Elsevier

The Lancet Neurology

Volume 7, Issue 4, April 2008, Pages 354-361
The Lancet Neurology

Review
Epidemiology and comorbidity of headache

https://doi.org/10.1016/S1474-4422(08)70062-0Get rights and content

Summary

The burden associated with headache is a major public health problem, the true magnitude of which has not been fully acknowledged until now. Globally, the percentage of the adult population with an active headache disorder is 47% for headache in general, 10% for migraine, 38% for tension-type headache, and 3% for chronic headache that lasts for more than 15 days per month. The large costs of headache to society, which are mostly indirect through loss of work time, have been reported. On the individual level, headaches cause disability, suffering, and loss of quality of life that is on a par with other chronic disorders. Most of the burden of headache is carried by a minority who have substantial and complicating comorbidities. Renewed recognition of the burden of headache and increased scientific interest have led to a better understanding of the risk factors and greater insight into the pathogenic mechanisms, which might lead to improved prevention strategies and the early identification of patients who are at risk.

Introduction

Headache is the most prevalent neurological symptom1 and is experienced by almost everyone. Headache can be a symptom of a serious life-threatening disease, such as a brain tumour, but in most cases it is a benign disorder that comprises a primary headache such as migraine or tension-type headache (TTH).2 Nevertheless, migraine and TTH can cause substantial levels of disability, not only to patients and their families but also to society as a whole owing to its high prevalence in the general population.3, 4, 5, 6, 7

Unfortunately, the scope and scale of the burden of headache is underestimated, and headache disorders are universally under-recognized and undertreated. An important initiative, Lifting the Burden: The Global Campaign to Reduce the Burden of Headache, focuses on these widespread aspects of headache and is a collaboration between multinational health-care organisations and professionals to raise awareness of headache disorders in general.8 Another initiative, Cost of the Brain Disorders in Europe, includes migraine as a separate neurological disorder that ranks as number nine on the list of the most costly neurological disorders in both sexes, and as number three in women.1, 6 TTH is the most common form of headache and is often thought of as a normal headache, in contrast to debilitating and characteristic migraine attacks or cluster headaches. Owing to its high prevalence, disability due to TTH is greater than that for migraine at the population level.3 Headache is among the ten most disabling disorders for both sexes and, if the burden of TTH is taken into account, among the five most disabling disorders for women, in accordance with the WHO's ranking of the most disabling disorders.3

The main objectives of this Review are to present the recent epidemiological knowledge about primary headache disorders, their comorbidities, costs, risk factors, and prognoses.

Section snippets

Prevalence

Although there are no biological markers for primary headaches such as migraine and TTH, their diagnosis is made with relatively high precision on the basis of the diagnostic criteria of the second edition of the International Classification of Headache Disorders (ICHD-II),9 which were published in 2004 and are now applied worldwide. There might, however, be problems with case definitions in epidemiological studies, particularly the definition of TTH, which can greatly influence the prevalence

Costs

The total economic burden of migraine has been estimated in the USA57 and Europe58 on the basis of population-based prevalence studies, which reported a prevalence of about 14% in both regions. The two studies used different types of data sources for the cost estimates, although the results of both clearly show that most of the cost of migraine can be attributed to indirect costs, such as absence from work or reduced efficiency when working with headache. The US study,57 which used cost data

Comorbidity

Comorbidity is defined as a medical condition that exists simultaneously but independently with another condition, although recent descriptions have questioned this and have implied causality between certain comorbid disorders.74

The study of the co-occurrence of highly prevalent disorders such as TTH and migraine with other disorders requires careful statistical analysis before any clear conclusions about causality can be made. Several headache disorders can occur within the same individual

Prognosis

The results of a 40-year follow-up of 73 children with pronounced migraine showed that before the age of 25, 23% of the patients did not have migraine, and women were significantly more likely to have migraine,91 but more than 50% still had migraine when they were around 50 years old.

In a 12-year longitudinal epidemiological study from Denmark, 549 people participated in the follow-up study. Of 64 migraineurs at baseline, 42% were in remission, 38% had low-frequency migraine, and 20% had a poor

Conclusions

In conclusion, headache disorders are among the most prevalent, burdensome, and costly diseases in the world, and there is an urgent need for acceptance, education, and scientific interest. Most of the severely affected patients also have profound comorbid disorders, which complicate their overall management and outcome. Thus, the burden of headache on the patient, their families, and on society is considerable. Limited knowledge of the underlying pathophysiology combined with a lack of

Search strategy and selection criteria

References for this Review were identified by searches of MEDLINE between 1988 and September, 2007, and from the extensive files of the authors. The search terms “migraine”, “cluster headache”, “tension-type headache”, “daily headaches”, “epidemiology”, “comorbidity”, “prognosis”, and “burden of headache” were used. Abstracts from meetings were also included. Only papers published in English were included. The final reference list was compiled on the basis of originality, quality, use of

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