Review

Epidemiology and comorbidity of headache

Rigmor Jensen, Lars J Stovner

Lancet Neurol 2008; 7: 354–61 The burden associated with headache is a major public health problem, the true magnitude of which has not been
Danish Headache Center, fully acknowledged until now. Globally, the percentage of the adult population with an active headache disorder is
Department of Neurology, 47% for headache in general, 10% for migraine, 38% for tension-type headache, and 3% for chronic headache that
University of Copenhagen,
Glostrup Hospital, DK-2600
lasts for more than 15 days per month. The large costs of headache to society, which are mostly indirect through loss
Glostrup, Denmark of work time, have been reported. On the individual level, headaches cause disability, suffering, and loss of quality of
(R Jensen MD); and Norwegian life that is on a par with other chronic disorders. Most of the burden of headache is carried by a minority who have
National Headache Centre, substantial and complicating comorbidities. Renewed recognition of the burden of headache and increased scientific
Department of Neuroscience,
Norwegian University of
interest have led to a better understanding of the risk factors and greater insight into the pathogenic mechanisms,
Science and Technology and which might lead to improved prevention strategies and the early identification of patients who are at risk.
St Olavs Hospital, Trondheim,
Norway (LJ Stovner MD) Introduction diagnostic criteria of the second edition of the
Correspondence to: Headache is the most prevalent neurological symptom1 International Classification of Headache Disorders
Rigmor Jensen,
Danish Headache Center,
and is experienced by almost everyone. Headache can be (ICHD-II),9 which were published in 2004 and are now
University of Copenhagen, a symptom of a serious life-threatening disease, such as a applied worldwide. There might, however, be problems
Glostrup Hospital, DK-2600 brain tumour, but in most cases it is a benign disorder with case definitions in epidemiological studies,
Glostrup, Denmark that comprises a primary headache such as migraine or particularly the definition of TTH, which can greatly
[email protected]
tension-type headache (TTH).2 Nevertheless, migraine influence the prevalence rate; for example, problems can
and TTH can cause substantial levels of disability, not arise because the definition of TTH can overlap with
only to patients and their families but also to society as a probable migraine,10 and migraine is almost always
whole owing to its high prevalence in the general comorbid with TTH. This might explain why the
population.3–7 prevalence of TTH tends to vary more than the prevalence
Unfortunately, the scope and scale of the burden of of migraine.
headache is underestimated, and headache disorders are Overall, the current global prevalence of headache is
universally under-recognized and undertreated. An 47%, of migraine is 10%, of TTH is 38%, and of chronic
important initiative, Lifting the Burden: The Global headache is 3%.3 As expected, the lifetime prevalences
Campaign to Reduce the Burden of Headache, focuses on are higher: 66% for headache, 14% for migraine, 46% for
these widespread aspects of headache and is a collaboration TTH, and 3·4% for chronic headache.3
between multinational health-care organisations and The ICHD criteria can be used to summarise regional
professionals to raise awareness of headache disorders in prevalences of headache disorders. Migraine is more
general.8 Another initiative, Cost of the Brain Disorders in prevalent in Europe and North America than it is in
Europe, includes migraine as a separate neurological Africa (figure 1),3,7,10–37 whereas the prevalence of TTH
disorder that ranks as number nine on the list of the most seems to be much higher in Europe (80%) than it is in
costly neurological disorders in both sexes, and as number Asia and the Americas (20–30%). The frequency and
three in women.1,6 TTH is the most common form of duration of TTH varies considerably: from infrequent,
headache and is often thought of as a normal headache, short-lasting periods of discomfort to frequent, long-
in contrast to debilitating and characteristic migraine lasting, or even continuous, disabling headaches.
attacks or cluster headaches. Owing to its high prevalence, Therefore, pooling these extremes into an overall
disability due to TTH is greater than that for migraine at prevalence figure might be misleading. The lifetime
the population level.3 Headache is among the ten most prevalence of TTH was as high as 86% in a population-
disabling disorders for both sexes and, if the burden of based study in Denmark, but most of the patients (59%)
TTH is taken into account, among the five most disabling had episodic infrequent TTH (1 day or less per month)
disorders for women, in accordance with the WHO’s without the need for medical attention.38 Nevertheless,
ranking of the most disabling disorders.3 24–37% had TTH several times a month, 10% had TTH
The main objectives of this Review are to present the weekly, and 2–3% of the population had chronic TTH for
recent epidemiological knowledge about primary most of their life.26,38,39
headache disorders, their comorbidities, costs, risk Data on chronic headache (lasting ≥15 days per month)
factors, and prognoses. are relatively scarce and therefore less reliable. In clinical
practice, reports of chronic headache should always raise
Epidemiology suspicion of a secondary headache due to neurological or
Prevalence systemic disease or frequent use of medication—so-
Although there are no biological markers for primary called medication-overuse headache. Medication-overuse
headaches such as migraine and TTH, their diagnosis is headache is a secondary chronic headache associated
made with relatively high precision on the basis of the with more than 3 months’ overuse of analgesics (15 days

