Global, Regional, and National Burden of Migraine

Articles
Global, regional, and national burden of migraine and

tension-type headache, 1990–2016: a systematic analysis
for the Global Burden of Disease Study 2016
GBD 2016 Headache Collaborators*
Summary
Lancet Neurol 2018; 17: 954–76 Background Through the Global Burden of Diseases, Injuries, and Risk Factors (GBD) studies, headache has emerged
This online publication has as a major global public health concern. We aimed to use data from the GBD 2016 study to provide new estimates for
been corrected. The corrected prevalence and years of life lived with disability (YLDs) for migraine and tension-type headache and to present the
version first appeared at
methods and results in an accessible way for clinicians and researchers of headache disorders.
thelancet.com/neurology on
November 17, 2021
See Comment page 929 Methods Data were derived from population-based cross-sectional surveys on migraine and tension-type headache.
*Collaborators listed at the end
Prevalence for each sex and 5-year age group interval (ie, age 5 years to ≥95 years) at different time points from
of the Article 1990 and 2016 in all countries and GBD regions were estimated using a Bayesian meta-regression model. Disease
Correspondence to: burden measured in YLDs was calculated from prevalence and average time spent with headache multiplied by
Prof Lars Jacob Stovner, disability weights (a measure of the relative severity of the disabling consequence of a disease). The burden
Department of Neuromedicine stemming from medication overuse headache, which was included in earlier iterations of GBD as a separate
and Movement Science,
Norwegian University of Science
cause, was subsumed as a sequela of either migraine or tension-type headache. Because no deaths were assigned
and Technology, Trondheim to headaches as the underlying cause, YLDs equate to disability-adjusted life-years (DALYs). We also analysed
N-7491, Norway results on the basis of the Socio-demographic Index (SDI), a compound measure of income per capita, education,
[email protected] and fertility.
Findings Almost three billion individuals were estimated to have a migraine or tension-type headache in 2016:
1·89 billion (95% uncertainty interval [UI] 1·71–2·10) with tension-type headache and 1·04 billion (95% UI 1·00–1·09)
with migraine. However, because migraine had a much higher disability weight than tension-type headache, migraine
caused 45·1 million (95% UI 29·0–62·8) and tension-type headache only 7·2 million (95% UI 4·6–10·5) YLDs
globally in 2016. The headaches were most burdensome in women between ages 15 and 49 years, with migraine
causing 20·3 million (95% UI 12·9–28·5) and tension-type headache 2·9 million (95% UI 1·8–4·2) YLDs in 2016,
which was 11·2% of all YLDs in this age group and sex. Age-standardised DALYs for each headache type showed a
small increase as SDI increased.
Interpretation Although current estimates are based on limited data, our study shows that headache disorders, and
migraine in particular, are important causes of disability worldwide, and deserve greater attention in health policy
debates and research resource allocation. Future iterations of this study, based on sources from additional countries
and with less methodological heterogeneity, should help to provide stronger evidence of the need for action.
Funding Bill & Melinda Gates Foundation.
Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0
license.
Introduction the evaluation not only of mortality but also of non-fatal

Migraine and other headache disorders are among the health outcomes. GBD offers a method of quantifying
most prevalent disorders worldwide,1 but recognition of health loss in time units, enabling comparisons over
their importance for public health has come only since time and across conditions, cultures, and countries,
2000. This delay has occurred in part because headache and, from 2016, at subnational levels in some countries.
is not fatal and does not result in permanent or objective GBD has become an important tool for priority setting
disability, and in part because headaches are and planning of health services by international health
experienced by most people from time to time, which organisations and governments.
has hindered the realisation that headache disorders Migraine was not included in GBD 1990, but was added
are debilitating for a relatively large minority of the in GBD 2000. In GBD 2010, tension-type headache was
people who are affected. added and in GBD 2013, medication overuse headache
The Global Burden of Diseases, Injuries, and Risk was included. In GBD 2000, migraine was ranked as the
Factors (GBD) studies have as one of their main aims 19th cause of disability globally.2 For the GBD 2000 study,
954 www.thelancet.com/neurology Vol 17 November 2018

Articles
Research in context
Evidence before this study globally, and was among the ten most disabling disorders in
Since 2000, the Global Burden of Diseases, Injuries, and Risk each of the 21 GBD regions. It was particularly burdensome
Factors (GBD) studies have produced estimates of prevalence among young and middle-aged women. Unlike many other
and burden of migraine. Since GBD 2010, tension-type diseases and injuries quantified in GBD studies, headache
headache and medication overuse headache have been added showed no clear relation to sociodemographic development, as
and estimates have been made by country spanning the measured by the Socio-demographic Index. No risk factors have
period from 1990 to the most recent year for which data are yet been established in the GBD studies for headache disorders,
available. Headache disorders, and in particular, migraine, and headache epidemiological studies are absent in many
have been found to be highly prevalent and a cause of large countries and regions.
burden. To date, no research article has focused on the
Implications of all the available evidence
detailed methods and results of headache estimates from
Through the GBD studies, headache disorders, and in particular,
GBD. With the present study, we updated a previous
migraine, have been shown to be among the most disabling
systematic review covering 1980–2001 by doing a review that
disorders worldwide. Many fatal and disabling disorders
searched PubMed for articles using the terms “migraine”,
decrease with socioeconomic development, but this does not
“tension”, “headache”, “medication”, and “epidemiology”
seem to be true for migraine and tension-type headache.
from Jan 1, 2001, until Dec 31, 2015. There were no language
Hence, their relative importance is likely to increase in the
restrictions.
future. More high-quality headache epidemiological studies
Added value of this study and studies aiming to identify modifiable risk factors should be
In 2016, of all GBD causes of disease, tension-type headache done. Effective strategies to modify the course of headaches
was the third most prevalent, and migraine the sixth. In terms and alleviate pain exist, but many people affected by headache
of years of life lived with disability, migraine ranked second are not benefiting from this knowledge.
data were absent for more than half of the world’s In the GBD cause hierarchy, migraine and tension-
population. When new data came from big countries like type headache are individual disorders on Level 3,
Russia, China, India, and some parts of Africa, and with under neurological disorders (Level 2) and non-
tension-type headache and medication overuse headache communicable diseases (Level 1). No further
also taken into account, headache disorders were subdivision exists for headaches, so each reappears at
collectively the third cause of disability in people under Level 4. In GBD 2013 and GBD 2015, medication
50 years of age in GBD 2015.3 Since GBD 2010, prevalence overuse headache was treated as a separate disorder,
and burden of disability have been re-estimated for the but in GBD 2016 it was considered a sequela of either
full time period from 1990 until the most recent year for migraine or tension-type headache. The burden of
which data are available, each time incorporating new medication overuse headache was therefore added to
data sources and any updates to methods. the burdens estimated for these headache types
Given the importance of headache disorders for according to a meta-analysis of three studies reporting
global public health, which has become evident through the proportions of medication overuse headache
GBD, we wanted to inform an audience of headache resulting from migraine (73·4%, 95% uncertainty
specialists about these studies. The aims of the present interval [UI] 63·9–82·0) or tension-type headache
Article are to provide an overview of the GBD methods (26·6%, 18·0–36·1).4–6
as applied to headache, to present detailed results of the In GBD, disease burden is estimated in disability-
update for 1990–2016 on headache burden in different adjusted life-years (DALYs), which are the sum of years
world regions and with time trends, and to discuss the of life lost (YLLs) to premature mortality and years of
implications of these results both for future iterations life lived with disability (YLDs). Because GBD does not
of GBD and for health policies around the world. estimate any deaths from headache disorders as the
underlying cause, DALYs for headaches are equivalent
Methods to YLDs. YLDs for each headache disorder are calculated
Overview from its prevalence and the mean time patients spend
The main elements of the GBD methods, both general with that type of headache multiplied by the associated
and pertaining to migraine and tension-type headache, disability weight. The determination of headache
are described in the appendix. In the main text of this disability weights through population and internet See Online for appendix
Article, we concentrate on methods pertaining to surveys was on the basis of lay descriptions (appendix).7,8
estimation of the burden of migraine and tension-type The disability weight for migraine was 0·434, meaning
headache. A flowchart of the different steps in these that during an attack the affected person experiences
methods is shown in the appendix. health loss of 43·4% compared with a person in full
www.thelancet.com/neurology Vol 17 November 2018 955

Articles
Migraine Tension-type headache

Prevalence YLDs Prevalence YLDs
2016 counts Percentage 2016 counts Percentage 2016 counts Percentage 2016 counts Percentage
change in age- change in age- change in age- change in age-
standardised standardised standardised standardised
rates, rates, rates, rates,
1990–2016 1990–2016 1990–2016 1990–2016
Global 1 044 771 478 –1·8% 45 121 909 –0·2% 1 890 670 389 –7·3% 7 195 122 –0·2%
(999 534 692 to (–2·0 to –1·5) (29 045 835 to (–0·8 to 0·4) (1 707 786 493 to (–7·8 to –6·7) (4 614 628 to (–2·5 to 1·9)
1 087 968 951) 62 826 904) 2 097 761 629) 10 499 903)
High SDI 167 752 331 –2·4% 7 183 304 –1·6% 245 115 740 –7·1% 1 055 366 –1·9%
(162 068 750 to (–3·0 to –1·8) (4 631 325 to (–2·3 to –0·9) (226 317 507 to (–8·7 to –5·3) (679 220 to (–3·8 to –0·1)
173 328 886) 10 020 672) 265 077 769) 1 539 885)
High-middle SDI 172 643 687 –5·1% 7 760 262 –3·4% 307 673 576 –8·8% 1 327 611 –2·5%
180 178 966) 10 735 182) 341 968 784) 1 948 910)
Middle SDI 294 085 908 2·9% 12 911 188 4·6% 569 499 609 –6·1% 2 160 117 2·9%
(281 017 554 to (2·5 to 3·2) (8 334 437 to (3·8 to 5·4) (511 283 994 to (–6·8 to –5·5) (1 381 284 to (–0·1 to 5·9)
306 959 499) 17 962 205) 635 895 815) 3 171 241)
Low-middle SDI 329 933 660 –2·1% 13 869 352 0·0% 596 330 852 –11·0% 2 096 630 –0·9%
(315 287 837 to (–2·6 to –1·7) (8 882 881 to (–0·9 to 0·9) (536 364 468 to (–12·0 to –10·0) (1 328 963 to (–4·1 to 2·6)
344 134 051) 19 370 615) 666 261 088) 3 104 125)
Low SDI 84 126 809 –2·2% 3 546 725 0·0% 175 779 968 –8·2% 572 499 –0·6%
(79 807 328 to (–2·8 to –1·6) (2 273 280 to (–1·1 to 1·0) (157 143 060 to (–9·1 to –7·3) (361 398 to (–3·2 to 2·3)
88 407 248) 5 001 221) 197 823 486) 852 525)
High-income North 53 344 669 –2·8% 2 276 046 –2·1% 74 430 873 –10·6% 329 298 –3·6%
America (52 296 498 to (–3·9 to –1·6) (1 465 260 to (–3·3 to –0·9) (71 702 414 to (–15·5 to –5·3) (211 947 to (–7·2 to –0·8)
54 399 071) 3 185 259) 76 995 483) 477 734)
Canada 6 301 113 –8·3% 264 844 –6·8% 8 696 062 –19·1% 36 169 –7·8%
(6 085 757 to (–10·2 to –6·3) (168 731 to 371 278) (–9·8 to –3·5) (7 792 089 to (–22·6 to –15·8) (23 180 to 53 026) (–13·1 to –1·9)
6 517 308) 9 694 541)
Greenland 8107 –3·7% 338 –2·5% 11 661 –14·4% 46 –5·0%
(7698 to 8523) (–5·9 to –1·4) (218 to 475) (–5·7 to 1·1) (10 384 to 13 064) (–17·3 to –11·2) (29 to 69) (–10·1 to 0·8)
USA 47 016 985 –2·0% 2 010 075 –1·4% 65 697 424 –9·3% 292 968 –3·1%
47 899 333) 2 814 841) 67 595 782) 423 703)
Australasia 5 334 994 –1·1% 219 745 –0·5% 8 124 243 –4·1% 29 676 –0·7%
(5 091 834 to (–3·0 to 1·1) (139 957 to (–3·1 to 2·4) (7 342 759 to (–6·3 to –1·6) (18 804 to 43 770) (–4·6 to 3·9)
5 583 436) 309 573) 9 000 939)
Australia 4 543 179 –1·3% 186 837 –0·6% 6 841 911 –4·1% 25 009 –0·7%
(4 330 318 to (–3·5 to 1·3) (119 136 to 263 360) (–3·7 to 2·8) (6 181 717 to 7 597 540) (–6·6 to –1·1) (15 828 to 36 960) (–5·2 to 4·7)
4 756 061)
New Zealand 791 815 –0·4% 32 908 0·0% 1 282 332 –3·9% 4667 –0·6%
(754 681 to (–2·9 to 2·2) (20 979 to 46 303) (–3·2 to 3·5) (1 162 388 to (–6·9 to –0·8) (2954 to 6859) (–5·1 to 4·5)
830 074) 1 415 407)
High-income Asia 27 032 727 –1·8% 1 137 019 –1·4% 49 382 811 –1·0% 173 818 0·0%
Pacific (25 957 086 to (–2·6 to –1·0) (727 818 to (–2·6 to –0·2) (44 532 535 to (–2·3 to 0·4) (110 645 to (–1·8 to 1·8)
28 086 345) 1 585 857) 54 333 934) 255 402)
Brunei 67 038 –0·9% 2782 0·0% 115 076 –1·9% 391 0·7%
(63 064 to 70 690) (–3·3 to 1·7) (1768 to 3935) (–3·4 to 3·4) (102 272 to 128 531) (–4·9 to 1·2) (244 to 583) (–4·1 to 5·9)
Japan 17 763 393 –1·4% 753 131 –1·3% 33 825 326 –0·4% 119 701 0·0%
(17 076 332 to (–2·1 to –0·9) (484 557 to (–2·2 to –0·3) (30 555 799 to (–1·2 to 0·3) (76 091 to (–1·2 to 1·3)
18 452 854) 1 049 616) 37 158 324) 175 096)
Singapore 577 459 –2·0% 24 637 –0·9% 966 159 –1·4% 3641 0·7%
(549 744 to (–4·1 to 0·6) (15 855 to 34 643) (–4·4 to 2·6) (866 174 to 1 077 672) (–4·9 to 2·4) (2311 to 5365) (–4·2 to 6·3)
604 482)
South Korea 8 624 838 –4·1% 356 469 –2·9% 14 476 250 –2·1% 50 085 0·1%
(8 242 808 to (–6·3 to –2·1) (226 037 to (–5·9 to 0·3) (13 005 907 to (–5·9 to 2·7) (31 775 to 74 160) (–4·7 to 5·4)
9 009 884) 498 464) 16 000 912)
(Table continues on next page)

