Abstract
Objective
To determine the current availability of care for headaches, in particular migraine in the Asian Oceanian region.
Method
A questionnaire-based, cross-sectional study from August 2020 to February 2021, surveyed country representatives from the member countries of the Asian Oceanian Association of Neurology. The items of the survey were influenced by the findings and recommendations of the 2011 Atlas of Headache by Lifting the Burden and the World Health Organization.
Results
Respondents from all of the 21 member countries of the Asian Oceanian Association of Neurology and 3 other Asian countries participated in this survey. All countries have an established neurological association except for Brunei where there are only 6 neurologists. Thirteen countries (54%) have a dedicated council for headaches. The majority have no subspecialty training program for headaches (75%). Prevalence studies are available in 14 countries while 10 out of the 24 have clinical practice guidelines. Among the 6 countries who offer subspecialty training for headache, only 3 countries cater foreign neurologists. Most of the countries have a wide selection of non-specific migraine drugs. All countries except for Mongolia have at least 1 triptan but non-oral forms for triptans are only available in 8 countries. Monoclonal antibody for migraine prophylaxis is available in 12 out of 24 countries (50%). The majority of respondents agree that migraine is under-diagnosed and under-treated by non-neurologists and that more time should be allotted for lectures dedicated to primary headaches in medical schools.
Conclusion
The survey showed the scarcity of clinical guidelines, subspecialty training, dedicated headache clinics, and patient advocacy organization for the care of headache patients in the participating countries. Acute and prophylactic medications approved for migraine are available in most countries but approved non-pharmacologic devices are lacking. The recommendations in the 2011 Atlas of Headache Disorders are still to be achieved.
Introduction
The 2011 Atlas of Headache Disorders and Resources in the World (1), a collaborative project of the WHO and Lifting the Burden organization surveyed 101 countries and documented the worldwide neglect for patients with primary headaches, particularly migraine and tension-type headaches. The survey revealed the lack of existing services, resource availability, and inadequate delivery of care for this public health problem. Among recommendations to improve the care for people with headaches were to enhance healthcare, fill up the knowledge gap, organize services, improve education, and invest in better services related to headaches.
Although tension-type headache is more prevalent, the burden due to migraine accounts for the high disability-adjusted life year lost (DALY) due to headaches. Ten years after the publication, migraine is the second leading cause of years lived with disability (2), being under-diagnosed and under-treated in many parts of the world especially in Asia, the largest and most populous continent.
This study describes the currently available care provided by neurologists, availability of pharmacologic and non-pharmacologic treatments, the support given by the government, and availability of patient advocacy organizations for patients with headaches, particularly migraine in the Asian Oceanian region. The aim is to help enhance national and regional awareness of the need to improve the care and service for people with migraine.
Methodology
Study design and participants
This cross-sectional study surveyed the country representatives of the Asian Oceanian Association of Neurology (AOAN) (3) regarding the current care for headaches in general and migraine in particular by answering a questionnaire sent by email. There are currently 21 countries in the AOAN including Afghanistan, Australia, China, Hong Kong, India, Indonesia, Israel, Japan, Malaysia, Mongolia, Myanmar, New Zealand, Pakistan, Philippines, Saudi Arabia, Sri Lanka, Singapore, South Korea, Taiwan, Thailand, and Vietnam. The official country representatives were free to designate another neurologist with an interest in headache to answer the survey. If there was no response from the country representative, another neurologist from the country, based on their published papers on headache, was invited. Other countries not belonging to the AOAN but within the Asia Pacific region can participate in the survey, either as recommended by the AOAN member countries or personally invited by the authors.
The questionnaire developed by the first author and reviewed by the third author contained items that explored the unmet needs for headaches influenced by the key messages and recommendations contained in the 2011 Atlas of Headache Disorders. The survey tool was pilot tested by two Filipino neurologists who are certified headache masters by the International Headache Society. The final items included ten different aspects of headache and migraine care, namely:
Availability of a headache council or its equivalent in the neurological organization Availability of subspecialty training for headache and whether this is offered for foreign neurologists Presence of dedicated headache specialty clinic for headache Availability of prevalence studies on migraine Availability of practice guidelines for headache or migraine Support provided by the government for the cost of headache treatment Availability of patient advocacy organizations for headache patients Availability of pharmacologic drugs for acute migraine treatment Availability for pharmacologic drugs for prophylactic treatment for migraine Availability of non-pharmacologic treatment for migraine
The survey also asked the country representatives on their personal opinion regarding several statements regarding the management of migraine in their country. The items were derived from previously published papers that surveyed neurologists regarding care for migraine (4,5). Using the Likert scale, they were asked how much they agree with the statements provided. Lastly, the respondents were asked about their recommendations on how to improve care for migraine patients in their country.