354 http://neurology.thelancet.com Vol 7 April 2008

 Review

13·223
11·622

10·026
14·710
13·311 23·221 10·237
11·714 22·335
9·628 8·436
12·212
14·325
5·934
14·015
16·727
24·624

11·613 8·516 7·733

8·5
7
10·129
10·07 9·032
13·519
12·6 7
3·0
30

9·37
16·317 5·031
8·27

5·318

7·320 5·07

Africa 4·0 (2 studies) Europe 14·8 (9 studies) • IHS or modified IHS criteria
Asia 10·6 (6 studies) North America 11·1 (7 studies) • Population or community based
Australia South America 9·6 (10 studies) • >500 participants
• Covering at least age groups 25–60 years

Figure 1: Studies on the 1-year migraine prevalence in adults3,7,10–37 For more on the global
campaign to lift the burden of
headache worldwide see http://
or more intake per month) or more specific substances, headache, in general, decreases with age. The prevalence www.liftingtheburden.org/
such as triptans or ergotamine (≥10 days’ intake per of migraine increases with age until a peak is reached
month).9 The global prevalence of chronic headache is during the fourth decade of life; thereafter, the prevalence
3·4%, and it is most common in Central and South declines, with a more pronounced decline in women
America (5%), and least common in Africa (1·7%).3,40–44 than in men.3,26,38,51,52
There are only a few large-scale epidemiological studies The most common age of onset of migraine is in the
of cluster headache, and the lifetime prevalence in five second and third decades of life (figure 2).26,52 The average
European studies ranges from 0·06% to 0·3%.45–49 age of onset of TTH is higher than for migraine, namely
Whether regional differences are real or mainly a result between 25 and 30 years in cross-sectional epidemiological
of differences in the methodology of the various studies studies,24,26,52 and TTH as well as other chronic headaches
is uncertain. Many factors in addition to case definition are probably lifelong disorders: prevalences tend to
influence the calculation of headache prevalence; these increase until the fifth decade, with only a minor decline
include the time frame of the headache, the method of with increasing age.
data collection, the age and sex of the population, the
participation rate, how the diagnostic criteria are applied, Incidence
which diagnoses are considered, and, most importantly, The incidence of developing migraine de novo has been
how the screening questions are asked.50 estimated only rarely with uncertain results. In a Danish
epidemiological follow-up study, the annual incidence of
Sex and age migraine was 8·1 per 1000 person years (male:female
The male:female ratio for migraine among adults varies ratio 1:6) and 14.2 per 1000 person years for frequent
from 1:2 to 1:3, and women have more migraine without TTH (male:female ratio 1:3).54 Both rates decreased with
aura than migraine with aura.51,52 In prepubertal children, age. Risk factors for migraine include familial disposition,
there is generally no sex difference.53 The male:female lack of secondary education, high work load, and frequent
ratio for TTH is 4:5, indicating that, unlike for migraine, TTH. The risk factors for TTH include poor self-rated
women are only slightly more affected than men.26,38,39 health, inability to relax after work, and sleeping for only
For both sexes, the prevalence of TTH peaks between a few hours per night. The incidence of migraine was
the ages of 30 and 39 years, and the prevalence of higher than previously estimated from cross-sectional

http://neurology.thelancet.com Vol 7 April 2008 355

 Review

the estimate was a review of the available migraine cost

studies in Europe59 combined with a review of the
30
epidemiological evidence50 corrected for comorbidity and
Women
differences in purchasing power of the different countries.58
25 Men
The total estimated cost of migraine was €579 per patient,
or €27 billion for the 41 million patients aged between 18
Migraine prevalence (%)