Articles

1990–2016 1990–2016 1990–2016 1990–2016
(Continued from previous page)
Western Europe 80 808 422 –1·2% 3 447 004 –0·2% 107 733 424 –5·7% 484 810 0·1%
84 034 957) 4 805 927) 119 221 162) 714 229)
Andorra 15 188 –1·3% 658 –0·6% 19 967 –4·2% 96 –0·5%
(14 355 to 16 017) (–3·6 to 1·3) (427 to 914) (–3·7 to 2·7) (17 952 to 22 290) (–7·6 to –0·9) (61 to 145) (–5·4 to 4·9)
Austria 1 819 880 –1·0% 77 370 –0·3% 2 282 375 –3·9% 10 546 –0·2%
(1 746 912 to (–3·0 to 1·0) (50 017 to 108 066) (–3·2 to 2·5) (2 039 267 to (–6·9 to –0·6) (6626 to 15 484) (–5·1 to 5·3)
1 893 539) 2 542 347)
Belgium 2 124 832 –1·2% 91 868 –0·7% 2 822 458 –4·5% 13 345 –0·4%
2 239 948) 3 130 995)
Cyprus 183 856 –1·1% 7892 0·2% 243 221 –6·8% 1108 0·9%
(173 763 to (–3·6 to 1·4) (5 088 to 11 079) (–3·1 to 3·8) (217 611 to 270 212) (–9·7 to –3·5) (696 to 1647) (–4·3 to 7·1)
194 234)
Denmark 1 026 797 –1·0% 44 524 –0·1% 1 409 715 –3·9% 6639 1·5%
1 074 089) 1 575 454)
Finland 1 012 067 –1·8% 43 829 –0·8% 1 351 804 –5·1% 6450 –0·5%
(955 827 to (–4·2 to 0·8) (28 398 to 61 020) (–4·1 to 2·6) (1 212 022 to 1 501 509) (–7·9 to –1·9) (4109 to 9646) (–5·3 to 4·9)
1 065 559)
France 11 892 970 –0·4% 517 500 0·7% 13 357 050 –3·0% 71 795 2·0%
(11 406 938 to (–2·8 to 2·1) (332 963 to 715 766) (–2·4 to 4·2) (11 965 824 to (–6·4 to 0·7) (45 872 to (–3·0 to 7·8)
12 378 827) 14 888 605) 103 336)
Germany 14 730 968 –1·5% 620 732 –0·8% 20 673 287 –7·8% 87 477 –1·9%
(14 105 025 to (–3·8 to 0·7) (401 735 to 869 239) (–4·0 to 2·5) (18 543 280 to (–10·8 to –4·6) (55 662 to (–6·9 to 3·5)
15 352 755) 22 985 159) 128 289)
Greece 2 014 931 –1·6% 87 918 –0·7% 2 669 218 –5·0% 12 997 0·1%
2 108 577) 2 964 387)
Iceland 61 873 –1·1% 2671 –0·3% 81 725 –5·0% 382 0·1%
Ireland 880 498 –1·2% 37 863 –0·1% 1 154 239 –6·5% 5375 0·4%
928 391) 1 286 283)
Israel 1 457 632 –1·4% 62 150 –0·6% 2 010 964 –4·8% 8642 –0·3%
1 535 790) 2 248 648)
Italy 12 977 731 –0·6% 534 275 0·1% 16 789 700 –5·8% 67 781 –0·8%
(12 486 461 to (–2·7 to 1·6) (343 210 to 753 112) (–2·8 to 3·3) (15 107 193 to (–8·8 to –2·7) (43 106 to 99 628) (–6·0 to 5·0)
13 468 642) 18 628 319)
Luxembourg 122 651 –0·8% 5205 0·3% 157 274 –4·6% 713 0·8%
(117 652 to (–3·0 to 1·5) (3338 to 7292) (–2·8 to 3·7) (141 189 to 174 944) (–7·8 to –1·4) (462 to 1039) (–4·0 to 6·3)
127 560)
Malta 80 226 –3·4% 3477 –2·0% 108 621 –6·9% 508 –0·6%
(75 934 to 84 851) (–5·8 to –1·0) (2270 to 4898) (–5·4 to 1·1) (97 601 to 120 997) (–9·9 to –3·8) (319 to 764) (–5·5 to 5·1)
Netherlands 3 489 189 –0·4% 142 336 0·2% 4 834 235 –4·2% 18 232 –0·1%
3 621 037) 5 369 211)
Norway 895 018 –1·2% 37 923 0·4% 1 340 876 –8·7% 5410 0·1%
933 252) 1 497 829)
Portugal 2 051 173 –1·5% 88 374 –0·3% 2 783 841 –6·2% 12 847 0·2%
2 165 133) 3 090 289)

Articles

1990–2016 1990–2016 1990–2016 1990–2016
Spain 9 449 914 –1·7% 405 466 –0·5% 11 981 430 –6·5% 56 193 0·6%
9 842 296) 13 301 336)
Sweden 1 487 390 –2·0% 65 352 –1·1% 2 422 653 –4·3% 10 567 0·2%
(1 431 549 to (–3·7 to –0·3) (42 366 to 90 761) (–3·5 to 1·6) (2 155 615 to 2 715 005) (–6·9 to –2·0) (6700 to 15 201) (–3·4 to 4·2)
1 543 234)
Switzerland 1 610 830 –1·3% 69 839 –0·4% 1 832 194 –1·5% 9709 0·5%
(1 540 457 to (–3·4 to 0·9) (45 338 to 98 043) (–3·5 to 2·9) (1 633 381 to (–5·3 to 3·4) (6146 to 14 649) (–4·4 to 6·0)
1 682 449) 2 053 349)
UK 11 340 953 –1·5% 496 293 –0·4% 17 297 990 –5·5% 77 508 0·1%
(10 878 185 to (–1·9 to –1·1) (322 502 to 691 283) (–1·0 to 0·2) (15 567 817 to (–6·2 to –4·7) (49 695 to (–1·8 to 1·7)
11 797 812) 19 198 683) 113 154)
Southern Latin 10 694 738 –1·5% 445 462 –0·7% 17 026 105 –3·0% 62 042 0·8%
America (10 201 211 to (–3·1 to 0·2) (284 632 to (–3·0 to 1·8) (15 295 127 to (–5·4 to –0·5) (39 481 to 90 851) (–2·5 to 4·7)
11 200 269) 625 408) 18 926 015)
Argentina 7 110 301 –1·2% 295 691 –0·5% 11 317 606 –3·6% 40 891 0·4%
(6 764 619 to (–3·4 to 1·2) (188 860 to (–3·8 to 2·8) (10 167 144 to (–6·6 to –0·4) (26 069 to 60 175) (–4·4 to 5·5)
7 449 734) 414 845) 12 619 260)
Chile 3 026 313 –2·1% 126 395 –0·9% 4 807 703 –1·7% 17 842 1·7%
(2 883 224 to (–4·4 to 0·3) (80 166 to 177 701) (–4·2 to 2·5) (4 316 782 to (–5·5 to 2·9) (11 347 to 26 106) (–3·2 to 7·0)
3 173 943) 5 321 021)
Uruguay 557 656 –1·7% 23 356 –1·0% 900 049 –3·2% 3306 0·3%
588 574)
Eastern Europe 36 522 399 –1·1% 1 666 165 0·0% 60 047 323 –6·4% 289 888 –0·4%
(34 831 810 to (–2·6 to 0·3) (1 087 007 to (–2·4 to 2·3) (54 252 621 to (–9·6 to –3·4) (183 340 to (–4·1 to 3·9)
38 180 675) 2 308 943) 66 001 997) 429 480)
Belarus 1 699 640 –1·3% 78 840 –0·1% 2 902 221 –4·1% 14 267 0·6%
1 807 785) 3 211 430)
Estonia 225 237 –2·2% 10 576 –0·5% 382 224 –4·2% 1951 0·7%
(211 324 to (–4·8 to 0·5) (6831 to 14 772) (–4·4 to 3·6) (341 190 to 422 705) (–7·2 to –0·9) (1206 to 3012) (–4·9 to 7·3)
239 545)
Latvia 342 799 –1·7% 16 031 –0·1% 583 339 –3·3% 2947 1·1%
365 126)
Lithuania 510 354 –1·3% 22 244 –0·2% 903 696 –2·4% 3679 0·5%
(487 671 to (–3·5 to 0·7) (14 485 to 31 106) (–3·5 to 3·0) (812 361 to 1 000 663) (–5·0 to 0·4) (2366 to 5314) (–4·0 to 5·5)
532 005)
Moldova 745 403 –1·7% 34 136 –0·4% 1 337 141 –3·1% 6084 0·6%
792 635) 1 488 115)
Russia 24 812 212 –0·9% 1 124 516 0·2% 39 795 927 –7·9% 191 895 –0·8%
(23 707 438 to (–2·9 to 1·0) (730 163 to (–2·8 to 3·3) (36 096 715 to (–12·6 to –3·5) (122 723 to (–6·0 to 4·4)
25 854 358) 1 560 488) 43 757 724) 281 246)
Ukraine 8 186 753 –1·2% 379 822 –0·1% 14 142 775 –2·5% 69 066 1·0%
(7 663 105 to (–3·9 to 1·4) (245 301 to 529 894) (–3·9 to 4·0) (12 662 586 to (–5·4 to 0·4) (41 700 to (–4·6 to 7·1)
8 701 072) 15 739 619) 106 641)
Central Europe 18 993 317 –1·4% 895 292 –0·4% 29 140 306 –5·3% 160 015 –0·4%
(17 924 101 to (–2·4 to –0·4) (580 928 to (–1·7 to 1·1) (26 070 435 to (–6·5 to –4·0) (100 777 to (–2·7 to 2·2)
20 107 210) 1 249 464) 32 262 618) 236 592)
Albania 470 177 0·1% 21 744 1·1% 751 910 –5·1% 3741 0·8%
497 241)