Statistical analysis
Descriptive statistics were performed using the SPSS software for Windows (Version 24). Utilizing the 2021 World Bank Classification, the countries were stratified by income level (6). The countries were further divided into “Lower Income Group” if belonging to the low and low middle-income category and “Higher Income Group" if a country belongs to the upper-middle and high-income group to determine if income group influenced the availability of care for headache patients.
Ethical considerations
This was an investigator-initiated, self-funded study approved by the AOAN in 2019. Ethics approval was obtained from the Research and Ethics Board of the University of the Philippines, Manila.
Results
The survey was conducted from August 2020 to January 2021. Overall, 24 countries participated comprising all of the 21 member countries of AOAN and 3 non-member Asian countries namely: Bangladesh, Nepal and Brunei Darussalam.
Table 1 shows the availability of headache resources amongst responding countries. All countries have an established neurological association except for Brunei where there are only six neurologists. Thirteen of the twenty-four countries (54%) have a dedicated council for headaches. Specialized headache units defined as a dedicated center or a clinic in a hospital with a structure and staff exclusively for headache patients are available in 8 countries (33%). Except for Vietnam, there are no headache units in the lower-income group.
Availability of resources for headache in the Asian Oceanian region.
a: Classification of income based on the 2020 World Bank Classification
f: Countries further divided into 2 groups namely -
b: Offers subspecialty training to foreign neurologists
c: Population based on 2021 worldpopulationreview.com
F: Full reimbursement
P: Partial reimbursement
The majority of AOAN countries (75%) have no subspecialty training program for headaches. The 6 countries with subspecialty training programs belong to the upper-income group with Japan, Singapore, and Taipei offering training to foreign neurologists. Prevalence studies for headaches and migraine are available in 14 of the 24 countries (58%). Clinical practice guidelines for headache or migraine are available in 10 of the 24 countries (42%) with Mongolia being the only one coming from the lower-income group. On average, about 2.77 hours are dedicated to lectures on primary headaches in medical schools, the majority offer less than 5 hours with Israel, Indonesia, and Myanmar allotting the most lecture time of approximately 8 hours.
As shown in Table 1, most of the countries in the upper-income group provide either full or partial reimbursement for acute and prophylactic medications. In the lower-income group, only 4 countires namely Myanmar, Sri Lanka, Vietnam, and India have migraine drug reimbursements. Nine out of the 24 countries (38%) have an available patient advocacy organization for headaches. In the lower-income countries, only Pakistan and the Philippines have patient advocacy organizations dedicated to headache disorders.
The availability of pharmacologic and non-pharmacologic approved treatments for migraine in the 24 countries surveyed is summarized in Table 2. All countries except for Mongolia have at least 1 triptan (sumatriptan). Not included in Table 2 is the availability in all countries of various popular NSAIDs like aspirin, ibuprofen, diclofenac, and naproxen for acute treatment of migraine. Some approved prophylactic drugs for migraine are not available in all countries (see Table 2). China has no approval for propranolol, amitriptyline, topiramate, divalproate for migraine prophylaxis. The novel CGRP monoclonal antibodies for migraine prophylaxis are available in 12 countries. Erenumab is available in 11 countries, galacanezumab in 10, and fremanezumab in 4 countries. These monoclonal antibody treatments are mainly available in all high-income countries except Brunei, China, Indonesia and Saudi Arabia. In the lower-income group, only the Philippines and India have a monoclonal antibody available. Herbal drugs or traditional medicines are a popular adjunctive treatment for migraine in 6 of 24 countries (Australia, China, Hong Kong, Israel, Japan, and Sri Lanka).
Availability of pharmacologic and non-pharmacologic treatments for migraine.
