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REVIEW ARTICLE
Year : 2021  |  Volume : 69  |  Issue : 7  |  Page : 4-9

Burden, Disability and Public Health Importance of Headache Disorders in India


1 Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Department of Neurology, GB Pant Institute of Post graduate Medical Education and Research, New Delhi, India

Date of Submission01-Dec-2020
Date of Acceptance18-Jan-2021
Date of Web Publication14-May-2021

Correspondence Address:
Dr. Anand Krishnan
Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.315984

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 » Abstract 


Headache disorders, characterized by recurrent headache, are among the most common disorders of the nervous system. The aim of this study was to document epidemiological and economic burden due to headache globally and in India and suggest a public health approach to address headache disorders for India. We reviewed the available literature on burden due to headache, its management using a primary health care approach and health system barriers, with special emphasis on India. Globally, it has been estimated that prevalence of current headache disorder (symptomatic within last year) among adults is about 50%, around 30% report migraine and headache on 15 or more days every month affects 1.7–4% people. The Global Burden of Disease Study 2016 estimated that migraine caused 45·1 million (95% UI 29·0–62·8) and tension-type headache 7·2 million (95% UI 4·6–10·5) years of life lived with disability. Limited data available in India support such high burden. These studies also indicate high diagnostic and treatment gaps for headache disorders in India. Major challenges in addressing headache disorders effectively in India are low perceived severity, absence of burden data, lack of standard treatment protocols for headache disorders and primary care models for neurological disorders in developing country context. There needs to be a better appreciation of the burden and a public health approach among all stakeholders, if burden of headache disorders is to be addressed effectively in India.


Keywords: Burden, headache, health system, public health
Key Messages: Despite headache disorders imposing a huge epidemiological and economic burden in India, there continues to be systemic lapses in measuring its burden and addressing it through a primary health care approach.


How to cite this article:
Krishnan A, Chowdhury D. Burden, Disability and Public Health Importance of Headache Disorders in India. Neurol India 2021;69, Suppl S1:4-9

How to cite this URL:
Krishnan A, Chowdhury D. Burden, Disability and Public Health Importance of Headache Disorders in India. Neurol India [serial online] 2021 [cited 2021 Jul 28];69, Suppl S1:4-9. Available from: https://www.neurologyindia.com/text.asp?2021/69/7/4/315984




Headache disorders, characterized by recurrent headache, are among the most common disorders of the nervous system.[1] Headache itself is a painful and disabling feature of a small number of primary headache disorders, namely migraine, tension-type headache(TTH), and trigeminal autonomic cephalalgias, the prototype of which is cluster headache. Headache can also be caused by or occur secondarily to a long list of other conditions, the most common of which is medication-overuse headache (MOH). Besides being quite common, the primary headaches constitute more than 90% of all headaches and are the principal contributors of the burden due to headache disorders. They are thus, most important from public health point of view. In the present review, we shall discuss the burden, disability of headache disorders and the gaps, challenges in their identification, and treatment in India. We shall also suggest a health service model to provide headache services in India.


 » Burden and Disability of Headache Disorders Top


Headache disorders impose a recognizable burden on sufferers including substantial personal impact, impaired quality of life and financial cost. Repeated headaches, and the constant fear of the next one, adversely affect family and social life and employment. The long-term effort of coping with a chronic headache disorder may also predispose the individual to other illnesses. For example, anxiety and depression are significantly more common in people with migraine than in healthy individuals.[2]

The burden of headache disorders has not been systematically studied and given its ubiquitous nature with little or no resultant mortality or permanent disability, it is considered to be of little public health significance. Our knowledge of the global burden of headache is incomplete due to major geographical gaps on burden data as well as methodological differences and variable quality among published studies of headache prevalence, burden, and cost.[3] In order to reliably estimate burden of a disease we need to have age-sex specific prevalence of the condition, duration of illness for reversible conditions and a measure of disability caused by it.