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1990–2016 1990–2016 1990–2016 1990–2016
Bosnia and 639 461 –2·2% 29 735 –0·9% 1 013 644 –8·0% 5267 –0·3%
Herzegovina (600 415 to (–4·5 to 0·2) (19 404 to 41 666) (–4·1 to 2·5) (904 473 to 1 132 866) (–11·1 to –4·8) (3305 to 7790) (–5·5 to 5·0)
677 877)
Bulgaria 1 181 688 –1·5% 56 032 –0·7% 1 815 845 –4·4% 10 155 –0·7%
1 252 908) 2 016 449)
Croatia 679 780 –1·0% 32 184 –0·4% 1 033 878 –4·6% 5775 –1·1%
(651 507 to (–2·8 to 0·9) (20 986 to 44 579) (–3·5 to 2·8) (929 465 to 1 144 445) (–8·1 to –1·4) (3674 to 8531) (–5·7 to 4·4)
708 132)
Czech Republic 1 722 598 –1·4% 81 407 –0·9% 2 614 501 –4·1% 14 690 –1·1%
1 823 581) 2 906 582)
Hungary 1 629 447 –1·3% 76 879 –0·3% 2 492 086 –4·8% 13 787 –0·2%
1 723 579) 2 761 247)
Macedonia 345 962 –1·0% 16 170 –0·3% 539 461 –4·3% 2832 –0·4%
366 814)
Montenegro 101 028 –0·8% 4722 –0·6% 156 302 –3·2% 830 –0·8%
Poland 6 377 038 –1·7% 301 540 –0·3% 9 750 850 –6·3% 53 962 –0·1%
6 774 657) 10 895 665)
Romania 3 174 876 –1·1% 149 483 0·0% 4 843 083 –5·0% 26 671 –0·2%
3 362 001) 5 372 688)
Serbia 1 430 906 –0·9% 66 755 –0·5% 2 246 471 –3·6% 11 808 –0·8%
1 517 239) 2 496 754)
Slovakia 908 113 –1·5% 42 923 –0·6% 1 380 345 –4·7% 7656 –0·6%
(855 264 to (–3·9 to 1·0) (27 978 to 60 511) (–3·9 to 3·0) (1 231 379 to 1 537 857) (–7·5 to –1·8) (4827 to 11 471) (–5·4 to 4·6)
963 273)
Slovenia 332 244 –1·7% 15 718 –1·1% 501 929 –4·3% 2842 –1·3%
351 811)
Central Asia 13 736 082 –1·2% 590 288 –0·3% 24 381 639 –4·2% 91 106 –0·3%
14 552 995) 822 544) 27 281 199) 134 027)
Armenia 504 582 –0·1% 21 922 0·8% 872 662 –4·2% 3459 0·2%
536 134)
Azerbaijan 1 600 921 –1·9% 69 408 –1·0% 2 774 204 –4·8% 10 807 –0·8%
1 704 523) 3 130 530)
Georgia 647 211 –1·1% 28 229 –0·5% 1 123 285 –2·3% 4510 –0·2%
(607 406 to (–3·5 to 1·5) (18 220 to 39 473) (–3·7 to 3·0) (1 004 197 to (–5·0 to 0·6) (2862 to 6646) (–4·6 to 5·1)
688 166) 1 246 394)
Kazakhstan 2 766 716 –1·0% 119 073 –0·2% 4 822 123 –3·5% 18 530 0·0%
2 930 998) 5 383 920)
Kyrgyzstan 901 584 –0·7% 38 461 –0·1% 1 645 510 –1·9% 5912 0·3%
954 712) 1 835 833)

Articles

1990–2016 1990–2016 1990–2016 1990–2016
Mongolia 472 326 –1·3% 20 224 –0·5% 845 589 –5·1% 3104 –0·7%
502 979)
Tajikistan 1 262 201 –1·2% 53 706 –0·4% 2 359 192 –3·0% 8165 –0·2%
1 339 385) 2 630 580)
Turkmenistan 855 817 –1·9% 36 916 –0·4% 1 502 813 –7·3% 5635 –0·7%
908 000) 1 688 181)
Uzbekistan 4 724 725 –1·4% 202 349 –0·1% 8 436 261 –6·3% 30 984 –0·5%
5 015 881) 9 462 315)
Central Latin 34 762 545 –1·9% 1 660 602 0·1% 72 991 274 –8·9% 322 845 –0·1%
America (33 133 735 to (–2·5 to –1·2) (1 076 145 to (–0·9 to 1·3) (65 889 598 to (–9·9 to –7·9) (208 259 to (–2·8 to 2·6)
36 289 519) 2 304 492) 81 184 037) 471 825)
Colombia 7 037 533 –1·9% 336 947 0·1% 13 988 578 –11·8% 64 386 –1·1%
7 402 769) 15 554 198)
Costa Rica 690 578 –1·6% 33 305 0·2% 1 386 207 –11·7% 6461 –1·2%
(650 177 to (–4·1 to 0·9) (21 674 to 46 323) (–3·2 to 3·6) (1 245 777 to 1 541 792) (–14·5 to –9·1) (4131 to 9495) (–6·4 to 4·8)
731 940)
El Salvador 861 889 –0·6% 40 795 1·5% 1 782 909 –12·2% 7794 –0·6%
(810 452 to (–3·1 to 2·1) (26 577 to 57 355) (–1·9 to 4·9) (1 604 549 to (–14·9 to –9·4) (4950 to 11 433) (–5·7 to 5·3)
915 206) 1 991 133)
Guatemala 2 118 201 –1·3% 98 348 1·1% 4 583 592 –12·0% 18 534 –0·6%
2 241 738) 5 140 291)
Honduras 1 099 359 –1·8% 51 332 0·2% 2 345 459 –12·1% 9695 –1·3%
1 165 020) 2 628 176)
Mexico 17 294 301 –2·2% 829 440 –0·1% 37 432 220 –6·2% 164 143 0·9%
18 007 210) 1 149 201) 41 615 456) 238 876)
Nicaragua 843 871 –1·6% 39 737 0·2% 1 768 388 –11·4% 7517 –1·5%
895 439) 1 971 937)
Panama 540 954 –1·5% 26 001 0·2% 1 083 812 –11·4% 5021 –1·1%
573 257)
Venezuela 4 275 858 –1·3% 204 698 0·5% 8 620 107 –11·4% 39 293 –1·0%
4 503 332) 9 650 749)
Andean Latin 7 900 228 –2·1% 369 316 –0·5% 15 134 012 –8·5% 67 651 –0·8%
America (7 520 345 to (–3·6 to –0·7) (238 655 to (–2·5 to 1·9) (13 576 568 to (–10·5 to –6·4) (42 518 to (–4·3 to 3·0)
8 280 881) 519 276) 16 934 973) 100 250)
Bolivia 1 384 973 –2·1% 64 043 0·0% 2 772 129 –10·7% 11 777 –1·1%
1 468 594) 3 114 809)
Ecuador 2 045 883 –1·6% 97 541 0·0% 4 184 493 –9·3% 18 790 –1·1%
2 147 691) 4 690 628)
Peru 4 469 372 –2·1% 207 731 –0·6% 8 177 390 –7·5% 37 084 –0·6%
(4 253 912 to (–4·1 to 0·0) (133 541 to 292 162) (–3·7 to 2·9) (7 313 037 to 9 128 152) (–10·5 to –4·1) (23 233 to 55 383) (–5·6 to 4·7)
4 684 114)

Articles

1990–2016 1990–2016 1990–2016 1990–2016
Caribbean 6 508 546 –1·3% 302 360 –0·3% 13 706 101 –8·0% 57 484 –1·8%
(6 133 601 to (–2·5 to –0·2) (195 258 to (–1·9 to 1·4) (12 409 230 to (–9·2 to –6·6) (36 307 to 85 384) (–4·5 to 0·9)
6 894 055) 420 752) 15 187 209)
Antigua and Barbuda 13 734 –0·6% 643 0·1% 27 539 –8·0% 121 –1·7%
The Bahamas 58 695 –1·3% 2762 –0·7% 117 526 –7·4% 526 –2·1%
Barbados 41 798 –1·5% 1987 –0·9% 84 944 –7·6% 389 –2·3%
Belize 50 816 –1·2% 2316 0·1% 108 679 –10·1% 425 –1·7%
Bermuda 10 187 –1·2% 481 –0·1% 20 501 –8·0% 91 –1·7%
(9558 to 10 788) (–3·8 to 1·3) (312 to 675) (–3·5 to 3·4) (18 500 to 22 854) (–10·5 to –5·2) (57 to 136) (–6·4 to 3·2)
Cuba 1 708 831 –1·6% 81 684 –0·3% 3 454 818 –8·3% 15 995 –1·7%
1 816 682) 3 847 980)
Dominica 10 714 –1·7% 501 –0·4% 22 146 –9·7% 95 –1·9%
Dominican Republic 1 469 656 –1·2% 68 151 0·1% 3 092 021 –10·1% 12 760 –1·4%
1 552 206) 3 444 270)
Grenada 15 150 –3·1% 700 –0·9% 31 508 –12·2% 131 –2·2%
Guyana 108 275 –2·6% 4950 –1·4% 233 389 –9·7% 933 –2·5%
(101 622 to (–5·2 to –0·2) (3181 to 6960) (–4·8 to 2·1) (209 966 to 262 659) (–12·5 to –6·9) (585 to 1387) (–7·1 to 2·6)
114 809)
Haiti 1 491 507 –1·9% 66 275 –0·4% 3 393 664 –8·7% 12 197 –1·8%
1 583 879) 3 768 652)
Jamaica 406 638 –1·7% 18 859 –0·9% 848 127 –8·5% 3564 –2·4%
431 984)
Puerto Rico 538 458 –2·0% 25 726 –0·9% 1 063 365 –9·2% 5005 –2·1%
571 270)
Saint Lucia 27 432 –1·7% 1278 0·3% 56 565 –10·2% 242 –1·3%
Saint Vincent and the 15 937 –2·5% 738 –1·2% 33 500 –10·3% 140 –2·5%
Grenadines (14 982 to 16 898) (–4·9 to 0·2) (476 to 1029) (–4·4 to 2·4) (30 097 to 37 170) (–13·0 to –7·3) (89 to 209) (–7·1 to 2·8)
Suriname 78 191 –1·3% 3616 –0·5% 162 947 –9·2% 682 –2·0%
Trinidad and Tobago 204 165 –1·5% 9576 –0·5% 412 057 –8·5% 1833 –2·0%
216 194)
Virgin Islands 14 900 –1·1% 716 –0·4% 30 156 –8·3% 142 –1·9%
(14 018 to 15 792) (–3·5 to 1·4) (467 to 1 004) (–3·9 to 2·8) (27 395 to 33 517) (–11·0 to –5·7) (91 to 211) (–6·4 to 3·5)
Tropical Latin 34 400 664 –2·3% 1 509 125 –0·7% 79 012 630 –9·4% 272 278 –2·1%
America (32 950 311 to (–3·0 to –1·7) (969 280 to (–1·8 to 0·4) (71 914 512 to (–10·4 to –8·5) (173 288 to (–4·7 to 0·9)
35 875 803) 2 104 691) 86 871 666) 400 837)
Brazil 33 392 533 –2·3% 1 465 378 –0·7% 76 805 591 –9·4% 264 748 –2·0%
34 814 190) 2 043 622) 84 431 513) 389 437)