Legend ✓ available; X- Not available; a - awaiting approval; b NS-neurostimulation;
c- Not limited to single pulse TMS; d Onabotulinum toxin type A; CMig- Chronic Migraine; Mig-migraine;
X OL – available but Off Label use
In terms of non-pharmacologic treatment (Table 2), onabotulinum toxin type A for chronic migraine is available in 22 of 24 countries except for Afghanistan and Bangladesh. Transcutaneous supraorbital stimulation (Cefaly) is available in 6 of 24 countries, non-invasive vagus nerve stimulation in 4 of 24, while transcranial magnetic stimulation of any type is available in 7 of 24 countries.
Table 3 shows the country respondents’ opinions on their perceived popular practice of care for migraine by local neurologists. The poll showed that the majority of respondents agree that migraine is under-diagnosed and under-treated by non-neurologist physicians but not by neurologists. During clinical encounters, measuring the burden due to migraine using Migraine Disability Assessment Score (MIDAS) or its equivalent (25%) and differentiating episodic from chronic migraine (50%) do not seem to be a popular practice by the neurologist. Based on opinion, the use of neuromodulation devices, as well as herbal treatment as an adjunct to migraine medications, is not well utilized in the region. However, all respondents strongly agree that there should be more time allotted for lectures dedicated to primary headaches in medical schools and that there is a need to do more research on migraine than what is currently being done in their respective countries.
Opinion of country respondents on the management of migraine in the region responses to statement: N=24
Discussion
The survey describes the current availability of care for headaches, in particular migraine, in 24 countries in the Asian Oceanian region. Data from 22 of the 50 countries of Asia (44%) and two from the Oceanian region, namely Australia and New Zealand formed the basis of this paper (7). Among others, the survey shows the scarcity of clinical guidelines, subspecialty training, dedicated headache clinics, patient advocacy organizations as well as the need for better professional education and support from the government to improve care for this major public health problem.
The 2011 Atlas of Headache Disorders (2011AHD) by the Lifting the Burden and World Health Organization surveyed neurologists, general practitioners, and patient representatives from 110 countries worldwide and dealt with headache in general. The present study was answered by neurologists focusing on migraine, as this is a more under-diagnosed, under-treated, and disabling illness, affecting people during their most productive years. The 2011AHD emphasized the lack and the underutilization of management guidelines especially in low-income countries, the non-availability of appropriate medication as a barrier to best management, and that only 4 hours are committed to headache disorder in formal undergraduate medical training. Among the proposals for change are better professional education, improving organizations, and delivery of healthcare for headaches.
The variability and the unmet needs in care for migraine in the Asian Oceanian region are understandably affected by the geographical location, ethnicity, economic status, government structure, country population, and the number of neurologists. This variability was also clearly shown in a study done by the AOAN showing marked diversity in overall neurological care (8). Although the economic status could be a significant reason for the differences, the Global Burden of Disease 2016 revealed no clear relationship between headache and the sociodemographic status based on the socioeconomic index (9). Many fatal and disabling disorders decrease with socioeconomic development, but this does not seem to be true for migraine and tension-type headaches (9).
The exact burden and impact of migraine in the Asian-Oceanian region are likely to be underestimated with only less than two-thirds of the participating countries having local prevalence studies on the disease. Epidemiologic studies are essential in gathering awareness and information for intervention planning and policymaking. As migraine is not fatal and does not result in permanent disability, lawmakers may not appreciate the real burden due to migraine. Knowing how neighboring countries are addressing migraine would help spread awareness which would, later on, help in getting support from the government and patient advocacy organizations.
The 2011AHD emphasized the importance of published management guidelines which are available only in the upper-income group. Clinical practice guidelines for headaches or migraine help standardize treatment and hopefully improve patient care. As the development of valid clinical guidelines require resources and skills, countries can always make local adaptations of existing guidelines. Adapting guidelines where local experts can modify an existing guideline to suit their local needs will help minimize resource use and promote evidence-based management of migraine.
