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Construct Overview of Headaches

Please note that this section is an archive and is no longer being updated.

Background

Headache is associated with a variety of health conditions, but frequently occurs in the absence of other pathology or injury. Primary headache is classified according to symptom-related criteria established by the International Headache Society (IHS). The three major categories for primary headache are migraine, tension-type headache, and cluster headache¹. Tension-type headache is the most prevalent of these conditions, but is typically sporadic in occurrence². Migraine, in contrast, often has a chronic course³. Cluster headache is the most uncommon form, with a prevalence of less than 1%.⁴ Cluster headache is marked by severe unilateral pain localized near the eye, short-lived attacks, and periods of full remission.

Episodic headache and recurrent headache disorders are associated with significant burden. Headache among the U.S. workforce was attributed to an estimated $19.6 billion annual loss in productive time⁵. According to the World Health Organization (WHO), migraine is the 20th leading cause of disability worldwide, and the 9th leading cause of disability among women⁶. Given the disability and associated public health burden attributed to headache disorders, in March 2000 the WHO Department of Mental Health and Substance Dependence called a meeting of representatives (including physicians and lay representatives) from 27 countries to discuss headache awareness, epidemiology, methodology, and recommendations. Their findings and recommendations were published in the key document, "Headache Disorders and Public Health."

VA Relevance

Headache is prevalent among the U.S. adult population. Migraine alone affects approximately 6.5% of men and 18.2% of women⁷ and is believed to be widely underdiagnosed and undertreated⁸. Few studies have examined the prevalence or treatment of primary headache in the VA population specifically, although one study identified a perceived need among women veterans for headache care⁹.

Chronic pain, including headache, is often comorbid with posttraumatic stress disorder (PTSD)¹⁰, a condition that is prevalent among some subgroups of the veteran population. A study conducted in a VA outpatient clinic reported that approximately one-third of combat veterans with PTSD reported chronic headache¹¹. Headache is also one of the most frequently reported health complaints associated with Gulf War-era service. In a large population-based study, 23% percent of deployed Gulf War veterans reported headache, compared to 8% of non-deployed controls¹².

Measurement

Pain is a personal, subjective experience, and as such no objective measures of headache severity are available. Subjective ratings of headache pain are commonly used in clinical research, often assessed by means of hourly or daily diary instruments. Headache diary instruments typically assess headache frequency, intensity/severity, and duration; secondary parameters may include medication use, affect/distress, or behavioral indicators¹³. Diary-based assessment techniques vary among studies, although the IHS has published clinical trial endpoint guidelines that may inform the development of diary measures¹⁴.

When using diary measures to assess headache, respondent burden should be taken into careful consideration. Requiring continuous or hourly diary entries may compromise respondent compliance and data integrity. Other strategies, such as time-sampling formats, may improve compliance at the expense of recall bias (for further discussion of diary-based assessment methods, see Andrasik¹³).

Alternative approaches to the assessment of headache tend to be retrospective, more global in nature, and take into account the effects of headache on quality of life and functional status. Such measures have largely emerged within the past decade and represent a shift of focus from symptom frequency/severity to functional and quality of life-related sequelae of headache. Advantages of these measures include their ease of use and their ability to assess the broader impact of headache. However, these measures do not show good concordance with diary-based assessments¹⁵ and should not be considered interchangeable.

Through literature review, METRIC identified three commonly used self-report instruments for measuring headache. These are ranked according to number of citations, as determined by the ISI Web of Knowledge¹⁶. What follows is a brief summary of each instrument and three applicable references.

Most Frequently Cited Instruments

1. Migraine Disability Assessment Questionnaire (MIDAS)
   [87 Citations]
2. Headache Disability Inventory (HDI)
   [55 Citations]
3. Migraine Quality of Life Questionnaire (MQoLQ)
   [52 Citations]

1. International Headache Society. The International Classification of Headache Disorders (2nd edition, 1st revision). Accessed September 2005. Available: http://www.i-h-s.org.
2. Schwartz BS, Stewart WF, Simon D, Lipton RB. Epidemiology of tension-type headache. JAMA 1998;279:381-383. [Abstract]
3. Ferrari MD. Migraine. Lancet 1998;351:1043-1051. [Abstract]
4. Russell MB. Epidemiology and genetics of cluster headache. Lancet 2004;3:279-283. [Abstract]
5. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in US workface. JAMA 2003;290:2443-2454. [Abstract]
6. Leonardi M, Mathers C. Global burden of migraine in the year 2000: Summary of methods and data sources. World Health Organization. Accessed September 2005. Available: http://www.who.int/en/.
7. 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;41:646-657. [Abstract]
8. Lipton RB, Scher AI, Steiner TJ, Bigal ME, Kolodner K, Liberman JN, Stewart WF. Patterns of health care utilization for migraine in England and in the United States. Neurology 2003;60:441-448. [Abstract]
9. Pierce PF, Antonakos C, Deroba BA. Health care utilization and satisfaction concerning gender-specific health problems among military women. Mil Med 1999;164:98-102. [Abstract]
10. Asmundson GJ, Coons MJ, Taylor S, Katz J. PTSD and the experience of pain: Research and clinical implications of shared vulnerability and mutual maintenance models. Can J Psychiatry 2002;47:930-937. [Abstract]
11. Beckham JC, Crawford AL, Feldman ME, Kirby AC, Hertzberg MA, Davidson JR, Moore SD. Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans. J Psychosom Res 1997;43:379-389. [Abstract]
12. Doebbeling BN, Clarke WR, Watson D, Torner JC, Woolson RF, Voelker MD, Barrett DH, Schwartz DA. Is there a Persian Gulf War syndrome? Evidence from a large population-based survey of veterans and nondeployed controls. Am J Med 2000;108:695-704. [Abstract]
13. Andrasik F. Assessment of patients with headache. In Turk DC, Melzack R (Eds). Handbook of pain assessment (2nd Ed). New York: Guilford Press; 2001.
14. Tfelt-Hansen P, Block G, Dahlof C, Diener HC, Ferrari MD, Goadsby PJ, Guidetti V, Jones B, Lipton RB, Massiou H, Meinert C, Sandrini G, Steiner T, Winter PB; International Headache Society Clinical Trials Subcommittee. Guidelines for controlled trials of drugs in migraine: Second edition. Cephalalgia 2000;20:765-786. [Abstract]
15. Cahn T, Cram JR. Changing measurement instrument at follow-up: A potential source of error. Biofeedback Self Regul 1980;5:265-273. [Abstract]
16. ISI Web of Knowledge. Accessed September 2005. Available: http://isi01.isiknowledge.com/portal.cgi/wos/.