46 Headache Medicine, v.2, n.2, p.46-49, Apr./May/Jun. 2011

The need for preventive therapy in primary

headaches

A necessidade da terapia preventiva nas cefaleias primárias

BSTRACTBSTRACT

BSTRACT

Introduction:Introduction:

Introduction: Primary headaches are common conditions.

In Brazil, the prevalence of migraine is 15.2%, tension-type

headache 13% and chronic daily headache (CDH) 6.9%.

Although frequent disorders a proportion of patients are

undertreated. Patients patterns of headache care can trend

toward acute medication only and those in need of prevention

may not receive it.

Objective: Objective:

Objective: To estimate the rates of

preventive treatment in primary headache sufferers.

Methods:Methods:

Methods: A telephone interview containing questions about

headache and socio-demographic characteristics was applied

to 3,848 people from 27 States of Brazil, in its five geographical

regions. We considered MIDAS > 10 points as a marker for

the need of preventive treatment. Patients were asked if they

were taking any medication on a daily basis or any treatment

to prevent headaches from happening. Subjects were divided

into: 1. Those who responded positively for the question

regarding preventive treatment regardless of the treatment

type. 2. Those who responded positively for the question,

but only medications or treatments studied for migraine

prevention, labeled as "Correct treatment" 3. Those who

responded positively for the question, but only medications

or treatments from the prevention consensus (Brazilian

Headache Society), labeled as "Consensus treatment"

Results: Results:

Results: In total, 12.8% of primary headache sufferers had

MIDAS higher than 10, meeting criteria for prophylactic

treatment, but only 8.4% of them reported it, 3.9% were using

a right preventive treatment. The percentage of patients in

need for prevention was 24.7% in migraine, 15.6 % in

probable migraine, 5 % for tension-type headache (TTH)

ORIGINAL ARTICLEORIGINAL ARTICLE

ORIGINAL ARTICLE

Mario Fernando Prieto Peres

1,2,3

, Daniel Krempel Amado

, André Leite Gonçalves

1,2,3

, Reinaldo Ribeiro

1,2,3

Jorge Roberto Pagura

1,2

, Luiz Paulo de Queiroz

Instituto Israelita de Ensino e Pesquisa Albert Einstein – São Paulo, SP

Faculdade de Medicina do ABC

Universidade Federal de São Paulo – UNIFESP-EPM – São Paulo, SP

Universidade Federal de Santa Catarina – UFSC – Florianópolis, SC

Peres MF, Amado DK, Gonçalves AL, Ribeiro R, Pagura JR, Queiroz LP.

The need for preventive therapy in primary headaches. Headache Medicine. 2011;2(2):46-49

and 4% for probable TTH. Only 2.6% of migraineurs, 7.5%

of probable migraine patients, 4.3% of tension-type headache

and 0% of probable TTH received proper preventive treatment

Conclusion:Conclusion:

Conclusion: Primary headaches are common, debilitating

conditions but a substantial proportion of those who might

need prevention do not receive it. Patient education, public

health initiatives in order to deliver migraine and other primary

headaches treatment for the general population should be

considered not only in Brazil, but worldwide.

eywords:eywords:

eywords: Migraine; Tension-type headache; Prevention,

epidemiology.

RESUMORESUMO

RESUMO

ntrodução:ntrodução:

ntrodução: As cefaleias primárias são condições comuns.

No Brasil, a prevalência da migrânea é 15,2%, da cefaleia

do tipo tensional é 13% e da cefaleia crônica diária (CDH),

6,9%. Apesar de tratar-se de doenças frequentes, uma

proporção dos pacientes é subtratada. Os padrões de

manejo da cefaleia dos pacientes podem levar ao uso

exclusivo de medicamentos para o tratamento agudo das

crises, e aqueles que necessitam de prevenção podem não

recebê-la.

Objetivo: Objetivo:

Objetivo: Estimar as taxas de tratamento

preventivo entre os indivíduos portadores de cefaleias

primárias.

Métodos: Métodos:

Métodos: Uma entrevista telefônica contendo

questões sobre cefaleia e características sociodemográficas

foi aplicado a 3.848 pessoas de 27 estados brasileiros, nas

suas cinco regiões demográficas. Nos consideramos um

escore na escala MIDAS>10 pontos como um marcador

da necessidade de tratamento preventivo. Os pacientes foram

questionados quanto ao uso de qualquer medicação em

Headache Medicine, v.2, n.2, p.46-49, Apr./May/Jun. 2011 47

INTRODUCTION

Primary headaches are common disorders

worldwide.

In Brazil, the prevalence of migraine is

15.2%,

tension-type headache 13%

and chronic daily

headache (CDH) 6.9%.

