Brazilian headache registry: methods and preliminary data of the pilot study

BACKGROUND

Evaluation and treatment of primary and secondary headaches is a global public health challenge. Recognizing the epidemiological impact of headaches, a group of researchers linked to the Brazilian Headache Society proposed the Brazilian Headache Registry and drew up its initial protocol.

OBJECTIVE

Here we describe the methods and preliminary data obtained from the pilot study.

METHODS

This was a multicenter longitudinal observational study conducted between September 2020 and August 2021. Prospective data were collected in three specialist centers for headache care in states in southern and southeastern Brazil. Patients aged 18 years or older who sought care for headache in tertiary centers and who agreed to participate in the study, were considered eligible.

RESULTS

Sixty-six patients were included in the pilot study: 43 (65%) from Rio Grande do Sul state and 23 (35%) from Minas Gerais state. Overall, 90% were female, and the subjects' mean age was 38.2 ± 11.2 years. Primary headaches accounted for 85.3% of the diagnoses made. Among secondary headaches, medication overuse headache was the most frequent type (7.1%).

CONCLUSIONS

The pilot study showed the feasibility of the research protocol developed for tertiary centers. The Brazilian Headache Registry will form a source of longitudinal data with the aim of contributing to better characterization of the various phenotypes of patients with primary and secondary headaches, and to detailing the use of health resources and identifying predictors of better clinical outcomes.

Consensus of the Brazilian Headache Society (SBCe) for prophylactic treatment of episodic migraine: part II

BACKGROUND

Migraine affects 1 billion people worldwide and > 30 million Brazilians; besides, it is an underdiagnosed and undertreated disorder.

OBJECTIVE

The need to disseminate knowledge about the prophylactic treatment of migraine is known, so the Brazilian Headache Society (SBCe, in the Portuguese acronym) appointed a committee of authors with the objective of establishing a consensus with recommendations on the prophylactic treatment of episodic migraine based on articles from the world literature as well as from personal experience.

METHODS

Meetings were held entirely online, with the participation of 12 groups that reviewed and wrote about the pharmacological categories of drugs and, at the end, met to read and finish the document. The drug classes studied in part II of this Consensus were: antihypertensives, selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, calcium channel blockers, other drugs, and rational polytherapy.

RESULTS

From this list of drugs, only candesartan has been established as effective in controlling episodic migraine. Flunarizine, venlafaxine, duloxetine, and pizotifen were defined as likely to be effective, while lisinopril, enalapril, escitalopram, fluvoxamine, quetiapine, atorvastatin, simvastatin, cyproheptadine, and melatonin were possibly effective in prophylaxis of the disease.

CONCLUSIONS

Despite an effort by the scientific community to find really effective drugs in the treatment of migraine, given the large number of drugs tested for this purpose, we still have few therapeutic options.

Consensus of the Brazilian Headache Society (SBCe) for the Prophylactic Treatment of Episodic Migraine: part I

The Brazilian Headache Society (Sociedade Brasileira de Cefaleia, SBCe, in Portuguese) nominated a Committee of Authors with the aim of establishing a consensus with recommendations regarding prophylactic treatment for episodic migraine based on articles published in the worldwide literature, as well as personal experience. Migraine affects 1 billion people around the world and more than 30 million Brazilians. In addition, it is an underdiagnosed and undertreated disorder. It is well known within the medical community of neurologists, and especially among headache specialists, that there is a need to disseminate knowledge about prophylactic treatment for migraine. For this purpose, together with the need for drug updates and to expand knowledge of the disease itself (frequency, intensity, duration, impact and perhaps the progression of migraine), this Consensus was developed, following a full online methodology, by 12 groups who reviewed and wrote about the pharmacological categories of the drugs used and, at the end of the process, met to read and establish conclusions for this document. The drug classes studied were: anticonvulsants, tricyclic antidepressants, monoclonal anti-calcitonin gene-related peptide (anti-CGRP) antibodies, beta-blockers, antihypertensives, calcium channel inhibitors, other antidepressants (selective serotonin reuptake inhibitors, SSRIs, and dual-action antidepressants), other drugs, and polytherapy. Hormonal treatment and anti-inflammatories and triptans in minimum prophylaxis schemes (miniprophylaxis) will be covered in a specific chapter. The drug classes studied for part I of the Consensus were: anticonvulsants, tricyclic antidepressants, monoclonal anti-CGRP antibodies, and beta-blockers.

