Headache disorders are real, neurobiological and often lifelong illnesses. They are common and ubiquitous and affect both sexes and all age groups everywhere in the world. Their lifetime prevalence in populations in which it has been measured is over 90%. They impose substantial burdens, both personal and societal, because headache disorders cause pain and suffering, and are disabling.

The World Health Organization (WHO) ranks migraine alone in the top 20 causes in the world of years of healthy life lost to disability¹. A recent US study measured indirect costs in a managed-care population at over $4,500 per migraine sufferer per year². In the United Kingdom, lost-productivity costs of migraine arise in part from absenteeism during acute attacks which is estimated to account each year for 25 million days of missed work or school³. Extrapolating this figure suggests that migraine is the cause of an estimated 400,000 lost days from work or school every year per million of the population in developed countries. Beyond productivity losses, migraine harms family and social relationships and damages quality of life⁴.

Migraine, however, is only one of several headache disorders with public-health importance. The others include tension-type headache and a group of so-called chronic daily headache disorders. Together, these are believed to be responsible for even more disability than migraine⁵. If this is so, headache disorders collectively are in the top ten causes of disability worldwide, and the top five in women.

"No-one should think that the humanitarian burdens imposed by headache disorders weigh less in developing countries because they are less evident."

The huge financial costs of headache focus attention on the developed world where money is persuasive. But no-one should think that the humanitarian burdens of headache - not only pain, suffering and disability but also the many secondary burdens of lifestyle compromises, damaged relationships and lost opportunities - weigh less elsewhere because they are less evident. Poverty and its consequences of poor sanitation and infectious diseases may seem to be of overwhelming priority in many low-income countries, but why should headache and the burdens it imposes be any less disagreeable in the presence of hunger and other illness?

Good health care can alleviate much of the symptom burden of most headache disorders. Effective health care can therefore mitigate both the humanitarian and the financial costs that arise from them.

But this solution depends not only on the existence of efficacious therapies; health-care resources must be allocated and health-care systems put in place so that these therapies are delivered to all who need them.

In fact, for the vast majority of those who need it - people whose quality of life is spoiled by headache - effective treatment requires no expensive equipment, tests or specialists. The essential components of effective medical management are five-fold, but none of them are beyond the capabilities of primary care: awareness of the problem, correct recognition and diagnosis, avoidance of mismanagement, appropriate lifestyle modifications and informed use of cost-effective pharmaceutical remedies.

Yet there is good evidence that needs are met at best only partially and in many places not at all. A consensus conference in 1998⁶ concluded that migraine throughout the world is under-diagnosed and under-treated.
Various barriers to care bring this about, many of which are artificial and therefore dispensable. In many countries, headache conditions are not acknowledged as diseases but only as self-limiting and therefore unimportant symptoms, deserving no allocation at all of resources which are anyway scarce. In consequence, large gaps exist between the need for health care for headache disorders and access to it. Added to this, mismanagement makes the burden of headache worse: overuse of headache medication is the cause of daily headache in large numbers of adults and in many children.

Thus the principal reason why the burdens attributable to headache persist, and indirect costs remain so high, is failure of health-care systems to provide the simple measures that effective headache management requires.
The key factor underlying this public-health disaster is education failure at every level. Lack of awareness and understanding of headache disorders amongst the general public allows myths to persist that they are not real and not worthy of medical attention. Lack of inclusion of diagnosis and management of headache disorders in the training curricula of health-care providers leaves them unskilled and therefore unwilling to offer health care in this field. Lack of recognition of the humanitarian burden and socioeconomic cost attributable to headache disorders leads health-policy makers grossly to misjudge the priority due to them.

References

^{1. World Health Organization. The World Health Report 2001. Geneva: WHO, 2001.}

^{2. Fishman P, Black L. Indirect costs of migraine in a managed care population. Cephalalgia 1999; 19: 50-57.}

^{3. Steiner TJ, Scher AI, Stewart WF, Kolodner K, Liberman J, Lipton RB. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia 2003; 23: 519-527.}

^{4. Lipton RB, Bigal ME, Kolodner K, Stewart WF, Liberman JN, Steiner TJ. The family impact of migraine: population-based studies in the USA and UK. Cephalalgia 2003; 23: 429-440.}

^{5. Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher AI, Steiner TJ, Zwart J-A. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007; 27: 193-210.}

^{6. American Association for the Study of Headache, International Headache Society. Consensus statement on improving migraine management. Headache 1998; 38: 736.}

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