Steiner, TJ

Stovner, LJ

Vos, T

The Journal of Headache and Pain

English

PubMed

Spiral - Imperial College Digital Repository

The Journal of Headache                           and PainSteiner et al. The Journal of Headache and Pain  (2016) 17:104 DOI 10.1186/s10194-016-0699-5EDITORIAL Open AccessGBD 2015: migraine is the third cause ofdisability in under 50sTimothy J. Steiner1,2*, Lars J. Stovner1,3 and Theo Vos4Keywords: Headache disorders, Migraine, Tension-type headache, Medication-overuse headache, Burden of disease,Disability, Public health, Global Burden of Disease study, Global Campaign against HeadacheHow much headache is there in the world?The answer depends on how headache is measured. Thequestion, however, is an important one. It is at the basisof health policy, prioritisation and the due allocation ofhealth resources to headache care and the mitigation ofits clinical sequelae. From this perspective, prevalencealone is not highly informative: it is the burdens arisingfrom headache disorders that dictate their impact onpublic health. These burdens are multiple, diverse andpartly invisible [1]. Methods do not yet exist to measurethem all [1], but the focus meanwhile has been on dis-ability. It is to this, primarily, that health, quality of life,productivity and financial security are hostage.So how much headache-related disability is there inthe world? Estimates of disability due to disease are aprincipal objective of the Global Burden of Disease(GBD) studies, performed reiteratively since 1990 anddescribed now as “the most comprehensive worldwideobservational epidemiological study to date” [2]. GBD1990 was initiated by the World Bank and GBD 2000 bythe World Health Organization; subsequently, GBD hasbeen led by the Institute for Health Metrics and Evalu-ation [3], and financially supported by the Bill and Me-linda Gates Foundation. GBD uses a number of metrics:among these, disability is measured in years lived withdisability (YLDs) and early mortality in years of life lost(YLLs); disability-adjusted life years (DALYs) are thesummation of YLDs and YLLs. Migraine first featured inGBD 2000 [4], and over 13 years ascended the ranks oftop causes of YLDs worldwide, from 19th in GBD 2000[4] to seventh in GBD 2010 [5, 6] and sixth in GBD* Correspondence: t.steiner@imperial.ac.uk1Department of Neuroscience, Norwegian University of Science andTechnology (NTNU), Edvard Griegs Gate, Trondheim, Norway2Division of Brain Sciences, Imperial College London, London, UKFull list of author information is available at the end of the article© The Author(s). 2016 Open Access This articleInternational License (http://creativecommons.oreproduction in any medium, provided you givthe Creative Commons license, and indicate if2013 [7, 8]. Meanwhile, of the other headache disordersof public-health importance, tension-type headache(TTH) was introduced in GBD 2010 [5] and medication-overuse headache (MOH) in GBD 2013 (and ranked 18thhighest cause of YLDs) [7]. GBD 2013 established head-ache disorders collectively as the third highest cause ofYLDs [8].The rise of migraine over these years is not indicativeof increasing prevalence. While GBD is dependent ondata from the entire world, headache epidemiology is astill-developing science [9]. Very large knowledge gapsexisted in 2000, particularly in regions outside theAmericas and Western Europe [10]. Filling these gapsbecame the first priority of the Global Campaign againstHeadache after its launch in 2004 [11–13]. Collaboratingin all subsequent GBD studies, the Global Campaign hasinformed them by conducting new population-basedsurveys in Georgia, Russia, China, Nepal, South India,Saudi Arabia, Pakistan, Zambia, Ethiopia and Morocco[14]. This concerted data-collection effort has allowedmuch better estimates from GBD 2010 onwards. Withempirical data replacing many of the assumptions under-lying the earlier GBD estimates, and an approach toYLD calculation based on prevalence rather than inci-dence and duration as in GBD 2000, estimates becamepossible by country rather than by large world regions.GBD 2015 has now been published [15, 16]. In thislatest iteration, a more systematic hierarchy has beenadopted in the grouping of related causes of DALYs.Non-communicable disorders, at level 1, include neuro-logical disorders at level 2; within the latter reside theindividual headache disorders (migraine, TTH andMOH) at both levels 3 and 4. Future iterations of GBDmay more logically group the headache disorders to-gether at level 3, as we have done in the followinganalysis.is distributed under the terms of the Creative Commons Attribution 4.0rg/licenses/by/4.0/), which