Most headache sufferers have

high frequency of attacks during the productive years

of their lives, disrupting their capacity to work on the

migraine days. Even if not absent from work, these

sufferers have lower productivity during the headache

attacks.

5-6

Migraine and other primary headaches treatment can

be acute and preventive. Frequent headaches should be

treated preventively, with cautious use of acute

medications. Patients patterns of headache care can trend

toward acute medication only and those in need of

prevention may not receive it.

In the American Migraine Prevalence Study (AMPP)

25.7% of migraineurs met criteria for prophylaxis, but just

13.0% reported current use of daily preventive migraine

medication. More than one in four migraineurs are

candidates for preventive therapy, but the majority who

might benefit from prevention do not receive it.

Based on the Brazilian Headache Epidemiology

Study we evaluated the number of candidates for

prophylaxis in sufferers of different types of primary

headaches, and the proportion of individuals receiving it,

estimating the degree of under treatment in our population.

METHODS

Sample and SurveySample and Survey

Sample and Survey

The Brazilian Headache Epidemiology Study is an

observational, cross-sectional population-based study.

3,848 telephone interviews were made (2,307 for females

and 1,541 for males). The subjects aged 18-79 year,

and were from 27 States of Brazil, in its five geographical

regions.

A detailed description of its methodology is published

elsewhere.

2-4

The questionnaire included questions about socio-

demographic characteristics of the population, as well as

questions about headache, based on the second edition

of the International Classification of Headache Disorders

(ICHD-II).

atterns of medical treatmentatterns of medical treatment

atterns of medical treatment

The interview contained the MIDAS' questionnaire,

and questions about frequency, intensity, localization,

duration of headache, preventive and acute medication

use. Then we stipulated MIDAS > 10 points as a marker

for the need of preventive treatment. Patients were asked

if they were taking any medication on a daily basis or any

treatment to prevent headaches from happening. The

percentage of subjects who used preventive medication

was divided into 3 groups: 1. Those who responded

positively for the question regarding preventive treatment

regardless of the treatment type; 2. Those who responded

positively for the question, but only medications or

treatments studied for migraine prophylaxis, labeled as

"Correct treatment"; 3. Those who responded positively

for the question, but only medications or treatments from

the prevention consensus (Brazilian Headache Society),

labeled as "Consensus treatment".

THE NEED FOR PREVENTIVE THERAPY IN PRIMARY HEADACHES

um padrão diário ou de qualquer tratamento para prevenir

a ocorrência de crises de cefaleia. Os indivíduos foram

divididos em: 1. Aqueles que responderam positivamente à

questão sobre o tratamento preventivo, independentemente

do tipo de tratamento. 2. Aqueles que responderam

positivamente à questão, mas apenas com medicamentos

ou tratamentos estudados no tratamento preventivo da

migrânea, rotulados como "tratamento correto". 3. Aqueles

que responderam positivamente à questão, mas apenas com

medicamentos ou tratamentos citados no consenso sobre

tratamento profilático da Sociedade Brasileira de Cefaleia,

rotulados como "tratamento consenso".

Resultados: Resultados:

Resultados: No

total, 12,8% dos indivíduos acometidos por cefaleias

primárias apresentaram MIDAS maior que 10, preenchendo

critérios para tratamento profilático, porém apenas 8,4%

deles relataram-no, apenas 3,9% destes utilizando um

tratamento correto. A porcentagem dos pacientes neces-

sitando de prevenção foi 24,7% na migrânea, 15,6% na

migrânea provável, 5% na cefaleia do tipo tensional e 4%

na cefaleia do tipo tensional provável. Apenas 2,6% dos

migranosos, 7,5% pacientes com migrânea provável, 4,3%

daqueles com cefaleia do tipo tensional e 0% daqueles com

cefaleia do tipo tensional provável receberam tratamento

preventivo adequado.

Conclusão:Conclusão:

Conclusão: As cefaleias primárias

são condições debilitantes e comuns, porém uma proporção

substancial daqueles que poderiam necessitar de prevenção

não a recebem. Educação dos pacientes e iniciativas de

saúde pública voltadas a proporcionar à população trata-

mento para a migrânea e outras cefaleias primárias devem

ser consideradas não apenas no Brasil, mas globalmente.

alavrasalavras

alavras

chaves:chaves:

chaves: Enxaqueca; Migrânea; Cefaleia do tipo

tensional; Prevenção, Epidemiologia.

48 Headache Medicine, v.2, n.2, p.46-49, Apr./May/Jun. 2011

Data analysisData analysis

Data analysis

Data from subjects were analyzed as previously

described to estimate prevalence and variation in

prevalence by demographic factors. Fisher or chi square

were used to estimate proportions, p<0.01 was

considered significant.

