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Abstract

The aim of the current study was to estimate the prevalence of all primary headaches and cranial neuralgias in the general community. As part of the population-based Bruneck Study, 574 men and women aged 55–94 years underwent extensive neurological and laboratory examinations involving a standardized headache interview. In the Bruneck Study population the lifetime prevalence of all primary headaches combined and of cranial neuralgias was 51.7 and 1.6%, respectively. Tension-type headache (40.9%) and migraine (19.3%) emerged as the most common types of headache. In men and women aged 55–94 years the 1-year prevalence of primary headaches was high at 40.5%. In this age range headaches caused significant impairment of health-related quality of life. The Bruneck Study has confirmed the high lifetime prevalence of primary headaches and cranial neuralgias in the general population and provided first valid prevalence data for all primary headaches based on International Classification of Headache Disorders, 2nd edition criteria.

Keywords

Primary headaches migraine tension-type headache cranial neuralgias prevalence

Introduction

Primary headaches rank among the most common neurological diseases and impose a significant burden on the individual affected and on society as a whole. The International Classification of Headache Disorders (ICHD) comprises the standard diagnostic criteria for headache and facial pain in clinical routine and research. It was first published in 1988 (ICHD-1) (1) and substantially revised and expanded in 2004 (ICHD-2) (2), taking into account recent advances in the understanding of disease pathophysiology and phenomenology. The revision represented a milestone for comprehensive classification of headaches, but also added complexity to the diagnostic criteria of individual diseases. Although the original ICHD guidelines were commonly applied in telephone interviews and posted questionnaires, the revised ICHD poses a challenge to epidemiological researchers owing to the substantial number of primary headache disorders considered and the differentiation from secondary forms of headaches requested.

Symptoms of headache have been studied in well over a quarter of a million subjects derived from the general community, but almost all studies have employed the old ICHD-1 criteria and very few have had a special focus on the elderly. In the FRAMIG 3 study, a recent nationwide population-based survey from France applying the ICHD-2 criteria, the prevalence of probable plus strict migraine was estimated at 21.3%, but no other types of primary headache were assessed (3). In a study from Brazil conducted in a tertiary referral centre (4), the prevalence of several primary headache disorders was estimated according to the new guidelines, but it is open to dispute whether these data can be transferred to the general community and to countries in Europe and Northern America given the presumed geographical differences in headache frequency.

The current study had two main objectives: (i) to assess the lifetime prevalence and burden of all primary headaches and cranial neuralgias outlined in the 2004 ICHD-2; and (ii) to estimate disease frequency (1-year prevalence) and severity in men and women 55–94 years old.

Methods

Population

This evaluation was part of a prospective population-based study of the epidemiology of cardiovascular and neurological diseases (the Bruneck Study) (5–8). Bruneck is a small town located in the alpine region of Northern Italy. The population of Bruneck is exclusively White and of heterogeneous geographic origin with sizeable segments of Austro-German or Italian background. Population mobility within the survey area is 0.2% per year. Baseline assessment took place in 1990 and follow-up assessments were carried out every 5 years. The study population was recruited as an age- and sex-stratified random sample of all inhabitants of Bruneck aged 40–79 years (n = 4793, entire population 13 534). One thousand persons were selected for inclusion from the official population register by a computer-based random number generator. Participants were split into age groups according to decades (125 women and 125 men in every decade from 40–49 years to 70–79 years). In 1990, 936 persons participated with data assessment completed in 919 subjects. Between 1990 and 2005, a total of 253 of the 919 men and women died; 574 persons returned for the 2005 follow-up (done in October) and formed the target population for this study (follow-up rate 86.2%). The study protocol was approved by the local ethics committee and all participants gave their written informed consent.