While most neurological associations have stroke, epilepsy and dementia councils, only half of the surveyed countries have a headache council. The availability of neurologists especially those with special interest and training in headache can raise the priority given to people with headaches throughout the region. Fellowship training for headache in the regions is available in only five countries, with only 3 countries offering subspecialty training for headache to foreign neurologists. Although a complete one to two-year headache fellowship would be ideal, the headache master courses offered by the International Headache Society (IHS) in Japan in 2013 and Australia in 2018 paved the way in producing headache masters who have become leaders in promoting evidence-based headache care to local physicians and supporting secular organizations involved with headaches. A third of the countries surveyed have dedicated headache units and all are initiated and maintained by a neurologist with training in headache medicine. Since neurology involves varied diseases and not all neurologists are adept at what is current and effective, continuing medical education on headache is warranted.
Emphasis on better education is a key recommendation by the 2011AHD. Comparing the 4 hours stated in the Atlas, the present survey showed an average of 2.77 hours for teaching primary headaches in medical schools. The limited hours provided may not be enough to prepare future physicians when confronted with the heavy load of patients with varied types of headache. Headache councils which are available in half of the surveyed countries can be instrumental in seeking representation in medical schools for more teaching time. Promoting awareness among the lay and physicians, as well as setting guidelines for managing headache disorders can be achieved through the initiatives of headache councils or professional organizations. This should include representations from other disciplines like psychiatry, pain, family medicine, and allied medicine.
The survey shows that non-specific migraine treatments like NSAIDs are available in all countries. Migraine-specific drugs like triptans are available in almost all countries while ergotamine can be accessed in 15 out of the 24 countries. Triptans are available mainly as oral preparations but a wider selection of triptans including non-oral forms can benefit patients who are difficult to treat and cannot tolerate their side-effect. Although more expensive, triptans are much preferred over ergotamine because of the many side effects of the pure formulation of oral ergotamine. As medications for acute migraine are widely available and can even be acquired without prescriptions in some countries, there is a risk for medication overuse headache, which is a more disabling type of headache.
Since 2018, there have been a lot of advancements in the pharmacologic treatment of migraine with the FDA approval for prophylaxis (erenumab, galcanezumab, fremanezumab, and eptinezumab) and acute treatment (ubrogepant, rimegepant, lasmiditan) (10). Half of the countries surveyed already have injectable CGRP monoclonal antibodies but the high cost of these newer drugs is a major barrier, especially in the lower-income group. A major concern is the long-term safety of these novel anti-migraine drugs in particular the monoclonal antibodies, especially for cardiovascular side effect due to chronic CGRP blockade. Lobbying for subsidies by the government and pharmaceutical companies for well-established acute and prophylactic drugs like the triptans and botulinum toxin for chronic migraine can make these drugs available and affordable to many. As shown in Table 1, there are many countries in the lower income group that do not offer reimbursement for drugs related to migraine.
The personal opinions coming from the country respondents (Table 3) provide us an insight into the current practice of neurologists and possible gaps in the care of migraine patients. About half of the respondents think that there is already enough medicine available for acute migraine while a minority thinks that there is a need for more prophylactic drugs than what is currently available. Based on the responses, there is a need to emphasize to the neurologists the indications for migraine prophylaxis, the need to differentiate episodic from chronic migraine, and to counsel patients on the possibility of medication overuse headache. Nearly half of respondents think that neurologists would request neuroimaging while few would request for electroencephalogram for patients fulfilling the ICHD-3 criteria for migraine (11) and this could lead to unnecessary use of expensive technologies, most especially in resource-limited countries. Based on the survey, neurologists may have to confidently utilize the criteria proposed by IHS for migraine and measure the burden of migraine through tools like MIDAS to properly manage patients (11,12). All respondents agree that there should be more time allotted in medical schools to study primary headaches and do more local researches on migraine than what is currently being done.
The respondents were asked on their personal suggestions to improve the current care of patients with migraine. Many expressed the need to expand knowledge concerning headache medicine among general practitioners and internists through the availability of short-term courses on headache. Webinars like the ones offered by the International Headache Society and the World Headache Society (13) are well appreciated. Others felt the need for the government to divide service provisions rationally between primary and secondary care as the majority of patients would consult primary care physicians and a much lesser percentage would need a higher level of care by specialists. Because of the introduction of newer and effective migraine drugs, advocacy for these medications to be approved and available by the country can provide better options for both patients and health providers, especially for very difficult to treat migraine headaches.
