Timothy J. Steiner

New appendix criteria open for a broader concept of chronic migraine.

After the introduction of chronic migraine and medication overuse headache as diagnostic entities in The International Classification of Headache Disorders, Second Edition, ICHD-2, it has been shown that very few patients fit into the diagnostic criteria for chronic migraine (CM). The system of being able to use CM and the medication overuse headache (MOH) diagnosis only after discontinuation of overuse has proven highly unpractical and new data have suggested a much more liberal use of these diagnoses. The International Headache Classification Committee has, therefore, worked out the more inclusive criteria for CM and MOH presented in this paper. These criteria are included in the appendix of ICHD-2 and are meant primarily for further scientific evaluation but may be used already now for inclusion into drug trials, etc. It is now recommended that the MOH diagnosis should no longer request improvement after discontinuation of medication overuse but should be given to patients if they have a primary headache plus ongoing medication overuse. The latter is defined as previously, i.e. 10 days or more of intake of triptans, ergot alkaloids mixed analgesics or opioids and 15 days or more of analgesics/NSAIDs or the combined use of more than one substance. If these new criteria for CM and MOH prove useful in future testing, the plan is to include them in a future revised version of ICHD-2.

Migraine in the United States Epidemiology and patterns of health care use

ObjectiveTo determine the prevalence and distribution of migraine in the United States as well as current patterns of health care use. MethodsA random-digit-dial, computer-assisted telephone interview (CATI) survey was conducted in Philadelphia County, PA, in 1998. The CATI identifies individuals with migraine (categories 1.1 and 1.2) as defined by the diagnostic criteria of the International Headache Society with high sensitivity (85%) and specificity (96%). Interviews were completed in 4,376 subjects to identify 568 with migraine. Those with 6 or more attacks per year (n = 410) were invited to participate in a follow-up interview about health care utilization and family impact of migraine; 246 (60.0%) participated. ResultsThe 1-year prevalence of migraine was 17.2% in females and 6.0% in males. Prevalence was highest between the ages of 30 and 49. Whereas 48% of migraine sufferers had seen a doctor for headache within the last year (current consulters), 31% had never done so in their lifetimes and 21% had not seen a doctor for headache for at least 1 year (lapsed consulters). Of current or lapsed consulters, 73% reported a physician-made diagnosis of migraine; treatments varied. Of all migraine sufferers, 49% were treated with over-the-counter medications only, 23% with prescription medication only, 23% with both, and 5% with no medications at all. ConclusionRelative to prior cross-sectional surveys, epidemiologic profiles for migraine have remained stable in the United States over the last decade. Self-reported rates of current medical consultation have more than doubled. Moderate increases were seen in the percentage of migraine sufferers who use prescription medications and in the likelihood of receiving a physician diagnosis of migraine.

The Prevalence and Disability Burden of Adult Migraine in England and their Relationships to Age, Gender and Ethnicity:

This study estimates the 1-year prevalence of migraine in adults in England in relation to the major demographic variables of age, gender and ethnicity, and describes some of its features, including aspects of consequential disability. A telephone survey was conducted of a random sample (n = 4007) of the population aged 16-65 years of mainland England using a previously validated diagnostic interview. The response rate was 76.5%. Overall, 7.6% of males and 18.3% of females reported migraine with or without aura within the last year meeting diagnostic criteria closely approximate to those of the International Headache Society. Prevalence of migraine varied with age, rising through early adult life and declining in the late 40s and early 50s. Prevalence was higher in Caucasians than in other races. Attack rates were ≥ 1/month in most migraineurs, and most experienced interference with daily activities in ≥ 50% of their attacks. On average, an estimated 5.7 working days were lost per year for every working or student migraineur, although the most disabled 10% accounted for 85% of the total. Results were in keeping with those from surveys in other countries. If these findings in mainland England are projected to the entire UK population, we estimate that 5.85 million people aged 16-65 years experience 190 000 migraine attacks every day and lose 25 million days from work or school each year because of them. Migraine is an important public health problem in the UK, associated with very substantial costs.

The cost of headache disorders in Europe: the Eurolight project.

Background and purpose:  Headache disorders are very common, but their monetary costs in Europe are unknown. We performed the first comprehensive estimation of how economic resources are lost to headache in Europe.

Classification of primary headaches

Given the range of disorders that produce headache, a systematic approach to classification and diagnosis is an essential prelude to clinical management. For the last 15 years, the diagnostic criteria of the International Headache Society (IHS) have been the accepted standard. The second edition of The International Classification of Headache Disorders (January 2004) reflects our improved understanding of some disorders and the identification of new disorders. Neurologists who treat headache should become familiar with the revised criteria. Like its predecessor, the second edition of the IHS classification separates headache into primary and secondary disorders. The four categories of primary headaches include migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalalgias, and other primary headaches. There are eight categories of secondary headache. Important changes in the second edition include a restructuring of these criteria for migraine, a new subclassification of tension-type headache, introduction of the concept of trigeminal autonomic cephalalgias, and addition of previously unclassified primary headaches. Several disorders were eliminated or reclassified. In this article, the authors present an overview of the revised IHS classification, highlighting the primary headache disorders and their diagnostic criteria. They conclude by presenting an approach to headache diagnosis based upon these criteria.

