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Migraine is first cause of disability in under 50s: will health politicians now take notice?

Migraine is first cause of disability in under 50s: will health politicians now take notice? Steiner et al. The Journal of Headache and Pain (2018) 19:17 The Journal of Headache https://doi.org/10.1186/s10194-018-0846-2 and Pain EDITORIAL Open Access Migraine is first cause of disability in under 50s: will health politicians now take notice? 1,2* 1,3 4 5 6,7 Timothy J. Steiner , Lars J. Stovner , Theo Vos , R. Jensen and Z. Katsarava Keywords: Headache disorders, Migraine, Tension-type headache, Medication-overuse headache, Burden of disease, Disability, Public health, Global Burden of Disease study, Global Campaign against Headache If it were needed, more evidence of the disconcerting enquiry, simultaneously into migraine, tension-type head- under-treatment of headache disorders has come from ache (TTH) and medication-overuse headache (MOH), the Eurolight study [1]. The topic is not new. Twenty the three headache disorders of major public-health years ago, the International and American Headache importance. This provided a broad view of headache in Societies jointly voiced their dismay at the inadequacies Europe. The different sampling methods employed by the of health care for headache [2]. In 2006, the European countries in Eurolight produced samples that varied in Headache Federation and World Headache Alliance their representativeness of the general population, argu- described migraine as a “forgotten epidemic” [3]. Mean- ably a strength in that it brought data into the survey from while, in 2003, the Global Campaign against Headache diversely-sourced samples [11, 12]. [4–6] engaged the World Health Organization (WHO) The new report analyses Eurolight data for indicators as partner in this cause [7], embarking on a worldwide of adequacy of medical care [1]. The focus is on action programme which began by assessing the magni- migraine, and the findings are depressing. Among 1175 tude of headache in the world [4, 8]. In 2011, WHO’s participants in the 10 countries reporting frequent global survey of headache disorders and resources, a migraine – on more than five days per month, indicating Global Campaign project, laid bare the scale and scope unambiguous need for preventative medication – fewer of under-treated headache everywhere, and its conse- than 20% had seen a health-care professional (general quences [9]. WHO wrote, in a message sent inter alia to practitioner [GP] or specialist). In most countries, fewer the world’s Ministries of Health: “This first global than 10% were receiving what might be considered ad- enquiry into these matters illuminates the worldwide equate acute treatment, and even smaller proportions neglect of a major public-health problem, and reveals had the preventative medication for which they were the inadequacies of responses to it in countries through- clearly eligible. Participants who had managed to make out the world” [9]. No words could be clearer but, to contact with specialists generally received better care by make sure, WHO repeated the message soon after [10]. these indicators, which might be expected. Those seeing Eurolight was a cross-sectional survey of over 8000 par- GPs were less well served, and those entirely dependent ticipants, conducted by multiple partners (scientific and on self-medication – the large majority – fared poorly. lay) in 10 European countries [11]. A considerable In other words, the authors conclude, in wealthy Europe, strength of this study, apart from its size and geographical too few people with migraine consult physicians, and scope, was the use in all countries of the same question- migraine-specific medications are used inadequately naire [12], a derivative of the HARDSHIP questionnaire even among those who do [1]. Is there hope at all for already employed in many different countries, cultures people with headache in less well-resourced countries? and translations [13]. Also a strength was its scope of The Eurolight report comes soon after publication of the latest (2016) Global Burden of Disease (GBD) study * Correspondence: t.steiner@imperial.ac.uk [14]. “The most comprehensive worldwide observational Department of Neuromedicine and Movement Science, NTNU Norwegian epidemiological study to date” [15], GBD has been per- University of Science and Technology, Edvard Griegs Gate, Trondheim, formed reiteratively since 1990, with estimates of health Norway Division of Brain Sciences, Imperial