Annual indirect costs secondary to headache disability in Brazil

Background

Disability imposed by headache disorders constitutes an expressive economic burden, mostly from indirect costs due to absenteeism and presenteeism.

Objective

To estimate indirect costs from absenteeism and presenteeism due to headache disorders in Brazil.

Methods

In a secondary, descriptive analysis of two nationwide databases, we estimated indirect costs based on headache-related disability and socioeconomic data.

Results

In the first database analyzed (n = 3838), 12.8% of the employed population with headache disorders missed at least 1 day of work in the last 3 months (mean, 95% CI = 4.2 days [3.7–4.6]). Based on the prevalence of headache disorders, days lost due to headaches and income data, R$ 40.4 billion (Int$ 20 billion) are lost due to headache-related absenteeism annually. For presenteeism, 26.2% of the employed population with headache disorders worked at least 1 day in the last 3 months with 50% reduced productivity (mean, 95% CI = 5.7 days [5.3–6.2]), amounting to R$ 27.3 billion (Int$ 13.5 billion) of financial loss annually. In the other database analysed (n = 205,546), 14,052 (6.8%) respondents missed work/school or household duties in the past 2 weeks due to some disease. Of these, 4.7% attributed their days lost to headaches disorders in the economically active population, which ranked 4th as main cause of days lost due to disease, among 23 common diseases.

Conclusions

The economic burden of headache disorders in Brazil, mostly due to migraine (55.4%), may cost up to R$ 67.6 billion (Int$ 33.5 billion) annually, and headache disorders represent a leading cause of absenteeism due to disease.

Migraine: a major debilitating chronic non-communicable disease in Brazil, evidence from two national surveys

Background

Even though migraine and other primary headache disorders are common and debilitating, major health surveys in Brazil have not included them. We repair this omission by combining data on non-communicable diseases (NCDs) in the Brazilian National Health Survey (PNS) 2013 with epidemiological data on migraine prevalence and severity in Brazil. The purpose is to rank migraine and its impact on public healthh among NCDs in order to support public-health policy toward better care for migraine in Brazil.

Methods

Data from PNS, a cross-sectional population-based study, were merged with estimates made by the Brazilian Headache Epidemiology Study (BHES) of migraine prevalence (numbers of people affected and of candidates for migraine preventative therapy) and migraine-attributed disability.

Results

Migraine ranked second in prevalence among the NCDs, and as the highest cause of disability among adults in Brazil. Probable migraine accounted for substantial additional disability. An estimated total of 5.5 million people in Brazil (or 9.5 million with probable migraine included) were in need of preventative therapy.

Conclusion

On this evidence, migraine should be included in the next health surveys in Brazil. Public-health policy should recognize the burden of migraine expressed in public ill health, and promote health services offering better diagnosis and treatment.

An Epidemiological Study of Headache in Florianopolis, Brazil

The aim of this study was to estimate the 1-year prevalence of headache, migraine, tension-type headache (TTH) and chronic daily headache (CDH), and the degree of association of migraine with some sociodemographic characteristics of the population of Florianopolis, Brazil. This is a cross-sectional, door-to-door, population-based study. In 300 randomly selected households, 625 subjects, aged 15–64 years, responded to a structured questionnaire. The 1-year prevalence of headache was 80.8%, of migraine 22.1%, of TTH 22.9%, and of CDH 6.4%. Migraine and CDH were significantly more prevalent in females than in males. Migraine was significantly associated with the following variables: low household income, low electricity consumption, and divorced or widowed marital status. We have shown high prevalences of migraine and CDH in Florianopolis, close to the higher rates of previous studies. There was a preponderance of migraine in females, divorced  or  widowed,  with  a  low  socioeconomic  level.

Recommendations for the treatment of migraine attacks - a Brazilian consensus

ABSTRACT In this article, a group of experts in headache management of the Brazilian Headache Society developed through a consensus strategic measurements to treat a migraine attack in both the child and the adult. Particular emphasis was laid on the treatment of migraine in women, including at pregnancy, lactation and perimenstrual period.

