of studies was that they present at least one measure of indirect costs specific to TTH.

DATA EXTRACTION

12 studies were finally selected for information extraction. Of all the selected articles, the characteristics of the study design, the types of costs included, as well as the measurement instrument, and the main results were synthesized.

RESULTS

The search yielded a total of 568 studies. Heterogeneity was found in the designs and samples/populations of the included studies. Only two studies estimated direct and indirect costs for TTH. Among the most notable results, we find an estimated moderate impact of disability due to TTH (between 0.037 and 0.15 per person, 0.06-0.09% for the population). Productivity and efficiency losses were observed and were very heterogeneous. The willingness to pay for effective treatment would range from $1.32 to $9.20 per month. Quality of life is low, between 28.2 and 28.4 points out of 100, and health-related quality of life seems to improve significantly with treatment.

CONCLUSIONS

Despite the high heterogeneity of the results, we can conclude that tension headache is characterized by a moderate impact on disability, on productivity and efficiency at work or school, and on the quality of life of those who suffer it.

Headache education and management in Cameroon: a healthcare provider study

Headache disorders are the most prevalent neurological conditions in the Sub-Saharan Africa and the second cause of disability. In this study, we analyze the knowledge about headache disorders and their management among Cameroonian healthcare providers. We conducted an interventional study with a prospective cohort design. Cameroonian health care providers from the whole country were invited. The evaluation was based on a questionnaire that was done before and after a 4-day educational course. The study included 42 participants, 52.4% female, aged 36.8 years. Participants treated a median of 240 monthly patients. Headache was reported as the most frequent neurological condition in their clinics (34%). Mean number of neurological patients seen per week was 69.3, among them 20 were headache patients. At baseline, only 35.8% correctly mentioned at least one primary headache, increasing to 78.6% after the course (p = 0.002). Secondary headaches were correctly identified by 19.0% at baseline and 40.5% after the course (p = 0.01). Clinical history was considered sufficient for headache diagnosis by 57.1% before and 78.6% after (p = 0.5). Correct red flags were mentioned at baseline by only 14.3% of participants, increasing to 40.5% after the course (p = 0.005). At baseline, the preferred symptomatic was paracetamol (47.6%) and Non-Steroidal Anti-Inflammatory Drugs (9.5%), changing to 23.8 and 66.7% after the course (p = 0.05 and < 0.001). Headache was reported as the most frequent neurological disorders. Knowledge about primary headache disorders and their etiology was scarce, and the clinical concept of red flags was limited. The acute drug of choice was paracetamol.

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.

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.

Complementary and alternative therapies for tension-type headache: A protocol for systematic review and network meta-analysis

BACKGROUND

Tension-type headache (TTH) is the most common form of primary headache with high prevalence, which affects the quantity of life seriously. The pharmacological treatment of TTH is not the most effective. Meanwhile, complementary therapies and alternative therapies play an essential role in the treatment of TTH, and there is an absence of comparison between various interventions. Therefore, we propose the network meta-analysis protocol to compare the efficacy and safety of various complementary therapies and alternative therapies for TTH.

METHODS

From the beginning to February 2021, we will search the database to collect randomized controlled trials of complementary and alternative therapies for TTH. Two researchers will be responsible for screening retrieve documents, extracting data. The risk of bias will be assessed based on the Cochrane bias risk tool. We will use STATA16.0 and WinBUGS1.4.3 for paired meta-analysis and Bayesian network meta-analysis. The quality of evidence will be assessed using the grading of recommendations assessment development and evaluation.

RESULTS

This study will compare and rank the efficacy and safety of various complementary and alternative treatments for TTH.

CONCLUSIONS

This study will provide more extensive evidence for the complementary and alternative therapies of TTH. We expect to assist clinicians and patients in choosing the optimum treatment.

PROTOCOL REGISTRATION NUMBER

INPLASY202130088.

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.

