A proposal of actions for stakeholders and policy makers to address the global burden of headache disorders by 2030: why is this important for global health?

KEYWORDS:

• Migraine
• medication overuse headache
• tension-type headache
• sustainable development goals
• global burden of disease study
• low- and middle-income countries

1. Introduction

Everyone might experience the situation of having a headache, herein intended as a symptom, i.e. head pain, in adult life. Based on the ‘headache yesterday’ approach – which estimated the presence of headache on a casual day − 4.8% to 17% of adults experienced headache the day before [1,2]. Headache might be truly occasional (e.g. tension-type-like headache presenting 3–4 times per year), or secondary to other clinical conditions. However, the majority of people, at some stages of life, develop a neurological condition that constitute one of the primary headache disorders. Few studies systematically produced one year and lifetime prevalence data on primary headache disorders: for example, the PACE study (PArma CEfalea) showed that in the Parma district (Italy) one-year prevalence of any headache was 42.8% (52.0% in women and 31.1% in men), whereas lifetime prevalence was 69.1% (75.8% in women and 60.6% in men) [3].

2. Prevalence and burden of headache disorders

According to the most recent estimates of Global Burden of Disease Study (GBD) [4], primary headache disorders are the most prevalent neurological disorders and the second most prevalent after oral disorders. In terms of age-standardized rates/100,000, headache disorders prevalence was 32,716.8 (95% UI 30,148.4 to 35,335.0), whereas that for oral disorders was 44,509.6 (95% UI 40,815.4 to 48,256.8) (see the permalink at: https://vizhub.healthdata.org/gbd-results?params=gbd-api-2019-permalink/e7a9df9e53a5293cf7abd4948d58f71b). Headaches affect people everywhere in the world, irrespectively of the place in which they live and the resources they have to treat such disorders. Globally, 2.6 billion people (or 35% of the all-age population) suffer from headache disorders: more than two billion headache sufferers, i.e. around 80%, live in low- and middle-income countries (LMIC), whereas only 490 million people (i.e. less than 20%) live in high-income countries (see the permalink at: https://vizhub.healthdata.org/gbd-results?params=gbd-api-2019-permalink/259f28273a8081b701da4231db6a73d3).

Headache disorders are not only highly prevalent but also highly disabling conditions, particularly among young adults, again as shown by the most recent GBD estimates [4]. In the last 30 years, and despite the availability of a paramount of treatments [5], disability associated with headache disorders has not decreased globally. Considering that headache disorders are responsible for approximately 5.5% of all-cause disability (around 8% among young adults), it becomes evident that reducing disability associated with headache disorders might therefore be a relevant driver for enhancing population health at global level.

3. The third sustainable development goal (SDG 3) in headache disorders

SDG 3, included in the 2030 Agenda for Sustainable Development, adopted in 2015 by all UN Member States, specifically focuses on means to improve global health. The analysis contained in the paper entitled ‘Rethinking headache as a global public health case model for reaching the SDG 3 HEALTH by 2030’ [6] is aimed to propose a set of policy initiatives aimed to set the stage for future concrete actions aimed to tackle headache disability as main driver for improving global health. Six specific domains of possible interventions have been identified:

• targeting chronic headaches;

• reducing the overuse of acute pain-relieving medications;

• promoting the education of healthcare professionals;

• granting access to medication in LMIC;

• implementing training and educational opportunities for healthcare professionals in LMIC;

• building a global alliance against headache disorders.

Far from being considered a complete analysis, the one produced by this group of international experts pointed out several elements for further development [6].

Moving forward from frequency-based parameters to define headache severity: this is of relevance due to the variable response to treatment and the variability in frequency of headaches over the life course of individuals. The sole parameter of headache frequency, which is relatively easy to be captured, in fact does not account for clinical features of patients’ headache which need to be accounted in order to provide the best available treatment to each patient [7,8]. Adding few clinical information, together with the ‘recent trend,’ are necessary, and viable, steps forward to enhance our ability to define headache severity. Also, information on the impact on daily life is of relevance, as the kind of activities a person carries out is influenced by headache (and migraine in particular) and might act as trigger. Examples of this include work-related stress, shift working, and working in the health care sector [7].

Recognizing and treating the overuse of medications early is of relevance as medication overuse is both a cause and an effect of clinical worsening, which leads to higher health resources consumption, and is a strong driver of increased disease cost and patients’ disability. The ability to early address medication overuse, i.e. to prioritize treatment of those patients eligible for preventive therapies, is fundamental to avoid other kind of health problems, such as those connected to the over-utilization of opioids, which increase the risk of clinical progression, are associated to high mortality and have poor efficacy [9–11].

