Migraine: An expensive headache to the world
Srimathy Vijayan discusses the global burden of migraine
We may have all experienced a headache of some nature during our lives; in fact, just less than 2% of the population have never had a headache. (1) Usually self-limiting and short lived, headaches tend to disappear causing few aftermath symptoms. However, Migraine, a primary headache disorder, is a distinct medical entity with characteristic symptomology, resulting in profound effects on the individual.
Pathophysiology and aetiological factors
The pathophysiology of a migraine attack involves activation of deep brain mechanisms which in turn cause release of pain-producing inflammatory substances around the nerves and blood vessels. (2) Increasing evidence suggests a strong genetic basis. (3) Migraine predominantly affects women, at a rate of approximately two to that of men, and this is further supported by its well established relationship with the female sex hormones. (4) It is therefore not surprising that there exists strong links with menarche, menstrual cycle patterns, pregnancy and the menopause. Many commonly noted trigger factors have been noted, including food items such as peanuts, cheese, and chocolate.
Epidemiology of Migraine
Recent studies estimate the prevalence of migraine at about 8% in men and 12-15% in women. (5) In terms of actual number of attacks, combined figures from prevalence and incidence studies suggest 3000 migraine attacks occur every day for each million of the general population. (6) The rates of migraine vary globally, and although there is a lack of epidemiological data available in many countries at present, recent anecdotal evidence suggests higher rates in certain places like India. This is theoretically meant to be reflective of the increasing triggers apparent in this country including high temperatures, high light levels, heavy noise pollution and spicy foods. (7) Likewise, in Turkey a prevalence rate of 29% in women has been implicated. (8) where both environmental factors and genetic causes are likely to contribute to this exceedingly higher epidemiological data.
The cost implications of Migraine
Personal costs
Migraine is disabling; WHO ranks it at 19th place among all causes of years of life lost to disability (YLDs). (9) It should be noted that over 80% of people with migraine report disability because of it. (10) The repercussions of repeated migraine attacks lead to a well established cycle of events whereby fear of the next attack causes damage to family life, social life and employment. WHO has re-iterated that social activity and work capacity are almost always reduced in migraine individuals. The inability to attend social events / employment often result in a negative perception, where the individual is deemed as “unreliable” - this can further exaggerate to the existing anxiety, making individuals uneasy and unlikely to cope. Moreover, such consistent/prolonged absenteeism can reduce the likelihood of promotion, undermining career and financial prospects. As one may appreciate, the repercussions of migraine are extensive, and personal development is markedly impaired.
Economic costs
Whilst it is obvious migraine impacts the individuals predominantly, the impact on other parties including employers, governments, fellow work colleagues, family and friends must be acknowledged. Recently a group of researchers evaluated the impact of migraine on the employed labour force in Taiwan (11) and concluded migraine resulted in 3.7 million missed workdays and an estimated cost of NT$4.6 billion due to loss of workdays in 2005. Similarly, migraine costs American employers about $13 billion a year because of missed workdays and impaired work function, of which close to $8 billion was directly due to missed workdays. (12) In the UK, 25 million working or school days are lost every year alone. (6) The loss of working days contributes to extra costs for employers/governments, who subsequently must seek for extra work cover, and may also lead to a decline in productivity.
Work Impact
Nevertheless, some individuals may pursue with work despite having migraines, as theirs may be a mild form, or indeed they may just be apprehensive about taking time off. A study (13) showed that when at work with headache, work effectiveness was reduced 41% for migraine headaches. It is apparent despite all the best intentions such individuals have, they may still not be as effective as they would like to be. Furthermore, the work environment itself may change, resulting in work-related problems. Unlike other chronic medical conditions, a particular problem with migraine is the fact that between attacks, individuals are perfectly normal and therefore able to work as per any other non-migraine individual. Often this can be most frustrating as the desire and ability to succeed is present, but the unpredictable nature of the attacks means that such individuals often feel powerless.
Treatment costs
Migraine accounts for a substantial chunk of health spending in many countries. In one study evaluating such costs the following conclusions were made; for adults, the presence of anxiety and depression along with migraine equated to significantly greater total direct medical costs when compared to their matched healthy cohorts, that is 12,642 US Dollars vs 5,179 US Dollars anxiety alone; 11,290 US Dollars vs 3,135 US Dollars depression alone. (14) Such costs are not only likely to reflect treatment costs, but also the increased amount of GP consultations / appointments with specialists. For example a Danish study (15) highlighted that 56% of migrainers consulted their GP, and that 16% had seen one or more specialists. Furthermore, the consultation rates of chiropractors and physiotherapists were in the region of 5-8%. Pharmaceutical treatment of migraine is complex, with no agreed upon guidelines. Most individuals often need medication during acute attacks and some prophylactic measure to reduce attacks. Moreover, the uncertainty regarding treatment and the need to perhaps trial patients on a variety of drugs adds to the escalating costs. Some specific drugs such as Triptans and ergotamine tartrate are often expensive and not used in resource poor-countries, resulting in a significant amount of pain and disability. (9) Another problem is the actual overuse of such medications which cause “over-use headaches”; further complicating management strategies. (16)
Conclusion
WHO places much emphasise on headache disorders, and certainly on migraine. It is most apparent that migraine, although perhaps not a serious life-threatening illness, is very much a global public health issue due to its extensive repercussions. The impacts on society and on the individual are both important aspects of this public health concern, each of which incur a significant amount of cost. It is imperative that public health bodies work together to reduce this cost burden by successfully treating individuals to reduce their attacks. Additionally, the impact of migraine on many under-developed countries needs to be assessed, with a view to understanding and providing the aid required.
Srimathy Vijayan
4th year Medical Student
University of East Anglia
Norwich, UK
s.vijayan@uea.ac.uk
(1 ) Migraine Action Assocaition. “About Migraine”2008. Migraine Action Association. http://www.migraine.org.uk/section.aspx?sid=3
(2) Neurological disorders: public health challenges. World Health Organization 2006.
(3) Ferrari MD. Migraine. Lancet, 1998, 351:1043-1051.
(4) Stephen D. Silberstein. Hormone-related headache. Medical Clinics of North America, Volume 85, Issue 4, 1 July 2001, Pages 1017-1035.
(5) Diener HC, Katsarava Z, Limmroth V. Current diagnosis and treatment of migraine. Schmerz. 2008 Jan 26.
(6) Steiner TJ et al. The prevelance and disabilty burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia, 2003, 23:519-527.
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(9) Neurological Disorders: public health challenges. World Health Organization. 2006.
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(11) Fuh JL, Wang SJ, Lu SR. Impact of migraine on the employed labor force in taiwan. J Chin Med Assoc. 2008 Feb;71(2):74-8.
(12) Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: disability and economic costs. Arch Intern Med. 1999 Apr 26;159(8):813-8.
(13) Von Korff M, Stewart WF, Simon DJ, Lipton RB. Migraine and reduced work performance: a population-based diary study. Neurology. 1998 Jun;50(6):1741-5.
(14) Pesa J, Lage MJ. The medical costs of migraine and comorbid anxiety and depression. Headache. 2004 Jun;44(6):562-70.
(15) Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. J Epidemiol Community Health. 1992 Aug;46(4):443-6.
(16) Limmroth V et al. Headache after frequent use of serotonin agonists zolmitrptan and naratriptan. Lancet, 1999, 353:378.
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