Ascertainment of headaches

All participants underwent a thorough neurological examination, including the question whether they had ever had a headache. In the case of a positive response subjects underwent a standardized interview designed to comply with the 2004 ICHD-2 (Supplementary Web Table S1). It included: (i) the assessment of core components of ICHD-2 criteria required for a diagnosis of migraine or tension-type headache (TTH) [location of headache (unilateral, bilateral), quality (pulsating, pressing/tightening), pain intensity (mild, moderate, severe), aggravation (by routine physical activity such as walking or climbing stairs), presence of nausea and/or vomiting, photophobia and/or phonophobia, duration and number of attacks, presence and type of aura, temporal relationship between aura and headache onset]; (ii) questions about potential triggers and associated circumstances (cough, exertion, sexual activity, development only during sleep or only at high altitude, head/neck trauma, cranial/cervical vascular disorder, non-vascular intracranial disorder, substance use or its withdrawal, infection, nasal obstruction or purulent nasal discharge, impaired vision or ocular pain, alcohol consumption, disorder of homeostasis, disorder of cranium, neck, ears, teeth or mouth and psychiatric disorder); and (iii) questions about the typical pain characteristics of primary stabbing headache, thunderclap headache, cluster headache, hemicrania continua and cranial neuralgias. As a second step we checked whether criteria for suitable disease categories were satisfied and defined the appropriate ICHD-2 code. Subjects were explicitly asked whether or not they had experienced different headaches. If so, the above information was separately assessed for each type of headache, resulting in two or more ICHD-2 diagnoses.

All interviews were performed by a single experienced investigator (J.S.). Of note, we strictly adhered to the wording of ICHD-2 criteria. Subjects with a diagnosis of probable migraine (codes 1.6.1–1.6.5) or probable TTH (codes 2.4.1–2.4.3) accounted for 10.8 and 3.4%, respectively, of patients in these headache categories and were analysed together with definite disease cases. For each individual and each type of headache the age at the first and last headache attack was assessed. Moreover, subjects were instructed to specify the number of headache attacks per day, week, month or year. If headache frequency changed over time, subjects were asked to define variable time periods and to provide separate frequency estimates for each of them. Responses served for computation of average annual and lifetime attacks. Finally, we asked for presence and frequency of headaches in the year preceding the 2005 evaluation. The duration of the interview strongly depended on the complexity of given headaches and lasted between 15 and 60 min. In the case of dementia or severe aphasia (n = 15), information was obtained from relatives and caregivers and confirmed by hospital records and self-reported information about headache characteristics and frequency provided at study baseline (1990). Finally, a detailed medication history was obtained with a focus on criteria suggesting medication-overuse headache.

The neurological work-up included a standard neurological examination, Mini Mental State Examination, olfactory function tests and passive head movements in the three plans to detect restrictions in the range of motion and neck tenderness. All individuals were asked whether they had ever had visual disturbances such as loss of vision or flickering lights and spots or lines, and subjects with a response suggestive of isolated migraine aura were administered the headache questionnaire as well. Furthermore, each subject underwent extensive blood tests (including erythrocyte sedimentation rate and thyroid function tests) and blood pressure readings. These examinations together with the headache interview served to identify secondary causes of headaches. In the case of abnormalities, individuals were subjected to additional tests such as X-ray of nasal sinus or cervical vertebral column, examination by an ophthalmologist or computed tomography/magnetic resonance imaging of brain and skull, or the findings of recent examinations were reviewed.

Assessment of health-related quality of life

To assess health-related quality of life (HRQoL), we used the German and Italian version of the WHOQoL-BREF (9), an abbreviated version of the WHOQoL-100 that measures the perception of a person's position in life regarding his goals, expectations, standards, concerns, culture and value system. The WHOQoL-BREF is a self-administered questionnaire composed of 26 items in four broad domains: physical health, psychological well-being, social relationships and environment. The items are rated on a five-point scale. Scores for each of the four domains and an overall score were computed according to standard formulae and transformed to scales of 0–100. Higher scores denote higher quality of life (10).

