PHA-Exchange> Headache disorders

[Claudio]

 "Judith Ladinsky" <jlladins at wisc.edu>

> *Headache disorders
>
> Various forms of headache, properly called headache disorders, are
> among the most common disorders of the nervous system. They are
> pandemic and, in many cases, life-long conditions.
>
> Headache itself is a painful and often disabling feature of a
> relatively small number of primary headache disorders. It also occurs
> secondarily to a considerable number of other conditions. A wide range
> of headache types have been classified in detail by the International
> Headache Society. The most common among them - tension-type
> headache (TTH), migraine, cluster headache and the so-called chronic
> daily headache syndromes - cause substantial levels of disability.
> Headache has been and continues to be underestimated in scope and
> scale, and headache disorders remain under-recognized and
> under-treated throughout the world.
>
> */A worldwide problem/*
> Although the epidemiology of headache disorders is only partly
> documented, taken together, headache disorders are extraordinarily
> common. Population-based studies have mostly focused on migraine
> which, although the most frequently studied, is not the most common
> headache disorder. Other types of headache, such as the more prevalent
> TTH and sub-types of the more disabling chronic daily headache, have
> received less attention. Few population-based studies exist for
> developing countries where limited funding and large and often rural
> populations, coupled with the low profile of headache disorders
> compared with other diseases, prevent the systematic collection of
> information.
>
> In developed countries, Tension Type Headache (TTH) alone affects
> two-thirds of adult males and over 80% of females. Extrapolation from
> figures for migraine prevalence and attack incidence suggests that
> 3000 migraine attacks occur/ every day/ for each million of the
> general population. Less well recognized is the toll of chronic daily
> headache: up to one adult in 20 has headache every or nearly every day.
>
> Not only is headache painful, but headache disorders are also
> disabling. Worldwide, according to the World Health Organization
> (WHO), migraine alone is 19^th among all causes of years lived with
> disability (YLDs). Headache disorders impose recognizable burden on
> sufferers including sometimes substantial personal suffering, impaired
> quality of life and financial cost. Repeated headache attacks, and
> often the constant fear of the next one, damage family life, social
> life and employment. For example, social activity and work capacity
> are reduced in almost all migraine sufferers and in 60% of TTH sufferers.
>
> The long-term effort of coping with a chronic headache disorder may
> also predispose the individual to other illnesses. For example,
> depression is three times more common in people with migraine or
> severe headaches than in healthy individuals.
>
> Migraine is a primary headache disorder with, almost certainly, a
> genetic basis. Activation of a mechanism deep in the brain causes
> release of pain-producing inflammatory substances around the nerves
> and blood vessels of the head. Why this happens periodically, and what
> brings the process to an end in spontaneous resolution of attacks, are
> to a large extent uncertain. Adults with migraine describe episodic
> attacks with specific features, of which nausea is
> the most characteristic. Attack frequency is anywhere between once a
> year and once a week (most commonly once a month). In children,
> attacks tend to be of shorter duration and abdominal symptoms more
> prominent.
> *
> *Headache        moderate or severe in intensity;
> one-sided and/or pulsating is
> aggravated by routine physical activity
> Duration        hours to 2-3 days
> Accompanying symptoms   nausea and sometimes vomiting and/or dislike
> or intolerance of normal levels of light and sound.
>
> Commonly starting at puberty, migraine most affects those aged between
> 35 and 45 years but can trouble much younger people, including
> children. European and American studies have shown that 6-8% of men
> and 15-18% of women experience migraine each year. A similar pattern
> is seen in Central and South America. Researchers in Puerto Rico, for
> example, have found 6% of men and 17% of women suffering from
> migraine. A survey conducted in Turkey revealed even greater
> prevalence in that country: 10% in men and 22% in women. The higher
> rates in women everywhere (2-3 times those in men) are hormonally-driven.
>
> Migraine appears somewhat less prevalent, but still common, in Asia
> (3% of men and 10% of women) and in Africa (3-7% in community-based
> studies). Major studies have yet to be conducted. But for example in
> India, anecdotal evidence suggests similar levels. "High temperatures
> and light levels for more than eight months of the year, the heavy
> noise pollution, the Indian habit of not having breakfast, frequent
> fasting and eating rich, spicy and fermented food, are common
> triggers," says Dr K. Ravishankar from Mumbai, a leading specialist.