RESULTS

In total, 12.8% of primary headache sufferers were

in MIDAS higher than 10, meeting study criteria for

prophylactic treatment. Only 8.4% of patients reported

this type of treatment (91.6% did not receive prevention),

and 3.9% were using any right preventive treatment.

Migraine affected 15.2% of the Brazilian population,

24.7% had MIDAS higher than 10, 6.1% of the entire

population should receive a prophylactic treatment,

approximately 11,685,000 individuals (estimated

Brazilian population by 2010 is 190,000,000 inhabitants).

Only 2.6%, however, were receiving a correct preventative

treatment.

Tension-type headache prevalence was 13%, 5%

should receive prevention by the same criteria, 0.65% of

the entire population (1,235,000 individuals), but again,

only 4.3% of TTH sufferers reported using a right

prophylactic medication.

Figure1. One-year prevalences for primary headaches in the general

Brazilian population and proportion of patients with MIDAS higher

than 10. TTH: tension-type headache, PTTH: probable tension-type

headache, PM: probable migraine.

The number of patients who presented MIDAS

higher than 10 was significantly more common in

migraine patients than probable migraine patients

(p<0.001).

Probable migraine and probable tension-type

headache also followed the same pattern (Figure 1 shows

general prevalences of primary headaches and

proportion of patients with MIDAS higher than 10).

Probable migraine was found in 14.9% of the

population, 15.6% needed prevention (2.3 % of the

population, 4,370,000 individuals), but only 7.5%

received proper preventive treatment. Probable tension-

type headache was present in 11%, 4% needed

prevention (0.44% of the population, 860.000

PERES MF, AMADO DK, GONÇALVES AL, RIBEIRO R, PAGURA JR, QUEIROZ LP

Headache Medicine, v.2, n.2, p.46-49, Apr./May/Jun. 2011 49

individuals), none of the patients reported receiving

preventive treatment.

Adding migraine with probable migraine, considering

both as only one disease, 30.1% of the population would

be affected, 8.4% of the whole population would need

prophylaxis, 16,055,000 people. Table 1 describes the

total number of primary headache diagnosis patients,

number of patients with MIDAS higher than 10 and number

of patients who reported any prevention treatment.

DISCUSSION

Our study shows a significant undertreatment of

primary headaches in Brazil. In average more than 90%

of those in need of preventive treatment are not getting

appropriate treatment. Migraine showed the highest rates

of both prevalence and impact.

Migraine and probable migraine patients in need

for prevention, together, accounted for a total of 8.4% of

the Brazilian population. It is a major public health issue

that should be dealt with. However, no public health policy

is current available for the management of migraine

disorders in Brazil. Interestingly probable migraine had a

higher rate for preventive treatment compared to migraine.

We used MIDAS higher than 10 as a criteria for

prevention treatment need. We choose this arbitrary cut

point in order to meet not only a minimum of headache

frequency but also headaches with a certain impact.

Considering MIDAS refers to 3 months, eleven points

would translate into three headache days with at least

50% of disability. Most of the migraine prophylaxis

consensus worldwide suggest start a medication or

intervention with 2 or 3 attacks per month. We think the

measure chosen here is better than just headache

frequency.

Migraine undertreatment is also present in other

countries. The AMPP study

showed that 25.7% of

migraineurs needed prevention, compared to 24.7%

found in our study. Only 13.0% of sufferers in the US

were taking daily preventive medication, but in our sample,

a lot less (2.6%) patients were on prophylaxis.

The national French migraine study (FRAMIG 2000)

found that only 6% of migraine sufferers actually took a

true prophylactic treatment, and another 4% mistakenly

considered the analgesics they took daily as prophylactic

treatments.

Improve the rate of migraine prevention is one of the

most important challenges in neurological practice, public

health initiatives should be focus this issue.

Correspondence

DrDr

. Mario F. Mario F

. Mario F

. P. P

. P

. P. P

. P

ereseres

eres

R. Joaquim Eugenio de Lima, 881 cj 708

Sao Paulo – Brazil

http://cefaleias.com.br

CONCLUSION

Migraine and tension-type headache are common,

severe, debilitating neurological conditions but a

substantial proportion of those who might need prevention

do not receive it.

Patient education, public health initiatives in order to

deliver migraine and other primary headaches treatment

for the general population, as well as continuing medical

education in all levels (medical school, residency, internal

medicine, family medicine, ginecology, pediatrics,

neurology) should be considered not only in Brazil, but

worldwide.

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THE NEED FOR PREVENTIVE THERAPY IN PRIMARY HEADACHES