Abstract
The authors have earlier reported a 1-year prevalence of 13.2 ± 1.9% for migraine in Sweden. This is a subsequent extensive postal survey of the burden of disease and attitudes among migraineurs in a sample (n = 423, 23% men and 77% women, aged 18-74 years) randomly recruited from all main regions of the country, representative of adults in the general Swedish population with self-considered migraine. Results are presented only from participants who after analysis of symptoms were found to fulfil the International Headache Society's migraine criteria. In order to assess headache duration open-mindedly, the strict time criterion 4-72 h was deliberately disregarded as an inclusion criterion. Individuals who did not consider themselves to have migraine were excluded. Less than half of the group (45%) had received a diagnosis of migraine from a physician. Accordingly, a large number of individuals that would not have come to attention in a clinic-based study have been included. The mean attack frequency was 1.3 per month, and the number of attacks per year in Swedish adults is approximately 10 million. A minority (27%) of sufferers have a majority (68%) of all attacks. The mean attack duration was 19 h. A considerable number of individuals reported attacks < 4 h (15.8%) or > 72 h (6.4%). Less than half of the individuals recovered completely between the attacks. Despite this, only every fourth (27%) participant was currently consulting a physician (6% regularly; 21% occasionally). Most of the migraineurs reported absence from school or work, a negative influence of migraine on the most important aspects of life, and an interest in testing other treatments for migraine during the last year. Of those (n = 231) migraineurs who had consulted a physician, about 60% were satisfied with information given or treatment offered. This implies, however, that there is still room for improvement in the management of migraine in Sweden.
Introduction
In an earlier epidemiological study (1), a randomly selected sample of 1668 adult Swedes were interviewed by telephone using a standardized questionnaire. The results obtained demonstrated that 21% of the Swedish population had suffered from severe headaches during the past year. A majority of these headache sufferers (61%) fulfilled the International Headache Society (IHS) criteria for migraine (2). The 1-year prevalence of migraine in Sweden was found to be 13.2 ± 1.9% (16.7% among women and 9.5% among men). The prevalence of migraine did not differ between the northern, middle and southern part of Sweden, or between urban and rural areas or different income groups. Based on the finding of a mean attack frequency of 1.3 per month, the total number of migraine attacks per year in Swedish adults is approximately 10 million. It could also be estimated that as many as 200 000 Swedes are unaware of the fact that their headaches are migraine (1).
In the long term, migraine can cause profound emotional changes and result in coping strategies that interfere with working, social and family life and many normal activities (3). There is still, both in Sweden and internationally, a marked lack of data on the burden of disease and attitudes among migraineurs in the general population. Because many sufferers do not consult physcians, community-based studies are required to obtain a complete picture of the disorder (4). The migraine patients’ organization in Sweden recently perfomed a postal survey (n = 261) on attitudes and impact of disease among their members (5). Due to its selection bias, however, the generalizability of these results is limited. We therefore present the results of the first nation-wide, comprehensive postal survey of self-considered migraineurs from the general Swedish population.
Methods
The presented study is a postal survey. Potential participants were recruited by telephone.
Sampling
From March to May 1997, sampling was performed by SIFO AB (Sifo Research & Consulting, Stockholm, Sweden), a national public opinion poll agency, by a method of randomized clustering in two major steps.
The basis for selection was the current 28 volumes of the national telephone catalogue. These were divided into the 70 different labour market regions in Sweden specified by the public statistics. The database of ‘Folk- och Bostadsräkningsdata’ provided further information on the number of households in each region. This was the basis for deciding how many individuals were included from each catalogue. Households without a telephone were not included in the sample. A computer program randomly chose the page, column and line in the catalogue. Numbers belonging to a company or a public authority were replaced by the closest following number. For every accepted number, nine additional numbers were generated by adding 1–9 to the last digit. Ex-directory phone numbers were thus picked up by this procedure. The result was an adequate number of bundles with 10 consecutive numbers from the same area code in each. The interviewer started with the top number in a bundle. If there was no answer, if it led to a company or a public authority, or if there was an unobtainable tone, the next number in the bundle was chosen. Numbers without reply were left in the bundle. This was repeated until an answer was received from a household. If there was no answer in a bundle, a spare bundle was chosen with the same area code.
When the interviewer came in contact with a household, he or she initially collected information on the number of Swedish-speaking household members in the age group 18–74 years. These were written down on consecutive lines in order of age, starting with the oldest. On every line, there was a random number deciding who should be interviewed.