College London, London, UK loss due to disease a principal objective [16]. Its findings, Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Steiner et al. The Journal of Headache and Pain (2018) 19:17 Page 2 of 4 Table 1 Top 10 level-4 causes of disability in GBD 2016 many of the assumptions underlying the earlier GBD esti- (global, both sexes, all ages) mates, and, as YLD calculations became prevalence-based Low back pain rather than reliant on the less-easily ascertained incidence and duration, estimates have gained in reliability. In GBD Migraine 2015, migraine dropped back to seventh among causes of Age-related hearing loss YLDs, partly because of revised estimates for other disor- Iron-deficiency anaemia ders, but, being notably age-related, it was third in both Major depression males and females aged 15–49 [23]. Neck pain GBD 2016 offers sobering findings for those affected Other musculoskeletal disorders by or who care about migraine [14]. At level two of GBD’s disease hierarchy, neurological disorders collect- Diabetes ively account for 8.6% of all YLDs in the world, and Anxiety disorders come fourth in the disability ranking (behind mental and Falls substance use, “other non-communicable” and musculo- skeletal disorders). At level three, headache disorders are informing national health policies, offer a rational basis the cause of more than three quarters of all neurological for priority setting and resource-allocation, driving YLDs (6.5% of all YLDs), despite that neurological service organisation and delivery to meet assessed needs. disorders include epilepsy, Alzheimer disease and other GBD now revises its estimates annually as it continu- dementias, Parkinson’s disease, multiple sclerosis and ously develops and refines the methodology of disease- motor neuron disease. At level four, migraine now takes burden estimation and its expression as premature second place, responsible for 5.6% of all YLDs in the mortality (years of life lost: YLLs) and disability (years world, behind only low back pain (7.2%) (Table 1). lived with disability: YLDs). At the same time, updated There is worse. In the age group 15–49 years, migraine estimates take account of new epidemiological evidence is the top cause of YLDs [14] (Table 2). Let us not forget as it continues to become available. that these are the productive years, when education is Since migraine was first included in GBD, it has completed, families formed, children raised, careers built ascended the ranks of top causes of YLDs worldwide, and prospects for the whole remainder of life estab- from its debut at 19th in GBD 2000 [17] to seventh in lished. Whatever impact migraine-attributed disability GBD 2010 [18, 19] and sixth in GBD 2013 [20, 21]. This may have more generally, during these years it is greatly persistent rise is not indicative of increasing prevalence: magnified. it follows the collection and assimilation into GBD of ever There is a ready explanation for the apparently steep better data as new population-based studies have slowly rise in migraine since GBD 2015, conducted a year filled the large knowledge gaps, which as recently as 2007 earlier: it lies with MOH. GBD 2015 regarded MOH as a related to more than half the world’spopulation [22]. separate disease [23]. While MOH is relatively uncom- With better knowledge, empirical data have replaced mon (prevalence estimates vary around the world but Table 2 GBD 2016: Years lived with disability (YLDs) attributed to migraine by gender, age and region (from [14]) Region Gender Age range (years) % of total YLDs Rank (95% CI) Global Both All 5.6 (4.0–7.2) 2 15–49 8.2 (6.0–10.6) 1 M All 4.3 (3.1–5.5) 3 15–49 6.4 (4.6–8.2) 2 F All 6.8 (4.9–8.8) 2 15–49 9.8 (7.1–12.7) 1 North America Both All 4.8 (3.5–6.1) 5 Latin America and Caribbean 6.7 (4.9–8.6) 2 Western Europe 6.2 (4.5–7.9) 2 Central and Eastern Europe and Central Asia 6.0 (4.4–7.7) 3 South Asia 6.5 (4.6–8.5) 2 SE and East Asia and Oceania 4.6 (3.3–6.0) 4 North Africa and Middle East 6.7 (5.0–8.6) 2 Sub-Saharan Africa 4.6 (3.2–6.1) 3 Steiner et al. The Journal of Headache and Pain (2018) 19:17 Page 3 of 4 are mostly in the range 1.5–3% [24, 25]), it is highly Authors’ contributions All authors contributed to drafting, read and approved the final manuscript. disabling, by definition characterised by headache on 15 or more days per month [26]. GBD 2015 placed it 18th Competing interests among the causes of YLDs [23]. Nosologically, MOH is TJS, LJS, RJ and ZK are Directors and Trustees of Lifting The Burden, a UK- undoubtedly a distinct