Etude GRIM 2 : CONSOMMATION DE SOINS ET CEPHALEES

C. Lucas, Clinique Neurologique, CHRU de Lille

Le cot annuel de la migraine en France a t estim 743 millions dEuros (949 millions dEuros de 1999) dans ltude GRIM I de 1989. Ceci correspondait un cot per capita de quinze Euros, et environ un pour cent du budget de sant de la France. Une nouvelle valuation pharmaco-conomique de limpact de la migraine a t ralise dans le cadre de ltude GRIM 2. Nous avons tendu notre analyse aux cphales chroniques quotidiennes, pour lesquelles aucune information nexistait concernant leur retentissement conomique en population gnrale.

PATIENTS ET METHODES Calcul des cots

Nous avons analys le cot direct des cphales avec valuation des recours au systme de soins (consultations, examens complmentaires, hospitalisations, traitements) et le cot indirect (absentisme). Il a t possible de calculer un cot unitaire par crise de cphale pour chaque sujet. Cette variable tait ensuite ajuste en fonction de la frquence des crises sur six mois, de faon gnrer le cot total du traitement sur cette priode. En ce qui concerne les traitements de fond, une consommation quotidienne pour toute la priode de six mois tait suppose.

Analyse des donnes

Nous avons compar les quatre sous-groupes de notre population en terme dutilisation des ressources et de dpenses de sant, sur une priode de six mois. Ces sous-groupes correspondent aux catgories diagnostiques suivantes : les cphales pisodiques non migraineuses (455 sujets), les migraineux probables (464 sujets), les migraineux (416 sujets) et les cphales chroniques quotidiennes (CCQ : 151 sujets). Nous avons galement regroup les deux sous-groupes de 'migraines' et de 'migraineux probables' en un seul groupe de 880 sujets. Pour cette analyse, un principe a minima pour le calcul du cot tait appliqu : les sujets qui ntaient pas en mesure de rpondre aux questions sur leur consommation de sant taient considrs comme des patients nayant rien consomm. Par consquent, les cots prsents doivent tre considrs comme une estimation basse des dpenses relles.

RESULTATS
Consultations chez le mdecin
Une minorit de notre chantillon (21 %) dclare avoir consult un mdecin gnraliste au moins une fois au cours des six mois prcdant l'enqute.

Traitements pharmaceutiques
La majorit des sujets (92,8 %), tous groupes diagnostiques confondus, dclare avoir pris des traitements pour soulager leurs maux de tte durant les six mois tudis. Les traitements les plus frquemment cits sont les anti-inflammatoires non strodiens pour un peu moins dun tiers et les antalgiques pour un peu moins de deux tiers. Une petite minorit seulement de sujets utilisent des triptans (8,0 % des migraineux, 2,7 % des cphalalgiques non migraineux et 6,7 % des CCQ). Les traitements de fond le plus souvent utiliss sont les drivs d'alcalodes de seigle et les bta-bloquants.

Dpenses de sant Consultations

Le montant total sur une priode de six mois slve 44 618 pour l'ensemble de la population des 1 486 cphalalgiques. Les sujets avec CCQ qui ne reprsentent que 10% de l'chantillon total, a gnr 40% de ces dpenses. Les dpenses varient de 7,35 pour les patients souffrant de cphales pisodiques non migraineuses 118,35 pour les patients souffrant de CCQ, en passant par 26,59 pour les migraineux.

Pharmacie
Le cot total des dpenses en pharmacie est de29 771 , ingalement repartis entre les diffrents groupes diagnostiques. Les dpenses du groupe de cphalalgies pisodiques non migraineuses ne reprsentent que moins de cinq pour cent du total. Une proportion importante de ces dpenses correspond l'automdication (antalgiques et AINS). Les dpenses pour des traitements de fond ( 6 373) sont principalement effectus par les migraineux (88 %). Les sujets prsentant des CCQ, bien que leurs dpenses mdicamenteuses soient globalement trs leves, n'utilisent que peu de traitements de fond. Le cot moyen par sujet dun traitement sur six mois est de 2,49 pour les patients souffrant de cphales non migraineuses, de 17,85 pour les migraineux et de 85,62 pour les patients souffrant de CCQ.

Hospitalisations
L'essentiel des cots d'hospitalisation correspond aux dpenses des sujets souffrant de CCQ (63 459 sur les 71 663 dpenss par les 1 486 individus).

Examens en laboratoire
Les examens de laboratoire pratiqus durant la priode des six mois ont cot un montant total de 17 778 pour l'ensemble de notre population de 1 486 cphalalgiques. Les sujets prsentant des CCQ dpensent, par individu, environ cinq fois plus que les migraineux.

Cots indirects A COMPLETER ++

La grande majorit des sujets (89,7 % du groupe des migraineux et 91,2 % du groupe de patients souffrant de cphales non migraineuses) na rapport aucun jour dabsentisme sur les trois derniers mois.

Cots globaux
Le cot global moyen par sujet pour les migraineux est de 127 . Ce cot unitaire est environ cinq fois plus lev que celui des cphalalgiques pisodiques non migraineux, mais dix fois infrieur celui des patients souffrant de CCQ. Les dpenses leves de ce dernier groupe tmoignent de limportance des cots de lhospitalisation.

CENM Consultations Hospitalisations Mdicaments Evaluations TOTAL 14,70 4,98 8,38 28,07

MP 46,33 8,82 43,78 18,12 117,05

Migraine 60,87 29,53 26,69 21,64 138,83

Total Mig 53,19 18,64 35,70 19,78 127,31

CCQ 236,69 818,83 171,25 94,94 1 321,71

Cots annuels des cphales par sujet, repartis par poste et par groupe diagnostique. CENM : cphales pisodiques non migraineuses ; MP : migraineux probables ; total Mig : migraineux probables et migraineux ; CCQ ; cphales chroniques quotidiennes.

Dterminants des cots

Nous disposions de trois mesures du retentissement des cphales : lchelle MIGSEV, mesure de la svrit des crises (lgre, modre ou svre) le questionnaire MIDAS avec quatre grades possibles (I - IV), mesure du caractre invalidant de la pathologie sur le trimestre prcdent, et lchelle QVM avec cinq plages

de score de qualit de vie spcifique aux cphales (> 90, 80-90, 70-80, 60-70 ou < 60). Sur lensemble des trois mesures, nous observons une relation significative (p < 0.001) entre la gravit de la pathologie au plan du retentissement fonctionnel et les dpenses engages. Le cot augmente de faon quasi-linaire en fonction de la catgorie MIGSEV. En ce qui concerne le questionnaire MIDAS et lchelle QVM, une augmentation importante des dpenses est constate pour les catgories les plus svres (MIDAS Grade IV et score QVM < 60 %).

CONCLUSION
Le cot total des cphales en France slve trois milliards dEuros, ce qui correspond environ 0,2 % du Produit Intrieur Brut. La plus grande partie de ces dpenses est attribue au groupe des sujets avec CCQ. Le cot de la migraine est de 1 044 [intervalle de confiance 95 : 706 - 1 318 millions], ce qui correspond un cot per capita de 18 par an. Le cot est corrl au retentissement fonctionnel des cphales mesur par i) lintensit des crises ii) le retentissement sur la vie sociale, familiale et professionnelle sur le dernier trimestre et iii) le profil de qualit de vie spcifique aux cphales. Ceci justifierait lutilisation dun outil dvaluation simple du retentissement fonctionnel de la migraine utilisable par tout praticien pour optimiser la prise en charge des patients migraineux.

Introducere: (International Journal of epidemilogy 2005 34(2):316-326 Socioeconomic differences in prevalence of common chronic diseases: an overview of eight European countries JAA Dalstra, AE Kunst, C Borell, E Breeze et al.) Multe patologii prezint o nalt prevalen a patologiilor n grupul cu nivel jos de educaie. Stroke-ul, patologiile sistemului nervos, diabetul i artritele au prezentat inegaliti relativ vaste(OR> 1,50). Diferene socio-economice relative au fost relativ mici printre cei din grupul de 60-79 ani n comparaie cu cei din grupul de 25-59 ani, iar printre cei cu nivel nalt de educaie n grupul de 60-70 ani. Diferenele socio-economice n morbiditatea general i mortalitate au fost gsite n toat Europa. Analiza mai detaliat a bolilor specifice, care cauzeaz aceste inegaliti socioeconomice este impotant att n scopuri descriptive, ct i pentru a prezenta o informaie mai complex asupra factorilor, ce contribuie la aceste inegaliti. Aceste date vor contribui la nelegerea cauzelor poverii patologiei printre grupul cu nivel mai jos socio- economic.

Acest studiu a utilizat setul de date noi, care prezint estimri ale inegalitilor de educaie pentru 17 diderite grupuri de patologii din opt ri din Europa pentu femei i brbai cu vrsta 2579 ani. Aceasta ne-a permis s studiem variaiile inegalitilor dup sex, vrst, ar i patologie i suplimentar s determinm dac descoperirile din fiecare ar pot fi generalizate pentru ntreaga Europ de Vest. Din Tab. 1: Pentu brbai mprirea populaiei cu nivelul cel mai jos a fost de 55,73%, iar pentru femei a fost de 62,37%.(date pe anii 1994-1997) la pers. de 25-79 ani. Educaia a fost selectat ca indicator socio-economic, deoarece ea a fost msurat ntr-un mod corect comparabil dintre ri. Patologiile cu o rat nalt a prevalenei(>10 la 100 n cel puin una din ri) au fost patologiile sistemului nervos, hipertensiunea, cefaleea/migrena, patologiile cronice respiratorii, cele genitourinare, osteoartroza, patologiile spatelui, ale coloanei vertebrale, patologiile cutanate i alergiile. n Tab. 2 este indicat rata prevalenei pentru grupul patologiilor cronice pentru persoanele cu vrsta cuprins ntre 25-79 ani. Cefaleea/migrena ( Rata la 100 respondeni): Danemarca-16,5 Marea Britanie-0,9 Niderlanda-7,8 Begia- 12,6 Frana-8,7 Italia-10,7

Tab.3 arat, c diferenele socio- economice n cazul patologiilor cronice au fost observate la majoritatea grupurilor patologiilor cronic n Europa. Sunt mari inegaliti socioeconomice(OR>1,50)pentru stroke, patologiile sistemului nervos, diabetul zaharat i artrite. OR(95% CI) Chronic group disease Total Men(Aged 25-79) 1,18 (1,06-1,32) Women(Aged Men and Men and women(Aged women(Aged 25-79) 25-59) Headache/migraine 1,35 (1,27-1,43) 1,29 (1,20-1,39) 1,28 (1,20-1,37) 60-79) 1,62 (1,42-1,84)

Diferenele socio-economice au fost adesea, n termeni relativi, mai multe printre populaia cu vrsta apt de munc, dect la cei mai n vrst.Mari diferene socio-economice printre persoanele mai n vrst au fost gsite pentru patologiile cronice respiratorii i cefalee/migren. Diferenele de educaie (nivelul jos versus superior) pentru grupul de persoane cu patologii cronice cu vrsta(25-79 ani)(Tab.4).
Chronic disease OR(95%CI) Interaction

group

Finland

Denmarc

Great Britain

The Netherlands

Belgium

France

Italy

Spain

between education & country

Headache/migraine

1,72 (1,272,32)

1,05 (0,751,49)

1,25 (1,11-1,42)

1,34 (1,151,57))

1,19 (1,041,36)

1,37 (1,271,47)

P<0,0001

O problem potenil important este, c datele patologiilor cronice s-au bazat pe cercetri desinestttoare. Raportarea problemei de sntate nu depinde doar de prezena actual a condiiei clinice, dar depinde deasemenea printre altele de astfel de caracteristici: cunoatine despre problema lor, abilitatea de a-i aminti despre ea, consecinele patologiei asupra vieii cotidiene, dorina de a vorbi despre aceasta i frecvena vizitelor la medicul de familie. Aceti factori pot varia n dependen de vrst. Totui pentru patologiile neurologice, artrite, patologile reg. lombare, a osteoartrozei oldului i genunchnilui precizia e joas. A fost gsit o cretere social invers pentru cefalee/migren i artrite. Unele studii ale cefaleei/migrenei i artritei au descoperit acelai cretere, pe cnd altele n-au observat nici o cretere.Rspndirea epidemiei fumatului n Europa de Sud a rmas n urm n comparaie cu Europa de Nord. n faza, cnd fumatul devine tot mai rspndit printre grupurile socioeconomice mai joase, n Europa de Nord, fumatul era totui mai egal repartizat printre grupurile socio-economice mai nalt i mai jos n Europa de Sud. Concluzii: Impactul patologiilor nefatale, dar incapacitante n-ar trebui ignorat. Tab1A Descrierea patologiilor cronice pe ar.
Chronic disease Headache/ migraine Migraine Finland Denmark Great Britain Migraine, headaches The Netherlands Migraine Migraine Hadache Recurrent headache or migraine Belgium France Italy Spain

Codul Headache/migraine ICD-9 code 784.0& 346. Smith R. Impact of migraine on the family. Hedache 1998;38:423-426. Studiul naional al suferinzilor de migren, intervievai la telefon, n care au fost interogai despre cum au perceput c migrena le-a afectat viaa de familie.

60% credeau, c familiile lor au fost considerabil afectate. Muli au afirmat, c familiile lor sunt nelegtoare, dar un numr considerabil a raportat,c membrii familiilor lor au luat o atitudine negativ. Aceasta a fost n special cu copiii mici, lipsii de ngrijirea printeasc pe parcursul atacului de migren. Relaiile de cuplu au suferit deasemenea. Frecvena i calitatea relaiilor sexuale au fost afectate i ntr-un numr mic de cazuri, divorul a fost rezultatul. Importana acestor cercetri n managementul migrenei s-a discutat. Comentarii: Migrena poate fi o suprare periodice(nefrecvent) pentru unii, dar disabilitate oribil pentru muli suferinzi i familiile lor. Strategiile de purtare... este o

Persoana bine tratat n societate, dar care n momentul de fa simte,c este o povar pentru familie i prieteni are nevoie de o metodic diferit de cea n cazul unui pacient cu ndreptire i dependen anormal.

DIAGNOZELE MIGRENA SI CTT 1+3 SI 2+4

Total N 2. sexul barbat femei e Total 279 744 1023 % 27,3 72,7 100

Migrene simpla+cron N 86 448 534 % 16,1 83,9 100

CTT simpla+cronic a N 193 296 489 % 39,5 60,5 100 U fiser -8,52299 8,52298 8 P <0.001 <0.002

Cum se repartizeaza dup sex persoanele cu migren si CTT? P. cu Migren: CTT: Brbai-16,1% 39,5% Femei-83,9% ( P<0,001) (P<0,002) P. cu BrbaiFemei-60,5%

Raportul femei/brbai la persoanele , ce sufer de migren este de 5,16, Iar la cei cu CTT raportul femei/brbai -1,53

8. Fumatu l

da nu

178 845 1023

17,4 82,6 100

75 459 534

14 86 100

103 386 489

21,1 -2,99606

<0.01

78,9 2,996058 <0.02 100

Total

n lotul persoanelor cu Migren fumeaz-14%, iar din cei cu CTT-21,1%(P<0,01) Nu fumeaz-86% (P<0.02) Sunt mai muli nefumtori n cazul respondenilor cu migren-86%, fa de 78,9% din cei cu CTT. nu fumeaz-78,9%

18. Maladii endocrin e

1 2

73 950 1023

7,1 92,9 100

48 486 534

9 91 100

25 464 489

5,1 94, 9 100

2,45708 5 -2,45708

<0.05 <0.06

Total

S-a depistat prezena maladiilor endocrine la persoanele cu Migren n 9% cazuri fa de 5,1% din cei cu CTT(p<0,05) 20. Maladii onco 1 2 Total

32 991 1023

3,1 96,9 100

22 512 534

4,1 95,9 100

10 479 489

2 98 100

1,981026 <0.05 -1,98103 <0.05

4,1% din cei diagnosticai cu migren au menionat, oncologice, iar din cei cu CTT doar 2%(P<0,05). x23 0 1 Total 1001 22 1023 97,8 2,2 100 515 19 534 96,4 3,6 100 486 3 489

c sufer de maladii 99,4 3,62213 <0.001 0,6 100 3,62213 <0.001

n timpul atacului de cefalee nu-i pot ndeplini activitile zilnice 3,6 % din totalul pers. cu Migren i 0,6% din cei cu CTT(P<0,001). x25 0 1 Total 983 40 1023 96,1 3,9 100 507 27 534 94,9 5,1 100 476 13 489 97,3 -2,00448 2,7 100 <0.05

2,004485 <0.05

Durerea de cap este nsoit de nausee diagnosticate cu Migren i

sau vom

la 5,1% din persoanele

La 2,7% din respondeii, ce sufer de Cefalee de tip tensional(P<0,05).

Triggerii cefaleei la persoanele cu Migren i CTT(rspuns spontan):

37. dcappro v 1,76129 3 -0,41956 3,76835 4 2,57428 9 0,77163 -4,2368

1 2 3 4 5 6

23 19 20 280 13 272

2,5 2,1 2,2 31 1,4 30,1

16 9 18 163 8 112

3,4 1,9 3,8 34,8 1,7 23,9

7 10 2 117 5 160

1,6 2,3 0,5 26, 9 1,1 36,

>0.05 >0.05 <0.001 <0.05 >0.05 <0.001

8 21 Total 54 904 6 100 20 469 4,3 100 34 435 7,8 100 -2,22844 <0.05

Factorii declanatori cel mai frecvent nominalizai(rspuns spontan) de ctre respondenii cu:
MIgren tensional 3.Menstruaia- 3,8% 0,5% (P<0,001) (P<0,05) Cefalee de tip 3.Menstruaia4.Stresul sau 6.Obosela21.Altceva-

4.Stresul sau ncetarea stresului-34,8% ncetarea stresului-26,9% 6.Obosela-23,9% 36,8% 21.Altceva-4,3% 7,8% 1.foamea-3,4% 2. alcoolul-1,9% 5.Somn insufficient-1,7% insufficient-1,1% 7.Incordarea psihic-2,6% psihic-4,1% 11. Lumini intense sau soare-5,5% sau soare-3,9% 17.Schimbri meteo-14,1% meteo-14,1%

(P<0,001) (P<0,05)

(P>0,05) (P>0,05) (P>0,05) (P>0,05) (P>0,05) (P>0,05)

1.foamea-1,6% 2. alcoolul-2,3% 5.Somn 7.Incordarea 11. Lumini intense 17.Schimbri

-----------------------------------------------------------------------------------------------------------------------------------------

Triggerii migrenei i cefaleei de tip tensional dup interviu:

d3701 0 1 Total 769 254 1023 75,2 24,8 100 381 153 534 71,3 28,7 100 388 101 489 79,3 -2,97241 <0.01 20,7 2,972413 <0.01 100

Persoanele cu migren menioneaz foamea n 28,7% cazuri, iar cei cu CTT-n20,3% (P<0,01) d3702 0 2 Total 813 210 1023 79,5 20,5 100 388 146 534 72,7 27,3 100 425 64 489 86,9 -5,73328 <0.001

13,1 5,733275 <0.001 100

Alcoolul ca factor declanator al migrenei a fost indicat de 27,3% din intervievai i doar de 13,1% din cei cu Cefalee de tip tensional (P<0,001) d3703 0 3 854 169 83,5 16,5 409 125 76,6 23,4 445 44 91 9 -6,39788 <0.001

6,397875 <0.001

Menstruaia ca factor-trigger a fost menionat de 23% de migrenoi i de 9% din persoane cu CTT(P<0,001) d3704 0 4 242 781 23,7 76,3 99 435 18,5 81,5 143 346 29,2 -4,03429 <0.001

70,8 4,034294 <0.001

Stresul sau ncetarea stresului a fost nominalizat ca trigger de 81,5% din respondenii cu migren i de 70,8% din cei cu CTT!!!

d3706 0 6

230 793

22,5 77,5

134 400

25,1 74,9

96 393

19,6 80,4

2,11289 2,11289

<0.05 <0.05

Oboseala este prezent ca factor-trigger la 74,9% din migrenoi i la 80,4% din cei cu cefalee de tip tensional(P<0,05)!!! d3708 0 8 864 159 84,5 15,5 411 123 77 23 453 36 92,6 -7,17924 7,4 <0.001

7,179237 <0.001

Mirosurile puternice cauzeaz cefaleea la 23% din intervievaii cu migren i la 7,4% din cei cu CTT(P<0,001) d3711 0 11 673 350 65,8 34,2 296 238 55,4 44,6 377 112 77,1 -7,42284 <0.001

22,9 7,422843 <0.001

Luminile intense sau soarele provoac migrena la 44,6%din suferinzi i la 22,9% de intervievai cu Cefalee de tip tensional(P<0,001) d3713 0 13 754 269 73,7 26,3 329 205 61,6 38,4 425 64 86,9 -9,52161 <0.001

13,1 9,521612 <0.001

Sunetele puternice sunt triggerii Migrenei n 38,4% din cazuri, iar la cei cu CTT- la 13,1% din suferinzi(P<0,001) d3714 0 14 835 188 81,6 18,4 410 124 76,8 23,2 425 64 86,9 -4,2244 <0.001

13,1 4,224399 <0.001

Somnul profund sau prea mult somn este nominalizat ca trigger n 23,2% n cazul respondenilor cu migren i n 13,1% cazuri de CTT(P<0,001) d3717 0 17 397 626 38,8 61,2 188 346 35,2 64,8 209 280 42,7 2,46007 <0.05 57,3 2,46007 <0.05

Total

1023

100

534

100

489

100

Schimbrile meteo migrenoi i la

au fost menionate ca factori- declanatori la 64,8% din 57,3% din persoanele cu Cefalee de tip tensional(P<0, 05).

Comportamentul n timpul durerii de cap(rspuns spontan:

DIAGNOZELE MIGRENA SI CTT 1+3 SI 2+4 Total N comport 0 1 2 3 4 5 6 7 8 102 25 1 65 16 483 258 6 1 % 10,2 2,5 0,1 6,5 1,6 48,3 25,8 0,6 0,1 21 6 285 134 5 4 1,1 54,3 25,5 1 N 45 9 Migrene simpla+cron % 8,6 1,7 CTT simpla+cronica N 57 16 1 44 10 198 124 1 1 % 12 3,4 0,2 9,3 2,1 41,7 26,1 0,2 0,2 -1,77211 -1,72747 -1,41292 -3,42796 -1,27444 3,99335 7 -0,21656 1,75069 4 -1,41292 >0.05 >0.05 >0.05 <0.001 >0.05 <0.001 >0.05 >0.05 >0.05

9 Total

43 1000

4,3 100

20 525

3,8 100

23 475

4,8 100

-0,77975

>0.05

3.Continu activitile zilnice- 4% din respondenii, ce sufer de migren i 9,3% din cei cu CTT(P<0,001). 5.Iau medicamente-54,3% din migrenoi i 41,7% din intervievaii cu Cefalee de tip tensional(P<0,001). Comportamentul n timpul durerii de cap(rspuns dup chestionare): d3801 0 1 Total 819 204 1023 80,1 19,9 100 479 55 534 89,7 10,3 100 340 149 489 69,5 8,255631 <0.001 30,5 -8,25563 100 <0.001

Merg la aer- 10,3% din CTT(P<0,001).

persoanele cu migren i 30,5% din respondenii cu

d3802

0 2

848 175

82,9 17,1

492 42

92,1 7,9

356 133

72,8 27,2

8,427462 -8,42746

<0.001 <0.001

Privesc televizorul-7,9% din respodenii, ce sufer de migren i 27,2% din cei cu CTT(P<0,001)

d3803

0 3

567 456

55,4 44,6

380 154

71,2 28,8

187 302

38,2 61,8

10,80193 -10,8019

<0.001 <0.001

Continu activitile obinuite-28,8% din intervievaii-migrenoi i 61,85% din respondenii, ce sufer de cefalee de tip tensional(P<0,001).

d3804

0 4

817 206

79,9 20,1

441 93

82,6 17,4

376 113

76,9 23,1

2,271193 -2,27119

<0.05 <0.05

Fac masaj la cap 17,4% din cei cu migren i 23,1% din cei cu CTT(P<0,05).

d3805

0 5

330 693

32,3 67,7

120 414

22,5 77,5

210 279

42,9 57,1

-7,02788 7,027876

<0.001 <0.001

Iau medicamente- 77,5% din respondenii ce sufer de migren i 57,1% din persoanele cu CTT(P<0,001).

d3806

346

33,8

120

22,5

226

46,2

-8,08886

<0.001

677

66,2

414

77,5

263

53,8

8,088861

<0.001

Prefer repaosul la pat 77,5% din migrenoi i 53,8% din cei cu CTT(P<0,001).

d3807

0 7

778 245

76,1 23,9

329 205

61,6 38,4

449 40

91,8 8,2

-12,0755 12,0755

<0.001 <0.001

Aleg o odaie ntunecoas-38,4 din cei, ce sufer de Migren i 8,2% din respondenii cu Cefalee de tip tensional(P<0,001). P.39. Antecedente eredo-colaterale Cineva din rudele apropiate sufer ( a suferit) de dureri de cap similare?
DIAGNOZELE MIGRENA SI CTT 1+3 SI 2+4 Total N rudele Total Nu 1 Da 2 364 659 1023 % 35,6 64,4 100 Migrene simpla+cron N 161 373 534 % 30,1 69,9 100 CTT simpla+cronica N 203 286 489 % 41,5 58,5 100 -3,81054 3,810541 <0.001 <0.001

n cazul respondenilor cu migren-69,9% au menionat prezena rudelor cu dureri similare, iar din cei cu cefalee de tip tensional -58,5% (P<0,001). 3. 52,8% din suferinzii de migren i 46,1%din cei cu CTT au numit mama, care a avut sau are cefalei similare(P>0,05). 5. sora sau fratele au fost menionai n cazul a 9,8% din respondenii cu migren i de 7,4% din cei cu CTT(P>0,05). 12. feciorul sa fiica au fost nominalizai n cazul a 14,3% din migrenoi i de 16% din cei, ce sufer de CTT(P>0,05).
14 Total 39 625 6,2 100 8 356 2,2 100 31 269 11,5 100 -4,87963 <0.001

2,2% din migrenoi i 11,5% din cei cu CTT- au indicat alte persoane din anturaj(P<0,001).

d3903 Total

0 3

282 377 659

42,8 57,2 100

141 232 373

37,8 62,2 100

141 145 286

49,3 50,7 100

-2,95798 2,957979

<0.01 <0.01

Dup chestionare 62,2% din suferinzii de Migren au numit mama, ca avnd dureri similare de cap i 50,7% din respondenii cu CTT au menionat acelai lucru(P<0,01).

d3913

0 13

549 110

83,3 16,7

321 52

86,1 13,9

228 58

79,7 20,3

2,171417 -2,17142

<0.05 <0.05

Soul a fost numit ca suferind de cefalei de acelai tip de 13,9% din migrenoi i de 20,3% din cei cu cefalee de tip tensional(P<0,05).
d3914 Total 0 14 618 41 659 93,8 6,2 100 361 12 373 96,8 3,2 100 257 29 286 89,9 10,1 100 3,653072 -3,65307 <0.001 <0.001

Altcineva a fost nominalizat de 3,2% din cei cu Migren i de 10,1% din cei cu CTT(P<0,001).

P.40 Cefaleea i somnul diurn. Se ntmpl ca n timpul durerii de cap ziua s reuii s adormii (cu sau fr medicamente)?
somnziua Total Da 1 Nu 2 693 330 1023 67,7 32,3 100 342 192 534 64 36 100 351 138 489 71,8 28,2 100 -2,67378 2,673782 <0.01 <0.01

N-au reuit s adoarm ziua, n timpul cefaleei respondenii cu migren n 36% cazuri, iar cei cu CTT n28,2% cazuri(P<0,01). Durerea poate s dispar dup trezire?
dispdure Total Da 1 Nu 2 624 69 693 90 10 100 291 51 342 85,1 14,9 100 333 18 351 94,9 5,1 100 -4,43538 4,435381 <0.001 <0.001

Durerea de cap persist dup trezirea din somnul diurn la 14,9% din cei cu migren i la doar 5,15 din respondenii cu cefalee de tip tensional(P<001), pe cnd la 85,1% din migrenoi i 94,9% din respondenii cu CTT cefaleea dispare. Comorbiditatea algic n cursul ultimului an:
p.80_07 Total 0 7 912 111 1023 89,1 10,9 100 466 68 534 87,3 12,7 100 446 43 489 91,2 8,8 100 -2,01945 2,019452 <0.05 <0.05

Durerile abdominale au nsoit cefaleea la 12,7% din respondenii cu migren i la 8,8% din cei cu CTT(P<0,05).
p.80_12 Total 0 12 701 322 1023 68,5 31,5 100 349 185 534 65,4 34,6 100 352 137 489 72 28 100 -2,27682 2,276817 <0.05 <0.05

Durerea n regiunea lombar(n ale) a fost nominalizat de 34,6% din suferinzii de migren i de 28% din cei cu cefalee de tip tensional8P<0,05). Anxietatea generalizat
p.81 0 Nu sau foarte rar 1 Rar Des 2 3 20 2 9 1,7 11 2,2 -0,5789 >0.05

361 364 246

35,3 35,6 24

152 204 146

28,5 38,2 27,3

209 160 100

42,7 32,7 20,4

-4,76056 1,83823 2,592837

<0.001 >0.05 <0.05

f. des, practic permanent 4 Total

32 1023

3,1 100

23 534

4,3 100

9 489

1,8 100

2,374464

<0.05

Prezena anxietii la respondenii cu Migren a fost indicat ca frecvent n 27,3% cazuri , iar la respondenii cu Cefalee de tip tensional-n20,4% cazuri, foarte des, practic permanent, respectiv n 4,3% i 1,8% n ambele gupuri(P<0,05).

0 7 Total

250 28 278

89,9 10,1 100

145 24 169

85,8 14,2 100

105 4 109

96,3 3,7 100

-3,13902 3,139021

<0.001 <0.001

Au menionat n calitate de fenomene frecvente(sau foarte frecvente) adiionale durerii de cap greaa i discomfortul abdominal persoanele cu migren n 14,2% de cazuri, iar cei cu CTT- n 3,7% cazuri(P<0,001).

Raportul doctorandei Catedrei de Neurologie a USMF N. Testemianu Crciun Cristina privind lucrul asupra tezei de doctor n tiine medicale socio-economic." "Epidemiologia cefaleelor primare n mediul rural i urban din Republica Moldova. Impactul

Rezumat: Actualitatea problemei cefaleelor primare e justificat prin prevalena nalt a migrenei-1315% i a cefaleei de tip tensional de 40-60% din numrul total al populaiei i impactul social i personal important al acestora. Cefaleea reprezint cel mai frecvent simptom neurologic pentru care pacienii se prezint la medic, ea a fost inclus de OMS n lista celor 10 cauze cele mai rspndite de incapacitate la ambele sexe i primelor 5 la femei. Elucidarea aspectelor epidemiologice i socio-economice ar permite obinerea unui tablou real al prevalenei cefaleelor primare n Republica Moldova i ar putea fi elaborate strategii adecvate att n aspect clinic, diagnostic i de tratament, ct i managerial. Monitorizarea atent a factorilor- declanatori a cefaleelor poate avea un rol i

important in tratamentul lor, deoarece evitarea acestora poate micora frecvena severitatea atacurilor de cefalee i poate duce la depistarea etiologiei cefaleelor.

Prevalena- numrul total de bolnavi prezeni la o populaie ntr-o perioad de timp(1 an, life-time). Inciden- cte cazuri noi au aprut ntr-o unitate de timp(1 an). Scopul studiului: Estimarea prevalenei cefaleelor primare (migrenei i cefaleei de tip Moldova . Un alt obietiv important al studiului dat a fost examinarea relaiei dintre factorii declanatori i migren, cefalee de tip tensional, cat i cu subtipurile migrenei: migrena cu aur i migrena fr aur, ct i evidenierea particularitilor clinice a diferitor tipuri de cefalee, cunoaterea incidenei acestora i compararea rezultatelor cu cele prezente n alte ri. In anul 1988,Sociataea Internaional a Cefaleeii a publicat prima clasificare a tulburrilor cefalgice, divizind toate tipurile de cefalee in : 19 20 primare(neasociate unei leziuni cerebrale clinic identificate) secundare(condiionate de o maladie neurologic sau somatic) tensional) i stabilirea frecvenei factorilor- triggeri la subiecii aduli (15-65 ani) cu acest tip de cefalei in localitile urban(mun Chiinu) i rural(Hanceti) din Republica

Ea a devenit un standard pentru diagnosticarea cefaleei. Acumularea cunotinelor in domeniul cefaleelor,cunoaterea mai bun a fiziopatologiei acestora, precum i descrierea de noi entiti clinice a condus la necesitatea revizuirii acestei

clasificri. Ediia adoua a Clasificrii Internaionale a Tulburrilor Cefalgice a aprut in ianuarie 2004, fiind complex, bine ierarhizat, astfel inct s fie util cercettotilor i clinicienilor, prezentnd o clasificare ampl i sistematizarea a 200 de forme ale cefaleei. In acelai an ea a fost tradus in limba roman in Republica Moldova la Catedra de Neurologie a Universitii de Stat de Medicin i Farmacie Nicolae Testemianu . Criteriile de diagnostic stricte i exacte expuse in clasificare ofer posibilitatea aprecierii unui diagnostic corect tiinific, fondat pe abordarea medicinei bazate pe dovezi. In raportul OMS din a. 2000 dup gradele de severitate a diferitor patologii, pacienii cu atacuri severe de migren au fost considerai mai afectai decat cei cu psihoze active, demene, sau cei cu tetraplegie. Privind numrul de ani trii cu disabilitate( YLDs), cauzat de variate patologii, migrena depete locul 19 in lume i locul 9 la femei(Maters et al 2002). Migrena este o form relativ sever de cefalee, ce survine in form de atacuri, de obicei cu durata de la 4 ore pan la 72 ore (3 zile), fiind acompaniat de astfel de fenomene disabilitante ca : nausea(greurile) sau vomele, intolerana sever a luminii, sunetelor, mirosurilor i al micrii corpului. Cefaleea de tip tensional este de obicei mai puin incapacitant ca migrena i cu mai puine fenomene insoitoare. Acest tip de cefalee nu a fost considerat in raportul OMS cel mai important, dar datorit fatului, c este cel mai prevalent tip de cefalee i are tendina de a deveni cronic la o substanial parte a pacienilor, consecinele individuale i sociale a Cefaleei de tip tensional pot fi la fel de semnificative, ca i cele ale migrenei. Alte forme relativ rare aa ca cefaleea in ciorchine(Cluster), poate fi chiar mai incapacitant ca migrena pe timpul atacului. Fr a ine cont de diagnostic, pentru majoritatea pacienilor, consecina este, c funcia normal e intrerupt de episoade de cefalee cu intervale neregulate i imprevizibile, iar aceasta poate impune severe limitri in viaa lor cotidian, la studii, munc i pe parcursul timpului de odihn. Toate acestea i faptul, c patologiile date par a fi extrem de prevalente in toat lumea, le face importante din punctul perspectivei economice. Materiale i metode: Studiu randomizatface-to-face", " door-to-door prin intermediul chestionarului structurat, elaborat de Profesorul I.Moldovanu in 2004, in conformitate cu Criteriile Clasificrii Internaionale a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee in anul 2004.Selectarea eantionului-

Chiinu-Hnceti. In studiu au fost inclui 2665 respondeni cu varsta cuprins intre 15-65 ani, care au alctuit 84% din 3165 persoane contactate . Chestionarea a fost efectuat in perioada : mai-iunie, septembrie-octombrie 2005 de un grup de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu i rezideni in neurologie, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee(IHS). Din totalul de 2665 de persoane au rspuns afirmativ la intrebare privind prezena cefaleelor- 1439, ce constituie 54% , 1226 din cei cercetai-46% n- au avut cefalee . Chestionarul care a fost utilizat in acest studiu include 145 intrebri, care vizeaz urmtoarele aspecte de baz:aspecte socio-demografice depistarea factorilor- declanatori ai migrenei i cefaleei de tip tensional,caracteristici clinice detaliate, tratamente farmacologice, date medico-economice , comorbiditatea, gradul de incapacitate(MIDAS i HIT),impactul cefaleelor i estimarea prezenei abuzului medicamentos. Analiza datelor chestionarelor s-a efectuat utilizand SPSS , varianta 12. Dat fiind, c cefaleea constituie o problem major de sntate, fiind inclus de Organizaia Mondial a Sntii(OMS) in lista primelor 10 cauze de incapacitate la ambele sexe i a primelor 5 cauze de incapacitate efecturii acestuia . Rezultate: Datele privind repartizarea tipurilor maladiilor cefalalgice sunt indicate in tabelului de mai jos: Tipul cefaleei Migren Cefaleea de tip tensional Migrena cronic CTT cronic Cefalee mixt Numrul suferinde 441 421 93 68 73 persoanelor Prevalena(%)(din pers.) 16,5% 15,8% 3,5% 2,6% 2,7% 2665 la femei, lipsa unui studiu epidemiologic al a impus necesitatea imperativ a prevalenei cefaleelor primare in Republica Moldova

Cefaleea mixt cronic Migrena probabil CTT probabil Migrena cronic probabil CTT cronic probabil Cefalee mixt probabil Cefalee mixt cronic probabil Cefalee secundar

43 61 54 44 49 41 24 26

1,6% 2,3% 2,0% 1,7% 1,8% 1,5% 0,9% 1%

Dup frecvena atacurilor pe lun Migrena-1-4 zile- 173p. Migrena-5-14 zile-291p. Migrena>sau egal 15 zile-70p. CTT-1-4 zile-185p. CTT-5-14 zile-235p. CTT >sau egal 15 zile-69p.

Din totalul de 2665 respondeni- 1587(59%) au fost femei, brbai au fost- 1078(40,5%), Din numrul persoanelor cu dureri de cap, femei au fost 1050- 73%, brbai- 38927%.

48,8% din cei intervievai locuiau in mun Chiinu, respectiv- 51,2%- in Hinceti. Divizarea dup starea matrimonial a respondenilor a avut loc astfel: Cstorii- 1834- 68,8%, celibatari- 586-22%, divorai-121- 4,5%, vduvi-124-4,7%. Dup varst persoanele chestionate aveau:

15-24 ani- 629p.- 23,6% 25-34 ani- 610p.- 22,89% 35-44 ani- 432p.- 16,21% 45-54 ani-486p.-18,23% 55- 65 ani- 508p.- 19,06%

Din ei: Nu erau incadrai in cimpul muncii- 829 respondeni- 31,1% Munc intelectual indeplineau- 1120 chestionai-42% Munceau fizic- 708 intervievai- 26,6%. Dup nivelul educaiei: intervievai, coala profesional- 25%, mediu- 18,9% : Studii liceale -5,6%, Studii postliceale- 13,2%, superior -48,5%: Universitatea au absolvit-o 35,3% din respondeni i Studii postuniversitare- 2,6% din 2665 persoane chestionate. jos- 43,2%: coala primar au absolvit-o 18,2% din cei

Tabagismul: fumtori- 623(23,4%), iar nefumatori-2042(76,6%).