20
and 65 years;1 almost 90% were indirect costs.58,59 Migraine
was by far the most prevalent of all the purely neurological
15 disorders, and although it had the lowest cost per patient it
was more costly than other neurological disorders, such as
10 stroke, multiple sclerosis, Parkinson’s disease, and
dementia.1 However, in the different countries where
5 migraine cost studies have been done there were large
variations in the cost estimates, most probably owing to
0 differences in methodology and the data available.59 All the
<10 10–19 20–29 30–39 40–49 50–59 60–69 70–79 European studies were done before or soon after the
Age (years) triptans were available; therefore, the high cost of this
group of drugs was not taken into account.
Figure 2: Migraine prevalence in relation to age in men and women in Europe Relatively little is known about the cost of TTH. The
Reproduced with permission from Blackwell Publishing.50 results of two Danish studies have shown that the
number of work days missed in the population owing to
studies. The sex difference in patients with TTH differed TTH was three times higher than the number for
from migraine and no association with educational level migraine;60,61 and a US study has also found that
was observed.54 There are only few data on the incidence absenteeism due to TTH is considerable.34 The indirect
of cluster headache, and this varies betweeen 2·5 per costs of all headaches are several times higher than the
100 000 person years in an Italian study45 and 9·8 per costs for migraine alone, which suggests that the costs of
100 000 person years in a US study.55 The peak incidence non-migrainous headaches (mainly TTH) are higher
in men was between the ages of 40 and 49 years and in than those for migraine.29 Under the assumption that the
women between 60 and 69 years.55 Intriguing data from indirect costs of TTH far outweigh the direct costs, we
the USA indicate that the incidence might be decreasing, can speculate that the cost of TTH is greater than the cost
but the case-finding method and the case definitions of of migraine.3,11,58,62 However, proper studies on the cost of
this study are unconventional, and the results need to be TTH are urgently needed to appraise the real burden of
confirmed.56 headache.
The direct costs due to medical services and medications
Costs and disability are 54% higher for TTH than for migraine because of the
Costs higher prevalence of TTH and because the probability of
The total economic burden of migraine has been consulting a physician is higher in the many younger
estimated in the USA57 and Europe58 on the basis of patients who have TTH.58,60–61 Owing to the lack of a
population-based prevalence studies, which reported a specific and effective treatment for TTH, patients usually
prevalence of about 14% in both regions. The two studies consult many doctors and spend large sums of money on
used different types of data sources for the cost estimates, so-called alternative treatments but have to live most of
although the results of both clearly show that most of the their lives without effective pain relief for the headaches.
cost of migraine can be attributed to indirect costs, such The burden of cluster headache has been studied in a
as absence from work or reduced efficiency when working series of 78 consecutive patients from The Danish
with headache. The US study,57 which used cost data from Headache Center and compared with the use of health-
1994, estimated the total cost of 22 million migraineurs care services in the general population:63 all patients had
aged between 20 and 65 years to be $14·4 billion. The consulted their GP; 43·5% had seen specialists; 10·6%
direct costs (eg, medication, consultations, investigations, had required emergency services; and 1·2% had been
and hospitalisation) accounted for only $1 billion, admitted to hospitals. The indirect costs were also
whereas the indirect costs were estimated at $13.3 billion. substantial: 29·6% of the gainfully employed patients
Woman incurred about 80% of both the direct and the with cluster headache had been absent from work
indirect costs of migraine. An important conclusion of compared with the headache-related absence rate of
the study was that the burden of migraine disproportionally 12·3% in the general population.63
falls on the patients and their employers.57
The European estimate was published in a report on the Disability
cost of all brain disorders in the 25 EU countries at the The US Migraine Cost Study calculated that migraine
time plus Iceland, Norway, and Switzerland.58 The basis of was the cause of 112 million bedridden days per year,

356 http://neurology.thelancet.com Vol 7 April 2008

 Review

which corresponds to 300 000 people staying in bed

30 Global
every 24 hours because of headaches.57 In population- Asia
based studies from Sweden, patients with migraine Europe
have also reported impairment between attacks,64 and North America
25
South and Central America
9% have stated that they do not recover completely from
attacks.65
Disability-adjusted life years—a measure of disease 20

Burden of headache
burden used by the WHO—is the sum of the years of life
lost and the years lived with disability.66 Although 15
migraine entails no increased mortality (ie, years of life
lost=0), it was ranked 19th in the leading global causes of
disability-adjusted life years among women aged 15–44; 10
with regard to years lived with disability, migraine was
ranked 19th for both sexes and 12th for women,
5
irrespective of age.6 By use of the WHO data to calculate
the burden of brain disorders (ie, psychiatric and
neurological disorders) in Europe, the overall burden of 0
migraine was lower than the seperate burdens of the Migraine Tension-type headache Total
major psychiatric disorders, dementias, stroke, and
injuries, but higher than the burden of epilepsy, multiple Figure 3: The burden of headache
sclerosis, and Parkinson’s disease, respectively.6,66 The burden of headache is calculated as headache days per year per person in the population multiplied by the
average intensity of headache. Reproduced with permission from Blackwell Publishing.3
The results of a Swedish study show that 27% of
patients have 70% of the migraine attacks, and thereby
carry most of the burden.64 This calculation has been
replicated through the application of the Migraine Sex life 7 8 28 Highly negative influence
Negative influence
Disability Assessment Scale.66,67,68 In France, 22% of Some negative influence
Love life 3 6 22
patients with active migraine, who correspond to 1·5%
of the whole population, had a Migraine Disability Finding
12 8
friends
Assessment Scale score of three or four, which indicates
Social
11 days or more absence from work during a 3-month position
3 10 24
period, a 50% or more reduction in productivity (job or
household chores), or an inability to participate in social Leisure time 8 14 37

activities.68 In the USA69 and England,70 the proportion

Finances 4 6 20
of patients with migraine who had a Migraine Disability
Assessment Scale score of three or four was more than Family
6 23 38
situation
50%.
Although Migraine Disability Assessment Scale score Studying 9 12 27
data are available for only a few countries, a recent review3 Work
of the global prevalence and burden of headaches has 11 18 47
attendance
tried to estimate the burden by the use of data on Career
3 8 16
migraine prevalence, attack frequency, and intensity. The progression
migraine burden was relatively similar for the four 0 20 40 60 80
continents that had sufficient data (Europe, Asia, North Percentage of migraineurs
America, South and Central America; figure 3).3 The
results of the study also showed that the burden of TTH Figure 4: Effect of migraine on important aspects of life
was greater than the burden of migraine, which is Reproduced with permission from Blackwell Publishing.65
supported by the finding that absence from work owing
to TTH is much greater than absence from work owing in patients with moderate or severe migraine,70 and a
to migraine.60 study from the Netherlands found that the negative
Some studies have measured quality of life with the influence of migraine was larger than the negative
SF-36 questionnaire, which enables migraine to be influence of disorders such as asthma.71 Comorbidities,
compared with other chronic disorders and eight quality such as depression, add to the reduction in the quality
of life measures. One US study69 that recruited patients of life of migraineurs,72 and the lower quality of life
with migraine from a medication trial found that remains after adjustments for socioeconomic status and
migraineurs had a lower quality of life than the general depression.72
US population. The authors of a population-based study The negative effect of migraine on family life has been
in the UK reported lower quality of life on all measures assessed in studies from Sweden, the UK, and the USA.