disease [26], but aetiologically it registered non-governmental organization conducting the Global Campaign against Headache in official relations with the World Health Organization. TJS is a complication arising from mistreatment of other and LJS were Global Burden of Disease Study 2015 collaborators as GBD headache disorders, principally migraine and to a Experts on headache disorders. TV is funded by the Bill and Melinda Gates lesser extent TTH: it does not occur otherwise [26]. Foundation. In GBD 2016, the decision was made that burden at- tributed to MOH would be more correctly attributed Publisher’sNote to the antecedent disorders, in due proportion (73.4% Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. to migraine, 26.6% to TTH, from a meta-analysis of three studies [27–29]). Author details Not everybody may agree with this, but there is both Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Edvard Griegs Gate, Trondheim, logic and purpose in recognising MOH as one of the Norway. Division of Brain Sciences, Imperial College London, London, UK. sequelae (health states) of the antecedent headache 3 Norwegian Advisory Unit on Headache, Department of Neurology and disorder. In GBD terms, therefore, migraine is associated Clinical Neurophysiology, St Olavs University Hospital, Trondheim, Norway. Institute for Health Metrics and Evaluation (IHME), University of Washington, with three potential health states, each occurring with Seattle, WA, USA. Danish Headache Centre, Department of Neurology, measurable probability (established in population-based University of Copenhagen, Rigshospitalet Glostrup, Glostrup, Denmark. studies): the ictal state (during an attack, with its symp- Department of Neurology, Evangelical Hospital Unna, Unna, Germany. Medical Faculty, University of Duisburg-Essen, Essen, Germany. toms), the interictal state (between recurrent attacks), and MOH. All three contribute to the disability burden Received: 13 February 2018 Accepted: 14 February 2018 of migraine, and all three contributions should be duly recognised. (We noted earlier that GBD does not References consider disability associated with the interictal state of 1. Katsarava Z, Mania M, Lampl C, Herberhold J, Steiner TJ (2018) Poor medical headache disorders [21], although significant interictal care for people with migraine in Europe – evidence from the Eurolight burden is reported by many people with migraine [30]). study. J Headache Pain 19:10 2. American Association for the Study of Headache, International Headache From GBD 2016 it is more evident than ever that Society. Consensus statement on improving migraine management. headache disorders have a very large detrimental effect Headache 1998; 38: 736 on public health. Table 2 shows that migraine is a major 3. Diener H-C, Steiner TJ, Tepper SJ (2006) Migraine – the forgotten epidemic: development of the EHF/WHA Rome declaration on migraine. J Headache contributor to disability throughout the world, in both Pain 7:433–437 high- and low-income countries [14]. It is worth noting 4. Lifting The Burden: the Global Campaign against Headache, at http:// that, of the 21 regions into which GBD divides the www.l-t-b.org (Accessed 15 January 2018) 5. Steiner TJ (2004) Lifting the burden: the global campaign against headache. world, five are still without any data on headache and Lancet Neurol 3:204–205 more have only scarce data. Furthermore, most data are 6. Steiner TJ (2005) Lifting The Burden: the global campaign to reduce the from adults, with relatively few studies reporting on chil- burden of headache worldwide. J Headache Pain 6:373–377 7. Steiner TJ, Birbeck GL, Jensen R, Katsarava Z, Martelletti P, Stovner LJ (2011) dren and adolescents. Nevertheless, headache disorders The global campaign, World Health Organization and Lifting The Burden: are, manifestly, an egregious cause of health loss. Why, collaboration in action. J Headache Pain 12:273–274 then, when efficacious and cost-effective treatments exist 8. Steiner TJ, Birbeck GL, Jensen R, Katsarava Z, Martelletti P, Stovner LJ (2010) Lifting The Burden: the first 7 years. J Headache Pain 11:451–455 [31, 32], do health services almost everywhere leave 9. World Health Organization, Lifting The Burden (2011) Atlas of headache them side-lined [9, 10, 33]? Will health politicians finally disorders and resources in the world 2011. Geneva: WHO take notice, now that migraine is top of the heap? 10. Steiner TJ, Stovner LJ, Dua T, Birbeck GL, Jensen R, Katsarava Z, Martelletti P, Saxena S (2011) Time to act on headache