The integrity of the selected persons was respected. All had a right to decline participation. If the chosen person was not at home, he or she was replaced by the youngest male in the first place, the youngest female in the second place, or another member of the household in the last place. The reason for this was that men and young individuals are more difficult to reach by phone.
Survey
A large group of lay interviewers above the age of 18, regularly engaged by SIFO, all of whom had undergone a special training course, administered an initial questionnaire by telephone. By way of introduction, the objective of the study and estimated expenditure of time was described to the individual. Verbal informed consent was obtained. The person was then asked a series of questions by way of a structured interview. The interviewers read their questions on a display. All questions had to be answered with yes or no, and the answers were fed directly into a computer. Successive questions were only visualized if motivated by earlier answers. On average, 7 min was required to complete each interview. Spot tests were performed, in which around 10% of the subjects were contacted by telephone again later on to check on household data, the performance of the interviewer and if the questionnaire had been applied correctly. Those who considered themselves to have migraine or migraine-like headache were invited to participate in an enlarged postal study.
Measures
We report here a translated version of the exact wording for those questions we found appropriate, while others, for the sake of the reader, are referred to more briefly. The first three questions aiming to screen for migraine were used both in the telephone interview and once again in the subsequent postal survey. The remaining questions appeared only in the postal survey.
I. Questions aiming to screen for considered migraine
The initial questions related to headache were if the interviewee had experienced a severe headache during the last year, if it could be considered very troublesome, whether or not they thought they had migraine or migraine-like headache, and if they had received a diagnosis of migraine from a physician.
II. Questions concerning characteristics of attacks
Detailed questions were then asked about the most severe type of headache during the last year. Prodromes were sought by asking if the subject could predict if an attack was on the way. They were asked directly if they ‘generally experience’ any aura symptoms (e.g. flashes of light during 5–60 min). No information was collected about the specific nature of aura disturbances. Specific symptoms associated with headaches including unilaterality, throbbing headache aggravated by physical exertion, sensitivity to light, sensitivity to sound and nausea and/or vomiting were registered. The subjects were asked what symptom they considered to be the most troublesome in the attacks (pain, nausea, photophobia, phonophobia or osmophobia).
III. Questions concerning time aspects
The questions concerning time were: For how long have you had migraine? How often do you have migraine? and What is the average duration of your attacks untreated or unsuccessfully treated?
IV. Questions concerning contacts with medical services
The initial question concerning contacts with medical services was: How regularly do you see a doctor because of your headaches? Those who had seen a physician were then asked to rate the experienced care/understanding, the physician's knowledge of migraine, and the information given on different treatment options. They were also asked how interested they were in treatments for migraine/migraine-like headache other than those they had already tried.
V. Questions concerning burden of disease
The first question on the impact of disease was: Do you completely recover from migraine symptoms between the attacks? They were then asked to estimate to what extent (very negative, quite negative, some negative influence, or not at all) the attacks influenced their prospects of making a career in their occupation, attendance at work, possibility of pursuing studies, family situation, finances, chances of having a meaningful leisure time, social position/relations, chances of finding new friends, ability to give and receive love and their sexual life. The last question on impact of disease was: How often are you absent from school/college or work (at home or other place of work) as a result of migraine/migraine-like headaches?
Case definition
Subjects were diagnosed in accordance with the most frequent type of headache experienced in the last year. The diagnosis in each case was reached via a questionnaire-based algorithm, constructed upon the 1988 IHS criteria for migraine with aura and/or migraine without aura (2). When analysing the attack duration in the postal survey, it was found that 15.8% of the attacks had a duration < 4 h and 6.4% longer than 72 h. An alternative diagnosis was used without taking the duration of the migraine attack into account but considering the other customary parameters of the HIS criteria (1). Migraine was thus diagnosed if the person had recurring headaches with at least two of the following characteristics: unilateral pain, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and at least one of the following; nausea and/or vomiting, phono- and photophobia.
Statistical analysis
All data were processed using the computerized, flexible crossorting program Diana® at SIFO in Stockholm. Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) software program (version 11.0 for MacOSX; SPSS Inc., Chicago, IL, USA). The χ2 test was used to compare the observed and expected frequencies in all categories. Separate means for gender and age groups are reported where the differences are statistically significant (P< 0.05). Since a skewness in the gender distribution was found compared with the earlier epidemiological survey (1), see Results, a post-stratification analysis was done. When a tendency (P <0.1) to a difference in response between men and women was noticed, the total mean was balanced in accordance with the gender ratio in the earlier survey. At most, this adjustment changed the total means by 1.6%.