Analysis

One-year prevalence of primary headaches in the population aged 55–94 years refers to the year prior to the 2005 examination (October 2004 to September 2005). Prevalence in each gender and age group was estimated from logistic regression models including gender and age (in years) (logistic regression smoothed prevalence) (11). Confidence intervals were calculated according to previously published methods (12). Adequacy of fit of each logistic regression model was carefully checked and confirmed by the Hosmer and Lemeshow test for goodness of fit and by examination of residuals (13). Non-linear effects of age on the log odds of primary headache disorders were proven by visual inspection of plots of age decades against the log odds of disease probability, by adding an age x ln(age) term to the regression models (Box–Tidwell transformation) and by using orthogonal polynomials (13). Differential effects of age on the prevalence of headaches in men and women were tested by adding an interaction term to the logistic regression equations (13). Summary estimates of the 1-year prevalence of primary headaches in the general elderly community were generated as weighted averages of age- and sex-specific measures. Weights were chosen according to the age and sex structure of all inhabitants of Bruneck within this age spectrum, which is similar to that of the European standard population (14). Numbers of headache attacks and days affected with headaches were presented as medians and interquartile range and compared between genders with the non-parametric Mann–Whitney U-test. In addition, arithmetic means were presented in the text to allow comparison with data from the literature. Calculations were performed with spss (version 15.0 for Windows; SPSS Inc., Chicago, IL, USA) and bmdp (Statistical Solutions, Saugus, MA, USA) statistical software packages.

Results

Lifetime prevalences and lifetime number of attacks (cumulative burden) of primary headache disorders are summarized in Table 1. At a prevalence of 40.9%, TTH was the most common form, followed by migraine (19.3%). The joint lifetime prevalence of all primary headaches was 51.7%. About one-fifth of persons affected suffered from two or more types of headache (63 of 297). Tables 2 and 3 depict 1-year prevalence and frequency of attacks for all primary headaches and cranial neuralgias in men and women aged 55–94 years, and age- and sex-specific rates for the most common types. Table 4 compares levels of WHOQoL-BREF domains and overall score between groups of subjects (55–94 years) without any primary headache and those suffering from migraine, TTH or neuralgias.

Table 1

Lifetime prevalence of primary headaches and cranial neuralgias in the Bruneck Study population (2004 ICHD-2)

Headache category	n	Lifetime prevalence, % (95% CI)			Number of attacks, median (IQR)∗
Headache category	n	All	Men	Women	Per year	Lifetime
Sample size	574
Migraine	111	19.3 (16.1, 22.6)	8.7	28.5	12 (6–24)	282 (98–549)
Migraine without aura (1.1, 1.6.1)	77	13.4 (10.6, 16.2)	5.7	20.1	12 (6–24)	300 (120–540)
Migraine with aura (1.2.1, 1.6.2)	33	5.8 (3.8, 7.7)	2.3	8.7	12 (6–24)	260 (112–724)
Typical aura with non-migraine headache (1.2.2)	0	< 0.2	< 0.4	< 0.3	—	—
Typical aura without headache (1.2.3)	5	0.9 (0.1, 1.6)	1.6	0.3	36 (3–50)	360 (35–604)
Familial/sporadic hemiplegic migraine (1.2.4/1.2.5)	0	< 0.2	< 0.4	< 0.3	—	—
Basilar-type migraine (1.2.6)	0	< 0.2	< 0.4	< 0.3	—	—
Retinal migraine (1.4)	1	0.2 (0.0, 0.5)	0.4	< 0.3	48 (NC)	480 (NC)
Chronic migraine (1.5.1)	2	0.3 (0.0, 0.8)	0.0	1.0	150 (NC)	3450 (NC)
Other complications of migraine (1.5.2, 1.5.3, 1.5.4, 1.5.5)	1	0.2 (0.0, 0.5)	0.0	0.0	1 (NC)	40 (NC)
TTH	235	40.9 (36.9, 45.0)	34.7	46.3	12 (5–48)	155 (50–520)
Infrequent episodic TTH (2.1, 2.4.1)	114	19.9 (16.6, 23.1)	16.2	23.0	5 (3–10)	60 (19–174)
Frequent episodic TTH (2.2, 2.4.2)	115	20.0 (16.8, 23.3)	16.6	23.0	30 (12–60)	312 (120–1125)
Chronic TTH (2.3)	16	2.8 (1.4, 4.1)	3.0	2.6	300 (86–365)	1674 (730–5110)
Cluster headache (3.1)	0	< 0.2	< 0.4	< 0.3	—	—
Other primary headaches	16	2.8 (1.4, 4.1)	3.4	2.3	12 (3–49)	44 (10–312)
Primary stabbing headache (4.1)	7	1.2 (0.3, 2.1)	2.0	0.7	12 (4–52)	36 (28–104)
Primary cough headache (4.2)	1	0.2 (0.0, 0.5)	0.4	< 0.3	3 (NC)	9 (NC)
Primary exertional headache (4.3)	3	0.5 (0.0, 1.1)	0.8	0.3	12 (NC)	40 (NC)
Primary headache associated with sexual activity (4.4)	0	< 0.2	< 0.4	< 0.3	—	—
Hypnic headache (4.5)	3	0.5 (0.0, 1.1)	< 0.4	1.0	24 (NC)	120 (NC)
Primary thunderclap headache (4.6)	2	0.3 (0.0, 0.8)	0.4	0.3	1 (NC)	1 (NC)
Hemicrania continua (4.7)	0	< 0.2	< 0.4	< 0.3	—	—
New daily-persistent headache (4.8)	0	< 0.2	< 0.4	< 0.3	—	—
All primary headaches (1.1–4.8)	297	51.7 (47.7, 55.8)	39.2	60.8	15 (7–52)	256 (72–720)
Trigeminal neuralgia (13.1.1, 13.1.2)	9	1.6 (0.6, 2.6)	0.8	2.3	> 100	> 1000
Secondary headaches (5.1–12.2)†	85	14.8 (11.9, 17.7)	15.5	14.3	—	—

