Abstract
Purpose
The aim of the present study was to assess the burden and health care use of adult patients with migraine and tension type headache in a post-conflict area of Serbia.
Methods
This cross-sectional study was conducted on a representative sample of adults, living in predominantly Serb communities on the Kosovo and Metohija territory. The required data was obtained through a survey, utilizing a culturally-adapted questionnaire. The study sample comprised of 1,062 adults.
Results
In the year preceding the study, 49.7% of included subjects suffering from migraines and 27.5% of those experiencing tension type headache sought medical assistance for their condition. The majority (88.5%) of the respondents utilized non steroid antiinfammatory drugs as analgesic, while 14.2% used prophylactic treatment. Migraine sufferers reported losing on average 11.1 days in a 3-month period, while those experiencing tension type headache lost 4.7 days (p < 0.001) due to headaches, preventing them from partaking in professional, family and social activities. On headache-free days, 24.5% of the respondents were anxious or tense in anticipation of a headache onset, while 30% did not feel that the headache had completely resolved. Moreover, 11.5% of the sample reported never or rarely feeling in control of the headache, while 20% of the respondents were of view that their headaches were not taken seriously by their employer and co-workers and rarely discuss them. Adverse effect of headaches on education is more frequently noted by migraine sufferers than those experiencing tension type headache (p = 0.001), and this disparity persists in relation to career (p < 0.001) and family planning (p = 0.001).
Conclusions
In Kosovo and Metohija, primary headaches exert a profound influence on the affected individuals and their community, and thus require recognition as one of the priorities of social initiatives aimed at the enhancement of public health.
Introduction
Headaches are among the most common disorders affecting the population (1). Tension-type headache (TTH) is the most prevalent headache type, affecting about half of adults, and more than 10% of the global population is estimated to suffer from migraine. It is particularly disconcerting that about 3% of adults experience a headache on more than 15 days per month (2). While pain is their major complaint, headaches are typically accompanied by other symptoms, such as nausea or photophobia, which further compromise functional capacity and productivity of the affected individuals. When a headache develops, it often renders the sufferer incapable of fulfilling family, work and other commitments. Even once the headache has passed, the burden remains, as most individuals fear that something in their behavior may trigger another episode, thus extending the incapacity to the headache-free days (3). Headache burden in the period between successive attacks can result in a complete withdrawal from social life (4). The main significance of this interictal burden stems from its unpredictable recurrence. Whereas ictal burden occurs as frequently as the actual headaches, on average once or twice per month, interictal symptoms extend the headache burden into the headache-free days (5).
Even though headache is experienced at an individual level, it places a burden on the entire family, as well as the society as a whole (3). As headaches can result in regular work absences, and withdrawal from social activities, they adversely affect individual’s self-esteem, undermining his/her career prospects and earning potential. Nonetheless, these consequences are not limited to the affected individuals, but rather extend to their families, friends, employers and colleagues, who are often called upon to compensate for the absenteeism and suboptimal productivity resulting from headaches and their consequences. The social burden induced by loss of productivity and absenteeism can also be immense (6). According to the findings yielded by a recent Global Burden of Disease study, TTH and migraine are respectively the second and third most common health problem globally (1), while migraine ranks sixth on the list of leading causes of disability, and headache accompanied by medication overuse is in the 18th place (7). Given the high worldwide prevalence of headaches and accompanying complaints, it seems that health services are insufficiently proactive in responding to this global problem. Within this context, we posit that continued education on preventive health measures and headache burden via population studies across the globe can assist in improving the outcomes of current and new initiatives aimed at mitigating this highly important public health issue. Unfortunately, in Serbia, including Kosovo and Metohija (KM), as well as in other countries in the region, no studies on healthcare seeking behaviors and headache burden in adults have been conducted to date.
We hypothesized that primary headaches cause significant burden for the affected individuals and consequently their community in the post-conflict area of Serbia. Therefore, the aim of the present study is to assess the burden and health care use of adult patients with primary headache disorders in post-conflict area of Serbia.
Material and methods
The study protocol for this investigation was approved by the Ethics Committee of the Faculty of Medicine, University of Pristina, Serbia. Prior to taking part in the study, all selected individuals were informed about the study aims and methods, as well as the nature of their involvement, and signed the informed consent form.