Two recent initiatives have resulted in an increased availability of data and visibility of burden due to headache disorders globally. These are the launch of global campaign “lifting the burden” and consequent development of a standard methodology for burden assessment.[4],[5] and; the inclusion of headache as a part of the Global Burden of Disease (GBD) estimations. The Global Campaign tries to correct the global failures in health care for headache disorders. Its essential purpose, pursued through its many partnerships, is to bring better health care to people with headache, thereby reducing the burden of headache worldwide. (https://www.l-t-b.org/go/the_global_campaign/purpose.html) The “lifting the burden” protocol has been used by many countries to assess their burden.[6],[7],[8],[9] Globally, it has been estimated that prevalence of current headache disorders (symptomatic within last year) among adults is about 50%. Half to three quarters of adults aged 18–65 years in the world have had headache in the last year and, among those individuals, 30% or more have reported migraine. Despite regional variations, headache disorders are a worldwide problem, affecting people of all ages, races, income levels and geographical areas. Headache on 15 or more days every month affects 1.7–4% of the world's adult population and represent an extreme end of the spectrum and its prevalence compares with many other severe conditions.[10]

Not only is headache painful, but it is also disabling. In GBD, disease burden is estimated in disability-adjusted life-years (DALYs), which are the sum of years of life lost (YLLs) to premature mortality and years of life lived with disability (YLDs). Because GBD does not estimate any deaths from headache disorders as the underlying cause, DALYs for headaches are equivalent to YLDs. YLDs for each headache disorder are calculated from its prevalence and the mean time patients spend with that type of headache multiplied by the associated disability weight. The headache disability weights, determined through population and internet surveys of lay descriptions that were used for migraine was 0·441 (0·294–0·588); tension-type headache 0·037 (0·022–0·057) and medication overuse headache 0·223 (0·146–0·313). In the GBD Study, updated in 2013, migraine on its own was found to be the sixth highest cause worldwide of years lost due to disability (YLD). Headache disorders collectively were third highest. The GBD 2016 estimated that almost three billion individuals have a migraine or tension-type headache in the world. It also estimated that migraine caused 45·1 million (95% UI 29·0–62·8) and tension-type headache 7·2 million (95% UI 4·6–10·5) YLDs globally in 2016.[11] GBD estimates from India show that migraine has jumped nine places from being ranked 24 to 15 in the disease burden for India between 1990 and 2016.[12]

Burden and disability of headache in India

In one of the earliest estimates of prevalence of headache in India from areas around Bengaluru in Karnataka in 1993-95, Gourie-devi et al. reported a current prevalence rate of 1.1% which was the highest among all the neurological disorders studied and had a slight rural preponderance.[13] However, the study was designed as general neurological disorder survey and headache was just a part of the many other neurological conditions that was identified in the study. The study lacked specific and validated criteria for headache diagnosis.

Much later in 2015, a study also from Karnataka, using the validated 'lifting the burden' criteria and methodology, reported that 63.9% of subjects had headache in the preceding year.[14] The age-standardised 1-year prevalence of migraine was 25.2%; prevalence was higher among women than men (OR: 2.1 [1.7-2.6]) and among those from rural areas than urban (OR = 1.5 [1.3-1.8]). The age-standardized 1-year prevalence of TTH was 35.1%. The estimated prevalence of all headaches on ≥15 days/month was 3.0%. In another study from Urban Kolkata, 1-year prevalence of primary headaches and migraine were estimated to be 14.9 % (95% CI: 13.3-16.6) and 14.1% (95% CI: 12.7-15.6) respectively. They also found that the overall DALY was much higher in women as compared to men per 100000 (7209 versus 2140) and highest in women in the age group of 30-34 years.[15] In a recently conducted epidemiological study to estimate headache burden in the national capital region of Delhi involving rural and urban areas our group by the authors, the 1-yr prevalence of migraine was estimated to be 27.2% (personal communication). Overall, these data show that primary headaches are at least as prevalent in India as in the West, or maybe more, and better epidemiological data are needed for the correct estimation of the disease burden. Applying the current estimates to population of India, the absolute numbers of people with headache look formidable and staggering [Figure 1]. This is the load that the health system has to address.
Figure 1: Absolute numbers of people with headache