The methodology of population surveys of headache prevalence, burden and cost: principles and recommendations from the Global Campaign against Headache

The global burden of headache is very large, but knowledge of it is far from complete and needs still to be gathered. Published population-based studies have used variable methodology, which has influenced findings and made comparisons difficult. Among the initiatives of the Global Campaign against Headache to improve and standardize methods in use for cross-sectional studies, the most important is the production of consensus-based methodological guidelines. This report describes the development of detailed principles and recommendations. For this purpose we brought together an expert consensus group to include experience and competence in headache epidemiology and/or epidemiology in general and drawn from all six WHO world regions. The recommendations presented are for anyone, of whatever background, with interests in designing, performing, understanding or assessing studies that measure or describe the burden of headache in populations. While aimed principally at researchers whose main interests are in the field of headache, they should also be useful, at least in parts, to those who are expert in public health or epidemiology and wish to extend their interest into the field of headache disorders. Most of all, these recommendations seek to encourage collaborations between specialists in headache disorders and epidemiologists. The focus is on migraine, tension-type headache and medication-overuse headache, but they are not intended to be exclusive to these. The burdens arising from secondary headaches are, in the majority of cases, more correctly attributed to the underlying disorders. Nevertheless, the principles outlined here are relevant for epidemiological studies on secondary headaches, provided that adequate definitions can be not only given but also applied in questionnaires or other survey instruments.

Diagnosis, prevalence estimation and burden measurement in population surveys of headache: presenting the HARDSHIP questionnaire

The global burden of headache is very large, but knowledge of it is far from complete and needs still to be gathered. Published population-based studies have used variable methodology, which has influenced findings and made comparisons difficult. The Global Campaign against Headache is undertaking initiatives to improve and standardize methods in use for cross-sectional studies. One requirement is for a survey instrument with proven cross-cultural validity. This report describes the development of such an instrument. Two of the authors developed the initial version, which was used with adaptations in population-based studies in China, Ethiopia, India, Nepal, Pakistan, Russia, Saudi Arabia, Zambia and 10 countries in the European Union. The resultant evolution of this instrument was reviewed by an expert consensus group drawn from all world regions. The final output was the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire, designed for application by trained lay interviewers. HARDSHIP is a modular instrument incorporating demographic enquiry, diagnostic questions based on ICHD-3 beta criteria, and enquiries into each of the following as components of headache-attributed burden: symptom burden; health-care utilization; disability and productive time losses; impact on education, career and earnings; perception of control; interictal burden; overall individual burden; effects on relationships and family dynamics; effects on others, including household partner and children; quality of life; wellbeing; obesity as a comorbidity. HARDSHIP already has demonstrated validity and acceptability in multiple languages and cultures. Modules may be included or not, and others (eg, on additional comorbidities) added, according to the purpose of the study and resources (especially time) available.

Prevalence of headache in patients with Parkinson's disease and its association with the side of motor symptom onset

We compared the lifetime prevalence and the prevalence of headache during the previous year in patients with Parkinson's disease (PD) and control subjects. We also investigated the association between the side of PD symptom onset and the side of the headache. We interviewed 98 consecutive patients with an established diagnosis of PD between December 2010 and January 2012. The control group consisted of the 98 oldest sex-matched individuals from the nationwide Brazilian headache database. PD patients showed a significantly lower prevalence (40.8%) of headache in the previous year than controls (69.4%) (adjusted OR 0.5, CI 95% 0.2-0.9, p = 0.03). PD patients also showed a lower prevalence of headache throughout life (74.5%) than controls (93.9%) (adjusted OR 0.2, CI 95% 0.1-0.6, p = 0.01). Considering only patients who presented headache during the previous year, PD patients showed a higher association with occurrence of migraine than tension-type headache compared with controls (adjusted OR 3.3, CI 95% 1.2-8.9, p = 0.02). The headache side was ipsilateral to the side of PD onset in 21 patients (84%), with a concordance of 85.7% on the left side and 81.8% on the right side (p < 0.01). The prevalence of primary headache was significantly lower in patients with PD than controls. The predominant side of headache was ipsilateral to the side of initial motor signs of PD.