This cross-sectional study was conducted on a sample of adult population residing in the Republic of Serbia’s Southern Autonomous Province KM. Keeping in mind lack of population census data, we tried to achieve the most representative sample possible. The sample comprised of native Serbian speakers aged 18 to 65 years that permanently reside in communities within the KM territory inhabited predominantly by ethnic Serbs. Specifically, three municipalities included in the study are situated north of the Ibar River (Severna Kosovska Mitrovica, Zubin Potok and Leposavic), while a further three (Gracanica, Strpce and Ranilug) are located south of the river. These six municipalities are home to the majority of Serbs that had remained in KM following the war of 1999, and the number of recruited participants from each community was proportional to the number of its residents. Random sampling method was adopted for this purpose, whereby the researchers started with the main street in a particular municipality, and selected every other street thereafter. The same alternating principle was adopted when selecting houses and flats within residential buildings. Once a household was selected, one of its members that met the study inclusion criteria was invited to take part in the study. In the case that several members of a household fulfilled inclusion criteria, we selected study participants alphabetically, by name. If the chosen person was not at home at the time of the visit, two further visits were arranged before marking that individual as non-respondent. No statistical power calculation was conducted prior to the study. The sample size was based on our previous experience with this design.
The data for the present study was gathered via the structured the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire specifically developed for this purpose (8), which was culturally adapted for the local population in line with relevant recommendations (4). Translation of the revised questionnaire items to Serbian language (spoken as the first language by the target population and thus all study participants) followed the “Lifting the burden” protocol (9). The questionnaire (10) comprised of four sections, the first of which aimed to capture the demographic and socio-economic data and was completed by all participants. At the end of this section, the respondents were required to state if, in the preceding year, they had experienced headache that was not accompanied by fever, head injury or cold. Those that responded affirmatively to this question proceeded to the second questionnaire section, inquiring into the headache characteristics (intensity, quality, localization, and presence of accompanying signs and symptoms). The third section included questions on the health services sought by headache sufferers (frequency of healthcare visits, consulted medical practitioner’s profile, prior headache diagnosis, headache treatment and prophylaxis, and their self-rated effectiveness). The final, fourth, section contained items pertaining to ictal, interictal and cumulative headache burden (absenteeism due to headaches, presence of interictal symptoms, sense of headache control, stigmatization and social isolation, and headache effects on education, career, family planning, family life and intimate relationships). In line with the approach adopted in the HARDSHIP survey, individuals that reported being affected by more than one headache type were asked to focus on the type that imposes the most severe burden on their wellbeing and functioning, and to respond to all related questions in reference to this headache type. Moreover, in order to assess the interictal anxiety most objectively and exclude influence of general anxiety, Hospital Anxiety and Depression Scale (HADS) was adopted.
General medical practitioners and students in the final year of a medical degree were responsible for the fieldwork and questionnaire administration. All individuals involved in this process had previously completed training on clinical headache characteristics, as well as theoretical and practical study design aspects, along with the aims and methods of data collection via face-to-face interviews. The skills and knowledge gained during training were assessed and those that met the required standards were invited to conduct data collection. To ensure adherence to the study protocol and verify the consistency and quality of the gathered information, the principal investigator performed random and unannounced spot checks of the investigators as they conducted the survey. All study participants were informed in advance about the potential visit by the principal investigator. Headache was diagnosed independently by two neurologists that took part in this research (NM and JZT), in accordance with the diagnostic criteria of the International Classification of Headache Disorders, 3rd edition (ICHD-3). When these two neurologists came to a different conclusion regarding the diagnosis, the third neurologist was consulted.
Statistical analysis
Gathered data was subjected to statistical analyses, using SPSS (Statistical Package for Social Sciences) for Windows, version 17. This is the primary analysis of these data (preplanned). Data regarding prevalence of primary headache in the in adults in the post-conflict area of Serbia has already been published (11). An appropriate 95% confidence interval (95%CI) was calculated for each point estimate that is intended to serve as a population estimate. Continuous variables were presented as means and standard deviations, whereas categorical variables were reported as number and percentage. For comparisons among continuous variables, independent two-sample t-test was utilized, while χ2 and Fisher’s exact test were used for inter-group comparisons involving categorical variables, with p < 0.05 signifying statistical significance. Before performed statistical tests mentioned above, we tested normality of distribution using Kolmogorov-Smirnov test. Additionally, two-tailed test hypothesis was used.
Results
The present study involved 1,062 adults recruited from different households, 571 of whom were women and 491 men, with 11.5% non-participation rate. There were no missing data. The demographic characteristics for the individuals in the survey are presented elsewhere (11).