permits unrestricted use, distribution, ande appropriate credit to the original author(s) and the source, provide a link tochanges were made.Steiner et al. The Journal of Headache and Pain  (2016) 17:104 Page 2 of 4Headache disorders account for more DALYs than allother neurological disorders combined (including de-mentias), despite having no association with mortality[16]. Because of this latter fact, the comparative impact ofheadache disorders on public health is better indicated byYLDs, taking disability but not mortality into account. Atlevel 3, headache disorders occupy sixth place among theleading causes of disability, varying between 3rd and 7th inregions around the world [15] (Table 1). While this demo-tion by three places compared with GBD 2013 [8] may ap-pear as a diminution, this is not so: successive iterations ofGBD, increasingly better informed, have shown total YLDsattributed to headache disorders rising consistently. Ra-ther, at level 3, headache disorders are displaced byGBD 2015 groupings of low back and neck pain,which clearly takes top place, sense organ diseases insecond place and skin diseases in fifth [15].At level 4, migraine on its own is the 21st leadingcause of DALYs worldwide, tenth in Western Europeand sixth worldwide in the age group 25–39 years [16].Migraine, TTH and MOH are all diseases mainly affect-ing young adults: in terms of YLDs, they remain collect-ively in third place among level-3 causes in both malesand females aged 15–49 years [15] (Table 1). This is duelargely to migraine, which on its own, at level 4, is thirdin this age group in both genders (Table 2). In presentestimates, migraine, estimated to affect 959 millionpeople worldwide, emerges by a long distance as theTable 1 Years lived with disability (YLDs) attributed to all headacheRegion Gender Age raGlobal Both All15–4950–69M All15–4950–69F All15–4950–69Western Europe Both AllCentral and Eastern Europe and Central AsiaNorth Africa and Middle EastSouth AsiaSE and East Asia and OceaniaHigh-income Asia PacificHigh-income North AmericaLatin America and CaribbeanSub-Saharan AfricaaMigraine, tension-type headache and medication-overuse headachebamong the top level-3 causes of disability in GBD 2015most disabling headache disorder at population level[15]. TTH, despite being the second most prevalent dis-order in the world (behind dental caries) [7], adds muchless to population disability estimates because a low dis-ability weight of 0.036 (on a scale of 0–1) is accorded tothe headache of TTH compared with 0.434 for the ictalstate of migraine [17]. MOH is recognised as far moredisabling at an individual level but, with its prevalencestill very poorly estimated in many regions [18, 19], itstays ranked as 18th cause of YLDs in GBD 2015 [15].There can be no doubt that migraine is a major con-tributor to public ill health in all countries, climes and cul-tures. Table 2 shows it consistently ranked fifth to eighthamong the top causes of disability in all world regions.Further, the notion that migraine is a disease preferentiallyaffecting rich industrialised nations is dispelled by thecomparison in Table 2 between low- and high-incomecountries. It is worth adding here that GBD currently con-siders only the disability burden associated with the ictalstate of headache disorders, whereas there is evidence ofinterictal burden in a considerable proportion of peoplewith migraine and in a small proportion of people withTTH [20]. The significance of interictal burden is that, al-though it may be at relatively low level, it is present forlonger periods of time than ictal burden. With new dataindicating that interictal disability in headache disorders isreal and measurable [20], future iterations of GBD shouldconsider adding this component of disability.disordersa by gender, age and world regionnge (years) YLDs per 100,000 % of total Rankb601 5.61 6813 8.13 3732 4.67 6438 4.35 7597 6.49 3516 3.25 6767 6.76 51,036 9.59 3940 5.58 6783 6.32 4778 6.41 4702 6.80 3730 6.55 5443 4.48 7607 5.34 5646 5.01 6688 6.76 4449 4.27 6Table 2 Years lived with disability (YLDs) attributed to migraine by gender, age, world region and country incomeRegion Gender Age range (years) YLDs per 100,000 % of total RankaGlobal Both All 446 4.17 715–49 615 6.16 350–69 495 3.03 8M All 311 3.09 815–49 432 4.70 350–69 324 2.05 13F All 584 5.15 415–49 805 7.46 350–69 659 3.91 7Western Europe Both All 580 4.69 5Central and Eastern Europe and Central Asia 515 4.25 6North Africa and Middle East 498 4.83 5South Asia 569 5.11 5SE and East Asia and Oceania 334 3.39 8High-income Asia Pacific 434 3.82 5High-income North America 