The sum of subjects in the various headache categories is higher than the overall number of subjects affected with headaches because two and more types of headaches co-existed in a proportion of subjects. The most common combination was migraine plus TTH. Similar is true for headache categories and subcategories. A proportion of subjects suffered from more than one headache subcategory either simultaneously or in different periods of life.

^∗Data presented are medians (interquartile range) of days affected with headache for TTH or numbers of headache attacks for other types of headache. Data for subjects in a certain headache subcategory (e.g. migraine with aura) denote the total number of attacks in this headache category (i.e. the number of all types of migraine attacks in these individuals).

^†On assessing the joint lifetime prevalence of secondary headaches we only considered headaches that were either moderate-to-severe, frequent (> 1 attack per month) or long-lasting (for a period of > 3 months).

TTH, tension-type headache; NC, not computable.

Table 2

One-year prevalence of primary headaches and cranial neuralgias in the general community aged 55–94 years

Headache category	1-year prevalence, % (95% CI)∗			Number of attacks per year median (IQR)† lifetime
Headache category	All	Men	Women	Number of attacks per year median (IQR)† lifetime
Migraine	5.7 (4.3, 7.2)	3.2 (1.6, 4.7)	7.8 (5.5, 10.1)	9 (3–21)
Migraine without aura (1.1, 1.6.1)	3.6 (2.5, 4.7)	1.2 (0.3, 2.1)	5.6 (3.7, 7.4)	11 (3–21)
Migraine with aura (1.2.1, 1.6.2)	2.0 (1.1, 2.9)	1.2 (0.2, 2.2)	2.6 (1.2, 4.0)	7 (3–30)
Typical aura with non-migraine headache (1.2.2)	< 0.2	< 0.4	< 0.3	—
Typical aura without headache (1.2.3)	0.3 (NC)	0.8 (NC)	< 0.3	20 (NC)
Familial/sporadic hemiplegic migraine (1.2.4/1.2.5)	< 0.2	< 0.4	< 0.3	—
Basilar-type migraine (1.2.6)	< 0.2	< 0.4	< 0.3	—
Retinal migraine (1.4)	< 0.2	< 0.4	< 0.3	—
Chronic migraine (1.5.1)	< 0.2	< 0.4	< 0.3	—
Other complications of migraine (1.5.2, 1.5.3, 1.5.4, 1.5.5)	0.2 (NC)	< 0.4	0.3 (NC)	1 (NC)
TTH	35.8 (32.7, 39.0)	27.8 (23.5, 32.1)	42.4 (37.9, 46.9)	12 (5–36)
Infrequent episodic TTH (2.1, 2.4.1)	19.4 (17.2, 21.6)	15.7 (12.6, 18.7)	22.4 (19.2, 25.6)	5 (3–10)
Frequent episodic TTH (2.2, 2.4.2)	16.0 (14.0, 18.0)	11.4 (8.9, 13.9)	19.8 (16.6, 22.9)	25 (12–60)
Chronic TTH (2.3)	2.1 (1.3, 2.9)	1.9 (0.8, 3.0)	2.3 (1.2, 3.4)	181 (68–349)
Cluster headache (3.1)	< 0.2	< 0.4	< 0.3	—
Other primary headaches	1.7 (1.0, 2.5)	2.7 (1.3, 4.1)	1.0 (0.3, 1.6)	8 (4–43)