Results
I. Screening, response rate and representativeness of the sample
Since the sampling was performed by the method of substitution (the interviewer took a new number if there was no reply, in the case of technical obstacles, or if a person not appropriate for inclusion answered), the total number of telephone calls was not documented. The number of other non-contacts such as persons not registered in the population data is unknown. The exclusion of households without telephone is not considered a bias of any note, since the coverage of telephones is very high in the country (1). Individuals with mental handicap or deafness were excluded. The drop-out rate, defined as individuals contacted and asked about inclusion but not interviewed due to refusal, unavailability or lack of interest, was 14.1%.
In preparation for the postal survey approximately 5400 telephone calls were made in order to reach 754 individuals reporting themselves as having migraine or migraine-like headache. Of these, 709 accepted participation and received a comprehensive postal questionnaire. When 495 persons (70%) hade answered, the collection of returned forms was ceased for reasons of time. Those who now had answered ‘no’ or ‘uncertain’ to the question if they had migraine or migraine-like headache were excluded. The analysis of the extensive postal survey was based on the remaining 444 persons. However, in the results presented here, only those 97% (n = 423, 23% men and 77% women, 20% aged 18–29 years, 53% aged 30–49 years, and 27% aged 50–74 years) who after analysis of symptoms were found to fulfil the IHS migraine criteria (apart from the strict duration 4–72 h, which was deliberately disregarded, see Methods) are taken into account.
Out of the 423 persons, 45% had received a diagnosis of migraine from a physician (34% of individuals aged 18–29 years, 41% of individuals aged 30–49 years, and 56% of individuals aged 50–74 years).
The study population and its relation to the source population is described in Fig. 1.
Recruitment of participants.
In Fig. 2, the demographical profile of the final sample (n = 423) is compared with that of the self-considered migraineurs in the earlier epidemiological survey (1). Participants in both studies were derived from the same source population and by applying the same basic screening methods (except regarding duration of attacks). There was no significant (P = 0.14) difference between the samples in the distribution of interviewees among the different age groups, but there was a significant difference (P = 0.001) in the gender ratio, with comparably more women in the postal survey. Generally, there were only minor differences in questionnaire responses between men and women and between the main age groups.
Demographic profiles of self-considered migraineurs. □, Earlier study (telephone based, n = 218); ▪, present study (postal, n = 423).
II. Characteristics of attacks
The frequencies of characteristic symptoms of the attacks is described in Fig. 3. Aura was generally experienced twice as often among those who had received a physician's diagnosis of migraine (61% with aura) compared with those undiagnosed (29% with aura). Nausea and/or vomiting was significantly (P = 0.023) more common in women (79%) than in men (68%). The reported total mean of 79% may therefore be an overestimation of 1–2%.
Characteristics of attacks. □, Diagnosed; ▪, undiagnosed; , all migraine.
Pain was reported by a large majority (86%) to be the most troublesome symptom in the attacks. A few answered photophobia (6%), phonophobia (3%) or nausea (5%), but nobody osmophobia.
III. Time aspects
Approximately one-half of the sample (52%) reported having suffered from migraine for > 10 years (15% of individuals aged 18–29 years, 50% of individuals aged 30–49 years, and 78% of individuals aged 50–74 years) (Fig. 4).
Duration of disease. , all migraine; ▪, undiagnosed; □, diagnosed.
The mean migraine attack frequency was 1.3 per month. A discrepancy in the proportion of migraineurs and attacks in the different severity groups is presented in Fig. 5a. The graph was published in preliminary form in the reports of an earlier epidemiological survey (1). Among these migraine sufferers, a subgroup (27%) have most (68%) of the attacks. There was a significant (P = 0.019) difference in attack frequency between the three main age groups (separate data are presented in Fig. 5b). The proportion (18%) of young individuals (aged 18–29 years) was relatively high compared with that of older individuals aged 30–74 and 50–74 years (both 7%) in the group with a mean number of 52 attacks per year. There was no significant (P = 0.23) gender difference in attack-frequency.
(a) Observed distribution of migraineurs and attacks among different severity groups. □, Attacks, n = 6324; ▪, migraineurs, n = 423. (b) Distribution of migraineurs (in separate ages) among different severity groups. ○, Age 18–29 years; ▪, age 30–49 years; □, age 50–74 years.
