Neglected headache: ignorance, arrogance or insouciance?

Headache is one of the most frequent medical complaints. Almost everybody has experienced it, 50–80% of adults from all countries report it as a recurring nuisance, 10–20% are at least sometimes disabled by it, and up to 3% bear it – with varying levels of difficulty – on more days than not (1). The consequences, not only pain but also disability, financial losses and impaired quality of life, are well known to all who work in the field. We write about them constantly. Over a decade ago, the World Health Organization (WHO) ranked migraine alone as the nineteenth highest cause of disability worldwide (2), and they have recognized it since as a public-health priority (3,4). Headache is the most frequent cause of consultation in both primary care and neurological practice, and, on top of this, headache promotes many visits to internists, ENT specialists, ophthalmologists, dentists, orthopaedic surgeons, psychologists and the proponents of a wide variety of complementary and alternative medical practices (4). Headache is far from unknown as a presenting symptom in emergency departments. So one would assume that a disorder so highly prevalent, and with such adverse consequences for people and the societies to which they belong, would be considered an important medical problem by people affected by them, by health-care providers and by health policy-makers everywhere. In Germany, Radtke and colleagues, reporting a study of 7431 adults (5), tell a quite different story: that ‘‘self-awareness and medical recognition of migraine are low’’. On the one hand, only 70% of people whose headaches met ICHD-II criteria for migraine recognized them as such; on the other, fewer than two-thirds of those who consulted a physician in the previous year, for headache, reported that migraine had been identified. Among apparent misdiagnoses, tension-type headache was most common (56%) but, depressingly, 9% were labelled with the non-existent disorder of ‘‘sinus headache’’. How robust are these findings? The study was part of a survey covering a wide range of health-related issues; it was large and population-based (6). Participants were randomly selected, and diagnosed by modified ICHDII criteria using computer-assisted telephone interviews. The estimated 1-year prevalence of migraine was 10.6% (15.6% in women and 5.3% in men), lower than in most surveys of Western Europe (7). If cases were missed, as seems likely, the reason lay probably in the screening question, which allowed the enquiry to proceed only when severe headache was reported in the previous year (not all migraine headaches are severe). If this led to ascertainment bias, it was towards those worse affected, and therefore consultation rates might be relatively high. Yet, only 41% of identified cases had made their way to a doctor. Radtke and colleagues did not report participation rate. Selection bias is likely in all telephone surveys, and enquiry over the past year is at the mercy of recall bias. Nevertheless, the pertinent finding of unconcern is entirely in line with others from elsewhere. The WHO’s survey of 102 countries (4) ‘‘illuminates the worldwide neglect of a major public-health problem, and reveals the inadequacies of responses to it in countries throughout the world’’ (our emphasis). Where economic constraints and social disparities mean that medical care is not freely accessible, this may, to some extent, be expected. (This is not to say that unconcern is justified: for example, in countries of the former Soviet Union, including Russia and Georgia, medical care for people with headache is