Dup starea material i condiii de trai- 15% din respondeni au menionat, c au un trai decent, 69,8%- considerau, c au condiii de trai medii i au bani doar pentru strictul necesar, iar 15,2%-c au condiii nefavorabile de trai i nu le ajung bani nici pentru strictul necesar.

Cefaleea este una din acuzele cele mai frecvente in practica medical, constituind o problem major a sntii publice cu un impact indvidual i social mare, , avind ca rezultat pierderea productivitii, limitarea activitii i deteriorarea calitii vieii, date confirmat de cercetrile epidemiologice actuale. Circa 45 de mln de americani au cefalee cronic,dintre care, 20 de mln sunt femei . (NWHJK) Rata prevalenei cefaleelor este aproximativ 1 din 6 sau 16.54% ,adic 45 mln de persoane din Statele Unite. Cefaleea este omniprezent i este o problem costisitoare a sntii publice in Japonia . Conform datelor prezentate( Ocuma H., Kitagawa Y. 2005),prevalena cefaleei pe via e aproximativ de 93% la brbai i 99% la femei. Aproximativ 8.4 mln de oameni in Japonia sufer de migren i 22 mln au cefalee de tip tensional. n pofida faptului impactului personal i economic, ct i disabilitatea cauzat de cefalee, muli pacieni cu cefalee nu se adreseaz dup servicii medicale. Studiile populaionale sunt in majoritaea lor focusate asupra migrenei deoarece ea a fost mai des studiat,dar ea nu este cea mai frecvent intilnit patologie cefalalgic. In rile dezvoltate doar CTT afecteaz 2/3 din brbai i mai mult de 80%din femei. Extrapolarea din datele privind prevalena migrenei i a incidenei atacurilor, prezint c 3000 de atacuri de migren au loc zilnic pentru fiecare 1 mln din populaia general. Adic mai mult de 1 adult din 20 are cefalee aproape zilnic sau chiar zilnic. Conform datelor Organizaiei Mondiale a Sntii,migrena se afl pe locul 19 printre maladiille incapacitante. Patologia cefalalgic impune o povar considerabil asupra suferinzilor, incluzind afectarea calitii vieii, suferina substanial personal periodic i costul financiar . Repetarea atacurilor de cefalee, urmate de o frecvent sau permanent fric, dauna pricinuit vieii de familie,vieii sociale i serviciului constitue impactul patologiei cefalalgice. Spre exemplu activitatea social i capacitatea de lucru sunt reduse aproape la toi

suferinzii de migren i la 60% din cei cu CTT. Migrena e intilnit la toate rasele. Totui evidena curent sugereaz , c prevalena migrenei este mai inalt la cei de ras alb decit la asiatici i africani.

ara 1. Canada 2. SUA 3.Peru 4.Britania 6.Malasia 7.Arabia Saudit

Prevalena 15% 11% 32% 11% 9% 3%

ara 8.Frana 9.Norvegia 10.Danemarca 11.Japonia 12.Hong Kong 13.Etiopia

Prevalena 12% 9% 17% 8% 1.5% 3%

Un efort de lung durat de a face fa patologiilor cefalgice persoanele cu migren sever sau cefalei severe decit la indivizii sntoi.

poate de asemenea

predispune persoanele fa de alte patologii . De exemplu, depresia e de 3 ori mai des intilnit la

De obicei cu debutul in pubertate, migrena afectez majoritar persoanele cu virsta cuprins intre 35 i 45 de ani, dar le poate crea probleme i persoanelor mult mai tinere, inclusiv copiilor. Studiile Americane i Europene demonstreaz c in fiecare an 6-8% din brbai i 15-18% dintre femei au migren . Un pattern similar se vede in America Central i de Sud. In urma cercetrilor din Puerto Rico,spre exemplu, s-a constatat prevalena migrenei de 6% la brbai i 17% la femei. Un Studiu efectuat in Turcia dezvluie o i mai mare prevalen in aceast ar: 10% la brbai i 22% la femei. Cea mai inalt rat pretutindeni la femei (de 2-3 ori mai mare decit la brbai) este cea hormonal condiionat. Migrena este aadar mai puin prevalent ,dar totui frecvent , in Asia(3% la brbai i ? 0% la femei ) i in Africa(3-7% in studiile bazate pe comunitate). Studii majore nu au fost inc petrecute. Incidence and prevalence of some neurological conditions

(rates per 100,000) Incidence: number of new cases per 100,000 that develop each year 25,000 per 100,000 in over 65 year olds per 100,000 27 new cases in year 2000 Migraine 400 100,000(1)

Condition

Prevalence: total number of people per 100,000

Source

Alzheimer's disease/dementia

1,000

Alzheimer's Society based on ONS population estimate 1996

CJD

Alzheimer's Society

vCJD

101 cases since 1995

Alzheimer's Society

per

15,000 (8,000,000)

1. Steiner TJ et al Epidemiology of migraine in England. Cephalalgia 2. Olesen J, Goadsby PJ, Cluster Headache and related conditions in Olesen J (Ed) Frontiers in Headache Research Vol 9 OUP 1999 3. Goadsby PJ, Lipton RB. A review of paroxysmal hemicaranias Brain 1997; 120:193-209 4. Silberstein SD et al, Headaches in Primary Care Oxford/Isis Medical Media 1999

Cluster Headache 4 per 100,000 (2) Headache Paroxysmal Hemicrania (3) Chronic Migraine (4) Chronic tensiontype headache (4) Headache Motor neurone disease

100

10

3,000

144 (85,000)

MS Society and MS Research Trust - estimates based on UK area studies and international data

Myalgic Encephalomyelitis (ME)

300 - 500

Dowsett E G, Richardson J The Epiemiology of Myalgic Encephalomyelitis (ME) in the UK 1919 - 1999 Evidence submitted to the All Party Parliamentary Group of MPs on ME 23.11.99 Parkinson's Disease Society - advice from medical adviser Last edited: 2/2/2004

Parkinson's disease

200

2003-4 World Health Organization - UK Collaborating Centre

Factors Associated With Low Socioeconomic Status Increase The Prevalence Of Migraines In Adolescents, New Study Shows Main Category: Headache / Migraine Also Included In: Pediatrics / Children's Health Article Date: 07 Jul 2007 - 7:00 PDT Adolescents from low-income families are much more likely to suffer from migraine headaches than teens from wealthier households, according to researchers at the Albert Einstein College of Medicine of Yeshiva University. The findings, published in Neurology, suggest that factors associated with low socioeconomic status --stress, poor diet and limited access to medical care, for example -- increase the prevalence of migraines in young people. But when the Einstein researchers focused on those teens without a strong family predisposition for migraines, they found that household income was strongly associated with migraine prevalence: In families with annual incomes of less than $22,500, the prevalence of migraines in teens was 4.4 percent; by contrast, the migraine prevalence among teens in households earning $90,000 or more was only 2.9 percent. "It would seem that for those teens who have a genetic predisposition for migraine, the stressful life events related to income don't matter," says Dr. Bigal. "They're more likely than other teens to get migraine regardless of their socioeconomic status, since they are predisposed. But for teens without a strong predisposition, reflected by the absence of migraine in first-degree relatives, family income factors into the prevalence of migraine, particularly among those teens whose families have low income." Dr. Bigal notes that this finding correlates with migraine prevalence for adults, which is consistently higher among people with lower income and less education. "Our study also suggests that we should explore environmental risk factors, such as stressful events and nutrition, as they relate to low income and migraine to understand how we might reduce the occurrence of migraine among these individuals." -----------------------------------------------------------------------------------------------------------------Article Date: 23 Sep 2007 - 0:00 PDT Herd P, Goesling B, House JS. Socioeconomic position and health: the differential effects of education versus income on the onset versus progression of health problems. J Health Soc Behav 48(3), 2007.

"Those with less education are more likely to develop health problems and those with low incomes who

already have health problems are more likely to see their health worsen," said lead author Pamela Herd, a University of Wisconsin-Madison sociologist. The study appears in the September issue of the Journal of Health and Social Behavior and examines how health differences in the United States often relate to people's socioeconomic status. Herd and colleagues say education influences occupation, income and wealth and with higher education comes healthier behaviors, such as good diet, increased physical activity, reduced stress and better use of preventive and therapeutic healthcare. The authors used data collected from 1986 to mid-2002 in the "Americans' Changing Lives Study," which conducted four waves of interviews of adults who were 25 years old and older. Herd and colleagues analyzed data for 8,287 participants. They looked at two groups of health problems: chronic conditions and functional limitations or disabilities. Compared with those with a college degree, the odds of having health problems were 81 percent higher for those without a high school diploma and 56 percent greater for those with a high school diploma. When comparing income, the researchers found that those with incomes of less than $10,000 had a 35 percent greater chance of developing health problems than those who made more than $30,000. In addition, those with incomes less than $10,000 had a 195-percent greater chance that their health problems would get worse. -----------------------------------------------------------------------------------------------------------------------------Cigarette Smoking Among Adults in the USA Main Category: Smoking / Quit Smoking Article Date: 01 Jun 2004 - 10:00 PDT This report summarizes the results of that analysis, which indicated that, in 2002, approximately 22.5% of adults were current smokers. Although this prevalence is slightly lower than the 22.8% prevalence among U.S. adults in 2001 and substantially lower than the 24.1% prevalence in 1998, the rate of decline has not been at a sufficient pace to achieve the 2010 national health objective. Cigarette smoking prevalence rates varied substantially across population subgroups (Table). The prevalence of smoking was higher among men (25.2%) than women (20.0%) and inversely related to age, from 28.5% for those aged 18--24 years to 9.3% for those aged >65 years. Among racial/ethnic groups, Asians (13.3%) and Hispanics (16.7%) had the lowest prevalence, and American Indians/Alaska Natives had the highest (40.8%). Current smoking prevalence also was higher among adults living below the poverty level* (32.9%) than among those at or above the poverty level (22.2%). During 1983--2002, the gap in smoking prevalence between those living below the poverty line and those living at or above it increased from 8.7 percentage points to 10.7 percentage points (Figure 1). By education level, smoking prevalence was highest among adults who had earned a General Educational Development diploma (42.3%) and lowest among those with graduate degrees (7.2%). Women with undergraduate (10.5%) or graduate degrees (6.4%) and men with graduate degrees (7.8%) also had smoking prevalence rates below the overall U.S. 2010 objective. During 1983--2002, the largest decreases in smoking prevalence occurred among adults with a college degree (10.0 percentage points) and those with some college education (9.3 percentage points); those with a high school diploma (6.6 percentage points) and those with less than a high school education (5.8 percentage points) showed the smallest decreases.

During this period, the gap in smoking prevalence between adults who had graduated from college and those with less than a high school education increased from 14.0 percentage points in 1983 to 18.2 percentage points in 2002 (Figure 2). Similar patterns occurred in the percentage of ever smokers who had quit among different educational groups. The percentage of ever smokers who had quit was highest for those with college degrees, followed by persons with some college education. High school graduates and those with less than high school education had the lowest percentage of ever smokers who had quit. The gap between adults with a college degree and those with less than a high school education increased from 19.0 percentage points in 1983 to 25.9 percentage points in 2002. Editorial Note: The findings in this report indicate that 1) the socioeconomic status of U.S. adults is inversely related to their likelihood of smoking and 2) during 1983--2002, the gap in smoking prevalence by socioeconomic status did not narrow and might have widened. These findings underscore the need for targeted interventions that can better reach persons of lower socioeconomic status. Persons of low socioeconomic status have less access to health care than those of high socioeconomic status (3). ----------------------------------------------------------------------------------------------------------------------------------

Lifetime Prevalence of Migraine and Other Headaches Lasting 4 or More Hours: The Atherosclerosis Risk in Communities (ARIC) Study Authors: Perry Carson A.L.; Rose K.M.; Sanford C.P.; Ephross S.A.; Stang P.E.; Hunt K.J.; Brown C.A.; Szklo M. Source: Headache: The Journal of Head and Face Pain, Volume 44, Number 1, January 2004 , pp. 2028(9) Abstract: Objective.To evaluate the lifetime prevalence of migraine and other headaches lasting 4 or more hours in a population-based study of older adults. Background.Migraine and other headaches not fulfilling migraine criteria are common afflictions. Yet the health and social effects of these conditions have not been fully appreciated, particularly among older adults. Methods.The study included 12 750 participants in the Atherosclerosis Risk in Communities (ARIC) Study from 4 US communities. Prevalence estimates of a lifetime history of migraine and other headaches lasting 4 or more hours were obtained for race and gender groups. A cross-sectional analysis was done to assess the relationship between headache type, by aura status, and various sociodemographic and health-related indices. Results.Compared to education beyond high school, having completed less than 12 years of education was significantly associated with an increased occurrence of migraine with aura

(prevalence odds ratio [POR], 1.47; 95% confidence interval [CI], 1.08 to 2.01). Family income less than $16 000, compared to family income of $75 000 or greater, was significantly associated with migraine with aura (POR, 1.68; 95% CI, 1.07 to 2.64), migraine without aura (POR, 1.56; 95% CI, 1.14 to 2.14), and other headaches with aura (POR, 1.89; 95% CI, 1.14 to 3.13). The prevalence odds ratio was higher in each headache category, particularly for those with an aura, for those with hypertension versus normotension and for those who perceived their general health as poor compared to those whose perception was excellent. Conclusions.A lifetime history of migraine with aura and other headaches with aura was more common among whites, women, and younger participants. Further investigation of headaches lasting 4 or more hours, particularly by aura status, is warranted. ---------------------------------------------------------------------------------------------------------------Cardiovascular risk factors and migraine: The GEM population-based study. Articles Neurology. 64(4):614-620, February 22, 2005. Scher, A I. PhD; Terwindt, G M. MD, PhD; Picavet, H S.J. PhD; Verschuren, W M.M. MD, PhD; Ferrari, M D. MD, PhD; Launer, L J. PhD Abstract: Background: Migraine, particularly with aura, is a risk factor for early-onset ischemic stroke. The underlying mechanisms are unknown, but may in part be due to migraineurs having an increased risk profile for cardiovascular disease. In this study, the authors compare the cardiovascular risk profile of adult migraineurs to that of nonmigraineurs. Methods: Participants (n = 5,755, 48% men, age 20 to 65 years) are from the Genetic Epidemiology of Migraine (GEM) study, a population-based study in the Netherlands. A total of 620 current migraineurs were identified: 31% with aura (MA), 64% without aura (MO), and 5% unclassified. Controls were 5,135 individuals without lifetime migraine. Measured cardiovascular risk factors included blood pressure (BP), serum total and high-density lipoprotein cholesterol (TC, HDL), smoking, oral contraceptive use, and the Framingham risk score for myocardial infarction or coronary heart disease (CHD) death. Results: Compared to controls, migraineurs were more likely to smoke (OR = 1.43 [1.1 to 1.8]), less likely to consume alcohol (OR = 0.58 [0.5 to 0.7]), and more likely to report a parental history of early myocardial infarction. Migraineurs with aura were more likely to have an unfavorable cholesterol profile (TC >= 240 mg/dL [OR = 1.43 (0.97 to 2.1)], TC:HDL ratio > 5.0 [OR = 1.64 (1.1 to 2.4)]), have elevated BP (systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg [OR = 1.76 (1.04 to 3.0)]), and report a history of early onset CHD or stroke (OR = 3.96 [1.1 to 14.3]); female migraineurs with aura were more likely to be using oral contraceptives (OR = 2.06 [1.05 to 4.0]). The odds of having an elevated Framingham risk score for CHD were approximately doubled for the migraineurs with aura. Conclusions: Migraineurs, particularly with aura, have a higher cardiovascular risk profile than individuals without migraine. -----------------------------------------------------------------------------------------------------------------------------Impact of comorbidity on headache-related disability. Saunders K, Merikangas K, Low NC, Von Korff M, Kessler RC. Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1600, Seattle, WA 98101,

USA. saunders.k@ghc.org OBJECTIVE: To assess and compare the extent to which comorbid conditions explain the role disability associated with migraine and other severe headaches. METHODS: A probability sample of US adults (n = 5,692) was interviewed. Presence of headaches, other chronic pain conditions, and chronic physical conditions was assessed in a structured interview administered by trained interviewers. Diagnostic criteria for migraine were based on the International Headache Society classification. Mental disorders were ascertained with the Composite International Diagnostic Interview that collected diagnostic criteria according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Role disability was assessed with World Health Organization Disability Assessment Schedule questions about days out of role and days with impaired role functioning. RESULTS: Eighty-three percent of migraineurs and 79% of persons with other severe types of headache had some form of comorbidity. Compared with headache-free subjects, migraineurs were at significantly increased risk for mental disorders (odds ratio [OR] 3.1), other pain conditions (OR 3.3), and physical diseases (OR 2.1). Compared with headache-free subjects, persons with nonmigraine headache were also at significantly increased risk for mental disorders (OR 2.0), other pain conditions (OR 3.5), and physical diseases (OR 1.7). Migraineurs experienced role disability on 25.2% of the last 30 days compared with 17.6% of the days for persons with nonmigraine headaches and 9.7% of the days for persons without headache. Comorbid conditions explained 65% of the role disability associated with migraine and all of the role disability associated with other severe headaches. CONCLUSIONS: Comorbidity is an important factor in understanding disability among persons with headache. ----------------------------------------------------------------------------------------------------------------Pathophysiology and Treatment of Migraine and Related Headache Article Last Updated: Sep 4, 2008 Soma Sahai, MD, Director of Neurology Ambulatory Clinics, LAC and USC Medical Center; Assistant Professor, Department of Neurology, University of Southern California Coauthor(s): David Y Ko, MD, Associate Professor, Laboratory Director, Department of Neurology, University of Southern California Medical Center Headache is a pervasive symptom and the most common problem neurologists encounter in their clinical practices. It affects an estimated 60-80% of Americans at any time. The history of headache can be traced almost to the beginning of the history of humankind. The first description of headache dates back to the third millennium BCE. Headache has been written about extensively since the time of the Babylonian civilization. Migraine headache and hemicrania are discussed in the Bible. Some famous historical figures (eg, Napoleon) are known to have had terrible headaches. Prevalence Migraine affects 17% of females and 6% of males in the United States.3 Before puberty, both the prevalence and incidence of migraine are higher in boys than in girls. In individuals older than 12 years, the prevalence increases in both males and females, and the incidence declines in individuals older than 40 years, except for women in perimenopause. The overall prevalence is higher in females than in males. The female-to-male ratio increases from 2.5:1 at puberty to 3.5:1 at age 40 years, after which it declines. The incidence of migraine with aura peaks in boys at around age 5 years and in girls at around age 12-13 years. The incidence of migraine without aura peaks in boys at age 10-11 years and in girls at age 14-17 years. The incidence of migraine in females of reproductive age has increased over the last 20 years, probably due to more awareness of the condition. In the United States, white women have the highest incidence of migraine, whereas Asian women have the lowest incidence. Moreover, low socioeconomic

status is associated with migraine. Currently, 1 of 6 American women has migraine headaches. Genetics Approximately 70% of patients have a first-degree relative with a history of migraine. The risk of migraine is increased 4-fold in relatives of people who have migraine with aura. However, no genetic basis has been identified for common migraine, although it generally demonstrates a maternal inheritance pattern.

NOVEMBER/DECEMBER 2004 ISSUE OF HEADACHE (sursa 11) Costul total consta din: 1.Costul direct medical de ingrijire ba migrenei asha ca: a)medicatia b)vizita la doctor 2.costul indirect,ce include:timpul pierdut de lucru, studii,sau activitatile din timpul liber. Acordarea medicatiei care previne migrena,daca folosirea ei ar fi dirijata ar putea reduce costul tratamentelor migrenei. Autorii anexeaza listea preturilor la 70preparate preventive,aratind ca gasirea sau apropierea de standard in reducerea producerii cefaleei cu 50% la 1/2 din pacientii tratati.

Factors Associated With Low Socioeconomic Status Increase The Prevalence Of Migraines In Adolescents, New Study Shows Main Category: Headache / Migraine Also Included In: Pediatrics / Children's Health Article Date: 07 Jul 2007 - 7:00 PDT email icon email to a friend article Ads by Google Levemir Information on Levemir for healthcare professionals. www.NovoNordisk.com Current Article Ratings: Patient / Public: 5 stars 5 (1 votes) Health Professional: 4 (1 votes) Article Opinions: 0 posts Find other articles on: "Socio-economic status in headache versus people without headache" 4 stars printer icon printer friendly write icon view / write opinions rate icon rate

Adolescents from low-income families are much more likely to suffer from migraine headaches than teens from wealthier households, according to researchers at the Albert Einstein College of Medicine of Yeshiva University. The findings, published in Neurology, suggest that factors associated with low socioeconomic status --stress, poor diet and limited access to medical care, for example -- increase the prevalence of migraines in young people. Led by Dr. Marcelo Bigal, assistant professor of neurology, the Einstein researchers mailed a headache questionnaire to 120,000 households encompassing 257,399 residents -- a sample representative of the U.S. population with respect to gender, age and geographic region. More than 32,000 teens were identified in this sample, and more than half of them (58.4 percent) answered the questionnaire. It is well known that heredity strongly influences whether someone will develop migraine headaches. So when this study looked at teens whose parents suffered from migraines, the prevalence of teens suffering one or more migraines in the previous year was nearly the same in lower vs. higher income groups -- 8.6 percent vs. 8.4 percent, respectively. But when the Einstein researchers focused on those teens without a strong family predisposition for migraines, they found that household income was strongly associated with migraine prevalence: In families with annual incomes of less than $22,500, the prevalence of migraines in teens was 4.4 percent; by contrast, the migraine prevalence among teens in households earning $90,000 or more was only 2.9 percent. "It would seem that for those teens who have a genetic predisposition for migraine, the stressful life events related to income don't matter," says Dr. Bigal. "They're more likely than other teens to get migraine regardless of their socioeconomic status, since they are predisposed. But for teens without a strong predisposition, reflected by the absence of migraine in first-degree relatives, family income factors into the prevalence of migraine, particularly among those teens whose families have low income." Dr. Bigal notes that this finding correlates with migraine prevalence for adults, which is consistently higher among people with lower income and less education. "Our study also suggests that we should explore environmental risk factors, such as stressful events and nutrition, as they relate to low income and migraine to understand how we might reduce the occurrence of migraine among these individuals." ---------------------------Article adapted by Medical News Today from original press release. ---------------------------In addition to Dr. Bigal and colleagues at Albert Einstein College of Medicine and its University Hospital Montefiore Medical Center, researchers from the following institutions took part in the study: The New England Center for Headache, Stamford, CT; The Palm Beach Headache Center, Palm Beach, FL; Vedanta Research, Chapel Hill, N.C.; The Diamond Headache Center, Chicago, IL; and The Center for Health Research and Rural Advocacy, Danville, PA. Source: Karen Gardner Albert Einstein College of Medicine---------------------------------------------------------------------------------------------------------------------------------------------------------------------References UTILE

Wilson JF. In the clinic. Migraine. Ann Intern Med. 2007: 147(9): ITC11-1-ITC11-16. Ebell MH. Diagnosis of migraine headache. Am Fam Physician. 2006: 74(12): 2087-8. Detsky ME, McDonald DR, et al. Does this patient with headache have a migraine or need neuroimaging? JAMA. 2006: 296(10): 1274-83. Lipton RB, Bigal ME, Steiner TJ, Silberstein SD, Olesen J. Classification of primary headaches. Neurology. 2004;63(3):427-35. Silberstein SD, Young WB. Headache and Facial Pain. In: Goetz, CG. Textbook of Clinical Neurology. 3nd ed. St. Louis, Mo: WB Saunders; 2007: chap. 53. -------------------------------------------------------------------------------------------------------------------------------------Those Who Stay In School, Stay Healthier Main Category: Public Health Article Date: 23 Sep 2007 - 0:00 PDT email icon email to a friend article printer icon printer friendly write icon view / write opinions rate icon rate

Ads by Google Obesity Health Information on prevention and treatment options for obesity. yourtotalhealth.ivillage.com Healthcare Systems Quality Medical Solutions Recover Re-use Recycle www.lundyhealthcare.co.uk Current Article Ratings: Patient / Public: not yet rated Health Professional: 5 (2 votes) Article Opinions: 0 posts Find other articles on: "Socio-economic status in headache versus people without headache" Both education and income can determine whether a person will remain healthy, but those who stay in school longer have the best odds, largely because education so strongly influences income, say the authors of a new study. "Those with less education are more likely to develop health problems and those with low incomes who already have health problems are more likely to see their health worsen," said lead author Pamela Herd, a University of Wisconsin-Madison sociologist. 5 stars

The study appears in the September issue of the Journal of Health and Social Behavior and examines how health differences in the United States often relate to people's socioeconomic status. Herd and colleagues say education influences occupation, income and wealth and with higher education comes healthier behaviors, such as good diet, increased physical activity, reduced stress and better use of preventive and therapeutic healthcare. The authors used data collected from 1986 to mid-2002 in the "Americans' Changing Lives Study," which conducted four waves of interviews of adults who were 25 years old and older. Herd and colleagues analyzed data for 8,287 participants. They looked at two groups of health problems: chronic conditions and functional limitations or disabilities. Compared with those with a college degree, the odds of having health problems were 81 percent higher for those without a high school diploma and 56 percent greater for those with a high school diploma. When comparing income, the researchers found that those with incomes of less than $10,000 had a 35 percent greater chance of developing health problems than those who made more than $30,000. In addition, those with incomes less than $10,000 had a 195-percent greater chance that their health problems would get worse. Herd said the results show this country's education policy must improve to reverse these types of disparities. "Policy makers tend to focus on individual behaviors, such as smoking and obesity, to address health disparities in the population," she said. "While it is clear that smoking and being obese are bad for one's health, a far more effective strategy is to go the actual source of the problem. Improving access to education can address numerous intermediary causes of poor health." Nancy Adler, a professor of medical psychology at the University of California, San Francisco, agreed that disparities are a problem, but said the necessary fix to the health care system lies in promoting health prevention. "Health care plays some role in disparities, but less than most people expect," she said. "Analyses from CDC data estimate that only about l0 percent of premature mortality is due to deficiencies in health care, either because of lack of access or poor quality. More 'action' is in who gets sick in the first place and right now the health system does relatively little in prevention." Herd P, Goesling B, House JS. Socioeconomic position and health: the differential effects of education versus income on the onset versus progression of health problems. J Health Soc Behav 48(3), 2007. ----------------------------------------------------------------------------------------------------------------------------------Cigarette Smoking Among Adults in the USA Main Category: Smoking / Quit Smoking Article Date: 01 Jun 2004 - 10:00 PDT email icon email to a friend article Ads by Google Current Article Ratings: printer icon printer friendly write icon view / write opinions rate icon rate

Patient / Public: 4 stars 4 (3 votes) Health Professional: 3 (2 votes) Article Opinions: 0 posts Find other articles on: "Socio-economic status in headache versus people without headache" One of the national health objectives for 2010 is to reduce the prevalence of cigarette smoking among adults to <12% (objective 27.1a) (1). To assess progress toward this objective, CDC analyzed selfreported data from the 2002 National Health Interview Survey (NHIS) sample adult core questionnaire. This report summarizes the results of that analysis, which indicated that, in 2002, approximately 22.5% of adults were current smokers. Although this prevalence is slightly lower than the 22.8% prevalence among U.S. adults in 2001 and substantially lower than the 24.1% prevalence in 1998, the rate of decline has not been at a sufficient pace to achieve the 2010 national health objective. During 1983--2002, adults with household incomes below the poverty level and those with less than some college education consistently had higher smoking prevalence. A comprehensive approach to smoking cessation that comprises educational, economic, clinical, and regulatory strategies and emphasizes reducing disparities is required to reduce further the prevalence of smoking (2). The 2002 NHIS adult core questionnaire was administered by personal interview to a nationally representative sample (n = 31,044) of the U.S. civilian, noninstitutionalized population aged >18 years; the overall survey response rate was 74.3%. Respondents were asked, "Have you smoked at least 100 cigarettes in your entire life?" and "Do you now smoke cigarettes every day, some days, or not at all?" Ever smokers were defined as those who reported having smoked >100 cigarettes during their lifetimes. Current smokers were defined as those who reported both having smoked >100 cigarettes during their lifetimes and currently smoking every day or some days. Former smokers were defined as ever smokers who currently did not smoke. Data were adjusted for nonresponses and weighted to provide national estimates of cigarette smoking prevalence. Confidence intervals (CIs) were calculated by using SUDAAN to account for the multistage probability sample. In 2002, an estimated 45.8 million adults (22.5%; 95% CI = 0.6) were current smokers; of these, an estimated 37.5 million (81.8%) smoked every day, and 8.3 million (18.2%) smoked some days. Among those who smoked every day, an estimated 15.4 million (41.2%; 95% CI = 1.5) reported that they had stopped smoking for >1 day during the preceding 12 months because they were trying to quit. In 2002, an estimated 46.0 million adults were former smokers, representing 50.1% (95% CI = 1.1) of adults who had ever smoked; 2002 was the first year that more than half of ever smokers were former smokers. Cigarette smoking prevalence rates varied substantially across population subgroups (Table). The prevalence of smoking was higher among men (25.2%) than women (20.0%) and inversely related to age, from 28.5% for those aged 18--24 years to 9.3% for those aged >65 years. Among racial/ethnic 3 stars

groups, Asians (13.3%) and Hispanics (16.7%) had the lowest prevalence, and American Indians/Alaska Natives had the highest (40.8%). Current smoking prevalence also was higher among adults living below the poverty level* (32.9%) than among those at or above the poverty level (22.2%). During 1983--2002, the gap in smoking prevalence between those living below the poverty line and those living at or above it increased from 8.7 percentage points to 10.7 percentage points (Figure 1). In addition, the percentage of ever smokers who had quit was higher for persons at or above the poverty level than for those below the poverty line. As with current smoking prevalence, this gap was larger in 2002 than in 1983 (20.0 percentage points versus 18.7 percentage points). Educational attainment has been associated consistently with adult smoking prevalence since 1983 (Figure 2). By education level, smoking prevalence was highest among adults who had earned a General Educational Development diploma (42.3%) and lowest among those with graduate degrees (7.2%). Women with undergraduate (10.5%) or graduate degrees (6.4%) and men with graduate degrees (7.8%) also had smoking prevalence rates below the overall U.S. 2010 objective. During 1983--2002, the largest decreases in smoking prevalence occurred among adults with a college degree (10.0 percentage points) and those with some college education (9.3 percentage points); those with a high school diploma (6.6 percentage points) and those with less than a high school education (5.8 percentage points) showed the smallest decreases. During this period, the gap in smoking prevalence between adults who had graduated from college and those with less than a high school education increased from 14.0 percentage points in 1983 to 18.2 percentage points in 2002 (Figure 2). Similar patterns occurred in the percentage of ever smokers who had quit among different educational groups. The percentage of ever smokers who had quit was highest for those with college degrees, followed by persons with some college education. High school graduates and those with less than high school education had the lowest percentage of ever smokers who had quit. The gap between adults with a college degree and those with less than a high school education increased from 19.0 percentage points in 1983 to 25.9 percentage points in 2002. Reported by: C Husten, MD, K Jackson, MSPH, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; C Lee, PhD, EIS Officer, CDC. Editorial Note: The findings in this report indicate that 1) the socioeconomic status of U.S. adults is inversely related to their likelihood of smoking and 2) during 1983--2002, the gap in smoking prevalence by socioeconomic status did not narrow and might have widened. These findings underscore the need for targeted interventions that can better reach persons of lower socioeconomic status. Persons of low socioeconomic status have less access to health care than those of high socioeconomic status (3). Specific efforts to reduce socioeconomic disparities in smoking prevalence could include 1) offering

comprehensive smoking cessation assistance through Medicaid and Medicare; 2) offer-ing smoking cessation advice and counseling through clinics that care for the uninsured; 3) increasing support for smoking cessation at work places, particularly for low-income and blue-collar workers; 4) implementing telephone quitlines in all states; and 5) employing more media-based cessation campaigns (2,4,5). Expanding the scope of cessation coverage through Medicaid, Medicare, and private insurance and ensuring that persons without health insurance can obtain medical assistance to quit smoking is a key strategy to help low-income smokers quit (4). The lower rates of quitting among blue-collar workers can be partially explained by the lack of social support for quitting in their work environments (5). Encouraging all employers to implement programs and policies supporting smoking cessation can help reduce consistently observed disparities in smoking prevalence between blue- and white-collar workers (6). In addition, because tobacco use prevalence is associated with failing or dropping out of high school (7), school-based antismoking programs and policies should target younger students before they leave school (8,9). The U.S. Department of Health and Human Services recently announced a new initiative to increase access to telephone quitlines. Quitlines provide free counseling and have been shown to be effective in reaching low-income populations (10). Media campaigns also have been shown to reach low-income smokers and increase cessation (4,10). The findings in this report are subject to at least two limitations. First, both the wording of NHIS cigarette smoking questions and NHIS data-collection procedures have changed since 1993. Because of these changes, trend analyses or comparisons of data from before 1993 with data collected since 1993 should be interpreted with caution. Second, because NHIS data for some population subgroups (e.g., American Indians/Alaska Natives) are small, data for a single year might be unreliable. Combining data for several years can produce more accurate estimates for these subpopulations. National health objectives for 2010 focus on eliminating health disparities among population subgroups (1). Closing the gap in smoking prevalence among persons of different socioeconomic strata will require comprehensive tobacco- control programs that discourage smoking initiation and promote smoking cessation among members of populations at high risk. Comprehensive tobacco-control programs at local, state, and national levels must ensure that their intervention efforts reach persons with inadequate resources and limited access to health care. Such efforts should address the needs of the uninsured (e.g., providing treatment through telephone quitlines and in community health centers), increase coverage for tobacco-use treatment under both public and private insurance, and improve workplace and social environments to better support smoking cessation, particularly for low-income and blue-collar workers. References 1. U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. With Understanding and Improving Health and Objectives for Improving Health (2 vols.). Washington, DC: U.S. Department of Health and Human Services, 2000.

2. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 2000. 3. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme LS. Socioeconomic inequalities in health: no easy solution. JAMA 1993;269:3140--5. 4. CDC. Strategies for reducing exposure to environmental tobacco smoke, increasing tobacco-use cessation, and reducing initiation in communities and health-care systems: a report of recommendations of the Task Force on Community Preventive Services. MMWR 2000;49(No. RR-12). 5. Sorensen G, Barbeau E, Hunt MK, Emmons K. Reducing social disparities in tobacco use: a socialcontextual model for reducing tobacco use among blue-collar workers. Am J Public Health 2004;94:230-9. 6. Nelson DE, Emont SL, Brackbill RM, et al. Cigarette smoking prevalence by occupation in the United States: a comparison between 1978 to 1980 and 1987 to 1990. J Occup Med 1994;36:516--25. 7. CDC. Youth risk behavior surveillance---National Alternative High School Youth Risk Behavior Survey, United States, 1998. In: CDC Surveillance Summaries (October 29). MMWR 1999;48(No. SS-7). 8. CDC. Best practices for comprehensive tobacco control programs. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 1999. 9. National Association of County and City Health Officials. Program and funding guidelines for comprehensive local tobacco control programs. Washington, DC: National Association of County and City Health Officials, 2000. 10. Haviland L, Thornton AH, Carothers S, et al. Giving infants a Great Start: launching a national smoking cessation program for pregnant women. Nicotine and Tobacco Research 2004;6:S181--8.

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Lifetime Prevalence of Migraine and Other Headaches Lasting 4 or More Hours: The Atherosclerosis Risk in Communities (ARIC) Study Authors: Perry Carson A.L.; Rose K.M.; Sanford C.P.; Ephross S.A.; Stang P.E.; Hunt K.J.; Brown C.A.; Szklo M. Source: Headache: The Journal of Head and Face Pain, Volume 44, Number 1, January 2004 , pp. 2028(9) Key: Free Content - Free Content New Content - New Content Subscribed Content - Subscribed Content

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Click here to find out more! Abstract: Objective.To evaluate the lifetime prevalence of migraine and other headaches lasting 4 or more hours in a population-based study of older adults. Background.Migraine and other headaches not fulfilling migraine criteria are common afflictions. Yet the health and social effects of these conditions have not been fully appreciated, particularly among older adults. Methods.The study included 12 750 participants in the Atherosclerosis Risk in Communities (ARIC) Study from 4 US communities. Prevalence estimates of a lifetime history of migraine and other headaches lasting 4 or more hours were obtained for race and gender groups. A cross-sectional analysis was done to assess the relationship between headache type, by aura status, and various sociodemographic and health-related indices. Results.Compared to education beyond high school, having completed less than 12 years of education was significantly associated with an increased occurrence of migraine with aura (prevalence odds ratio [POR], 1.47; 95% confidence interval [CI], 1.08 to 2.01). Family income less than $16 000, compared to family income of $75 000 or greater, was significantly associated with migraine with aura (POR, 1.68; 95% CI, 1.07 to 2.64), migraine without aura (POR, 1.56; 95% CI, 1.14 to 2.14), and other headaches with aura (POR, 1.89; 95% CI, 1.14 to 3.13). The prevalence odds ratio was higher in each headache category, particularly for those with an aura, for those with hypertension versus normotension and for those who perceived their general health as poor compared to those whose perception was excellent. Conclusions.A lifetime history of migraine with aura and other headaches with aura was more common among whites, women, and younger participants. Further investigation of headaches lasting 4 or more hours, particularly by aura status, is warranted. Keywords: headache; migraine; aura; epidemiology -------------------------------------------------------------------------------------------------------------------------------Cardiovascular risk factors and migraine: The GEM population-based study. Articles Neurology. 64(4):614-620, February 22, 2005. Scher, A I. PhD; Terwindt, G M. MD, PhD; Picavet, H S.J. PhD; Verschuren, W M.M. MD, PhD; Ferrari, M D. MD, PhD; Launer, L J. PhD Abstract: Background: Migraine, particularly with aura, is a risk factor for early-onset ischemic stroke. The underlying mechanisms are unknown, but may in part be due to migraineurs having an increased risk profile for cardiovascular disease. In this study, the authors compare the cardiovascular risk profile of adult migraineurs to that of nonmigraineurs.