disorders. J Headache Pain 12: Looking forward, and not to end on an impliedly 501–503 negative note, we remind researchers that further 11. Andrée C, Stovner LJ, Steiner TJ, Barré J, Katsarava Z, Lainez JM, Lair M-L, population-based studies are needed to fill the remaining Lanteri-Minet M, Mick G, Rastenyte D, Ruiz de la Torre E, Tassorelli C, Vriezen P, Lampl C (2011) The Eurolight project: the impact of primary headache knowledge gaps. Quality in these is all-important: disorders in Europe. Description of methods. J Headache Pain 12:541–549 published methodological guidelines [34]and instru- 12. Steiner TJ, Stovner LJ, Katsarava Z, Lainez JM, Lampl C, Lantéri-Minet M, ments [13] are available, and surveys should follow Rastenyte D, Ruiz de la Torre E, Tassorelli C, Barré J, Andrée C (2014) The impact of headache in Europe: principal results of the Eurolight project. and adopt these. Ultimately, if studies contributing to J Headache Pain 15:31 GBD are standardized, future iterations of GBD may 13. Steiner TJ, Gururaj G, Andrée C, Katsarava Z, Ayzenberg I, Yu SY, Al Jumah not only show the relative importance of headache in M, Tekle-Haimanot R, Birbeck GL, Herekar A, Linde M, Mbewe E, Manandhar K, Risal A, Jensen R, Queiroz LP, Scher AI, Wang SJ, Stovner LJ (2014) global public health but also monitor the benefits of Diagnosis, prevalence estimation and burden measurement in population improvements in headache care, new treatments and surveys of headache: presenting the HARDSHIP questionnaire. J Headache societal change. Pain 15:3 Steiner et al. The Journal of Headache and Pain (2018) 19:17 Page 4 of 4 14. Vos T, Abajobir AA, Abbafati C, Abbas KM, Abate KH, Abd-Allah F et al 33. Katsarava Z, Steiner TJ (2012) Neglected headache: ignorance, arrogance or (2017) Global, regional, and national incidence, prevalence, and years lived insouciance? Cephalalgia 32:1019–1020 with disability for 328 diseases and injuries for 195 countries, 1990-2016: a 34. Stovner LJ, Al Jumah M, Birbeck GL, Gururaj G, Jensen R, Katsarava Z, systematic analysis for the global burden of disease study 2016. Queiroz LP, Scher AI, Tekle-Haimanot R, Wang SJ, Steiner TJ (2014) The Lancet 390:1211–1259 methodology of population surveys of headache prevalence, burden and 15. The Lancet, at http://www.thelancet.com/gbd (Accessed 15 January 2018) cost: Principles and recommendations from the Global Campaign against Headache. J Headache Pain 15:5 16. Institute for Health Metrics and Evaluation. Global Burden of Disease (GBD), at http://www.healthdata.org/gbd/about (Accessed 15 January 2018) 17. World Health Organization (2001) The world health report 2001. WHO, Geneva, pp 19–45 18. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY, Ali MK, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Bahalim AN, Barker-Collo S, Barrero LH, Bartels DH, Basáñez MG, Baxter A, Bell ML, Benjamin EJ, Bennett D et al (2012) Years lived with disability (YLD) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet 380:2163–2196 19. Steiner TJ, Stovner LJ, Birbeck GL (2013) Migraine: the seventh disabler. J Headache Pain 14:1 20. Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, Charlson F, Davis A, Degenhardt L, Dicker D, Duan L, Erskine H, Feigin VL, Ferrari AJ, Fitzmaurice C, Fleming T, Graetz N, Guinovart C, Haagsma J, Hansen GM, Hanson SW, Heuton KR, Higashi H, Kassebaum N, Kyu H, Laurie E, Liang X, Lofgren K, Lozano R, MacIntyre MF, Moradi-Lakeh M, Naghavi M, Nguyen G, Odell S, Ortblad K et al (2015) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the global burden of disease study 2013. Lancet 386:743–800 21. Steiner TJ, Birbeck GL, Jensen RH, Katsarava Z, Stovner LJ, Martelletti P (2015) Headache disorders are third cause of disability worldwide. J Headache Pain 16:58 22. Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton RB, Scher AI, Steiner TJ, Zwart J-A (2007) The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 27:193–210 23. GBD 2015 Disease and injury incidence and prevalence collaborators (2016) global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the global burden of disease study 2015. Lancet 388:1545–1602 24. Westergaard ML, Holme Hansen E, Glümer C, Olesen J, Jensen RH (2014) Definitions of medication-overuse headache in population-based studies and their implications on prevalence estimates: a systematic review. Cephalalgia 34:409–425 25. Steiner TJ (2014) Can we know the prevalence of MOH? Cephalalgia 34: 403–404 26. International Headache Society Classification Committee (2018) The international classification