Primary stabbing headache (4.1)	1.2 (0.6, 1.8)	1.9 (0.7, 3.0)	0.6 (0.1, 1.2)	12 (4–52)
Primary cough headache (4.2)	0.2 (NC)	0.4 (NC)	< 0.3	1 (NC)
Primary exertional headache (4.3)	0.2 (NC)	0.4 (NC)	< 0.3	10 (NC)
Primary headache associated with sexual activity (4.4)	< 0.2	< 0.4	< 0.3	—
Hypnic headache (4.5)	0.2 (NC)	< 0.4	0.3 (NC)	6 (NC)
Primary thunderclap headache (4.6)	< 0.2	< 0.4	< 0.3	—
Hemicrania continua (4.7)	< 0.2	< 0.4	< 0.3	—
New daily-persistent headache (4.8)	< 0.2	< 0.4	< 0.3	—
All primary headaches (1.1–4.8)	40.5 (36.6, 44.4)	31.9 (26.7, 37.0)	47.6 (41.9, 53.3)	12 (5–36)
Trigeminal neuralgia (13.1.1, 13.1.2)	1.6 (0.9, 2.2)	0.7 (0.2, 1.2)	2.3 (1.2, 3.4)	> 100

^∗Prevalences (95% confidence interval) were adjusted to the age and sex structure of the general community of Bruneck aged 55–94 years.

^†Data presented are medians (interquartile range) of days affected with headache for TTH or numbers of headache attacks for other types of headache. Data for subjects in a certain headache subcategory (e.g. migraine with aura) denote the total number of attacks in this headache category (i.e. the number of all types of migraine attacks in these individuals).

TTH, tension-type headache; NC, not computable.

Table 3

One-year prevalence (95% CI) of primary headaches and neuralgias in the general community aged 55–94 years

Gender/age groups	Primary headaches				Neuralgias
Gender/age groups	All primary headaches	Migraine	TTH	Other primary headaches	Trigeminal neuralgia
Men
55–64	35.4 (26.5, 44.3)	4.3 (1.2, 7.4)	29.8 (22.3, 37.3)	3.0 (0.4, 5.6)	0.3 (0.0, 0.8)
65–74	30.9 (22.7, 39.2)	2.7 (0.8, 4.6)	27.4 (20.6, 34.1)	2.6 (0.8, 4.4)	0.6 (0.0, 1.5)
75–84	26.8 (17.9, 35.8)	1.7 (0.2, 3.2)	25.1 (17.5, 32.7)	2.2 (0.0, 4.5)	1.2 (0.0, 2.9)
85–94	22.5 (12.2, 32.8)	1.0 (0.0, 2.2)	22.6 (13.2, 32.0)	1.9 (0.0, 4.9)	2.7 (0.0, 7.1)
Women
55–64	53.2 (43.7, 62.6)	11.6 (6.3, 16.8)	45.6 (37.2, 54.1)	1.1 (0.0, 2.4)	0.8 (0.0, 1.9)
65–74	48.0 (38.9, 57.0)	7.4 (4.4, 10.4)	42.6 (35.2, 50.0)	1.0 (0.0, 2.0)	1.7 (0.3, 3.1)
75–84	42.6 (32.2, 53.1)	4.6 (1.6, 7.6)	39.5 (30.8, 48.3)	0.8 (0.0, 1.9)	3.5 (1.0, 6.0)
85–94	38.3 (14.1, 62.5)	3.0 (0.1, 5.9)	37.0 (26.1, 48.0)	0.7 (0.0, 1.9)	6.3 (0.3, 12.4)
P for sex differences	< 0.001	0.011	< 0.001	0.154	0.212
P for age trends	0.018	0.017	0.169	0.664	0.033

Tests for trend in prevalence rates by age and differences in prevalence rates by gender were based on the coefficients for age and sex in the regression model used to obtain smoothed prevalence estimates.