Impact of Individual Headache Types on the Work and Work Efficiency of Headache Sufferers

Background: Headaches have not only medical but also great socioeconomic significance, therefore, it is necessary to evaluate the overall impact of headaches on a patient’s life, including their work and work efficiency. The aim of this study was to determine the impact of individual headache types on work and work efficiency. Methods: This research was designed as a cross-sectional study performed by administering a questionnaire among employees. The questionnaire consisted of general questions, questions about headache features, and questions about the impact of headaches on work. Results: Monthly absence from work was mostly represented by migraine sufferers (7.1%), significantly more than with sufferers with tension-type headaches (2.23%; p = 0.019) and other headache types (2.15%; p = 0.025). Migraine sufferers (30.2%) worked in spite of a headache for more than 25 h, which was more frequent than with sufferers from tension-type and other-type headaches (13.4%). On average, headache sufferers reported work efficiency ranging from 66% to 90%. With regard to individual headache types, this range was significantly more frequent in subjects with tension-type headaches, whereas 91–100% efficiency was significantly more frequent in subjects with other headache types. Lower efficiency, i.e., 0–40% and 41–65%, was significantly more frequent with migraine sufferers. Conclusions: Headaches, especially migraines, significantly affect the work and work efficiency of headache sufferers by reducing their productivity. Loss is greater due to reduced efficiency than due to absenteeism.

Knowledge, Attitude, and Practice on Over-the-Counter Drugs Among Pharmacy and Medical Students: A Facility-Based Cross-Sectional Study

Background

Self-medication with over-the-counter (OTC) medications is common among medicine and health science students. For safe use of OTC medications, students are expected to have proper knowledge, attitude, and practice (KAP) towards OTC medications and subsequent adverse drug reactions (ADRs).

Objective

The aim of this study was to assess KAP of OTC medications use and related factors among medical and pharmacy students at the University of Gondar, Gondar, Northwest Ethiopia.

Methods

A cross-sectional study was conducted. Data were collected using a self-administered questionnaire and analyzed using Statistical Package for Social Sciences (SPSS) version 24. Chi-square analysis was conducted and multivariable logistic regression analysis was used to determine the association between KAP and OTC use and its related adverse effects. A P value of less than 0.05 was used to declare statistical significance.

Results

A total of 380 students (229 medical students and 151 pharmacy students) participated in the study. The majority of the respondents 303 (79.7%) reported that they have the practice of self-medication. Fever 69 (80.2%), headache 21 (24.4%), and abdominal cramp 20 (23.3%) were the most common conditions for which the students go for self-medication while paracetamol 51 (59.3%) followed by non-steroidal anti-inflammatory drugs (NSAIDs) 44 (51.2%) were the most commonly used classes of drugs. An intention for time-saving caused by the waiting time due to crowds in medical consultation rooms 212 (77.4%) and a desire for quick relief 171 (62.4%) were the main reasons for the self-medication practice with OTC medications.

Conclusion

Self-medication is widely practiced among medical and pharmacy students. Significant problems and malpractices were identified, such as sharing of OTC medications, the use of expired medicines, doubling the dose of medications when they were ineffective, storage of OTC medications, and not reading labels and expiry dates.

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

Background

The Global Burden of Disease (GBD) study establishes headache as the second-highest cause of disability worldwide. Because most headache data in GBD are from adults, leading to underestimation of headache-attributed burden, a global schools-based programme within the Global Campaign against Headache is contributing data from children (7–11 years) and adolescents (12–17 years). This national study in Ethiopia is the first in this programme reported from sub-Saharan Africa.

Methods

A cross-sectional survey following the generic protocol for the global study was conducted in six schools (urban and rural), in Addis Ababa city and three regions of Ethiopia. Structured questionnaires were self-completed under supervision by pupils within their classes. Headache diagnostic questions were based on ICHD-3 beta criteria but for the inclusion of undifferentiated headache (UdH).