Last, a relevant aspect to reach SGD 3 is the effort toward enhancing education of healthcare professionals but also cultural promotion toward recognizing headaches as neurological diseases. In LMICs, in fact, there is a dramatic shortage of neurologists − 0.04 to 0.1 neurologists per 100,000 citizens in South-East Asia and Africa vs. 6/100,000 in Europe [12] – and a limited access to few medications. This is unfortunately coupled with erroneous beliefs which support the idea that headache disorders ‘cover’ the presence some common comorbidities, such as psychiatric diseases, emotional difficulties, visual impairments, cardiovascular, and infectious diseases. Also, the outcomes of traumatic brain injuries should be accounted: these are often under recognized but lifetime prevalence is estimated at 2.4 to 4.7%, but is likely underestimated due to the underestimation of mild traumas prevalence [13]. So, headaches, rather than a group of diseases, are often understood as a manifestation of the aforementioned associated ones, thus decreasing the likelihood that appropriate care is searched for primary headaches whilst maintaining the stigma associate to headaches [14,15].

The interventions proposed by this group of international experts [6] constitute prerequisites for the organization of healthcare systems at different levels of care, from primary- to third-level one. What will surely be needed is to support and develop a framework for healthcare professional education which is consistent with the three-level organization. The Global Campaign against Headache-Lifting the Burden project showed that in Europe most headache centers are highly specialized (i.e. third level), but primary structures able to provide basic headache care are largely lacking. This contrasts with care policies for headaches, which support the need to establish and maintain adequate primary headache care centers: primary-care level can be provided effectively and constitutes an adequate response to the majority of patients, and moreover basic care is the only viable way to reach the large amount of people who globally needs headache care, i.e. 35% of the all-age population [4]. The three-level organization calls for a vertical integration between the levels, and particularly for the reinforcement of the primary and protection of the more advanced levels for the minority of patients who need them [16].

It is crucial to identify the educational activities that are important to provide the practical knowledge and skills needed to treat the most common primary headaches, which in many cases could be done at the pharmacy level. This specifically include training how to treat tension-type headache, and common migraine without aura at low frequency at primary-care level [17]. Referral to specialty headache centers is for those patients who suffer from high-frequency episodic migraine or chronic migraine, who do not respond to first- and second-line treatments, for patients who suffer from trigeminal autonomic cephalalgias, such as cluster headache, and for those who suffer from medication overuse headache due either to chronic migraine or chronic tension-type headache [6].

Training is the first step toward reaching SDG 3 as, particularly in LMIC, the amount of clinicians with specific skills on diagnoses and management of headache disorders is dramatically low. An ongoing experience tailored for the needs and resources of LMIC is being launched in 2023 (see https://www.unitelmasapienza.it/en/training-course-in-headaches-lmic/) [17].

Overall, the analysis of this group of international experts [6] is aimed to define a possible direction for the development of future health policies, rather than presenting direct and immediate actions. These, in fact, should to be tailored on the specificity, in terms of economic and health situations, of the different countries in which they should be implemented [18,19]. Practical and culture-tailored solutions need to be identified, in order to make actions realistic and, thus, achievable.

4. Conclusions

To conclude, making headache care sustainable across the globe is an achievable objective which will require multi-stakeholder collaborations across all sectors of different societies, and which will directly improve health and productivity of populations, particularly young adult women worldwide. The 2023 Agenda for Sustainable Development turned half of its life: the next 7 years will therefore have to be exploited to reach the SDGs comprised in the Agenda. Defining strategies to enhance headache patients’ health status is a way to reach SDG 3 and thus to increase global health.

5. Expert opinion

Headache disorders cause high costs, associated both with their management (including prevention and early treatment strategies) and with their impact on productivity. Thus, solutions that need to be considered for reducing the overall impact should embrace different perspectives. As chronic headaches are major causes of disability and health service utilization, an early identification of those patients at risk of becoming chronically ill is desirable to provide appropriate medical treatments and social security measures; such a double action will undoubtedly reduce both direct and indirect, e.g. by reducing acute episodes, the use of specialist or hospital care, and ultimately improving quality of life.

The 2030 Agenda for Sustainable Development includes 17 SDGs, which represent a call to action by all countries, for core areas such as health and education promotion, reduction of social and health inequalities, and fostering economic growth.

The specific SGD 3 statement ‘Ensuring Healthy Lives and Promoting Well-Being for All at All Ages’ includes all non-communicable diseases and the headache model can be correctly included as a priority target, given the enormous epidemiological, social and economic impact it generates and the inequalities it accentuates in LMICs.

Declaration of interest

AR: Associate Editor of The Journal of Headache and Pain. PM: Editor-in-Chief of The Journal of Headache and Pain and of SN Comprehensive Clinical Medicine; EU Expert, European Medicines Agency. ML: Associate Editor of The Journal of Headache and Pain.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

Author contributions

All authors conceived the article and contributed to development and revisions of the final draft. All authors read and approved the final version of the manuscript for publication.

Acknowledgments

AR is supported by the Italian Ministry of Health (RRC).

Additional information

Funding

This paper was not funded. AR is supported by the Italian Ministry of Health (RRC).