"I have a headache" is a refrain most people utter in a typical year, but they may not realize how much this health condition taxes their ability to engage in daily activities.
Relying on the latest Global Burden of Disease (GBD) study, nearly three billion people, 1 in 3 worldwide, are estimated to suffer from at least one or more headache disorders every year. This rate makes headache the second most common health condition globally following dental caries and other oral disorders. People easily recognize when they need to visit a dentist, but in many cases they miss or skip medical attention for headaches despite the existence of useful treatments or management methods.
This common trivial view of headaches greatly overlooks the substantial global burden it poses to the public, particularly its impact on health, productivity, and socioeconomic costs. Moreover, public education on headache treatments and management is needed, in terms of not only raising awareness about effective preventive treatments but also proper use of pain medications.
Most Common and Disabling Headaches
Findings published in the Lancet Neurology show that headache disorders are the sixth biggest cause of health loss, measured by years lived with disability (YLDs). By this accounting, headaches account for almost 5% of the world's total health loss.
Despite the 200 different types, almost everyone with a headache disorder has migraines or tension-type headaches.
5%
Headaches account for almost 5% of the world's total health loss
Tension-type headache is what most people think of when they say headache. In essence, it is defined by a mild to moderate headache and the absence of any other symptoms. It is almost twice as common as migraine, affecting around 1 in every 4 people in a given year. Migraine attacks, meanwhile, affect 1 in 7 and are far more disabling.
During a migraine attack, individuals will typically experience moderate to severe throbbing head pain, accompanied by nausea and sensitivity to light and sound. People are often confined to bed, and an attack may last as long as 72 hours. It's therefore estimated that migraine causes nearly 10 times more health loss globally than tension-type headache.
Disproportional Burden on Women and Youths
The geographical variation in overall headache burden is small, signaling that no countries or regions have solved this problem yet. Some populations, however, are disproportionately affected. Women experience more than twice the burden of men. The reason is not only that migraine is simply more common in women, but also that headache episodes in women are more frequent and last longer.
Unlike most other chronic conditions, headache disorders more often affect people who are relatively young. Most are in early to mid-adulthood, a season of life when people finish their education, raise kids, and start building their careers.
Headaches, therefore, create a substantial and indirect burden on societies. Analyses from Europe have shown that indirect costs (such as lost productivity) contribute more than 90% of the total costs of headache disorders—estimated to be more than 170 billion euros ($197 billion) annually. The direct costs of treating headache disorders—17 billion euros ($19 billion)—are therefore small in comparison with the huge indirect costs that might be saved if resources were properly allocated. The humanitarian argument for alleviating headache suffering is well supported by the economic argument.
Headache Relief with Pain Medication—Not All Sunshine
Despite the toll on well-being and finances, migraine and other headache disorders are not perceived by the public as serious threats to health because they are mostly occasional, often subside on their own, do not cause death, and are not contagious. Low consultation rates in the Global North could also indicate that many affected individuals are not aware that effective treatments exist.
Currently, self-treatment using over-the-counter or common prescription pain medications is the most widespread source of management when it comes to alleviating headaches.
An excessive intake of pain medications is actually the most common trigger for the development of chronic daily headaches. The exact mechanism behind this is not fully understood, but sensitization, due to down- or up-regulation of receptors in the brain following pain medication intake, is believed to be important.
Opioids and migraine-relief medications such as triptans carry the biggest risk and should as an international rule of thumb be consumed on no more than nine days per month. Simple analgesics, such as aspirin or paracetamol/acetaminophen, also carry this risk, and should as a rule of thumb be consumed on no more than 14 days per month.
In the latest estimates from GBD, overuse of pain medications contributed to more than 20% of all headache-related health loss. This health loss could potentially easily be prevented with proper management and care. Once a chronic daily headache has developed in response to overuse of pain medications, the treatment is simple: Stop or taper the intake of the medications.
Simple should not be confused with easy, because withdrawal of pain medications can be associated with temporary worsening of the headache. Nevertheless, this step is necessary to achieve long-term headache improvement and increased health. Some people, especially those addicted to opioids, may need follow-up from professional health-care providers to successfully manage this phase.
New Generation of Headache Treatments
Newer targeted migraine medications, calcitonin gene-related peptide (CGRP) inhibitors, have emerged over the last years. People take these drugs to prevent headache attacks from developing, and, akin to other headache preventives (and unlike pain medications), CGRP inhibitors do not carry the risk of overuse leading to exacerbation of headaches.
Unfortunately, because of the high costs, very few people—even in high-income countries—use these new medications. In large parts of the world, even the less costly (but still effective) alternatives are not available. Governments and decision-makers need to recognize and break down these barriers to effective care, given that the global health losses caused by headache disorders have not changed since 1990.
A Way Forward Without Headaches
Education and health systems changes are needed to fully address the issue. The Global Campaign Against Headache, aimed at addressing the burden of headache disorders equitably around the world, has proposed novel frameworks in service of this goal: structured headache services. About 90% of people with headache do not need specialist care and can be managed in primary care.
Upward referral channels to intermediate and specialist care ensure proper care also for the small minority who need a higher level of care. Theoretical modeling, incorporating the effectiveness of available treatment options, has shown structured headache services to be cost effective, and, when considering recovered productivity, in some economies also cost saving. Educating health-care providers and general public is a valuable pillar of structured headache services. The huge health loss attributed to pain medication overuse requires little less than education to be remedied.
In terms of health improvement, not many fruits are hanging lower.