of headache disorders, 3rd edn. (ICHD-3). Cephalalgia (in press) 27. Colas R, Munoz P, Temprano R, Gomez C, Pascual J (2004) Chronic daily headache with analgesic over-use: epidemiology and impact on quality of life. Neurology 62:1338–1342 28. Katsarava Z, Muessig M, Dzagnidze A, Fritsche G, Diener HC, Limmroth V (2005) Medication overuse headache: rates and predictors for relapse in a 4-year prospective study. Cephalalgia 25:12–15 29. Jonsson P, Hedenrud T, Linde M (2011) Epidemiology of medication overuse headache in the general Swedish population. Cephalalgia 31:1015–1022 30. Lampl C, Thomas H, Stovner LJ, Tassorelli C, Katsarava Z, Laínez JMA, Lantéri-Minet M, Rastenyte D, Ruiz de la Torre E, Andrée C, Steiner TJ (2016) Interictal burden attributable to episodic headache: findings from the Eurolight project. J Headache Pain 17:9 31. Steiner TJ, Paemeleire K, Jensen R, Valade D, Savi L, Lainez MJA, Diener H-C, Martelletti P, Couturier EGM (2007) European principles of management of common headache disorders in primary care. J Headache Pain 8(suppl 1):S3–S21 32. Linde M, Steiner TJ, Chisholm D (2015) Cost-effectiveness analysis of interventions for migraine in four low- and middle-income countries. J Headache Pain 16:15 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Journal of Headache and Pain Springer Journals

Migraine is first cause of disability in under 50s: will health politicians now take notice?

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Medicine & Public Health; Pain Medicine; Internal Medicine; Neurology
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Abstract

Steiner et al. The Journal of Headache and Pain (2018) 19:17 The Journal of Headache https://doi.org/10.1186/s10194-018-0846-2 and Pain EDITORIAL Open Access Migraine is first cause of disability in under 50s: will health politicians now take notice? 1,2* 1,3 4 5 6,7 Timothy J. Steiner , Lars J. Stovner , Theo Vos , R. Jensen and Z. Katsarava Keywords: Headache disorders, Migraine, Tension-type headache, Medication-overuse headache, Burden of disease, Disability, Public health, Global Burden of Disease study, Global Campaign against Headache If it were needed, more evidence of the disconcerting enquiry, simultaneously into migraine, tension-type head- under-treatment of headache disorders has come from ache (TTH) and medication-overuse headache (MOH), the Eurolight study [1]. The topic is not new. Twenty the three headache disorders of major public-health years ago, the International and American Headache importance. This provided a broad view of headache in Societies jointly voiced their dismay at the inadequacies Europe. The different sampling methods employed by the of health care for headache [2]. In 2006, the European countries in Eurolight produced samples that varied in Headache Federation and World Headache Alliance their representativeness of the general population, argu- described migraine as a “forgotten epidemic” [3]. Mean- ably a strength in that it brought data into the survey from while, in 2003, the Global Campaign against Headache diversely-sourced samples [11, 12]. [4–6] engaged the World Health Organization (WHO) The new report analyses Eurolight data for indicators as partner in this cause [7], embarking on a worldwide of adequacy of medical care [1]. The focus is on action programme which began by assessing the magni- migraine, and the findings are depressing. Among 1175 tude of headache in the world [4, 8]. In 2011, WHO’s participants in the 10 countries reporting frequent global survey of headache disorders and resources, a migraine – on more than five days per month, indicating Global Campaign project, laid bare the scale and scope unambiguous need for preventative medication – fewer of under-treated headache everywhere, and its conse- than 20% had seen a health-care professional (general quences [9]. WHO wrote, in a message sent inter alia to practitioner [GP] or specialist). In most countries, fewer the world’s Ministries of Health: “This first global than 10% were receiving what might be considered ad- enquiry into these matters illuminates the worldwide equate acute treatment, and even smaller proportions neglect of a major public-health problem, and reveals had the preventative medication for which they were the inadequacies of responses to it in countries through- clearly eligible. Participants who had managed to make out the world” [9]. No words could be clearer but, to contact with specialists generally received better care by make sure, WHO repeated the message soon after [10]. these