http://neurology.thelancet.com Vol 7 April 2008 357

 Review

In Sweden, migraine affected family, love life, and sex diabetes, asthma, and obesity,78,79 and some less well
life almost as much as it affected work (figure 4).65 The defined disorders, such as fibromyalgia, lower back pain
US and UK studies69,70 also found considerable effects on or local muscle pain,80 anxiety, and depression.81,82
the partners of patients with migraine: 24% of partners Migraine, hypertension, and obesity are all independent
missed days of family or social activities, and 12% avoided risk factors for cardiovascular diseases, particularly
making plans for family or social activities owing to the stroke, and the relative risk of stroke is 2·27–8·7 in
proband’s migraine. The patients with migraine also women with migraine with aura who are younger than
reported that the disease considerably influenced their 45 years, and 1·83 in women with migraine without aura.
ability to be a good parent, and a minority (0·4%) stated The risks increase significantly when migraine with aura
that they avoided having children because of their is associated with smoking or the use of oral
migraine. contraceptives.83,84 Similarly, there is an increased risk of
The effects of TTH on the individual include physical stroke in women with migraine with aura (odds ratio
suffering, loss of quality of life, and economic effects, but [OR] 2·25), but not with migraine without aura, who are
these are difficult to quantify. Chronic TTH had a between the ages of 45 and 55 years, although this risk
profound negative effect on the emotional life of the was not seen in older women.84 Isolated hypertension
affected patients because they were seven times more was unrelated to migraine; rather, it was inversely related
likely to be classified as impaired on all subscales of the to non-migrainous headache in a large Norwegian
applied quality of life surveys than were the controls, population study.85 In the same population, diabetes
which is similar or worse than for patients with a well seemed to have a protective effect against migraine
accepted diagnosis of chronic pain.73 Specific measures (OR 0·4) in migraineurs compared with non-
of disability and quality of life in patients with TTH have migraineurs.79 This and many of the other studies that
not been developed. show comorbidities with headache have a cross-sectional
With regard to cluster headache, 78% of patients design, and interpretations of the results in terms of a
reported restrictions in daily living, and 13% of patients causal relationship must be made with caution.
reported inhibition outside cluster periods. Major Although obesity is a major risk factor for diabetes, it is
decreases in the ability to participate in social activities, also thought to be associated with increased frequency
family life, and housework were reported by 25% of and intensity of migraine in clinical studies from the
patients with TTH. The disease led to lifestyle changes in USA. However, obesity is not comorbid with the diagnosis
96% of patients, most commonly in sleeping habits and of migraine itself.86 Nevertheless, the association between
avoidance of alcohol.63 a more complex group of patients with other chronic
headaches and obesity is more pronounced because
Comorbidity chronic headache is five times more prevalent in obese
Comorbidity is defined as a medical condition that exists individuals (body mass index >30) than in those who are
simultaneously but independently with another normal weight.78
condition, although recent descriptions have questioned The area is further complicated because obesity is also
this and have implied causality between certain comorbid a dependent risk factor for depression and anxiety. The
disorders.74 association between depression and migraine is reported
The study of the co-occurrence of highly prevalent to be bidirectional: migraineurs have a fivefold higher
disorders such as TTH and migraine with other disorders risk of depression than the general population, and
requires careful statistical analysis before any clear patients with depression have a threefold higher risk of
conclusions about causality can be made. Several migraine than the general population.87 There is a similar
headache disorders can occur within the same individual bidirectional association between anxiety and migraine.
(ICHD-II), and patients can have up to five different Taken together, the results of these studies support
ICHD-II diagnoses.75,76 In the general population, 94% of theories of a common neurobiology.88,89 However, when
migraineurs have TTH, and 56% of these have frequent population-based data were adjusted for coexisting TTH,
episodic TTH.38 By contrast, TTH occurs with similar it was clear that TTH but not pure migraine was the main
prevalence in patients with and without migraine, which predictor for depression and anxiety.90 Therefore, in
leads to the assumption that migraine can trigger TTH, future long-term epidemiological studies, and in our
whereas TTH might not trigger migraine.38 The prevalent work as headache doctors, it is important to identify
secondary headache and potentially preventable comorbid disorders, including coexisting headache
medication-overuse headache occur, by definition, most diagnoses, because the neurobiology, management, and
frequently in patients with primary headaches and are outcome of headache are closely correlated with
closely linked by a common, as yet, unknown comorbidity.
neurobiological denominator.77
In general, headache disorders, and particularly Prognosis
migraine, have been linked to various illnesses, including The results of a 40-year follow-up of 73 children with
well defined disorders, such as stroke, hypertension, pronounced migraine showed that before the age of 25,

