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Year : 2021  |  Volume : 69  |  Issue : 7  |  Page : 1--3

Headache Disorders: The Painful Truth About the Neglect and Deprivation

Debashish Chowdhury1, P Sarat Chandra2,  
1 Editor, Headache Supplement, Neurology India, India
2 Editor, Neurology India, India

Correspondence Address:
Dr. Debashish Chowdhury
Editor, Headache Supplement, Neurology India

How to cite this article:
Chowdhury D, Chandra P S. Headache Disorders: The Painful Truth About the Neglect and Deprivation.Neurol India 2021;69:1-3

How to cite this URL:
Chowdhury D, Chandra P S. Headache Disorders: The Painful Truth About the Neglect and Deprivation. Neurol India [serial online] 2021 [cited 2021 Jun 15 ];69:1-3
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The headache disorders as a group of medical illnesses have not received adequate attention from doctors, researchers, funding agencies, and the governments. This is despite the fact that headache sufferers report significant problems in performing their day to day activities at the individual, family, and societal levels. Also, it is underappreciated that countries lose a large amount of money in managing (and mismanaging) various headache disorders, especially migraine.

One reason for not paying enough attention to headache disorders is probably because headaches are ubiquitous. As per one estimate, about 50-75% of adults aged 18-65 years in the world have had a headache in the last year.[1] However, in about 40% of these individuals, headaches become recurrent and problematic and the condition changes from a mere symptom into a disorder. The second and probably more important reason is the lack of mortality and motor disability associated with most headache disorders. However such erroneous perceptions are belied by the estimates provided by the Global Burden of Disease (GBD) 2016 report.[2] GBD 2016 estimates showed that not only about three billion individuals in the world have a forward migraine or tension-type headache, the sufferers of these disorders also rank very high in terms of the years lived in disability.[3] Migraine is also the most burdensome disease in people aged less than 50 years.[4] About 1.7-4% of the world's adult population suffer from chronic headaches consisting of 15 or more days of headaches every month.[1] Considering the adult world population (>14 years) of 5.82 billion in 2020, and a conservative 1-year prevalence estimate of chronic headache as 2%, 116.4 million adult people in the world suffered from at least half a month's headache every month in 2020. It is no surprise that a significant proportion of them are occupationally disabled. Recent data also showed that there is an increased risk of mortality in migraine with aura in women and an increased risk of suicidality in cluster headache patients.[5],[6] These are just a few statistics that should make us ponder why headache disorders are still not considered a major public health problem in most countries.[4]

The roots of this neglect and deprivation can be traced from the undergraduate medical training programs. Despite these humongous estimates of prevalence and disability, the education about headache disorders amongst the undergraduate, post-graduate, and post-doctoral courses have not received adequate attention. It is a fact that the so-called "long and short cases" during traditional medical exams rarely have "headache cases". Even theory questions are rarely based on a headache problem. The lack of knowledge and orientation about headache disorders deprives physicians to confidently tackle these problems. It has been observed that headache disorders are incorrectly diagnosed and sub-optimally treated on many occasions. For example, the chronic migraine epidemiology and outcomes (CaMEO) study found that less than 5% of chronic migraine patients finally reach a tertiary care centre to receive optimal treatment, which is often delayed due to multiple barriers.[7] Similarly, the average delay in the diagnosis of cluster headache was reported to be 44 months in one study.[8] This situation must change.

Research funding in headache disorders has been disproportionately low in high-income countries and almost negligible in low-to-middle-income countries. For example, federal funding in the USA and National Health and Research Australia[9] allocated only 0.6 and 0.009% of research funding for headache disorders, respectively. As a direct consequence of poor funding, research output has been much lower in headache medicine compared to other specialities.

The economic burden of headache disorders has also been a neglected area of research. A recent study from the USA showed that migraine patients had total annual direct plus indirect costs that were $8924 (in 2014 United States dollars) higher than those of demographically similar individuals without evidence of migraine.[10] Migraine patients' mean annual direct all-cause healthcare costs were $6575 higher than those of matched patients without migraine. In fact, recent reports suggest that the indirect cost can be much more than the direct cost. A study that estimated the economic burden of migraine on US employees, using a migraine impact model, projected that "approximately 60,000 to 686,000 annual workdays to be affected by lost productive time due to migraine (often referred to as "absenteeism" and "presenteeism") and estimated annual indirect costs to total between 6.2 and 8.5 times the annual direct costs".[11] Similarly, Australians aged 20-64 years over the next ten years are likely to spend 1.67 billion Australian dollars in health-care costs for headache disorders.[12] These figures should really be wake-up call for health planners and policymakers of various countries.

Indeed lately, there has been some progress in this direction. Based on the first Global Patient Advocacy Summit in 2017, the Vancouver Declaration on Global Headache Patient Advocacy was published.[13] The world brain day on 22nd July 2019 was celebrated the world over as "migraine: the painful truth" by the World Federation of Neurology partnering with the International Headache Society.[14] This program underscored the major goals in headache healthcare such as achieving the correct headache diagnosis (using the International classification of headache disorders), equitable access to standard headache care for all and enabling the proper education for the clinicians who can provide individualised treatments based on age, gender, culture, and the goal-changing needs of the patients.

