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Migraine in the 21st Century:
Lessons from Epidemiologic Studies
Marcelo E. Bigal, M.D.; Ph.D.
Global Director for Scientific Affairs ─Neuroscience Merck Research Laboratories
Dept of Neurology, Albert Einstein College of Medicine
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Overview
•
To review the epidemiology of migraine. Is migraine worth attention?
•
To review the burden of migraine on the individual, family and society. Is migraine worth recognition?
•
To estimate patterns of diagnosis and treatment for migraine, as well as barriers for care
•
To discuss the prognosis of migraine
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Epidemiology Lesson 1
Migraine peaks with incidents in the teens and early twenties
Accordingly, first migraine attacks often happen in childhood or
puberty
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Incidents per 1000
person-years
Age at OnsetStewart et al: Am J Epidemiol 1991
FemaleMale30
25
20
15
10
5
00 5 10 15 20 25 30
Migraine, Incidence
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Epidemiology Lesson 2
Migraine is Very Prevalent
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14.7
Prevalence in adults worldwide: 1-year prevalence
11.7
14.0
13.3
12.2
11.6
3.0
5.0
8.5
11.613.2
10.010.2
9.6
16.7
23.2
14.3
Population or community-based surveys of >500 participants covering ages 25-60 y,
using IHS or modified IHS criteria
Africa 4.0 (2 studies)
Asia 10.6 (6 studies)
Australia
Europe 13.8 (9 studies)
N. America 12.6 (8 studies)
S. America 9.6 (10 studies)
8.4
5.9
22.3
9.0
10.1
7.7
5.3
5.0
16.3
12.69.3
8.2
10.0
8.5
7.3
13.5Tekle Haimanot
Dent
Sakai
Takeshima
Roh
Alders
Deleu
Wang
Lampl
Zivadinov
Rasmussen
Bank
Launer
Hagen
Dahlof
Steiner
Kryst
Schwartz
O’Brien
Stewart
Stewart Lipton
Lipton
Jaillard
Morillo
Wiehe
Morillo
Morillo
Morillo
Morillo
Morillo
Miranda
Lavados
15.5Lyngberg
14.7Patel
Mean: 11.2
Median: 10.2Steiner TJ. Lifting the burden: The global campaign against headache. Lancet Neurol
2004;3(4):204-205.
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Epidemiology Lesson 3
•
In the US migraine affects over 12% of the adults
•
Migraine is the most common neurological disease in men (6%)
•
Migraine is 3 times more common in women (18%) P
•
Prelavence
peaks in adulthood, coinciding with the peak of work productivity
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Migraine is very common in US. Results of 3 large studies conducted 15 years apart
12.1%
5.7%
17.6%
11.7%
5.6%
17.1%
6.5%
18.2%
12.6%
Total Males Females
AMS-I AMS-II AMPP
Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007;68(5):343-349.
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0
5
10
15
20
25
30
0 20 30 40 50 60 70 80 100
Age (Years)
Mig
rain
e Pr
eval
ence
(%)
FemalesMales
Migraine is Most Common in Women and During Peak Productive Years
Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence
and burden of migraine in the United States: data from the American Migraine Study II. Headache 2001;41(7):646-657.
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Epidemiology Lesson 4
The Burden of Migraine is Severe and Complex
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pain and suffering
Burdens of One Person’s Migraine
anxiety
patienthood
personal financial costs
employer & work
colleagues
lifestyle compromise
societal burdenfamily burden
co-morbidity
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The burden of migraine is severe and affects:•
Burden on Individual: – Health-related quality of life– Disability– Interictal burden of migraine
•
Burden on the family:– Migraine affects relationships
• Burden on society:– Costs
The Several Burdens of Migraine
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Burden on the Individual -
Leading Causes of Years of Life Lost to Disability (YLDs) –
WHO Report
Steiner TJ. Lifting the burden: The global campaign against headache. Lancet Neurol
2004;3(4):204-205.
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The Burden of Migraine is Not Restricted to the Attack –
The Interictal
Burden
Symptom Burdens
•
During attacks– pain and suffering, leading to– reduced functional ability
•
Beyond the attack– fear of the next attack, leading to– avoidance behaviour and
lifestyle compromise
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The Family Impact of Migraine –
Migraine Damages Relationships With
Sufferer’s Partner
36%36%
20%20%
From their partners’
perspective
56%56%
35%35%
29%29%
USA and UK populations (245 migraine sufferers, 100 partners)
From the sufferers’
perspective56%56%Spend less time with partnerSpend less time with partner
50%50%More likely to argueMore likely to argue
47%47%Be a better partnerBe a better partner
without headacheswithout headaches
60%60%Less involved withLess involved withpartner at homepartner at home
% Sufferers affected0 20 40 60 80
73%73%Less able to communicateLess able to communicate
100
Lipton et al. Cephalalgia 2003;23:429-440
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The Economic Burden of Migraine - Migraine is Costly to Society
Annual Cost in the US ≈ $14.5 Billion Annually (1998)
Hu H et al. Arch Intern Med. 1999;159:813-818.
