Beruflich Dokumente
Kultur Dokumente
Neuroepidemiology 2010;35:5965
DOI: 10.1159/000310940
Department of Neurology, University Hospital Sestre milosrdnice, Reference Centers for Headaches and
Neurovascular Disorders of the Ministry of Health of the Republic of Croatia, and b Research Department, Childrens
Hospital Srebrnjak, Zagreb, c Department of Neurology, University Hospital Split, Split, d Department of Neurology,
University Hospital Osijek, Osijek , and e Department of Neurology, General Hospital Dubrovnik, Dubrovnik , Croatia
Key Words
Migraine Probable migraine Tension-type headache
Croatia
Abstract
Background/Aim: Population-based epidemiological studies about headaches, especially migraine, have been carried
out in many countries. The aim of this study was to assess the
1-year prevalence of migraine, probable migraine and tension-type headache (TTH) in the Croatian population. Methods: The design of the study was a cross-sectional survey of
an adult population sample using a self-completed questionnaire. Results: The 1-year crude prevalence of migraine
without and with aura in this study was 7.5%, of probable
migraine 11.3%, and of TTH 21.2%. The 1-year age- and sexadjusted prevalence of migraine was 6.2%, of probable migraine 8.8%, and of TTH 20.7%; the prevalence of migraine
combined with probable migraine was 15.0%. Total crude
prevalence of headache (combination of migraine, probable
migraine and TTH) was 39.9%. Prevalence of migraine was
higher in continental than in Mediterranean areas of Croatia.
Multivariate regression analysis showed that the highest risk
of suffering from any kind of headache is observed for the
Introduction
Population-based epidemiological studies about headaches, especially migraine, have been carried out in many
countries. The 1-year prevalence of migraine has been
estimated to range from 3 to 24.6% and for tension-type
headache (TTH) from 21.7 to 86.5%, whereas the lifetime
prevalence of migraine has been estimated to range from
3.1 to 27.5% and for TTH from 12.9 to 78%, depending on
the study population and methods of assessment [1, 2].
According to these studies, migraine is present in 629%
of women and 312% of men depending on the data
source [1].
The majority of epidemiological studies were undertaken before the second edition of the International ClasVlasta Vukovi, MD, PhD
Department of Neurology
University Hospital Sestre milosrdnice
Vinogradska c. 29, HR10 000 Zagreb (Croatia)
Tel. +385 1 3787 752, Fax +385 1 376 8282, E-Mail vlasta.vukovic@uclmail.net
sification of Headache Disorders (ICHD-2) [3] and assessed the prevalence of strict migraine. Since clinical
and epidemiological studies show that a proportion of the
studied population does not fulfill all criteria for migraine but clinically most likely have migraine, a subgroup of probable migraine was introduced. Some studies published before the ICHD-2 criteria have classified
migraine that does not fulfill all criteria for migraine as
border-line migraine [4, 5] and others as probable migraine which refers to the migraineur disorder in the
ICHD-1 (1.7) [68].
The only epidemiological population-based survey
carried out in Croatia was in 2001, and the study population consisted of all residents aged 1565 years of the city
Bakar [9].
The aim of this study was to assess the 1-year prevalence of migraine, probable migraine and TTH in the
Croatian population.
Methods
The design of the study was a cross-sectional survey of an adult
population sample using a self-completed questionnaire. The survey was conducted from March to October 2006 in 4 Croatian cities: Zagreb, Split, Osijek and Dubrovnik. The study population included adults 618 years of age. General practice registers provide
a convenient frame for sampling a local population [10]. In Croatia,
96% of the population are registered with a general practitioner
(GP), so the sample represents 4,437,000 Croatian adults [11]. Approximately 7002,000 patients are registered with 1 general practice. The questionnaires were distributed in general practices to get
a mix of urban, suburban and rural settings, and a spread of social
classes. The GPs (18 in total: 7 in Zagreb, 2 in Osijek, 4 in Dubrovnik and 5 in Split) were randomly selected by a computer from
a national list and then contacted by phone by our researchers. All
GPs who were contacted agreed to participate in this study. The
GPs selected patients randomly from their computer database; we
did not apply any formal (computerized) method of randomization: the GPs were asked to choose a list of any 110120 patients
from their database. The nurse then contacted the patients by
phone, explained the purpose of the study and if the patient gave
consent to participate in the survey (fill out the questionnaire), the
questionnaire was sent by mail. Gender distribution was approximately the same at the beginning of the study (questionnaires were
sent to 2,070 inhabitants: 50% men and 50% women).
The questionnaire comprised 3 sections. Section 1 consisted
of questions regarding demographic data (age, gender, education,
marital status, employment and place of living). Section 2 consisted of questions regarding the presence of headache, such as: (a)
Do you suffer from headaches? (b) Do you suffer from migraine?