Methods: Participants (n = 5,755, 48% men, age 20 to 65 years) are from the Genetic Epidemiology of Migraine (GEM) study, a population-based study in the Netherlands. A total of 620 current migraineurs were identified: 31% with aura (MA), 64% without aura (MO), and 5% unclassified. Controls were 5,135 individuals without lifetime migraine. Measured cardiovascular risk factors included blood pressure (BP), serum total and high-density lipoprotein cholesterol (TC, HDL), smoking, oral contraceptive use, and the Framingham risk score for myocardial infarction or coronary heart disease (CHD) death. Results: Compared to controls, migraineurs were more likely to smoke (OR = 1.43 [1.1 to 1.8]), less likely to consume alcohol (OR = 0.58 [0.5 to 0.7]), and more likely to report a parental history of early myocardial infarction. Migraineurs with aura were more likely to have an unfavorable cholesterol profile (TC >= 240 mg/dL [OR = 1.43 (0.97 to 2.1)], TC:HDL ratio > 5.0 [OR = 1.64 (1.1 to 2.4)]), have elevated BP (systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg [OR = 1.76 (1.04 to 3.0)]), and report a history of early onset CHD or stroke (OR = 3.96 [1.1 to 14.3]); female migraineurs with aura were more likely to be using oral contraceptives (OR = 2.06 [1.05 to 4.0]). The odds of having an elevated Framingham risk score for CHD were approximately doubled for the migraineurs with aura. Conclusions: Migraineurs, particularly with aura, have a higher cardiovascular risk profile than individuals without migraine. (C)2005AAN Enterprises, Inc. ------------------------------------------------------------------------------------------------------------------------------Impact of comorbidity on headache-related disability. Saunders K, Merikangas K, Low NC, Von Korff M, Kessler RC. Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA. saunders.k@ghc.org OBJECTIVE: To assess and compare the extent to which comorbid conditions explain the role disability associated with migraine and other severe headaches. METHODS: A probability sample of US adults (n = 5,692) was interviewed. Presence of headaches, other chronic pain conditions, and chronic physical conditions was assessed in a structured interview administered by trained interviewers. Diagnostic criteria for migraine were based on the International Headache Society classification. Mental disorders were ascertained with the Composite International Diagnostic Interview that collected diagnostic criteria according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Role disability was assessed with World Health Organization Disability Assessment Schedule questions about days out of role and days with impaired role functioning. RESULTS: Eighty-three percent of migraineurs and 79% of persons with other severe types of headache had some form of comorbidity. Compared with headache-free subjects, migraineurs were at significantly increased risk for mental disorders (odds ratio [OR] 3.1), other pain conditions (OR 3.3), and physical diseases (OR 2.1). Compared with headache-free subjects, persons with nonmigraine headache were also at significantly increased risk for mental disorders (OR 2.0), other pain conditions (OR 3.5), and physical diseases (OR 1.7). Migraineurs experienced role disability on 25.2% of the last 30 days compared with 17.6% of the days for persons with nonmigraine headaches and 9.7% of the days for persons without headache. Comorbid conditions explained 65% of the role disability associated with migraine and all of the role disability associated with other severe headaches. CONCLUSIONS: Comorbidity is an important factor in understanding disability among persons with headache. Publication Types: --------------------------------------------------------------------------------------------------------------------------------------

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Pathophysiology and Treatment of Migraine and Related Headache Article Last Updated: Sep 4, 2008 AUTHOR AND EDITOR INFORMATION Section 1 of 12 Click here to go to the next section in this topic * Authors and Editors * Introduction * Pathophysiology of Migraine * Demographics and Etiology * Clinical Features * Treatment and Prophylaxis of Migraine * Cluster Headache * Chronic Daily and Other Headaches * Secondary Headache * Acknowledgments * Multimedia * References

Author: Soma Sahai, MD, Director of Neurology Ambulatory Clinics, LAC and USC Medical Center; Assistant Professor, Department of Neurology, University of Southern California Coauthor(s): David Y Ko, MD, Associate Professor, Laboratory Director, Department of Neurology, University of Southern California Medical Center Editors: Joseph Carcione Jr, DO, MBA, Consultant in Neurology and Medical Acupuncture, Medical Management and Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center; Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital; Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants Author and Editor Disclosure Synonyms and related keywords: cluster headache, chronic daily headache, daily chronic headache, tension-type headache, analgesic abuse, rebound headache, analgesic-abuse headache, secondary headache, vascular headache, migraine variants, migraines, cluster headache, tension headache, medication-overuse headache, MOH, migraine with aura, migraine without aura, migrainous aura, migraine transformation, familial hemiplegic migraine, ophthalmoplegic migraine, migraine equivalent, classic aura, late-life migrainous accompaniments, retinal migraine, ocular migraine, abdominal migraine, complicated migraine, vertebrobasilar migraine, status migrainosus, histamine cephalalgia, Horton neuralgia, erythromelalgia INTRODUCTION Section 2 of 12 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic

* Authors and Editors * Introduction * Pathophysiology of Migraine * Demographics and Etiology * Clinical Features * Treatment and Prophylaxis of Migraine * Cluster Headache * Chronic Daily and Other Headaches * Secondary Headache * Acknowledgments * Multimedia * References

Headache is a pervasive symptom and the most common problem neurologists encounter in their clinical practices. It affects an estimated 60-80% of Americans at any time. The history of headache can be traced almost to the beginning of the history of humankind. The first description of headache dates back to the third millennium BCE. Headache has been written about extensively since the time of the Babylonian civilization. Migraine headache and hemicrania are discussed in the Bible. Some famous historical figures (eg, Napoleon) are known to have had terrible headaches. Much debate exists among headache specialists regarding the evolutionary mechanisms; however, all agree on the paucity of literature related to this topic. This lack most likely exists because headache is a subjective symptom, because no objective measures or standardizations are available, and because species studies are limited to humans. Two common evolutionary mechanisms of disease production have been described. The first is a protective mechanism in response to what the body perceives as an external environmental stress. The second, and simpler, mechanism is pathogen-mediated disease production (eg, disease due to infections caused by bacteria, viruses, or other pathogens). The first seems most likely to apply to headache. Several observations give credence to the theory that the evolution of headache may be an internal protective response developed against environmental stressors. When exposed to extremes of temperature, humans can develop the classic vascular headache. The same is true for people who have had a sudden lack of sleep or food. Common triggers of vascular headaches are stress, heat, or a lack of sleep or food. People with a predisposition to headache may have a lower threshold of response to these external stressors than other people. Patients with migraine may have inherited the predisposition for this lowered threshold. Therefore, some experts have theorized that headache is a slow, adaptive response. Most primary headaches develop slowly over minutes, if not hours. The pain associated with headache is transmitted by the slowest of all unmyelinated nerves. For clinical purposes, the International Headache Society (IHS) (which revised the classification of headaches in 2004 [IHS-2]) divides headaches into 2 broad categories: primary headaches and secondary headaches. Primary headaches, which are headaches with no organic or structural etiology, include vascular (migraine) headache, trigeminal autonomic cephalalgias (which includes cluster headache), tension headache, and other secondary headaches (ie, hemicrania continua, new daily persistent headache, exertional headache, hypnic headache, thunderclap headache). Secondary headaches are those due to an underlying structural or organic disease and include 9 subcategories.

For related information, see Medscape's Headache Resource Center. PATHOPHYSIOLOGY OF MIGRAINE Section 3 of 12 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic * Authors and Editors * Introduction * Pathophysiology of Migraine * Demographics and Etiology * Clinical Features * Treatment and Prophylaxis of Migraine * Cluster Headache * Chronic Daily and Other Headaches * Secondary Headache * Acknowledgments * Multimedia * References

Two main schools of thought exist to explain the pathophysiology of migraine. The first is older and is based purely on a vascular theory; it has fallen out of favor and has been replaced by the neurovascular theory. What is now clear is that migraine is a chronic disorder of the CNS and the vascular changes that occur are more of an epiphenomenon. Vascular Theory In the 1940s and 1950s, the vascular theory was proposed to explain the pathophysiology of migraine headache. Wolff et al believed that intracranial vasoconstriction is responsible for the aura of migraine and that the subsequent rebound vasodilatation and activation of perivascular nociceptive nerves resulted in headache. This theory was based on the observations that (1) extracranial vessels become distended and pulsatile during a migraine attack; (2) stimulation of intracranial vessels in an awake person induces headache; and (3) vasoconstrictors (eg, ergots) improve the headache, whereas vasodilators (eg, nitroglycerin) provoke an attack. However, this theory has been challenged for several reasons, including the theories described below. Neurovascular Theory The current view is that a complex series of neural and vascular events initiates migraine. This view is now called the neurovascular theory, the key features of which are described in detail below. At baseline, a migraineur who is not having any headache has a state of neuronal hyperexcitability in the cerebral cortex, especially in the occipital cortex. This finding has been demonstrated in studies of transcranial magnetic stimulation and with functional MRI. This observation explains the special susceptibility of the migrainous brain to headaches. One can draw a parallel with the patient with epilepsy who similarly has interictal neuronal irritability. The best data for such an excitability come from studying aura. Aura is initiated by cortical spreading

depression (CSD), which is a migraine trigger. Cortical spreading depression In 1944, Leao proposed the theory of CSD to explain the mechanism of migraine with aura. A migraine aura is due to a well-defined wave of neuronal excitation in the cortical gray matter that spreads from its site of origin at the rate of 2-6 mm/min. This spread is followed by a wave of neuronal suppression in the same manner. The blood vessels in this area simultaneously dilate and then constrict. Therefore, migrainous aura is a cortical event with a definite and well-defined neuroelectrical basis. The neurochemical basis of the CSD is the release of potassium or the excitatory amino acid glutamate from neural tissue. This release depolarizes the adjacent tissue, which, in turn, releases more neurotransmitters, propagating the spreading depression. Positron emission tomography (PET) scanning demonstrates that blood flow is moderately reduced during a migrainous aura, but the spreading oligemia does not correspond to vascular territories. The oligemia itself is insufficient to impair function. Instead, the flow is reduced because the spreading depression reduces metabolism. The reason why these neurons are more excitable at a cellular level in certain patients is not entirely clear. Specific groups of patients with migraine have a genetic defect leading to a lowered threshold for CSD, and this is called familial hemiplegic migraine (FHM). However, for the vast majority of patients, a clear metabolic or genetic defect that easily explains this neuronal excitability cannot be determined. Brainstem activation PET scanning in patients having an acute migraine headache demonstrates activation of the contralateral pons, even after medications abort the pain. Weiler et al proposed that brainstem activation may be the initiating factor of migraine. Once the CSD occurs on the surface of the brain, H+ and K+ ions diffuse to the pia mater and activate Cfiber meningeal nociceptors, which releases a proinflammatory soup of neurochemicals (eg, calcitonin generelated peptide) and plasma extravasation occurs. Therefore, a sterile, neurogenic inflammation of the trigeminovascular complex is present. Once the trigeminal system is activated, it stimulates the cranial vessels to dilate. The final common pathway to the throbbing headache is the dilatation of blood vessels. Cutaneous allodynia Burstein et al described the phenomenon of cutaneous allodynia, in which secondary pain pathways of the trigeminothalamic system become sensitized during a migrainous episode.1 This observation further demonstrates that sensitization of central pathways in the brain mediates the pain of migraine, in addition to the previously described neurovascular events. Dopamine Pathway Some authors have proposed a dopaminergic basis for migraine.2 In 1977, Sicuteri postulated that a state of dopaminergic hypersensitivity is present in patients with migraine. Interest in this theory has recently been renewed. A variety of prodromal symptoms (eg, yawning, irritability, nausea, vomiting) can be attributed to relative

dopaminergic stimulation. Dopamine antagonists, such as prochlorperazine, completely relieve almost 75% of acute migraine attacks. Magnesium Deficiency Another theory proposes that deficiency of magnesium in the brain triggers a chain of events, starting with platelet aggregation and glutamate release and finally resulting in the release of 5-hydroxytryptamine, which is a vasoconstrictor. DEMOGRAPHICS AND ETIOLOGY Section 4 of 12 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic * Authors and Editors * Introduction * Pathophysiology of Migraine * Demographics and Etiology * Clinical Features * Treatment and Prophylaxis of Migraine * Cluster Headache * Chronic Daily and Other Headaches * Secondary Headache * Acknowledgments * Multimedia * References

Prevalence Migraine affects 17% of females and 6% of males in the United States.3 Before puberty, both the prevalence and incidence of migraine are higher in boys than in girls. In individuals older than 12 years, the prevalence increases in both males and females, and the incidence declines in individuals older than 40 years, except for women in perimenopause. The overall prevalence is higher in females than in males. The female-to-male ratio increases from 2.5:1 at puberty to 3.5:1 at age 40 years, after which it declines. The incidence of migraine with aura peaks in boys at around age 5 years and in girls at around age 12-13 years. The incidence of migraine without aura peaks in boys at age 10-11 years and in girls at age 14-17 years. The incidence of migraine in females of reproductive age has increased over the last 20 years, probably due to more awareness of the condition. In the United States, white women have the highest incidence of migraine, whereas Asian women have the lowest incidence. Moreover, low socioeconomic status is associated with migraine. Currently, 1 of 6 American women has migraine headaches. Genetics Approximately 70% of patients have a first-degree relative with a history of migraine. The risk of migraine is increased 4-fold in relatives of people who have migraine with aura. However, no genetic basis has been identified for common migraine, although it generally demonstrates a maternal inheritance pattern.

FHM type 1 is a type of migraine with aura that is preceded or followed by hemiplegia, which typically resolves. In approximately 50% of affected families, FHM is linked to band 19p13 or a mutation in the calcium channel gene (CACNA1A4) at the 1q locus. FHM may be associated with cerebellar ataxia, which is also linked to the 19p locus. Evidence suggests that the 19p locus for FHM may also be involved in patients with nonhemiplegic migraine. FHM type 2 is due to mutation in the sodium channel gene ATP1A2 on chromosome 1. Migraine occurs with increased frequency in patients with mitochondrial disorders, such as MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes). CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a genetic disorder of the notch 3 gene on chromosome 19 that causes migraine with aura. Comorbidities of migraine Migraine is associated epilepsy (eg, benign rolandic epilepsy, benign childhood epilepsy), familial dyslipoproteinemias, hereditary hemorrhagic telangiectasia, Tourette syndrome, hereditary essential tremor, hereditary cerebral amyloid angiopathy, ischemic stroke (migraine with aura is a risk factor, with an odds ratio of 6), depression and anxiety, asthma, patent foramen ovale, and stroke. Epilepsy increases the relative risk of migraine by 2.4. The risk of posterior circulation strokes, especially cerebellar, is increased in migraineurs with aura. Female migraineurs, with or without aura, have an increased risk of deep white matter brain lesions. Several studies are currently investigating patent foramen ovale, which is seen in 18-21% of migraine patients. For related information, see Medscape's Epilepsy and Anxiety Resource Centers. CLINICAL FEATURES Section 5 of 12 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic * Authors and Editors * Introduction * Pathophysiology of Migraine * Demographics and Etiology * Clinical Features * Treatment and Prophylaxis of Migraine * Cluster Headache * Chronic Daily and Other Headaches * Secondary Headache * Acknowledgments * Multimedia * References

Diagnosis, description, and triggers of migraine

The diagnosis of migraine is clinical in nature, based on criteria established by the IHS. Some patients describe a prodromal phase as early as 48 hours before the headache. This phase includes irritability, depression, frequent yawning, or hyperexcitability. The headache itself is usually described as throbbing or pulsatile. It is usually unilateral, but the side affected in each episode may be different. The headache usually lasts 6-24 hours. During a headache, patients prefer to lie quietly in a dark room. Nausea, vomiting, photophobia, phonophobia, irritability, and malaise are common. A history of certain triggers can be elicited. Common triggers include certain foods (eg, chocolate, cheese, oranges, tomatoes, onions, monosodium glutamate [MSG], aspartame, red wine, alcohol), hormonal changes (eg, menstruation, ovulation, oral contraceptives, hormone replacement), head trauma, physical exertion, fatigue, medications (eg, nitroglycerin, histamine, reserpine, hydralazine, ranitidine, estrogen), and stress. Types of migraine * Migraine with aura: Migraine with aura (ie, classic migraine) includes several premonitory visual symptoms that occur as early as 60 minutes before the headache phase. These symptoms include flashes of light (photopsia) and wavy linear patterns on the visual fields (fortification spectra), migrating scotoma, or blurred vision. Other nonvisual prodromata have also been described. * o Aura with migraine headache o Aura with nonmigraine headache o Aura with no headache o Familial hemiplegic migraine o Basilar-type migraine * Migraine without aura: Migraine without aura (ie, common migraine) is a throbbing headache without prodromal symptoms. * Childhood variants: Childhood periodic syndromes evolve into migraine in adulthood and include cyclic vomiting, abdominal migraine, and benign paroxysmal vomiting of childhood. * o Cyclic vomiting: The child has at least 5 attacks of intense nausea and vomiting ranging from 1 hour to 5 days. o Abdominal migraine/recurrent episodic vomiting: This is episodic midline abdominal pain lasting 1-72 hours with 2 of 4 other symptoms (ie, nausea, vomiting, anorexia, and/or pallor). o Benign paroxysmal vertigo of childhood: This is recurrent attacks of vertigo often associated with vomiting or nystagmus. * Retinal migraine: Occasionally, patients develop retinal and optic nerve ischemia and present with monocular blindness, papilledema, and retinal hemorrhages; this variant is called retinal migraine or ocular migraine. * Complications of migraine: Complications of migraine include chronic migraine (headache for >15 d/mo), migrainous infarction (stroke with migraine), status migrainosus (migraine lasting >72 h), persistent aura without infarction (aura lasting >60 min), and migraine-triggered seizures. * Probable migraine Migraine variants

* Late-life migrainous accompaniments: In elderly persons, a stereotypical series of prodromelike symptoms may entirely replace the migrainous episode, which is termed late-life migrainous accompaniments. If the headache is always on one side, a structural lesion needs to be excluded using imaging studies. Eliciting a history of recurrent typical attacks and determining the provoking agent are important because a secondary headache can mimic migraine. A new headache, even if it appears typical on the basis of its history, should always suggest a broad differential diagnosis and the possibility of a secondary headache. * Complicated migraine: This is a type of migraine in which migraine attacks are accompanied by persistent neurologic deficits, such as paralysis. * Vertebrobasilar migraine: Patients with vertebrobasilar migraine can present without headaches but with vertebrobasilar symptoms, such as vertigo, dizziness, confusion, dysarthria, tingling of extremities, and incoordination. * Status migrainosus: This variant occurs when the migraine attack persists for more than 72 hours. This type may result in complications such as dehydration. * Ophthalmoplegic migraine: This variant has recently been reclassified by the IHS-2 as a neuralgia. It is associated with transient palsies of the extraocular muscle with dilated pupils and eye pain. It is thought to be due to idiopathic inflammatory neuritis. In the acute phase, enhancement of the cisternal segment of the third cranial nerve occurs.

TREATMENT AND PROPHYLAXIS OF MIGRAINE Section 6 of 12 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic * Authors and Editors * Introduction * Pathophysiology of Migraine * Demographics and Etiology * Clinical Features * Treatment and Prophylaxis of Migraine * Cluster Headache * Chronic Daily and Other Headaches * Secondary Headache * Acknowledgments * Multimedia * References

Treatment Successful treatment of migraine involves 5 steps. Step 1 Step 1 is an accurate clinical diagnosis based on the IHS criteria. A full neurologic examination should be performed during the first visit; the findings are usually normal. Neuroimaging is not necessary in a typical

case. Step 2 Step 2 is a disability assessment. Simple questionnaires, such as the Migraine Disability Assessment Scale (MIDAS), can be used to quantify the extent of disability on the first visit. These questionnaires can also be used for follow-up evaluations. Step 3 Step 3 is stratified care for the acute treatment of the headache. Patients who have mild symptoms and disability can be adequately treated with acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), propoxyphene, or a combination of these. Patients with moderate disability need migraine-specific oral medications. The 2 categories of such medications are triptans and ergot alkaloids. The specific triptans are sumatriptan, rizatriptan, zolmitriptan, naratriptan, almotriptan, eletriptan, and frovatriptan. The specific ergot alkaloids are ergotamine and dihydroergotamine. Do not administer vasoconstrictors, such as ergots or triptans, to patients with known complicated migraine; treat their acute attacks with one of the other available agents, such as NSAIDs or prochlorperazine. The first combination product of a 5HT receptor agonist (ie, sumatriptan) and an NSAID (ie, naproxen sodium), Treximet, was approved by the US Food and Drug Administration in April 2008. Efficacy was demonstrated in 2 randomized, double-blind, multicenter, parallel-group trials comparing the combination product to placebo and each individual active component (ie, sumatriptan and naproxen sodium). The percentage of patients remaining pain free without use of other medications through 24 hours postdose was significantly greater (p<0.01) among patients receiving a single dose of Treximet (25% and 23%) compared with placebo (8% and 7%) or either sumatriptan (16% and 14%) or naproxen sodium (10%) alone.4 Patients with severe headaches need subcutaneous, intravenous, or oral formulations of these drugs. Patients with severe nausea and vomiting at the onset of an attack may respond best to intravenous prochlorperazine. These patients may be dehydrated, and adequate hydration is necessary. Approximately 40% of all attacks do not respond to a given triptan or any other substance. If all else fails, an intractable migraine attack (status migrainosus), or an attack lasting longer than 72 hours, should be addressed in an urgent care or emergency department. In rare cases, patients may need to be hospitalized for a short period. Step 4 Step 4 is to individualize treatment on the basis of the patient's profile. No 2 patients with migraine are the same. Each patient has a unique psychosocial environment that heavily influences his or her treatment. Step 5 Step 5 is patient education, which is key to successful long-term management. Migraine is a chronic neurologic disorder that requires a lifestyle change at some level. Patient education includes teaching the patient to avoid triggers. Patients should avoid factors that precipitate a migraine attack (eg, lack of sleep, fatigue, stress, certain foods, use of vasodilators).

Encourage patients to use a daily diary to document the headaches. This is an effective and inexpensive tool to follow the course of the disease. Changes in hormonal levels, particularly estrogen levels, may exacerbate headaches in women. Women may be advised to modify, change, or discontinue use of their oral contraceptives for a trial period. Leuprolide (Lupron) has been used to simulate menopause to assess the relative role of estrogenic changes as a trigger. Nonpharmacologic treatment Americans spend more than $13.7 billion a year on complementary medicine, and more than 70% of patients do not tell their doctors about it. Interest in the use of complementary and alternative medicine (CAM) by headache patients has been increasing. A recent survey showed that more than 85% of headache patients use CAM therapies and 60% felt they provided some relief.5 Some CAM techniques have good scientific evidence of benefit and have been proven by studies to be effective in preventing migraine. Biofeedback and behavioral therapy should be part of the standard of care for a difficult migraine patient. Recently, some good studies have demonstrated the effectiveness of the herb Butterbur (Petasites hybridus) in preventing migraines.6 Another herb, Feverfew, is also widely used and some studies have shown it to be safe and possibly effective for migraine prevention. A variety of other CAM techniques are not bolstered by solid scientific data, but they may be perceived to be of benefit to patients. A few techniques commonly practiced for headache relief include body work (eg, chiropractic, massage), creative arts (eg, dance, music), nutritional/herbal supplements (eg, vitamins, herbs), Eastern medicine (eg, yoga), acupressure and acupuncture7, and Ayurveda. Overall, scientific evidence on the efficacy of these studies is lacking, partly due to the poor design and/or poor quality of the studies performed to date. The advantages of CAM therapies are that many of these remedies have no adverse effects, they advocate a self-help technique that is attractive to patients, and they offer a holistic approach. The practitioners often spend significant time with their patients, and that in itself makes the patient feel as if he or she has been given careful attention. The disadvantages of CAM therapies are that the method to either the practice or the dispensing of the therapies and techniques is not standardized. In addition, no standard format exists to ensure the practitioners are adequately trained in the techniques they use. Besides those described, one of the most effective and simple ways to manage migraines includes patient education, including the recognition of and avoidance of factors that precipitate a migraine attack (eg, lack of sleep, fatigue, stress, certain foods, vasodilators). Encouraging the use of a diary to document the headache pattern is a very effective and inexpensive tool to follow the course of the disease. Migraine Prophylaxis Indications Therapy to prevent migraine is indicated if (1) the patient has more than 2 migraine attacks per month, (2) the patient has single attacks that last longer than 24 hours, (3) the headaches cause major disruptions in the patient's lifestyle, (4) abortive therapy fails or is overused, and (5) the patient has complicated migraine.

The goals of preventive therapy are (1) to reduce attack frequency, severity, and/or duration; (2) to improve responsiveness to acute attacks, and (3) to reduce disability. Classes of prophylactic drugs The 3 classes of medications that are effective for migraine prevention are antiepileptics, antidepressants, and antihypertensives. Botulinum toxin A (BOTOX) may be another effective medication.8 Tailor the choice of medication to the patient profile. Antiepileptics such as topiramate9 (Topamax) are indicated for migraine prophylaxis and are well tolerated. The main adverse effects are weight loss and dysesthesia. Valproic acid (Depakote) is also indicated as a migraine prophylactic and is useful as a first-line agent. However, it can cause weight gain, hair loss, and polycystic ovary disease; therefore, it may not be ideal for young female patients who have a tendency to gain weight. It also carries substantial risks in pregnancy, but it may be best suited for women who have had tubal ligation and who cannot tolerate calcium channel blockers because of dizziness. Valproic acid is a good mood stabilizer and can benefit patients with concomitant mood swings. Data for other antiepileptics (eg, gabapentin, lamotrigine, oxcarbazepine) are limited in migraine. Tricyclic antidepressants are good second-line alternatives because of their adverse-effect profile and efficacy. Amitriptyline and nortriptyline are most effective, as has been shown in the current data. Although serotonin-selective reuptake inhibitors are widely used, data regarding their efficacy in migraine prevention are lacking. Antihypertensives such as beta-blockers are approved by the US Food and Drug Administration for migraine prophylaxis, but they should be tailored if the patient is young and anxious. They may not be the ideal choice for elderly patients or patients with depression, thyroid problems, or diabetes. Calcium channel blockers are another possible choice of treatment. ACE inhibitors (eg, lisinopril) and angiotensinreceptor blockers (eg, candesartan) have recently been shown to be effective for migraine prevention.10 Botulinum toxin A (BOTOX) may be beneficial in patients with intractable migraine headaches that fail to respond to conventional preventive medication. The injections are administered to the scalp and temple. They may reduce the frequency and severity of migraine attacks after 2-3 months of injections. The injections are expensive and must be administered every 2-3 months to maintain their effectiveness. The most appropriate duration of prophylactic therapy has not been determined. In most patients who are receiving prophylaxis, therapy must be continued for at least 3-6 months. For any of these prophylactic agents, prophylaxis should not be considered a failure until it has been given at the maximum tolerable dose for at least 30 days. CLUSTER HEADACHE Section 7 of 12 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic * Authors and Editors * Introduction * Pathophysiology of Migraine * Demographics and Etiology * Clinical Features * Treatment and Prophylaxis of Migraine * Cluster Headache

* Chronic Daily and Other Headaches * Secondary Headache * Acknowledgments * Multimedia * References

Cluster headache has more than a dozen synonyms, including histamine cephalalgia, Horton neuralgia, or erythromelalgia. It was first described by Horton in 1939. In recent years, some exciting new discoveries have been made with regard to the pathophysiology and treatment of this strange headache. The IHS-2 has recently subclassified cluster headache as a trigeminal autonomic cephalalgia because of the prominent autonomic findings that accompany the headache. Prevalence Cluster headaches are rare, with a prevalence of less than 1% (1 in a 1000), and they are more common in white persons. The disease usually appears in persons aged 20-40 years. Men peak in the third decade of life. Women have 2 peaks, in the second and sixth decades of life. The male-to-female ratio is 5-8:1. However, in recent years, the incidence among women is rising, probably because of better understanding of the disorder. Women's cluster headaches are of shorter duration, they have fewer autonomic symptoms, and they have less miosis. Migrainous symptoms are more common. Episodic cluster headaches occur in 80% of patients. These headaches last 7 days to 1 year, with painfree periods for up to 14 days. Chronic cluster headaches last 1 year or more without remission or remission that lasts less than 14 days. Other headaches with a higher male-to-female ratio are short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and exertional headache (including cough and coital headache). Certain personality and physical characteristics, such as a leonine appearance, peau d'orange skin, and coarse features, have been associated with cluster headache. Strong associations with smoking, alcohol use, and previous head and face trauma have been noted. A positive family history is present in 11% of patients. Although no gene has been identified as being causative of cluster headaches, a 14-fold increase in cluster headache incidence is noted in first-degree relatives. A polymorphism of the hypocretin receptor 2 gene (responsible for narcolepsy) has been found to be associated with cluster headache, and the risk increases 5-fold with this finding.11, 12 Interestingly, sleep apnea is common in cluster headache patients. Attacks of cluster headache occur 60-90 minutes after falling asleep, during the first rapid eye movement period. Pathophysiology In accordance with the vascular theory, cluster headache was previously thought to be due to cavernous sinus venous vasculitis, because this is the only anatomic location in the nervous system where all 3 key elements in question are in close proximity. A venous vasculitis blocks venous drainage and damages the carotid plexus of sympathetic nerve fibers. Angiograms performed on patients during a cluster headache episode have shown vasodilation of the ophthalmic artery. Other findings include increased corneal indentation, intraocular pressure, and skin temperature around the eyes. With regard to the neurovascular theory, exciting evidence has indicated from PET scanning and functional MRI studies of cluster patients during an episode that the (ipsilateral) hypothalamus is the

primary generator of cluster headaches.13 A wide range of endocrinological disturbances (eg, low testosterone and melatonin levels) are seen in cluster headache patients. The hypothalamus then activates the superior salivatory nucleus, which stimulates the parasympathetic pathway. The parasympathetic pathway is responsible for tearing, rhinorrhea, and conjunctival redness, among other things. Levels of the neurotransmitter vasoactive intestinal peptide are very high in persons with cluster headache. Furthermore, regarding the neurovascular theory, the hypothalamus also activates the trigeminal vascular pathway, which is responsible for the head pain. Pain is mediated by the V1 division of the trigeminal nerve. Ocular sympathetic defects are thought to be due to neurapraxic injury of postganglionic fibers, autonomic dysregulation that originates centrally, or vasodilation and perivascular edema. The sympathetic chain is hypoactivated, resulting in the development of a partial Horner syndrome. With regard to parasympathetic overactivity, only 7% of patients have no autonomic symptoms. Some patients have only autonomic symptoms but no headache. During acute cluster episodes, PET studies have shown that the ipsilateral hypothalamus, the anterior cingulate gyrus, and the bilateral insula are activated. Moreover, PET studies have consistently shown increased density of the ipsilateral hypothalamus in cluster headache patients. A magnetic resonance spectroscopy study of hypothalamic metabolism in 26 cluster headache patients performed in Italy showed that N-acetyl aspartase levels were of lower peak in cluster headache patients. Thus, the density of neurons in the hypothalamus is increased with a reduced ratio of N-acetyl aspartase to creatine, which indicates neuronal dysfunction in that area. Clinical features No premonitory features are associated with cluster headaches. Cluster pain is described as extremely severe, unilateral, orbital or supraorbital pain associated with ipsilateral facial autonomic symptoms, such as ptosis, tearing, and injection. Of cluster headache patients, 7% may not have autonomic symptoms. The pain also may radiate to the back of the neck, to the suboccipital area, and along the carotid artery. The pain often is boring or piercing in nature and lasts from 15 minutes to 4 hours. The headache typically awakens the patient in the middle of the night. Tenderness of the temporal artery, facial flushing, and elevated skin temperature on the ipsilateral side have been reported. During an attack, the patient is restless and may find relief in pacing or crying. Clusters start rapidly over a few minutes, and maximum pain is in the distribution of the first or second divisions of the trigeminal nerve. Periodicity is characteristic of the disease; the patient experiences clusters of headaches, each lasting as long as several months, once or twice a year. Attacks are more common during the months with the longest and shortest days of the year. During a cluster period, patients may experience many attacks per day. The use of alcohol, histamine, or nitroglycerin during an attack of cluster headache may worsen the attack. Treatment of acute attack Oxygen therapy is safe and effective; thus, it is the treatment of choice. Oxygen delivered through a face mask at a dose of 8 L/min for 10 minutes, early on during an attack, often terminates or diminishes the intensity of the attack. Oxygen is postulated to be a vasoconstrictor and increases synthesis of serotonin in the CNS, which may be the reason for its efficacy. Subcutaneously administered sumatriptan (6-12 mg) is effective in treating an acute attack of cluster headache. In one study, 74% of patients responded to subcutaneous sumatriptan, compared with 26% who took placebo. Sumatriptan also relieves the autonomic symptoms associated with cluster headaches. Oral agents are less effective and less useful because cluster headache typically lasts for less than 1-2

hours and oral agents may take up to 1 hour to be effective. Oral zolmitriptan (10 mg) and oral sumatriptan have also been used. Cocainization of the sphenopalatine ganglion has been shown in the past to abort cluster headaches; thus, viscous lidocaine dropped into the ipsilateral nose may work. Intranasal administration of 2% lidocaine (1 mL) with the patient in the supine position is effective in some patients. Transitional prophylaxis with nightly administration of oral or suppository ergotamine (2 mg) can also be used. Relief is reported in more than 50% of patients when ergotamine is given early during the attack. The inhaled form of ergotamine is given in the dose of 0.5 mg, with a maximum total dose of 2.16 mg delivered in as many as 6 puffs. The sublingual dose is 2 mg every half hour, with a maximum of 8 mg/d. Dihydroergotamine is as effective as ergotamine, but it has the disadvantage of self-administration during an attack. The dose is 0.5-1 mg given intravenously or intramuscularly. Prophylactic therapy Prophylactic therapy should be initiated early, during the beginning of a cluster period, and discontinued only after the patient has an attack-free period of 2 weeks. Therapy should typically be started at the lowest dose and gradually increased to the maximum effective and tolerated dose. The adverse-effect profile determines the choice of medication. Medication doses should be tapered and not abruptly withdrawn at the end of a cluster period. Calcium channel blockers are the first-choice agents for the prophylactic treatment of cluster headaches. Verapamil is the most effective calcium channel blocker; the dose is 120 mg in 3-4 divided doses. Adverse effects include constipation and water retention. Prednisone is dramatically effective in some patients and should be tried if other therapies fail. The dose is 30-75 mg/d for the first few days, followed by a quick taper, or maintenance at a dose of 5-10 mg for the duration of the cluster headache. The dose of ergotamine is 2 mg orally given twice a day. Dihydroergotamine can be given for severe, recurrent attacks. The dose is 0.5-1 mg given intravenously every 8 hours for 72 hours. For methysergide maleate, the dose is 2 mg/d, with a daily 2-mg increase to a maximum of 8 mg/d. Adverse effects include nausea, vomiting, abdominal cramps, leg cramps, skin swelling and discoloration, and fibrotic reactions in peritoneal, pleural, cardiac, and pulmonary tissue. Contraindications include peripheral vascular disease, chronic pulmonary disease, hypertension, deep vein thrombosis, and active peptic ulcer. The dose for lithium is 600-900 mg/d in divided doses. Adverse effects include hypothyroidism, renal complications, and adverse neurological effects (eg, tremor, slurred speech, blurred vision, confusion, nystagmus, ataxia, extrapyramidal effects, seizures). Adverse effects of indomethacin include gastric irritation, mental confusion, and psychosis in some patients with cluster headaches.

Steroid injections into the occipital nerve are another option. Methylprednisolone acetate at 120 mg in polyethylene glycol with lidocaine is injected into the ipsilateral greater occipital nerve, resulting in remission of the attack. For valproic acid, the dose is 250 mg given twice a day. The dosage can be increased to 1000 mg/d as tolerated. Newer treatment modalities Somatostatin inhibits the release of calcitonin generelated peptide and vasoactive intestinal peptide. The chief source is the hypothalamus. Octreotide is a somatostatin analog. It has a peripheral mode of action. Matharu et al reported on a study of 57 patients given octreotide (46 provided efficacy data) and 45 given placebo. The headache response rate with 100 mcg of octreotide subcutaneously was 52%, and the headache response rate was 36% for those given placebo. GI upset was the main adverse effect reported.14 Surgical treatment for patients with intractable disease Ipsilateral hypothalamic stimulation has now been used on more than 12 patients as a treatment for intractable cluster headache, especially for those with chronic disease. The hypothesis is that the hypothalamus is the clock-pulse generator. Constant depolarization discontinues the biological clock like an impulse from a distant trigeminal anatomic execution. Leone et al reported the results over 4 years in 20 patients, the first procedure being in 2000. Thirteen of 16 patients did extremely well. Only transient diplopia was noted as an adverse effect. However, the stimulator takes several weeks to work.15

NOVEMBER/DECEMBER 2004 ISSUE OF HEADACHE (sursa 11) Costul total consta din: 1.Costul direct medical de ingrijire ba migrenei asha ca: a)medicatia b)vizita la doctor 2.costul indirect,ce include:timpul pierdut de lucru, studii,sau activitatile din timpul liber. Acordarea medicatiei care previne migrena,daca folosirea ei ar fi dirijata ar putea reduce costul tratamentelor migrenei. Autorii anexeaza listea preturilor la 70preparate preventive,aratind ca gasirea sau apropierea de standard in reducerea producerii cefaleei cu 50% la 1/2 din pacientii tratati.

Prevalena cefaleelor primare( migrenei i cefaleei de tip tensional) n Republica Moldova: factori de risc pentru progresare(indici socio-demografici). Introducere: Este bine cunoscut, c cefaleele exercit un efect considerabil asupra calitii vieii i asupra studiilor, activitilor familiale sau individuale , i impactul economic nu e deloc de neglijat. Rata prevalenei cefaleelor este aproximativ 1 din 6 sau 16.54%, adic 45 mln de persoane din

Statele Unite. Cefaleea este omniprezent i este o problem costisitoare a sntii publice in Japonia . Conform datelor prezentate( Ocuma H., Kitagawa Y. 2005), prevalena cefaleei pe via e aproximativ de 93% la brbai i 99% la femei. Aproximativ 8.4 mln de oameni in Japonia sufer de migren i 22 mln au cefalee de tip tensional. Studiile populaionale sunt in majoritaea lor focusate asupra migrenei deoarece ea a fost mai des studiat,dar ea nu este cea mai frecvent intilnit patologie cefalalgic. In raportul OMS din a. 2000 dup gradele de severitate a diferitor patologii, pacienii cu atacuri severe de migren au fost considerai mai afectai decat cei cu psihoze active, demene, sau cei cu tetraplegie. Privind numrul de ani trii cu disabilitate( YLDs), cauzat de variate patologii, migrena depete locul 19 in lume i locul 9 la femei(Maters et al 2002).

Studiile Americane i Europene demonstreaz c in fiecare an 6-8% din brbai i 15-18% dintre femei au migren . Un pattern similar se vede in America Central i de Sud. In urma cercetrilor din Puerto Rico,spre exemplu, s-a constatat prevalena migrenei de 6% la brbai i 17% la femei.