$7.9B$7.9B
$5.4B$5.4B
$1.2B$1.2B
10%10%
30%30%
60%60%
Emergency
Room, Other
Rx
Office Visits
Missed Work
Direct Direct Medical Medical CostCost
Reduced Productivity
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Epidemiology Lesson 5: There Are Several Barriers
Preventing Good Outcomes in Migraine Treatment
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EncourageFollow-Up
ImproveTreatment
ImproveDiagnosis
Barriers to Successful Outcomes
Lipton RB et al. Neurology. 1994.
Motivate Patientsto Seek Care
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Although Progresses Were Made, a Significant Proportion of Migraineurs are Unaware of Their Diagnosis
AMS-I AMS-II AMPP Change of 15 years
Migraine Diagnosis 38% 48% 56.20% 47.9%
Sinus Diagnosis 43.10% 42% 39% -9.5%
Tension Headache 44% 32.30% 31% -29.5%
"Sick" headaches 13.10% 7.80% 7.50% -42.7%
Cluster headache 17.90% 6.50% 9.90% -44.7%
Lipton RB, Bigal ME. Ten lessons on the epidemiology of migraine. Headache 2007;47 Suppl
1:S2-9.
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Most People With Migraine Still Use OTC Medications
1999
57%
41%
2%
None
Any Rx
OTCOnly
1989
59%
37%
4%
6 in 10 Sufferers Still Rely on OTCs Alone or No Medication to Manage Headache Pain
Lipton RB et al. Headache. 2001;41:638-645.
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Epidemiology Lesson 6: Comorbidities are Frequent in
Migraine and Complicate Diagnosis and Treatment
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Migraine is Comorbid With:
•
Neurologic disorders– Epilepsy– Ischemic stroke– Tourette’s
•
Psychiatric disorders– Depression– Bipolar disease– Anxiety/panic disorder
•
Other disorders– Raynaud’s– Snoring/sleep apnea– Asthma/allergy– Noncephalic pain– GI disorders– Arthritis– Low back pain
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Comorbidities Increase With Increased Headache Frequency
15
22
3
19
26
31
34
5
30
41
0 5 10 15 20 25 30 35 40 45
Chronic Pain
Arthritis
Bipolar
Anxiety
Depression (PHQ-9)
EM CM
OR=2.1 (1.7 –
2.5)*%
%
%%
* ORs
and 95% confidence intervals adjusted for age, gender and SES (income)
%
%%
%%
%
OR=1.8 (1.5 –
2.2)*
OR=1.6 (1.1 –
2.4)*
OR=1.7 (1.4 –
2.1)*
OR=2.5 (2.1 –
3.02)*
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Epidemiology Lesson 7
Although the Prognosis of Migraine is Variable, in a
Subgroup Migraine Progresses Into Chronic Migraine
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Migraine
Remission Evolution to symptom free over prolonged period of time
Persistence Relative clinical stability and no markers of progression
Progression
Clinical- Evolution to chronic migraineFunctional- Changes in the PAG- Central sensitizationAnatomical- Lesions in the brain- Lesions outside the brain
Bigal ME, Lipton RB. The prognosis of migraine. Curr
Opin
Neurol
2008;21(3):301-308.
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Evidence from Epidemiology
Baseline 1-year follow-up
798
Migraineurs
Stable controls (2 to 104 headache days/year)
Intermediate (105 to 179 headache days/year)
New-onset CDH (180+ headache days/year)
23 (3%)
49 (6%)
726 (91%)
Scher AI et al. Pain. 2003;16:81-89.
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Risk Factors for Migraine Progression
Bigal and Lipton, Headache 2006
Not modifiable
by health interventionsFemaleSex
Low Socioeconomic Status
Head Trauma
Modifiable by health interventionsAttack Frequency
Obesity
Medication Overuse
Caffeine Overuse
Stressful life events
Snoring
OtherAllodynia
Other pain syndromes
Pro-Inflammatory Status
Pro-Thrombotic Status
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Probability of Chronic Migraine as a Function of Barbiturate Exposure
Bigal ME, Serrano D, Buse
D, Scher A, Stewart WF, Lipton RB. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8):1157-1168.
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Probability of Chronic Migraine as a Function of Opioid
Exposure
Bigal ME, Serrano D, Buse
D, Scher A, Stewart WF, Lipton RB. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8):1157-1168.
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Summary
•
Migraine is a frequent and disabling chronic disease with recurrent attacks
•
Migraine is common in men and 3 times more common in women
•
The burden of migraine is higher in the years of peak productivity
•
The burden of migraine affects the individual, family and society
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Summary
•
Despite improvements, several barriers to good migraine outcomes still exist
•
Several disorders are comorbid to migraine. They complicate diagnosis and treatment
•
In a subgroup, migraine progresses. Risk factors for progression have been identified and should be screened and treated.