Headache unrelated to other medical conditions was reported by 503 (47.4%) individuals, 161/1,062 (15.2%) were diagnosed with migraine, and 342/1,062 (32.2%) indicated suffering from TTH. A proportion of headache sufferers (225/503, 44.7%, 95%CI 40.8%–48.6%) reported having 3 to 4 headaches per month, mostly describing them as of moderate strength, with each episode lasting 4–12 hours. A higher frequency (>6 per month) and longer headache duration (>24 hours) was reported by 13/161 (8.1%, 95%CI 4.2%-12.0%) migraine sufferers and 16/342 (4.7%, 95%CI 2.7%-6.7%) respondents affected by TTH.
In the year preceding the study, 80/161 (49.7%, 95%CI 43.8%–55.6%) and 94/342 (27.5%, 95%CI 25.5%–29.5%) of migraine and TTH sufferers, respectively, sought medical help for their condition. Both groups predominantly consulted their primary physician (37/161, 23%, 95%CI 17.1%–28.9% and 47/342, 13.7%, 95%CI 9.8%–17.6%) and neurologist (33/161, 20.5%, 95%CI 14.6%–26.4% and 29/342, 8.5%, 95%CI 6.5%–10.5%), while 26/503 (5.2%, 95%CI 5.0%–5.3%) of the respondents experiencing headaches were seen by other medical specialties. Headache was previously diagnosed in 56/503 (11.1%, 95%CI 10.1%–13.1%) of subjects complaining of headaches (33/161, 20.4%, 95%CI 19.8%–21.0% of those with migraine and 23/342, 6.7%, 95%CI 4.7%–8.7% of individuals with TTH). Irrespective of the headache type, non steroid antiinfammatory drugs (NSAIDs) was the most commonly used analgesic (445/503, 88.5%, 95%CI 86.5%–90.5%), while 71/503 (14.2%, 95%CI 13.2%–16.2%) used prophylactic treatment. On average, medication for headache relief was taken on four days per month. Beta blockers were the most common prophylactic pharmacological class of medications recommended to migraine sufferers, whereas those experiencing TTH were recommended antidepressants. Both groups rated the symptom alleviation and prophylaxis as good, as indicated in Table 1.
Participant distribution with respect to headache type and responses given to the questionnaire items pertaining to headache treatment and prophylaxis.
TTH: tension type headache; NSAIDs: non steroid antiinflammatory drugs; SD: standard deviation.
The headache-attributed lost time (HALT) questionnaire was utilized to obtain data on loss of productivity due to headaches (10). According to the findings yielded by the analysis of questionnaire responses, in the 3-month period preceding the study, on average, participants suffering from headaches had lost 5.0 (interquartile range-IQR 16.0) days designated for professional, family and social activities. It is noteworthy that women reported statistically significantly greater productivity loss relative to men (7.0, IQR = 18.0 vs. 2.0, IQR = 13.0 days; p < 0.001). Statistically significant differences were also noted between participants suffering from migraine and TTH (11.1 vs. 4.7; p < 0.001), as well as between those suffering from chronic and episodic headaches (15.4 vs. 6.0; p < 0.001). Table 2 summarizes the findings pertaining to the absenteeism (measured in days) from professional, family and social activities, based on the HALT questionnaire responses.
Headache burden in participants suffering from migraine and TTH.
*Median (interquartile range). TTH: tension type headache; HALT: headache attributed lost time.
As can be seen from Table 2, on headache-free days, 123/503 (24.5%, 95%CI 20.6%-28.4%) of the respondents (including those affected by general anxiety) feel anxious or tense in anticipation of the next headache onset. A slightly higher percentage (21.7%) of headache sufferers avoids certain activities on headache-free days to prevent inducing another episode. Moreover, 30% of those suffering from headaches do not feel free from headache associated symptoms on headache-free days. Statistically significantly higher interictal symptom prevalence was noted among migraine sufferers relative to participants experiencing TTH (Table 2), while no statistically significant differences were found between men and women. It is also noteworthy that 20% of the respondents suffering from headaches felt stigmatized, and believed that their condition was not taken seriously by their employer and colleagues, due to which they rarely discussed their symptoms. Moreover, 14% of this group felt misunderstood by their family members. However, the differences in stigmatization rates with respect to headache type were not statistically significant (Table 2).
Table 2 also summarizes the headache effects on education, career, family planning and intimate relationships. As can be seen, women are more likely than men to cite adverse effects of headaches on family planning (3.6% vs. 0.6%, p = 0.034, Fisher's exact test), while their responses to other questionnaire items were not statistically significantly different. On the other hand, with the exception of divorce/relationship breakup, migraine sufferers were statistically significantly more likely than respondents with TTH to state that headaches have had adverse cumulative effect on their wellbeing and functioning (Table 2).