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Economic burden of headache disorders

If the epidemiological burden of headache is less documented, economic burden is still poorly documented as it has only received attention in recent past. In general, economic burden is estimated in terms of direct cost (cost of treatment including transport etc.) and indirect costs (loss of productivity of case and caregivers). In Iran, MOH patients spend on an average $1046 for medical services, $132 for nonmedical services, and $1432 due to lost productivity per year.[16] In Philippines, the mean annual productivity costs lost due to migraine disability were US$556 per person.[17] Using a more complex, Markov state-transition model to simulate follow-up of Australians aged 20-64 years over the next 10 years, migraine was predicted to lead to a loss of 2,577,783 (95% CI 2,054,980 to 3,000,784) QALYs among this cohort (2.02 per person and 2.43% of total QALYs), and AU$1.67 (95% CI $1.16 to $2.37) billion in health-care costs (AU$1313 per person, 95% CI $914 to $1862).[18] In a web-based survey from United States on direct and indirect costs of chronic and episodic migraine, the researchers reported that the direct cost of illness constituted about 60-64% of the cost and most (70%) of the direct cost was due to pharmaceutical interventions. They also reported that the mean total annual cost of headache among people with chronic migraine ($8243]) was over three times that of episodic migraine ($2649).[19] Evaluation of economic aspects of available headache related intervention are still rarer in literature. Among those few, one study concluded that self-management with simple analgesics was by far the most cost-effective strategy for migraine treatment in low- and middle-income countries and represents a highly efficient use of health resources.[20] The economic burden of any disease on the society ultimately depends on the utilization and quality of treatment services available. Larger the diagnosis and treatment gaps in the headache management, higher will be the actual economic burden. Unfortunately, not much information is available from India. In the study from Karnataka referred to earlier, participants with headache lost 4.3% of productive time; those with migraine lost 5.8%. Lost paid worktime accounted for 40% of this.[21]


 » Diagnosis and Treatment Gaps of Headache Disorders in India Top


In the recent survey from Karnataka, about one quarter of participants with headache in last one year had a contact with a healthcare provider.[21] Of those with migraine, 30.3% had consulted, 84.0% of these in primary care. Primary care providers were the most important source of treatment for headaches except those with headache on ≥15 days/month where almost half of them had gone to a specialist doctor. This indicates that there is a large diagnostic and treatment gap for headaches which need to be corrected by re-organizing our health services, if we are to reduce the burden of headache on the society.


 » Challenges in Organizing Headache Services Top


The key challenges in organizing headache services in developing countries are summarized in [Figure 2]. From the perspective of the community, headaches are seen as ubiquitous, self-limiting resulting in no demand for headache services. In contrast, neurologists think that headaches could be indicators of serious disease and need management by experts and accordingly propose specialized services in tertiary settings like headache clinics. Lack of clear understanding of causal mechanisms means that population level preventive measures for headache are not yet possible. Absence of use of standardized protocol for their management and the need for multi-disciplinary teams also act as health system barriers.
Figure 2: Perspective of stakeholders on addressing headache disorders

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Addressing headache disorders using a public health approach

For justifying a public health approach to address any disease, first thing we need is evidence of high population level burden due to the disease. Resources in health care sector are always scarce and evidence-based prioritization need data on burden for competing priorities and a functional public health model for addressing it. A typical public health model will have simplified approach for diagnosis and treatment so that bulk of the patients can be managed by primary level healthcare providers.[22] Such programs will have to be pilot tested in real-life settings using pragmatic trials with clear-cut evidence of effectiveness. However, such evidence from developing countries is currently lacking. We list below the possible steps to be taken if we are to promote a public health approach to headaches,