>
> */Tension-type headache (TTH)/*
> The mechanism of TTH is poorly understood, although it has long been
> regarded as a headache with muscular origins. It may be stress-related
> or associated with musculoskeletal problems in the neck. TTH has
> distinct sub-types. As experienced by very large numbers of people,/
> episodic TTH/ occurs, like migraine, in attack-like episodes. These
> usually last no more than a few hours, but can persist for several
> days./ Chronic TTH/, one of the chronic daily headache syndromes, is
> less common than episodic TTH but present most of the time: it can be
> unremitting over long periods. This variant of TTH is much more
> disabling. Headache in either case is usually mild or moderate and
> generalized, though it can be one-sided. It is described as pressure
> or tightness, like a band around the head, sometimes spreading into or
> from the neck. It lacks the specific features and associated symptoms
> of migraine.
>
> TTH often begins during the teenage years, affecting three women to
> every two men, and reaches peak levels in the 30s. Episodic TTH is the
> most common headache disorder, reported by over 70% of some
> populations. Its prevalence varies greatly. African community-based
> studies, for example, have found only 1.7% of the population affected,
> but cultural attitudes to reporting a relatively minor complaint may
> largely explain this finding. Chronic TTH affects 1-3% of adults.
>
> */Cluster headache (CH)/*
> CH is one of a group of primary headache disorders of uncertain mechanism
that are characterized
> by frequently recurring, short-lasting but extremely severe headache.
> CH also has episodic and chronic forms./ Episodic CH/ occurs in bouts
> (clusters), typically of 6-12 weeks' duration once a year or two years
> and at the same time of year. Strictly one-sided intense pain develops
> around the eye once or more daily, mostly at night, until the pain
> diminishes after 30-60 minutes. The eye is red and waters, the nose
> runs or is blocked on the affected side and the eyelid may droop. In
> the less common/ chronic CH/ there are no remissions between clusters.
> The episodic form can become chronic, and/ vice versa/, but once CH
> has struck it may recur over 30 years or more.
>
> Though relatively uncommon (affecting fewer than 1 in 1000 adults), CH
> is clearly highly recognizable. It is unusual among primary headache
> disorders in affecting six men to each woman. Most people developing
> CH are in their 20s or older.
>
> */Medication-overuse headache (MOH)/*
> Chronic and excessive use of medication to/ treat/ headache is the
> cause of MOH, another of the chronic daily headache syndromes. A
> typical history of MOH begins with episodic headache - migraine or
> TTH. The condition is treated with an analgesic or other medication.
> Over time, headache episodes become more frequent, as does medication
> intake, until both are daily. A common and probably key factor in the
> development of MOH is a switch to pre-emptive use of medication. MOH
> is oppressive, persistent and often at its worst on awakening. What
> constitutes overuse is not clear. Suggested limits are the regular
> intake of simple analgesics on 15 or more days per month or of
> codeine- or barbiturate-containing combination analgesics, ergotamine
> or triptans on more than 10 days a month. In prevalence, MOH far
> outweighs all other secondary headaches. It affects up to 5% of some
> populations, women more than men.
>
> */Headache disorders and public health/*
> While those suffering from headache disorders bear much of the burden,
> they do not carry it all. Because headache disorders are most
> troublesome in the productive years (late teens to 50s), estimates of
> their financial cost to society - principally from lost working hours
> and reduced productivity - are massive. In the United Kingdom, for
> example, some 25 million working- or school-days are lost every year
> because of migraine alone. TTH, less disabling but more common, and
> chronic daily headache, less common but more disabling, together cause
> losses which are almost certainly of at least similar magnitude.
> Headache rarely signals serious underlying illness; its public-health
> importance lies in its causal association with these personal and
> societal burdens of pain, disability, damaged quality of life and
> financial cost. Headache is high among causes of consulting medical
> practitioners. A survey of neurologists found that up to one-third of
> all their patients consulted because of headache - more than for any
> other complaint.