Soma Sahai et al.(8) n articolul su afirm, c:Cefaleea este un simptom foarte rspndit i e cea mai des ntlnit problem a neurologilor, care se ia n consideraie n activitatea clinic. S-a estimat, c 60-80% de Americani din orice timp sunt afectai de ea . Migrena afecteaz 17% din femei i 6% de brbai n SUA. nainte de pubertate , ambeele : prevalena i incidena migrenei este mai nalt la biei dect la fete. La indivizii, mai mari de 12 ani, prevalena crete la ambele sexe(biei i fete), iar incidena descrete la persoanele mai mari de 40 ani, cu excepia femeilor n perimenopauz. Peste tot prevalena e mai nalt la femei dect la brbai. Proporia femei/brbai crete de la 2,5: 1 la pubertate pn la 3,5:1 la 40 ani, dup ce scade.

Incidenia migrenei cu aur la biei atinge vrful la 5 ani, iar la fete pe la 12-13 ani.. Incidenia migrenei fr aur la biei ajunge n vrf la 10-11 ani, iar la fete pe la 14-17 ani. Incidena migrenei la femeile de vrst reproductiv crete pe parcursul a 20 ani, probabil datorit contientizrii mai bune a condiiilor. n Statele Unite, femeile albe au cea mai nalt inciden a mirenei, pe cnd femeile asiatice au cea mai joas inciden. Pe lng aceasta, statutul socioeconomic jos este asociat cu migrena. n prezent, 1 din 6 femei din America au cefalei migrenoase. Un Studiu efectuat in Turcia dezvluie o i mai mare prevalen in aceast ar: 10% la brbai i 22% la femei. Cea mai inalt rat pretutindeni la femei (de 2-3 ori mai mare decit la brbai) este cea hormonal condiionat. Migrena este o form relativ sever de cefalee, ce survine in form de atacuri, de obicei cu durata de la 4 ore pan la 72 ore (3 zile), fiind acompaniat de astfel de fenomene disabilitante ca : nausea(greurile) sau vomele, intolerana sever a luminii, sunetelor, mirosurilor i al micrii corpului. Cefaleea de tip tensional este de obicei mai puin incapacitant ca migrena i cu mai puine fenomene insoitoare. Acest tip de cefalee nu a fost considerat in raportul OMS cel mai important, dar datorit fatului, c este cel mai prevalent tip de cefalee i are tendina de a deveni cronic la o substanial parte a pacienilor, consecinele individuale i sociale a Cefaleei de tip tensional pot fi la fel de semnificative, ca i cele ale migrenei. Alte forme relativ rare aa ca cefaleea in ciorchine(Cluster), poate fi chiar mai incapacitant ca migrena pe timpul atacului. Fr a ine cont de diagnostic, pentru majoritatea pacienilor, consecina este, c funcia normal e intrerupt de episoade de cefalee cu intervale neregulate i imprevizibile, iar aceasta poate impune severe limitri in viaa lor cotidian, la studii, munc i pe parcursul timpului de odihn. Toate acestea i faptul, c patologiile date sunt extrem de prevalente in toat lumea, le face importante din punctul perspectivei economice. Rezultatele unui studiu extins executat n 1999, ce a fost efectuat pe un lot de 10582

pers.adulte din Frana( Auray JP(1)) au demonstrat o prevalen de 17,3% pentru migren i aproximativ 30% pentru cefalei. Lipton RB et al.(11) afirm n stidiul su, c migrena este o patologie foarte rspndit, ce afecteaz circa 11% din populaia adult a rilor vestice. In rile dezvoltate doar CTT afecteaz 2/3 din brbai i mai mult de 80%din femei.

Extrapolarea din datele privind prevalena migrenei i a incidenei atacurilor, prezint c 3000 de atacuri de migren au loc zilnic pentru fiecare 1 mln din populaia general. Adic mai mult de 1 adult din 20 are cefalee aproape zilnic sau chiar zilnic. Patologia cefalalgic impune o povar considerabil asupra suferinzilor, incluzind afectarea calitii vieii, suferina substanial personal periodic i costul financiar . Repetarea atacurilor de cefalee, urmate de o frecvent sau permanent fric, dauna pricinuit vieii de familie,vieii sociale i serviciului constitue impactul patologiei cefalalgice. Spre exemplu activitatea social i capacitatea de lucru sunt reduse aproape la toi suferinzii de migren i la 60% din cei cu CTT. In rile dezvoltate doar CTT afecteaz 2/3 din brbai i mai mult de 80%din femei. Migrena e intilnit la toate rasele. Totui evidena curent sugereaz , c prevalena migrenei este mai inalt la cei de ras alb decit la asiatici i africani. ara 1. Canada 2. SUA 3.Peru 4.Britania 6.Malasia 7.Arabia Saudit Prevalena 15% 11% 32% 11% 9% 3% ara 8.Frana 9.Norvegia 10.Danemarca 11.Japonia 12.Hong Kong 13.Etiopia Prevalena 12% 9% 17% 8% 1.5% 3%

Un efort de lung durat de a face fa patologiilor cefalgice poate de asemenea predispune persoanele fa de alte patologii . De exemplu, depresia e de 3 ori mai des intlnit la persoanele cu migren sever sau cefalei severe decit la indivizii sntoi. De obicei cu debutul in pubertate, migrena afectez majoritar persoanele cu virsta cuprins intre 35 i 45 de ani, dar le poate crea probleme i persoanelor mult mai tinere, inclusiv copiilor. Scopul studiului: Scopul acestui studiu a fost estimarea prevalenei cefaleelor primare (migrenei i cefaleei de tip tensional), aprecierea relaiei dintre statutul socio- economic i prevalena cefaleelor primare i stabilirea frecvenei factorilor- triggeri la subiecii aduli (15-65 ani) cu acest tip de cefalei in localitile urban(mun Chiinu) i rural(Hanceti) din Republica Moldova. Acesta este primul studiu epidemiologic al migrenei i cefaleei de tip tensional din Republica

Moldova, efectuat

in conformitate cu Criteriile Clasificrii Internaionale

a Tulburrilor

Cefalalgice editat de Societatea Internaional de Cefalee in anul 2004.

Materiale i metode: Studiu randomizatface-to-face", " door-to-door a populaiei adulte din localitile urban i rural (cetenii (15-65 ani) din municipiul Chiinu i or. Hnceti) din Republica Moldova prin intermediul chestionarului structurat, elaborat de Profesorul I.Moldovanu in 2004, in conformitate cu Criteriile Clasificrii Internaionale a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee din anul 2004. Cercetatare efectuat sub conducerea profesorului I.Moldovanu in anul 2005 n coordonare cu Societatea Internaional de Cefalee(International Headache Society) cu selectarea eantionuluiChiinu-Hnceti. In studiu au fost inclui 2665 respondeni cu varsta cuprins intre 15-65 ani, rata de participare a fost de 84% din 3165 persoane contactate . Toi participanii au fost evaluai asupra istoricului durerii de cap n conformitate cu criteriile Societii Internaionale a Cefalee. Cei care au fost diagnosticai cu cefalee- 1439(54%) i cei 1226(46%) au fot intervievai. Chestionarea a fost efectuat de o echip de medici neurologi special pregtii( rezideni in neurologie, de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu) in perioada : mai-iunie, septembrie-octombrie 2005 de un grup de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu i rezideni in neurologie, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee(IHS). Studiul a fost efectuat n baza Chestionarului referitor la durerile de cap complex, structurat, bazat pe criteriile stabilite de Clasificarea Societii Internaionale a Cefaleelor( ediia II, 2004), ce const din 145 ntrebri(mare), care vizeaz urmtoarele aspecte de baz: aspecte sociodemografice, variabile farmaco i medico- economice, caracteristici clinice detaliate ale cefaleelor, factorii-triggeri, comorbiditatea(algic, psiho-afectiv, tulburri de somn), gradul de incapacitate, impactul medicamentos. Chestionarul structurat( mic) Referitor la durerile de cap i tulburrile de somn a fost prevzut pentru intervievarea persoanelor fr cefalee convenional sntoase, utilizat in cefaleelor (MIDAS i HIT-6), estimarea prezenei abuzului

acest studiu, conine

17 intrebri, ce cuprind

urmtoarele aspecte: aspecte socio-

demografice: nivelul economic i educaional, statutul matrimonial i profesional, tulburrile de somn, utilizarea medicamentelor pentru normalizarea somnului i frecvena utilizrii lor. Analiza statistic SPSS varianta 12. Dup ntrebrile introductive privind vrsta, nivelul economic i educaional, statutul matrimonial i profesional, persoanele au fost interogate despre prezena cefalee n perioada ultimului an. Din totalul de 2665 de persoane au rspuns afirmativ la intrebare privind prezena cefaleelor1439, ce constituie 54% lor li s-au adresat ntrebri din Chestionarul Referitor la durerile de cap de 145 ntrebri (mare), iar restul 1226 din cei cercetai-46%, respondenii fr cefalee, au fost intervievai dup chestionarul Referitor la durerile de cap i tulburrile de somn de 17 ntrebri(mic), n ambele chestionare au fost incluse ntrebri privind venitul: Cum v apreciai starea D-voastr material? Condiiile de trai. Dac cefaleea era declarat, li se adresau ntrebri, privind caracteristicele cefaleelor lor i relatarea unor astfel de date cum ar fi: frecvena, durata, triggerii(factorii declanatori), simptomele nsoitoare, dereglrile de somn, istoricul familial, tratamentele suportate pn acum etc. Rezultate: Din totalul de 2665 persoane chestionate au fost intervievate1587 femei, 1050(39,4%) din ele au suportat diverse tipuri de cefalee n decursul ultimului an. Din 1078 brbai intervievai-389 (39,4%) au avut cefalei n decursul ultimului an. Totalul suferinzilor de cefalee a alctuit 54%(1439ptts.). O prevalen similar a cefaleelor de 54% din totalul persoanelor chestionate s-a obinut i n studiul lui K Hagen et al.(1). Dac cefaleea era declarat, li se adresau ntrebri, privind caracteristicele cefaleelor lor i relatarea unor astfel de date cum ar fi: frecvena, durata, triggerii(factorii declanatori), simptomele nsoitoare, dereglrile de somn, istoricul familial, tratamentele suportate pn acum etc. n studiul nostru s-au obinut urmtoarele date ale prevalenei migrenei i cefaleei de tip tensional: n lotul mixt(brbai +femei).

448 femei+86 brbai= 534 ptts. cu migren-20,03% din 2665- numrul total al persoanelor chestionate-; 534ptts- 37,10% din 1439 pers cu cefalee; 296 femei+193 brbai= 489 ptts. cu CTT- 18,34% din numrul total al persoanelor chestionare2665; 489ptts- 33,98% din 1439 pers cu cefalee. Ne-am propus s stabilim ul lot de baz fr cefalee - lot de control din persoane convenional sntoase- 1226p., iar cei 1439 ptts. cu cefalee suferinzi de cefalee. Repartiia dup vrst a celor suferinzi de cefalee i fr dureri de cap: Majoritatea o alctuiesc persoanele cu vrsta 20-29 ani- 320ptts. (22,2% din 1439)- cu cefalei, 327p.fr cefalei(26.7% din 1226); (P<0,01). Persoanele cu vrsta 40-49, 50-59 sunt mai numeroase n lotul celor cu cefalee: de 40-49 ani- 293ptts.(20,4% din 1439)- cu cefalee, versus- 193p.(15,7% din1226)- cei fr dureri de cap(P<0,01); de 50-59 ani- 268ptts(18,6% din 1439) cu cefalee, versus 175p.(14,3%)- pers. fr dureri de cap(P<0,01)de aceiai vrst. K Hagen et al (1) menioneaz, c Indivizii, care au rspuns la chestionarul cefaleei aveau

tendina s fie mai tineri (55,0 vs 58,6 ani,P<0,0001), n majoritate erau femei(47% vs. 44%, P<0,0001), i cu o mai nalt SSE(stare socio-economic), msurat(evaluat prin educaie, ocupaie i venit(P<0,0001), dect acei, care n-au rspuns. Respondenii, care niciodat n-au utilizat medicamente, considerai iniial fr cefalei, au fost ceva mai tineri i au avut un venit mai nalt, un nivel educaional i o clas social, legat de profesie n comparaie cu cei care au utilizat analgezice. Respondenii, care au raportat , c sufer de migren n chestionar au fost diagnosticai ca suferinzi de migren i corespunztor suferinzi de cefalee de tip tensional . Cea mai mare prevalena a migrenei a fost depistat la persoanele cu vrsta 20-29ani-124ptts. (4,6%); 40-49 ani-113ptts.(4,24%). Cea mai mare prevalena a cefaleei de tip tensional a fost depistat la persoanele cu vrsta 2029ani- 102 ptts.(3,8%); 50-59 ani-97ptts.(3,6%). Dup frecvena atacurilor pe lun Migrena-1-4 zile- 173p. Migrena-5-14 zile-291p. CTT-1-4 zile-185p. CTT-5-14 zile-235p.

Migrena 15 zile-70p.

CTT 15 zile-69p.

Datele privind repartizarea tipurilor maladiilor cefalalgice sunt indicate in tabelului de mai jos: Tipul cefaleei Migren Cefaleea de tip tensional Migrena cronic CTT cronic Cefalee mixt Cefaleea mixt cronic Migrena probabil CTT probabil Migrena cronic probabil CTT cronic probabil Cefalee mixt probabil Cefalee mixt cronic probabil Cefalee secundar Numrul suferinde 441 421 93 68 73 43 61 54 44 49 41 24 26 16,5% 15,8% 3,5% 2,6% 2,7% 1,6% 2,3% 2,0% 1,7% 1,8% 1,5% 0,9% 1% persoanelor Prevalena(%)(din 2665 pers.)

Repartiia dup sex a persoanelor cu cefalee versus cele fr dureri, convenional sntoase ? P. fr cefalee: Brbai-689-56,2%(din 1226) 1439) Femei-537-43,8% (din 1226) 1439) Raportul femei/brbai la persoanele este de- 0,78, iar la cei ce sufer de cefalei raportul femei/brbai -2,7. .Trsturile socio-demografice ale migrenei i CTT: vrsta, nivelul educaional , statutul (P<0,002) Femei- 1050- 73% (din ( P<0,001) P. cu cefalee Brbai- 389- 27%(din

matrimonial i locul de trai au fost demonstrate n Tab.1. Tab.1. Trsturile socio- demografice a tuturor persoanelor intervievate i a pacienilor cu cefalee. Parametri demografici Vrsta(ani) 15-19 20-29 30-39 40-49 50-59 60-65 Nivelul educaional jos mediu superior Statutul matrimonial Cstorit() Divorat Vduv 1834(68,8%) 121(4,5%) 124(4,7) 118 (13,8%) 17 (9,5%) 8 (7,0%) 160 (18,7%) 28 (15,7%) 28 (24,3%) Celibatar()(singur()) 586(22%) 1150(43,2%) 503(18,9%) 1012(38%) 226 (42,32%) 100 (18,73%) 208 (38,95%) 217(44,38%) 82 (16,77%) 190 (38,85%) 298(11,2%) 647(24,3%) 493(18,5%) 486(18,2%) 443(16,6%) 298(11,2%) 55 (10,3%) 124 (23,22%) 101 (18,91%) 113 (21,16%) 104(19,48%) 37(6,93) 49(10,02%) 102(20,86%) 75(15,34%) 96(19,63%) 97(19,84%) 70(14,31%) socio- Toate persoanele Pacienii migren(n=534) cu Pacienii CTT(n=489) cu

intervievate(n=2665)

Locul de trai Localitate urban Localitate rural 1301(48,8%) 1364(51,2%)

Cum se repartizeaza dup sex persoanele cu migren si CTT? P. cu Migren: Brbai-16,1% Femei-83,9% ( P<0,001) (P<0,002) P. cu CTT: Brbai-39,5% Femei-60,5%

Raportul femei/brbai la persoanele , ce sufer de migren este de 5,16,

Iar la cei cu CTT raportul femei/brbai -1,53

Lipton RB et al.(11) afirm, c prevalena e cea mai nalt n anii de productivitate maxim de la 25 la 55 ani. Prevalena e mai nalt la femei dect la brbai n toi anii dup pubertate, dar proporia pe sexe variaz cu anii. n SUA, prev. migr. e mai nalt la persoane cu nivel jos de educaie, probabil din cauza, c migrena interfer cu coala i munca.

Conform datelor noasre n lotul persoanelor, ce sufer de dureri de cap majoritatea o alctuiesc cei cstorii- 991ptts.(68,9% din1439), situaie similar se observ i n cazul celor fr cefalei843p.(68,8% din1226)(P>0,05). O parte important din persoanele fr cefalee o alctuiesc celibatarii-291(23,7%) (pers. celor cu dureri de cap. Numrul celor

necstorite), versus 295(20,5%)(P<0,05)- n lotul

divorai e minor n cazul persoanelor convenional sntoase-40(3,3%), iar n cazul celor cu cefalee-81(5,6%)(P<0,01)- dublu fa de cei fr cefalee. Date similare au fost obinutede AP Jain et al(14): Cefaleele de tip tensional au fost mai desntlnite printre gospodine casnice(40,1%), personae cstorite(69,3%), toi acetea aparinnd clasei socio-economice II (47%) i din familii complete(75,25%). Educaia nu are s joace vre-un rol semnificativ. n studiul efectuat de K Hagen et al.(1)toi participanii au fost divizai dup ocupaiile lor (10 categorii) i aceast informaie a fost utilizat pentru reclasificarea subiecilor(n aproximativ din schema social naional, recomandat Portocarero, EGP). Participanii au fost reclasificai n 3 categorii : clasa social nalt( clasa I-II EGP social): posturi managerial n ntreprinderi publice sau private i profesionitii( lucrtorii cu gulerae albe); clasa social medie(clasa III-IV EGP social): muncitorii , ce efectuiaz munc de rutin nemanual, proprietarii mici, fermierii i pdurarii i ali muncitori autoangajai din producia primar; cea mai joas clas social (clasa V-VII EGP social): tehnicieni necalificai, supraveghetori ai muncitorilor specializai n munci manual, muncitori sei i necalificai(cu gulerae albastre). Statutul jos a fost asociat cu riscul crescut al cefaleelor frecvente i cronice ca urmare. Riscul cefaleelor frecvente i cronice descrete cu creterea venitului personal, dar doar n cazul brbailor. n raportul OMS(WHO)(Erikson, Goldthope and

n studiul nostru divizarea dup caracterul activitii s-a efectuat astfel: 1. Pers. neangajate; 2. pers., ce muncesc fizic(munc manual); 3. Pers. cu munc intelectual ; 4. Munca administrativ; 5. Afaceri; 6.Altele. Dar pentru comoditate toi respondenii a fost inclui n trei grupuri de baz: I- Persoanele neangajate;II-P. ce efectuiaz munc intelectual; III-P. ce muncesc fizic . Dup caracterul activitii se observ o majoritate vdit a persoanelor , ce efectuiaz munc intelectual: 414(33,8%)-pers. fr cefalei, 547(38%)-ptts. cu cefalee(P<0,05); Persoanele neangajate n cmpul muncii: 363p.(29,6%)-din grupul respondenilor fr dureri de cap; 466ptts.(32,4%)- din cei cu cefalee(P>0,05); n lotul respondenilor , ce munceau fizic numrul respondenilor fr cefalei- 371(30,3%), ct i a celor cu dureri de cap -337(23,4%) nu difer considerabil(P<0,001). O prevalen nalt a cefaleei frecvente i cronice a fost deasmena descoperit printre cei care nu aveau o profesie anume(studeni/elevi,gospodari sau pensionari )(Hagen et al.(1))date similare am obinut i n studiul nostru, persoanele neangajate fiind foarte numeroase n lotul suferinzilor de cefalee-466ptts.(17,49% din 2665p.; 32,4% din 1439ptts.). Aceiai afirmaie e valabil i n cazul migrenei-173(32,4% din534 migrenoi; 6,5% din

2665pers.)) i n cazul pers. cu CTT-164(33,54%-din 489ptts. cu CTT; 6,2% di 2665pers.)- nu erau angajai n cmpul muncii. n acelai studiu K Hagen et al.(1) gsim, c n analiza intra-secional, un SSE jos era asociat cu prevalena mai nalt a cefaleelor frecvente i cronice , evident att pentru migren ct i pentru cefaleea non-migrenoas. n mod similar,clasa social joas definit de tipul profesiei i venit era asociat cu o frecven mai nalt a cefaleii frecvente i cronice, evident pentru ambele sexe. O analiz ulterioar a dezvluit c o legtur strins dintre pensia de invaliditate i cefaleea frecvent poate explica cel puin parial aceste rezultate(nu sunt prezentate date). n final, frecvena cefaleelor frecvente i cronice era dublu mai nalt la indivizii care au prezentat probeme economice n comparaie cu cei care experimentau foarte rar sau niciodat asfel de probleme, menioneaz acelai autor. Tabagismul: n lotul persoanelor fr cefalei fumeaz-354p.(28,9%), iar din cei cu cefalee269(18,7%)(P<0,001), date, ce se confirm i n literatura de specialitate Sunt mai muli nefumtori n grupul respondenilor cu cefalee- 1170(81,3%), fa de

872(71,1%)din cei fr dureri de cap, ce nu coincide cu datele prezentate de Scher, A I. PhD et al.(12), care afirm n cercetatrea sa c: n comparaie cu grupul de control, migrenoii sunt mai

predispui s fumeze(OR = 1.43 [1.1 to 1.8]), mai puin predispui s consume alcool(OR = 0.58 [0.5 to 0.7]). n articolul Cigarette Smoking Among Adults in the USA(4) se indic c economic al adulilor din SUA este invers proporional un statut socioeconomic mai nalt. statutul socio

cu obiceiul lor de fumatori i c

persoanele cu un statut socioeconomic jos au un acces mai mic la ngrijirea sntii dect cei cu

Nivelul educaional: Participanii au raportat nivelul de educaie, ce-l deineau(6 categorii) i bazndu-ne pe aceast informaie am divizat participanii n 3 categorii,n accord cu durata studiilor : I-nivel jos de educaie 9ani(coala obligatorie primar sau coala profesional), IInivel mediu- 10-12 ani(Liceu, colegiu) i III 13 ani(studii universitare i postuniversitare ). O divizare similar dup nivelul educaiei(studuiilor) a fost efectuat i de authorii Perry Carson A.L. et al.(9) i K Hagen et al(1). Cu un nivel jos de educaie(coala primar sau coala profesional) au fost 533(43,5%)

respondeni fr dureri de cap, cu acelai nivel de educaie au fost 617 ptts. cu cefalei (42,9%) (P<0,05) ; Un numr practic de 2 ori mai mic de respondeni au avut studii medii- 239(19,5%)- fr dureri de cap, 264(18,3%)- ptts cu cefalee. Cu studii superioare au fost 454(37%)respondeni fr dureri de cap i 558 ptts.(38,8%) cu cefalei (P<0,05); Un numr mare din cei suferinzi de cefalee au avut nivel de studii jos i mediu, 42,9% i 38,8% respective, date, ce difer de cele din studiile anterioare(K Hagen et al.(1)), n care se menioneaz , c n mediu, indivizii cu mai puin de 10 ani de educaie aveau o prevalena mai nalt cu 90% a cefaleelor frecvente (OR=19.5% CI 1.7-2.1)i o prevalen cu 70 % mai nalt pentru cefaleea cronic(OR=1.7, 95% CI 1.4-2.0) n comparaie cu acei cu educaie superioar(13 ani), deci un SSE jos, definit de nivelul educaiei i profesie ca un prim-plan a fost asociat cu un risc crescut al cefaleelor frecvente i cronice. Schwartz et al. (31) a raportat o cretere a prevalenei cefaleei de tip tensional cronice odat cu descreterea nivelului de educaie, pe cnd prevalena CTT episodice a descrescut. Riscul cefaleelor frecvente crete printre persoanele cu nivel jos de educaie de ambele sexe, mai proeminent la pers .cu vrsta <60 menioneaz K Hagen et al (1) .

Curry K, Green R(7) a menionat, c majoritatea studenilor supravegheai au raportat, c au suportat cefalei de intensitate moderat sau severe. 16% din respondeni au indicat, c cefaleele lor s-au intercalat cu activitile lor zilnice(uzuale), Starea material: Majoritatea net o alctuiesc persoanele,ce au bani doar pentru strictul

necesar-862p.(70,3%)-fr cefalee, 997(69,3%)-ptts. cu dureri de cap; celelalte dou grupuri- ce au un trai decent- 185(15,1%)-respondeni fr cefalee, respectiv217(15,1%)-ptts. cu dureri de cap; nu le ajung bani nici pentru strictul necesar la 179p.(14,6%) din grupul pers. fr dureri de cap i la 225ptts.(15,6%)-cu cefalee. Nu s-a observat o diferen statistic nici n unul din cazurile enumrate(P>0,05). O situaie similar se observ i n cazul repartizrii respondenilor dup condiiile de trai: Condiii medii au -804(65,6%) respondeni fr cefalee i 950(66%)ptts. cu cefalee; condiii bune de trai au avut -346p.(28,2%)- fr cefalee, versus 407(28,3%)-ptts. cu dureri de cap; un numr mic de respondeni -76(6,2%)- fr cefalee i 82(5,7%)- au menionat, c au condiii nefavorabile de trai . n toate trei cazuri P>0,05. K Hagen et al.(1) a menionat, c ntr-o analiza intra-secional un SSE jos era asociat cu prevalena mai nalt a cefaleelor frecvente i cronice , evident att pentru migren ct i pentru cefaleea non-migrenoas. n mod similar,clasa social joas definit de tipul profesiei i venit era asociat cu o frecven mai nalt a cefaleii frecvente i cronice, evident pentru ambele sexe. n final acelai autor concluzioneaz, c frecvena cefaleelor frecvente i cronice era dublu mai nalt la indivizii care au prezentat probeme economice n comparaie cu cei care experimentau foarte rar sau niciodat asfel de probleme. n articolul Factors Associated With Low Socioeconomic Status Increase The Prevalence Of Migraines In Adolescents(6) se menioneaz, c:Adolescenii din familiiile cu un venit jos sunt mai predispui s sufere de migren dect cei cu gospodrii mai nstrite, dup cum spun cercetrile din Universitatea de medicin Albert Einstein a Universitii Zeshiva. Descoperirile , publicate n Neurology, sugereaz c factorii asociai cu statutul socioeconomic-stresul, malnutriia i accesul limitat la ngrijirea medical, de exemplu, mresc prevalena migrenei la persoanele tinere. Ar prea c la acei adolesceni care au o predispoziie genetic pentru migren, viaa stresant n legtur cu venitul nu are vreun impact.spune Dr.Bigal. Ei sunt mai predispui dect ali

adolesceni de a avea migren nectnd la statutul lor socioeconomic, deoarece ei sunt predispui la aceasta.Dar pentru adolescenii fr o predispoziie acut, reflectat de absena migrenei la rudele de primul grad, venitului familia este un factor n prevalena migrenei, n particular la cei cu venit jos. Dr. Bigal noteaz c aceast descoperire coreleaz cu prevalena migrenei la aduli, care este consistent mai nalt la persoanele cu un venit mai jos i o educaie mai joas .Studiul nostru sugereaz c noi ar trebui s explorm factorii de mediu de risc , precum evenimentele stresante i nutriia, dup cum ele se leag de venitul jos i migren, pentru a nelege cum putem reduce apariia migrenei printre aceti indivizi.

Discuii: n studiul prospectiv efectuat K Hagen et al.(1) afirm, c un SSE jos, definit de nivelul educaiei i profesie ca un prim-plan a fost asociat cu un risc crescut al cefaleelor frecvente i cronice 11 ani mai trziu. Aceasta era evident pentru ambele sexe i pentru migren la fel ct i pentru cefaleea non-mogrenoas. Riscul cefaleii frecvente i cronice descretea odat cu creterea venitului individual, dar numai n cazul brbailor. Deasemenea, n partea intrasecional a studiului, SSE-ul jos era asociat cu cefaleea frecvent i cronic. Nici un studiu precedent privitor la SSE i cefalee nu a avut un design prospectiv. Totui, numai partea intra-secional a studiului dat poate fi comparat cu studiile anterioare. Rezultatele prezente difer de cteva din acele studii, care au descoperit o prevalen destul de uniform printre categoriile de educaie(8-11,14,15,19), clasa profesional(8-10,15,19)sau venit(5-7,1618). Descoperirea noastr principal , este totui, n concordan cu studiile din SUA. Scher et al.(25) a raportat c cefaleea fecvent definit cu 180 sau mai multe cefalei pe an era mai pevalent la cei cu un nivel jos de educaie, i Stewart et al.(20) a descoperit c cefaleea era mai frecvent la migrenoi a grupele cu venitul cel mai mic. Pe cnd SSE jos a fost asociat cu un risc crescut al cefaleei frecvente i cronice, noi nu am gsit vreo relaie ntre cefalea non-frecvent i SSE. n concordan, Schwartz et al. (31) a raportat o cretere a prevalenei cefaleii de tip tensional cronice odat cu descreterea nivelului de educaie, pe cnd prevalena CTT episodice a descrescut. Rezultatele noastre indic c SSE este legat de frecvena cefaleei mai mult dect de tipul cefaleei. Lipsa unei diferene dintre 2 categorii diagnostic poate reflecta c aceste 2 tipuri de cefalei mpart aceiai factori de risc. Totui, ea poate deasemenea reflecta o acuratee sczut a diagnozei (27) i faptul c muli dintre migrenoi au i CTT.

n studiile intra-secionale, relaia dintre cauz i effect nu poate fi distins , n timp ce informaia despre educaie, profesie sau venit este prezentat n acelai timp ca informaie n baza creia este obinut cefaleea. n accord cu acest fapt , o relaie invers dintre pevalena cefaleei i SSE poate fi explicat de interferena cefaleei cu reuitele colare i cariera profesional, dup cum este sugerat n modelul social selectat(32,33). n studiul nostru prospectiv informaia despre SSE era obinut ntr-o populaie presupus fr cefalee. Totui, era mai puin probabil c cefaleea a interferat cu eduaia sau cariera profesional ntr-un prim-plan. Rezulatele noastre indic c ali factori asociai cu un SSE jos, precum stresul, malnutriia sau ngrijirea medical necorespunztoare, poate influena riscul cefaleii(modelul social al cauzelor) (32,33). mpotriva acestui fapt, cineva ar putea declara c ajustarea pentu factorii sociali precum fumatul i activitatea fizic nu a schimbat rezultatele noastre. Nectnd la acest lucru, informaia din baza chestionarului despre fumat, consumul de alcool i activitatea fizic poate fi considerat cu precauie( atenie) , deoarece aceste date nu au fost validate. Prin urmare , ali factori nemsurai relatai cu cu SSE ar putea confunda informaia. Riscul cefaleelor frecvente crete printre persoanele cu nivel jos de educaie de ambele sexe, mai proeminent la pers .cu vrsta <60 . Astfel, nivelul educaional nu pare a fi un indicator puternic al SSE printre persoanele nscute naintea celui de-al rzboi mondial II-lea Rzboi Mondial ori, ca alternativ SSE nu influieneaz prevalena cefaleelor frecvente la pacienii n vrst. A fost (gsit)un risc nalt al cefaleelor frecvente , asociat cu un nivel jos de venit. n analiza cross- secional, aceasta a fost adevrat pentru ambele sexe, dar n partea prospectiv a studiului, el a fost gsit doar printre brbai. O msurare mai exact pentru SSE este venitul gospodriei ajustat la numrul membrilor familiei(gospodriei). n particular acesta ar putea fi un indicator mai sensibil pentru femei, dar din pcate aceast informaie n-a fost disponibil. Este de asemenea o asociere ntre problemele economice expuse desinestttor i cefaleele frecvente. Astfel, pare a fi rezonabil s presupunem, c nivelul jos economic reflect problemele financiare. Unii pot specula, c astfel de problem induc un stress nalt psiho-social, ce cauzeaz cefaleea frecvent n grupurile cu nivel economic jos. Prevalena cefaleei frecvente i cronice a fost nalt printre indivizii, care aveau SSE neclasificabil, definit de ocupaie, mai evident n grupul persoanelor , care primesc pensie de incapacitate. Aceast cercetare a fost surprinztoare, deoarece foarte puini subieci primesc pensie de incapacitate n Nord-Trondelag din cauza cefaleei, acesta sugeraz, c alte patologii dect cefaleea pot fi accentuate, cnd se efectuiaz aplicaia pentru pensie de desabilitate.

Exist o dovad, c e mai bine s defineti statutul ocupaiei femeii pe baza statutului ocupaiei partenerului su . Totui n studiul present, clasa social joas , definit doar de ocupaie a fost asociat cu un risc nalt al cefaleelor frecvente deasemenea i printre femei. Deoarece SSE pare a fi un predictor destul de puternic al cefaleelor frecvente, este important s fie considerat acest factor n studiile pacienilor cu cefalei frecvente i cronice . Dac SSE difer printre grupuri, diferenele n frecvena cefaleei pot fi ateptate i rezultatele trebuie ajustate la SSE. Trei tipuri de msurare al SSE s-au aplicat n acest studio, toate avnd avantaje i dezavantaje, dar toate probabil reflect(careva) diferite aspect al SSE. n concluzie , statutul socio-economic jos ca punct de pornire a fost asociat cu un risc crescut al cefaleelor frecvente cu 11 ani mai trziu, evident pentru ambele migren i cefaleea nemigrenoas. Asumnd faptul, c participanii au fost relativ fr cefalee din start, este puin probabil, c cefaleea interfer cu funcia educaional sau ocupaional. S-ar prea important s identificm mai ndeaproape care factori interacioneaz (sunt n relaie) cu SSE jos, sunt responsabili de riscul crescut al cefaleelor frecvente. Concluzii: Prevalena migrenei si cefaleei de tip tensional n cadrul populaiei din Republica Moldova a demonstrat rate aproximativ similare cu cele raportate la rile nvecinate, precum Croaia i Turcia, Frana i Italia, prevalena cefaleelor e cea mai nalt la persoanele apte de munc, prevalena de vrf al migrenei este la 20-29 i 40-49 ani, iar pentru cefaleea de tip tensional la 20-29 i 50-59 ani, n grupurile cu nivel jos i n cele cu un nivel nalt de studii, ce au condiii medii de trai, au bani doar pentru strictul necesar, sunt n mare majoritate nefumtori i preponderent femei. Datele prezentate n acest studiu difer parial de cele prezentate n cercetrile anterioare(K Hagen(1)), n care se menioneaz, c riscul cefaleelor frecvente crete printre persoanele cu un nivel mai jos de educaie de ambele sexe, mai frecvent la cele cu vrsta<60 ani i cu un venit individual jos i n partea prospectiv a studiului, a fost gsit doar printre brbai, dar coincide cu cele expuse de Lipton RB i Bigal ME(11), care au concluzionat n studiul lor, c prevalena cefaleei e cea mai nalt la femei, la persoanele cu vrsta de 25-55 ani i n sfrit nSUA, la persoanele cu un buget mic(din gospodrii cu buget mic). Iar n alt studiu Lipton RB et al.(10) afirm, c n SUA, prev. migr. e mai nalt la persoane cu nivel jos de educaie, probabil din cauza, c migrena interfer cu coala i munca.

Obiective: Cefaleea este una din acuzele cele mai frecvente in practica medical, constituind o problem major a sntii publice cu un impact indvidual i social mare, avind ca rezultat pierderea productivitii, limitarea activitii i deteriorarea calitii vieii, date confirmate de cercetrile epidemiologice actuale. Studiile prevalenei, ce au cercetat relaia dintre statutul socio-economic(SSE) i cefalee au demonstrat rezultate contradictorii, inegaliti n morbiditate din cauza diferenelor substaniale n statutul socio-economic n Europa de Vest i n SUA. Metode: Studiul populaiei a constat din 2665 ceteni aduli (15-65 ani) din municipiul

Chiinu i or. Hnceti din Republica Moldova. Studiul a fost efectuat utiliznd metodele de intervievare face-to-face", " door-to-door de o echip de medici- neurologi special pregtii ( rezideni in neurologie, colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu) in perioada : mai-iunie, septembrie-octombrie 2005, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee . Rata de participare a fost de 84%(2665persoane) din 3165 persoane contactate .Toi participanii au fost evaluai asupra istoricului durerii de cap n conformitate cu criteriile Societii Internaionale a Durerii de Cap. Au fost diagnosticai cu cefalee-1439(54%). Diagnosticul tipurilor de cefalee s-a stabilit ulterior de neurologi specialiti n cefalei. Rezultate: Din lotul general de 2665 respondeni cu cefalee au fost 1439ppts., din ei au fost intervievate 1587 femei, 1050(39,4%) din ele au suportat atacuri de cefalee n decursul ultimului an. Din 1078 brbai intervievai-389 (39,4%) din ei au avut cefalei n decursul ultimului an.

Din 1439, 534 de persoane au fost diagnosticai cu migren. Prevalena migrenei la femei era de 16,81%(448ptts.) i prevalena migrenei la brbai e de 3,22%(86 ptts.) i de 20,03% la ambele sexe. Cea mai mare prevalena a migrenei a fost depistat la persoanele cu vrsta 2029ani-124ptts.(4,6%); 40-49 ani-113ptts.(4,24%). Cu cefalee de tip tensional au fost diagnosticai 489 persoane (18,34%). Prevalena cefaleei de tip tensional la femei era de 11,1%(296ptts.) i prevalena CTT la brbai e de 7,24%(193) i de 18,34% la ambele sexe.

Cea mai mare prevalena a cefaleei de tip tensional a fost depistat la persoanele cu vrsta 2029ani- 102 ptts.(3,8%); 50-59 ani-97ptts.(3,6%). Obiective: Cefaleea este una din acuzele cele mai frecvente in practica medical, constituind o problem major a sntii publice cu un impact indvidual i social mare, avind ca rezultat pierderea productivitii, limitarea activitii i deteriorarea calitii vieii, date confirmate de cercetrile epidemiologice actuale. Studiile prevalenei, ce au cercetat relaia dintre statutul socio-economic(SSE) i cefalee au demonstrat rezultate contradictorii, inegaliti n morbiditate din cauza diferenelor substaniale n statutul socio-economic n Europa de Vest i n SUA. Metode: Studiul populaiei a constat din 2665 ceteni aduli (15-65 ani) din municipiul

Chiinu i or. Hnceti din Republica Moldova. Studiul a fost efectuat utiliznd metodele de intervievare face-to-face", " door-to-door de o echip de medici- neurologi special pregtii ( rezideni in neurologie, colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu) in perioada : mai-iunie, septembrie-octombrie 2005, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee . Rata de participare a fost de 84%(2665persoane) din 3165 persoane contactate .Toi participanii au fost evaluai asupra istoricului durerii de cap n conformitate cu criteriile Societii Internaionale a Durerii de Cap. Au fost diagnosticai cu cefalee-1439(54%). Diagnosticul tipurilor de cefalee s-a stabilit ulterior de neurologi specialiti n cefalei. Rezultate: Din lotul general de 2665 respondeni cu cefalee au fost 1439ppts., din ei au fost intervievate 1587 femei, 1050(39,4%) din ele au suportat atacuri de cefalee n decursul ultimului an. Din 1078 brbai intervievai-389 (39,4%) din ei au avut cefalei n decursul ultimului an.