Lifting the burden: the global campaign against headache

On March 26, 2004—after 7 years of planning and discussions—WHO’s European Office in Copenhagen will host the launch of a global enterprise unique in the specialty of headache disorders. Headache disorders are ubiquitous. Their lifetime prevalence is over 90% in those populations that have been studied. Pain, suffering, and disability caused by headache disorders impose substantial burdens, at both personal

The Prevalence and Burden of Primary Headaches in China: A Population-Based Door-to-Door Survey

Objectives.— In the absence of reliable data on the prevalence and burden of primary headache disorders in the mainland of China, a population‐based survey was initiated by Lifting The Burden: the Global Campaign against Headache.

Patterns of health care utilization for migraine in England and in the United States

Objective: To assess patterns of medical consultation, diagnosis, and medication use in representative samples of adults with migraine in England and the United States. Methods: Validated computer-assisted telephone interviews were conducted in the United Kingdom (n = 4,007) and the United States (n = 4,376). Individuals who reported six or more headaches per year meeting the criteria for migraine were interviewed. Results: Patients with migraine in the United Kingdom were more likely to have consulted a doctor for headache at least once in their lifetime (86% vs 69%, p < 0.0001), but also were more likely to have lapsed from medical care (37% vs 21%, p < 0.001). In the United States, patients with migraine who had consulted made more office visits for headache and were more likely to see a specialist. In the United States, but not in the United Kingdom, women with migraine were more likely than men to consult doctors for headache. Patients with migraine in the United Kingdom were more likely to receive a medical diagnosis of migraine (UK 67%, US 56%; p < 0.05). Patterns of medication use were similar in both countries, with most people treating with over-the-counter (OTC) medications. Substantial disability occurred in a high proportion of those who never consulted (UK 60%, US 68%), never received a correct medical diagnosis (UK 64%, US 77%), and treated only with OTC medication (UK 72%, US 70%). Conclusion: Medically unrecognized migraine remains an important health problem both in the United States and the United Kingdom. Furthermore, there may be barriers to consultation for men in the United States that do not operate in the United Kingdom.