A major limitation of this study is that the responses were derived from a single neurologist of a country and the opinion of primary physicians would have shed more information on the actual delivery of care for headache and migraine. The authors were not able to validate the responses to each survey item as some questions could be interpreted differently. To mitigate this, repeated emails were sent for clarifications. The responses stated in Table 3 are the personal opinions of the respondents and may not reflect the opinions of their colleagues. All the respondents are well-established clinical neurologists with 15 out of the 24 affiliated with a university and 10 out of the 24 are headache specialists. The data in this survey reflects what is currently available during the study period, which occurred during the COVID-19 pandemic. Future evaluations should be done to track the progress in headache and migraine care in the region.
A comparison between this study and the 2011AHD would have been worthwhile because the Atlas contained data for 18 countries surveyed. However, due to the unavailability of details and the different sources of information in the Atlas, comparison of the results was not possible.
With the use of modern telecommunication technology, advancing the knowledge on headache medicine in the region through sharing of best practices and professional resources can be enhanced, especially with support coming from higher income group. Creating more headache awareness programs and researches that document how disabling migraine is may prompt policymakers in lobbying strategies to improve existing care. Neurologists, in collaboration with other specialties and discipline, have a major role in promoting education, awareness, creation of clinical guidelines, and ensuring the availability of essential treatment for migraine patients.
Conclusion
The survey shows the scarcity of clinical guidelines, subspecialty training, dedicated headache clinics, professional and patient advocacy organizations for the care of headache patients in 24 Asian Oceanian countries. Traditional acute and prophylactic medications approved for migraine are available in most countries but non-pharmacologic devices are still lacking. The respondents agree that migraine is under-diagnosed and under-treated by non-neurologists, that more time should be allotted for the study of headache in medical schools, and that more research be done than what is currently available.
Clinical implications
The unmet needs and recommendations of the 2011 Atlas of Headache Disorders are still relevant and must be pursued to improve care for people with headaches, in particular, migraine in the Asian Oceanian Region. Awareness of the public, the government and policymakers that migraine is disabling, under-diagnosed, under-treated affecting people in their most productive years should be pursued with the neurologist taking a lead role in the advocacy. To properly prepare primary physicians to handle patients with headaches, more hours should be dedicated to teaching primary headaches in medical schools. More confidence in using the criteria set by the International Headache Society (ICHD-3) can reduce the need for expensive work-up including neuroimaging especially in resource-limited countries. Sharing of best practices, clinical guidelines, the expertise of headache specialists, and collaborative research on migraine should be promoted.
Supplemental Material
sj-pdf-1-cep-10.1177_03331024211024153 - Supplemental material for Delivery of care for migraine in the Asian Oceanian region: A cross-sectional study
Supplemental material, sj-pdf-1-cep-10.1177_03331024211024153 for Delivery of care for migraine in the Asian Oceanian region: A cross-sectional study by Artemio Roxas Jr Liz Edenberg Quiles and Shuu-Jiun Wang in Cephalalgia
Footnotes
Author contributions
AAR conceptualized and created the protocol, survey tools and supervised the invitation and data collection of country representatives, drafting and submission of the paper. LEQ helped in the literature search for literature, analysis of data, and drafting the manuscript. SJW assisted in improving the protocol and survey tool as well as the writing of the final paper. All authors read and approved the final manuscript.
Acknowledgements
The authors thank Ms. Rochelle Lamarca for her assistance in coordinating and collecting data from the collaborators, and Dr. Pearl Angeli Diamante for helping in the submission to the journal. Thank you also to Dr. Bronwyn Jenkins and Dr. Tissa Wijeratne for their assistance in the completion of the paper and the country representatives: Beomseok Jeon MD, (President of the Asian Oceanian Association of Neurology);
Declaration of conflicting interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Artemio Roxas Jr. has served as a speaker and drug trialist for Novartis. Liz Edenberg Quiles declared no potential conflicts of interest to the research, authorship, and/or publication of this article. Shuu-Jiun Wang has served on the advisory boards of Eli Lilly and Novartis. He has received honoraria as a moderator or speaker from AbbVie, Pfizer, Eli Lilly, Bayer, and Eisai. He has received research grants from the Taiwan Minister of Technology and Science, National Yang Ming Chiao Tung University, Taipei Veterans General Hospital, Taiwan Headache Society, Taiwan Novartis and Taiwan Eli Lilly.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
References
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