A summary of findings pertaining to headache control is given in Table 3, where it can be seen that more than 60% of patients feel that they have control of their headaches and 10% never or rarely feel in control of their condition. Moreover, men statistically significantly more frequently report sense of full or nearly complete control of their headache (p = 0.001).
Control of headache.
Discussion
Despite their high prevalence, public health issues stemming from headache disorders are not fully understood. Specifically, it is presently unknown how and to what extent headaches affect various populations across the globe, or how successfully healthcare and other resources are utilized in alleviating their effects (12,13). With the primary aim of reducing headache burden, in a collaboration between the World Headache Alliance, the International Headache Society, the European Headache Federation and the World Health Organization, a global “Lifting the burden” campaign was launched in 2004 (14). It was envisioned that, by adopting a comprehensive approach and by integrating all available resources in all parts of the world, it would be possible to better manage the headache burden and its effects on the affected individuals, their families and the society. It is within this overarching context that this first population study was conducted, aiming to establish the headache burden and healthcare seeking behavior in individuals suffering from primary headaches residing in the KM territory, which is also unique for Serbia as a whole, and it seems for the entire region.
Our findings revealed that, only 11.1% of all study participants that suffered from headaches in the preceding years, had received a previous headache diagnosis, which is a much lower percentage compared to other European countries. For example, 16.6% of the participants in an Italian study had a prior headache diagnosis (15). In addition, 9.7% of those that reported having headaches in the past 12 months sought help from their primary physician, while 4.8% consulted a headache specialist. On the other hand, 70% of headache sufferers that took part in a study conducted in the UK visited their general practitioner for this ailment (16). Similarly, 64.4% of participants from Kuwait sought medical help for their migraine (17). Furthermore, 62.4% of these individuals consulted a general practitioner, while 17.2% were referred to a neurologist and further 3.7% to a different medical specialist. Nonetheless, only 4.6% of the study sample had prior headache diagnosis (18). Participants in the present study mostly (16.7%) sought help from their primary physician, followed by consulting a neurologist (12.3%) and other medical experts (5.2%). In line with the findings yielded by the aforementioned Italian study (15), only 0.2% of the headache sufferers sought help in the emergency room or called an ambulance. Earlier studies, however, indicate that headache is the most common complaint encountered by general practitioners and neurologists (6,18). In addition, in an earlier survey, participating neurologists indicated that third of all their reports pertain to headaches (19).
In the present study, 93% of headache sufferers reported utilizing medication to treat acute headache attacks, while 14.2% relied on prophylactic therapy. It is important to underline that in our study there were few migraine patients that were using triptans (or ergots), only 1.9%. There are several reasons that may explain this finding. One of them is irregular supply to pharmacies in this region. Another one may be low level of awareness about importance of migraine specific treatments (such as triptans). These percentages are somewhat higher than previously reported by Allena et al, who noted 84% and 2.4%, respectively, based on their sample drawn from Italian population (15). However, these authors opined that the actual medication use for symptom management is likely to be much higher. This view is supported by the findings of another study, focusing on illness perception among headache sufferers, where only a third of the respondents that experienced headaches in the preceding year defined themselves as headache sufferers. The disease perception was primarily related to the headache frequency, with women being more likely than men to consider headache as an illness (20). Nonetheless, in the present study, as well as in prior research, reliance on prophylaxis was much greater among migraine sufferers compared to those suffering from TTH. For example, in the previously discussed study conducted in Kuwait (17), 39.9% of the respondents that experienced migraines used prophylactic medication, compared to only 21.1% noted in our study. However, only 5.6% of the current study participants that reported having migraine in the preceding year relied on non-pharmacological methods (exercise, acupuncture, homeopathy, plant extracts), whereas 17% of the individuals partaking in the aforementioned study sought relief in traditional Arab medicine (17).
Despite high worldwide headache burden, little is known about its causes and effects, especially in countries in which no studies exploring this disorder have been conducted (4). In a study conducted in 1996, 66% migraine sufferers reported interictal effects on their functioning, including compromised family relationships (54%), work productivity (35%), lack of control over their life (34%) and reduced opportunities for self-actualization (15%) (21). Findings yielded by a more recent Swedish study indicate that only 43% of individuals experiencing migraines recover between episodes (22). In another Swedish study focusing on migraine sufferers, the participants reported reduction in contentment and vitality, as well as sleep disturbance and loss of wellbeing, in addition to a range of subjective symptoms in the interictal period, all of which were less prevalent in the control group (23).