473 3.68 8Latin America and Caribbean 497 4.89 7Sub-Saharan Africa 312 3.12 6All low-income countries Both All 314 3.18 6M 227 2.41 8F 400 3.88 5All high-income countries Both All 502 4.09 6M 296 2.62 7F 700 5.31 4aamong the top level-4 causes of disability in GBD 2015Steiner et al. The Journal of Headache and Pain  (2016) 17:104 Page 3 of 4Where to next? If future GBD studies group the head-ache disorders together at level 3, they might considerincluding neck pain in this grouping rather than withlow back pain: the last is markedly different from neckpain not only in its clinical sequelae but also aetiologically,whereas how much neck pain is actually secondary toheadache? Meanwhile it is still not known how muchheadache – or headache-related disability – there is in theworld. There are still large data gaps to be filled, particu-larly with regard to MOH, which only recently has beenincluded as a separate entity in population-based studies[18, 19]. The Global Campaign has further studies under-way or planned: in Guatemala, Peru, Nigeria, Uganda,Kuwait, North India, Sri Lanka and Mongolia [14]. GBDestimates of global averages properly take into account allavailable data, but published surveys are up to 30 yearsold, and use a variety of ascertainment methods [10].Crude adjustments are relied upon to correct for measure-ment biases arising from less than ideal study methods orquestionable case definitions. Global Campaign studiesuse standardised and higher quality methodology [9].With the single exception of China, all of them so farperformed have produced national estimates greater thanGBD’s mean global estimates [6, 8]. As the new studiescontinue to feed data into future iterations of GBD, it isinevitable that the proportion of global disability correctlyattributed to headache will continue to rise.The importance of this measure is that it serves as aneeds assessment, marking the existence of a very largeburden of ill health to inform health policy in countriesand regions the world over. GBD measures disease bur-den as it is – alleviated by whatever treatments are madeavailable. The persistence of this heavy headache burdenis a clear signal of continuing health-care failures thatmust be addressed [21, 22].Authors’ contributionAll authors read and approved the final manuscript.Competing interestsTJS and LJS are Directors and Trustees of Lifting The Burden, a UK-registerednon-governmental organization conducting the Global Campaign againstHeadache in official relations with the World Health Organization, and wereGlobal Burden of Disease Study 2015 collaborators as GBD Experts on head-ache disorders. TV is funded by the Bill and Melinda Gates Foundation.Steiner et al. The Journal of Headache and Pain  (2016) 17:104 Page 4 of 4Author details1Department of Neuroscience, Norwegian University of Science andTechnology (NTNU), Edvard Griegs Gate, Trondheim, Norway. 2Division ofBrain Sciences, Imperial College London, London, UK. 3Norwegian AdvisoryUnit on Headache, Department of Neurology and Clinical Neurophysiology,St Olavs University Hospital, Trondheim, Norway. 4Institute of Health Metricsand Evaluation (IHME), University of Washington, Seattle, WA, USA.Received: 7 November 2016 Accepted: 10 November 2016References1. Steiner TJ, Gururaj G, Andrée C, Katsarava Z, Ayzenberg I, Yu SY, Al JumahM, Tekle-Haimanot R, Birbeck GL, Herekar A, Linde M, Mbewe E, ManandharK, Risal A, Jensen R, Queiroz LP, Scher AI, Wang SJ, Stovner LJ (2014)Diagnosis, prevalence estimation and burden measurement in populationsurveys of headache: presenting the HARDSHIP questionnaire. J HeadachePain 15:32. The Lancet, at http://www.thelancet.com/gbd. Accessed 29 Oct 2016.3. 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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 theEurolight project. J Headache Pain 17:921. World Health Organization, Lifting The Burden (2011) Atlas of headachedisorders and resources in the world 2011. WHO, Geneva22. 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 12:501–503Submit your manuscript to a journal and benefi t from:7 Convenient online submission7 Rigorous peer review7 Immediate publication on acceptance7 Open access: articles freely available online7 High visibility within the fi eld7 Retaining the copyright to your article    Submit your next manuscript at 7 springeropen.com

GBD 2015: migraine is the third cause of disability in under 50s

Timothy J. Steiner

Lars J. Stovner

Theo Vos

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GBD 2015: migraine is the third cause of disability in under 50s

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