Articles

1990–2016 1990–2016 1990–2016 1990–2016
Paraguay 1 008 131 –2·6% 43 747 –1·3% 2 207 039 –11·5% 7530 –3·0%
(952 308 to (–5·2 to –0·1) (27 869 to 61 297) (–4·7 to 2·1) (1 988 371 to (–13·9 to –9·1) (4730 to 11 145) (–7·7 to 2·6)
1 067 392) 2 456 628)
East Asia 138 171 702 –1·9% 6 165 860 –0·2% 269 879 994 –10·9% 1 058 408 –2·1%
143 745 425) 8 612 689) 303 834 702) 1 557 133)
China 132 930 661 –1·9% 5 938 315 –0·2% 260 794 517 –11·2% 1 022 673 –2·2%
138 273 863) 8 301 696) 293 800 999) 1 503 383)
North Korea 2 593 897 –1·8% 112 513 –1·8% 4 963 157 0·0% 18 288 –1·3%
2 746 024) 5 605 148)
Taiwan (province of 2 647 143 –0·5% 115 031 1·2% 4 122 320 –4·9% 17 447 2·0%
China) (2530 864 to (–2·5 to 1·7) (73 874 to 160 100) (–2·7 to 5·5) (3 650 654 to (–7·9 to –2·1) (11 118 to 25 979) (–3·5 to 8·3)
2 761 814) 4 662 418)
Southeast Asia 84 397 472 –2·4% 3 466 178 –1·0% 176 724 151 –6·7% 524 458 –1·4%
88 755 912) 4 878 575) 197 116 698) 794 140)
Cambodia 1 972 188 –2·8% 79 763 –0·5% 4 282 356 –7·6% 11 963 –1·3%
(1 850 593 to (–5·5 to –0·3) (50 572 to 113 503) (–4·4 to 3·4) (3 807 064 to (–10·2 to –4·8) (7381 to 18 296) (–6·1 to 4·1)
2 098 567) 4 787 193)
Indonesia 33 130 967 –2·4% 1 359 211 –1·3% 71 377 953 –6·4% 208 622 –1·5%
34 597 261) 1 909 535) 79 957 483) 317 615)
Laos 819 097 –2·3% 33 283 –0·3% 1 803 437 –7·4% 4992 –1·5%
871 911) 2 042 738)
Malaysia 3 911 967 –1·8% 161 953 –0·6% 7 989 485 –7·6% 24 399 –1·6%
4 142 386) 9 022 928)
Maldives 47 268 –1·0% 1935 1·1% 97 407 –8·3% 286 –0·9%
Mauritius 171 325 –1·9% 7042 –0·9% 339 204 –5·7% 1066 –0·9%
182 098)
Myanmar 7 065 448 –2·7% 288 950 –0·5% 14 831 091 –8·8% 43 369 –2·0%
7 496 340) 16 598 830)
Philippines 12 301 469 –1·6% 503 476 –0·3% 25 812 371 –4·6% 75 184 –0·4%
13 053 083) 29 075 489) 114 014)
Sri Lanka 2 685 239 –0·5% 110 736 0·8% 5 407 181 –6·0% 16 703 –0·2%
2 854 287) 6 038 976)
Seychelles 12 522 –2·4% 518 –1·4% 25 010 –5·6% 78 –1·2%
Thailand 9 517 252 –2·6% 393 165 –1·2% 18 391 437 –7·1% 58 561 –1·5%
(8 993 897 to (–4·9 to –0·3) (252 248 to 555 245) (–5·1 to 2·4) (16 475 970 to (–10·1 to –4·3) (36 905 to 87 121) (–6·2 to 4·2)
10 052 983) 20 522 514)
Timor-Leste 124 351 –2·6% 5038 –0·7% 274 567 –7·9% 759 –1·7%
132 519)
Vietnam 12 526 388 –2·8% 516 501 –1·2% 25 861 953 –7·8% 77 772 –1·8%
13 291 801) 28 991 367) 117 920)

Articles

1990–2016 1990–2016 1990–2016 1990–2016
Oceania 1 160 780 –1·3% 47 331 –0·7% 2 498 945 –4·2% 7356 –0·9%
1 231 905) 2 820 943)
American Samoa 8396 –0·4% 347 0·1% 16 352 –4·4% 53 –0·3%
(7890 to 8920) (–3·0 to 2·3) (222 to 494) (–3·6 to 4·1) (14 407 to 18 430) (–7·7 to –1·2) (33 to 79) (–5·4 to 5·5)
Federated States of 10 657 –2·3% 438 –1·4% 22 231 –7·2% 67 –1·9%
Micronesia (9996 to 11 313) (–4·8 to 0·2) (277 to 624) (–5·0 to 2·6) (19 603 to 25 296) (–9·9 to –4·1) (42 to 101) (–6·9 to 3·7)
Fiji 97 017 –2·0% 4015 –1·1% 189 834 –5·6% 616 –1·1%
Guam 18 623 0·9% 781 1·0% 35 267 –1·4% 120 0·7%
(17 552 to 19 718) (–1·7 to 3·3) (504 to 1101) (–2·9 to 4·9) (31 369 to 39 835) (–4·4 to 1·7) (77 to 177) (–4·8 to 6·5)
Kiribati 12 021 –1·6% 490 –0·9% 25 841 –5·3% 76 –1·3%
Marshall Islands 7520 –1·3% 307 –1·1% 15 690 –4·4% 47 –1·4%
(7081 to 7958) (–3·8 to 1·6) (195 to 435) (–5·0 to 2·9) (13 851 to 17 837) (–7·6 to –1·1) (30 to 71) (–6·5 to 4·0)
Northern Mariana 15 147 1·2% 630 1·5% 29 416 –2·4% 93 0·5%
Islands (14 178 to 16 163) (–1·5 to 3·8) (401 to 889) (–2·5 to 5·5) (25 480 to 34 090) (–5·5 to 0·9) (58 to 142) (–4·7 to 6·5)
Papua New Guinea 800 421 –1·5% 32 504 –0·9% 1 757 374 –4·7% 5063 –1·2%
850 011) 1 979 788)
Samoa 18 992 –2·4% 786 –1·6% 39 840 –5·0% 122 –1·5%
Solomon Islands 59 294 –1·0% 2 418 –0·5% 129 342 –4·6% 374 –1·1%
(55 709 to 62 863) (–3·5 to 1·4) (1 535 to 3 425) (–4·2 to 3·6) (114 221 to 146 662) (–7·3 to –1·7) (231 to 568) (–5·7 to 4·2)
Tonga 10 616 –1·9% 437 –1·1% 22 090 –5·3% 67 –1·2%
Vanuatu 27 789 –1·1% 1134 –0·4% 59 608 –5·1% 175 –0·8%
North Africa and 93 437 442 –2·3% 4 289 081 1·1% 175 091 388 –8·5% 777 533 3·2%
Middle East (88 329 677 to (–3·1 to –1·5) (2 774 191 to (–0·4 to 2·6) (156 773 718 to (–9·6 to –7·3) (495 248 to (–0·4 to 6·7)
98 428 935) 5 940 727) 194 351 068) 1 158 025)
Afghanistan 4 841 208 –1·9% 208 981 0·5% 9 939 058 –4·8% 35 909 1·5%
5 141 654) 11 103 449)
Algeria 6 651 343 –1·9% 309 251 1·2% 12 127 472 –7·9% 56 455 2·9%
7 093 673) 13 521 074)
Bahrain 240 046 –3·3% 11 300 –0·6% 443 334 –7·0% 2112 1·4%
(223 355 to (–5·5 to –0·5) (7222 to 15 841) (–4·2 to 3·2) (390 844 to 499 432) (–10·2 to –4·0) (1327 to 3201) (–4·1 to 6·8)
256 642)
Egypt 14 623 084 –2·2% 674 197 0·9% 26 934 828 –7·3% 121 944 3·0%
15 493 197) 30 075 283) 181 851)
Iran 13 616 955 –2·1% 653 679 2·3% 26 496 199 –12·3% 128 660 4·1%
14 325 355) 29 527 389) 188 190)
Iraq 5 534 181 –0·9% 245 414 0·6% 10 732 501 –3·1% 42 924 1·7%
5 886 763) 11 948 005)
Jordan 1 203 358 –1·1% 55 454 1·9% 2 196 597 –7·2% 9934 3·7%
1 284 958) 2 462 165)

Articles

1990–2016 1990–2016 1990–2016 1990–2016
Kuwait 712 246 –2·0% 33 859 0·6% 1 250 436 –7·2% 6281 2·6%
759 904) 1 414 499)
Lebanon 1 017 537 –2·8% 47 836 0·5% 1 795 208 –7·2% 8862 2·8%
1 084 062) 2 009 884)
Libya 1 054 747 1·0% 49 500 3·3% 1 837 414 –6·2% 9053 4·4%
1 121 886) 2 055 257)
Morocco 5 883 012 –2·1% 271 235 1·3% 10 851 241 –8·4% 49 517 3·3%
6 260 127) 12 093 488)
Oman 773 924 –9·8% 36 619 –3·5% 1 476 286 –19·2% 6862 0·9%
827 174) 1 688 025)
Palestine 714 895 –0·6% 31 910 0·2% 1 399 904 –2·1% 5548 1·0%
(666 691 to (–3·0 to 1·9) (20 345 to 44 967) (–3·1 to 3·5) (1 254 072 to 1 570 053) (–4·8 to 0·7) (3486 to 8251) (–3·6 to 6·0)
761 373)
Qatar 395 766 –3·3% 18 937 –0·8% 702 549 –5·4% 3540 2·1%
(367 481 to (–6·0 to –0·8) (12 171 to 26 563) (–4·3 to 3·1) (610 417 to 805 880) (–8·6 to –2·2) (2191 to 5423) (–3·5 to 8·2)
425 083)
Saudi Arabia 5 797 325 –1·9% 267 107 2·8% 8 683 665 –14·3% 44 858 5·3%
(5 544 243 to (–2·9 to –1·0) (172 575 to 373 293) (0·8 to 4·9) (7 709 945 to (–16·0 to –12·6) (28 544 to 65 886) (–0·3 to 10·5)
6 045 186) 9 724 810)
Sudan 6 119 599 –1·9% 273 586 1·2% 11 733 161 –7·8% 47 952 3·0%
6 502 575) 13 096 213)
Syria 2 864 674 –1·9% 130 923 1·4% 5 310 861 –8·9% 23 274 3·5%
3 057 047) 5 968 312)
Tunisia 1 898 520 –1·2% 90 158 1·8% 3 545 921 –7·9% 17 148 3·3%
2 006 354) 3 944 544)
Turkey 13 712 859 –2·4% 617 788 0·9% 26 323 266 –6·7% 109 395 3·6%
14 355 744) 29 061 442) 159 399)
United Arab Emirates 1 566 357 –4·8% 76 336 –1·2% 3 050 507 –10·3% 15 103 0·5%
1 672 209) 3 465 766)
Yemen 4 113 092 –3·9% 180 267 0·2% 8 070 505 –10·0% 31 337 2·5%
4 385 146) 9 038 084)
South Asia 297 880 096 –2·6% 12 432 812 –0·6% 499 729 138 –14·1% 1 801 808 –2·6%
(285 188 495 to (–3·1 to –2·1) (7 979 873 to (–1·5 to 0·4) (450 049 525 to (–15·3 to –12·8) (1 142 781 to (–6·2 to 1·2)
310 043 695) 17 372 734) 558 211 468) 2 654 364)
Bangladesh 29 833 591 –2·3% 1 251 149 0·2% 49 777 226 –9·1% 180 304 0·4%
31 671 803) 1 755 583) 55 776 067) 265 713)
Bhutan 143 348 –4·4% 6028 –1·6% 237 971 –12·6% 879 –0·7%
(134 491 to (–6·7 to –1·9) (3879 to 8474) (–5·1 to 2·2) (212 853 to 266 542) (–15·1 to –9·7) (553 to 1295) (–6·4 to 6·1)
151 726)
India 231 458 617 –2·7% 9 642 457 –0·7% 384 460 770 –15·3% 1 392 107 –3·4%
240 869 588) 13 483 361) 429 907 693) 2 038 166)