Din 1439, 534 de persoane au fost diagnosticai cu migren. Prevalena migrenei la femei era de 16,81%(448ptts.) i prevalena migrenei la brbai e de 3,22%(86 ptts.) i de 20,03% la ambele sexe. Cea mai mare prevalena a migrenei a fost depistat la persoanele cu vrsta 2029ani-124ptts.(4,6%); 40-49 ani-113ptts.(4,24%). Cu cefalee de tip tensional au fost diagnosticai 489 persoane (18,34%). Prevalena cefaleei de tip tensional la femei era de 11,1%(296ptts.) i prevalena CTT la brbai e de 7,24%(193) i de 18,34% la ambele sexe.

Cea mai mare prevalena a cefaleei de tip tensional a fost depistat la persoanele cu vrsta 2029ani- 102 ptts.(3,8%); 50-59 ani-97ptts.(3,6%). Concluzii: Prevalena migrenei si cefaleei de tip tensional n cadrul populaiei din Republica Moldova a demonstrat rate aproximativ similare cu cele raportate la rile nvecinate, precum Croaia i Turcia, Frana i Italia, prevalena cefaleelor e cea mai nalt la persoanele apte de munc , prevalena de vrf al migrenei este la 20-29 i 40-49 ani, iar pentru cefaleea de tip tensional la 20-29 i 50-59 ani, n grupurile cu nivel jos i n cele cu un nivel nalt de studii, ce au condiii medii de trai, au bani doar pentru strictul necesar, sunt n mare majoritate nefumtori i preponderent femei. Datele prezentate n acest studiu difer parial de cele prezentate n cercetrile anterioare(K Hagen(1)), n care se menioneaz, c riscul cefaleelor frecvente crete printre persoanele cu un nivel mai jos de educaie de ambele sexe, mai frecvent la cele cu vrsta<60 ani i cu un venit individual jos i n partea prospectiv a studiului, a fost gsit doar printre brbai, dar coincide cu cele expuse de Lipton RB i Bigal ME(11), care au concluzionat n studiul lor, c prevalena cefaleei e cea mai nalt la femei, la persoanele cu vrsta de 25-55 ani i n sfrit nSUA, la persoanele cu un buget mic(din gospodrii cu buget mic). Iar n alt studiu Lipton RB et al.(10) afirm, c n SUA, prev. migr. e mai nalt la persoane cu nivel jos de educaie, probabil din cauza, c migrena interfer cu coala i munca. Cuvinte cheie: migren, cefalee de tip tensional,epidemiologie, prevalen, interviuface-toface", " door-to-door. Abrevieri: MFA- migren fr aur, MCA- migren cu aur, MCAFA- migren cu aur i fr aur, CTT-cefalee de tip tensional.

Reviul literaturii: 1. Cephalalgia, 2002, 22, 672-679

Low socio-economic status is associated with increased risc of frequent headache: a prospective study of 22718 adults in Norway. K Hagen, L Vatten, L J Stovner, J-A Zwart, S Krokstad & G Bovim) 2. Headache. 2005 Apr;45 Suppl 1:S3-S13. Migraine: epidemiologyimpact, and risc factors for progression. Lipton RB, Bigal ME.

3.Socio-economic impact of migraine and headaches in France Auray JP 4. Cigarette Smoking Among Adults in the USA Main Category: Smoking / Quit Smoking Article Date: 01 Jun 2004 - 10:00 PDT 5. J am acad Nurse Pract. 2007 jul, 19(7):378-82. Prevalence and management of headache in a university undergraduate population. Curry K, Green R 6. Factors Associated With Low Socioeconomic Status Increase The Prevalence Of Migraines In Adolescents, New Study Shows Main Category: Headache / Migraine Also Included In: Pediatrics / Children's Health Article Date: 07 Jul 2007 - 7:00 PDT 7. Article Date: 23 Sep 2007 - 0:00 PDT Herd P, Goesling B, House JS. Socioeconomic position and health: the differential effects of education versus income on the onset versus progression of health problems. J Health Soc Behav 48(3), 2007.

8 Article Last Updated: Sep 4, 2008

Soma Sahai, MD, Director of Neurology Ambulatory Clinics, LAC and USC Medical Center;

Assistant Professor, Department of Neurology, University of Southern California

Coauthor(s): David Y Ko, MD, Associate Professor, Laboratory Director, Department of Neurology, University of Southern California Medical Center

9.Lifetime Prevalence of Migraine and Other Headaches Lasting 4 or More Hours: The Atherosclerosis Risk in Communities (ARIC) Study

Authors: Perry Carson A.L.; Rose K.M.; Sanford C.P.; Ephross S.A.; Stang P.E.; Hunt K.J.; Brown C.A.; Szklo M.

Source: Headache: The Journal of Head and Face Pain, Volume 44, Number 1, January 2004 , pp. 20-28(9)

10. . Curr Med Res Opin. 2001; 17 Suppl 1:S4-S12 Epidemilogy and economic impact of migraine. Lipton RB, Stewart WF, Scher AI. 11. 1.Am J Med. 2005 Mar; 118 Suppl 1:3S-10S. The epidemilogy of migraine. Lipton RB, Bigal ME. 12. Cardiovascular risk factors and migraine: The GEM population-based study.

Articles Neurology. 64(4):614-620, February 22, 2005. Scher, A I. PhD; Terwindt, G M. MD, PhD; Picavet, H S.J. PhD; Verschuren, W M.M. MD, PhD; Ferrari, M D. MD, PhD; Launer, L J. PhD

13. 6.Pharmaco economics. 2004;22(9):591-603.

The burden of migraine in Spain: beyond direct costs. Badia X, Magaz S, Gutierrez L, Galvan J. 14.JIACM 2007; 8(1): 26-28 Sociodemografic and Clinical Profile of Headache- A Rural Hospital- based Study AP Jain, B Chauhan, AD Bhat.

de ctre studenii antrenai n medicin, utiliznd un chestionar detaliat focusat pe cefalei. Inegaliti n morbiditate din cauza diferenelor n statutul socio-economic sunt substaniale n Europa de Vest i n SUA, dar studii al statutului socio-economic i cefaleei conin rezultate contradictorii( ce se contrazic). Studiile clinice raporteaz, c migrena survine mai frecvent printre indivizii inteligeni i cu un nivel de educaie(studii) nalt, pe cnd studiile populaionale cross-sectional n-au confirmat aceste rezultate. n contrast unii au raportat o cretere a prevalenei cefaleei i migrenei printre grupurile cu venituri mici i nivel jos educaional. Asemenea relaii ntre cefalee i SSE (statutul socio-economic) n-au fost raportate n studiile din afara SUA. Cauza i efectul n-a fost distins n studiile populaionale cross-sectionale i este de preferat un studiu-design prospectiv. n acest studiu prospectiv randomizat cu un numr mare de persoane noi am examinat relaia dintre statutul socio-economic (SSE), msurat n perioada anilor 19841986 i riscul ulterior al migrenei, cefaleei nemigrenoase i a cefaleei frecvente(>6 zile cu cefalee/lun) peste 11 ani.

4.a.Socio-economic impact of migraine and headaches in France Auray JP Societatea internaional de cefalee are ghiduri(ndrumtoare) clar definite diagnostic, ce clasific cefaleele n 3 categorii. Acum este bine cunoscut, c cefaleele exercit un efect considerabil asupra calitii vieiii supra studiilor, activitilor familiale sau individuale , i impactul economic nu e deloc de neglijat. Un studiu extins, ce a fost efectuat pe un lot de 10582 pers.adulte din Frana, a fost ndeplinit n 1999. Rezultatele au demonstrat o prevalen de 17,3% pentru migren i aproximativ 30% pentru cefalei. Cheltuiala bneasc medie pentru un

pacient

cu cefalee este de circa 220 Euro, s-a mprit dup cum urmeaz: 10% pentru

consultaia medicului-generalist, 11% pentru evalurile de laborator, 17% pentru consultaiile specialitului, 18% pentu medicamente i 44% costul tratamentului n spital. Aceast divizare depinde n mare msur de categoria cefaleei. Dei cele mai acute cefalei afecteaz cel mai mult calitatea vieii, activitile colare i profesionale nu sunt afectate n aceia msur

Rata prevalenei cefaleelor este aproximativ 1 din 6 sau 16.54%, adic 45 mln de persoane din Statele Unite. Cefaleea este omniprezent i este o problem costisitoare a sntii publice in Japonia . Conform datelor prezentate( Ocuma H., Kitagawa Y. 2005), prevalena cefaleei pe via e aproximativ de 93% la brbai i 99% la femei. Aproximativ 8.4 mln de oameni in Japonia sufer de migren i 22 mln au cefalee de tip tensional. Tab.2Repartiia dup vrst a persoanelor cu migren i cefalee de tip tensional persoanele fr cefalee( convenional sntoase sau lot de control). Cigarette Smoking Among Adults in the USA Main Category: Smoking / Quit Smoking Article Date: 01 Jun 2004 - 10:00 PDT Acest raport indic c 1) statutul socio economic al adulilor din SUA este invers proporional cu obiceiul lor de fumatori i 2) n peioada 1983-2002, golul n prevalena fumatului dup statutul socioeconomic nu s-a ngustat i s-ar fi putut fi extins. Aceste dscoperiri accentueaz necesitatea de a stabili intervenii care pot mai bine ajunge la persoanele cu un statut socioeconomic mai jos. Persoanele cu un statut socioeconomic jos au un acces mai mic la ngrijirea sntii dect cei cu un statut socioeconomic mai nalt(3). versus

Dar atunci cnd cercettorii de la Einstein s-au focusat pe acei adolesceni fr o predispoziie familial crescut pentru migren, eu au descoperit c venitul gospodriei este strns legat de prevalena migrenei. n familiiile cu un venit anual de mai puin de 22,500$, prevalena migrenei la adolesceni era de 4.4%; n contrast cu acetea , prevalena migrenei la adolescenii din gospodriile cu un venit anual de mai mare de 99000$ era de 2.9%.

n articolulFactors Associated With Low Socioeconomic Status Increase The Prevalence Of Migraines In Adolescents (6) se afirm, c dolescenii din familiiile cu un venit jos sunt mai predispui s sufere de migren dect cei cu gospodrii mai nstrite, dup cum spun cercetrile din Universitatea de medicin Albert Einstein a Universitii Zeshiva. Descoperirile , publicate n Neurologz, sugereaz c factorii asociai cu statutul socioeconomic-stresul, malnutriia i accesul limitat la ngrijirea medical, de exemplu, mresc prevalena migrenei la persoanele tinere. Dar atunci cnd cercettorii de la Einstein s-au focusat pe acei adolesceni fr o predispoziie familial crescut pentru migren, eu au descoperit c venitul gospodriei este strns legat de prevalena migrenei. n familiiile cu un venit anual de mai puin de 22,500$, prevalena migrenei la adolesceni era de 4.4%; n contrast cu acetea , prevalena migrenei la adolescenii din gospodriile cu un venit anual de mai mare de 99000$ era de 2.9%. Ar prea c la acei adolesceni care au o predispoziie genetic pentru migren, viaa stresant n legtur cu venitul nu are vreun impact.spune Dr.Bigal. Ei sunt mai predispui dect ali adolesceni de a avea migren nectnd la statutul lor socioeconomic, deoarece ei sunt predispui la aceasta.Dar pentru adolescenii fr o predispoziie acut, reflectat de absena migrenei la rudele de primul grad, venitului familia este un factor n prevalena migrenei, n particular la cei cu venit jos. Dr. Bigal noteaz c aceast descoperire coreleaz cu prevalena migrenei la aduli, care este consistent mai nalt la persoanele cu un venit mai jos i o educaie mai joas .Studiul nostru sugereaz c noi ar trebui s explorm factorii de mediu de risc , precum evenimentele stresante i nutriia, dup cum ele se leag de venitul jos i migren, pentru a nelege cum putem reduce apariia migrenei printre aceti indivizi.

Autorul principal al studiului Pamela Herd, Sociologul Universitii Wisconsin-Madison(7) menioneaz: Persoanele fr studii sunt mai predispuse la dezvoltarea problemelor de sntate i acei, cu un nivel jos de venit, care deja au probleme de sntate sunt mai predispui s-i vad sntatea nrutindu-se. Studiul prezentat a examinat ct de des diferenele de sntate n SUA sunt influienate de statutul socio- economic al persoanelor. Herd i colegii spun, c educaia(studiile) influieneaz profesia, venitul i bunstarea i cu ct nivelul educaiei e mai nalt, cu att comportamentul e mai sntos, aa ca: alimentaia sntoas, creterea activitii fizice, reducerea stresului i utilizarea mai optim a tratamentului preventiv i terapeutic. Autorii au utilizat datele colectate din 1986 pn la mijlocul 2002 n Studiul "Americans'

Changing Lives," care a avut loc n 4 etape de interviuri al adulilor cu vrsta 25 years . Herd i coleagii au analizat datele a 8,287 participani.

Ei au studiat dou grupuri de problem de sntate: problemele cronice i limitrile funcionale sau incapacitile. S-au comparat persoanele cu studii superioare, care pot avea probleme de sntate n 56% cazuri cu persoanele fr studii universitare la care probabilitatea de a avea probleme de sntate a fost 81%. Cnd s-a comparat venitul, cercetrile au descoperit, c acei cu venitul mai mic de 10.000$ au avut ansa de dezvoltare a problemelor de sntate cu 35% mai mare, dect acei, care aveau mai mult de 30.000$. n plus, indivizii, a cror venit era mai mic de 10.000$ aveau cu 195% mai multe anse ca problemele lor de sntate se vor agrava.

Pathophysiology and Treatment of Migraine and Related Headache Article Last Updated: Sep 4, 2008

Soma Sahai, MD, Director of Neurology Ambulatory Clinics, LAC and USC Medical Center; Assistant Professor, Department of Neurology, University of Southern California

Coauthor(s): David Y Ko, MD, Associate Professor, Laboratory Director, Department of Neurology, University of Southern California Medical Center Cefaleea este un symptom foarte rspndit i e cea mai des ntlnit problem a neurologilor, care se ia n consideraie n activitatea clinic. S-a estimat, c 60-80% de Americani din orice timp sunt afectai de ea . Migrena afecteaz 17% din femei i 6% de brbai n SUA. nainte de pubertate , ambeele : prevalena i incidena migrenei este mai nalt la biei dect la fete. La indivizii, mai mari de 12 ani, prevalena crete la ambele sexe(biei i fete), iar incidena descrete la persoanele mai mari de 40 ani, cu excepia femeilor n perimenopauz. Peste tot prevalena e mai nalt la femei dect la brbai. Proporia femei/brbai crete de la 2,5: 1 la pubertate pn la 3,5:1 la 40 ani, dup ce scade.

Incidenia migrenei cu aur la biei atinge vrful la 5 ani, iar la fete pe la 12-13 ani The incidence of migraine with aura peaks in boys at around age 5 years and in girls at around age 12-13 years. Incidenia migrenei fr aur la biei ajunge n vrf la 10-11 ani, iar la fete pe la 14-17 ani. Incidena migrenei la femeile de vrst reproductiv crete pe parcursul a 20 ani, probabil datorit contientizrii mai bune a condiiilor. n Statele Unite, femeile albe au cea mai nalt inciden a mirenei, pe cnd femeile asiatice au cea mai joas inciden. Pe lng aceasta, statutul socio-economic jos este asociat cu migrena. n prezent, 1 din 6 femei din America au cefalei migrenoase.

Prevelena de un an a migrenei-12%, cefalei non-migrenoase-26%, cefaleei frecvente-8% i cronice era de2% la HUNT-2. (29) Lifetime Prevalence of Migraine and Other Headaches Lasting 4 or More Hours: The Atherosclerosis Risk in Communities (ARIC) Study Authors: Perry Carson A.L.; Rose K.M.; Sanford C.P.; Ephross S.A.; Stang P.E.; Hunt K.J.; Brown C.A.; Szklo M. Source: Headache: The Journal of Head and Face Pain, Volume 44, Number 1, January 2004 , pp. 20-28(9) Rez.: Comparnd educai(studiile) dincolo de universitate, acei,ce aveau mai puin e 12 ani de studii, erau strns asociai cu o cretere a probabilitii(ntmplrii) migrenei cu aur (proporia prii prevalenei [POR], prevalence odds ratio 1.47; 95% confidence interval [CI], 1.08 to 2.01). Venitul familiei mai jos de 16 000$, comparat cu venitul de 75 000$ sau mai nalt, a fost considerabil asociat cu migren cu aur (POR, 1.68; 95% CI, 1.07 to 2.64), migrena fr aur (POR, 1.56; 95% CI, 1.14 to 2.14), i alte cefalei cu aur (POR, 1.89; 95% CI, 1.14 to 3.13). Proporia prii prevalenei a fost mai nalt n fiecare categorie de cefalee, n special la acele cu aur la cei hipertensivi versus normotensivi i la cei care-i percepeau sntatea lor general ca mai rea fa de cei, care i-o percepeau ca excelent. Concluzii. Un istoric de via de migren cu aur sau a altor cefalei e mai frecvent printre participanii albi, femei i tineri.

. Curr Med Res Opin. 2001; 17 Suppl 1:S4-S12 Epidemilogy and economic impact of migraine. Lipton RB, Stewart WF, Scher AI. Migrena este o patologie foarte rspndit, ce afecteaz circa 11% din populaia adult a rilor vestice. Prevalena e cea mai nalt n anii de productivitate maxim de la 25 la55 ani. Prevalena e mai nalt la femei dect la brbain toi anii dup pubertate, dar proporia pe sexe variaz cu anii. n SUA, prev. migr. e mai nalt la persoane cu nivel jos de educaie, probabil din cauza, c migrena interfer cu coala i munca.

1.Am J Med. 2005 Mar; 118 Suppl 1:3S-10S. The epidemilogy of migraine. Lipton RB, Bigal ME. Prevalena e cea mai nalt la femei, la persoanele cu vrsta de 25-55 ani i n sfrit nSUA, la persoanele cu un buget mic(din gospodrii cu buget mic). Totui, prevalena este nalt n alte grupuri, n afara acestui grup cu risc nalt. ntr-un subgrup de pacieni, migrena poate fi o patologie progresiv.

Cardiovascular risk factors and migraine: The GEM population-based study.

Articles Neurology. 64(4):614-620, February 22, 2005. Scher, A I. PhD; Terwindt, G M. MD, PhD; Picavet, H S.J. PhD; Verschuren, W M.M. MD, PhD; Ferrari, M D. MD, PhD; Launer, L J. PhD Au fost identificai n total de 620 de migrenoi actuali: 31% cu aura (MA), 64% fr aura (MO) i 5% neclasificabili.

Rez.: n comparaie cu grupul de control, migrenoii sunt mai predispui s fumeze(OR = 1.43 [1.1 to 1.8]), mai puin predispui s consume alcool(OR = 0.58 [0.5 to 0.7]) i s-au raportat mai frecvent cazuri de istoric de infarct miocardic precoce la prinii acestora.

6.Pharmaco economics. 2004;22(9):591-603. The burden of migraine in Spain: beyond direct costs. Badia X, Magaz S, Gutierrez L, Galvan J. Obiective: ESTIMAREA PAGUBEI ECONOMICE AL MIGRENEI N SPANIA din perspective sociale. Metode: Costul anual direct( medicamentele, trat. de ambulator, cons. specialistului i vizitele ambulanei) i indirect(zilele lipsite de la serviciu i capacitatea redus de munc) pe anul 2001 au fos calculate, utiliznd modul de abordare al prevalenei. Metoda capitalului uman a fost utilizat la calcularea costului indirect. Sursele utilizate epidemiologice au fost publicate , utiliznd criteriile de diagnostic ale SIC(Societii Internaionale de Cefalee) di baza de date oficial i neoficial. Rezultate: Populaia Spaniei cu migren a fost estimat a fi de 3,617,600 pacieni, 92,5% fiind n vrsta apt de munc. Povara economic a migrenei a fost de aproximativ 1076 milioane Euro. Costul direct reprezenta doar 32,0% dinpovara total(344 milioane de Euro), 39,2% au fost pentru vizita la medicul-generalist, 28,7% pentru vizitele la specialist, 20,5% pentru vizitele ambulanei la domiciliu i mai departe 11,7% pentru medicamentele prescrise specifice migrenei(serotonin 5-HT(1B/1d)receptor agonist

Costul indirect a fost estimat n 732 milioane Euro anual, reprezentnd 453,55 Euro pentru un pacient apt de munc(ce muncete ) cu migren. Concluzii: Ca i nmulte alte ri dezvoltate, migrena reprezint o povar economic

considerabil n Spania, n special n termenii productivitii pierdute. Deci activitile trebuie specific direcionate spre reducerea costului indirect , i spre tratamente eficiente, care ar reduce semnificativ pierderea productivitii trebuie date publicitii(promovate n public). 4.a.Socio-economic impact of migraine and headaches in France Auray JP Societatea internaional de cefalee are ghiduri(ndrumtoare) clar definite diagnostic, ce clasific cefaleele n 3 categorii. Acum este bine cunoscut, c cefaleele exercit un efect

considerabil asupra calitii vieiii supra studiilor, activitilor familiale sau individuale , i impactul economic nu e deloc de neglijat. Un studiu extins, ce a fost efectuat pe un lot de 10582 pers.adulte din Frana, a fost ndeplinit n 1999. Rezultatele au demonstrat o prevalen de 17,3% pentru migren i aproximativ 30% pentru cefalei. Cheltuiala bneasc medie pentru un pacient cu cefalee este de circa 220 Euro, s-a mprit dup cum urmeaz: 10% pentru consultaia medicului-generalist, 11% pentru evalurile de laborator, 17% pentru consultaiile specialitului, 18% pentu medicamente i 44% costul tratamentului n spital. Aceast divizare depinde n mare msur de categoria cefaleei. Dei cele mai acute cefalei afecteaz cel mai mult calitatea vieii, activitile colare i profesionale nu sunt afectate n aceia msur ---------------------------------------------------------------------------------------------------------------------------

Curry K, J am acad Nurse Pract. 2007 jul, 19(7):378-82. Prevalence and management of headache in a university undergraduate population. Curry K, Green R Concluzii: Majoritatea studenilor supravegheai au raportat, c au suportat cefalei de intensitate moderat sau severe. 16% din respondeni au indicat, c cefaleele lor s-au intercalat cu activitile lor zilnice(uzuale),n timp ce 92,5% au raportat utilizarea preparate neprescrise de uurare doar pentru managementul cefaleei. Cunotinele privind prevenirea cefaleei i tratamentul lor lipsea n acest grup. . n mediu, indivizii cu mai puin de 10 ani de educaie aveau o prevalena mai nalt cu 90% a cefaleelor frecvente (OR=19.5% CI 1.7-2.1)i o prevalen cu 70 % mai nalt pentru cefaleea cronic(OR=1.7, 95% CI 1.4-2.0) n comparaie cu acei cu educaie superioar(>= 13 ani).

Factors Associated With Low Socioeconomic Status Increase The Prevalence Of Migraines In Adolescents, New Study Shows Main Category: Headache / Migraine Also Included In: Pediatrics / Children's Health Article Date: 07 Jul 2007 - 7:00 PDT Adolescents from low-income families are much more likely to suffer from migraine headaches than teens from wealthier households, according to researchers at the Albert Einstein College of Medicine of Yeshiva University. The findings, published in Neurology, suggest that factors associated with low socioeconomic status --stress, poor diet and limited access to medical care, for example -- increase the prevalence of migraines in young people. But when the Einstein researchers focused on those teens without a strong family predisposition for migraines, they found that household income was strongly associated with migraine prevalence: In

families with annual incomes of less than $22,500, the prevalence of migraines in teens was 4.4 percent; by contrast, the migraine prevalence among teens in households earning $90,000 or more was only 2.9 percent. "It would seem that for those teens who have a genetic predisposition for migraine, the stressful life events related to income don't matter," says Dr. Bigal. "They're more likely than other teens to get migraine regardless of their socioeconomic status, since they are predisposed. But for teens without a strong predisposition, reflected by the absence of migraine in first-degree relatives, family income factors into the prevalence of migraine, particularly among those teens whose families have low income." Dr. Bigal notes that this finding correlates with migraine prevalence for adults, which is consistently higher among people with lower income and less education. "Our study also suggests that we should explore environmental risk factors, such as stressful events and nutrition, as they relate to low income and migraine to understand how we might reduce the occurrence of migraine among these individuals." -----------------------------------------------------------------------------------------------------------------Article Date: 23 Sep 2007 - 0:00 PDT Herd P, Goesling B, House JS. Socioeconomic position and health: the differential effects of education versus income on the onset versus progression of health problems. J Health Soc Behav 48(3), 2007.

"Those with less education are more likely to develop health problems and those with low incomes who already have health problems are more likely to see their health worsen," said lead author Pamela Herd, a University of Wisconsin-Madison sociologist. The study appears in the September issue of the Journal of Health and Social Behavior and examines how health differences in the United States often relate to people's socioeconomic status. Herd and colleagues say education influences occupation, income and wealth and with higher education comes healthier behaviors, such as good diet, increased physical activity, reduced stress and better use of preventive and therapeutic healthcare. The authors used data collected from 1986 to mid-2002 in the "Americans' Changing Lives Study," which conducted four waves of interviews of adults who were 25 years old and older. Herd and colleagues analyzed data for 8,287 participants. They looked at two groups of health problems: chronic conditions and functional limitations or disabilities. Compared with those with a college degree, the odds of having health problems were 81 percent higher for those without a high school diploma and 56 percent greater for those with a high school diploma. When comparing income, the researchers found that those with incomes of less than $10,000 had a 35 percent greater chance of developing health problems than those who made more than $30,000. In addition, those with incomes less than $10,000 had a 195-percent greater chance that their health problems would get worse. -----------------------------------------------------------------------------------------------------------------------------Cigarette Smoking Among Adults in the USA Main Category: Smoking / Quit Smoking Article Date: 01 Jun 2004 - 10:00 PDT This report summarizes the results of that analysis, which indicated that, in 2002, approximately 22.5% of adults were current smokers. Although this prevalence is slightly lower than the 22.8% prevalence among

U.S. adults in 2001 and substantially lower than the 24.1% prevalence in 1998, the rate of decline has not been at a sufficient pace to achieve the 2010 national health objective. Cigarette smoking prevalence rates varied substantially across population subgroups (Table). The prevalence of smoking was higher among men (25.2%) than women (20.0%) and inversely related to age, from 28.5% for those aged 18--24 years to 9.3% for those aged >65 years. Among racial/ethnic groups, Asians (13.3%) and Hispanics (16.7%) had the lowest prevalence, and American Indians/Alaska Natives had the highest (40.8%). Current smoking prevalence also was higher among adults living below the poverty level* (32.9%) than among those at or above the poverty level (22.2%). During 1983--2002, the gap in smoking prevalence between those living below the poverty line and those living at or above it increased from 8.7 percentage points to 10.7 percentage points (Figure 1). By education level, smoking prevalence was highest among adults who had earned a General Educational Development diploma (42.3%) and lowest among those with graduate degrees (7.2%). Women with undergraduate (10.5%) or graduate degrees (6.4%) and men with graduate degrees (7.8%) also had smoking prevalence rates below the overall U.S. 2010 objective. During 1983--2002, the largest decreases in smoking prevalence occurred among adults with a college degree (10.0 percentage points) and those with some college education (9.3 percentage points); those with a high school diploma (6.6 percentage points) and those with less than a high school education (5.8 percentage points) showed the smallest decreases. During this period, the gap in smoking prevalence between adults who had graduated from college and those with less than a high school education increased from 14.0 percentage points in 1983 to 18.2 percentage points in 2002 (Figure 2). Similar patterns occurred in the percentage of ever smokers who had quit among different educational groups. The percentage of ever smokers who had quit was highest for those with college degrees, followed by persons with some college education. High school graduates and those with less than high school education had the lowest percentage of ever smokers who had quit. The gap between adults with a college degree and those with less than a high school education increased from 19.0 percentage points in 1983 to 25.9 percentage points in 2002. Editorial Note: The findings in this report indicate that 1) the socioeconomic status of U.S. adults is inversely related to their likelihood of smoking and 2) during 1983--2002, the gap in smoking prevalence by socioeconomic status did not narrow and might have widened. These findings underscore the need for targeted interventions that can better reach persons of lower socioeconomic status. Persons of low socioeconomic status have less access to health care than those of high socioeconomic status (3). ----------------------------------------------------------------------------------------------------------------------------------

Lifetime Prevalence of Migraine and Other Headaches Lasting 4 or More Hours: The Atherosclerosis Risk in Communities (ARIC) Study Authors: Perry Carson A.L.; Rose K.M.; Sanford C.P.; Ephross S.A.; Stang P.E.; Hunt K.J.; Brown C.A.; Szklo M.

Source: Headache: The Journal of Head and Face Pain, Volume 44, Number 1, January 2004 , pp. 2028(9) Abstract: Objective.To evaluate the lifetime prevalence of migraine and other headaches lasting 4 or more hours in a population-based study of older adults. Background.Migraine and other headaches not fulfilling migraine criteria are common afflictions. Yet the health and social effects of these conditions have not been fully appreciated, particularly among older adults. Methods.The study included 12 750 participants in the Atherosclerosis Risk in Communities (ARIC) Study from 4 US communities. Prevalence estimates of a lifetime history of migraine and other headaches lasting 4 or more hours were obtained for race and gender groups. A cross-sectional analysis was done to assess the relationship between headache type, by aura status, and various sociodemographic and health-related indices. Results.Compared to education beyond high school, having completed less than 12 years of education was significantly associated with an increased occurrence of migraine with aura (prevalence odds ratio [POR], 1.47; 95% confidence interval [CI], 1.08 to 2.01). Family income less than $16 000, compared to family income of $75 000 or greater, was significantly associated with migraine with aura (POR, 1.68; 95% CI, 1.07 to 2.64), migraine without aura (POR, 1.56; 95% CI, 1.14 to 2.14), and other headaches with aura (POR, 1.89; 95% CI, 1.14 to 3.13). The prevalence odds ratio was higher in each headache category, particularly for those with an aura, for those with hypertension versus normotension and for those who perceived their general health as poor compared to those whose perception was excellent. Conclusions.A lifetime history of migraine with aura and other headaches with aura was more common among whites, women, and younger participants. Further investigation of headaches lasting 4 or more hours, particularly by aura status, is warranted. ---------------------------------------------------------------------------------------------------------------Cardiovascular risk factors and migraine: The GEM population-based study. Articles Neurology. 64(4):614-620, February 22, 2005. Scher, A I. PhD; Terwindt, G M. MD, PhD; Picavet, H S.J. PhD; Verschuren, W M.M. MD, PhD; Ferrari, M D. MD, PhD; Launer, L J. PhD Abstract: Background: Migraine, particularly with aura, is a risk factor for early-onset ischemic stroke. The underlying mechanisms are unknown, but may in part be due to migraineurs having an increased risk profile for cardiovascular disease. In this study, the authors compare the cardiovascular risk profile of adult migraineurs to that of nonmigraineurs. Methods: Participants (n = 5,755, 48% men, age 20 to 65 years) are from the Genetic Epidemiology of Migraine (GEM) study, a population-based study in the Netherlands. A total of 620 current migraineurs were identified: 31% with aura (MA), 64% without aura (MO), and 5% unclassified. Controls were 5,135 individuals without lifetime migraine. Measured cardiovascular risk factors included blood pressure (BP), serum total and high-density lipoprotein cholesterol (TC, HDL), smoking, oral contraceptive use, and the Framingham risk score for myocardial infarction or coronary heart disease (CHD) death.

Results: Compared to controls, migraineurs were more likely to smoke (OR = 1.43 [1.1 to 1.8]), less likely to consume alcohol (OR = 0.58 [0.5 to 0.7]), and more likely to report a parental history of early myocardial infarction. Migraineurs with aura were more likely to have an unfavorable cholesterol profile (TC >= 240 mg/dL [OR = 1.43 (0.97 to 2.1)], TC:HDL ratio > 5.0 [OR = 1.64 (1.1 to 2.4)]), have elevated BP (systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg [OR = 1.76 (1.04 to 3.0)]), and report a history of early onset CHD or stroke (OR = 3.96 [1.1 to 14.3]); female migraineurs with aura were more likely to be using oral contraceptives (OR = 2.06 [1.05 to 4.0]). The odds of having an elevated Framingham risk score for CHD were approximately doubled for the migraineurs with aura. Conclusions: Migraineurs, particularly with aura, have a higher cardiovascular risk profile than individuals without migraine. -----------------------------------------------------------------------------------------------------------------------------Impact of comorbidity on headache-related disability. Saunders K, Merikangas K, Low NC, Von Korff M, Kessler RC. Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA. saunders.k@ghc.org OBJECTIVE: To assess and compare the extent to which comorbid conditions explain the role disability associated with migraine and other severe headaches. METHODS: A probability sample of US adults (n = 5,692) was interviewed. Presence of headaches, other chronic pain conditions, and chronic physical conditions was assessed in a structured interview administered by trained interviewers. Diagnostic criteria for migraine were based on the International Headache Society classification. Mental disorders were ascertained with the Composite International Diagnostic Interview that collected diagnostic criteria according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Role disability was assessed with World Health Organization Disability Assessment Schedule questions about days out of role and days with impaired role functioning. RESULTS: Eighty-three percent of migraineurs and 79% of persons with other severe types of headache had some form of comorbidity. Compared with headache-free subjects, migraineurs were at significantly increased risk for mental disorders (odds ratio [OR] 3.1), other pain conditions (OR 3.3), and physical diseases (OR 2.1). Compared with headache-free subjects, persons with nonmigraine headache were also at significantly increased risk for mental disorders (OR 2.0), other pain conditions (OR 3.5), and physical diseases (OR 1.7). Migraineurs experienced role disability on 25.2% of the last 30 days compared with 17.6% of the days for persons with nonmigraine headaches and 9.7% of the days for persons without headache. Comorbid conditions explained 65% of the role disability associated with migraine and all of the role disability associated with other severe headaches. CONCLUSIONS: Comorbidity is an important factor in understanding disability among persons with headache. ----------------------------------------------------------------------------------------------------------------Pathophysiology and Treatment of Migraine and Related Headache Article Last Updated: Sep 4, 2008 Soma Sahai, MD, Director of Neurology Ambulatory Clinics, LAC and USC Medical Center; Assistant Professor, Department of Neurology, University of Southern California Coauthor(s): David Y Ko, MD, Associate Professor, Laboratory Director, Department of Neurology, University of Southern California Medical Center

Headache is a pervasive symptom and the most common problem neurologists encounter in their clinical practices. It affects an estimated 60-80% of Americans at any time. The history of headache can be traced almost to the beginning of the history of humankind. The first description of headache dates back to the third millennium BCE. Headache has been written about extensively since the time of the Babylonian civilization. Migraine headache and hemicrania are discussed in the Bible. Some famous historical figures (eg, Napoleon) are known to have had terrible headaches. Prevalence Migraine affects 17% of females and 6% of males in the United States.3 Before puberty, both the prevalence and incidence of migraine are higher in boys than in girls. In individuals older than 12 years, the prevalence increases in both males and females, and the incidence declines in individuals older than 40 years, except for women in perimenopause. The overall prevalence is higher in females than in males. The female-to-male ratio increases from 2.5:1 at puberty to 3.5:1 at age 40 years, after which it declines. The incidence of migraine with aura peaks in boys at around age 5 years and in girls at around age 12-13 years. The incidence of migraine without aura peaks in boys at age 10-11 years and in girls at age 14-17 years. The incidence of migraine in females of reproductive age has increased over the last 20 years, probably due to more awareness of the condition. In the United States, white women have the highest incidence of migraine, whereas Asian women have the lowest incidence. Moreover, low socioeconomic status is associated with migraine. Currently, 1 of 6 American women has migraine headaches. Genetics Approximately 70% of patients have a first-degree relative with a history of migraine. The risk of migraine is increased 4-fold in relatives of people who have migraine with aura. However, no genetic basis has been identified for common migraine, although it generally demonstrates a maternal inheritance pattern.

Repartiia dup vrst a persoanelor cu i fr dureri de cap: Majoritatea o alctuiesc persoanele cu vrsta 20-29 ani- 327p.fr cefalei(26.7% din 1226); 320ptts. (22,2% din 1439)- cu cefalei(P<0,01). Persoanele cu vrsta 40-49, 50-59 sunt mai numeroase n lotul celor cu cefalee: de 40-49 ani- 293ptts.(20,4% din 1439)- cu cefalee, versus- 193p.(15,7% din1226)cei fr dureri de cap(P<0,01); de 50-59 ani- 268ptts(18,6% din 1439) cu cefalee, versus 175p.(14,3%)- pers. fr dureri de cap(P<0,01)de aceiai vrst. Repartiia dup sex a persoanelor cu cefalee versus cele fr dureri,

convenional sntoase ? P. fr cefalee: cefalee P. cu

Brbai-689-56,2%(din 1226) 27%(din 1439) Femei-537-43,8% (din 1226) 73% (din 1439) Raportul femei/brbai la persoanele

( P<0,001)

Brbai- 389-

(P<0,002)

Femei- 1050-

este de- 0,78, iar la cei ce sufer de

cefalei raportul femei/brbai -2,7. n lotul persoanelor, ce sufer de dureri de cap fr cefalei-843p.(68,8% din1226)(P>0,05). O parte important din persoanele fr cefalee o alctuiesc celibatarii-291(23,7%) (pers. necstorite), versus 295(20,5%)(P<0,05)- n lotul celor cu dureri de cap. Numrul celor divorai e minor n cazul persoanelor convenional sntoase40(3,3%), iar n cazul celor cu cefalee-81(5,6%)(P<0,01). majoritatea o alctuiesc cei

cstorii- 991ptts.(68,9% din1439), situaie similar se observ i n cazul celor

Dup caracterul activitii se observ o majoritate vdit a persoanelor , ce efectuiaz munc intelectual: 414(33,8%)-pers. fr cefalei, 547(38%)-ptts. cu cefalee(P<0,05); Persoanele neangajate n cmpul muncii: 363p.(29,6%)-din grupul respondenilor fr dureri de cap; 466ptts.(32,4%)- din cei cu cefalee(P>0,05); n lotul respondenilor , ce munceau fizic numrul respondenilor fr cefalei371(30,3%), ct i a celor cu dureri de cap -337(23,4%) nu difer considerabil(P<0,001).