>
> Headache ought to be a public-health concern. Yet there is good
> evidence that very large numbers of people troubled by headache do not
> receive effective care. For example, in representative samples of the
> general populations of the United States of America and the United
> Kingdom, only half of those identified with migraine had seen a doctor
> for headache-related reasons in the previous 12 months, and only
> two-thirds had been correctly diagnosed. Most were solely reliant on
> over-the-counter medications.
>
> */Barriers to effective care/*
> The common headache disorders require no special investigation and
> they are diagnosed and managed with skills that should be generally
> available to physicians. In theory, therefore, most headache can be
> optimally managed in primary care. The barriers vary throughout the
> world, but may be classified as clinical, social or political/economic*.
> *
> */Clinical barriers/*
> Lack of knowledge among health-care providers is the principal
> clinical barrier. This problem begins in medical schools where there
> is limited teaching on the subject, the consequence of low priority
> accorded to it. It is likely to be even more pronounced in countries
> with fewer resources generally and, as a result, more limited access
> to doctors and effective treatments.
>
> */Social barriers/*
> Poor awareness extends to the general public. Headache disorders are
> not perceived by the public as serious since they are mostly episodic,
> do not cause death and are not contagious. In fact, headaches are
> often trivialized. These important social barriers inhibit people who
> might otherwise seek help from doctors. Surprisingly poor awareness
> exists even among people directly affected A Japanese study found, for
> example, that many patients were unaware that their headaches were
> migraine, or that this required proper medical care. The low
> consultation rates in developed countries may indicate that many
> sufferers are unaware that effective treatments exist.
>
> */Political/economic barriers/*
> Many governments, seeking to constrain health-care costs, do not
> acknowledge the substantial burden of headache on society. They might
> not recognize that the direct costs of treating headache are small in
> comparison with the huge indirect-cost savings that might be made
> (/eg/, by reducing lost working days) if resources were allocated to
> treat headache disorders appropriately.
>
> */Management and prevention of headache disorders/*
> The great majority of headache disorders can be successfully managed.
> However:
>
>      * the sufferer must seek medical treatment;
>      * a correct diagnosis should be made;
>      * the treatment offered must be appropriate to the diagnosis;
>      * the treatment should be taken as directed;
>      * the patient should be followed up to assess the outcome of
>        treatment, which should be changed if necessary.
>
>
> The key in most areas of the world is education, which first should
> create awareness that headache disorders are a medical problem
> requiring treatment. Education of health-care providers should
> encompass correct recognition, diagnosis and treatment of common
> headache disorders*.
> *
> */What needs to be done?/*
> The evident burden of headache disorders on individuals and on society
> is sufficient to justify a strategic change in the approach to
> headache management. In order to implement beneficial change, the
> following must be achieved globally:
>
>      * The prevalence of all common headache disorders in all regions
>        of the world needs to be known, through further research where
>        necessary. The disability burden of all headache, not just
>        migraine, must be quantified. This can be achieved using WHO's
>        disability-adjusted life years (DALYs) methodology, which
>        measures years of healthy life lost both to premature mortality
>        (YLLs) and to disability (YLDs).
>      * This information, as it is accumulated, should be employed to
>        persuade health-care providers in all regions of the world of
>        the powerful humanitarian and socioeconomic arguments for change
>        leading to better care for headache. To combat stigma, it should
>        be used to increase public awareness of headache as a real and
>        substantial health problem.
>      * Education, as the key to effective headache management, needs
>        improving at all levels. In the case of the medical profession,
>        this should begin in medical schools by giving headache
>        disorders a place in the undergraduate curriculum that matches
>        their clinical importance as one of the most common causes of
>        consultation.
>      * Region-based demonstrational projects need to be set up in
>        collaboration with WHO Regional Offices, bringing together
>        country policy-makers and other key stakeholders to plan and set
>        up headache-related health-care services appropriate to local
>        systems and local needs. These projects will evaluate outcomes
>        in terms of measurable reductions in population burden
>        attributable to headache disorders.