Migraine: the seventh disabler

With the agreement of the Editors-in-Chief, this editorial is published simultaneously by Cephalalgia, Headache and The Journal of Headache and Pain. On 15th December 2012, a special edition of Lancet published the principal findings of the Global Burden of Disease Survey 2010 (GBD2010). Few reports are likely to have more profound meaning for people with headache, or carry greater promise for a better future, than the seven papers (and one in particular [1]) that were presented. GBD2010 was not the first such survey to be conducted, nor the first to give some recognition to the burden of migraine. The Global Burden of Disease Survey 2000 (GBD2000), conducted 12 years ago by the World Health Organization (WHO), listed migraine as the 19th cause of disability in the world, responsible for 1.4% of all years of life lost to disability (YLDs) [2]. This finding has been cited repeatedly ever since; it has fuelled attempts to generate political acceptance of headache as a public-health priority [3], and given credibility to calls for greater investment in headache care and research. It pushed headache into WHO’s field of view, and became an essential part of the platform on which the Global Campaign against Headache has since been built [3-5]. In spite of all this, GBD2000 considerably underreported the disability that migraine imposed on people throughout the world, and gave a very poor account of headache disorders collectively. The evidence was not there. For more than half the world’s population, estimates for migraine were based on very little: data of acceptable quality were not in existence for China, India and most other countries in South East Asia, most of Africa, all of the Eastern Mediterranean and all of eastern Europe [6]. Headache disorders other than migraine did not feature in GBD2000 at all; for these disorders, at that time, dependable evidence was lacking everywhere. Filling this evidence gap has been a priority of the Global Campaign in its first years [7]. As a result, GBD2010 has been much better informed and built on much sounder foundations than its predecessor (we return to this point later). GBD2010 was not a simple update of GBD2000, but a complete rerun: an entirely new world survey. Working with many partners, the Global Campaign against Headache being one, it took from the world literature all the epidemiological evidence pertaining to burdensome diseases, assessed it for quality and derived from it, for each of 21 world regions, best age-related estimates of prevalence. Like GBD2000, it measured burden in disability-adjusted life years (DALYs), separated into the two components of YLDs and years of life lost to early mortality (YLLs); for headache, only the former are relevant. New disability weights (DWs) were assigned to each disease: lay descriptions of the various health states that were predictable sequelae of each disease were fed into a web-based worldwide consultation, which conducted an iterative series of comparisons, one health state with another. For migraine and tension-type headache (TTH), descriptions were agreed of average cases and three health states of each: ictal (during attacks), interictal (between attacks), and the health state associated with medication-overuse headache (MOH), which was considered as a potential complication of either. Information from published studies on frequency and duration of migraine or TTH episodes was pooled in order to estimate the average proportions of time (pT) spent in the ictal as opposed to interictal state. MOH was assumed to be continuous (pT=1) when present. YLDs for each of these states were then derived as products of prevalence, pT and DW, and for each disease as the sum of YLDs for each health state. Data were included from 84 studies of migraine in 43 countries in 16 of the 21 world regions, and from 45 studies of TTH in 34 countries in 13 world regions. TTH (estimated global prevalence 20.1%) and migraine (14.7%) ranked respectively as second and third most common diseases in the world (behind dental caries) in both males and females. For migraine, the estimated proportion of time spent in the ictal state was 5.3%, and the DW assigned to migraine episodes was 0.433 (43.3% disability). On the basis of ictal disability alone, migraine was ranked seventh highest among specific causes of disability globally (responsible for 2.9% of all YLDs), and in the top ten causes of disability in 14 of the 21 world regions, showing little evidence of a gradient falling from west to east or of being a disorder preferentially of rich countries. Migraine was, by a wide margin, the leading cause of disability among neurological disorders, accounting for over half of all YLDs attributed to these. For TTH, the estimated proportion of time spent with headache was 2.4%, and the DW assigned to headache episodes was 0.040 (4% disability). TTH accounted for only 0.23% of all YLDs, much less than predicted [6], which undoubtedly was because of the very low DW accorded to the ictal state. Regrettably, GBD2010 is still an incomplete account of the global burden of headache, and it continues to underestimate the disability arising from headache disorders. TTH got in, but MOH, which would probably have added much more substantially to the total YLDs, was excluded late in the survey for reasons not made clear and despite the evidence submitted in support of it. Also at a late-stage, the inclusion of interictal disability was considered inconsistent with measurements made of other chronic episodic conditions, which penalized migraine more than TTH. Even so, this very high-profile survey of the world’s causes of ill health better recognizes headache than anything before, and this is a big step forward. We might be satisfied by this; but rather we should be appalled. GBD measures disease burden as it is – alleviated by whatever treatments are made available. Headache disorders are among the top ten causes of disability because they are common and disabling; that is clear. Headache is one of the most frequent medical complaints: almost everybody has experienced it, at least 10% of adults everywhere are sometimes disabled by it, and up to 3% live with it on more days than not [6]. But for what conceivable reason do headache disorders remain among these ignominious top ten when they are largely treatable? Another recent global survey, conducted collaboratively by WHO and Lifting The Burden, described “worldwide neglect of major causes of public ill-health, and the inadequacies of responses to them in countries throughout the world” [8]. It drew attention to the very large numbers of people disabled by headache who do not receive effective health care. The barriers responsible for this might vary throughout the world, but poor awareness of headache in a context of limited resources generally – and in health care in particular – was constantly among them [8]. The consequences are inevitable: illness that can be relieved is not, and heavy burdens, both individual and societal [9], persist when they can be mitigated. The findings of GBD2010 sadly reflect this. GBD2010 sends out a clarion call, conveying a message of which governments need to take note [3]. Experience suggests this call will need constantly to be re-echoed, but the opportunity to use GBD2010 – for a better future for people with headache – must not be missed.

Primary headache disorders in the Republic of Georgia: Prevalence and risk factors

Objective: To estimate the 1-year prevalences of migraine and tension-type headache (TTH), and identify their principal risk factors, in the general population of the Republic of Georgia. Methods: In a community-based door-to-door survey, 4 medical residents interviewed all biologically unrelated adult members (≥16 years) of 500 adjacent households in Tbilisi, the capital city, and 300 in rural Kakheti in eastern Georgia, using a previously validated questionnaire based on International Headache Society diagnostic criteria. Results: The target population included 1,145 respondents, 690 (60%) women, mean age 45.4 ± 12.0 years. The 1-year prevalences were as follows: migraine 6.5% (95% confidence interval 5.0–7.9), probable migraine 9.2% (7.5–10.8), all migraine 15.6% (13.5%–17.7%), TTH 10.0% (8.2–11.7), probable TTH 27.3% (24.8–29.9), all TTH 37.3% (34.5%–40.1%). Female gender and low socioeconomic status were risk factors for migraine but not for TTH. Headache on ≥15 days/month was reported by 87 respondents, a prevalence of 7.6% (6.1–9.1). Female gender, low socioeconomic status, and frequent use (≥10 days/month) of acute headache drugs were risk factors. The likely prevalence of medication overuse headache was 0.9% (0.3–1.4), of chronic migraine 1.4% (0.7–2.1), and of chronic TTH 3.3% (2.3–4.4), but caution is needed in interpreting these estimates. Conclusions: While the prevalences of migraine and tension-type headache are comparable with those in Europe and the United States, a remarkably high percentage of the population of Georgia have headache on ≥15 days/month. This study demonstrates the importance of socioeconomic factors in a developing country and unmasks the unmet needs of people with headache disorders.