The burden of headache disorders in Ethiopia: national estimates from a population- based door-to-door survey

DOI: https://doi.org/10.1186/s10194- 017- 0765- 7

Abstract-Summary Headache disorders are the third-highest cause of disability worldwide, with migraine and medication-overuse headache (MOH) the major contributors.

In Ethiopia we have shown these disorders to be highly prevalent: migraine 17.7%, TTH 20.6%, probable MOH (pMOH) 0.7%, any headache yesterday (HY) 6.4%.

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To inform local health policy, we now estimate disability and other burdens

attributable to headache in this country.

We interviewed one member (18–65  years old) of each household using the

HARDSHIP structured questionnaire.

We estimated disability using disability weights (DWs) from the Global Burden

of Disease 2013 study.

People with migraine spent 11.7% of their time in the ictal state (DW: 0.441);

they were therefore 5.2% disabled overall.

People with pMOH spent 60.2% of time with headache (DW: 0.223), and were

13.4% disabled.

Average proportions of per-person lost productive time were, for migraine, 4.5% from paid work, 5.3% from household work; for pMOH they were 29.2% and 16.0%. There were highly-disabled minorities, and large gender differences, males los-

ing more paid workdays, females more household workdays.

Across the population aged 18–65  years (effectively the working population), disability from headache was 1.4%, with 1.6% of workdays lost (half from migraine). Ethiopia is a low-income country, and cannot afford these losses—including,

perhaps, 1.6% of GDP.

WHO has recommended structured headache services with their basis in primary care as the most efficient, effective, affordable and equitable solution, potentially cost-saving.

Extended: Headache disorders are not only common in Ethiopia but also heavily

burdensome.

People with pMOH are only 0.7% of the adult population but, as might be expected, carry much more individual disability: 60.2% of their time was spent in the ictal state, a huge loss of healthy time, with headache rated severe (2.95 on the scale 1–3) and a disability burden of 13.4%.

People with pMOH in Zambia were 8.3% disabled and lost 7.4% of paid work-

days and 5.0% of household workdays [204].

WHO has recommended structured headache services with their basis in primary care as the most efficient, effective, affordable and equitable solution [205], and the model proposed by LTB for Europe [178], which is highly adaptable, could be reworked to match the health-care infrastructure of Ethiopia.

Background The Global Campaign against Headache is conducted by Lifting The Burden (LTB), a UK-registered non-governmental organization in official relations with the World Health Organization (WHO) [38].

At its launch in 2004, our knowledge of both the scope and scale of the burdens attributable to headache was extraordinarily imprecise; from very large areas of the world, there were almost no reliable data [89].

Findings from these studies have informed various iterations of the Global Burden of Disease (GBD) study [31–94], while providing country policy-makers with local knowledge to guide priority-setting in health care.

Expressly as a needs-assessment to inform national health policy, we present

data from the same survey on the burdens attributable to headache in Ethiopia.

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1 Public Health

Few studies of headache burden are yet available from sub-Saharan Africa (SSA), but this survey follows, and mirrors, a similar one conducted by LTB in Zambia [204].

Methods The timeframes for burden enquiry were the preceding 3 months and preceding day, the latter addressed to those responding positively to “Did you have a headache yesterday?”

We recorded headache frequency in days affected per month, and usual duration

of headache in hours.

We assumed headache frequency in days per month was equal to attack fre- quency per month unless reported headache duration was >24 h; when this was the case, we applied a correction factor to avoid over-counting.

We derived average time per month spent in the ictal state of each headache type as the product of attack frequency and duration, and expressed it as a proportion of all time (dividing by [30*24]).

We calculated headache-attributed disability at individual level as the product of time in ictal state and the disability weight (DW) from GBD2013 [206] for the dis- order in question.

Results For migraine, headache was reported on an average of 3.3 ± 2.6 days/month, with mean intensity of 2.6 ± 0.5 (moderate to severe pain).

Headache was reported on an average of 2.4  ±  2.1  days/month, with a mean

intensity of 2.4 ± 0.5 (also moderate to severe pain).

The mean proportion of total time spent in the ictal state was 7.3% (100[1.534.9]/ [3024]%) and the disability level (mean disability attributed to TTH per adult with the disorder) was 0.27% (0.0377.3%).

These numbers disguised large gender differences associated with working prac- tices in Ethiopia: males with migraine lost 4.9  ±  7.0  days from paid work and 2.2 ± 6.1 days from household work, females 1.9 ± 5.0 (p < 0.0001; t-test, 2-sided) and 6.1 ± 8.9 (p < 0.0001) respectively.

Discussion People with pMOH are only 0.7% of the adult population but, as might be expected, carry much more individual disability: 60.2% of their time was spent in the ictal state, a huge loss of healthy time, with headache rated severe (2.95 on the scale 1–3) and a disability burden of 13.4%.

At population level (among those aged 18–65  years), we estimated disability from migraine at 0.92%, with 0.80% of paid workdays lost, from pMOH at 0.09%, with 0.20% of paid workdays lost, and from other headache on ≥15 days/month at 0.30%, with 0.22% of paid workdays lost.

In Zambia but not Ethiopia, lost paid worktime exceeded the underlying esti- mated disability level, which again may reflect the poverty of Ethiopia (people can- not afford to miss paid work).

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In Zambia, estimated disability from migraine in the entire working population was 0.98%, in Ethiopia very similar (0.92%); but in Zambia, 1.4% of all workdays were lost to migraine, in Ethiopia only 0.80%.

Conclusions: What is to be Done? At population level, Ethiopia may lose 1.6% of its GDP to headache, but the country has many other health-care problems.

Communicable diseases (including HIV) and malnutrition, along with lack of access to clean water for nearly half the population [207], are high among the causes of ill-health.

Health politicians need to sit down with experts and discuss what must be done to alleviate the headache burden, and how, not just because people in Ethiopia lose much of their health and quality of life to headache but also with the expectation of cost-saving nationally [205].

WHO has recommended structured headache services with their basis in primary care as the most efficient, effective, affordable and equitable solution [205], and the model proposed by LTB for Europe [178], which is highly adaptable, could be reworked to match the health-care infrastructure of Ethiopia.

Acknowledgement A machine generated summary based on the work of Zebenigus, Mehila; Tekle- Haimanot, Redda; Worku, Dawit K; Thomas, Hallie; Steiner, Timothy J. 2017 in The Journal of Headache and Pain.

The burden of headache disorders in the Eastern Mediterranean Region, 1990–2016: findings from the Global Burden of Disease study 2016