Tabagismul: n lotul persoanelor fr cefalei fumeaz-354p.(28,9%), iar din cei cu cefalee- 269(18,7%)(P<0,001), date, ce se confirm i n literature de specialitate Sunt mai muli nefumtori n grupul respondenilor cu cefalee- 1170(81,3%), fa de 872(71,1%)din cei fr dureri de cap.

Nivelul educaional: 617 ptts. cu cefalei (42,9%) au avut un nivel jos de educaie(coala primar sau coala profesional), acelai nivel l-au avut 533(43,5%) respondeni fr dureri de cap(P<0,05);

Cu studii superioare au fost 558 ptts.(38,8%) cu cefalei i 454 fr dureri de cap(37%) (P<0,05); Un numr practic de 2 ori mai mic de respondeni au avut studii medii- 239(19,5%)fr dureri de cap, 264(18,3%)- ptts cu cefalee. Starea material: Majoritatea net o alctuiesc persoanele,ce au bani doar pentru strictul necesar-862p.(70,3%)-fr cefalee, 997(69,3%)-ptts. cu dureri de cap; celelalte dou grupuri- ce au un trai decent- 185(15,1%)-respondeni fr cefalee, respective 217(15,1%)-ptts. cu dureri de cap; nu le ajung bani nici pentru strictul necesar la 179p.(14,6%) din grupul pers. fr dureri de cap i la 225ptts. (15,6%)-cu cefalee. Nu s-a observant diferen statistic nici n unul din cazurile enumrate(P>0,05). O situaie similar se observ i n cazul repartizrii respondenilor dup condiiile de trai: Condiii medii au 804(65,6%) respondeni fr cefalee i 950(66%)ptts. cu cefalee; condiii bune de trai au avut 346p. (28,2%)- fr cefalee, versus 407(28,3%)-ptts. cu dureri de cap; un numr mic de respondeni -76(6,2%)- fr cefalee i 82(5,7%)- au menionat, c au condiii nefavorabile de trai . toate 3 cazuri P>0,05.

Prevalena migrenei i cefaleei de tip tensional n localitile rurale i urbane din Republica Moldova
Obiective: Scopul acestui studiu a fost estimarea prevalenei cefaleelor primare (migrenei

i cefaleei de tip tensional) i stabilirea frecvenei factorilor- triggeri la subiecii aduli (15-65 ani) cu acest tip de cefalei in localitile urban(mun Chiinu) i rural(Hanceti) din Republica Moldova. Acesta este primul studiu epidemiologic al migrenei i cefaleei de tip tensional din Republica Moldova, efectuat in conformitate cu Criteriile Clasificrii Internaionale a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee in anul 2004. Metode: Studiul populaiei a constat din 2665 ceteni aduli (15-65 ani) din municipiul " door-to-door de o echip de medici- neurologi special pregtii(

Chiinu i or. Hnceti din Republica Moldova. Studiul a fost efectuat utiliznd metodele de intervievare face-to-face", rezideni in neurologie, de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu) in perioada : mai-iunie, septembrie-octombrie 2005, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee . Rata de participare a fost de 84%(2665persoane). din 3165 persoane contactate .Toi participanii au fost evaluai asupra istoricului durerii de cap n conformitate cu

criteriile Societii Internaionale a Durerii de Cap. Au fost diagnosticai cu cefalee1439(65.5%). Diagnosticul tipurilor de cefalee s-a stabilit ulterior de neurologi specialiti n cefalei. Rezultate: Au fost diagnosticai 534 de persoane cu migren. Prevalena migrenei la femei era de 16,81%(...% intervalul de ncredere, de la ... la ...) i prevalena migrenei la brbai e de 3,22%(...% interval de ncredere ,de la ... la...), i de 20,03%(...%, ...) la ambele sexe. Cea mai mare prevalena a migrenei a fost depistat la persoanele cu vrsta 20-29ani-124ptts.(4,6%); 4049 ani-113ptts.(4,24%). Printre cei 534 de migrenoi activi, 448(16,81%) erau femei i 86(3,22%)- brbai. Cu cefalee de tip tensional au fost diagnosticai 489 persoane (18,34%). Prevalena cefaleei de tip tensional la femei era de 11,1%(...% intervalul de ncredere, de la ... la ...) i prevalena CTT la brbai e de 7,24%(...% interval de ncredere ,de la ... la...), i de 18,34%(...%, ...) la ambele sexe. Cea mai mare prevalena a cefaleei de tip tensional a fost depistat la persoanele cu vrsta 2029ani- 102 ptts.(3,8%); 50-59 ani-97ptts.(3,6%). Printre cei 489 de persoane cu cefalee de tip tensional activi, 296(11,1%) erau femei i 193(7,24%)- brbai; Concluzii: Prevalena migrenei si cefaleei de tip tensional n cadrul populaiei din Repunlica Moldova a demonstrat rate aproximativ similare cu cele raportate la rile nvecinate , precum Italia i Frana,Croaia i Turcia. Studiile viitoare trebuie s fie proiectate pentru a estima ratele prevalenei migrenei n toat populaia Croaiei. Cuvinte cheie: migren, cefalee de tip tensional,epidemiologie, prevalen, interviuface-toface", " door-to-door. Abrevieri: MFA- migren fr aur, MCA- migren cu aur, MCAFA- migren cu aur i fr aur, CTT-cefalee de tip tensional. Materiale i metode: Studiu randomizatface-to-face", " door-to-door a populaiei adulte din localitile urban i rural (cetenii (15-65 ani) din municipiul Chiinu i or. Hnceti) din Republica Moldova prin intermediul chestionarului structurat, elaborat de profesorul I.Moldovanu in 2004, in conformitate cu Criteriile Clasificrii Internaionale a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee din anul 2004. Cercetatare efectuat sub conducerea profesorului I.Moldovanu in anul 2005 n coordonare cu Societatea Internaional de Cefalee(International Headache Society) cu selectarea eantionuluiChiinu-Hnceti.

In studiu au fost inclui 2665 respondeni cu varsta cuprins intre 15-65 ani, rata de participare a fost de 84% din 3165 persoane contactate . Toi participanii au fost evaluai asupra istoricului durerii de cap n conformitate cu criteriile Societii Internaionale a Cefalee. Din totalul de 2665 de persoane au rspuns afirmativ la intrebare privind prezena cefaleelor1439, ce constituie 54%, 1226 din cei cercetai-46% n- au avut cefalee . Dac cefaleea era declarat, li se adresau ntrebri, privind caracteristicele cefaleelor lor i relatarea unor astfel de date cum ar fi: frecvena, durata, triggerii(factorii declanatori), simptomele nsoitoare, dereglrile de somn, istoricul familial, tratamentele suportate pn acum etc. Cei care au fost diagnosticai cu cefalee- 1439(54%) au fot intervievai de o echip de medicineurologi special pregtii( rezideni in neurologie, de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu) in perioada : maiiunie, septembrie-octombrie 2005, de un grup de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu i rezideni in neurologie, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee. Diagnosticul ulterior al tipurilor de cefalee s-a stabilit ulterior de neurologi specialiti n cefalei. Chestionarul care a fost utilizat in acest studiu include 145 intrebri, care vizeaz urmtoarele aspecte de baz: aspecte socio-demografice, depistarea factorilor- declanatori ai migrenei i cefaleei de tip tensional, caracteristici clinice detaliate, tratamente farmacologice, date medicoeconomice, comorbiditatea, gradul de incapacitate(MIDAS i HIT), impactul cefaleelor i estimarea prezenei abuzului medicamentos. Analiza statistic a datelor chestionarelor s-a efectuat utilizand SPSS , varianta 12. Dup ntrebrile introductive privind vrsta, nivelul economic i educaional, statutul matrimonial i profesional, persoanele au fost interogate despre prezena oricror patologii cronice, diagnosticate de medicul-generalist i au avut vreo cefalee important, care atrage atenia(deranjant) n perioada ultimului an. A fost gsit partea prevalenei migrenei i al cefaleei de tip tensional . Prevalena migrenei i cefaleei de tip tensional: n lotul mixt(brbai +femei). 448 femei+86 brbai= 534 ptts. cu migren-20,03% din numrul total al persoanelor chestionare- 2665; 534ptts- 37,10% din 1439 pers cu cefalee;

296 femei+193 brbai= 489 ptts. cu CTT- 18,34% din numrul total al persoanelor chestionare- 2665; 489ptts- 33,98% din 1439 pers cu cefalee. Dat fiind, c cefaleea constituie o problem major de sntate, fiind inclus de Organizaia Mondial a Sntii(OMS) in lista primelor 10 cauze de incapacitate la ambele sexe i a primelor 5 cauze de incapacitate la femei, lipsa unui studiu epidemiologic al prevalenei cefaleelor primare in Republica Moldova s-a impus necesitatea imperativ a efecturii acestuia. Prin intermediul acestei cercetri s-a evaluat relaia dintre prevalena tipurilor de cefalee i proprietile cefaleelor pacienilor, aa ca vrsta , nivelul educaional i economic, statutul matrimonial i profesional, locul de reedin i compararea caracteristicelor clinice printre subtipurile cefaleei analizat. Tipurile cefaleelor migrenoase i particularitile socio-demografice. Au fost diagnosticai 534(20%) persoane cu migren. Prevalena migrenei la femei era de 16,81% i prevalena migrenei la brbai e de 3,22% i de 20,03% la ambele sexe. Cea mai mare prevalena a migrenei a fost depistat la persoanele cu vrsta 20-29ani-124ptts.(4,6%); 4049 ani-113ptts.(4,24%). Printre cei 534 de migrenoi activi, 448(16,81%) erau femei i 86(3,22%)- brbai. Prevalena( de 1 an) migrenei a fost de 20%(534ptts.), cuprinznd ...%(...) migr.cu aur i ...% (...)-migr. fr aur. Prevalena migrenei a fost gsit statistic mai nalt la grupul de vrst de 20-29ani-124ptts.(4,6%); 40-49 ani-113ptts.(4,24%); 50-59 ani -104 ptts(19,48%) (P<0.01)i mai joas la grupul de peste 65 ani-37ptts.(6,93%)(P<0.01), n comparaie cu alte grupuri. Cefaleea de tip tensional i particularitile socio-demografice. Prevalena (de 1 an) CTT a fost gsit de 18,34% %(489 persoane), incluznd... (...% )episodic i ...(...%)-tipul cronic al cefaleei. Cea mai mare prevalena a cefaleei de tip tensional a fost depistat la persoanele cu vrsta 2029ani- 102ptts.(3,8%)(P<0,05); 50-59 ani-97ptts.(3,6%)(P0,01). Printre cei 489 de persoane cu cefalee de tip tensional activi, 296(11,1%) erau femei i 193(7,24%)- brbai; (Pacienii cu CTT cronic au fost gsii a fi cu mult mai n vrst dect cei cu forme episodice)?( Media de vrst SD pentruCTT episodic i cronic:......, ... ..., P...). Corelaia dintre caracteristicele clinice i severitatea cefaleei a fost

1587 femei au fost intervievate, 1050(39,4%) din ele au suportat migrena sau CTT n decursul ultimului an. Din 1078 brbai intervievai-389 (39,4%) din ei au avut migrena sau CTT n decursul ultimului an.

Rezultate Trsturile socio-demografice ale migrenei i CTT: vrsta, nivelul educaional , statutul matrimonial i locul de trai au fost demonstrate n Tab.1. Tab.1. Trsturile socio- demografice a tuturor persoanelor intervievate i a pacienilor cu cefalee.
Parametri demografici Vrsta(ani) 15-19 20-29 30-39 40-49 50-59 60-65 Nivelul educaional jos mediu superior Statutul matrimonial Cstorit() Celibatar()(singur()) Divorat Vduv 1834(68,8%) 586(22%) 121(4,5%) 124(4,7) 118 (13,8%) 17 (9,5%) 8 (7,0%) 160 (18,7%) 28 (15,7%) 28 (24,3%) 1150(43,2%) 503(18,9%) 1012(38%) 226 (42,32%) 100 (18,73%) 208 (38,95%) 217(44,38%) 82 (16,77%) 190 (38,85%) 298(11,2%) 647(24,3%) 493(18,5%) 486(18,2%) 443(16,6%) 298(11,2%) 55 (10,3%) 124 (23,22%) 101 (18,91%) 113 (21,16%) 104(19,48%) 37(6,93) 49(10,02%) 102(20,86%) 75(15,34%) 96(19,63%) 97(19,84%) 70(14,31%) socio- Toate persoanele Pacienii migren(n=534) cu Pacienii CTT(n=489) cu

intervievate(n=2665)

Locul de trai Localitate urban Localitate rural 1301(48,8%) 1364(51,2%)

Tab.2Repartiia dup vrst a persoanelor cu migren i cefalee de tip tensional versus persoanele fr cefalee( convenional sntoase sau lot de control). Majoritatea o alctuiesc persoanele cu vrsta cuprins ntre 20-29 ani, att n lotul persoanelor convenional sntoase, ct i n lotul celor cu migren. Diferene statistice se observ la grupurile de vrst 40-49; 50-59; 60-65 ani

Persoanele CTT(20-29 ani) 102p.-3,8% n total;

cu P<0,05

Persoanele sntoase(20-29 ani) 327p.-12,27% din 2665p.chestionate n total; 26,7% din 1226 cefalee. p. fr P> 0,05

Persoanelecu migren(20-29 ani) 124p.-4,6% n total; 8,6%- din tot. de 1439ptts. cefalee; 23,22%- din 534 ptts. cu migren. cu din

din

2665p.chestionate

2665p.chestionate

7,08%- din tot. de 1439ptts. cefalee; 20,86%- din 489 ptts. cu CTT cu

Persoanele sntoase(40-49 ani) 193p.-7,24% din 2665p.chestionate n total; 15,74% 1226p. cefalee din fr P<0,01

Persoanelecu migren(40-49 ani) 113p.-4,24% n total; 7,8%- din tot. de 1439ptts. cefalee; 21,16%- din 534 ptts. cu migren. cu din

2665p.chestionate

Persoanele CTT(50-59 ani) 97p.-3,6% n total;

cu P<0,01

Persoanele sntoase(50-59 ani) 175p.-6,56% din 2665p.chestionate n total; 14,27% 1226p. cefalee din fr P< 0,01

Persoanelecu migren(50-59 ani) 104p.-3,9% n total; 7,23%- din tot. de 1439ptts. cefalee; 19,48%- din 534 ptts. cu migren. cu din

din

2665p.chestionate

2665p.chestionate

6,7%- din tot. de 1439ptts. cefalee; 19,84%- din 489 ptts. cu CTT cu

Persoanele sntoase(60-65 ani) 144p.-5,4% n total; din P< 0,01

Persoanelecu migren(60-65 ani) 37p.-1,38% n total; din

2665p.chestionate

2665p.chestionate

1587 femei au fost intervievate, 1050(39,4%) din ele au suportat migrena sau CTT n decursul ultimului an. Din 1078 brbai intervievai-389 (39,4%) din ei au avut migrena sau CTT n decursul ultimului an. Tab.2Repartiia dup vrst a persoanelor cu migren i cefalee de tip tensional versus persoanele fr cefalee( convenional sntoase sau lot de control). Majoritatea o alctuiesc persoanele cu vrsta cuprins ntre 20-29 ani, att n lotul persoanelor convenional sntoase, ct i n lotul celor cu migren. Diferene statistice se observ la grupurile de vrst 40-49; 50-59; 60-65 ani Dac cefaleea era declarat, li se adresau ntrebri, privind caracteristicele cefaleelor lor i relatarea unor astfel de date cum ar fi: frecvena, durata, triggerii(factorii declanatori), simptomele nsoitoare, dereglrile de somn, istoricul familial, tratamentele suportate pn acum etc.

Cum se repartizeaza dup sex persoanele cu migren si CTT? P. cu Migren: CTT: Brbai-16,1% 39,5% Femei-83,9% ( P<0,001) (P<0,002) P. cu BrbaiFemei-60,5%

Raportul femei/brbai la persoanele , ce sufer de migren este de 5,16, Iar la cei cu CTT raportul femei/brbai -1,53

n lotul persoanelor cu Migren fumeaz-14%, iar din cei cu CTT-21,1%(P<0,01) Nu fumeaz-86% (P<0.02) Sunt mai muli nefumtori n cazul respondenilor cu migren-86%, fa de 78,9% din cei cu CTT. ------------------------------------------------------------------------------------------------------------------------nu fumeaz-78,9%

S-a depistat prezena maladiilor endocrine la persoanele cu Migren n 9% cazuri fa de 5,1% din cei cu CTT(p<0,05)

4,1% din cei diagnosticai cu migren au menionat, oncologice, iar din cei cu CTT doar 2%(P<0,05).

c sufer de maladii

n timpul atacului de cefalee nu-i pot ndeplini activitile zilnice 3,6 % din totalul pers. cu Migren i 0,6% din cei cu CTT(P<0,001). Durerea de cap este nsoit de nausee diagnosticate cu Migren i sau vom la 5,1% din persoanele

La 2,7% din respondeii, ce sufer de Cefalee de tip tensional(P<0,05).

Triggerii cefaleei la persoanele cu Migren i CTT(rspuns spontan): Factorii declanatori cel mai frecvent nominalizai(rspuns spontan) de ctre respondenii cu:
MIgren tensional 3.Menstruaia- 3,8% 0,5% (P<0,001) (P<0,05) Cefalee de tip 3.Menstruaia4.Stresul sau 6.Obosela21.Altceva-

4.Stresul sau ncetarea stresului-34,8% ncetarea stresului-26,9% 6.Obosela-23,9% 36,8% 21.Altceva-4,3% 7,8% 1.foamea-3,4% 2. alcoolul-1,9%

(P<0,001) (P<0,05)

(P>0,05) (P>0,05)

1.foamea-1,6% 2. alcoolul-2,3%

5.Somn insufficient-1,7% insufficient-1,1% 7.Incordarea psihic-2,6% psihic-4,1% 11. Lumini intense sau soare-5,5% sau soare-3,9% 17.Schimbri meteo-14,1% meteo-14,1%

(P>0,05) (P>0,05) (P>0,05) (P>0,05)

5.Somn 7.Incordarea 11. Lumini intense 17.Schimbri

-----------------------------------------------------------------------------------------------------------------------------------------

Triggerii migrenei i cefaleei de tip tensional dup interviu:

Persoanele cu migren menioneaz foamea n 28,7% cazuri, iar cei cu CTT-n20,3% (P<0,01) Alcoolul ca factor declanator al migrenei a fost indicat de 27,3% din intervievai i doar de 13,1% din cei cu Cefalee de tip tensional (P<0,001) Menstruaia ca factor-trigger a fost menionat de 23% de migrenoi i de 9% din persoane cu CTT(P<0,001) Stresul sau ncetarea stresului a fost nominalizat ca trigger de 81,5% din respondenii cu migren i de 70,8% din cei cu CTT!!!

Oboseala este prezent ca factor-trigger la 74,9% din migrenoi i la 80,4% din cei cu cefalee de tip tensional(P<0,05)!!! Mirosurile puternice cauzeaz cefaleea la 23% din intervievaii cu migren i la 7,4% din cei cu CTT(P<0,001) Luminile intense sau soarele provoac migrena la 44,6%din suferinzi i la 22,9% de intervievai cu Cefalee de tip tensional(P<0,001) Sunetele puternice sunt triggerii Migrenei n 38,4% din cazuri, iar la cei cu CTT- la 13,1% din suferinzi(P<0,001)

Somnul profund sau prea mult somn este nominalizat ca trigger n 23,2% n cazul respondenilor cu migren i n 13,1% cazuri de CTT(P<0,001) Schimbrile meteo migrenoi i la au fost menionate ca factori- declanatori la 64,8% din 57,3% din persoanele cu Cefalee de tip tensional(P<0, 05)

Comportamentul n timpul durerii de cap(rspuns spontan: 3.Continu activitile zilnice- 4% din respondenii, ce sufer de migren i 9,3% din cei cu CTT(P<0,001). 5.Iau medicamente-54,3% din migrenoi i 41,7% din intervievaii cu Cefalee de tip tensional(P<0,001). Comportamentul n timpul durerii de cap(rspuns dup chestionare): Merg la aer- 10,3% din CTT(P<0,001). persoanele cu migren i 30,5% din respondenii cu

Privesc televizorul-7,9% din respodenii, ce sufer de migren i 27,2% din cei cu CTT(P<0,001)

Continu activitile obinuite-28,8% din intervievaii-migrenoi i 61,85% din respondenii, ce sufer de cefalee de tip tensional(P<0,001).

Fac masaj la cap 17,4% din cei cu migren i 23,1% din cei cu CTT(P<0,05).

Iau medicamente- 77,5% din respondenii ce sufer de migren i 57,1% din persoanele cu CTT(P<0,001).

Prefer repaosul la pat 77,5% din migrenoi i 53,8% din cei cu CTT(P<0,001).

Aleg o odaie ntunecoas-38,4 din cei, ce sufer de Migren i 8,2% din respondenii cu Cefalee de tip tensional(P<0,001). P.39. Antecedente eredo-colaterale Cineva din rudele apropiate sufer ( a suferit) de dureri de cap similare? n cazul respondenilor cu migren-69,9% au menionat prezena rudelor cu dureri similare, iar din cei cu cefalee de tip tensional -58,5% (P<0,001).

3. 52,8% din suferinzii de migren i 46,1%din cei cu CTT au numit mama, care a avut sau are cefalei similare(P>0,05). 5. sora sau fratele au fost menionai n cazul a 9,8% din respondenii cu migren i de 7,4% din cei cu CTT(P>0,05). 12. feciorul sa fiica au fost nominalizai n cazul a 14,3% din migrenoi i de 16% din cei, ce sufer de CTT(P>0,05). 2,2% din migrenoi i 11,5% din cei cu CTT- au indicat alte persoane din anturaj(P<0,001).

Dup chestionare 62,2% din suferinzii de Migren au numit mama, ca avnd dureri similare de cap i 50,7% din respondenii cu CTT au menionat acelai lucru(P<0,01).

Soul a fost numit ca suferind de cefalei de acelai tip de 13,9% din migrenoi i de 20,3% din cei cu cefalee de tip tensional(P<0,05). Altcineva a fost nominalizat de 3,2% din cei cu Migren i de 10,1% din cei cu CTT(P<0,001).

P.40 Cefaleea i somnul diurn. Se ntmpl ca n timpul durerii de cap ziua s reuii s adormii (cu sau fr medicamente)? N-au reuit s adoarm ziua, n timpul cefaleei respondenii cu migren n 36% cazuri, iar cei cu CTT n28,2% cazuri(P<0,01). Durerea poate s dispar dup trezire? Durerea de cap persist dup trezirea din somnul diurn la 14,9% din cei cu migren i la doar 5,15 din respondenii cu cefalee de tip tensional(P<001), pe cnd la 85,1% din migrenoi i 94,9% din respondenii cu CTT cefaleea dispare. Comorbiditatea algic n cursul ultimului an: Durerile abdominale au nsoit cefaleea la 12,7% din respondenii cu migren i la 8,8% din cei cu CTT(P<0,05).

Durerea n regiunea lombar(n ale) a fost nominalizat de 34,6% din suferinzii de migren i de 28% din cei cu cefalee de tip tensional8P<0,05). Anxietatea generalizat Prezena anxietii la respondenii cu Migren a fost indicat ca frecvent n 27,3% cazuri , iar la respondenii cu Cefalee de tip tensional-n20,4% cazuri, foarte des, practic permanent, respectiv n 4,3% i 1,8% n ambele gupuri(P<0,05).

Au menionat n calitate de fenomene frecvente(sau foarte frecvente) adiionale durerii de cap greaa i discomfortul abdominal persoanele cu migren n 14,2% de cazuri, iar cei cu CTT- n 3,7% cazuri(P<0,001).

Comentarii: Acesta a fost primul studiu epidemiologic al migrenei i al cefaleei de tip tensional i a subtipurilor acesteia din Republica Moldova, efectuat n baza criteriilor operaionale al SIC(Societii Internaionale de Cefalee). Exist cteva aspecte ale procedurii noastre metodologice care trebuie luate n consideraie. Studiile epdemiologice asupra migrenei n care au fost aplicate metodele de intervievareface-to-face", " door-to-door sunt rare. Acest metod a colectrii de date este probabil mai sensibil n definirea cazurilor de migren i cefalee de tip tensional dect interviurile telefonice sau chestionarele prin pot. Un interviu clinicface-toface" rmne referin-standart pentru diagnosticarea cefaleelor primare n absena oricror indicatori neuroradiologici sau biologici. ntr-un studiu bazat pe populaia dintr-o comunitate , problema major este de a petrece un interviu direct cu participanii cu scopul de a clarifica semnele i simptomele MCA i a MFA ,ct i al CTT i astfel de a mbunti excactitatea diagnosticului. Alt surs major de variaii n studiile cu interviuri fa-n-fa este acordul intra i interobservatorilor n rndurile intervievatorilor. n evaluarea de fa, noi am petrecut , nainte de a ncepe studiul , un curs de instruire de 1 lun care implica o echip de medici- neurologi special pregtii( rezideni in neurologie, colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu), condui de ctre medicii specialiti n cefalei. n plus nainte de demararea procesului de colectare a datelor , neurologii seniori au petrecut o consulataie lunar ,

ntlnindu-se cu intervievatorii pentru a stabiliza o diagnoz final a migrenei i al cefaleei de tip tensional i a subtipurlor acestora. O astfel de abordare minimalizez potenialele devieri de diagnosticare i contribuie la obinerea unei informaii ct mai veridice asupra prevalenei migrenei i caefaleei de tip tensional. n afar de aceasta, iterviul nostru de identificare a fost deasemena petrecut pentru a introduce o ntreag mostr de pacieni negativi (1226p.- fr cefalee) n baza clinic. Dup cum cunoatem, trebuie notat c doar Rasmussen et al1 i Stewart et al18 au administrat un interviu de diagnosticare ntregului grup de intervievai. Deaceea , noi considerm c c stabilirea definiiei cazului nostru este precis i senzitiv. Mostra de intervievai ai studiului nostru bazat pe populaie costituia 2665p.(84%) din totalul de rezideni. Rata de participare n cadrul studiului nostru a fost mai nalt de ct cele prezentate n studiile recent publicate care prevedeau interviuri fa-n-fa asupra migrenei, dar era n concordan cu studiile raportate anterior. Cu acordul celorlali autori, noi am identificat 54% de respondeni pozitivi la cefalee n mostra clinic de participani . prevalena pe via a migrenei era nalt, n special printre femei cu vrsta 40-49 ani i 60-65(38.1% i 37.5%, respectiv). Aceste rate sunt aproximativ similare cu cele raportate n rile nvecinate , precum Frana i Italia Croaia i Turcia , dar puin mai joase dect cele raportate n rile nordice din Europa. Totui, este bine stabilit c migrena este mai frecvent ntlnit la femei dect la brbai, evidena arat c ratele da la femeie la brbat variaz considerabil n dependen de vrst ; prevalena crete din adolescen pn la 40 ani i descrete apoi, mai ales la brbai. Exist probail o anumit influien a factorului hormonal asociate cu genul femenin care pot explica predominarea la femei mai n vrst de 60 de ani, dup cum a sugerat Stewart et al. Descoperirile noastre aprob aceats ipotez. Ratele noatre pentru prevalena pe durata unui an erau similare cu ratele obinute ntr- un studiu-exemplu american. Prevalena de 1 an n dependen de vrst a artat un tipar bimodal cu vrful n grupele de vrst 20-29, 40-49 i 50-59 de ani pentru ambele sexe. Cauza exact pentru o prevalen de vrf n grupul cel mai tnr nu este clar. Dup cum a presupus un studiu Korean, o explicaie posibil poate fi sindromul stresului printre elevii de liceu care se pregtesc de examenele de intrare la universitate. n studiul nostru , noi am subclasificat cei 534 de migrenoi activi, n dependen de subtipul lor. Majoritatea(...%) aveau MFA, urmai de cei cu MCA(...%) i MCAFA(...%). Ratele noastre sunt puin mai joase det cele raportate n studiul GEM care prevedea MFA i MCAFA(...% i ...%, respectiv),dar mai nalte pentru rata de MCA(...%). Posibil diferenele de studiu pentru MCA, MFA i MCAFA pot fi explicate de descoperirea i clasificarea lor, avnd in vedere c n studiul GEM numai o parte din respondenii negativi au fost interogai.). Aceste descoperiri sunt n concordan cu un studiu epidemiologic din Ungaria, asupra MFA i MCA , recent publicat . n studiul de fa, noi am observat o predominan n cazul femeilor n toate cele 3 grupe dup cum era sugerat i de ceilali autori.

Unii autori au sugerat c MCA i MFA au probabil diferita etiologii. n studiul d fa, noi am ncercat s investigm diferenele dintre caracteristicile clinice a migrenoilor pe via pentru cei cu migren cu i fr aur, ct i cele ale pacienilor cu cefalee de tip tensional.( Ratele de la femeie la brbat erau semnificativ mai nalte la pacienii afectai de MCA(P=.03). Majoritatea migrenoilor cu aur au resimit atacuri mai frecvente i mai severe cu simptomele nsoitare generale. Aceste descoperiri pot susine ipoteza c MCA i MFA sunt du entiti clinice diferite. Grupul amestecat (MCAFA) poate fi un alt grup distinct de migrenoi, iar aura la pacienii afectai de MCAFA probabil are o baz diferit det cea la migrenoii cu MCA. Noi am identificat numai 6.9% de migrenoi activi afectai de MCAFA. Aceast rat este mai joas dect ratele raportate de studiul GEM . pentru a investiga epidemiologia analitic descriptiv i clinic a MCA, MFA i MCAFA ,) ar fi important de standardizat o procedur de scanare a investigaiilor i a subclasificrii pentru a putea fi folosit n studiile din viitor. Studiile care vor urma trebuie s estimeze ratele reale ale prevalenei migrenei i ale cefaleei de tip tensional n populaia Moldovei. --------------------------------------------------------------------------------Raportul doctorandei Catedrei de Neurologie a USMF N. Testemianu Crciun Cristina privind lucrul asupra tezei de doctor n tiine medicale socio-economic." Rezumat: Actualitatea problemei cefaleelor primare e justificat prin prevalena nalt a migrenei-1315% i a cefaleei de tip tensional de 40-60% din numrul total al populaiei i impactul social i personal important al acestora. Cefaleea reprezint cel mai frecvent simptom neurologic pentru care pacienii se prezint la medic, ea a fost inclus de OMS n lista celor 10 cauze cele mai rspndite de incapacitate la ambele sexe i primelor 5 la femei. Elucidarea aspectelor epidemiologice i socio-economice ar permite obinerea unui tablou real al prevalenei cefaleelor primare n Republica Moldova i ar putea fi elaborate strategii adecvate att n aspect clinic, diagnostic i de tratament, ct i managerial. Monitorizarea atent a factorilor- declanatori a cefaleelor poate avea un rol i "Epidemiologia cefaleelor primare n mediul rural i urban din Republica Moldova. Impactul

important in tratamentul lor, deoarece evitarea acestora poate micora frecvena severitatea atacurilor de cefalee i poate duce la depistarea etiologiei cefaleelor.

Prevalena- numrul total de bolnavi prezeni la o populaie ntr-o perioad de timp(1 an,

life-time). Inciden- cte cazuri noi au aprut ntr-o unitate de timp(1 an). Scopul studiului: Estimarea prevalenei cefaleelor primare (migrenei i cefaleei de tip Moldova . Un alt obietiv important al studiului dat a fost examinarea relaiei dintre factorii declanatori i migren, cefalee de tip tensional, cat i cu subtipurile migrenei: migrena cu aur i migrena fr aur, ct i evidenierea particularitilor clinice a diferitor tipuri de cefalee, cunoaterea incidenei acestora i compararea rezultatelor cu cele prezente n alte ri. In anul 1988,Sociataea Internaional a Cefaleeii a publicat prima clasificare a tulburrilor cefalgice, divizind toate tipurile de cefalee in : 21 22 primare(neasociate unei leziuni cerebrale clinic identificate) secundare(condiionate de o maladie neurologic sau somatic) tensional) i stabilirea frecvenei factorilor- triggeri la subiecii aduli (15-65 ani) cu acest tip de cefalei in localitile urban(mun Chiinu) i rural(Hanceti) din Republica

Ea a devenit un standard pentru diagnosticarea cefaleei. Acumularea cunotinelor in domeniul cefaleelor,cunoaterea mai bun a fiziopatologiei acestora, precum i descrierea de noi entiti clinice a condus la necesitatea revizuirii acestei clasificri. Ediia adoua a Clasificrii Internaionale a Tulburrilor Cefalgice a aprut in ianuarie 2004, fiind complex, bine ierarhizat, astfel inct s fie util cercettotilor i clinicienilor, prezentnd o clasificare ampl i sistematizarea a 200 de forme ale cefaleei. In acelai an ea a fost tradus in limba roman in Republica Moldova la Catedra de Neurologie a Universitii de Stat de Medicin i Farmacie Nicolae Testemianu . Criteriile de diagnostic stricte i exacte expuse in clasificare ofer posibilitatea aprecierii unui diagnostic corect tiinific, fondat pe abordarea medicinei bazate pe dovezi. In raportul OMS din a. 2000 dup gradele de severitate a diferitor patologii, pacienii cu atacuri severe de migren au fost considerai mai afectai decat cei cu psihoze active, demene, sau cei cu tetraplegie. Privind numrul de ani trii cu disabilitate( YLDs), cauzat de variate patologii, migrena depete locul 19 in lume i locul 9 la femei(Maters et al 2002). Migrena este o form relativ sever de cefalee, ce survine in form de atacuri, de obicei cu durata de la 4 ore pan la 72 ore (3 zile), fiind acompaniat de astfel de fenomene disabilitante ca :

nausea(greurile) sau vomele, intolerana sever a luminii, sunetelor, mirosurilor i al micrii corpului. Cefaleea de tip tensional este de obicei mai puin incapacitant ca migrena i cu mai puine fenomene insoitoare. Acest tip de cefalee nu a fost considerat in raportul OMS cel mai important, dar datorit fatului, c este cel mai prevalent tip de cefalee i are tendina de a deveni cronic la o substanial parte a pacienilor, consecinele individuale i sociale a Cefaleei de tip tensional pot fi la fel de semnificative, ca i cele ale migrenei. Alte forme relativ rare aa ca cefaleea in ciorchine(Cluster), poate fi chiar mai incapacitant ca migrena pe timpul atacului. Fr a ine cont de diagnostic, pentru majoritatea pacienilor, consecina este, c funcia normal e intrerupt de episoade de cefalee cu intervale neregulate i imprevizibile, iar aceasta poate impune severe limitri in viaa lor cotidian, la studii, munc i pe parcursul timpului de odihn. Toate acestea i faptul, c patologiile date par a fi extrem de prevalente in toat lumea, le face importante din punctul perspectivei economice. Materiale i metode: Studiu randomizatface-to-face", " door-to-door prin intermediul chestionarului structurat, elaborat de Profesorul I.Moldovanu in 2004, in conformitate cu Criteriile Clasificrii Internaionale Chiinu-Hnceti. In studiu au fost inclui 2665 respondeni cu varsta cuprins intre 15-65 ani, care au alctuit 84% din 3165 persoane contactate . Chestionarea a fost efectuat in perioada : mai-iunie, septembrie-octombrie 2005 de un grup de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu i rezideni in neurologie, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee(IHS). Din totalul de 2665 de persoane au rspuns afirmativ la intrebare privind prezena cefaleelor- 1439, ce constituie 54% , 1226 din cei cercetai-46% n- au avut cefalee . Chestionarul care a fost utilizat in acest studiu include 145 intrebri, care vizeaz urmtoarele aspecte de baz:aspecte socio-demografice depistarea factorilor- declanatori ai migrenei i cefaleei de tip tensional,caracteristici clinice detaliate, tratamente farmacologice, a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee in anul 2004.Selectarea eantionului-

date medico-economice , comorbiditatea, gradul de incapacitate(MIDAS i HIT),impactul cefaleelor i estimarea prezenei abuzului medicamentos. Analiza datelor chestionarelor s-a efectuat utilizand SPSS , varianta 12. Dat fiind, c cefaleea constituie o problem major de sntate, fiind inclus de Organizaia Mondial a Sntii(OMS) in lista primelor 10 cauze de incapacitate la ambele sexe i a primelor 5 cauze de incapacitate efecturii acestuia . Rezultate: Datele privind repartizarea tipurilor maladiilor cefalalgice sunt indicate in tabelului de mai jos: Tipul cefaleei Migren Cefaleea de tip tensional Migrena cronic CTT cronic Cefalee mixt Cefaleea mixt cronic Migrena probabil CTT probabil Migrena cronic probabil CTT cronic probabil Cefalee mixt probabil Cefalee mixt cronic probabil Cefalee secundar Numrul suferinde 441 421 93 68 73 43 61 54 44 49 41 24 26 persoanelor Prevalena(%)(din pers.) 16,5% 15,8% 3,5% 2,6% 2,7% 1,6% 2,3% 2,0% 1,7% 1,8% 1,5% 0,9% 1% 2665 la femei, lipsa unui studiu epidemiologic al a impus necesitatea imperativ a prevalenei cefaleelor primare in Republica Moldova

Dup frecvena atacurilor pe lun Migrena-1-4 zile- 173p. CTT-1-4 zile-185p.

Migrena-5-14 zile-291p. Migrena>sau egal 15 zile-70p.

CTT-5-14 zile-235p. CTT >sau egal 15 zile-69p.

Din totalul de 2665 respondeni- 1587(59%) au fost femei, brbai au fost- 1078(40,5%), Din numrul persoanelor cu dureri de cap, femei au fost 1050- 73%, brbai- 38927%.

48,8% din cei intervievai locuiau in mun Chiinu, respectiv- 51,2%- in Hinceti. Divizarea dup starea matrimonial a respondenilor a avut loc astfel: Cstorii- 1834- 68,8%, celibatari- 586-22%, divorai-121- 4,5%, vduvi-124-4,7%. Dup varst persoanele chestionate aveau: 15-24 ani- 629p.- 23,6% 25-34 ani- 610p.- 22,89% 35-44 ani- 432p.- 16,21% 45-54 ani-486p.-18,23% 55- 65 ani- 508p.- 19,06%

Din ei: Nu erau incadrai in cimpul muncii- 829 respondeni- 31,1% Munc intelectual indeplineau- 1120 chestionai-42% Munceau fizic- 708 intervievai- 26,6%. Dup nivelul educaiei: intervievai, coala profesional- 25%, jos- 43,2%: coala primar au absolvit-o 18,2% din cei

mediu- 18,9% : Studii liceale -5,6%, Studii postliceale- 13,2%, superior -48,5%: Universitatea au absolvit-o 35,3% din respondeni i Studii postuniversitare- 2,6% din 2665 persoane chestionate.

Tabagismul: fumtori- 623(23,4%), iar nefumatori-2042(76,6%).