The mean attack duration was 19 h. A highly significant gender difference (P = 0.0001) was found (longer attacks among women). In Fig. 6, separate data of attack duration are given for men and women, and also total means adjusted for skewness in gender. Half of the group (49%) had an attack duration of 4–12 h.
Duration of attacks. □, Female; ▪, male; , total means adjusted for gender differences.
IV. Contacts with medical care
Three out of four persons (73%) had stopped seeing (29%) or had never seen (44%) a doctor for their headaches. Thus, only every fourth subject (27%) was a current consulter (Fig. 7).
Consultation rates. , total; ▪, undiagnosed; □, diagnosed.
The opinions on contacts with medical care among those who had seen a physician are presented in Table 1. Most considered the care/understanding and the physician's knowledge of migraine to be good or very good. The information given on different treatment options was deemed as bad or very bad by every third migraineur.
Patients’ opinions on their contacts with medical care
More than half of the group were quite (31%) or very (26%) interested in treatments for migraine/migraine-like headache other than those they had already tried. Interest in alternatives was ranked 3.4 on a scale of 1–5 (1 being not interested at all and 5 being very interested) by the group as a whole. Only a minority were not at all (15%) or hardly at all (12%) interested in other treatments.
V. Burden of disease
A group of individuals (9%) did not consider themselves to recover completely from migraine symptoms between the attacks. Of the others, equal numbers answered ‘yes’ as ‘yes, more or less’ to this question. Less than half (43%) of the subjects recovered completely between the attacks.
The percentages of individuals who reported various degrees of negative influence of their headaches on various parameters are presented in Fig. 8.
Impact of migraine on important aspects of life. , very negative influence; □, quite negative influence; ▪, some negative influence.
As presented in Fig. 9, almost two-thirds (65%) reported some degree of absence from school/college or work (at home or other place of work) as a result of migraine/migraine-like headaches. Once or a ‘couple of days’ per year was the most commonly reported frequency.
Absenteeism from school or work as a result of migraine.
Discussion
I. Screening, response rate and representativeness of the sample
In clinic-based studies, factors leading to consultation can mistakenly be taken for attributes of the disease (6). It has therefore been our aim to study a randomly selected sample from the general adult population. Thus, one strength of this study in comparison with similar reports is that the sample is not only reasonably representative of self-considered migraineurs, but also relatively large and recruited from all main regions of the country (1, 5, 7–17).
Subjects were primarily recruited on the basis of their own opinion on diagnosis, for two reasons. On the one hand, the lay interviewer's computer during the process of sampling did not indicate whether or not the subject actually fulfilled the IHS migraine criteria. Accordingly, 3% of the collected forms were subsequently excluded from the presentation, since they did not meet the criteria for migraine according to the IHS. Lipton and coworkers have recently reported that the positive predictive value for self-assessed migraine in the USA was 33.1%, and that as many as 54% of individuals with IHS migraine did not know that their headaches were migraine (18). Notably, the corresponding degree of unawareness of having true IHS migraine among Swedish sufferers was only 24% (1). Such unaware individuals were excluded by our sampling procedure, because it would have been unreasonable to go deeply into questions concerning a migraine condition according to the consensus criteria that the interviewed subject did not consider themselves to have. A deliberate feature of this survey is therefore that we have not studied those who might have migraine but without feeling so themselves. On the other hand, we have included a large number of self-considered cases that would not have come to light in a clinic-based study.
Since the studied sample by definition was spread all over the country, for practical reasons it was never an option for the authors at the Gothenburg Migraine Clinic (GMC) to meet the subjects in person for a diagnostic clinical interview. As is often the case, a matched control group was not an option because of costs and resource limitations. Furthermore, we doubt that individuals suffering from another disease would have been a valuable comparator.
The male : female ratio in this studied group of migraineurs (n = 423) was 1 : 3.3. This is in good agreement with most previous studies, where the corresponding figures lie around 1 : 2–3 (19, 20). It was notably higher than the sex ratio of 1 : 1.9 found among self-considered migraineurs in the earlier epidemiological survey (1). The main reason for this difference is probably the relatively higher response rate for women in the postal survey than in the telephone-based study. When the results were balanced to match the distribution of genders in the earlier study, the total means changed at the most by 1–2%. This can in no way influence the conclusions of this study. The case definitions differ insofar as the time factor is disregarded in the migraine criteria of the postal survey. It could be argued that the deletion of the duration criteria overestimates migraine prevalence, leading to figures with a divergent relationship to true migraine, but we consider the studied self-considered group represents true self-considered migraineurs, particularly in an era with new effective therapies. Cluster headache has not been excluded, but given the comparably low prevalence, it would not influence the figures.