Articles

1990–2016 1990–2016 1990–2016 1990–2016
Nepal 5 671 848 –1·8% 234 171 0·5% 8 813 328 –5·1% 31 406 2·8%
5 912 071) 9 847 113)
Pakistan 30 772 692 –2·5% 1 299 007 –0·6% 56 439 842 –10·5% 197 112 –0·7%
32 056 038) 1 845 495) 62 527 542) 292 966)
Southern 8 855 681 –1·2% 380 398 –1·0% 18 825 137 –4·8% 64 951 –0·7%
sub-Saharan Africa (8 430 740 to (–2·0 to –0·4) (245 291 to (–2·2 to 0·3) (16 695 800 to (–5·9 to –3·8) (41 251 to 95 803) (–2·8 to 1·6)
9 247 481) 530 950) 21 235 581)
Botswana 263 435 –2·9% 11 307 –2·6% 535 013 –8·1% 1888 –2·5%
279 636)
Lesotho 235 920 –3·3% 9931 –3·4% 503 816 –7·8% 1655 –2·8%
250 093)
Namibia 274 485 –2·1% 11 775 –1·2% 568 190 –7·4% 1952 –1·2%
290 730)
South Africa 6 276 496 –1·3% 270 768 –1·1% 13 305 448 –5·1% 46 821 –0·8%
6 543 621) 15 008 733)
Swaziland 140 193 –4·1% 5900 –4·7% 296 385 –7·0% 976 –3·3%
(131 788 to (–6·7 to –1·6) (3755 to 8360) (–8·3 to –0·9) (260 404 to 338 444) (–9·8 to –3·7) (621 to 1442) (–7·9 to 2·4)
148 708)
Zimbabwe 1 665 152 –0·3% 70 716 –0·1% 3 616 284 –2·2% 11 658 0·2%
1 767 683) 4 110 865)
Western sub- 43 730 076 –1·5% 1 812 846 0·2% 93 543 672 –2·5% 284 089 1·2%
Saharan Africa (41 301 709 to (–2·7 to –0·2) (1 147 969 to (–1·7 to 2·2) (83 595 903 to (–3·9 to –1·1) (177 657 to (–1·3 to 4·0)
46 083 516) 2 553 029) 104 836 362) 427 908)
Benin 1 272 254 –3·1% 52 523 –0·9% 2 743 528 –3·8% 8212 0·2%
1 339 904) 3 091 386)
Burkina Faso 2 043 309 –2·8% 83 979 0·0% 4 536 772 –3·6% 13 186 1·0%
2 168 388) 5 083 218)
Cameroon 2 654 052 –1·6% 109 958 0·2% 5 632 723 –1·8% 17 156 1·4%
2 813 638) 6 379 645)
Cape Verde 67 017 –5·5% 2828 –3·5% 137 081 –9·0% 445 –2·5%
Chad 1 523 050 –1·6% 62 328 –0·4% 3 373 712 –1·6% 9748 0·9%
1 617 545) 3 801 564)
Côte d’Ivoire 2 571 760 0·2% 106 293 2·0% 5 497 208 –0·8% 16 656 2·7%
2 736 143) 6 207 625)
The Gambia 221 140 0·8% 9 84 1·7% 481 184 0·6% 1 18 2·8%
(207 744 to (–1·7 to 3·8) (5 61 to 12 840) (–2·0 to 5·6) (430 104 to 542 602) (–2·1 to 3·6) (879 to 2 33) (–2·0 to 8·0)
234 781)
Ghana 3 249 877 –0·3% 136 143 1·3% 6 764 987 –1·5% 21 357 2·3%
3 438 538) 7 607 359)

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1990–2016 1990–2016 1990–2016 1990–2016
Guinea 1 450 515 –1·7% 59 790 –0·2% 3 176 932 –1·7% 9438 1·0%
1 539 945) 3 559 576)
Guinea-Bissau 216 496 –1·6% 8929 –0·4% 472 228 –2·3% 1410 0·7%
(203 476 to (–4·4 to 1·0) (5669 to 12 625) (–4·0 to 3·5) (420 380 to 529 458) (–5·1 to 0·5) (878 to 2112) (–3·7 to 6·1)
230 130)
Liberia 523 128 –1·6% 21 394 0·1% 1 141 762 –1·7% 3385 1·4%
554 766) 1 280 295)
Mali 1 915 462 –2·5% 78 717 –0·4% 4 270 772 –3·0% 12 373 0·8%
2 026 148) 4 776 282)
Mauritania 476 034 –2·5% 19 871 –0·8% 996 788 –3·9% 3116 0·2%
504 230)
Niger 2 091 231 –2·0% 86 090 –0·7% 4 735 150 –0·9% 13 571 0·9%
2 214 577) 5 331 112)
Nigeria 20 102 348 –1·8% 836 053 –0·1% 42 325 359 –3·5% 130 870 0·7%
21 198 231) 1 176 086) 47 530 187) 196 851)
São Tomé and 21 799 –2·0% 909 –0·7% 46 418 –3·0% 142 0·5%
Príncipe (20 434 to 23 145) (–4·8 to 0·6) (579 to 1294) (–4·2 to 3·2) (41 228 to 52 354) (–5·8 to 0·0) (90 to 213) (–4·0 to 5·9)
Senegal 1 729 552 –0·3% 71 629 0·9% 3 758 765 –0·7% 11 215 2·0%
1 831 698) 4 202 726)
Sierra Leone 751 211 –1·2% 31 036 0·1% 1 628 771 –2·1% 4865 1·3%
796 776) 1 824 155)
Togo 849 307 –1·6% 35 269 0·2% 1 822 412 –2·8% 5521 1·3%
903 033) 2 043 937)
Eastern sub-Saharan 35 406 307 –2·1% 1 521 377 0·0% 77 059 874 –11·2% 255 465 –2·2%
Africa (33 581 801 to (–2·9 to –1·2) (966 800 to (–1·5 to 1·3) (68 504 260 to (–12·4 to –9·9) (161 337 to (–5·5 to 1·3)
37 179 036) 2 138 404) 87 437 615) 377 559)
Burundi 1 058 994 –1·8% 45 360 0·1% 2 419 541 –7·9% 7677 –1·4%
(990 051 to (–4·6 to 0·9) (29 050 to 64 184) (–3·4 to 3·9) (2 147 315 to 2 748 254) (–11·0 to –4·6) (4781 to 11 540) (–6·5 to 4·4)
1 129 267)
Comoros 77 572 –2·3% 3357 –0·1% 168 749 –11·2% 567 –2·1%
Djibouti 94 816 –2·6% 4119 –0·9% 207 419 –12·5% 706 –3·2%
Eritrea 508 641 –2·8% 21 853 –0·4% 1 130 826 –12·0% 3689 –2·4%
(474 930 to (–5·4 to –0·3) (14 069 to 30 946) (–4·3 to 3·5) (1 000 222 to (–15·0 to –9·0) (2320 to 5510) (–7·8 to 4·0)
541 485) 1 285 282)
Ethiopia 9 229 249 –1·2% 401 119 1·1% 17 741 436 –15·1% 64 633 –3·1%
9 658 414) 20 337 447)
Kenya 4 461 186 –2·4% 192 821 –1·0% 10 067 590 –11·0% 33 220 –2·6%
4 661 140) 11 433 434)
Madagascar 2 374 755 –1·3% 102 173 0·6% 5 283 896 –8·6% 17 325 –1·0%
2 536 836) 6 016 456)

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health. The disability weight for medication overuse adjustment led to a downward correction for YLDs for
headache was 0·223 and for tension-type headache was migraine in women and children by factors ranging
0·037. After all diseases were estimated separately, an from 2·1% (at ages 5–9 years) to 20·6% (at ages
adjustment was made to YLDs to account for ≥95 years), reflecting a strong correlation between
comorbidity by use of simulation methods assuming a comorbidity and age. The corresponding figures in
multiplicative, rather than additive, model. This males were 2·1% and 20·7%, respectively.

1990–2016 1990–2016 1990–2016 1990–2016
Malawi 1 606 835 –2·9% 68 422 –1·1% 3 628 261 –10·1% 11 551 –2·5%
1 712 573) 4 114 340)
Mozambique 2 629 177 –3·1% 111 324 –1·5% 5 946 894 –10·5% 18 844 –2·8%
2 797 480) 6 719 065)
Rwanda 1 172 540 –0·9% 50 301 1·0% 2 565 086 –11·8% 8450 –1·8%
1 251 213) 2 912 265)
Somalia 989 744 –1·3% 42 078 0·0% 2 277 745 –7·5% 7156 –1·3%
1 051 398) 2 584 784)
South Sudan 1 220 526 –1·7% 51 468 1·2% 2 870 947 –8·5% 8871 –0·8%
1 300 220) 3 236 742)
Tanzania 4 763 051 –2·5% 206 249 –0·3% 10 878 846 –8·5% 35 827 –0·9%
4 988 380) 12 327 415)
Uganda 3 521 034 –2·7% 149 693 0·2% 7 878 653 –11·9% 25 070 –1·9%
3 751 194) 9 055 646)
Zambia 1 674 732 –1·8% 70 027 –1·0% 3 943 390 –7·6% 11 708 –1·9%
1 752 842) 4 390 941)
Central sub-Saharan 11 692 589 –1·3% 487 602 0·6% 26 207 351 –3·3% 80 144 0·6%
Africa (11 010 516 to (–3·1 to 0·5) (310 136 to (–2·0 to 3·2) (23 356 289 to (–5·2 to –1·3) (50 424 to (–2·5 to 4·5)
12 369 766) 687 809) 29 570 790) 120 657)
Angola 2 487 245 –2·1% 104 491 –0·2% 5 461 252 –7·0% 16 978 –0·6%
2 633 502) 6 175 196)
Central African 543 715 –1·0% 22 595 0·4% 1 229 346 –2·9% 3760 0·5%
Republic (510 448 to (–3·5 to 1·6) (14 527 to 31 973) (–3·1 to 4·5) (1 090 885 to (–6·0 to 0·2) (2352 to 5688) (–4·0 to 5·5)
575 835) 1 385 696)
Congo (Brazzaville) 478 926 –1·9% 20 205 0·1% 1 018 864 –6·1% 3312 –0·1%
507 643)
Democratic Republic 7 907 386 –0·9% 328 595 0·9% 17 930 616 –1·7% 54 169 1·1%
of the Congo (7 433 746 to (–3·4 to 1·6) (208 899 to 463 527) (–2·6 to 4·8) (15 956 310 to (–4·6 to 1·0) (34 017 to 81 520) (–3·3 to 6·2)
8 374 225) 20 188 762)
Equatorial Guinea 89 144 –3·7% 3802 –0·8% 181 012 –14·1% 622 –2·5%
Gabon 186 172 –3·2% 7915 –1·7% 386 261 –7·5% 1303 –1·5%
197 012)
95% uncertainty intervals are in parentheses. YLDs=years of life lived with disability. SDI=Socio-demographic Index.
Table: Prevalent cases and YLDs for migraine and tension-type headache in 2016 and percentage change of age-standardised rates by location