358 http://neurology.thelancet.com Vol 7 April 2008

 Review

23% of the patients did not have migraine, and women

were significantly more likely to have migraine,91 but Search strategy and selection criteria
more than 50% still had migraine when they were around References for this Review were identified by searches of
50 years old. MEDLINE between 1988 and September, 2007, and from the
In a 12-year longitudinal epidemiological study from extensive files of the authors. The search terms “migraine”,
Denmark, 549 people participated in the follow-up study. “cluster headache”, “tension-type headache”, “daily
Of 64 migraineurs at baseline, 42% were in remission, headaches”, “epidemiology”, “comorbidity”, “prognosis”, and
38% had low-frequency migraine, and 20% had a poor “burden of headache” were used. Abstracts from meetings
outcome—more than 14 migraine days per year—at were also included. Only papers published in English were
follow-up. Poor outcome was associated with a high included. The final reference list was compiled on the basis of
frequency of migraine at baseline and an age of onset originality, quality, use of the ICHD classification system, and
younger than 20 years,54 which accords with the results of relevance to the topic.
a UK study on the prognosis of headache in general.92
Few studies have investigated the prognosis of patients
with TTH. In the longitudinal study of the Danish pharmacological management, although we still lack
population, 45% were in remission, 39% had unchanged specific preventive modalities. Most importantly, early
frequent episodic TTH, and 16% had unchanged or intervention, the identification of risk factors, and lifestyle
newly developed chronic TTH at follow-up. Poor associations might lead to effective strategies to prevent
outcome was associated with chronic TTH at baseline, chronification of headache, which will have considerable
coexisting migraine, not being married, and sleeping benefits for the patient and the society.
problems.54 Contributors
In a clinic-based 10-year follow-up study of 62 patients RJ made the initial plan and wrote the abstract, the introduction, and the
with episodic TTH, 75% continued to have episodic sections about prevalence, incidence, and comorbidities. LJS participated
in the planning of the Review, the literature list, and wrote the sections
headache, whereas episodic TTH had developed into the about cost and disability of headache.
chronic form in 25% of patients. In those patients with
Conflicts of interest
initial chronic TTH, at follow-up 31% were unchanged, We have no conflicts of interest.
21% had developed medication-overuse headache, and
References
the remainder had reverted to the episodic form, with or 1 Andlin-Sobocki P, Jönsson B, Wittchen HU, Olesen J. Cost of
without prophylactic treatment.93 Depression, anxiety, disorders of the brain in Europe. Eur J Neurol 2005; 12: 1–27.
and medication overuse were predictors of poor outcome 2 Jensen R, Rasmussen BK. Burden of headache.
Expert Rev Pharmacoeconomics Outcomes Res 2004; 4: 353–59.
in the clinical setting, and these patients might request
3 Stovner L, Hagen K, Jensen R, et al. The global burden of headache:
increased medical attention in the future. a documentation of headache prevalence and disability worldwide.
Also, there are few clinical longitudinal reports for Cephalalgia 2007; 27: 193–210.
cluster headaches. In a 10-year Italian follow-up study, 4 Schwartz BS, Stewart WF, Simon D, Lipton RB. Epidemiology of
tension-type headache. JAMA 1998; 279: 381–83.
13% of patients with an episodic form of cluster headache 5 Boardman HF, Thomas E, Croft PR, Millson DS. Epidemiology of
developed chronic cluster headache, whereas 33% of headache in an English district. Cephalalgia 2003; 23: 129–37.
those with a chronic form developed the episodic form,94 6 Olesen J, Leonardi M. The burden of brain diseases in Europe.
Eur J Neurol 2003; 10: 471–77.
and only 10% had no cluster headache during the past
7 Morillo LE, Alarcon F, Aranaga N, et al. Prevalence of migraine in
3 years.94 Latin America. Headache 2005; 45: 106–17.
8 Steiner TJ. Lifting the burden: the global campaign against
Conclusions headache. Lancet Neurol 2004; 3: 204–05.
9 The International Classification of Headache Disorders: 2nd
In conclusion, headache disorders are among the most edition. Cephalalgia 2004; 24 (suppl 1): 9–160.
prevalent, burdensome, and costly diseases in the world, 10 O’Brien B, Goeree R, Streiner D. Prevalence of migraine headache
and there is an urgent need for acceptance, education, and in Canada: a population-based survey. Int J Epidemiol 1994;
scientific interest. Most of the severely affected patients 23: 1020–26.
11 Schwartz BS, Stewart WF, Lipton RB. Lost workdays and decreased
also have profound comorbid disorders, which complicate work effectiveness associated with headache in the workplace.
their overall management and outcome. Thus, the burden J Occup Environ Med 1997; 39: 320–27.
of headache on the patient, their families, and on society 12 Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M.
Prevalence and burden of migraine in the United States: data from
is considerable. Limited knowledge of the underlying the American Migraine Study II. Headache 2001; 41: 646–57.
pathophysiology combined with a lack of academic interest 13 Lipton RB, Scher AI, Kolodner K, Liberman J, Steiner TJ, Stewart
has previously resulted in the use of non-specific WF. Migraine in the United States: epidemiology and patterns of
health care use. Neurology 2002; 58: 885–94.
treatments, although management of migraine has
14 Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of
improved and interest has increased during the past migraine headache in the United States. Relation to age, income,
decade. Headache-related disability can be markedly race, and other sociodemographic factors. JAMA 1992; 267: 64–69.
reduced by increasing general awareness of headache, 15 Stewart WF, Lipton RB, Liberman J. Variation in migraine
prevalence by race. Neurology 1996; 47: 52–59.
better education among health-care professionals, and the 16 Kryst S, Scherl E. A population-based survey of the social and
identification of trigger factors combined with personal impact of headache. Headache 1994; 34: 344–50.