II. Characteristics of attacks
Our finding of a high prevalence of migraine aura (44%) should be interpreted with caution. Incorrect reporting and diagnosis of migraine aura seems to be a common problem, and the data differ a lot between studies (20). It is a common opinion among epidemiologists that aura can only be accurately diagnosed in an interview where symptoms are clarified. Since one entry criterion for the study was whether or not the interviewee thinks he/she has migraine, this could load the series with migraine with aura. Aura was twice as prevalent among those who had received a physician's diagnosis compared with those undiagnosed. It is therefore possible that the presence of an aura leads to an earlier diagnosis of migraine. This could be explained by a higher rate of consultation among individuals with migraine aura in combination with a higher tendency among physicians to make a diagnosis of migraine if a patient has headache plus aura. Nausea and/or vomiting was significantly more common in women, although the difference was modest. The other reported migraine symptoms were in accordance with earlier reports.
III. Time aspects
The mean attack frequency of 1.3 per month is in line with other population-based studies, generally reporting one or two attacks per month (21). Notably, a minority of migraine sufferers in the study had a major proportion of all attacks. We found a significant difference in attack frequency among the different age groups, with a disproportionately high number of young individuals among the most frequently burdened migraineurs. As here, the mean attack duration is generally considered to be less than 1 day (22). The headache duration was assessed closely in the study. In order to do this open-mindedly and without restriction, we deliberately disregarded the strict time criterion of 4–72 h for inclusion and being interviewed. It is important to keep in mind that such a rigid time frame would not always apply to clinical practice. This is particularly true for young and adolescent subjects, who in general tend to have shorter attacks (2, 23). A longer duration of attacks was observed among women. A considerable number of individuals reported attacks shorter than 4 h. One reason for this finding may be the treatment used. In addition, some interviewees reported their migraine attacks to be longer than 72 h. It has been noted before that the duration of pain is of little use in the discrimination of migraine from tension-type headache (24). Based on the presented data, we have therefore earlier proposed (1) that, in certain cases, it could be well founded from a pragmatic point of view to disregard an exact duration of migraine attacks when making the diagnosis in clinical practice.
IV. Contacts with medical care
In our earlier epidemiological study (1), it was found that only about half (49%) of the Swedish migraineurs who fulfilled the IHS criteria had been diagnosed by a physician, which is similar to the the USA (4, 25). Presumably the individuals in the present study who identified themselves as suffering from migraine or migraine-like headaches might be the most likely to seek migraine-specific treatment. Yet the proportion who had never consulted (44%) was significantly higher than the international mean (34%) (26). Inversely, just as in Rasmussen's Danish study, only 56% of the subjects had at some time consulted a doctor because of migraine (15). This is less than in population-based reports from the USA and Canada (8, 27).
It is also remarkable that not more than approximately every fourth Swedish self-considered migraineur seems to be a current consulter of a physician. This is below the international mean (31%) and lower than in Canada (36%), the USA (47%) and the UK (47%). There are no comparative data available from Denmark (26). Participants (n = 2670) in a multicentre, Phase III triptan study were retrospectively asked about the number of visits to doctors during the last year. Bearing the selection bias in mind, it is of interest to note that Sweden had the lowest number [1.26, 95% confidence interval (CI) 1.13, 1.39] of all the participating 25 countries and ended up significantly under the international average (2.78, 95% CI 2.6, 3.6) (9).
It has already been found in population-based studies that most individuals who have seen a doctor for their migraine thereafter no longer do so regularly (8, 28), but the reasons why so many migraineurs have no contact with a physician are seldom discussed. Possible explanations given are an impression among the migraineurs that the doctor is incapable of diagnosing or treating migraine effectively, a belief that there is no effective treatment, or dissatisfaction with earlier consultations or treatments (3, 21, 28). Needless to say, it is important to ask about the patients’ opinion of their contacts with medical care in order to improve their experiences and meet their expectations. There seems to be room for improvement of physicians’ knowledge of migraine and doctor–patient communication about different treatment options in Sweden. Even migraineurs who have consulted a physician may still not have received satisfactory information or suitable treatment. Several authors have estimated that an increase in healthcare utilization for migraine is probably warranted (19, 26, 27). This is also supported in the present study by the facts that a majority reported some degree of absence from school or work, a negative influence of migraine on the most important aspects of life, and an interest in other treatments for migraine/migraine-like headache than they had already tried. More than half of the group were quite or very interested in treatments for migraine/migraine-like headache other than those they had already tried. Similar findings were reported earlier (29). We suspect that the finding of a large number of tested complementary therapies such as acupuncture and yoga (data not reported here) is an indicator of discontent with the national healthcare system and perhaps also with the available treatments offered by physicians.