indicators, which might be expected. Those seeing Eurolight was a cross-sectional survey of over 8000 par- GPs were less well served, and those entirely dependent ticipants, conducted by multiple partners (scientific and on self-medication – the large majority – fared poorly. lay) in 10 European countries [11]. A considerable In other words, the authors conclude, in wealthy Europe, strength of this study, apart from its size and geographical too few people with migraine consult physicians, and scope, was the use in all countries of the same question- migraine-specific medications are used inadequately naire [12], a derivative of the HARDSHIP questionnaire even among those who do [1]. Is there hope at all for already employed in many different countries, cultures people with headache in less well-resourced countries? and translations [13]. Also a strength was its scope of The Eurolight report comes soon after publication of the latest (2016) Global Burden of Disease (GBD) study * Correspondence: t.steiner@imperial.ac.uk [14]. “The most comprehensive worldwide observational Department of Neuromedicine and Movement Science, NTNU Norwegian epidemiological study to date” [15], GBD has been per- University of Science and Technology, Edvard Griegs Gate, Trondheim, formed reiteratively since 1990, with estimates of health Norway Division of Brain Sciences, Imperial College London, London, UK loss due to disease a principal objective [16]. Its findings, Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Steiner et al. The Journal of Headache and Pain (2018) 19:17 Page 2 of 4 Table 1 Top 10 level-4 causes of disability in GBD 2016 many of the assumptions underlying the earlier GBD esti- (global, both sexes, all ages) mates, and, as YLD calculations became prevalence-based Low back pain rather than reliant on the less-easily ascertained incidence and duration, estimates have gained in reliability. In GBD Migraine 2015, migraine dropped back to seventh among causes of Age-related hearing loss YLDs, partly because of revised estimates for other disor- Iron-deficiency anaemia ders, but, being notably age-related, it was third in both Major depression males and females aged 15–49 [23]. Neck pain GBD 2016 offers sobering findings for those affected Other musculoskeletal disorders by or who care about migraine [14]. At level two of GBD’s disease hierarchy, neurological disorders collect- Diabetes ively account for 8.6% of all YLDs in the world, and Anxiety disorders come fourth in the disability ranking (behind mental and Falls substance use, “other non-communicable” and musculo- skeletal disorders). At level three, headache disorders are informing national health policies, offer a rational basis the cause of more than three quarters of all neurological for priority setting and resource-allocation, driving YLDs (6.5% of all YLDs), despite that neurological service organisation and delivery to meet assessed needs. disorders include epilepsy, Alzheimer disease and other GBD now revises its estimates annually as it continu- dementias, Parkinson’s disease, multiple sclerosis and ously develops and refines the methodology of disease- motor neuron disease. At level four, migraine now takes burden estimation and its expression as premature second place, responsible for 5.6% of all YLDs in the mortality (years of life lost: YLLs) and disability (years world, behind only low back pain (7.2%) (Table 1). lived with disability: YLDs). At the same time, updated There is worse. In the age group 15–49 years, migraine estimates take account of new epidemiological evidence is the top cause of YLDs [14] (Table 2). Let us not forget as it continues to become available. that these are the productive years, when education is Since migraine was first included in GBD, it has completed, families formed, children raised, careers built ascended the ranks of top causes of YLDs worldwide, and prospects for the whole remainder of life estab- from its debut at 19th in GBD 2000 [17] to seventh in lished. Whatever impact migraine-attributed disability GBD 2010 [18, 19] and sixth in GBD 2013 [20, 21]. This may have more generally, during these years it is greatly persistent rise is not indicative of increasing prevalence: magnified. it follows the collection and assimilation into GBD of ever There is a ready explanation for the apparently steep better data as new population-based studies have slowly rise in migraine since GBD 2015, conducted a year filled the large knowledge gaps, which as recently as 2007 earlier: it lies with MOH. GBD 2015 