TTH, tension-type headache.

Table 4

Health-related quality of life (HRQoL) in groups of subjects aged 55–94 years defined by the presence or absence of primary headaches and cranial neuralgias

WHOQOL-BREF domains	No headache	Primary headaches			Neuralgias
WHOQOL-BREF domains	No headache	Migraine	TTH	Other primary headaches	Trigeminal neuralgia
Physical health	75.3 ± 13.8	74.3 ± 12.7	72.8 ± 14.3∗	71.1 ± 17.5	59.2 ± 19.4∗∗
Psychological well-being	73.0 ± 12.5	67.2 ± 11.2∗	68.4 ± 12.5∗∗∗	71.7 ± 2.6	60.1 ± 15.6∗∗
Social relationships	70.6 ± 13.7	69.5 ± 18.2	69.9 ± 13.0	69.2 ± 11.8	58.3 ± 15.2∗
Environment	74.6 ± 11.1	74.8 ± 9.7	72.3 ± 10.5	72.5 ± 9.2	68.0 ± 9.0∗
Overall score	74.3 ± 14.6	67.6 ± 17.9∗∗	70.1 ± 15.3∗∗	76.3 ± 12.4	53.6 ± 17.3∗∗∗

^∗ P < 0.05;

^∗∗ P < 0.01;

^∗∗∗ P < 0.001.

P-values were derived from analyses adjusted for age, gender and social status.

Data presented are unadjusted means ± standard deviation (s.d.) of the WHOQOL-BREF domain scores and overall score (available in 560 of the 574 subjects; scales, 0–100).

Subjects free of primary headaches and cranial neuralgias during lifetime (‘no headache’, n = 264) served as the reference group and were compared with subjects suffering from migraine (n = 32), tension-type headache (TTH, n = 201), other primary headaches (n = 10) and cranial neuralgias (n = 7) at an age of 55–94 years.

Migraine

The Bruneck Study shows lifetime prevalences for migraine of 28.5 and 8.7% in women and men, respectively, and a sex ratio of 3.3:1. The most common type of migraine was migraine without aura, followed by migraine with aura and typical aura without headache (Table 1). Mean age at onset was slightly lower in men than in women (23 vs. 29 years, P = 0.085). In 28.4 and 5.7% of women migraine manifested at an age of ≥ 40 and ≥ 60 years, respectively. Corresponding percentages in men were 8.7 and 0.0% (P = 0.047 for gender difference). In most women migraine attacks ceased between age 40 and 59 years. In one-fifth of women symptoms of migraine disappeared with menopause, in the decade before or the decade thereafter, giving a total of three-fifths of women. Interestingly, men tended to experience more migraine attacks than did women (median lifetime attacks 360 vs. 260, P = 0.152).

In the elderly, the prevalence of migraine and female predominance declined, as did the number of headache attacks (Tables 1–3). The distribution of migraine subtypes remained very similar to that observed during lifetime (Table 2).

Tension-type headache

The Bruneck Study revealed a lifetime prevalence for TTH of 46.3 and 34.7% in women and men, respectively, and a sex ratio of 1.3:1. Infrequent and frequent episodic TTH occurred at equal rates, whereas chronic TTH manifested in 2.8% of the study population. Mean age at onset was slightly higher in men than in women (49 vs. 44 years, P = 0.058) and substantially higher than in migraineurs (P < 0.001). TTH manifested in all age categories (preferentially between ages 45 and 64 years) and persisted throughout life in the vast majority of subjects (approximately 85%), even though with intraindividual changes in disease expression. No gender differences in the lifetime number of days affected with headaches [median 167 (men) vs. 150 (women), P = 0.610] or in the frequency of chronic TTH were observed. Prevalence, characteristics and number of days affected with headaches did not change significantly with advancing age.