Dup starea material i condiii de trai- 15% din respondeni au menionat, c au un trai decent, 69,8%- considerau, c au condiii de trai medii i au bani doar pentru strictul necesar, iar 15,2%-c au condiii nefavorabile de trai i nu le ajung bani nici pentru strictul necesar.

Cefaleea este una din acuzele cele mai frecvente in practica medical, constituind o problem major a sntii publice cu un impact indvidual i social mare, , avind ca rezultat pierderea productivitii, limitarea activitii i deteriorarea calitii vieii, date confirmat de cercetrile epidemiologice actuale. Circa 45 de mln de americani au cefalee cronic,dintre care, 20 de mln sunt femei . (NWHJK) Rata prevalenei cefaleelor este aproximativ 1 din 6 sau 16.54% ,adic 45 mln de persoane din Statele Unite. Cefaleea este omniprezent i este o problem costisitoare a sntii publice in Japonia . Conform datelor prezentate( Ocuma H., Kitagawa Y. 2005),prevalena cefaleei pe via e aproximativ de 93% la brbai i 99% la femei. Aproximativ 8.4 mln de oameni in Japonia sufer de migren i 22 mln au cefalee de tip tensional.

n pofida faptului impactului personal i economic, ct i disabilitatea cauzat de cefalee, muli pacieni cu cefalee nu se adreseaz dup servicii medicale. Studiile populaionale sunt in majoritaea lor focusate asupra migrenei deoarece ea a fost mai des studiat,dar ea nu este cea mai frecvent intilnit patologie cefalalgic. In rile dezvoltate doar CTT afecteaz 2/3 din brbai i mai mult de 80%din femei. Extrapolarea din datele privind prevalena migrenei i a incidenei atacurilor, prezint c 3000 de atacuri de migren au loc zilnic pentru fiecare 1 mln din populaia general. Adic mai mult de 1 adult din 20 are cefalee aproape zilnic sau chiar zilnic. Conform datelor Organizaiei Mondiale a Sntii,migrena se afl pe locul 19 printre maladiille incapacitante. Patologia cefalalgic impune o povar considerabil asupra suferinzilor, incluzind afectarea calitii vieii, suferina substanial personal periodic i costul financiar . Repetarea atacurilor de cefalee, urmate de o frecvent sau permanent fric, dauna pricinuit vieii de familie,vieii sociale i serviciului constitue impactul patologiei cefalalgice. Spre exemplu activitatea social i capacitatea de lucru sunt reduse aproape la toi suferinzii de migren i la 60% din cei cu CTT. Migrena e intilnit la toate rasele. Totui evidena curent sugereaz , c prevalena migrenei este mai inalt la cei de ras alb decit la asiatici i africani.

ara 1. Canada 2. SUA 3.Peru 4.Britania 6.Malasia 7.Arabia Saudit

Prevalena 15% 11% 32% 11% 9% 3%

ara 8.Frana 9.Norvegia 10.Danemarca 11.Japonia 12.Hong Kong 13.Etiopia

Prevalena 12% 9% 17% 8% 1.5% 3%

Un efort de lung durat de a face fa patologiilor cefalgice persoanele cu migren sever sau cefalei severe decit la indivizii sntoi.

poate de asemenea

predispune persoanele fa de alte patologii . De exemplu, depresia e de 3 ori mai des intilnit la

De obicei cu debutul in pubertate, migrena afectez majoritar persoanele cu virsta cuprins intre 35 i 45 de ani, dar le poate crea probleme i persoanelor mult mai tinere, inclusiv copiilor. Studiile Americane i Europene demonstreaz c in fiecare an 6-8% din brbai i 15-18% dintre femei au migren . Un pattern similar se vede in America Central i de Sud. In urma cercetrilor din Puerto Rico,spre exemplu, s-a constatat prevalena migrenei de 6% la brbai i 17% la femei. Un Studiu efectuat in Turcia dezvluie o i mai mare prevalen in aceast ar: 10% la brbai i 22% la femei. Cea mai inalt rat pretutindeni la femei (de 2-3 ori mai mare decit la brbai) este cea hormonal condiionat. Migrena este aadar mai puin prevalent ,dar totui frecvent , in Asia(3% la brbai i ? 0% la femei ) i in Africa(3-7% in studiile bazate pe comunitate). Studii majore nu au fost inc petrecute. Incidence and prevalence of some neurological conditions (rates per 100,000) Incidence: number of new cases per 100,000 that develop each year 25,000 per 100,000 in over 65 year olds per 100,000 27 new cases in year 2000 Migraine

Condition

Prevalence: total number of people per 100,000

Source

Alzheimer's disease/dementia

1,000

Alzheimer's Society based on ONS population estimate 1996

CJD

Alzheimer's Society

vCJD

101 cases since 1995 15,000

Alzheimer's Society

1. Steiner TJ et al Epidemiology of

400 100,000(1)

per

(8,000,000)

migraine in England. Cephalalgia 2. Olesen J, Goadsby PJ, Cluster Headache and related conditions in Olesen J (Ed) Frontiers in Headache Research Vol 9 OUP 1999 3. Goadsby PJ, Lipton RB. A review of paroxysmal hemicaranias Brain 1997; 120:193-209 4. Silberstein SD et al, Headaches in Primary Care Oxford/Isis Medical Media 1999

Cluster Headache 4 per 100,000 (2) Headache Paroxysmal Hemicrania (3) Chronic Migraine (4) Chronic tensiontype headache (4) Headache Motor neurone disease

100

10

3,000

144 (85,000)

MS Society and MS Research Trust - estimates based on UK area studies and international data Dowsett E G, Richardson J The Epiemiology of Myalgic Encephalomyelitis (ME) in the UK 1919 - 1999 Evidence submitted to the All Party Parliamentary Group of MPs on ME 23.11.99 Parkinson's Disease Society - advice from medical adviser Last edited: 2/2/2004

Myalgic Encephalomyelitis (ME)

300 - 500

Parkinson's disease

200

2003-4 World Health Organization - UK Collaborating Centre

Caracteristicile epidemiologice si clinice a migrenei si cefaleei de tip tensional in cazul a 1146 de femei din Kayseri, Turcia

Kseoglu E., Naar M., Talaslioglu A., etinkaya F.

Caracteristici epidemiologice si clinice ale migrenei si a cefaleei de tip tensional in cazul a 1146 de femei din Kayseri, Turcia. Cephalalgia 2003 ; 23 :381-338. London ISSN 0333-1024

In populatia feminina a Turciei (1146 de femei adulte), au fost investigate unele caracteristici epidemiologice si clinice ale migrenei si cefaleei de tip tensional si unele subtipuri ale lor. Relatia intre severitatea durerii de cap si caracteristicile clinice au fost investigate amanuntit. Statisticile arata o raspandire mai mare a migrenei la grupul de varsta intre 35 si 44 de ani (P<0.01), la cei cu studii superioare (P<0.001), la cei casatoriti (P<0.01) precum si la persoanele care locuiesc in localitati urbane. Cefaleea de tip tensional a fost apreciata ca fiind mai inalta la grupul de varsta cuprins intre 45 si 64 de ani (P<0.05). Sa constatat ca pacientii cu cefalee cronica (P<0.01) sunt mult mai avansati in varsta comparativ celor cu cefalee de tip tensional de tip episodic si deseori sunt cu un nivel de educatie scazut (P<0.05). Prezenta impactului asupra activitatii lor zilnice datorat severitatii durerilor de cap a fost legata de agravarea starii fizice (P=0.001) in cazul cefaleei de tip tensional, fara caracteristici clinice ale durerii de cap migrenoase si considerand toti pacientii cu dureri de cap pulsatile (P<0.05), agravarea starii fizice (P=0.001), greturi (P<0.01), vome (P<0.05), si phonofobie (P<0.05). Migrena, cefalee de tip tensional, populatia feminina, Turcia.

Introducere

Exista multe studii epidemiologice a durerilor de cap, dar relativ putine sunt efectuate in tarile asiatice. Aceasta relateaza faptul ca factorii de risc de ordin rasial, cultural si cel al mediului inconjurator joaca un rol important in cercetarile epidemiologice(1). Acest studiu a fost efectuat intr-o tara asiatica, a carei populatie apartine rasei Caucaziene. Studiile, in special cele cu privire la femei, sunt si ele relativ putine la numar. Un studiu epidemiologic a durerilor de cap din Turcia, publicat sub forma de rezumat, efectuat in cazul a 2007 de persoane, arata o raspandire a migrenei si cefaleei de tip tensional (CTT) in decursul unui an de 16.4% si respectiv 31.7%(2). Dar caracteristicile clinice ale cefaleelor n-au fost evaluate. Acesta este primul studiu detaliat, bazat pe cercetari masive a cefaleei si caracteristicile sale clinice bazate pe Sistemul International al Cefaleei (criteriul IHS) in populatia feminina a Turciei. Prevalenta de 1 an, date socio-demografice si caracteristicile migrenei, CTT si subtipurile cefaleei de tip tensional au fost investigate. De asemenea, a fost apreciata si corelatia dintre caracteristicile clinice si severitatea cefaleei.

Materiale si metode

Studiul a fost efectuat in provincia Kayseri avand ca obiect de cercetare femei in varsta mai mare de 14 ani, in cazul a 375 441 de persoane. Marimea-mostra minima a fost calculata ca fiind cea de 1100 de persoane (95% interval confidential, SD: 1.6%) prevalenta migrenei estimata la 8%. 1300 de femei intre varsta de 15 si 87 de ani au fost selectate la intamplare dupa grup si metodele de sistematizare din regiune, folosind registrul civil in centrele de sanatate primare, care au inregistrari a tuturor locuitorilor a regiunilor; 1146 din aceste femei a putut fi contactate pentru studiu. Simptomele durerii de cap au fost evaluate prin intervievarea structurata fata-n fata, bazata pe criteriul IHS (3) . Inaintea fiecarui interviu era descris obiectivul studiului si era primit acordul verbal de a participa. Studiul a fost aprobat de Comitetul Etic al Universitatii Erciyes. In urma unor intrebari introductive cu privire la varsta, nivelul educational si economic, statutul marital si profesional, indivizii au fost intrebati daca medicii generalisti au depistat vre-o boala cronica si cel mai important, daca au avut dureri de cap bine resimtite (discomfortante) pe parcursul anului trecut. In cazul in care durerea de cap era raportata, li se puneau intrebari pe marginea caracteristicilor durerilor de cap si intrebari legate de cele din urma, cum ar fi frecventa, durata, factorii declansatori, simptomele concomitente, dereglari ale somnului, istoricul familiei, tratamentele facute, etc.

Intervievarile erau executate de studentii la medicina, antrenati in acest subiect prin lucrul la policlinicile de studiere a cefaleelor. Dupa intervievare, tipurile de dureri de cap au fost determinate dupa criteriul IHS in interviurile dintre neurologi si studenti. Diagnosticile altor boli erau bazate pe deciziile generalistilor din centrul primar al sanatatii. Alte cauze ale durerii de cap, ca sinusitele si hipertensiunea au fost luate in consideratie si evaluate ca posibilitate a existentei cauzei migrenei. In 15 (1,31 %) dintre cazuri durerea de cap era gasita de a fi cauzata de aceste boli. Proportia prevalentei migrenei cu aura (MWA) si a migrenei fara aura (MWOA), tipul episodic si cel cronic CTT au fost depistate. Evaluarea relatiei dintre prevalenta tipurilor de cefalee si proprietatile pacientilor cu cefalee, cum ar fi varsta, nivelul educational si economic, statutul marital si profesional, aria rezidentiala si comparatia caracteristicilor clinice dintre severitatea durerii de cap au fost evaluate folosind sirul Spearman al analizelor corelative.

Rezultatele

Proprietatile socio-demografice ale pacientilor CTT si pacientilor migrenosi: varsta, nivelul educational si economic, statutul marital si profesional, aria rezidentiala sunt prezentate in Tabelul nr.1

Tebelul 1 Particularitatile socio-demografice a tuturor persoanelor intervievate si pacientilor cu cefalee

Persoane intervievate (n=1146) Varsta (ani) 15-24 25-34 35-44 45-64 >65 Nivelul educational <5 ani 5 ani 8 ani 11 ani >11 ani Statutul marital Casatorite Celibatare Divortate Statutul profesional Femei de casa Lucratoare Resedinta Urban 636 975 171 853 178 115 312 526 99 126 83 289 311 253 228 65

Pacienti cu migrena (n=143)

Pacientii CTT (n=216)

23 (8.0%) 48 (15.4%) 41 (16.2%) 29 (12.7%) 2 (3.0%)

46 (15.9%) 55 (17,7%) 47 (18.5%) 59 (25.9%) 9 (13.8%)

33 (10.5%) 72 (13.7%) 6 (6.0%) 11 (8,7%) 21 (25.8%)

57 (18.2%) 96 (18.2%) 19 (19.2%) 22 (17.4%) 22 (26.5%)

118 (13.8%) 17 (9.5%) 8 (7.0%)

160 (18.7%) 28 (15.7%) 28 (24.3%)

116 (11.9%) 27 (15.8%)

180 (18.4%) 36 (21.0%)

97 (15.2%)

123 (19.3%) 93 (18.2%)

Rural 510 46 (9.0%) Durerea de cap de tip migrenos si aspectele socio-demografice

1146 de femei au fost intervievate. 359 (31.1%) dintre ele au suportat migrena sau cefaleea de tip tensional pe parcursul ultimului an. Prevalenta migrenei timp de un an a fost de 12.5% (143 de pacienti), inclunzand 7,3 % (84) MWA si 5.2% (59) MWOA. Prevalenta migrenei a fost gasita ca fiind statistic mai inalta in grupul de persoane cuprinse intre 35-44 de ani si mai joasa in grupul de persoane cu varsta mai mare de 65 de ani, comparativ cu alte grupe (2: 16.38, P<0.01). O prevalenta mai mare a durerii de cap migrenoase a fost determinata la persoanele cu un nivel educational relativ mai inalt, universitar (2: 6.04, P<0.05) precum si la cei care au locuit in zonele urbane (2: 9.5, P<0.01). Totusi, in cazul statutului profesional si situatia economica nu au fost gasite tangente semnificative cu prezenta durerilor de cap de tip migrenos.

Cefaleea de tip tensional si aspectele socio-demografice

Prevalenta de un an al CCT a fost gasita de 18.8% (216 persoane) incluzand 144 (12.5%) tip episodic si 72 (6.3%) cu tip cronic al cefaleei. Prevalenta CTT a fost gasita mai inalta la grupul de varsta 45-64 de ani (2: 10.34, P<0.05). Cefaleea de tip tensional cronica a fost gasita semnificativ mai mare decat cea de tip episodic (media de varsta SD pentru tipul cronic si episodic al cefaceei de tip tensional: 41.11 15.57, 35.85, 12.91, P<0.01). Cu respectarea studiilor, tipul cronic al cefaleei a fost gasit cel mai prevalent (2: 6.83, P<0.05). La persoanele cu nivel cel mai scazut de studii.

Frecventa atacurilor de cefalee

Aproximativ 73.4% din pacientii cu migrena au 1-4 atacuri pe luna, pe cand restul trec prin >4 atacuri pe luna. 55 de pacienti migrenosi (38.5% din toti migrenosii; 21 MWA, 14 MWOA) au cel putin 180 de atacuri pe an. Luand in consideratie, ca la cefalee de tip tensional 31.9% de pacienti au 1-3 cefaleei pe luna si 68.1% din pacienti sufera de cefalee minim 1 data pe saptamana; 33.3% din pacienti au cel putin 180 de atacuri pe an, de cefalee de tip tensional.

Durata cefaleei

In acord cu criteriile Societatii Internationale ale Cefaleei, durata acceptata a atacului de migrena la pacientul netratat e de 4-72 ore. 22 de pacienti (15.4%) cu migrena au avut durata <4 ore, dar toti acesti pacienti au utilizat tratamentul medicamentos pentru atacurile lor de cefalee. Acest studiu demonstreaza ca cea mai raspandita durata a

atacurilor de migrena (71.3%) a fost intre 4-24 ore. In cefalee de tip tensional, atacurile s-au sfarsit in cadrul mai multor ore (51.9%, au continuat pe parcursul zilei 22.2%, au durat de la 1-3 zile (14.8%) si de la 3-7 zile la 11.1% din pacienti). Cefalee de tip tensional episodica difera de tipul cronic prin aceea ca atacurile de obicei au durata mai scurta, 15 min. - cateva ore (2: 10.52, P<0.05).

Caracteristica cefaleei

Pulsatia a fost observata la 88.8% din migrenosi si 62.0% din pacientii cu cefalee de tip tensional, pe cand pacientii aveau senzatii de presiune/inclestare.

Tabelul 2 Caracteristicile migrenei cu aura si fara aura

Unilateralitatea

Caracterul pulsatil

Agravarea la efort fizic

Impactul asupra activitatilor zilnice % 78.6 76.2

% MWA 54.8

% 83.3

% 78.6 89.8

MWOA 49.2 96.6 Nota: MWA Migrena cu aura; MWOA - Migrena fara aura.

53.1% din pacientii cu migrena au avut cefalee unilaterala. Cefalee bilaterala a fost raportata la 72.7% din pacientii cu cefalee de tip tensional. La 82.5% din pacientii cu migrena si 43.3% din pacientii cu cefalee de tip tensional, cefaleea a fost agravata de activitati fizice de rutina.

Caracteristicile tipurilor migrenei cu aura si fara aura au fost demonstrate in Tabelul 2. Compararea acestor caracteristici cu 2 test a demonstrat caracterul pulsativ, care a fost gasit mai frecvent in migrena cu aura. (2: 4.88, P<0.005). Caracteristicile cefaleei de tip tensional cronica si episodica au fost prezentate in Tabelul 3. N-au fost diferente statistice (2 test) intre cele doua tipuri de cefalei tensionale.

Tabelul 3 Caracteristicile cefaleei de tip tensional cronice si episodice Bilateralitatea Caracterul de presiune/inclestar e Impactul asupra activitatilor zilnice % 33.3 38.2

Agravarea la efort fizic

% Cronica Episodica 73.6 70.1

% 34.7 39.6

% 45.8 45.1

Simptome insotitoare

Phonofobia 85.3% a fost cel mai frecvent simptom al migrenei insotit de greata (80.4%) si photofobia 177.6%. Voma a fost observata la 44.8% din pacientii cu migrena in MWA, cea mai comuna aura au fost dereglarile vizuale, incluzind scintilatia sau distorsia imaginii, hemianopsia si intunecarea vederii (81.8%), insotita de tinitus/vertije (67.1%), simptome senzoriale (34.3%) si afazie (15.4%). In cazurile de cefalee de tip tensional, phofobia a fost de asemenea cel mai des simptom insotitor. Greata a fost observata la 40.7% din pacienti, iar photofobia la 14.4% din pacienti. Simptomele insotioare ale migrenei cu si fara aura, au fost demonstrate in Tabelul 4, iar cele de cefalee de tip tensional episodice si cronice in Tabelul 5. In ceea ce priveste aceste constatari, n-a fost diferenta statistica intre migrena cu si fara aura. Totusi, cand comparatia similara a fost facuta intre subtipurile cefaleei de tip tensional, simptomele de greata (2: 6.48, P<0.001), voma (2: 5.12, P<0.05) si phonofobie (2: 4.48, P<0.005), au fost gasite ca cele mai frecvente in cefaleea cronica de tip tensional.

Tabelul 4 Simptomele insotitoare ale migrenei cu si fara aura Greata % MWA 81.0 Voma % 47.6 Phofobia % 89.2 79.6 Photofobia % 82.1 71.2

MWOA 83.1 40.7 Nota: MWA Migrena cu aura; MWOA - Migrena fara aura.

Factorii trigger (declansatori)

Cei mai frecventi factori declansatori ai atacurilor de cefalee au fost stresul (la migrena 81.8%; la cefalee de tip tensional 83.3%), privarea de somn (la migrena 37.1%, cefalee de tip tenional 39.4%), factorii hormonali ca menstruatia (la migrena 35.6%, cefalee de tip tensional 24.5%), sarcina (la migrena 16.1%, cefalee de tip tensional 6.0%). Diverse alimente nu joaca vre-un rol semnificativ ca factor declansator la pacientii cu migrena (cascavalul 0%, ciocolata 1.4%). 32.2% a migrenei cu aura si 42.4% a migrenei fara aura au fost raportate ca cefalei provocate de menstruatie. Cand comparam aceste frecvente, ele au fost gasite din punct de vedere statistic neschimbate. 5 pacienti (3.5% migrenosi; 3 MWA, 2 MWOA) au fost raportati cu cefalee de tip migrenos, relatate doar la menstruatie, iata de ce ei sunt considerati pacienti cu migrena menstruala pura.

Impactul asupra activitatilor zilnice

Activitatile zilnice de rutina au fost afectate in 76.6% de migrena 37.5% din pacientii cu cefalee de tip tensional, din cauza severitatii cefaleei. In ceea ce priveste acest factor, o diferenta nesemnificativa a fost gasita intre migrena cu si fara aura sau intre cefalee de tip tensional cronica si episodica. La pacientii cu cefalee de tip tensional comparand prezenta impactului asupra activitatilor zilnice cu caracteristicile cefaleei si simptomele insotitoare a fost gasita legatura intre impactul asupra activitatilor si agravarea lor la efort fizic (Spearman p:0.27, P=0.001). Cand o comparatie asemanatoare a fost efectuata la pacientii cu cefalee de tip migrenos n-a fost gasita vre-o relatie. In cazul altor pacienti cu cefalee, caracterul pulsatil (P<0.005), agravarea la eforturi fizice (P<0.01), simptomele insotitoare de greata (P<0.001), voma (P<0.05), si photofobia (P<0.05) au fost gasite pentru a relata impactul cefaleei asupra activitatilor zilnice in analizele gradului de corelatie al lui Spearman.

Tabelul 5 Simptomele insotitoare ale cefaleei de tip tensional cronice si episodice

Greata % Cronica Episodica 52.8 34.7

Voma % 13.0 10.0

Phofobia % 61.1 45.8

Photofobia % 19.4 12.5

Somnul si cefaleea In studiul nostru lipsa somnului a fost raportata la 23% de migrenosi si 20.8% de pacienti de tip tensional.

Relatiile pacient medic 75.5% din pacientii cu migrena si 56.7% din cei cu cefalee de tip tensional au fost consultati de medicul generalist in privinta durerii lor de cap. 51% din migrenosi stiu despre migrena lor.

Masuri de tratament Partea utilizarii medicamentelor la pacientii migrenosi a fost identificata pana la 90.9%, in timp ce la pacientii cu cefalee de tip tensional 63.4%. O alta masura importanta este aflarea in singuratate intr-o odaie si somnul (la migrena 86.0%, CTT 66.7%), masajul (migrena 38.5%, CTT 31.0%), compresele reci sau fierbinti (migrena 10.5%, CTT 6.0%).

Istoricul familial 43.4% din migrenosi aveau un istoric familial cu cefalei similare (48.8% migrena cu aura, 35.6% migrena fara aura), in timp ce istoricul pozitiv familial a fost raportat la 32.9% din pacientii cu CTT. Reisend din acestea, nu a fost gasita o diferenta semnificativa intre tipurile de cefalee.

Discutii Acesta este studiul epidemiologic al populatiei bazat pe femeile cu cefalee din Turcia. Noi am incercat sa evaluam caracteristicile socio-demografice si clinice ale cefaleelor de tip tensional si cele de tip migrenos. In cele ce urmeaza noi am clasificat cefaleele de tip tensional si cele de tip migrenos in episodice si cronice, iar la migrena cu aura si fara aura. Caracteristicile clinice ale simptomelor insotitoare au fost evaluate la toate subtipurile cefaleelor si comparate intre ele. Atitudinea pacientilor fata de cefalee a fost investigata si ea. Indicii de corespundere criteriului IHS in toate tipurile si subtipurile au fost considerate si comparate. Orice necorespundere semnificativa intre subtipuri a fost evaluata. Relatia dintre caracteristicile durerilor de cap si simptomele insotitoare, si impactul asupra activitatilor zilnice au fost special studiate in tipurile cefaleelor si pacientii cu dureri de cap. Ca rezultat, luand in consideratie toti pacientii cu cefalee, am identificat relatii statistice semnificative intre unele caracteristici si simptomele insotitoare cu severitatea durerii de cap. Aceste caracteristici si simptome insotitoare au fost tipic asociate cu cefaleea migrenoasa; pulsatii, agravarea starii fizice, greturi, vome, phonofobia. La cefalee de tip tensional, severitatea a fost asociata cu agravarea starii fizice. Constatarea aceasta era in conformitate cu lucrarea lui Lavados si a lui Tenhamm (4), in care ei indicau ca agravarea cefaleei cu migrarea durerii la cefalee nu sunt discriminatori specifici ai sindromurilor de cefalee, ci posibil ca erau mai mult legate de severitatea durerii. Nici o legatura de acest fel nu a fost gasita la tipul cefaleelor migrenoase. Migrena este de obicei unilaterala, pulsatila, de la moderat pana la sever ca intensitate, si deseori asociata cu greturi, photofobie si phonofobie. Intr-un studiu realizat anterior asupra pacientilor cu migrena fara aura intr-un spital universitar din Turcia (5), 58% sufereau de dureri pulsatile, 74% aveau dureri de cap unilaterale. Agravarea prin activitati fizice de rutina a fost gasita in proportie de 96% in cadrul studiului mentionat. Rezultatele noastre (pulsatia 96.6%, dureri unilaterale 49.2% la pacienti cu MWOA) se deosebesc de acest studiu, posibil datorita diferentei de studiu a populatiei. Caracteristicile clinice a migrenei au fost gasite relativ similare cu cele din tarile vestice (6,7). Cel mai mic coeficient de cazuri unde se intalneste asa simptom ca voma, intalnit in Korea si Ungaria, nu a fost confirmat de cercetarile noastre (8,9). Am depistat un coeficient semnificativ mai mare al pulsatiei in MWOA comparativ cu MWA. Acest fapt nu a fost confirmat nicaieri in alta parte. Russell et al.(10) au declarat ca ei s-au retinut sa faca o analiza statistica comparativa intre MWOA si MWA din motivul ca exista o diferenta in criteriul de includere. Insa noi credem ca manifestarea pulsatiei la MWA se datoreaza patofiziologiei. Depresia corticala raspandita si schimbarile fluxului sanguin celebral sunt responsabile de aura migrenei. Aceste

procese pot cauza dureri din ambele parti a capului prin conexiuni centrale (11). Aria rostrala a creierului are un rol central si determinant in migrena (12). Este de-a dreptul plauzibil de considerat daca proiectiile de la aceste zone centrale a creierului spre cortex participa la initierea aurei si schimbarile vasculare a migrenei (11), precum si daca ele cauzeaza o astfel de diferenta a durerii la alte subtipuri ale migrenei. Cefaleea de tip tensional este caracterizata de o prezenta bilaterala, presiune/inclestare, domoala sau moderata ca intensitate, si de obicei, nu este agravata de activitatile fizice de rutina (13). Coeficientul indicat de noi privind cefaleele insotite de presiune/inclestare (38%) a fost determinat ca fiind mai mic comparativ cu cele indicate in lucrarile anterioare (52%-73.8%) (4,8). Un coeficient inalt al caracterului unilateral a fost indicat (28.7%) pentru acest tip de cefalee. Prezenta unui inalt coeficient al exacerbarii activitatilor fizice (45.4%), fapt prezentat in cateva studii recente (7, 14-16). In studiul nostru, photofobia a fost anuntata in 14.8% de cazuri la pacienti cu CTT. Aceasta descoperire este in corespundere cu alte studii (17, 18). N-am depistat un coeficient inalt al photofobiei (82%) indicat de Vanagait si Stovner (19). In evaluarea criteriului de diagnosticare IHS, unii autori cum sunt Messinger et al. (20) au sugerat evaluarea separata a criteriului in loc de cea traditionala, a tuturor criteriilor laolalta. Ei au raportat ca suprapunerea diagnosticilor in cazul migrenei si cefaleei de tip tensional ar putea fi diminuata daca simptomele cefaleei, cum sunt intensitatea, durata, calitatea, agravarea prin activitati fizice, nu ar fi folosite impreuna pentru a construi un criteriu comun, ci fiecare simptom ar fi tratat ca un criteriu separat (21). Unii autori au propus ca intensitatea durerii sa fie cel mai important dintre cele patru caracteristici ale durerii la migrena fara aura. Astfel, aceasta poate ajuta in diferentierea migrenei fara aura si CTT (18, 21). In acest studiu, noi am gasit o relatie dintre severitatea intensitatii durerii si cateva alte caracteristici migrenoase, facand o analiza a situatiei tuturor pacientilor. Insa, n-am fi putut constata nici o relatie intre pacientii cu cefalee migrenoasa si CTT, considerate aparte una de alta. Aceasta constatare a relevat ca atunci cand durerea devine mai severa, ea capata caracteristici migrenoase, cum ar fi pulsatia, agravarea starii fizice, greturi, vome si phonofobia. Totusi, caracterul unilateral si photofobia nu au fost determinate ca fiind datorate intensitatii durerii. Comparand CTT cronic si episodic, greturile, vomele si phonofobia au fost gasite ca mai des intalnite in cazul CTT cronice. Aceasta descoperire este considerata in corespundere cu criteriul IHS, conform caruia simptomele apar mai ales la CTT cronice. Prevalenta migrenei studiata timp de un an corespunde rezultatelor altor studii (22). Insa noi am depistat mai multi pacienti MWA decat MWOA, faptul care este surprinzator de contradictoriu fata de rezultatele altor studii (2, 10, 21, 23). Prezenta aurei face ca

MWA sa fie mai usor depistata. Exista si o problema diferentiala mai cu seama intre cefaleea de tip tensional episodica si migrena fara aura (24, 25). De asemenea, uneori aceste doua tipuri de cefalee pot coexista la unul si acelasi pacient (26, 27). In asa caz, in studiul efectuat de noi, pacientii s-ar fi putut plange doar de cefaleea de tip tensional, care probabil este mai frecventa si retinuta ca cea mai deranjanta, ca raspuns la intrebarea: Aveti dureri de cap pronuntate, care deranjeaza?. Prevalenta CTT de un an a fost similara celor prezentate in alte studii (8, 28). Prevalenta cefaleei de tip tensional cronice a fost depistata in 2-3% de cazuri conform studiilor precedente (6, 28). Coeficientul de prevalenta CTT cronica prezentata de noi, a fost mai inalt (6.3%) comparativ cu cele, similare studiului efectuat mai devreme in Turcia (2). In studiul nostru, prevalenta migrenei a fost mai inalta la grupul de varsta 35-44 de ani si respectiv mai joasa la grupul de varsta mai mare de 65 de ani. Acest fapt corespunde rezultatelor multor studii (14, 29-34). Rata mai mare a migrenei la femeile de varsta reproductiva, comparativ cu femeile de alte varste a fost legata de prezenta oestrogenului (35). Inainte se sugera ideea ca migrena este asociata cu inteligenta sporita si clasa sociala (9). Mai tarziu, in unele studii, a fost regasita tot mai des la pacientii cu un nivel mai jos de educatie si o situatie economica mai slaba (1, 6, 10, 36-39). Am depistat o rata mai mare a prevalentei migrenei la pacienti cu studii si casatoriti. Totusi, statutul profesional si nivelul economic nu au fost gasite sa aiba legatura cu rata prevalentei migrenei. In studiul efectuat de noi, prevalenta a fost gasita a fi mai mare in zonele urbane, opus rezultatelor prezentate de Martin et al. (40). In majoritatea studiilor, aria rezidentiala nu a fost corelata cu prevalenta. In literatura de specialitate, multe studii prezinta teoria ca prevalenta CTT este cea mai mare intre 30 si 39 de ani si apoi scade cu inaintarea in varsta (7, 28, 41). In cercetarile noastre, prevalenta CTT a fost determinata a fi mai mare la grupul de varsta 45-64 de ani. Aceasta descoperire poate fi atribuita unur stresuri sociale in viata familiala a grupului de varsta respectiv. Nu am putut identifica nici o legatura intre alte proprietati socio-demografice si prevalenta CTT, in conformitate cu alte studii (42). Am observat ca tipul de CTT cronic se intalneste la cei varstnici si cu mai putine studii, ceea ce coincide cu descoperirea facuta de Schwartz et al. (28). In literatura, aproape jumatate din persoane care sufera de migrena si mai mult de 80% de persoane cu CTT au recunoscut ca nu au contactat un medic generalist pentru cefalee (22). In cazul femeilor si pacientilor suferinzi de migrena, procentul de prezentare la consultatii au fost declarate a fi mai mare (43). Procentul de prezentare la

consultatii la medicii generalisti a fost mai mare decat cel indicat in studiile precedente, fapt datorat posibil studiului nostru care se efectueaza la femei. Am avut cateva limitari in studiul nostru. Rasmussen et al.(29) a indicat ca modul in care sunt puse intrebarile despre cefalee, cum ar fi Suferiti de dureri de cap? sau Ati avut vre-odata dureri de cap? ar putea influenta rezultatele studiilor epidemiologice. Presupunem ca utilizarea cuvintelor a suferi de a fost indicata sa aiba o prevalenta mai mica decat utilizarea verbului aveti. Aceeasi idee este aplicata, in studiul nostru, si intrebarii Aveti dureri de cap pronuntate, care deranjeaza?. Am pus intrebari detaliate despre caracterul celor mai suparatoare dureri de cap subiectilor. Aceasta exprimare ar putea fi confundata de unii pacienti, care sufera de mai multe tipuri de dureri de cap si ar putea influenta prevalentele. Aceasta insa este o problema generala in incercarile de a face o clasificare a pacientilor in grupuri, conform tipurilor de cefalee. Intervievarile sunt o metoda preferata in cercetarile masive (44). In acest studiu, studentii la medicina, antrenati de neurologi, au efectuat intervievari, iar deciziile finale asupra cazurilor intalnite au fost luate atat de neurologi cat si de studenti. Totusi, ar fi fost mai bine daca cei care intervievau pacientii sa fi fost neurologi specializati in obiectul cefaleelor. Studiul a fost efectuat in exclusivitate la femei, deoarece stabilirea unui contact cu ele a fost mai usoar decat in cazul barbatilor si pentru ca ele pot fi mai usor gasite acasa. De altfel, femeile sunt o categorie speciala si importanta in studierea cefaleelor.

Concluzie Aceste cercetari, bazate pe cercetari masive, a avut ca obiect de studiu caracteristicile clinice si factorii socio-demografici in manifestarea migrenei, CTT si a subtipurilor lor. Credem ca aceste cercetari sunt de asemenea interesante, deoarece discutarea simptomelor clinice si relatia lor cu severitatea durerii este actuala.

Neurol Sci. 2003 May;24 Suppl 2:S122-4.

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Prevalence of primary headaches in Italian elderly: preliminary data from the Zabut Aging Project.
Camarda R, Monastero R.

Adult Headache Centre, Department of Neurology and Rehabilitation, Institute of Neuropsychiatry, University of Palermo, Via La Loggia 1, I-90129 Palermo, Italy.

We describe preliminary 1-year prevalence data of recurrent migraine headache (MH), tension-type headache (TTH), and other headaches (OH) in a rural elderly population. A door-to-door two-phase survey was conducted on all elderly (>or=65 years) residents of a rural village in southern Italy. Participants underwent a two-phase screening including a validated semi-structured questionnaire for headaches based on the International Headache Society criteria, and a neurological evaluation. Recurrent headache was defined as 3 or more attacks within the past 12 months. Out of 1031 participants evaluated, 225 (21.8%) suffered from recurrent headaches. One-year prevalence rates for headaches were respectively 4.6% for MH, 16% for TTH, and 1.3% for OH. For MH and TTH, but not for OH, prevalence rates were significantly higher for women than for men. Only MH prevalence rates significantly decrease with increasing age. In our population, about one-fifth of elderly subjects suffered from recurrent primary headaches. Prevalence rates were higher in women, and tended to decline with increasing age. PMID: 12811609 [PubMed - indexed for MEDLINE]

What's Related: Primary headaches in obese patients December 2005. "Obesity is a major public health problem worldwide. Little is known about the prevalence and impact of headache disorders in obese patients. The objective of this study was to assess the prevalence of primary headaches in obese patients and controls. METHOD: Seventy-four consecutive obese patients from the obesity surgery service were studied, and compared to controls with body mass index less than 25. RESULTS: Fifty-six patients (75%) had a headache diagnosis, 49 migraine (66%), 7 tension-type headache (9%), 36 (48%) had incapacitating headaches. CONCLUSION: Primary headaches are more common and incapacitating in obese patients than controls, migraine is the most important diagnosis in this population. Headaches should be properly diagnosed and treated in obese patients." Obesity and migraine. A population study. December 2005. "To assess the influence of body mass index (BMI) on the prevalence, attack frequency, and clinical features of migraine. METHODS: In a population-based telephone interview study, the authors gathered information on headache, height, and weight. The 30,215 participants were divided into five categories, based on BMI: 1, underweight (<18.5), normal weight (18.5 to 24.9), overweight (25 to 29.9), obese (30 to 24.9), and morbidly obese (>/=35). Migraine prevalence and modeled headache features were assessed as a function of BMI, adjusting by covariates (age, sex, marital status, income, medical treatment, depression).

RESULTS: Subjects were predominantly female (65% female) and in middle life (mean age 38.4). BMI group was not associated with the prevalence of migraine, but was associated with the frequency of headache attacks. In the normal weight group, 4.4% had 10 to 15 headache days per month, increasing to 5.8% of the overweight (odds ratio [OR] = 1.3), 13.6% of the obese (OR = 2.9), and 20.7% of the morbidly obese (OR = 5.7). The proportion of subjects with severe headache pain increased with BMI, doubling in the morbidly obese relative to the normally weighted (OR = 1.9). Similar significant associations were demonstrated with BMI category for disability, photophobia, and phonophobia. CONCLUSION: Though migraine prevalence is not associated with body mass index, attack frequency, severity, and clinical features of migraine increase with body mass index group."