Ictal headache burden pertains to the inability to perform paid work and household duties, as well as engage in social activities due to headaches. In the present study, on average, participants were absent from work, and withdrew from family and social engagements for 6.7 days in the preceding three months. The findings related to work absenteeism (2.7 days) and withdrawal from family commitments (2.8 days) obtained in the present study are similar to those reported in the earlier Italian study, where authors reported loss of 2.3 and 2.4 days per 3-month period (15). Moreover, when the sample was segregated by gender, the HALT index for women was statistically significantly higher than that obtained for men suffering from headaches. Similar gender differences were noted in prior research, where men reported greater work absenteeism, while women cited greater headache effects on their ability to perform household chores (24). When work absenteeism reported by participants suffering from migraines and TTH was analyzed separately, the former on average reported loss of 4.7 days, while latter lost 1.8 days of paid work, exceeding figures reported for most European countries (25). On the other hand, in line with the European averages, average time lost due to headache from household duties and social activities was greater among migraine sufferers (4.7 and 1.79 days) compared to those experiencing TTH (1.9 and 0.89 days) (25).
Following the methodology recently adopted in the “Eurolight project” conducted in 10 European countries, we also inquired into the participants’ interictal and cumulative headache burden (5). Our findings revealed that the prevalence of these symptoms is much greater in adults of Serb ethnicity residing in KM compared to the European average, as 39.1% of the migraine sufferers and 36.6% of those with TTH reported experiencing some interictal symptoms, compared to 26% and 18.9% of the respondents that took part in the “Eurolight project”. Moreover, we failed to establish gender-related statistical differences, which were noted in this project (5). On the headache-free days, 20% and 25% of our participants that suffered from migraines and TTH, respectively, reported interictal anxiety, compared to only 10.6% and 3.1% “Eurolight project” participants. Even after excluding respondents that experienced general anxiety, interictal tension was noted in 20% of our sample. Avoidance of certain activities as a coping strategy was reported by 32.3% and 16.7% of our participants that suffered from migraines and TTH, respectively, which is significantly higher than the European averages of 14.8% and 4.7% (5).
In the present study, headaches compromised education in 10% of the sample, while 12.3% of the respondents noted negative effects on their career. As expected, migraine sufferers reported much greater education and career restrictions than did those with TTH, whereas no gender differences were noted. Reluctance to discuss their symptoms was reported by 20% of the individuals suffering from headaches, irrespective of their type, as they were of view that the debilitating effects of their condition were insufficiently appreciated by their employer and colleagues, while 14% of the participants also felt misunderstood by their family members. Intimate relationship issues were reported by 8.9% of our participants suffering from headaches, which is below the European average. Nonetheless, a much higher percentage of our respondents (1.8%) felt that their headaches contributed to the relationship dissolution, compared to 0.5% and 0.2% of the European cohort that cited headaches are the reason for breakup and divorce, respectively (5).
Our study has certain limitations. The first of them is lack of population census data, which made it difficult to achieve the most representative sample possible. Another limitation is a consequence of the lack of information about the specificities of headache medical service in the regions included in the study. Another limitation stems from restricting the study sample to native Serbian speakers due to the language barrier, and replication study which included other ethnics groups would be warranted.
In line with the findings obtained in other European studies, in post-conflict area of Serbia, in the Kosovo and Metohija territory, primary headaches exhibit a significant adverse impact on the affected individuals and those in their environment. This suggests that the individual and social awareness of the debilitating consequences that headaches may have on one’s wellbeing, functioning and productivity is still relatively low. It is further disconcerting that a relatively minor fraction of headache sufferers seeks medical help for their condition. As primary headaches affect about 50% of individuals in their most productive life phase, it is necessary to recognize them as a social priority in order to improve public health conditions globally, an initiative that must be led by those responsible for public health policy and funding allocation for medical health coverage.
Clinical implications:
In the present study, 93% of headache sufferers reported utilizing medication to treat acute headache attacks, while 14.2% relied on prophylactic therapy. On the headache-free days, 20% and 25% of participants that suffered from migraines and TTH, respectively, reported interictal anxiety, compared to only 10.6% and 3.1% participants in the Eurolight project. Avoidance of certain activities as a coping strategy was reported by 32.3% and 16.7% of our participants that suffered from migraines and TTH, respectively, which is significantly higher than the European averages of 14.8% and 4.7%. The individual and social awareness of the debilitating consequences that headaches may have on one’s wellbeing, functioning and productivity is still relatively low in the ethnic Serb population residing in the Kosovo and Metohija territory. The awareness of both headache diagnoses and specific treatments (such as triptans) need to increase in the Kosovo and Metohija territory.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.