V. Burden of disease
In addition to the disability perceived during the migraine attack, it seems that impairment is also experienced between attacks. The unpredictability of migraine and anxiety regarding the potential occurrence of future attacks may contribute to this interictal (between attack) impact. When the participants were asked about ‘back to normal functioning’, less than half reported that they recovered completely between attacks. This confirms earlier findings that the disruptive effect of migraine is not confined to the duration of the attack (3, 30, 31). Many migraineurs live in constant worry about the next attack, leading to anxiety and avoidance behaviour, or in practice chronic disablement even in the headache-free phases (3, 6, 8, 32). Many attempts have been made to capture this important component of the burden of the disease (10).
Migraine has a tendency to extend its burdens to others than the immediate sufferer (33). Steiner stated that ‘many more people can be said to suffer from migraine than actually have it’ (32). It has earlier been suggested that it is the unpredictability of migraine in combination with unsatisfactory treatment options that causes this distress and frustration not only for the patient, but also for their families (30, 31, 34). Bearing in mind that being together with the family was ranked highest among aspects of life (data on file), the finding of a particularly negative influence of migraine here is very serious. There are comparatively few earlier studies of the impact of migraine on the family and social relations (4, 8, 11, 25, 33, 35). The percentage of individuals who reported various degrees of negative influence of their headaches on family situation is in the same size range as in a recently published interview with migraineurs (n = 1142) living as married with partners in the USA and UK (33).
Every second individual in the present study reported various degrees of negative influence on the inability to pursue studies. There are data from other studies suggesting a reduced lifetime educational achievment among migraineurs (3). In several recent studies from the USA, the prevalence of migraine was inversely correlated to grade of education (6, 15, 20). This tendency could not be found in our material (data on file). Scandinavian studies have so far not revealed an increased prevalence of migraine in the more or less educated or financially privileged (1, 20).
Almost every third participant reported a negative influence of migraine on their finances. Conflicting data exist with regard to the relationship between migraine and income (3), but it is not uncommon that consulting migraineurs report failure to develop an optimal career potential, which over a lifetime can add up to substantial cumulative financial loss (32).
Estimates of lost labour time due to migraine in population-based studies are reasonably consistent, ranging from 1.5 to 4.2 days per year (28). Earlier reports suggest that a large proportion of migraineurs attend work or school during episodes, although their productivity is impaired (4, 25, 36, 37). This leads to feelings of guilt, low self-esteem, a lack of enjoyment or job satisfaction and an inability to take pride in the work done (36).
In the authors’ opinion, the Swedish system with one unpaid qualifying day strikes disproportionately hard at sufferers of episodic diseases, such as migraineurs. It is admittedly possible for the patient to apply for exemption from qualifying days, but the information regarding this tedious maneouvre is very sparse, and it is based on the assumption that the sufferer is a consulter. In Sweden, there is no need for a certificate of illness from a physician to be put on the sick list during the initial period, since 80% of one's income is guaranteed by the social insurance system on days 2–10.
Headaches are a considerable health problem in the general population and a major socioeconomic burden to society, the affected individuals and their families. Internationally, migraine remains underestimated, under-diagnosed and under-treated (21, 32). Direct treatment costs are masked by the cost to the national economy of absenteeism from work due to migraine and reduced productivity of people at work with migraine (10, 28, 38).
It has been our intention to contribute to a better understanding of these circumstances in our country by looking into and presenting the self-identified migraineurs’ own opinions and experiences. The findings contradict the sweeping statement that migraine patients are well between attacks. It is remarkable that the Swedish self-considered migraineurs report a consultation pattern significantly below the international average level. Furthermore, even migraineurs who have consulted a physician may still not have received satisfactory information or suitable treatment. We recommend that screening for migraine should be considered in order to identify sufferers with significant migraine-associated disability. This assumes greater attention to the problem amongst health planners and politicians responsible for healthcare planning and research in Sweden. A continuous improvement has already probably been achieved, since physician education programmes are implemented to improve diagnosis and treatment of migraine in our country.
Footnotes
Acknowledgements
We thank Martin Gellerstedt for his skilful help with statistical analysis. This study was supported financially by Zeneca.