http://neurology.thelancet.com Vol 7 April 2008 359

 Review

17 Wiehe M, Fuchs SC, Moreira LB, Moraes RS, Fuchs FD. Migraine 42 Lanteri-Minet M, Auray JP, El Hasnaoui A, et al. Prevalence and
is more frequent in individuals with optimal and normal blood description of chronic daily headache in the general population in
pressure: a population-based study. J Hypertens 2002; France. Pain 2003; 102: 143–49.
20: 1303–06. 43 Pascual J, Colas R, Castillo J. Epidemiology of chronic daily
18 Jaillard AS, Mazetti P, Kala E. Prevalence of migraine and headache headache. Curr Pain Headache Rep 2001; 5: 529–36.
in a high-altitude town of Peru: a population-based study. 44 Wang SJ, Fuh JL, Lu SR, et al. Chronic daily headache in Chinese
Headache 1997; 37: 95–101. elderly: prevalence, risk factors, and biannual follow-up.
19 Miranda H, Ortiz G, Figueroa S, Pena D, Guzman J. Prevalence of Neurology 2000; 54: 314–19.
headache in Puerto Rico. Headache 2003; 43: 774–78. 45 Tonon C, Guttmann S, Volpini M, Naccarato S, Cortelli P,
20 Lavados PM, Tenhamm E. Epidemiology of migraine headache in D’Alessandro R. Prevalence and incidence of cluster headache in
Santiago, Chile: a prevalence study. Cephalalgia 1997; 17: 770–77. the Republic of San Marino. Neurology 2002; 58: 1407–09.
21 Launer LJ, Terwindt GM, Ferrari MD. The prevalence and 46 Sjaastad O, Bakketeig LS. Cluster headache prevalence. Vaga study
characteristics of migraine in a population-based cohort: the GEM of headache epidemiology. Cephalalgia 2003; 23: 528–33.
study. Neurology 1999; 53: 537–42. 47 Torelli P, Beghi E, Manzoni GC. Cluster headache prevalence in the
22 Hagen K, Zwart JA, Vatten L, Stovner LJ, Bovim G. Prevalence of Italian general population. Neurology 2005; 64: 469–74.
migraine and non-migrainous headache-head-HUNT, a large 48 Katsarava Z, Obermann M, Yoon MS, et al. Prevalence of cluster
population-based study. Cephalalgia 2000; 20: 900–6. headache in a population-based sample in Germany.
23 Dahlof C, Linde M. One-year prevalence of migraine in Sweden: a Cephalalgia 2007; 27: 1014–19.
population-based study in adults. Cephalalgia 2001; 21: 664–71. 49 Ekbom K, Svensson DA, Pedersen NL, Waldenlind E. Lifetime
24 Merikangas KR, Whitaker AE, Isler H, Angst J. The Zurich Study: prevalence and concordance risk of cluster headache in the Swedish
XXIII. Epidemiology of headache syndromes in the Zurich cohort twin population. Neurology 2006; 67: 798–803.
study of young adults. Eur Arch Psychiatry Clin Neurosci 1994; 50 Stovner LJ, Zwart JA, Hagen K, Terwindt G, Pascual J.
244: 145–52. Epidemiology of headache in Europe. Eur J Neurol 2006; 13: 333–45.
25 Steiner TJ, Scher AI, Stewart WF, Kolodner K, Liberman J, 51 Zwart JA, Dyb G, Holmen TL, et al. The prevalence of migraine and
Lipton RB. The prevalence and disability burden of adult migraine tension-type headaches among adolescents in Norway: The Nord-
in England and their relationships to age, gender and ethnicity. Trøndelag Health Study (Head-Hunt). Cephalagia 2004; 24: 373–79.
Cephalalgia 2003; 23: 519–27. 52 Rasmussen BK. Epidemiology of headache. Cephalalgia 2001;
26 Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of 21: 774–77.
headache in a general population--a prevalence study. 53 Bille B. Migraine and tension-type headache in children and
J Clin Epidemiol 1991; 44: 1147–57. adolescents. Cephalalgia 1996; 16: 78.
27 Zivadinov R, Willheim K, Jurjevic A, Sepic-Grahovac D, Bucuk M, 54 Lyngberg AC, Rasmussen BK, Jørgensen T, et al. Prognosis of
Zorzon M. Prevalence of migraine in Croatia: a population-based migraine and tension-type headache. Neurology 2005; 65: 580–85.
survey. Headache 2001; 41: 805–12.
55 Swanson JW, Yanagihara T, Stang PE, et al. Incidence of cluster
28 Bank J, Marton S. Hungarian migraine epidemiology. headaches: a population-based study in Olmsted County,
Headache 2000; 40: 164–69. Minnesota. Neurology 1994; 44: 433–37.
29 Deleu D, Khan MA, Al Shehab TA. Prevalence and clinical 56 Black DF, Swanson JW, Stang PE. Decreasing incidence of cluster