India has seen a substantial jump of nine places from being ranked 24 to 15 in terms of headache disease burden between 1990 and 2016.[15] In a survey from Karnataka, the 1-year prevalence of migraine was found to be 25.2%, much higher than the corresponding figure from the West.[16] More importantly, only about one-quarter of participants with headache in the last year had contact with a healthcare provider. Thus, managing headache disorders in primary care shall be a big challenge for India. The model proposed by "Lifting The Burden: the Global Campaign against Headache" can be adapted to suit our local needs.[17]

In view of the above, the decision of the Editorial board of Journal, Neurology India to bring a special supplement dedicated to headache medicine is indeed laudable. I am thankful to Professor Sarat Chandra, Editor of Neurology India for inviting me to be the guest editor of the headache supplement. This supplement contains 28 articles that have been written by eminent headache specialists across the globe covering the latest in the field of headache medicine. The focus is on primary headaches and both the medical and surgical management updates have been provided. Migraine, tension-type headache, trigeminal autonomic cephalalgias, other uncommon primary headaches, cervicogenic headache, medication-overuse headache, trigeminal and occipital neuralgias have been covered exhaustively. I am thankful to Mrs. Saumya Awasthi, the editorial assistant of Neurology India, for providing all the help whenever needed. I hope our readers will find these articles useful and these will make a difference in their day-to-day practice while dealing with a headache patient.

The proper diagnosis and treatment of various headache disorders not only benefit individuals suffering from it in terms of alleviation or reduction in pain but also significantly improves their quality of life in terms of family and societal engagements. From a national perspective, a reduction in direct and indirect costs due to headache disorders shall lead to saving a great deal of public exchequer's money. Finally, improving the quality of life of the young workforce of the country produces intangible benefits that go far beyond any numbers.


1World Health Organization. Atlas of headache disorders and resources in the world 2011. A collaborative project of World Health Organization and Lifting The Burden. 2011 ISBN 978 92 4 156421 2.
2GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2018;17:954-76.
3Reuter U. GBD 2016: still no improvement in the burden of migraine. Lancet Neurol 2018;17:929-30.
4Steiner TJ, Stovner LJ, Vos T, Jensen R, Katsarava Z. Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain 2018;19:17.
5Rohmann, JL, Rist, PM, Buring, JE, et al. Migraine, headache, and mortality in women: a cohort study. J Headache Pain 2020;21:27.
6Ji Lee M, Cho SJ, Wook Park J, Kyung Chu M, Moon HS, Chung PW, et al. Increased suicidality in patients with cluster headache. Cephalalgia 2019;39:1249-56.
7Dodick DW, Loder EW, Manack Adams A, Buse DC, Fanning KM, Reed ML, et al. Assessing barriers to chronic migraine consultation, diagnosis, and treatment: results from the chronic migraine epidemiology and outcomes (CaMEO) study. Headache: The Journal of Head and Face Pain 2016;56:821-34.
8Van Alboom E, Louis P, Van Zandijcke M, et al. Diagnostic and therapeutic trajectory of cluster headache patients in Flanders. Acta Neurologica Belgica 2009;109:10-17.
9Wijeratne T, Crewther D, Crewther S. Migraine: the greatest disability of all in Australia. Neuroepidemiology 2019;52:12-13.
10Bonafede M, Sapra S, Shah N, Tepper S, Cappell K, Desai P. Direct and Indirect Healthcare Resource Utilization and Costs Among Migraine Patients in the United States. Headache 2018;58:700-14.
11Yucel A, Thach A, Kumar S, Loden C, Bensink M, Goldfarb N, et al. Economic Burden of Migraine on US Employers. Am J Manag Care 2020;26:e403-e408.
12Tu S, Liew D, Ademi Z, Owen AJ, Zomer E. The Health and Productivity Burden of Migraines in Australia. Headache 2020;60:2291-303.
13Dodick D, Edvinsson L, Makino T, Grisold W, Sakai F, Jensen R, et al. Vancouver Declaration on Global Headache Patient Advocacy 2018. Cephalalgia 2018;38:1899-909.
14Wijeratne T, Grisold W, Dodick D, Carroll W. World Brain Day 2019: migraine, the painful truth. Lancet Neurol 2019;18:914.
15India State-Level Disease Burden Initiative Collaborators. Nations within a nation: variations in epidemiological transition across the states of India, 1990-2016 in the Global Burden of Disease Study. Lancet 2017;390:2437-60.
16Kulkarni GB, Rao GN, Gururaj G, Stovner LJ, Steiner TJ. Headache disorders and public ill-health in India: prevalence estimates in Karnataka State. J Headache Pain 2015;16:67.
17Steiner TJ, Jensen R, Katsarava Z, et al. Aids to the management of headache disorders in primary care (2nd edition). J Headache Pain 2019;20:57.