Results

Of 2349 potential participants, 2344 completed the questionnaire (1011 children [43.1%], 1333 adolescents [56.9%]; 1157 males [49.4%], 1187 females [50.6%]), a participation proportion of 99.8%. Gender- and age-adjusted 1-year prevalence of headache was 72.8% (migraine: 38.6%; tension-type headache: 19.9%; UdH: 12.3%; all headache on ≥15 days/month: 1.2%; probable medication-overuse headache: 0.2%). Headache was more prevalent in females (76.2%) than males (71.0%), a finding reflected only in migraine among the headache types. Headache was more prevalent among adolescents (77.6%) than children (68.4%), reflected in all types except migraine, although prevalence of UdH fell sharply after age 14 years to 3.9%.

For headache overall, findings matched those in Turkey and Austria, obtained with the same questionnaire, but the high prevalence of migraine, not increasing with age, was surprising. The study highlighted diagnostic difficulties in young people, especially when poorly educated, with migraine diagnoses driven by improbably high proportions reporting nausea (44.8%) and vomiting (28.0%) as usual symptoms accompanying their headaches.

Conclusions

Headache is very common in children and adolescents in Ethiopia. This has major public-health implications, since half the country’s population are aged under 18 years.

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

BACKGROUND

The Global Campaign against Headache collects data from children (7-11 years) and adolescents (12-17 years) both to inform health and education policies and to contribute to the Global Burden of Disease (GBD) study. This survey in Mongolia was part of this global enquiry.

METHODS

Following the generic protocol for the global enquiry, this was a schools-based cross-sectional survey. Self-completed structured questionnaires were administered, within classes, in seven schools in four districts of the Capital city and three rural areas of Mongolia, selected to represent the country's diversities. Headache diagnostic questions were based on ICHD-3 criteria but for the inclusion of undifferentiated headache (UdH).

RESULTS

Of 4515 potential participants, 4266 completed the questionnaire (children 2241 [52.5%], adolescents 2025 [47.5%]; males 2107 [49.4%], females 2159 [50.6%]). Children were therefore slightly over-represented, although overall mean age was 11.3 ± 3.3 years (range: 6-17; median 11). The non-participation proportion was 4.5%. Observed lifetime prevalence of headache was 81.0%. Gender- and age-adjusted 1-year prevalence was 59.4% (migraine: 27.3%; tension-type headache [TTH]: 16.1%; UdH: 6.6%; all headache on ≥15 days/month: 4.2%; probable medication-overuse headache: 0.7%). All headache types except UdH were more prevalent among females than males, and all were more prevalent among adolescents than children, although UdH represented a higher proportion of all headache in children (13.0%) than in adolescents (10.0%). Headache yesterday was reported by 15.9% of the sample, 26.0% of those with headache.

CONCLUSIONS

At least in adolescents, headache in Mongolia is no less common than in adults. The clear difference from similar studies in other countries was a lower prevalence of UdH, perhaps a consequence of reporting bias in a non-troublesome headache (mild and short-lasting by definition). This study informs policy in Mongolia and, with no similar study yet from elsewhere in Western Pacific Region, makes an important contribution to the global enquiry.

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.

Assessment of community pharmacy professionals' knowledge and counseling skills achievement towards headache management: a cross-sectional and simulated-client based mixed study

BACKGROUND

Headache is one of the most common disabling medical condition affecting over 40% of adults globally. Many patients with headache prefer to alleviate their symptom with a range of over-the-counter analgesics that are available in community medicine retail outlets (CMROs). However, data regarding how community pharmacists respond to headache presentation and their analgesic dispensing behaviors in Ethiopia is scarce. The present study aimed to assess the self-reported and actual practice of community pharmacists toward management of a headache in Gondar town, Ethiopia.

METHODS

A dual-phase mixed-methods research design, including pseudo-client visits (between April 1 and 30, 2018) followed by a questionnaire-based cross-sectional study (between May 1 and 20, 2018) was conducted among CMROs in Gondar town, Ethiopia.

