1. 17/10/15TJ Steiner1 The burden of headache TJ Steiner Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway and Imperial College London, London, UK

2. The multiple, diverse and often hidden burdens attributable to headache 17/10/15TJ Steiner 2

3. 22/1/09TJ Steiner3 Leading causes of years of life lost to disability (YLDs) WHO’s World Health Report 2001

4. widespread common disabling underestimated TJ Steiner4 Headache disorders 17/10/15

5. Migraine in adults: 1-year prevalence Africa4.0 (2 studies) Asia10.6 (6 studies) Australia Europe13.8 (9 studies) N. America12.6 (8 studies) S. America9.6 (10 studies) 14.7 11.7 14.0 13.3 12.2 11.6 3.0 5.0 8.5 11.6 13.2 10.0 10.2 9.6 16.7 23.2 14.3 Population-based surveys of >500 participants covering ages 25-60 y, using IHS or modified IHS criteria 8.4 5.9 22.3 9.0 10.1 7.7 5.3 5.0 16.3 12.6 9.3 8.2 10.0 8.5 7.3 13.5 Tekle Haimanot Dent Sakai Takeshima Roh Alders Deleu Wang Lampl Zivadinov Rasmussen Bank Launer Hagen Dahlof Steiner Kryst Schwartz O’Brien Stewart Lipton Jaillard Morillo Wiehe Morillo Miranda Lavados 15.5 Lyngberg 14.7 Patel Mean: 11.2 Median: 10.2 17/10/15 5

6. Migraine in adults: 1-year prevalence Africa4.0 (2 studies) Asia12.3 (8 studies) Australia Europe14.5 (10 studies) N. America12.6 (8 studies) S. America9.6 (10 studies) 6 14.7 11.7 14.0 13.3 12.2 11.6 3.0 5.0 8.5 11.6 13.2 10.0 10.2 9.6 16.7 23.2 14.3 Population-based surveys up to 2010 of >500 participants covering ages 25-60 y, using IHS or modified IHS criteria 8.4 5.9 22.3 9.0 10.1 7.7 5.3 5.0 16.3 12.6 9.3 8.2 10.0 8.5 7.3 13.5 Tekle Haimanot Dent Sakai Takeshima Roh Alders Deleu Wang Lampl Zivadinov Rasmussen Bank Launer Hagen Dahlof Steiner Kryst Schwartz O’Brien Stewart Lipton Jaillard Morillo Wiehe Morillo Miranda Lavados 15.5 Lyngberg 14.7 Patel Mean: 14.7% Russia: 20.3% India: 25.6% China: 9.3% 17/10/15

7. GBD2010 Vos T et al. Lancet 2012; 380: 2163-96 17/10/15TJ Steiner7

8. GBD2010 Vos T et al. Lancet 2012; 380: 2163-96 17/10/15TJ Steiner8 10 most prevalent disorders in the world

9. Global Burden of Disease Study 2010 (GBD 2010) The top 7 specific causes of disability worldwide: –low back pain58,245,000 YLDs –major depressive disorder46,139,000 –iron-deficiency anaemia42,731,000 –neck pain23,866,000 –COPD20,097,000 –anxiety disorder19,664,000 –migraine15,927,000 17/10/15 TJ Steiner 9

10. 17/10/15 Migraine disables through pain and associated symptoms 1 Lipton RB et al. Headache 2001;41:638-645. 1% 18% 47% 33% Mild Moderate Severe Extremely severe Severity of pain 1 80% of migraine patients report severe or extremely severe pain Vomiting Blurred vision Nausea PhonophobiaPhotophobia 29% 44% 73% 76% 80% 020406080100 Patients reporting symptom Prevalence of migraine- associated symptoms 2 2 Lipton RB et al. Headache 2001;41:646-657.

11. 11 17/10/15 Migraine is most common during the productive years Steiner TJ et al. Cephalalgia 2003;23:519-527. 7.6% 18.3% 14.3% 0 2 4 6 8 10 12 14 16 1820OverallFemalesMales % of UK population Prevalence of migraine Age-related prevalence of migraine Females Males Age (years) 0 5 10 15 20 25 30 Migraine prevalence (%) 3020405060

12. 17/10/15 Migraine has a very heavy financial cost. Hu H et al. Arch Intern Med 1999;159:813-818. $7.9bn $5.4bn $1.2bn 10% 30% 60% Emergency room, other Rx Office visits Missed work Direct medical costs Reduced productivity All costs in the US: about $14.5 billion annually

13. Global Burden of Disease Study 2010 (GBD 2010) Objectives of the Global Campaign against Headache: by filling in the major knowledge gaps: a)update migraine b)include other important headache disorders 17/10/15 TJ Steiner 13 migraine 7 th TTH in, but low DW so limited additional impact MOH not reported

14. Global Burden of Disease Study 2010 (GBD 2010) Disability weights: –migraine, ictal0.433 –TTH, ictal0.040 –MOH0.220 17/10/15 TJ Steiner 14

15. New studies to fill the knowledge gaps for GBD2013 and onwards … Completed: Georgia Russia China India (South) Saudi Arabia Pakistan Nepal Zambia Ethiopia Guatemala Morocco In progress: Peru In planning: Sudan Sri Lanka India (North) Ivory Coast Brazil Commencing: Global school- based survey of child and adolescent headache burden 17/10/15TJ Steiner15

16. Global Burden of Disease Study 2013 (GBD 2013) Migraine 6 th cause of disability MOH among top 20 (18 th ) Headache disorders collectively 3 rd Lancet on-line 8 June, 2015 17/10/15 TJ Steiner 16