regarded MOH as a related to more than half the world’spopulation [22]. separate disease [23]. While MOH is relatively uncom- With better knowledge, empirical data have replaced mon (prevalence estimates vary around the world but Table 2 GBD 2016: Years lived with disability (YLDs) attributed to migraine by gender, age and region (from [14]) Region Gender Age range (years) % of total YLDs Rank (95% CI) Global Both All 5.6 (4.0–7.2) 2 15–49 8.2 (6.0–10.6) 1 M All 4.3 (3.1–5.5) 3 15–49 6.4 (4.6–8.2) 2 F All 6.8 (4.9–8.8) 2 15–49 9.8 (7.1–12.7) 1 North America Both All 4.8 (3.5–6.1) 5 Latin America and Caribbean 6.7 (4.9–8.6) 2 Western Europe 6.2 (4.5–7.9) 2 Central and Eastern Europe and Central Asia 6.0 (4.4–7.7) 3 South Asia 6.5 (4.6–8.5) 2 SE and East Asia and Oceania 4.6 (3.3–6.0) 4 North Africa and Middle East 6.7 (5.0–8.6) 2 Sub-Saharan Africa 4.6 (3.2–6.1) 3 Steiner et al. The Journal of Headache and Pain (2018) 19:17 Page 3 of 4 are mostly in the range 1.5–3% [24, 25]), it is highly Authors’ contributions All authors contributed to drafting, read and approved the final manuscript. disabling, by definition characterised by headache on 15 or more days per month [26]. GBD 2015 placed it 18th Competing interests among the causes of YLDs [23]. Nosologically, MOH is TJS, LJS, RJ and ZK are Directors and Trustees of Lifting The Burden, a UK- undoubtedly a distinct disease [26], but aetiologically it registered non-governmental organization conducting the Global Campaign against Headache in official relations with the World Health Organization. TJS is a complication arising from mistreatment of other and LJS were Global Burden of Disease Study 2015 collaborators as GBD headache disorders, principally migraine and to a Experts on headache disorders. TV is funded by the Bill and Melinda Gates lesser extent TTH: it does not occur otherwise [26]. Foundation. In GBD 2016, the decision was made that burden at- tributed to MOH would be more correctly attributed Publisher’sNote to the antecedent disorders, in due proportion (73.4% Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. to migraine, 26.6% to TTH, from a meta-analysis of three studies [27–29]). Author details Not everybody may agree with this, but there is both Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Edvard Griegs Gate, Trondheim, logic and purpose in recognising MOH as one of the Norway. Division of Brain Sciences, Imperial College London, London, UK. sequelae (health states) of the antecedent headache 3 Norwegian Advisory Unit on Headache, Department of Neurology and disorder. In GBD terms, therefore, migraine is associated Clinical Neurophysiology, St Olavs University Hospital, Trondheim, Norway. Institute for Health Metrics and Evaluation (IHME), University of Washington, with three potential health states, each occurring with Seattle, WA, USA. Danish Headache Centre, Department of Neurology, measurable probability (established in population-based University of Copenhagen, Rigshospitalet Glostrup, Glostrup, Denmark. studies): the ictal state (during an attack, with its symp- Department of Neurology, Evangelical Hospital Unna, Unna, Germany. Medical Faculty, University of Duisburg-Essen, Essen, Germany. toms), the interictal state (between recurrent attacks), and MOH. All three contribute to the disability burden Received: 13 February 2018 Accepted: 14 February 2018 of migraine, and all three contributions should be duly recognised. (We noted earlier that GBD does not References consider disability associated with the interictal state of 1. Katsarava Z, Mania M, Lampl C, Herberhold J, Steiner TJ (2018) Poor medical headache disorders [21], although significant interictal care for people with migraine in Europe – evidence from the Eurolight burden is reported by many people with migraine [30]). study. J Headache Pain 19:10 2. American Association for the Study of Headache, International Headache From GBD 2016 it is more evident than ever that Society. Consensus statement on improving migraine management. headache disorders have a very large detrimental effect Headache 1998; 38: 736 on public health. Table 2 shows that migraine is a major 3. Diener H-C, Steiner TJ, Tepper SJ (2006) Migraine – the forgotten epidemic: development of the EHF/WHA Rome declaration on migraine. J Headache contributor to disability throughout the world, in both Pain 7:433–437 high- and low-income countries [14]. It is worth noting 4. 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Published: Feb 21, 2018

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