The Global Burden of Headache

Deanna Saylor, MD, MHS; Timothy J. Steiner, MB, PhD

Disclosures

Semin Neurol. 2018;38(2):182-190. 

In This Article

Abstract and Introduction

Abstract

At the turn of the century, most of the world's population lived in regions where the prevalence of headache was unknown and its impact poorly understood. Lifting The Burden (LTB), a nonprofit organization in official relations with the World Health Organization, established the Global Campaign against Headache, with the ultimate purpose of reducing the burden of headache worldwide. First, the scope and scale of this burden had to be known. LTB embarked upon a program of population-based studies in countries in all world regions in order to achieve its aim. Its studies have demonstrated a high prevalence of headache disorders, including migraine, tension-type headache, and medication-overuse headache, and their associations with impaired quality of life, substantial lost productivity, and high economic costs in every country surveyed. Informed by these, the Global Burden of Disease study ranks headache disorders as the second leading cause of years lived with disability worldwide; migraine alone is third among people aged 15 to 49 years. With interventions urgently needed to reduce these burdens throughout the world, we review the epidemiological studies conducted by LTB, examine proposed interventions to improve provision of headache care including a three-tier system of structured headache services, and consider the challenges still remaining in providing effective, efficient, and equitable headache care especially in low-income countries.

Introduction

The most common headache disorders worldwide are migraine, tension-type headache (TTH), and medication-overuse headache (MOH).[1] In recent years, the scale of the personal, societal, and economic burdens attributable to these disorders have increasingly been recognized, along with the extent of their contributions to global ill health. Behind this growing awareness has been the steady accrual, over 15 years, of more and better evidence.

In this regard, the Global Burden of Disease (GBD) studies have been highly informative (Box 1). GBD 2010 established TTH as the second most prevalent condition in the world (22%) and migraine third (15%), trailing only dental caries in the numbers of people affected.[2] GBD 2015 found that more disability-adjusted life years (DALYs) were attributable worldwide to headache disorders than to all other neurologic disorders combined despite the fact that headache disorders have no impact on mortality.[3] Headache disorders ranked sixth among the leading causes of years lived with disability (YLDs) worldwide.[3,4] Migraine alone was seventh, and third in both men and women aged 15 to 49 years.[4] GBD 2000, the first iteration of GBD to include any headache disorder, ranked migraine 19th among causes of YLDs while ignoring TTH.[3]

Epidemiological data are essential to burden estimates. Where data are lacking, regionally or nationally, GBD does the best it can by extrapolating from areas adjacent or similar. It is imperfect methodology, generating inexact estimates. In 2000, more than half of the world's population lived in regions where headache prevalence was unknown: the Western Pacific region (including China), Southeast Asia (including India), Eastern Mediterranean, (including the Middle East) and North Africa, most of sub-Saharan Africa and much of Eastern Europe.[1] With regard to headache, GBD 2000 was very poorly informed and its estimates unreliable.[5]

In 2003, the Global Campaign against Headache was launched in partnership with the World Health Organization (WHO).[6,7] Now led by Lifting The Burden (LTB), a United Kingdom registered nonprofit organization in Official Relations with the WHO,[8] the Campaign's ultimate goal was and is to reduce the burden of headache worldwide. It is a goal not easily achieved, calling for implementation everywhere of headache services appropriate to local needs in a world of competing demands for limited resources. The Campaign's first requirement was reliable knowledge of local needs, a requirement ill-served by GBD 2000 and the data then available. LTB's first priority was therefore to fill the knowledge gaps.

A review in 2007 of the published epidemiological studies of headache noted frequent methodological shortcomings in study design, case definitions and ascertainment, sampling, data interpretation, and reporting.[9] LTB engaged an expert panel to develop consensus guidelines on the design and conduct of cross-sectional population-based studies of headache.[10] Questionnaires were produced to assess not only the prevalence of headache disorders but also many components of the burden attributable to them in adults[11] and children.[12] These were employed and validated in multiple countries,[13] along with an instrument to help health care providers evaluate and adjust headache treatment.[14–16] Population-based studies using these standardized methods in Georgia,[17] Moldova,[18] Lithuania,[19] Russia,[20] China,[21] India,[22] Nepal,[23] Pakistan,[24] Zambia,[25] Ethiopia,[26] Saudi Arabia (unpublished), Morocco (unpublished), and nine European Union countries[27] have provided data to successive iterations of GBD, each, as a consequence, better informed to make more dependable YLD estimates.[28] The result is a better, albeit still incomplete, understanding of the impact of headache disorders worldwide.

Here, we review the recent population-based studies of headache prevalence and personal and societal burdens, interventions that might fill the yawning gaps in headache treatment,[29] and challenges remaining in the continuing quest for better diagnosis and efficient, cost-effective, and equitable treatment of headache disorders worldwide.

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