Other primary headaches and cranial neuralgias

The lifetime and 1-year prevalence of other primary headache disorders ranged between 0.0 and 1.2% (Tables 1 and 2). The lifetime frequency of trigeminal neuralgia was unexpectedly high at 1.6%. Whereas classical trigeminal neuralgia was diagnosed in eight patients, one had symptomatic trigeminal neuralgia (caused by osteolysis in the upper jaw).

Discussion

In 2004 the long-awaited revision of the ICHD-1 from 1988 was published as a response to the substantial progress in understanding headache pathophysiology and clinical disease expression. The classification was enriched by a large number of newly defined headache disorders, and classic headaches experienced further specification and sub-categorization.

Joint prevalence of primary headaches

The current study is the first launched in a Western country to depict population-based prevalence of all primary headache disorders and cranial neuralgias described in the 2004 ICHD-2, thereby strictly adhering to this classification (Table 1). It has demonstrated a high joint lifetime prevalence of 51.7% for primary headaches with a clear female predominance (prevalence ratio 1.6, P < 0.001) and around one-fifth of individuals affected suffering from two or more types of primary headache, either simultaneously or in different periods of life.

The substantial number of high-quality studies in young and middle-aged individuals contrasts with the considerable paucity of data on headache epidemiology in the elderly. Only few studies have had an exclusive focus on the elderly, most of which were launched in the early 1990s (15, 16), involved a two-phase screening procedure with only part of the study subjects being investigated by experienced neurologists (15, 17) or lacked representativeness of the general community (18). In the Bruneck Study primary headaches and cranial neuralgias occurred at rates of 40.5 and 1.6% (1-year prevalences), respectively, and caused significant impairment of HRQoL (Table 4). Prevalence modestly decreased with advancing age, but remained high up to an age of 94 years (Table 3). Our findings were similar to those of another study among elderly Italians (age range 65–96 years, overall headache prevalence 51%) (15), considering that this evaluation also counts symptomatic headaches, and of two Asian surveys (age ranges 61–98 and ≥ 65 years, prevalence of primary headaches 54.8 and 38%, respectively) (16, 18). Prevalence estimates, however, were higher than those assessed in a previous population-based study with sizeable segments of elderly subjects (19).

Migraine

Previous population-based studies have yielded lifetime prevalence estimates for migraine ranging from 6.9 to 23.2% (20). Results of the Bruneck Study cohort fit very well into this range (19.3%), and prevalence curves by age closely match those obtained in meta-analyses of preceding evaluations (20). As expected, there was a clear female preponderance in disease prevalence (prevalence ratio 3.3, P < 0.001), but the frequency of migraine attacks tended to be higher in men. On average, migraine patients were affected with headaches 24 times per year [literature range, 16–26 attacks per year (21, 22) and 34 days per year (23)]. In men and women aged ≥ 55 years migraine was still a substantial health burden (1-year prevalence 5.7% compared with 2.9–11.0% in previous studies conducted in the elderly) (15–18), even though the number of attacks declined and the impact on HRQoL was significant for some HRQoL domains but absent for others (Table 4). Migraine characteristics did not change with advancing age. Migraine without aura was twice as frequent as migraine with aura, in keeping with previous data (24). Isolated migraine auras occurred in > 4% of migraine patients, i.e. 1% of the entire population. In contrast, other disease phenotypes and migraine complications were rare (≤ 0.5%).

Tension-type headache

TTH was the most common type of primary headache with a lifetime prevalence of 40.9% (literature range 34.8–78%) (25), and this also applied to the elderly (1-year prevalence 35.8%; literature range 16.0–44.5%) (15–18). Female preponderance was less pronounced than for migraine (prevalence ratio 1.3, P = 0.005). Patients with episodic TTH were affected with headaches about 41 days per year (literature, 35 days per year) (23), corresponding to an overall burden of 586 days in lifetime. The lifetime prevalence of chronic TTH was high at 2.8%. Frequency, characteristics and severity of TTH did not change substantially with advancing age. In subjects aged ≥ 55 years TTH ranked first among all headache disorders with regard to impairment of HRQoL (Table 4).