characteristics of headache in a rural community in oman. headache: a population-based study in Olmsted County, Minnesota.
Headache 2002; 42: 963–73. Headache 2005; 45: 220–23.
30 Tekle Haimanot R, Seraw B, Forsgren L, Ekbom K, Ekstedt J. 57 Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden
Migraine, chronic tension-type headache, and cluster headache in of migraine in the United States: disability and economic costs.
an Ethiopian rural community. Cephalalgia 1995; 15: 482–88. Arch Intern Med 1999; 159: 813–18.
31 Dent W, Spiss H, Helbok R, Matuja W, Scheunemann S, 58 Berg J, Stovner LJ. Cost of migraine and other headaches in Europe.
Schmutzhard E. Prevalence of migraine in a rural area in South Eur J Neurol 2005; 12 (suppl 1): 59–62.
Tanzania: a door-to-door survey. Cephalalgia 2004; 24: 960–66.
59 Berg J. Economic evidence in migraine and other headaches: a
32 Alders EE, Hentzen A, Tan CT. A community-based prevalence review. Eur J Health Econom 2004; 5: S43–S54.
study on headache in Malaysia. Headache 1996; 36: 379–84.
60 Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness
33 Wang SJ, Fuh JL, Young YH, Lu SR, Shia BC. Prevalence of absence and utilisation of medical services: a Danish population
migraine in Taipei, Taiwan: a population-based survey. study. J Epidemiol Community Health 1992; 46: 443–46.
Cephalalgia 2000; 20: 566–72.
61 Lyngberg AC, Rasmussen BK, Jensen R, et al. Secular changes in
34 Takeshima T, Ishizaki K, Fukuhara Y, et al. Population-based door- health care utilization and work absence for migraine and tension-
to-door survey of migraine in Japan: the Daisen study. type headache. A population based study.
Headache 2004; 44: 8–19. J Epidemiol Com Health 2005; 20: 1007–14.
35 Roh JK, Kim JS, Ahn YO. Epidemiologic and clinical characteristics 62 Lenaerts ME. Burden of tension-type headache.
of migraine and tension-type headache in Korea. Headache 1998; Curr Pain Headache Rep 2006; 10: 459–66
38: 356–65.
63 Jensen RM, Lyngberg A, Jensen RH. Burden of cluster headache.
36 Sakai F, Igarashi H. Prevalence of migraine in Japan: a nationwide Cephalalgia 2007; 27: 535–41.
survey. Cephalalgia 1997; 17: 15–22.
64 Dahlöf CG, Dimenäs E. Migraine patients experience poorer
37 Lampl C, Buzath A, Baumhackl U, Klingler D. One-year prevalence subjective well-being/quality of life even between attacks.
of migraine in Austria: a nation-wide survey. Cephalalgia 2003; Cephalalgia 1995; 15: 31–36.
23: 280–86.
65 Linde M, Dahlöf C. Attitudes and burden of disease among self-
38 Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Has the considered migraineurs—a nation-wide population-based survey in
prevalence of migraine and tension-type headache changed over a Sweden. Cephalalgia 2004; 24: 455–65.
12-year period? A Danish population survey. Eur J Epidemiol 2005;
66 Leonardi M, Steiner TJ, Scher AT, Lipton RB. The global burden of
20: 243–49.
migraine: measuring disability in headache disorders with WHO’s
39 Göbel H, Petersen-Braun M, Soyka D. The epidemiology of classification of functioning, disability and health (ICF).
headache in Germany: a nationwide survey of a representative J Headache Pain 2005; 6: 429–40.
sample on the basis of the headache classification of the
67 Stewart WF, Lipton RB, Kolodner KB, Sawyer J, Lee C, Liberman
International Headache Society. Cephalalgia 1994; 14: 97–106.
JN. Validity of the Migraine Disability Assessment (MIDAS) score
40 Cheung RT. Prevalence of migraine, tension-type headache, and in comparison to a diary-based measure in a population sample of
other headaches in Hong Kong. Headache 2000; 40: 473–79. migraine sufferers. Pain 2000; 88: 41–52.
41 Kavuk I, Yavuz A, Cetindere U, Agelink MW, Diener HC. 68 Lucas C, Chaffaut C, Artaz MA, Lantéri-Minet M. FRAMIG 2000:
Epidemiology of chronic daily headache. Eur J Med Res 2003; medical and therapeutic management of migraine in France.
8: 236–40. Cephalalgia 2005; 25: 267–79.