  1. Establish Population level Burden: As the first step, we need a comprehensive assessment of burden due to headache in India with representative studies covering both epidemiological and economic aspects. These surveys should also assess the baseline treatment and diagnostic gap for headaches to enable future evaluation of their reductions by appropriate interventions.
  2. Develop standardized treatment protocol for management of headaches: One of the basic principles of a public health approach is that most patients can do with a standardized treatment at the first contact with only a minority requiring an individual level clinical decision making. Many examples exist of such approaches including treatment of childhood illnesses (diarrhea and pneumonia[23]) and adult illnesses like tuberculosis[24] While standardization of treatment eliminates the need for “specialized” care, it also provides an entry point in the long term to these conditions being managed at primary care level maybe by non-medical or paramedical persons. Public health approach recognizes the fact that the best treatment for all is an utopian dream and instead bases it approach on the principles “Let best not be the enemy of good “ and “Good for many is better than best for few”. [Figure 3] shows an algorithm simplifying the diagnosis and treatment of headache disorders for use in primary care.[25]
  3. Develop a primary care model of headache services with a focus on primary health care: While there has been progress globally on strengthening primary care for all diseases, neurological disorders have been among the latecomers. In fact, there are hardly any primary care model for any neurological disorders including stroke and epilepsy. A recent review of models of community-based primary care for epilepsy in low- and middle-income countries showed major gaps in evidence in terms of sustainability or demonstration of a reduction in treatment gap.[26] There is a need for demonstration projects within the existing national health system on using these standard management protocol and medical colleges can use their field practice area to undertake such operational research projects. [Table 1] below shows how headache services can be organized through the existing health services. This is only indicative and further discussions between various stakeholders are needed to decide on what can be done or managed at each level. The primary consideration will have to be that most of the headache disorders need to be managed as peripherally as possible. There must be a compromise between what needs to be done and what can be done through a process of dialogue between neurologists and public health specialists within the context of the existing health system. This trade-off must be accepted. Such an approach has been tried for many diseases in the past and there is no reason why this cannot work for neurological diseases including headache. In the area of other noncommunicable diseases (NCDs), WHO has already prepared a package of essential NCD interventions. (https://www.who.int/ncds/management/pen_tools/en/). Lessons for implementing NCD related care in primary setting have already been learnt in India and these would also be applicable to neurological disorders.[27] We need to move in the same direction for other neurological diseases including headache.
  4. Identify referral pathways: It is also important to identify the care pathways for referral to higher centres in case a headache sufferer has ominous symptoms and signs or becomes refractory to the treatments offered at the primary level. The doctors and paramedics need to be trained to identify the red flags and headache types for the correct diagnosis. Health system will need strengthening at all levels with trained human resources and appropriate diagnostic and treatment technologies and medicines.
  5. Establish Partnerships with all stakeholders including community: Large scale health system interventions cannot be implemented without an effective partnership between clinicians, public health practitioners and patients. The concerned stakeholders from policy makers to community need to be identified and engaged with appropriate communication channels and materials. There should be provision for dissemination of information regarding the diagnosis and management of various headache disorders for the public so that they can become a partner in the decision making for their headache problems.
Table 1: Management of headache at different levels of health system

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Figure 3: Primary care management algorithms adapted from guideline for primary care management of headache in adults

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 » Conclusion Top


Primary headache disorders are common in India. Roughly 1 in 4 to 1 in 8 persons in India suffer from migraine. Out of this, about 50% of patients require active intervention. There is significant disability attached to primary headache disorders and the country carries an unseen but huge economic burden. Considering the population of India, delivering an optimum headache care is a huge challenge. The proposed model to deliver headache services must be integrated with the existing heath system for delivering care for non communicable diseases. Our country must develop a cheap, affordable, and viable model for headache care.

Financial support and sponsorship

Nil.

Conflicts of  interest

There are no conflicts of interest.



 
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