The patients have been instructed to respond to section 2 with
no if they had not suffered from headaches within the past year,
or had no more than 1 mild headache attack not requiring treatment. If the respondents answered yes to section 2, they were
asked to complete the rest of the questionnaire (section 3). Section
60
Neuroepidemiology 2010;35:5965
3 included questions that aimed to define the nature of the headache according to the ICHD-2 criteria for migraine and TTH [3].
The algorithm classified headache sufferers into three groups: (a)
migraine fulfilling ICHD-2 criteria for migraine without or
with aura (ICHD-2 1.1 and 1.2); (b) probable migraine respondents were categorized as having probable migraine if they fulfilled all but 1 criteria for migraine (ICHD-2 1.6); (c) TTH fulfilling the criteria for TTH (ICHD-2).
Patients who had migraine and TTH were classified into the
group of migraine.
The questionnaire was designed using a combination of similar studies, the ICHD-2 criteria and advice from epidemiologic
researchers. The respondents were asked to tick one or more offered answers to the questions regarding the description of their
headaches in terms of pain location, headache frequency, character of pain, duration of pain, pain intensity, associated symptoms
and the presence of aura symptoms.
On return, the questionnaires were checked for completeness
and questionnaires containing more than 1 unanswered question
from any of the 3 sections were excluded from the final analysis.
The diagnosis of migraine, probable migraine and TTH was
assessed by 2 authors (V.V. and D.J.) and the 1-year prevalence
(crude and age- and sex-adjusted) was calculated. Demographic
characteristics of patients with and without headache were analyzed as well as of the patients with headaches according to headache subtype. The study had been approved by the committee for
research ethics.
Statistical Analysis
Data analysis was performed using the Statistica for Windows
release 6.0. Continuous variables were summarized as mean and
standard deviation. Categorical variables were summarized as
number and percentage. In the statistical analysis, the 2 test was
used to compare the distribution of categorical variables between
subgroups and the Student t test to compare continuous variables.
The gender- and age-adjusted prevalence was also calculated.
Univariate and multivariate logistic regression analysis was used
to identify the odds ratios (ORs) with 95% confidence intervals
(CIs) for having a headache, and its subtypes according to demographic characteristics of the population in question. Statistical
significance was considered at p ! 0.05.
Results
Demographic
characteristic
City
Zagreb
Split
Dubrovnik
Osijek
Women
Age (mean8SD)
Education
Elementary
High school
College
University
NA
Marital status
Married
Not married
Widower
Divorced
NA
Employment
Employed
Not employed
Student
Retired
NA
Place of living
City
Suburb
Rural area
NA
Total
Headache
(n = 1,542) (n = 640)
No
headache
(n = 902)
p
value
<0.0001
333 (36.9)
285 (31.6)
150 (16.6)
57 (6.3)
474 (52.5) <0.0001
0.4533
42817
0.6754
183 (11.9) 78 (12.2) 105 (11.6)
827 (53.6) 350 (54.7) 477 (52.9)
49 (7.7)
84 (9.3)
133 (8.6)
150 (23.4) 204 (22.6)
354 (23)
43 (2.8)
0.0095
814 (52.8) 369 (57.7) 445 (49.3)
553 (35.9) 202 (31.6) 351 (38.9)
56 (3.6)
20 (3.1)
36 (4.0)
66 (4.3)
29 (4.5)
37 (4.1)
52 (3.4)
<0.0001
895 (58)
408 (63.8) 487 (54.0)
228 (14.8) 90 (14.1) 138 (15.3)
185 (12)
68 (10.6) 117 (13.0)
203 (13.2) 58 (9.1) 145 (16.1)
31 (2.0)
0.1024
402 (62.8) 585 (64.9)
987 (64)
414 (26.8) 189 (29.5) 225 (24.9)
120 (7.7)
43 (6.7)
76 (8.4)
21 (1.4)
578
485
307
95
926 (60.1)
42817
245 (38.3)
200 (31.3)
157 (24.5)
38 (5.9)
452 (70.6)
42814
Prevalence
Crude
Women
Men
Age-adjusted
Women
Men
Total, %
Crude
Age-adjusted