Improving quality in population surveys of headache prevalence, burden and cost: key methodological considerations

Population-based studies of headache disorders are important. They inform needs assessment and underpin service policy for a set of disorders that are a public-health priority. On the one hand, our knowledge of the global burden of headache is incomplete, with major geographical gaps; on the other, methodological differences and variable quality are notable among published studies of headache prevalence, burden and cost. The purpose here was to start the process of developing standardized and better methodology in these studies. An expert consensus group was assembled to identify the key methodological issues, and areas where studies might fail. Members had competence and practical experience in headache epidemiology or epidemiology in general, and were drawn from all WHO world regions. We reviewed the relevant literature, and supplemented the knowledge gathered from this exercise with experience gained from recent Global Campaign population-based studies, not all yet published. We extracted methodological themes and identified issues within them that were of key importance. We found wide variations in methodology. The themes within which methodological shortcomings had adverse impact on quality were the following: study design; selection and/or definition of population of interest; sampling and bias avoidance; sample size estimation; access to selected subjects (managing and reporting non-participation); case definition (including diagnosis and timeframe); case ascertainment (including diagnostic validation of questionnaires); burden estimation; reporting (methods and results). These are discussed.

Characteristics of migraine visual aura in Southern Brazil and Northern USA

BACKGROUND

Migraine aura, made up of one or more neurological symptoms arising from the cortex or brainstem, is a complex neurological phenomenon. Visual aura is the most frequent aura manifestation. Studying the subjective components of visual aura makes it possible to identify common characteristics.

OBJECTIVE

To thoroughly describe the characteristics of migraine visual aura in patients with migraine with aura.

METHODS

We performed a retrospective, descriptive study of the visual aura of 122 migraine patients collected at two headache clinics in the Americas. This study was designed to determine the characteristics of a typical visual aura.

RESULTS

The most common features of the visual aura in our study are that it occurs before the headache with a gap of less than 30 minutes, lasts 5 to 30 minutes, has a gradual onset, usually begins peripherally, is unilateral, and shimmers. Furthermore, the location of typical visual aura in the visual field has no fixed relationship to headache laterality, is slightly more often without color, and is often described as small bright dots and zigzag lines. Blurred vision, not typically considered to be an aura phenomenon of cortical origin, is in fact the most frequently reported visual symptom.

CONCLUSIONS

Migraine visual aura is heterogeneous and pleomorphic, and some of our findings run contrary to common beliefs.

Headache among mesial temporal lobe epilepsy patients: a case-control study

Epilepsy and headache are two chronic disorders that are characterized by recurrent attacks, but the relationship between them is not completely understood. Using a structured questionnaire, we investigated the prevalence of headache during the previous year in a homogeneous group of 100 patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). The control group consisted of 100 age-matched individuals who were randomized from a nationwide Brazilian headache database. There was a significantly higher prevalence of headache (92%) among the MTLE-HS patients when compared with the controls (73%; p=0.001). Chronic daily headache (CDH) was significantly associated with MTLE-HS (OR 6.1, CI 95% 1.7-22, p=0.005). We did not find any association between the diagnosis of migraine or tension-type headache and MTLE-HS. This study showed that MTLE-HS increases the likelihood of a headache diagnosis. In addition, CDH was more prevalent among the MTLE-HS patients, which supports a common pathophysiological mechanism for epilepsy and headache.

A nationwide population-based study of migraine in Brazil

The aim of this study was to estimate the 1-year prevalence of migraine and the degree of the association of migraine with some sociodemographic characteristics of a representative sample of the adult population of Brazil. This was a cross-sectional, population-based study. Telephone interviews were conducted on 3848 people, aged 18-79 years, randomly selected from the 27 States of Brazil. The estimated 1-year gender- and age-adjusted prevalence of migraine was 15.2%. Migraine was 2.2 times more prevalent in women, 1.5 times more in subjects with > 11 years of education, 1.59 times more in subjects with income of < 5 Brazilian Minimum Wages per month, and 1.43 times more in those who do not do any physical exercise. The overall prevalence of migraine in Brazil is 15.2%. Migraine is significantly more prevalent in women, subjects with higher education, with lower income, and those who do not exercise regularly, independently of their body mass index.