360 http://neurology.thelancet.com Vol 7 April 2008

 Review

69 Hamelsky SW, Lipton RB, Stewart WF. An assessment of the 82 Tietjen GE, Herial NA, Hardgrove J, Utley C, White L. Migraine
burden of migraine using the willingness to pay model. comorbidity constellations. Headache 2007; 47: 857–65.
Cephalalgia 2005; 25: 87–100. 83 Bousser MG, Welch KM. Relation between migraine and stroke.
70 Lipton RB, Liberman JN, Kolodner KB, Bigal ME, Dowson A, Lancet Neurol 2005; 4: 533–42.
Stewart WF. Migraine headache disability and health-related 84 Kurth T, Gaziano JM, Cook NR, Logroscino G, Diener HC,
quality-of-life: a population-based case-control study from England. Buring JE. Migraine and risk of cardiovascular disease in women.
Cephalalgia 2003; 23: 441–50. JAMA 2006; 296: 283–91.
71 Terwindt GM, Ferrari MD, Tijhuis M, Groenen SM, Picavet HS, 85 Hagen K, Stovner LJ, Vatten L, Holmen J, Zwart JA, Bovim G.
Launer LJ. The impact of migraine on quality of life in the general Blood pressure and risk of headache: a prospective study of 22 685
population: the GEM study. Neurology 2000; 55: 624–629. adults in Norway. J Neurol Neurosurg Psychiatry 2002; 72: 463–66.
72 Lipton RB, Bigal ME, Kolodner K, Stewart WF, Liberman JN, 86 Bigal ME, Lipton RB. Obesity is a risk factor for transformed
Steiner TJ. The family impact of migraine: population-based studies migraine but not chronic tension-type headache. Neurology 2006;
in the USA and UK. Cephalalgia 2003; 23: 429–40. 67: 252–7.
73 Lipton RB, Hamelsky SW, Kolodner KB, Steiner TJ, Stewart WF. 87 Breslau N, Lipton RB, Stewart WF, Schultz LR, Welch KM.
Migraine, quality of life, and depression: a population-based case- Comorbidity of migraine and depression: investigating potential
control study. Neurology 2000; 55: 629–35. etiology and prognosis. Neurology 2003; 60: 1308–12.
74 First MB. Mutually exclusive versus co-occurring diagnostic 88 Merikangas KR, Merikangas JR, Angst J. Headache syndromes and
categories: the challenge of diagnostic comorbidity. psychiatric disorders: association and familial transmission.
Psychopathology 2005; 38: 206–10. J Psychiatr Res 1993; 27: 197–210.
75 Bigal ME, Sheftell FD, Rapoport AM, Lipton RB, Tepper SJ. Chronic 89 McWilliams LA, Goodwin RD, Cox BJ. Depression and anxiety
daily headache in a tertiary care population: correlation between the associated with three pain conditions: results from a nationally
International Headache Society diagnostic criteria and proposed representative sample. Pain 2004; 111: 77–83.
revisions of criteria for chronic daily headache. Cephalalgia 2002; 90 Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. The
22: 432–38. association between poor well-being and migraine is related to
76 Zeeberg P, Olesen J, Jensen R. Efficacy of multidisciplinary coexisting tension-type headache. Cephalalgia 2005; 5: 968.
treatment in a tertiary referral headache centre. Cephalalgia 2005; 91 Bille B. A 40-year follow-up of school children with migraine.
25: 1159–67. Cephalalgia 1997; 17: 488–491.
77 Katsarava Z, Jensen R. Medication-overuse headache: where are we 92 Boardman HF, Thomas E, Millson DS, Croft PR. The natural
now? Curr Opin Neurol 2007; 20: 326–30. history of headache: predictors of onset and recovery.
78 Scher A, Bigal, ME Lipton RB. Comorbidity of migraine. Cephalalgia 2006; 26: 1080–88.
Curr Opin Neurol 2005; 18: 305–10. 93 Mork H, Jensen R. Prognosis of tension-type headache: a 10-year
79 Aamodt AH, Stovner LJ, Midthjell K, Hagen K, Zwart JA. Headache follow-up study of patients with frequent tension-type headache.
prevalence related to diabetes mellitus. The Head-HUNT study. Cephalalgia 2000; 20: 434.
Eur J Neurol 2007; 14: 738–44. 94 Manzoni GC, Micieli G, Granella F, Tassorelli C, Zanferrari C,
80 Hagen K, Einarsen C, Zwart JA, Svebak S, Bovim G. The co- Cavallini A. Cluster headache course over ten years in 189 patients.
occurrence of headache and musculoskeletal symptoms amongst Cephalalgia 1991; 11: 169–74.
51050 adults in Norway. Eur J Neurol 2002; 9: 527–33.
81 Zwart JA, Dyb G, Hagen K, et al. Depression and anxiety disorders
associated with headache frequency. The Nord-Trondelag Health
Study. Eur J Neurol 2003; 20: 147–52.

http://neurology.thelancet.com Vol 7 April 2008 361