Age- and sex-adjusted
Migraine
(n = 115)
88 (9.5)
27 (4.6)
138 (14.9)
36 (6.1)
226 (24.4)
63 (10.7)
215 (23.2)
112 (19.1)
441 (47.6)
175 (28.4)
76.8 (8.3)
24.6 (4.0)
113.7 (12.3)
31.1 (5.0)
190.5 (20.6)
55.7 (9.0)
220.8 (23.8)
105.5 (17.1)
411.3 (44.4)
161.2 (26.1)
7.5
6.7
6.2
11.3
9.4
8.8
18.7
16.0
15.0
21.2
21.2
20.7
39.9
37.1
35.7
Neuroepidemiology 2010;35:5965
61
headache subtype
Demographic
characteristic
City
Zagreb
Split
Dubrovnik
Osijek
Women
Age (mean8SD)
Education
Elementary
High school
College
University
NA
Marital status
Married
Not married
Widower
Divorced
NA
Employment
Employed
Not employed
Student
Retired
NA
Place of living
City
Suburb
Rural area
NA
Probable
migraine
(n = 174)
p
value
Migraine
(n = 115)
TTH
(n = 327)
50 (43.5)
28 (24.4)
25 (21.7)
12 (10.4)
88 (77.9)
43814
13 (11.5)
58 (51.3)
10 (8.9)
32 (28.3)
2 (1.7)
40 (12.4)
197 (60.8)
28 (8.6)
59 (18.2)
18 (10.8)
85 (50.9)
9 (5.4)
55 (32.9)
0.0529
65 (59.1)
35 (31.8)
5 (4.6)
4 (3.6)
6 (5.2)
198 (62.1)
94 (29.5)
10 (3.1)
17 (5.3)
95 (55.6)
65 (38.0)
4 (2.3)
7 (4.1)
0.3034
76 (67.9)
14 (12.5)
9 (8.0)
13 (11.6)
3 (2.6)
72 (63.7)
35 (31.0)
6 (5.3)
2 (1.7)
0.07303
(95% CI, 1.171.95) for TTH (table2). In our study, women had an ORage-adjusted of 2.26 (95% CI, 1.812.82) for any
headache type compared with men (p = 0.0042; table3).
The level of education in our study was not significantly different among respondents with or without
headache (p = 0.675). However, analysis of headache subgroups showed that more educated participants suffered
from migraine or probable migraine than from TTH
alone, while respondents who have elementary or high
school education more frequently suffered from TTH
(p= 0.053; table3).
Married (45.3%) and divorced (43.9%) respondents were
more likely to suffer from headaches than single (36.5%) or
widowed (35.7%) respondents (p = 0.0095; table1).
62
Neuroepidemiology 2010;35:5965
Table 4. Crude and age- and sex-adjusted prevalence of subtypes of headache with ORs according to the geographic region (Zagreb
and Osijek are in the continental part; Split and Dubrovnik are in the Mediterranean part of Croatia)
Demographic characteristic
Crude
Zagreb (n = 578)
Split (n = 485)
Dubrovnik (n = 307)
Osijek (n = 95)
Age- and sex-adjusted
Zagreb (n = 578)
Split (n = 485)
Dubrovnik (n = 307)
Osijek (n = 95)
TTH (n = 327)
cases
(prevalence, %)
cases
(prevalence, %)
OR
(95% CIs)
OR
(95% CIs)
149 (25.8)
89 (18.4)
32 (10.4)
19 (20.0)
2.98 (1.994.55)
1.93 (1.263.01)
1.00 reference
2.14 (1.133.99)
85 (14.7)
102 (21.0)
122 (39.7)
18 (18.9)
1.00 reference
1.54 (1.122.12)
3.82 (2.765.29)
1.36 (0.762.35)
133.9 (23.2)
72.4 (14.9)
25.4 (8.3)
14.5 (15.3)
3.34 (2.175.35)
1.95 (1.223.18)
1.00 reference
2.00 (1.054.20)
83.5 (14.4)
97.7 (20.1)
129.9 (42.3)
15.2 (16.0)
1.00 reference
1.49 (1.082.05)
4.34 (3.135.97)
1.13 (0.612.01)
Neuroepidemiology 2010;35:5965
63
Neuroepidemiology 2010;35:5965
Acknowledgement
This study was supported in part by a grant from GSK.
References
6 Henry P, Auraray JP, Gaudin AF, et al: Prevalence and clinical characteristics of migraine in France. Neurology 2002; 59: 222
227.
7 Rains JC, Penzien DB, Lipchik GL, Ramadan
NM: Diagnosis of migraine: empirical analysis of a large clinical sample of atypical migraine (IHS 1.7) patients and proposed revision of the IHS criteria. Cephalalgia 2001;21:
584595.
8 Lipton RB, Cady R, Dodick D, Diamond M:
Demographics of migrainous headache sufferers in the United States: additional data
from the American Migraine Study II. Headache 2002;42:440.
9 ivadinov R, Willheim K, Jurjevi A, SepiGrahovac D, Bucuk M, Zorzon M: Prevalence of migraine in Croatia: a populationbased survey. Cephalalgia 2001;41:805812.
10 Bowling A: Research Methods in Health: Investigating Health and Health Services.
Buckingham, Open University Press, 1997.