17. 06/09/12 TJ Steiner17 Cost of headache in Europe 2009 (Eurolight) 17/10/15 TJ Steiner17 Total societal annual cost of headache among adults aged 18-65 years: – migraine €50 billion – TTH €21 billion – MOH€37 billion – other headaches€ 3 billion – all headache€112 billion per year (>90% indirect costs)

18. Cost of headache in China 2009 Estimated annual indirect (lost productivity) costs (CNY billion):  migraine:274  TTH:233  headache on ≥15 days/month: 57  all primary headache disorders:564 16 million lost person-years/year, accounting for 1.88% of GDP Yu, S et al (2012). The prevalence and burden of primary headaches in China: a population-based door-to-door survey. Headache, 52, 582–591 17/10/15

19. The visible burdens of headache Symptom burden –pain and suffering Disability burden –years of life lost to disability (YLDs) Cost burden –lost productive time –cost of health care 17/10/15TJ Steiner19

20. The invisible burdens of headache Interictal burden –fear of the next attack, leading to –avoidance of potential triggers, leading to –lifestyle compromise, leading to –reduced quality of life 17/10/15TJ Steiner20

21. WHO-QoL-8 total scores: no headache27.9 migraine25.7* † TTH 26.6* headache on ≥days/month:25.2* † *P<0.05 compared with no headache; † P<0.05 compared with TTH 17/10/15 Headache and quality of life in China (WHO-QoL 8) Yu, S et al (2012). The prevalence and burden of primary headaches in China: a population-based door-to-door survey. Headache, 52, 582–591

22. Interictal burden among Eurolight participants (N=6,455) 17/10/15TJ Steiner22 DiagnosisGender Interictal anxiety % Interictal avoidance % Not free of all symptoms % Migraine (n=2,959) F M All 11.0 9.9 10.6 14.8 14.7 14.8 25.6 27.0 26.0 Tension-type headache (n=3,033) F M All 3.1 4.2 5.2 4.7 17.1 21.0 18.9 Probable MOH (n=249) F M All 28.2 31.1 28.9 30.9 24.6 29.3 40.4 41.0 40.6

23. Interictal burden among Eurolight migraineurs (N=2,959) Ictal burden measure Probability of reporting interictal burden Odds ratios (95% CIs) Interictal anxiety Interictal avoidance Headache intensity (reference: “not bad”) “bad” “very bad” 2.8 7.6 1.6 3.0 Headache frequency (days/year) (reference: ≤12) 13-24 25-48 49-90 >90 2.4 2.5 3.7 6.4 1.6 2.0 2.7 2.5 In control of headaches (reference: “always”) “often” “sometimes” “rarely” or “never” 1.1 3.5 4.1 1.5 2.8 2.6

24. Interictal burden among Eurolight migraineurs (N=2,959) Ictal burden measure Probability of reporting interictal burden Odds ratios (95% CIs) Interictal anxiety Interictal avoidance HALT index: lost work time (days/3 months) (reference: ≤11) 12-22 23-33 >33 5.3 4.2 2.9 2.3 2.7 lost household time (days/3 months) (reference: ≤11) 12-22 23-33 >33 2.4 3.6 5.3 2.4 2.3 3.8 17/10/15TJ Steiner24

25. The cumulative burdens of headache Missed opportunities through chronic recurring illness –in education –in employment leading to reduced achievement and earnings over a lifetime TJ Steiner2517/10/15

26. Cumulative burdens among Eurolight migraineurs (N=2,959) 11.8% did less well in their education 5.9% on reduced earnings 7.4% felt their careers had suffered generally 2.1% had taken easier jobs 1.4% on long-term sick leave TJ Steiner2617/10/15

27. 17.6% had difficulties in sexual relationships (M 12.8%, F 19.7%) 1% had fewer children or avoided having children 0.5% headaches caused marital separation 0.2% headaches caused divorce TJ Steiner2717/10/15 Cumulative burdens among Eurolight migraineurs (N=2,959)

28. Global Burden of Disease Study 2013 (GBD 2013) Migraine –global prevalence 14.7%, 3 rd worldwide –6th highest cause of disability MOH –global prevalence 1-2% –18th highest cause of disability but… 17/10/15 TJ Steiner 28 Lancet June 8 2015

29. Lifting The Burden Population-based door-to- door burden-of-headache studies Russia (N=2,023) migraine 20.3% h/a ≥15d/m MOH India (N=2,329) migraine 25.6% h/a ≥15d/m MOH China (N=5,041) migraine 9.3% h/a ≥15d/m MOH 17/10/15 TJ Steiner29 Georgia (N=1,145) migraine 15.6% h/a ≥15d/m MOH Zambia (N=1,085) migraine 22.9% h/a ≥15d/m MOH Ethiopia (N=2,461) migraine 20.4% h/a ≥15d/m MOH Pakistan (N=4,223) migraine 22.9% h/a ≥15d/m MOH

30. Lifting The Burden Population-based door-to- door burden-of-headache studies Russia (N=2,023) migraine 20.3% h/a ≥15d/m 10.5% MOH 7.1% India (N=2,329) migraine 25.6% h/a ≥15d/m 2.7% MOH 1.2% China (N=5,041) migraine 9.3% h/a ≥15d/m 1.0% MOH 0.6% 17/10/15 TJ Steiner30 Georgia (N=1,145) migraine 15.6% h/a ≥15d/m 7.6% MOH 0.9% Zambia (N=1,085) migraine 22.9% h/a ≥15d/m 11.5% MOH 7.1% Ethiopia (N=2,461) migraine 20.4% h/a ≥15d/m 3.7% MOH 0.9% Pakistan (N=4,223) migraine 22.9% h/a ≥15d/m 7.4% MOH 0.7%

31. widespread common disabling still underestimated TJ Steiner31 Headache disorders 17/10/15

32. TJ Steiner 3217/10/15