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Data sources disorder.11 An exception is secondary headache caused by

For headaches, the data sources were mostly published medication overuse, which occurs almost exclusively in
population-based studies of prevalence; however, patients with either migraine or tension-type headache.
survey data for which we had the individual record data For GBD 2016, data on migraine were extracted from
were also included. The PubMed search terms are 135 studies, covering 16 of the 21 GBD world regions.
shown in the appendix. Reference lists in published For tension-type headache, data were extracted from
articles were reviewed and data were solicited from our 76 studies covering 16 GBD regions. All data sources
For data sources see GBD network of more than 2500 collaborators. are available online. For medication overuse headache,
http://ghdx.healthdata.org/ Only studies diagnosing the headaches according to data were extracted from 37 studies from ten regions
gbd-2016/data-input-sources
the International Classification of Headache Disorders (for details about the numbers of studies from each
(ICHD) were considered. This classification was first region see the appendix). In addition, hospital claims
published in 1988, updated in 2004 (ICHD-2),9 and data from the USA on migraine and tension-type
updated again in 2018 (ICHD-3).10 In the three ICHD headache for 3 years (2000, 2010, and 2012) were
versions, no major differences exist with regard to used.12–14 Sets of claims data were included because,
diagnostic criteria of migraine, tension-type headache, owing to their size, they provide more detailed
and medication overuse headache. For evaluation of information on age patterns and time trends than
headache burden, these diagnoses were selected because published epidemiological studies, and also provide
they are, by far, the most common and of the greatest estimates on subnational locations. Because claims
public health importance.11 Cluster headache causes data might not be nationally representative, do not refer
severe pain and disability, but with a lifetime prevalence to the ICHD criteria, and capture only those individuals
of approximately 0·2% the effect on public health is who are able to seek health care, they are evaluated for
much less.1 Diagnosis of the many secondary headaches systematic biases compared with data sources of high
(eg, due to infections or brain tumours) is difficult in quality (appendix).
epidemiological studies, and the burden of these Approximately half of the 135 studies from which data
headaches should be attributed to the underlying were extracted were from three of the 21 GBD regions
Prevalence per 100 000 population

8000 to <9000 15 000 to <16 000
9000 to <10 000 16 000 to <17 000
10 000 to <11 000 17 000 to <18 000
11 000 to <12 000 18 000 to <19 000
12 000 to <13 000 19 000 to <20 000
13 000 to <14 000 20 000 to 21 000
14 000 to <15 000
ATG VCT Barbados Comoros Marshall Isl Kiribati

West Africa Eastern
Mediterranean
Solomon Isl FSM
Dominica Grenada Maldives Mauritius Malta

Vanuatu Samoa
The Caribbean LCA TTO TLS Seychelles Persian Gulf Singapore Balkan Peninsula Fiji Tonga
Figure 1: Age-standardised prevalence of migraine per 100 000 population by location for both sexes, 2016
ATG=Antigua and Barbuda. FSM=Federated States of Micronesia. LCA=Saint Lucia. TLS=Timor-Leste. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines.

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Prevalence per 100 000 population

15 000 to <17 000 27 000 to <29000
17 000 to <19 000 29 000 to <31000
19 000 to <21 000 31 000 to <33000
21 000 to <23000 33 000 to <35000
23 000 to <25000 35 000 to 37000
25 000 to <27000
ATG VCT Barbados Comoros Marshall Isl Kiribati

West Africa Eastern
Mediterranean
Solomon Isl FSM
Dominica Grenada Maldives Mauritius Malta

Vanuatu Samoa
The Caribbean LCA TTO TLS Seychelles Persian Gulf Singapore Balkan Peninsula Fiji Tonga
Figure 2: Age-standardised prevalence of tension-type headache per 100 000 population by location for both sexes, 2016
ATG=Antigua and Barbuda. FSM=Federated States of Micronesia. LCA=Saint Lucia. TLS=Timor-Leste. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines.
(western Europe, high-income North America, and with headache. For both migraine and tension-type
high-income Asia Pacific), and no data on any of the headache, frequency and duration were reported most
headaches were available from the Caribbean, central commonly in categories, and the midpoint was
sub-Saharan Africa, southern sub-Saharan Africa, or assumed to represent each category. For medication
Oceania (see appendix) regions. In all regions and overuse headache, only one study included in GBD
countries, prevalence was estimated with a Bayesian 2016 (from Russia) gave data on time in symptomatic
meta-regression model (DisMod-MR 2.1), and estimates state, reporting a mean headache frequency of 23·1
were obtained in this way also for countries and regions (SD 6·7) days per month.15 According to the ICHD-3
where no relevant headache studies had been done. definition, medication overuse headache is present on
more than 15 days per month for more than 3 months.10
Calculation of proportion of time in the symptomatic
state Modelling of prevalence
Headache disorders are modelled as chronic episodic In the mathematical modelling, the mortality due to
conditions. The prevalence reflects the individuals in headache was set at zero,16 as was occurrence below age
the population who have had at least one episode in the 5 years.17 In the sources used for this study, prevalence
past 12 months fulfilling ICHD criteria. To calculate the rates vary, but the degree to which this reflects real
average proportion of time with headache (ie, in the variation across borders and time, or methodological
symptomatic state) necessary for YLD calculation, differences, is mostly not known. Method most
13 population-based studies were identified that had probably plays a large role because results can be
data on frequency and duration of migraine attacks substantially influenced by relatively minor differences,
(appendix). From these studies, we estimated the such as variations in the screening question.18 To adjust
average number of hours migraineurs spend in attacks, for differences in methodological quality, all prevalence
and expressed this as a proportion of a year, which was studies included in GBD are scored according to a
8·5% (95% UI 5·8–11·2). modified version (dichotomised variables) of published
For tension-type headache, seven studies on duration methodological quality criteria for headache epidemio
and frequency of attacks showed that affected people logical studies,11 taking into account the repre sen
spend, on average, 4·7% (95% UI 1·3–8·0) of their time tativeness of the population of interest (representative

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of country or community vs selected population), measure of income per capita, education, and fertility.19
quality of sampling (random sample of the population We also present results by groupings of countries into
of interest vs not random sample), recall period (1-year quintiles (high SDI, middle-high SDI, middle SDI,
prevalence vs other recall period), participation rate middle-low SDI, and low SDI) based on their 2016 SDI
(≥70% vs <70%), survey method (face to face with value. Additional details on the SDI methods can be
For the online results tool used headache expert or trained interviewer vs other), found online.
for estimation see validation of diagnostic instrument (sensitivity or
http://ghdx.healthdata.org/gbd-
results-tool
specificity ≥70% vs <70% or no validation), and Role of the funding source
application of ICHD criteria (strict criteria or reasonable The funder of the study had no role in study design,
modification of criteria vs other modification of data collection, data analysis, data interpretation or the
criteria). In DisMod-MR 2.1, these methodological writing of the report. All authors had full access to the
variables were evaluated for a systematic difference and data in the study and had final responsibility for the
corrected accordingly (appendix). decision to submit for publication.
For the data visualisations of
GBD 2016 results see
Socio-demographic Index (SDI) Results
https://vizhub.healthdata.org/ We examined the relationships between migraine and In 2016, almost three billion individuals were estimated
gbd-compare/ tension-type headache DALYs and SDI, a composite to have a headache disorder: 1·89 billion (95% UI
1·71–2·10) with tension-type headache and 1·04 billion
A (95% UI 1·00–1·09) with migraine (table). All data on
60 Female age-standardised prevalence and YLDs for all countries
Male
and regions, for both 1990 and 2016, are publicly
available in online visualisations and results download
tools. For tension-type headache, the global age-
standardised prevalence was 26·1% (23·6–29·0)
40 overall: 30·8% (28·0–34·0) for women and 21·4%
(19·2–23·9) for men. All results for both sexes are
Prevalence (%)
publicly available online. For migraine, global age-

standardised prevalence was 14·4% (13·8–15·0) overall:
18·9% (18·1–19·7) for women, and 9·8% (9·4–10·2) for
20 men. Maps of age-standardised prevalence of migraine
and tension-type headache in each country are shown
in figures 1 and 2. In 2016, the age-standardised
prevalence of migraine was highest in Italy and Nepal,
and that of tension-type headache was highest in Brazil
0 and Afghanistan. The lowest prevalence of both
disorders was in China.
B
Migraine was estimated to have caused 45·1 million
60
(95% UI 29·0–62·8) YLDs in 2016 (table), an increase
of 51·2% (49·7–52·8) from the 29·8 million (19·1–41·8)
YLDs in 1990 (see online results tool). Tension-type
headache caused 7·2 million (4·6–10·5) YLDs in 2016
(table), an increase of 53·1% (47·5–58·4) from the
40
4·7 million (3·0–7·0) YLDs in 1990 (online results
Prevalence (%)
tool). Together, in 2016, migraine and tension-type

headache caused 52·3 million (34·5–72·5) YLDs
globally, which was 6·5% of all YLDs: 7·7% among
women and 5·1% among men. The global age-
20
standardised YLD rates per 100 000 population for
migraine were 598·7 (95% UI 385·9–833·3). The
change from the 1990 values was –0·2% (–0·8 to 0·4).
For tension-type headache, the global age-standardised
YLD rate per 100 000 population was 95·9 (61·5–140·0),
0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 a change of –0·2% (–2·5 to 1·9) from 1990 values. The
Age (years) age-standardised YLD rates in 2016 of both disorders
Figure 3: Global prevalence of (A) migraine and (B) tension-type headache by age and sex, 2016
were higher in women (migraine 777·6, 500·4–1083·6;
Prevalence is expressed as the percentage of the population that is affected by the disease. Shaded areas show tension-type headache 114·6, 73·6–162·4) than in men
95% uncertainty intervals. Values are plotted at the midpoint of 5-year age categories. (migraine 422·3, 274·3–586·7; tension-type headache

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77·4, 49·6–113·2). The percentage of all YLDs due to 1500 Migraine

migraine were 5·6% (4·0–7·2) overall: 6·8% (4·9–8·8) Tension-type headache
for women and 4·3% (3·1–5·5) for men. The corres
ponding values for tension-type headache were 0·9%
(0·7–1·2) overall: 1·0% (0·7–1·3) for women and 0·8%
(0·6–1·0) for men.
YLD rate (per 100 000 population)