11 Hrvatski zavod za zdravstveno osiguranje.
2006. www.hzzo-net.hr.
12 Lyngberg AC, Rasmusen BK, Jorgensen T,
Jensen R: Has the prevalence of migraine and
tension-type headache changed over a 12year period? A Danish population survey.
Eur J Epidemiol 2005;20:243249.
13 Cheung RTF: Prevalence of migraine, tension-type headache and other headaches in
Hong Kong. Headache 2000;40:473479.
14 Takeshima T, Ishizaki K, Fukuhara Y, et al:
Population-based door-to-door survey of
migraine in Japan: the Daisen study. Headache 2004;44:819.
15 Pryse-Phillips W, Findlay H, Tugwell P, et al:
A Canadian population survey on the clinical, epidemiologic and societal impact of migraine and tension-type headache. 2. Can J
Neurol Sci 1992;19:333339.
16 Queiroz LP, Barea LM, Blank N: An epidemiological study of headache in Florianoplois, Brazil. Cephalalgia 2005;26:122127.
17 Lampl C, Buzath A, Baumhackl U, Klingler
D: One-year prevalence of migraine in Austria: a nation-wide survey. Cephalalgia 2003;
23:280286.
18 Schwartz BS, Stewart WF, Simon D, Lipton
RB: Epidemiology of tension type headache.
JAMA 1998;279:381383.
19 Jensen R, Symon D: Epidemiology of tension-type headaches; in Olesen J, Goadsby
PJ, Ramadan N, et al (eds): The Headaches,
ed 3. Philadelphia, Lippincott Williams &
Wilkins, 2005, pp 621624.
20 Kececi H, Dener S: Epidemiological and clinical characteristics of migraine in Sivas, Turkey. Headache 2002;42:275280.
21 Dahlf C, Linde M: One-year prevalence of
migraine in Sweden: a population-based
study in adults. Cephalalgia 2001; 21: 664
671.
36 Hagen K, Zwart JA, Vatten L, Stovner LJ, Bovim G: Prevalence of migraine and non-migrainous headache-head-HUNT, a large
population-based study. Cephalalgia 2000;
20:900906.
37 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;41:646657.
38 Lanez JM, Vioque J, Hernndez-Aguado I,
Titus F: Prevalence of migraine in Spain. An
assessment of the questionnaires validity by
clinical interview; in Olesen J (ed): Frontiers
in Headache Research. Health Classification
and Epidemiology. New York, Raven Press,
1994, pp 221225.
39 Roncolato O, Fabbri L, Recchia G, Cavazutti
L, Visona G, Bringoli O, et al: An epidemiological study to assess migraine prevalence
in a sample of Italian population presenting
to their GPs. Eur Neurol 2000;43:102106.
40 Gobel H, Petersen-Braun M, Soyka D: The
epidemiology of headache in Germany: a nationwide survey of a representative sample
on the basis of the headache classification of
the International Headache Society. Cephalalgia 1994;14:97106.
41 Roh JK, Kim JS, Ahn YO: Epidemiologic and
clinical characteristics of migraine and tension-type headache in Korea. Headache
1998;38:356365.
42 Perry Carson AL, Rose KM, Sanford CP,
Ephros SA, Stang PE, Hunt KJ, Brown A,
Szklo M: Lifetime prevalence of migraine
and other headaches lasting 4 or more hours:
The Atherosclerosis Risk in Communities
(ARIC) Study. Headache 2004;44:2028.
43 Classification and diagnostic criteria for
headache disorders, cranial neuralgias and
facial pain. Cephalalgia 1988;8(suppl 7):196.
44 Patel NV, Bigal ME, Kolodner KB, et al: Prevalence and impact of migraine and probable
migraine in a health plan. Neurology 2004;
63:14321438.
45 Silberstein S, Loder E, Diamond S, Reed ML,
Bigal ME, Lipton RB, on behalf of the AMPP
advisory group: Probable migraine in the
United States: results of the American Migraine Prevalence and Prevention (AMPP)
Study. Cephalalgia 2007;27:220229.
46 Aygul R, Deniz O, Kocak N, Orhan A, Ulvi
H: The clinical properties of a migrainous
population in eastern Turkey-Erzurum.
South Med J 2005;98:2327.
47 Kseoglu E, Naar M, Talaslioglu A, etinkaya F: Epidemiological and clinical characteristics of migraine and tension type
headache in 1,146 females in Kayseri, Turkey.
Cephalalgia 2003;23:381388.
48 Stang PE,Osterhaus JT: Impact of migraine
in the United States: data from the National
Health Interview Survey. Headache 1993;33:
2935.
49 Kryst S, Scherl E: A population-based survey
of the social and personal impact of headache. Headache 1994;34:344350.
Neuroepidemiology 2010;35:5965
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