Other primary headaches and facial neuralgias

Hypnic headache has so far been considered a rare disease entity based on estimates from patient series (prevalence estimate 0.07%) (26). In our population study the lifetime prevalence of hypnic headache was higher at 0.5%, but the confidence interval was fairly broad, ranging from 0.0 to 1.1%. We are not aware of any previous prevalence estimates for thunderclap headache, which was 0.3% in our study, whereas the frequency of 0.2–1.2% for primary stabbing, cough and exertional headache and of < 0.2% for cluster headache, hemicrania continua, new daily persistent headache and sexually induced headaches was in keeping with results from the few prior assessments in this field. Of note, lifetime and 1-year prevalence of trigeminal neuralgia in the Bruneck cohort were 1.6%, each thus surpassing previous estimates (0.012 and 0.02% for men and women, respectively) by a factor of approximately 100 (27). The unexpectedly high rate is explained by the segment of women aged ≥ 75 years who accounted for six of the nine cases.

Limitations and strengths

Our assessment has some limitations. A population size of 574 does not permit a precise estimate of the prevalence of rare diseases, especially those occurring with a frequency of < 1%, and this caveat probably explains why there were no cases of cluster headache in this survey. Moreover, our findings do not necessarily apply to other ethnic groups. Even within Whites it is unknown whether and to what extent geographical variations in disease frequency exist (25). Finally, accuracy in ascertaining lifetime prevalence relies on headache characteristics and the memory performance of study participants. Accordingly, the frequency of mild and temporary headache phenotypes may well have been underestimated. Previous investigations have observed that lifetime prevalence estimates of headache paradoxically declined with increasing age of the responder (recall bias) (28). In our study this trend did not emerge, suggesting high accuracy in headache classification.

There are also a number of strengths: (i) participation and follow-up rates in our population study exceeded or approached 90% and were thus higher than in most comparable studies, the bulk of which achieved 40–80%. Moreover, our study was primarily designed to investigate epidemiology and risk factors of atherosclerosis and later extended to neurological diseases. Selective responding according to the presence or absence of headache is thus unlikely; (ii) unlike in a majority of previous assessments, headache classification was not based on posted self-administered questionnaires or telephone interviews, but on a structured in-person interview designed for the operational criteria of ICHD-2 and embedded in an extensive neurological examination involving screenings for and classification of secondary headache disorders. Strictly speaking, this procedure is mandatory for a one-to-one application of the ICHD-2, because affirmation of the absence of plausible secondary causes is an obligatory component of classification criteria for all primary headaches; (iii) further features of our study are its special focus on the elderly, assessment of all headache forms in given individuals and of headache severity in quantitative terms, and the application of HRQoL questionnaires; and (iv) the Bruneck population is representative of a typical Western population with respect to demographic and lifestyle characteristics and has a heterogeneous geographic origin with sizeable segments of Austro-German or Italian background.

Conclusions

Our study has demonstrated a high lifetime prevalence of primary headache disorders in an unselected population sample from a typical Western community. It provides first prevalence estimates for all individual categories of primary headache and cranial neuralgia outlined in the 2004 ICHD-2 and shows that some, such as hypnic headache and trigeminal neuralgia, are more common than generally assumed. Among men and women aged ≥ 55 years, primary headaches still manifested in four out of 10 subjects and caused significant impairment of HRQoL. These findings add substantially to the so far scant data on headache epidemiology in the elderly, and tend to enhance awareness of the fact that headache constitutes a major health issue up to higher ages, requiring allocation of adequate resources.

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Prevalence of Primary Headaches and Cranial Neuralgias in Men and Women Aged 55–94 Years (Bruneck Study)

Abstract

Keywords

Introduction

Methods

Population

Ascertainment of headaches

Assessment of health-related quality of life

Analysis

Results

Migraine

Tension-type headache

Other primary headaches and cranial neuralgias

Discussion

Joint prevalence of primary headaches

Migraine

Tension-type headache

Other primary headaches and facial neuralgias

Limitations and strengths

Conclusions

References