For both migraine and tension-type headache, a peak 1000
in prevalence and YLD rate occurred between ages
35 and 39 years (figures 3 and 4). In both sexes, the
percentages of all YLDs were highest in the group aged
15–49 years (migraine 8·2%, tension-type headache
1·3%), but was also high in children aged 5–14 years
(migraine 4·5%, tension-type headache 0·6%), in 500
individuals aged 50–69 years (migraine 4·2%, tension-
type headache 0·7%), and in the elderly (ie, ≥70 years;
migraine 1·3%, tension-type headache 0·3%). In
women between ages 15 and 49 years, migraine caused
20·3 million (95% UI 12·9–28·5) and tension-type
headache caused 2·9 million (95% UI 1·8–4·2) YLDs 0
in 2016, which together were 11·2% of all YLDs in this 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Age (years)
age and sex group.
The proportions of all DALYs for both sexes were Figure 4: Global years of life lived with disability (YLD) rate per 100 000 population due to migraine and
tension-type headache by age, 2016
1·9% (1·3–2·5) for migraine and 0·3% (0·2–0·4) for
Shaded areas show 95% uncertainty intervals. Values are plotted at the midpoint of 5-year age categories.
tension-type headache. The values were 2·7% (1·8–3·6)
and 0·4% (0·3–0·5) for women, and 1·2% (0·8–1·7)
and 0·2% (0·3–0·3) for men. Globally, migraine ranked (5·1%), or among the group aged 50–69 years (4·9%),
12th of all disorders at GBD cause Level 4 in terms of and the group aged 70 years or older (1·6%). Together
DALYs for both sexes in 2016, up from 17th in 1990. In the two disorders are the cause of more than 2% of all
2016, migraine ranked fifth for women (up from 13th in DALYs: almost 3% in women and almost 1·5% in men.
1990), and 20th for men (up from 28th in 1990). When analysed at cause Level 4, migraine was the
Migraine was among the top five Level 4 causes of second cause of disability after low back pain and
age-standardised YLDs in all five SDI quintiles both in ranked among the top ten causes of YLDs (age-
1990 and 2016. Age-standardised DALYs for each standardised) in all 195 countries, both in 1990 and in
headache type showed a small increase as SDI 2016.20 In 2016, it ranked first in two regions, second in
increased. The values estimated for the 21 world nine, third in five, fourth in two, fifth in two, and sixth
regions between 1990 and 2016 varied little over time, in one region. Globally, tension-type headache ranked
but markedly between regions (figure 5). These results 28th in both 1990 and 2016.
indicate that the SDI level of the country is not a major The increase in YLDs between 1990 and 2016 reflects
determinant of the size of the headache burden. population growth and potentially some effect of a
change in the age composition of many populations
Discussion (ie, fewer children and adolescents and more middle-
Almost three billion people had a migraine and tension- aged people). The fact that age-standardised YLD rates
type headache together in 2016; tension-type headache are unchanged indicates that, overall, the underlying
was the third most prevalent disorder (after dental causes of headache have remained the same. Any
caries and latent tuberculosis infection) and migraine improvements in the efficacy of headache treatments
the sixth most prevalent out of 328 diseases and injuries during this period (which saw the introduction of
for which GBD 2016 made estimates.20 triptans for migraine) have had no detectable effect—
GBD 2016 shows that headache, and in particular, perhaps partly a reflection of how poorly available they
migraine, is one of the main causes of disability are worldwide21 and of the scarcity of data on the
worldwide, particularly in young adult and middle-aged proportion of time patients are symptomatic, which did
women (figure 3). Globally, migraine and tension-type not allow us to find a treatment effect over time and by
headache together accounted for 6·5% of all YLDs: location. In the DALY rankings, headaches are higher
7·7% among women and 5·1% among men. Headache in 2016 than in 1990, because of an overall decrease in
is particularly burdensome in people aged 15–49 years, YLLs from fatal disorders. In general, DALY rates for
being the cause of 9·5% of all YLDs in this group non-communicable diseases increase rapidly with age;22
(11·2% among women and 7·5% among men) but the hence, counts of deaths and DALYs from non-commun
effect is not negligible in the group aged 5–14 years icable diseases will increase in ageing populations.

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A short supply of data is still a limitation in headache

A
800
burden estimates. Although several epidemiological
studies on headache have been done in the past decade
Age-standardised DALY rate per 100 000
in large and populous regions of the world where none

700 existed before (ie, Russia, China, India, and parts of
Africa), the majority of studies are still from high-
population
600 income countries, and there remain five regions of low-

income and middle-income countries without data for
migraine. No data exist for populous countries like
500
Indonesia, Vietnam, Bangladesh, Egypt, South Africa,
and the Democratic Republic of Congo. In sub-Saharan
400 Africa, only five countries have data on headache. For
tension-type headache and medication overuse
0 headache, the data are even scarcer. In addition, too few
B population-based studies give good estimates of average
140 headache duration and frequency, which are necessary
for calculation of time spent in the symptomatic state.
Age-standardised DALY rate per 100 000
The small number of studies did not allow us to

120
differentiate the estimates of time spent with symptoms
by location, although, in countries with better access to
population
100 health care, the frequency and duration of migraine

attacks would be expected to decrease with treatment.
There is also a need to update results in many places, to
80
get more reliable results (many old studies are of low
quality) and possibly also to monitor secular trends in
headache epidemiology. Because data on headache are
0
0 0·25 0·50 0·75 poorly captured in national health surveys, and
Socio-demographic index administrative data collections such as those from
Global Andean Latin America Central Europe East Asia claims or primary care are unreliable measures of
High-income Asia Pacific Tropical Latin America Eastern Europe Oceania
High-income North Central Latin America Central Asia Western sub-Saharan Africa
prevalence (appendix), it is desirable that surveys on
America Southern Latin America North Africa and Middle East Eastern sub-Saharan Africa headache be done in many more places, and preferably
Western Europe Caribbean South Asia Central sub-Saharan Africa
Australasia Southeast Asia Southern sub-Saharan Africa
at regular intervals as part of national health reporting
systems.
Figure 5: Age-standardised disability-adjusted-life-years (DALY) rates for (A) migraine and (B) tension-type In GBD, DisMod-MR 2.1 makes it possible to adjust
headache by 21 Global Burden of Disease regions by Socio-demographic Index (SDI), 1990–2016
The solid black line represents expected values based on SDI from a regression of all location data over the entire
results of studies that were done using suboptimal case
1990 to 2016 estimation period. definitions or methods. However, an important aspect
that has not yet been taken into account in the model is
the distinction between definite and probable diagnoses
However, ageing has a lesser effect on headaches as of migraine and tension-type headache. People with a
these, and in particular migraine, are most common definite diagnosis fulfil all ICHD diagnostic criteria for
among young and middle-aged adults, and become less the disorder, whereas those with probable diagnoses do
prevalent with old age. not meet one of them; the probable diagnosis is not
The principal reason migraine has climbed from the meant to signify a separate nosological entity. In a
seventh largest cause of YLDs in GBD 2015 to second clinical setting, probable diagnoses are useful for
place in GBD 201620,23 is that medication overuse patients for whom there is diagnostic uncertainty, but
headache used to be treated as a separate disease entity, confirmation (or refutation) of the diagnosis is expected
but in GBD 2016 it was considered a sequela of either later. However, this will not be the case in epidemio
migraine or tension-type headache, with more than logical studies and, unless the large number of probable
70% of medication overuse headache burden being cases are included for either migraine or tension-type
reattributed to migraine. We believe this change in the headache as appropriate, these people will not be
status of medication overuse headache is correct, from counted, despite experiencing headache-related
both clinical and patho physiological viewpoints, disability. Several studies have investigated, in more
because medication overuse headache virtually never detail, participants in epi demiological studies who
develops de novo, but almost always from either received probable diagnoses. In the great majority, a
migraine or tension-type headache, and the presence of definite diagnosis of migraine was withheld because
a primary headache is considered to be a prerequisite attacks reportedly lasted less than 4 h (the minimum
for medication overuse headache.10,24 allowed by the criteria).25–27 Otherwise, the diagnosis

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resembled migraine closely, and was associated with done in the past 10 years that are of higher quality than
considerable disability. Until 2000, the majority of earlier studies.
studies reported only definite migraine, and not both Despite these methodological challenges, headache
definite and probable diagnoses. After 2000, more disorders are ubiquitous and contribute to a large
studies reported both types, and these studies indicate burden of lost health. Sizeable resources would be
that the prevalence of probable migraine is almost as needed to prevent or alleviate this burden in the
high as that of definite migraine.26,28 Future iterations of hundreds of millions of people with headache world
GBD should therefore find a reasonable and consistent wide. Until now, most interventions have aimed at the
way to deal with probable migraine because it is a management of symptoms, but preferable for such an
common cause of disability that otherwise will be immense public health problem might be modification
unaccounted for. Similar arguments can be made for at a population level of risk factors, if such can be
probable tension-type headache, although knowledge of identified. This intervention would require greater
this headache type is far less, and the YLDs missed by knowledge of the modifiable factors that drive headache:
omitting this are fewer because of the much lower several have been suggested with varying degrees of
disability weight of tension-type headache compared scientific support, such as obesity, smoking, indoor and
with migraine. outdoor air pollution, level of physical activity, altitude,
Another problem is the handling of chronic headache blood pressure, and level of stress.29–32 Of these factors,
disorders (ie, present on 15 or more days per month altitude and stress are not included as risks in GBD.
for more than 3 months). Many of these headaches will For the other postulated risks, the evidence for an effect
fall into the categories of chronic migraine, chronic on headaches is, in our opinion, insufficient. Potential
tension-type headache, or medication overuse head headache risk factors should be tested against GBD
ache, but the high frequency of headaches tends to blur causal criteria for inclusion of risks and associated
the features necessary for diagnosis. These headaches outcomes.33 If none of these risk factors pass the
become even more difficult to diagnose with certainty criteria, more and better epidemiological and patho
in cross-sectional epidemiological studies based on physiological studies should be done to prove or refute
questionnaires, especially when these are self-admin hypotheses about causation.
istered or applied by lay interviewers. With the Headache disorders do not appear to be strongly
exception of medication overuse headache, which is linked to socioeconomic development, as measured by
diagnosed by enquiry into medication use, these head SDI (table). The previous notion that headache was
aches are usually lumped into a descriptive category of mainly a disorder of high-income countries and
headache on 15 or more days per month, and not particularly prevalent among the wealthy, is refuted by
counted in GBD. Hence, there might be additional, and the present study, but neither is the opposite true.
perhaps considerable, headache-related morbidity that Hence, no significant reduction in the global burden of
is not captured by the diagnoses used in GBD. headache can be expected from the demographic and
Despite efforts to adjust for methodological diff epidemiological transitions22 that large parts of the
erences between studies, part of the variation between world are presently undergoing, because no clear
countries might be due to residual measurement error, pattern of decreasing YLD rate with increasing SDI
rather than true variation. Efforts have been made to exists. It can, however, be predicted that the relative
standardise the methods for studies on prevalence and importance of headaches will further increase as the
burden of headache,11 and in the future adherence to importance of other disorders, such as malnutrition,
these will hopefully make it easier to compare the infections, maternal and child diseases, and cardio
burden over geographical borders and time periods. vascular and other fatal non-communicable disorders
One of the greater challenges in modelling headache is decreases. Although a socioeconomic index like the
the poor knowledge of predictors. Such predictors help SDI does not reflect differences in headache prevalence
to stabilise disease models in the sense that they adjust when applied across countries and cultures, the
data points that are affected by measurement error. possibility that such factors are important within a
Another problem concerns how to estimate the country or region cannot be eliminated. A socioecon
proportion of time during which people with a headache omic gradient, to the effect that low socioeconomic
disorder actually have headache (time in symptomatic status is linked to higher headache prevalence, has
state). This difficulty exists partly because average been shown in countries of high, middle, and low
duration and frequency of headaches are usually income.15,34–36
reported in categories, and estimates thus depend on Even if it proves difficult to establish, with reasonable
choice of mean value in each category, and partly certainty, that modifiable risk factors exist for headache,
because the present figures rely on older studies that the results of GBD definitely give a strong call for
are of rather poor general quality. Better estimates can improving health care for headache. This call involves
probably be obtained with a more systematic analysis of the inclusion of headache care in existing health-care
individual record data in some of the major surveys systems, and not only in the high-income part of the