RESULTS

Among the 60 pseudo-client visits, 95% of them dispensed medications. The overall counseling approach was found to be 42.6% which improved to 58.3% when the pseudo-clients demanded it. Duration (73.3%) and signs/symptoms (45%) of headache were asked before dispensing the medications. Dosing frequency (86.7%), indication (60%) and dosage form (35%) were the most discussed items. Ibuprofen (45%) and diclofenac (41.5%) were primarily added to paracetamol for better headache treatment. Effectiveness (61.7%) and cost (21.7%) were the main criteria to choose drugs. In the cross-sectional survey, 60 participants were requested and 51 of them agreed to participate (response rate of 85%). Of these participants, 64.7% agreed that managing headache symptomatically is challenging. Patient lack of confidence in dispensers (41.2%) and lack of updated medical information (31.4%) were reported as the primary barriers to counsel clients.

CONCLUSION

This study demonstrated the practical gaps in counseling practices and poor headache management of community pharmacies in Gondar city. National stakeholders in collaboration with academic organizations should be involved in continuous clinical training and education regarding proper counseling practices.

The Headache-Attributed Lost Time (HALT) Indices: measures of burden for clinical management and population-based research

BACKGROUND

The burden attributable to headache disorders has multiple components: a simple measure summarising them all does not exist. The Migraine Disability Assessment (MIDAS) instrument has proved useful, estimating productive time lost in the preceding 3 months due to the disabling effect of headache. We developed adaptations of MIDAS for purposes of the Global Campaign against Headache, embracing epidemiological studies and the provision of clinical management aids.

METHODS

We reviewed the structure, content, wording and scoring of MIDAS and made revisions, developing the Headache-Attributed Lost Time (HALT) Indices in three versions. Over 10 years, these were employed in multiple epidemiological and clinical studies in countries worldwide.

RESULTS

In the original HALT-90, we made no changes to the structure and scoring of MIDAS, but used wording in questions 1-4 that we believed would be more widely understood and more easily translated into other languages. Of the two alternative versions, HALT-30 kept the same structure, question format and wording except that "3 months" was replaced by "1 month". HALT-7/30 was a variant of HALT-30: focusing only on lost work time for population-based studies of headache-attributed burden, it enquired into lost days in the preceding month (30 days) and week (7 days).

CONCLUSIONS

Three versions of the HALT Indices serve different purposes as measures of headache-attributed burden, and offer different means of scoring. In studies using HALT as a population measure, there is no need to reflect the states of individuals, whereas a measure over shorter periods than 3 months is likely to be more reliable through better recall. Assessment of individual patients prior to treatment may best estimate impact if enquiry is made into the preceding 90 days, except in cases where headache is highly frequent. Follow-up in clinical management may be better served by assessments over 30 rather than 90 days.

The burden of headache is associated to pain interference, depression and headache duration in chronic tension type headache: a 1-year longitudinal study

Background

To investigate variables associated at one year (longitudinal design) with the physical or emotional component of burden in chronic tension type headache (CTTH).

Methods

One hundred and thirty (n = 130) individuals with CTTH participated in this longitudinal study. Clinical features were collected with a 4-weeks headache diary at baseline and 1-year follow-up. The burden of headache was assessed at baseline and one -year follow-up with the Headache Disability Inventory (HDI), physical (HDI-P) or emotional (HDI-E) component. Sleep quality (Pittsburgh Sleep Quality Index), anxiety and depression (Hospital Anxiety and Depression Scale-HADS), and quality of life (SF-36) were also assessed at baseline. Hierarchical regression analyses were conducted to determine the associations between the baseline variables and the headache burden at 1-year. Simple mediation models were also applied to determine the potential mediation effect of any intermediary variable.

Results

Regression analyses revealed that baseline pain interference and depression explained 32% of the variance in the emotional burden of headache, whereas baseline emotional burden of the headache, pain interference, and headache duration explained 51% of the variance in the physical burden of headache (P < .01) at 1-year. The mediation models observed that the effect of baseline pain interference on emotional burden of headache at 1-year was mediated through baseline depression, whereas the effect of baseline pain interference on the physical burden of headache at 1-year was mediated through baseline emotional burden of headache (both P < .05).

Conclusions

The current study found a longitudinal interaction between pain interference and depression with the burden of headache in individuals with CTTH.