Chronic Daily Headache in Brazil: A Nationwide Population-Based Study

The objectives of this study were to estimate the 1-year prevalence of chronic daily headache (CDH) and the degree of the association of CDH with some sociodemographic characteristics of the adult population of Brazil. This was a cross-sectional, population-based study. We conducted telephone interviews with 3848 people, aged 18-79 years, randomly selected from the 27 States of Brazil. The degree of the association was calculated through prevalence ratios, adjusted with Poisson regression by gender, age and some sociodemographic factors. The estimated 1-year gender- and age-adjusted prevalence of CDH was 6.9±. CDH was 2.4 times more prevalent in women, 1.72 times more in unemployed, 1.63 times more in subjects with high household income and two times greater in those who did not exercise. The overall prevalence of CDH in Brazil is high. CDH is significantly more prevalent in women, the unemployed, subjects with higher income, and in those who do not exercise.

Symptoms and therapies: exertional and sexual headaches

This article discusses the headache disorders associated with physical and sexual activity, highlighting their differences and similarities. The place of exertional and sexual headaches in the classification of the International Headache Society and in the proposed classification of Indomethacin-Responsive Headache Disorders is addressed here. The Valsalva's maneuver as a shared pathophysiologic mechanism is mentioned as well. Exertional headaches are divided into two subtypes, according to the pattern of physical exercises. Sexual headaches are divided into three subtypes, based on the onset time, related to orgasm. The clinical characteristics of each type are presented, and their etiologies pointed out. The diagnostic approach is discussed, as well as the nonpharmacologic and pharmacologic treatment options.

Characteristics of migraine visual aura

Visual auras (VAs) of 100 patients with migraine with aura were studied by questionnaire. Visual auras accompanied the patients' first headache (HA) in 39% of patients. Only 19% had VAs with every attack. Patients with VAs over the entire HA history had a high frequency (greater than 50%) of attacks with VA; patients with VA during only part of the HA history had a low frequency (less than 50%) of attacks with VA. The auras occurred exclusively prior to the HA in 57%. The free interval between the end of the VA and the start of the HA was usually (75%) shorter than 30 minutes. Most (59%) patients had VAs that lasted from 1 to 30 minutes. They started in the periphery of the visual fields in 56%. The most common phenomena described were: small bright dots (42%), flashes of light (39%), "blind spots" (32%), and "foggy vision" (27%). Fortification spectra was reported by only 20%. Although most (65%) patients had a combination of phenomena, the majority (72%) had only one uniform constellation of manifestations. There was no clear-cut relationship between side of VA and side of HA. Migraine VA is a pleomorphic and complex symptom. Many patients not qualifying for the diagnostic criteria of migraine with aura, as proposed by the International Headache Society (IHS), unequivocally present with visual phenomena that strongly suggest this diagnosis.

Early and transient side effects of repetitive intravenous dihydroergotamine

Side effects associated with administration of repetitive intravenous dihydroergotamine (DHE) were prospectively studied in 72 patients with chronic daily headache who were hospitalized in a dedicated inpatient headache treatment program. All patients received 11 consecutive doses of DHE, starting with 0.25 mg and increasing by 0.25 mg up to a maximum dose of 1.25 mg, depending on side effects and/or headache relief. The adverse events were recorded after each dose administered. The great majority of patients (91.6%) reported at least one side effect. The most common were: nausea (72.2%), increase in previous headache (47.2%), lightheadedness (33.3%), "new" headache (27.8%), and leg cramps (23.6%). The overall number of side effect complaints did not increase proportionally with the strength of the dose of DHE administered. These complaints declined from the earlier to the later doses of DHE, except for leg cramps, which were more common with the later doses. Side effects determined the strength of subsequent doses of DHE in only 18.1% of patients. Only four patients had to have a decrease in dosage and none required termination of DHE due to side effects. Although repetitive intravenous DHE causes frequent side effects, they are usually mild and transient and decrease with subsequent doses, even at higher doses.