Articles
world. Implementation of a headache service in Alessandra C Goulart, Rahul Gupta, Graeme J Hankey, Simon I Hay,
Georgia, a country where none existed previously, has Mohamed I Hegazy, Esayas Haregot Hilawe, Amir Kasaeian,
Dessalegn H Kassa, Ibrahim Khalil, Young-Ho Khang,
been economically sustainable.37 An educational Jagdish Khubchandani, Yun Jin Kim, Yoshihiro Kokubo,
programme among general practitioners in Estonia has Mohammed A Mohammed, Mohammed A Mohammed,
been shown to reduce unnecessary referrals to Ali H Mokdad, Maziar Moradi-Lakeh, Huong Lan Thi Nguyen,
specialists and special examinations.38 A programme to Yirga Legesse Nirayo, Mostafa Qorbani, Anna Ranta, Kedir T Roba,
Saeid Safiri, Itamar S Santos, Maheswar Satpathy, Monika Sawhney,
increase competence in headache care in China is now Mekonnen Sisay Shiferaw, Ivy Shiue, Mari Smith,
being implemented.39 Some simple remedies and Cassandra E I Szoeke, Nu Thi Truong,
methods, like aspirin for attack treatment and ami Narayanaswamy Venketasubramanian, Kidu Gidey Weldegwergs,
triptyline for prevention of migraine, together with Ronny Westerman, Tissa Wijeratne, Bach Xuan Tran,
Naohiro Yonemoto, Valery L Feigin, Theo Vos, Christopher J L Murray.
provision of information for patients and education for
health-care providers, should be highly cost-effective in Affiliations
Neuromedicine and Movement Science, Norwegian University of
low-income and middle-income countries.40 A study Science and Technology, and Norwegian Advisory Unit on Headaches,
from European and Latin American countries has St Olav’s Hospital, Trondheim, Norway (Prof L J Stovner PhD,
shown that discontinuation of medication overuse can Prof T J Steiner PhD); Institute for Health Metrics and Evaluation,
reduce the proportion of severely disabled patients with University of Washington, Seattle, WA, USA (E Nichols BA,
K J Foreman PhD, Prof S I Hay DSc, Prof Ali H Mokdad PhD,
medication overuse headache by almost 60%.41 This M Smith MPA, M Smith BPA, Prof T Vos PhD,
study also indicates that increased awareness of the Prof C J L Murray DPhil, Prof V L Feigin PhD); Division of Brain
danger of non-critical use of acute medication might Sciences, Imperial College London, London, UK (Prof T J Steiner);
prevent millions of people from developing this Department of Neurology, Cairo University, Cairo, Egypt
(Prof F Abd-Allah MD, Prof A Abdelalim MD, Prof M I Hegazy PhD);
prevalent and disabling disorder. Family and Community Medicine, King Abdulaziz University, Jeddah,
In high-income parts of the world, the results Saudi Arabia (Prof R M Al-Raddadi PhD); Public Health Debre Berhan
presented here also highlight a strong moral obligation University, Debre Berhan, Ethiopia (M G Ansha MPH); Clinic for
Infectious and Tropical Diseases, Clinical Center of Serbia, Belgrade,
to allocate more resources to research aimed at
Serbia (A Barac PhD); Faculty of Medicine, University of Belgrade,
understanding the mechanisms of headache to enable Belgrade, Serbia (A Barac); Department of Internal Medicine
development of more effective prevention and (I M Bensenor PhD, Prof I S Santos PhD) and Center for Clinical and
treatments. At the same time, current treatments need Epidemiological Research (A C Goulart PhD), University of São Paulo,
São Paulo, Brazil; Institute for Global Health Innovations, Duy Tan
to be recognised as ineffective more because of poor
University, Hanoi, Vietnam (L P Doan BMedSc, H L T Nguyen MPH,
availability than inefficacy, and health services must do N T Truong BHlthSci); School of Pharmacy (D Edessa MPharm,
a better job of reaching people if new treatments are to Prof M S Shiferaw MSc) and School of Nursing and Midwifery
have an effect.42 For the pharmaceutical industry, the (K T Roba PhD), Haramaya University, Harar, Ethiopia; Neurology,
Charité–Universitätsmedizin Berlin, Berlin, Germany
market for proven cost-effective remedies is huge, as is
(Prof M Endres MD); Neurosurgery Department, Faculty of Medicine
the potential for a large decrease in pain and disability, and Pharmacy of Fez, Fez, Morocco (F G Gankpe MD);
and an increase in productivity, for the global Non-communicable Disease Department, Laboratoire d’Etudes et de
community. Recherche-action en Santé (leras Afrique), Porto Novo, Benin
(F G Gankpe); National Institute of Mental Health and Neurosciences,
In conclusion, major limitations still exist in the GBD Bangalore, India (G Gopalkrishna MD); West Virginia Bureau for
headache burden estimations, the most notable being Public Health, Charleston, WV, USA (Prof R Gupta MD); Health
the short supply of epidemiological data from large Policy, Management and Leadership West Virginia University School
parts of the world, the paucity of studies giving data on of Public Health, Morgantown, West Virginia, USA (Prof R Gupta);
Medical School, University of Western Australia, Perth, WA, Australia
average time with headache, and great methodological (Prof G J Hankey MD); Oxford Big Data Institute, Li Ka Shing Centre
heterogeneity. Nevertheless, GBD 2016 confirms that for Health Information and Discovery, University of Oxford, Oxford,
headache, and in particular, migraine, is a large public UK (Prof S I Hay); Tigray Health Research Institute, Mekelle, Ethiopia
health problem in both sexes and all age groups (E H Hilawe PhD); Hematology-oncology and Stem Cell
Transplantation Research Center, and Hematologic Malignancies
worldwide, but most so in young and middle-aged Research Center, Tehran University of Medical Sciences, Tehran, Iran
women. Headache is not limited to the high-income (A Kasaeian PhD); Department of Nursing, Debre Markos University,
part of the world and, unless action is taken, it is here to Debre Markos, Ethiopia (D H Kassa MS); Department of Health Policy
stay: there is no indication that the demographic and and Management, College of Medicine, and Institute of Health Policy
and Management, Medical Research Center, Seoul National University,
epidemiological transitions alone will improve the Seoul, South Korea (Prof Y H Khang MD); Department of Nutrition
situation. Rather, these profound changes which reduce and Health Science, Ball State University, Muncie, IN, USA
mortality will increase the relative importance of (Prof J Khubchandani PhD); School of Medicine, Xiamen University
headache for public health. Malaysia, Sepang, Malaysia (Prof Y Kim PhD); Department of
Preventive Cardiology, National Cerebral and Cardiovascular Center,
GBD 2016 Headache Collaborators Suita, Japan (Prof Y Kokubo PhD); Department of Public Health,
Lars Jacob Stovner, Emma Nichols, Timothy J Steiner, Foad Abd-Allah, Jigjiga Unviersity, Jigjiga, Ethiopia (M A Mohammed PhD); University
Ahmed Abdelalim, Rajaa M Al-Raddadi, Mustafa Geleto Ansha, of Sydney, Sydney, NSW, Australia (M A Mohammed); Preventive
Aleksandra Barac, Isabela M Bensenor, Linh Phuong Doan, Medicine and Public Health Research Center, Iran University of
Dumessa Edessa, Matthias Endres, Kyle J Foreman, Medical Sciences, Tehran, Iran (M Moradi-Lakeh MD); Department of
Fortune Gbetoho Gankpe, Gururaj Gopalkrishna, Clinical Pharmacy, Mekelle University, Mekelle, Ethiopia

Articles
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(M Qorbani PhD); Department of Medicine, University of Otago, 2nd edn. Cephalalgia 2004; 24 (suppl 1): 1–160.
Wellington, New Zealand (Prof A Ranta PhD); Department of 10 Headache Classification Committee of the International
Neurology, Capital and Coast District Health Board, Wellington, New Headache Society. The International Classification of Headache
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principles and recommendations from the Global Campaign
(S Safiri PhD); Public Health Sciences, University of North Carolina at
against Headache. J Headache Pain 2014; 15: 5.
Charlotte, Charlotte, NC, USA (M Sawhney PhD); University Grants
12 United States MarketScan Claims and Medicare Data. Ann Arbor:
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University, Bhubaneswar, India (M Satpathy PhD); Institute for
Medical Epidemiology, Biometrics and Informatics, Martin Luther
University Halle-Wittenberg, Halle, Germany (I Shiue PhD); Medicine
Dentistry and Health Science, University of Melbourne, Melbourne,
VIC, Australia (Prof C E I Szoeke PhD); Department of Medicine,
15 Ayzenberg I, Katsarava Z, Sborowski A, et al. The prevalence of
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(Prof T Wijeratne); Department of Health Economics, Hanoi Medical participants in HUNT 3: the impact of the screening question on
University, Hanoi, Vietnam (Prof B X Tran PhD); Department of headache prevalence. J Headache Pain 2008; 9: 289–94.
Biostatistics, School of Public Health, Kyoto University, Kyoto, Japan 19 GBD 2016 Mortality Collaborators. Global, regional, and national
(Prof N Yonemoto MPH); National Institute for Stroke and Applied under-5 mortality, adult mortality, age-specific mortality, and life
Neurosciences Auckland University of Technology, Auckland, expectancy, 1970–2016: a systematic analysis for the Global
New Zealand (Prof V L Feigin PhD). Burden of Disease Study 2016. Lancet 2017; 390: 1084–150.
20 GBD 2016 Disease and Injury Incidence and Prevalence
Contributors
Collaborators. Global, regional, and national incidence,
LJS prepared the first draft. TJS, EN, and TV analysed the data and
prevalence, and years lived with disability for 328 diseases and
edited the first draft and final versions of the Article. LJS finalised all injuries for 195 countries, 1990–2016: a systematic analysis for the
drafts, and approved the final version of the Article. All other authors Global Burden of Disease Study 2016. Lancet 2017; 390: 1211–59.
provided data, developed models, reviewed results, provided guidance on 21 WHO and Lifting The Burden. ATLAS of headache disorders and
methodology, or reviewed the Article, and approved the final version. resources in the world 2011. In: Saxena S, Dua T, Saraceno B,
Declaration of interests et al, eds. Geneva: World Health Organization, 2011.
CEIS reports grants from the National Health and Medical Research 22 GBD 2016 DALYs and Hale Collaborators. Global, regional,
Council, during the study; and grants from Lundbeck and the and national disability-adjusted life-years (DALYs) for 333 diseases
and injuries and healthy life expectancy (HALE) for 195 countries
Alzheimer’s Association, outside the submitted work. CEIS also
and territories, 1990–2016: a systematic analysis for the Global
reports the patent PCT/AU2008/001556. All other authors declare no Burden of Disease Study 2016. Lancet 2017; 390: 1260–344.
competing interests.
23 GBD 2015 Disease and Injury Incidence and Prevalence
Acknowledgments Collaborators. Global, regional, and national incidence,
This research was supported by the Bill & Melinda Gates Foundation. prevalence, and years lived with disability for 310 diseases and
injuries, 1990–2015: a systematic analysis for the Global Burden of
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Global, regional, and national burden of migraine and

Funding Bill & Melinda Gates Foundation.

Introduction the evaluation not only of mortality but also of non-fatal

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Migraine Tension-type headache

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Data sources disorder.11 An exception is secondary head­ache caused by

Prevalence per 100 000 population

ATG VCT Barbados Comoros Marshall Isl Kiribati

Dominica Grenada Maldives Mauritius Malta

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Prevalence per 100 000 population

ATG VCT Barbados Comoros Marshall Isl Kiribati

Dominica Grenada Maldives Mauritius Malta

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publicly available online. For migraine, global age-

tool). Together, in 2016, migraine and tension-type

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77·4, 49·6–113·2). The percentage of all YLDs due to 1500 Migraine

YLD rate (per 100 000 population)

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A short supply of data is still a limitation in headache

in large and populous regions of the world where none

600 income countries, and there remain five regions of low-

The small number of studies did not allow us to

100 health care, the frequency and duration of migraine

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Data sources disorder.11 An exception is secondary headache caused by