Ho K-Hand ONG BK-C. A community-based study of Headache diagnosis and prevalence in Singapore Cehalalgia...13. de la 27.02.2003 Prevalena general pe timpulvieii a fost estimat a fi 80% la brbai i 85% la femei, i nu s-a diminuat cu vrsta. Dac inem seama de toate, mai multe femei suport cefaleele, incluznd migrenele i att femeile, ct i brbaii, practic la fel de frecvent suport cefaleea de tip tensional.
Male(%) Migraine Episodic tension-type Chronic tension-type 2,4 11,1 0,9 Female(%) 3,6 11,8 1,8

Incluznd cazurile, ce sunt aproape de a satisface criteriile IHS, prevalena migrenei a fost 9,3%, 40% pentru cefaleele episodice i 2,4% pentru cefaleea de tip tensional cronic. Vrsta atacurilor de cefalee nu difer printre migrenoi i cei cu CTT. Cu puin peste 34% din suferinzii de migren suport cefalee fiecare cteva luni; 53%ctva timp pe lun i 13%- de cteva ori pe sptmn. Migrena survine cu mult mai frecvent dect cefaleea de tip tensional n general. Triggerii cefaleelor Rezultatele studiului arat, c lipsa somnului va fi cea mai frecvent cauz a cefaleei de tip tensional.Suferinzii de migren menioneaz stresul mental(ncordarea psihic) drept factor principal, urmat de lipsa somnului. Pentru acei, la care dieta e factorul, ce provoac cefaleea, alcoolul e cel mai frecvent factor solitar(20,4%), urmat de alimentele picante(9,7%) cele calde(7,7%) i de alimentegrase(4,9%). Comparaii cu alte studii populaionale Prevalena migrenei n acest grup (3,1%) corespunde cu prevalena general joas a migrenei n comunitile Chinei(la rasa mongoloid)(0,63-1,5%), n comparaie cu cei

de ras alb(caucazieni)(8,1-16%) sau negroid(africani)(3,0-7,2%). Dr. Ho a spus, c factorii de mediu, culturi genetici influieneaz prevalena migrenei. Frecvena ataccurilor de migren este similar cu cea gsit n studiile German i Etiopian. Dr. Ho menioneaz, c se evideniaz o disabilitate mai mare din cauza migrenei dect din cauza altor tipuri de cefalei, aceast descoperire pote avea implicri economice. Ambele tipuri de CTT: episodic i cronic sunt relativ mai rar ntlnite n Singapore fa de studiile din alte ri. Studiul dat n-a gsit diferene statistice de vrst privind CTT, dar nu cefaleele migrenoase, frecvena CTT n Singapore poate fi mai joas dect oriundeDatele noastre sugereaz, c CTT i Migr. sunt entiti cu diferii factori precipitani. Stresul, exerciii fizice excesive, clima, somnul insuficient au fost triggerii pentru ambele: migren i CTT n acest studiu. Deasemenea, menstruaia, alcoolul i alimentele pot provca de asemenea migrena i CTT. Sntatea n Singapore este considerat n general ca bun dup standardele internaionale.Ambele sectoare: cel public l asigur la 80% spitalele i 205 de instituiile private... Hadache: The Journal of Head and Face Pain Vol 45 Issue 1 Page 32 January 2005 Migraine Prevalence and Some Related Factors in Turkey Yahya Celik et al. Rezultate: Prevalena pe via al migrenei a fost gsit ca 19,9%(95% CI: 18.321.5) (9,34% (95% CI: 8,610)) la brbai, 29,3% (95% CI: 2731.6) la femei). Concluzii: Aceste rezultate demonstreaz, c ntreaga prevalen a migrenei la femeile din Turcia este mai nalt dect cele raportate n studiile anterioare din Europa i SUA, prevalena pe via este similar n toat populaia. Oscar H DelBrutto, Department of Neurological Sciences, Hospital- Clinica Kennedy, Guayaquil(09-01)3734, Ecuador. Studiile epidemiologice n rile dezvoltate au artat o prevalen de 40% al cefaleelor sporadice i 15% al cefaleelor primare cronice- migrena i CTT n populaia general. Deoarece majoritatea pacienilor sunt tineri i aduli de vrst medie n ani lor productivi, cefaleea are un impact economic uria, care se estimeaz n cteva milioane de dolari pe an.

n America latin, magnitudinea patologiei e dificil de apreciat din cauza, c studiile bune sunt rare(puine). Problema o alctuiesc suprafeele, unde mase largi ale populaiei n-au acces la doctor i unde nu sunt accesibile facilitrile pentru diagnostic. Totui, studiul recent din Brazilia, Chile i Ecuador demonstreaz, c cefaleea are o prevalen nalt n aceste ri i impune o povar considerabil pe sistemul de ocrotire a sntii, care e deja la limit. Ca i n rile dezvoltate, migrena i CTT sunt cele mai rspndite subtipuri ale patoogiilor cefalalgice n America de sud. Acceasta poate fi explicat parial de statutul socio-economic jos al unui numr mare al populaiei, ct i de susceptibilitatea genetic, obiceiurile alimentare, condiiile de mediu. Condiiile de mediu pot fi un factor de risc important pentru cefalei, n special pentru oamenii, ce locuiesc la altitudine nalt n regiunea Anzilor. Alte studii au demonstrat, c unele patologii parazitare ale sistemului nervos aa ca neurocisticercoza, mai au o pondere mare n prevalena nalt a cefaleelor cronice n aceast zon. Cefaleea de abuz medicamentos n-a fost investigat n America de Sud, dar ea poate fi nalt n rile, unde majoritatea oamenilor se trateaz desinestttor la majoritatea patologiilor i analgezicele pot fi obinute de la fermacii fr prescripii. Scenariul cefaleelor cronice oate fi mai mult sau mai puin acelai n rile n curs de dezvoltare ca i n cele dezvoltate,dar prevalena, cauzele i pronosticul cefaleelor acute este practic diferit. n America de Sud astfel de procese infecioase ca dengue, salmoneloza sau encefalita viral(Venezuelan equine encephalitis) ocup un mare procent din cazurile de cefalee acute la pacienii, ce se prezint la ca cabinetul de urgen. Aceste patologii trebuie diagnosticate i tratate la timp pemtru a evita continuarea morbiditii i al mortalitii.

S 111 European Journal of Neurology 2005.12(suppl 1)59-62. Original Article Cost of migraine and other headaches in Europe. Costul migrenei i a altor cefalei n Europa. J.Berg and L.J. Stovner Cu mai bune(mai optime), dar mai costisitoare opiuni de tratament devenite mai accesibile pe parcursul ultimilor 10- 15 ani migrena i alte patologii cefalalgice au devenit subiectul unui interes considerabil pentru economia sntii i perspectivele sntii publice.

n raportul OMS, din 2000 grade de severitate a diferitor patologii, pacienii cu atacuri severe de migren au fost considerai mai afectai dect cei cu psihoze active, demene sau cei cu tetraplegie. Privind numrul de ani trii cu disabilitate(ILDs), cauzate de variate patologii mondiale, migrena depete numrul 19 ( numrul 9 la femei(printre femei))(Maters et al. 2002). Migrena e o form relativ sever de cefalee, ce survine n form de atacuri, de obicei cu durata ntre 4 ore i 3 zile, acompaniat(nsoit) de fenomene dizabilitante ca greaa sau vomele, intolerana sever a luminii, sunetelor, mirosurilor i al micrilor corpului. Cefaleea de tip tensional e de obicei mai puin dizabilitant ca migrena i cu mai puine fenomene asociate( de acompaniere, de nsoire). Acest tip de cefalee nu a fost considerat n raportul OMS cel mai impotant( mai presus de orice), dar deoarece el este cel mai prevalent tip de cefalee i de asemenea are tendina de a deveni cronic la o substanial parte a pacienilor, consecinele individuale i sociale ale CTT pot fi la fel de semnificative ca i cele ale migrenei. Alte forme relativ rare, aa ca cefaleea n ciorchine(cluster), poate fi chiar mai disabilitant dect migrena pe timpul atacului. Fr a ine cont de diagnoz consecina pentru majoritatea suferinzilor este, c funcia normal este ntrerupt de episoade de cefalee cu intervale neregulate i imprevizibile, iar aceasta poate impune severe limitri n viaa cotidian, la coal, munc i pe parcursul timpului de odihn. Aceasta i faptul, c patologiile date par a fi extrem de prevalente n toat lumea, le face importante din punctul perspectivei economice. Faptul, c cefaleele predomin la femei i c suferinzii de dureri de cap au o ateptare a vieii normale poate explica de ce pacienilor cu cefalee nu li s-a acordat atenia i resursele, pe care ei le merit. Prezentul studiu(cercetare) este o ncercare de a calcula costul patologiilor cefalalgice n Europa, bazat pe studiu epidemiologic i economic. Metodologia Cercetrile studiilor epidemiologice relevante au fost descrise anterior n revistele studiilor epidemilogice al cefaleelor n Europa(Stovner et al.) Studiile epidemiologice privind cefaleea i migrenele sunt accesibile pentru majoritatea rilor Europei de Vest, dar sunt foarte puine studii pentru Europa de Est i cele privind cefaleea de tip tensional. Doar studiile bazate pe populaie cu date epidemiologice privind cefaleea n general , migrena i cefaleea de tip tensional au fost incluse n studiu(overview). Caatare nu sunt studii(virtual), ce ar avea date despre incidena cefaleelor i aproape toate studiile au prezentat rata prevalenei(de 3 luni, de 1 an sau pe via).

Majoritatea studiilor au utilizat ratele prevalenei de un an ( pe 1 an), parametrul, ce indic proporia populaiei cu patologie activ(prezent), ce este mai relevant pentru calcularea consecinelor economice. Privind migrena i cefaleea de tip tensional doar studiile aprute dup ncercarea(advent) publicrii n 1988 al criteriilor de diagnostic de Societatea Internaional de Cefalei(IHS) au fost discutate(luate n consideraie). Datele extrase din acest studiu au fost prevalena general i distribuia printre sexe i diverse grupuri de vrst i de fiecare dat accesibile datele despre prevalena cefaleei cronice(definite ca cefalee, ce dureaz > 15 zile pe lun sau e zilnic), frecvena cefaleei(numrul zilelor pe lun sau pe an) i absenteismul la serviciu. Cercetrile metodologiei i a rezultatelor studiilor economice de sntate au fost deasemenea descrise detaliat anterior(Berg, 2004). Bazate pe studiera literaturii studiilor, ce conin date despre costul migrenelor i a altor cefalei, 11 studii Europene, care au evaluat costurile direct i indirect al migrenei au fost identificate. Trei din aceste studii au fost excluse din cercetare din moment ce ele nu au utilizat perspectivele sociale. N-au fost gsite studii, ce ar analiza costul cefaleei de tip tensional sau alte cefalei nemigrenoase. n concluzie costul estimat pentru migren a fost accesibil pentru Frana(Mchel et al., 1993,1999),Germania(Neubauer and Ujlaky, 2002), Niderlanda(Van Roijen et al., 195), Spania(Lainez, 2003), Suedia(Bjork and Roos, 1991) i din Marea Britanie(Blau and Drummond, 1991; Cull et al., 1992). n general majoritatea studiilor au fost efectuate nainte de 1995, nsemnnd, c impactul clasei triptanelor asupra ambelor- costului direct i indirect nu a fost inclus n acest studiu. Deoarece aceste medicamente probabil(posibil) au dus la creterea costului medical direct, aceasta ar putrea duce la salvarea termenilor sau ameliora productivitatea. Deoarece nu sunt studii bazate pe populaie, privind costul patologiilor, care au condus la aprecierea potenialelor schimbri n distribuia costului, rezultat din patternul nou de tratament. Toate identificrile costurilor estimate s-au bazat pe prevalen, dar au fost altfel primite(derivate, extrase prin amestecarea metodologiilor).Costul direct a fost mai frecvent calculat, utiliznd modurile de abordare cele mai inferioare, n timp ce costul indirect a fost mai des obinut prin metoda de vrf. n cazul migrenei vizitele pacienilor de ambulator i tratamentul farmacologic s explice(s justifice majoritatea costurilor medicale directe .(?)

Studiile bazate pe populaie, analiznd costul indirect au utilizat de obicei chestionare pentru estimarea impactului migrenei, privind lipsa de la lucru i producivitatea. N-au fost identificate studii, care ar statifica costul dup vrst sau severitate bolii.Datele costurilor au suferit inflaie n jurul anului2004 cu indicele de pre al consumatorului i schimbat n Euro, ajustat la puterea de cumprare (Eurostat, 2004 a,b; European Central Bank, 2004). Rezultate Lund n consideraie datele epidemiologice, au fost gsite mari variaii n prevalena att a migrenei, ct i a cefaleei n diferite ri Europene(Tab.1). Durerea de cap i migrena au prevalat n grupurile de vrst de la 20 pnla 50 ani la ambele sexe i aici era o preponderen feminin clar n tote grupurile de vrst, cu excepia copiilor. Selectnd articole, care includeau grupuri de vrst de cel puin 25-65 ani, a fost gsit media prevalenei de 1 an a durerii de cap ca fiind-51%(61%- femei; 44%Brbai), a migrenei-14%(17%- femei, 8%- brbai), a durerii cronice de cap4%(6%-femei, 2%- brbai). Deoarece a fost efectuat numai un studiu, care percepea prevalena de 1 an al CTT la aduli, nu a putut fi calculat media pentru acest tip de dureri de cap. Deseori a fost dificil de comparat datele despre durerea de cap din diferite studii, dar pare , c att migrenoii,ct i cei cu CTT au dureri de cap n medie 30 de zile pe an. Relativ recent i studiile bazate pe populaie au indicat, c 14-15% din persoanele adulte au absentat de la serviciu din cauza durerii de cap n Danemarca(Rasmussen et al.,1992) i n Anglia(Boardman et al., 2003), i numrul zilelor absentate de la serviciu erau de la 1100 pn la 1300 zile pentru 1000 de angajai pe an n aceste studii . Dac se iau n considerie studiile, ce vizeaz(au de afacere) consecinele economice a durerii de cap, a fost gsit, c costul anual, estimat pentru migren variaz substanial n dependen de 1 din 6 ri, unde au fost percepute(efectuate), ncepnd cu 100 Euro pentru un pacient n Suedia pn la 900 Euro n Germania. (Tab. 2.) Numrul zilelor cu eficacitatea lucrului redus au fost estimate ca fiind de 4 ori mai mare(Boardman et al., 2003) i totui rezultat ntr-o pierdere de timp de lucru chiar mai mare dect zilele absentate . Cauzele majore pentru aceste variaii nu sunt corecte n diferite metodologii i ani de referin. Marea majoritate a costurilor totale, ntre 72% i 98% sunt din cauza pierderii productivitii, sub forma absenei de la serviciu i o medie a nivelului

eficacitii de 65%. n timpul lucrului cu migrena, care duce la pierderea a mai mult de 4,1 zile pentru un pacient. Costurile raportate la genuri, femeile tind s piard mai multe zile lucrtoare dect brbaii, dar costurile indirecte sunt similsre pentru salarii mai joase i fora de participare printre femei. Discutarea(dezbaterea) Principalele dificulti a datelor epidemiologice sunt lipsa de studii n pri mari a Europei(n particular n Est) i a puinelor informaii despre cefalei de tip tensional, care este i cel mai frecvent tip de durere de cap. Cea din urm deficien este compensat de datele bune despre cefalei n general, dup ce se poate aprecia rezonabil c diferena dintre prevalena cefaleei i cea a migrenei pentru un nalt grad(>80%) const din pacienii cu CTT. Analiznd variaiile n prevalena durerii de cap dintre diferite studii i ri, pare, c cea mai mare parte, dac nu n ntregime, din aceast variaie poate fi asociat ca diferene de metodologie. Factorii metodologici importani par a fi vrsta i compoziia n dependen de sex a populaiei, tipul prevalenei perioadei( un an versus prevalena pe via), i cile criteriilor Societii Internaionale de studiere a cefaleei(IHS) sunt implimentate n studiu. Frazarea exact a ntrebrii ecranizate(?) este foarte important, dup cum ratele prevalenei cefaleei sunt n general mult mai nalte n studii, utiliznd o ntrebare neutr(Ai avit dureri de cap?) dect n studiile cu o ntrebare referitoare la gradul cefaleei sau a frecvenei cefaleei.(Ai suferit vreo dat o durere de cap, Ai avut mai mult de 3 cefalei n ultimul timp X?, etc. ). Avnd n vedere faptul, c este imposibil de corectat aceste diferene metodologice n mod sistematic, nimeni nu poate concluziona cu precizie faptul, c acestea sunt variaii reale n prevalena cefaleei de-a lungul coninutului. Deci pentru calcularea costurilor durerii de cap bazate numai pe date epidemiologice pentru orice ar n particular, probabil este mai corect de a folosi datele sumare pe prevalena dat n selectarea rezultatelor . O problem principal n informaiile despre cost accesibile n Europa i n State este c ele se refer doar la migren. Spre cunotina noastr nici un studiu nu a cuprins costurile CTT sau a cefaleelor nemigrenoase ca informaii( pentru date). Aceasta conine un gol major n cercetrile curente, de cnd Ctt afecteaz o proporie mult mai mare a populaiei, dect o face migrena i totui un component major al costurilor cefaleei nu poate fi estimat cu precizie. Pe deasupra studiile costurilor de boal n cazul migrenei identificate pe parcursul acestui sondaj s-a bazat n principiu pe datele obinute n 1995, nsemnnd, c majoritate costului estimeaz , c nu s-au identificat schimbri recente n strategiile de management(control) a pacientului, incluznd utilizarea medicamentelor cu triptan. n medie, se pare datele disponibile despre pre n Europa se afl sub estimarea costurilor actuale.

Pe de-o parte estimarea cea mai aproape de nivelul minim, n general folosit pentru costurile directe poart riscul subestimrii sau neglijrii itemii relevani a costurilor, n timp ce costurile indirecte au o sensibilitate nalt la metoda de calculare utilizat, care variaz pe parcursul studiilor. Totui, estimrile conservative luate din studiile relevante constituie pragul minim al costului. n fnal, majoritatea studiilor despre cost nu au inclus copii i adolesceni n evalurile sale, nsemnnd, c costurile introduse de acest segment a pacienilor nu snt implicate. Oferind disponibilitatea limitat a studiilor moderne i surprinztoare de cost al bolii pentru majoritatea rilor Europene, oricare estimare al impactului total al migrenei i a altor cefalei n Europa trebuiau s fie interpretate ca cele mai bune presupuneri, bazate pe o eviden disponibil(util) i presupuneri rezonabile. Totalitatea diferenelor absolute i relative a preurilor ntre ri trebuie ajustate, calea prin care serviciul de sntate e finanat i furnizat e i mai greu de evaluat. Cea mai reuit cale de extrapolare din datele existente este utilizarea mediei celor mai reprezentative estimri a costului ca baz. Pentru migren, estimrile relevante a costurilor sunt din Marea Britanie, Germania(ajustate cu utilizarea ratei salariale n loc de venitul total intern familial pentru costul indirect ) i Frana (ajustate, adaptate) cu utilizarea mediei dintre Marea Britanie i costurile adaptate din Germania cu productivitatea redus de munc).Studiul Danez nu a fost inclus datorit utilizrii metodei neclare de apreciere a costului. Astfel costul anual mediu e de 590 Euro pentru un pacient cu migren poate fi asumat de aceste trei ri europene. De aici sunt 14% de migrenoi printre aduli, costul anualtotal al acestei patologii n rile date poate fi estimat de numrul adulilor n populaie0,14 590 Euro. O estimare i mai aproximativ pentru costul cefaleei, mai degrab dect migrena singur(n parte poate fi obinut prin utilizarea rezultatelor din Danemarca (Rasmussen et al., 1992) i Marea Britanie(Boardman et al.) studiile bazate pe populaie, care la un loc (mpreun) demonstreaz, c n jurul a 1100-1300 zile la 1000 de persoane, ce lucreaz, au lupsit de la serviciu din cauza cefasaleei n fiecare an. Cercetrile Britanice de asemeni sugereaz c numrul zilelor cu reducerea eficacitii (n= 5213) e aproximativ de 4 ori mai mare dect numrul zilelor omise(lips) (n=1327). Dac cineva presupune, c eficiena lucrului a fost redus (s-a redus) cu o treime pe parcursul acestor zile( privete secia rezultatelor) de aici rezult, ca adaos la 1700 zile de munc pierdute(i.e)din totalul a 3000 zile pentru 1000 de lucrtori au fost probabil pierdute din cauza cefaleei n fiecare an. Productivitatea pierdut din cauza cefaleei a putut fi calculat(estimat) dup aceea n baza a 3 zile pierdute pe an pentru toi angajaii, care, spre exemplu n

germania au rezultat din costul indirect de 18 Euro pe an din cauza cefaleei. Presupunnd acestea, pentru estimrile ajustate pntru migren, costul direct constituie aproximativ 8% din costul indirect, costul total pentru pacienii cefalalgici(fr corespundere cu diagnoza) pot fi apoi aproximate pe baza ratei prevalenei 51%n populaia general. Utiliznd estimrile din Frana, Germania, Marea Britanie costul total pentru pacienii cefalalgici putea fi astfel estimat brut la 425 Euro pe an(din care 394 Euro ar fi costul indirect i 32 E.- costul medical direct. Totui, deoarece aceste date s-au bazat pe estimri aproximative a costului cefaleei d tip tensional, costul total al cefaleelor poate fi scopul(centrul) viitoarelor cercetri i nu va fi utilizat la estimarea costului patologiei creierului la aceast etap. Concluzii n sumar, migrena cu prevalena de 1 an de 14% la populaia adult pare s determine costul de 590 de Euro pe an pentru pacient n rile Vest-Europene. Nu au fost gsite date despre costuri pentru Europa n privina cefaleei n general i deci estimarea costului agregat(?) se centreaz pe migren. Dei costul unui pacient pentru alte tipuri de cefalei pare a fi ceva mai jos dect cel pentru migren, costurile ntregii societi pentru cefalee sunt, desigur, mult mai mari dect ceea, ce poate fi calculat n baza datelor migrenei, n timp, ce cefaleea afecteaz n general 50% din populaie n fiecare an. Ambele costuri i datele prevalenei trebuie, totui , considerate (ca date curente cu cele mai bune aproximri) asupra epidemiologiei i a costului migrenei i a altor dureri de cap(suferine). n plus datele despre costuri nu sunt recente i nu iau n consideraie evoluiile(descoperirile) recente n managementul durerilor de cap. Prin urmare este nevoie de a avea studii recente i bazate pe nelegerea populaiei, care includ toate costurile, care rezult din cauza migrenei i a altor cefalei. Sunt necesare i alte studii din ri aflaten afara majoritii pieelor farmaceutice din Europa de vest. La un nivel metodologic, o apropiere standartizat i s sperm mai de ndejde(ncredere) asupra costului de boal ar facilita o viitoare hotrre asupra fondrii cercetrilor de cefalei i managementul lor. Pentru noi msuri severe de(soluionare a problemei) urgen a durerii de cap, ar fi important de neles cum sunt relatate costurile la severitatea bolii, astfel nct strategiile de management pot fi specificate pentru fiecare subpopulaie.

n special viitoarele analize a diferito r msuri(date) ale productivitii sunt necesare pentru a permite o evaluare real a costurilor indirecte, care constituie ...(?) atacului migrenei. n acest context, ar fi interesant de neles costurile intangibile a condiiei prin conducerea cercetrilor asupra scorurilor utilitare pentru diferite nivele ale severitii i a costurilor relatate calitii anilor de via , pierdui din cauza migrenei.

A dobindi vindecarea este mai presus de orice in stiinta medicala, mai multe cai, ns ducnd ctre aceast inta, trebuie s-o alegem pe cea mai puin vtmtoare" HIPOCRATE

"FERICIT E ACELA, ASCUNS A LUCRURILOR"

CARE

PUTUT

CUNOASC

CAUZA

VERGILIUS, poet latin

Headaches & Migraines

Puff, Puff, Puff Throb, Throb, Throb Smoking and Headaches: Another Reason To Quit Join the Discussion

Fumatul i fumatul pasiv sunt triggeri principali pentru majoritatea cefaleelor, n special al migrenelor i a cefaleei cluster. Fumatul blocheaz semnificativ reducerea cefaleei cronice cotidiene, abinerea de la fumat practi elimin cefaleele majoritii suferinzilor de cefaleele cronice cotidiene. Fumatul reduce eficiena multor, dac nu a tuturor tratamentelor doastre pentru cefalei.
Headache: The Journal of Head and Face Pain Volume 36 Issue 9, Pages 561 - 564 Published Online: 24 Feb 2002 An Epidemiological Study of Headaches Among Medical Students in Athens Dr. D.D. Mitsikostas, MD 1 2 * ; Dr. S. Gatzonis, MD 1 ; Dr. A. Thomas, MD 1 ; Dr. N. Kalfakis, MD 1 ; Dr. A. llias, MD 1 ; Dr. C. Papageoergiou, MD 1

1 Department of Neurology, Aeginition Hospital, Athens, Greece Naval Hospital, Athens, Greece.

2 Department of Neurology Athens

Correspondence to Dr. Dimos-Dimitrios Mitsikostas, Department of Neurology, Athens Naval Hospital, 70 Dinokratous Str., Athens 115 21, Greece. Copyright American Headache Society KEYWORDS headache migraine tension-type headache prevalence epidemiology students Greece ABSTRACT Accepted for publication February 8, 1996.

Cu scopul studierii prevalenei cefaleelor frecvente printre studenii medici al Universitii din Atena, a fost efectuat studiul epidemiologic printre 588 studenii medici(318 men and 270 women),cu vrsta medie de23,5 ani. Dou chestionare au fost utilizate n
studiu: unul general, ce a constat din 10 ntrebri i cel de-al doilea, specific pentru suferinzii de migren, compus din 117 ntrebri. Toi acei cu cefalei, care au completat voluntar cele dou chestionare au trecut examinarea neurologic. 30,8% din brbai i 50,3% din femei au raportat diverse atacuri de cefalee pe parcursul celor 6 luni precedente(39.6% la ambele sexe). Totui, doar 1,9% din studeni de ambele sexe)au declarat, c au suportat cefalei copleitoare. Prev. de 6 luni al migrenei a fost de 2,4% i 9,55 pentru cefaleea de tip tensional( la ambele sexe). Cefaleea cluster n-afost depistat. Prevalena cefaleelor neclasificabile(according to the criteria of the International Headache Society) a fost de 0.85%. Cefaleea a fost corelat cu sexul(mai frecvent printre femei) i nivelul anxietii(Hamilton scale for anxiety). Prevalena cefaleei n-a fost corelat cu fumatul i clasa social. 2008 European Federation of Neurological Societies The Official Journal of the European Federation of Neurological Societies (EFNS) European Federation of Neurological Societies (EFNS) Headache prevalence related to smoking and alcohol use. The Head-HUNT Study A. H. Aamodt a,b , L. J. Stovner a,b , K. Hagen a,b , G. Brthen b and J. Zwart a,b,c KEYWORDS alcohol epidemiology headache migraine smoking ABSTRACT

Scopul acestui studiu a fost examinarea posibilei asocieri dintre fumat, alcool i cefalee ntr-un vast studiu populaional. Un total de 51 383 subieci au completat chestionare privind
cefaleea i au constituit Studiul 'Head-HUNT. Informaia privind fumatul a fost disponibil la 95% cazuri, iar alcoolul la 89% de pers. asocierea a fost evaluat n analize multiple, s-a estimat raportul prilor(odds ratios-ORs)la 95% cu interval de confiden(Cl).Rata prevalenei la cefalei a fost nalt printre fummtori n comparaie cu nefumtorii(n-au ncercat niciodat), mai evident printre cei sub 40 ani, ce fumeaz mai mult de 10 igri pe zi(OR 1.5, 95% CI 1.31.6). Fumatul pasiv a fost deasemenea asociat cu prevalena nalt a cefaleelor. Pentru utilizarea alcoolului, a fost o tendin de scdere a prevalenei migrenei cu creterea cantitii de alcool consumat n comparaie cu cei, ce nu consum(alcohol abstinence). Doar privind simptomele ,ce indic abuzul de alcool, a fost gsit o asociere pozitiv cu cefaleele frecvente. Asocierea dintre cefalee i fumat a fost gsit n studiul present strnee(raises) ntrebri privind relaia cauzal,(e.g.), c fumatul cauzeaz cefaleea, sau fumatul calmeaz atenuiaz stresul Indus de cefalee.

Asocierea negativ observat dintre cefalee i consumul de alcool se explic probabil prin proprietile alcoolului de a provoca cefaleea .

Epidemiology, co-morbidity, and impact on health-related quality of life of self-reported headache and musculoskeletal pain a gender perspective . European Journal of Pain , Volume 8 , Issue 5 , Pages 435 - 450 K . Bingefors , D . Isacson Abstract Cefaleea i durerea musculo-scheletal sunt probleme majore de sntate public. Proporia substamial a celor care raporteaz c problemele de sntate(durerea) le afecteaz lucrul, viaa de zi cu zi i relaiile sociale. Studiile epidemiologice au prezentat n mod consistent c prevalena majoritii strilor atribuite durerii este mai nalt la femei dect la brbai. Design-ul studiului Studiu cross-sectional n inutul Uppland, Suedia, 1995. Cinci mii patru sute i patru de personae au completat chestionarul(RATA respondenei=68%). n aceste nalize au fost incluse 4506 de persoane cu vrsta ntre 20-64 ani. Rezultate Durerea de spate(22.7%) i durerea de umr(21.0%) erau cele mai des raportate probleme medicale de ctre persoanele chestionate , cei cu durere de mini/picioare(15.7%) erau pe locul cinci i cei cu cefalee(12.5%) pe locul opt. Au fost descoperite diferene majore dintre sexe. Prevalena condiiilor durerii, n special n cefalee, era mai nalta printre femei. Femeile au raportat o durere mai sever. Comorbiditatea dinte condiiile bolii i problemele psihiatrice i somatic era mai nalt pentru femei. Calitatea vieii legat de sntate(SF-36) era diferit n dependen de gen i condiia durerii. Dimensiunile fizice a HRQoL erau mai afectate de cefalee n azul brbailor; dimensiunile psihologie eraumai afectate n cazul femeilor. Att n cazul femeilor ct i brbailor , condiiile bolii erau associate cu condiii socioeconomice i factori ai stilului de via mai proaste dar au existat i diferene ntre sexe. Educaia i omajul aveau importan numai n cazul brailor n timp ce dificultile economice, serviciul n semi-ture i starea matrimonial erau associate cu durerea n cazul femeilor. Obezitatea,pensionarea buletinele pe caz de boal prelungite, i lipsa exerciiului fizic erau associate cu condiiile dreri n general. Factorii asociai cu condiiile durerii erau inegal distribuite ntre sexe. Concluzia. Exist diferene majore ntre brbai i femei n prevalna i severitatea durerii raportate individual n populaie. Factorii biologici pot explica unele dintre aceste diferene dar explicaia principal const probabil n diferenele dintre sexe ce in de serviciu, economie, viaa de zi cu zi, viaa social i ateptrile dintre femei i brbai. Dei condiiile de lucru mbuntite sunte importante, schimbrile sociale mai profunde sunt necesare pentru a reduce aprofundarea experienelor dureroase la femei i brbai.

SEX AND GENDER-RELATED DIFFERENCES IN PAIN AND ANALGESIC RESPONSE NIH GUIDE, Volume 26, Number 23, July 18, 1997 RFA: DE-97-003 P.T. 34

National Institute of Dental Research National Institute for Nursing Research National Institute on Drug Abuse National Cancer Institute Office of Research on Women's Health Letter of Intent Receipt Date: August 25, 1997 Application Receipt Date: September 25, 1997 RESEARCH OBJECTIVES Background The terminology used throughout this RFA encompasses both solely biological factors influencing differential pain or analgesic responses observed in male and female animals or humans (i.e., sex-related differences) and the interactions between biological factors and differential cultural expectancies, socialization, or experiential factors influencing pain or analgesic response in men and women (gender-related differences). Recent reviews of sex and gender differences related to pain highlight important questions that need additional study (Unruh, 1996; Fillingim and Maixner, 1995; Berkely, 1996; Miaskowski, 1996). In general, the existing research literature on experimentally-induced pain suggests that women tend to show lower pain thresholds, assign higher ratings of pain intensity to the same stimulus, and to discontinue pain- inducing tasks earlier (i.e., show lower pain tolerance) than do men. However, gender-related differences observed in response to experimentally-induced cutaneous pain are relatively small and are most reliably observed in response to mechanical or electrical (but not thermal) nociceptive stimuli. Animal studies also suggest that female rats, as compared with males, show enhanced discrimination of nociceptive stimuli, and are more likely to show persisting pain behaviors after experiencing procedures which can lead to neuropathic pain.

Several recent studies indicate that gonadectomy in both males and females decreases nociceptive thresholds, and that the administration of testosterone to gonadectomized males, as well as females, increases the antinociceptive effects of morphine. Other studies indicate sex-related differences in the underlying neurochemical mediation of stress-induced analgesia, the development of which is sensitive to the hormonal environment during early post-natal development. Several studies suggest that cyclical or pregnancy-related hormonal variations, as well as the use of exogenous hormones, influence pain. For example, data from both animal and human studies indicate marked endorphin-mediated increases in pain thresholds in pregnant females during the final days of gestation. Findings from a recent epidemiological study using a large, longitudinal data set obtained from a health maintenance organization indicated that post-menopausal estrogen use was associated with a 77% increase in the odds of referral for treatment of temporomandibular disorder (jaw) pain, even when patients' overall patterns of health care utilization had been controlled for statistically. Use of oral contraceptives was also significantly, though less strongly, associated with an increased probability of referral for treatment of temporomandibular disorder pain. Clinically, gender differences have been noted in the prevalence of a number of pain syndromes. Women, for example, show a higher prevalence of fibromyalgia, temporomandibular joint disorders, and rheumatoid arthritis, while cluster headaches, duodenal ulcers, and ankylosing spondylitis are more prevalent in men. In general, given the same diagnosis, women report greater pain intensity, indicate higher numbers of painful sites, and are more likely to use over-the-counter pain medications. In contrast, studies focusing on patterns of health care delivery suggest that health care professionals managing post-operative and cancer pain tend to provide less potent analgesic coverage for women as compared with men. In adolescence and early adulthood, women report higher levels of recurrent pain than do men. It has not been determined whether sexrelated differences in natural occurring experiences which generate pain (e.g., menstruation, pregnancy, parturition) may favor the

development of biological or behavioral changes altering pain sensitivity or analgesic response. Also, many questions remain regarding the mechanisms through which hormonal variations influence pain behaviors and response to analgesics. Few studies have focused on sex-specific differences in analgesic response. However, a recent study indicates that drugs activating kappa opioid receptors produce more powerful, persisting post-operative pain relief in females as compared with males. This and related work suggests the possibility that fundamental differences may exist in pain modulatory systems, or in interactions between sex hormones and pharmacological agents impacting upon pain and analgesic response. Scope of Research Sought This initiative focuses upon expanding our understanding of biologically significant differences between males and females in response to experimentally-induced or clinical pain or analgesics and the underlying mechanisms through which such differences occur. It is recognized that pain is a multidimensional phenomenon, including physiological, behavioral, sensory, cognitive, affective, and sociocultural factors.

Prevalence and Characteristics of Recurrent Headaches in Turkish Adolescents . Pediatric Neurology , Volume 34 , Issue 2 , Pages 110 - 115 A . Unalp , E . Dirik , S . Kurul These results indicate that approximately one half of Turkish high school students have recurrent headaches which reduce the quality of their lives. Obiectivele acestui studiu au fost determinarea prevalenei i caracteristicilor cefaleelor recurente i investigarea diferenelor socio-demografice dintre studenii universitilordin Izmir, Turcia cu i fr cefalei recurente. A fost utilizat metoda-mostr pe tape, stratificat n acest studiu bazat pe studeni, analytic, cross-sectional. 21 de universiti au fost selectate randomizat i 2384 preparatory, first-, second-, and third-grade high school students from 84 din diferite clase au constitutit cohort de studiu. Prevalena cefaleelor recurente a fost de 45.7% (1090/2384). Studentele femei au avut o frecven a cefaleelor considerabil mai nalt dect brbaii (P = 0.000). N-a fost o relaie evident dintre ani i cefalee (P = 0.065). Deasemenea, n-a fost o diferen semnificativ dintre adolescenii cu i fr cefalee pentru astfel de variabile ca divorul parental (P = 0.052), existena unui parinte vitreg (P = 0.32), oamenii cu care studentul tria n cas (P = 0.186), numrul frailor (P = 0.37), i nivelul educational maternal i paternal (P = 0.62 and P = 0.15, respectively). Frecvena cefaleei a fost nalt cnd nivelul venitului familiilor studenilor era jos(P = 0.016).

Printre studenii ce au avut cefalei 53.3% au utilizat medicaia, 37.3% au fost trimii la medic, i la 27.2% din ei li s-a stability diagnosticul. Absenteismul colar cu o parte de 26.5% a fost o problem rspndit printre studenii cu cefalee. Aceste rezultate indic c aproximativ o jumtate din studenii dinTurciaau cefalei recurente, care reduc calitatea vieii lor. Headache: The Journal of Head and Face Pain Volume 37 Issue 2, Pages 95 - 101 Published Online: 19 Jan 2002 Copyright 2008 American Headache Society Prevalence of Migraine and Headache in a High-Altitude Town of Peru: A Population-Based Study Assia S. Jaillard, MD Dr 1 * ; Pilar Mazetti, MD Dr 2 ; Edwin Kala, MD Dr 3 migraine headache epidemiology altitude Peru ABSTRACT Studiul populaional epidemiologic door-to-door bazat pe popoulaie al prevalenei migrenei i cefaleei ntr-un lot de 3246 pers.,mai mari de 15 ani a fost executat n Cuzco, un ora aflat la altitudine nalt n Anzii Peruani, apmlasat la 3380 metri. Printre 3246 de personae chestionate au fost 172 cazuri de migren i 930 cazuri de cefalee, supus unei prevalee crude de1 an este de 5.3% pentru migren (2.3% printre brbai i 7.8% printre femei) i 28.7% pentru cefalee (17.5% printre brbai and 38.2% printre femei). Rezultatele noastre sugereaz, c prevalena migrenei n Cuzco este aproape de aceea din alte ri dezvoltate pe cnd prevalena cefaleei poate fi mai nalt dect nalte ri dezvoltate.Multiple i variate studii logistice sugereaz, c ambele migrena i cefaleea au fost nrudite cu genul feminine, sex, vrst i anxietatea i sau depresia. Acest studio sugereaz, c migrena este o patologie relativ rspndit n Cuzco, dar nu demonstreaz nici o diferen , ce ar fi semnificativ legate de altitudine. n contrast, rezultatele noaste sugereaz, c cefaleea poate fi mai frecvent la altitudine nalt deasupra nivelului mrii.

J Headache Pain. 2008 April; 9(2): 119128. Published online 2008 February 19. doi: 10.1007/s10194-008-0024-z. PMCID: PMC2276239 Copyright Springer-Verlag 2008 Prevalence and burden of primary headache in Akaki textile mill workers, Ethiopia Getahun Mengistu Takele,corresponding author1 Redda Tekle Haimanot,1 and Paolo Martelletti2 1School of Medicine, Department of Neurology, Addis Ababa University, Addis Ababa, Ethiopia 2Master in Headache Medicine, 2nd School of Medicine and Surgery, Sapienza University of Rome, Italy, Rome Abstract Headache disorders are the most common complaints worldwide. Migraine, tension-type and cluster headaches account for majority of primary headaches and impose a substantial burden on the individual, family or society at large. The burden is immense on workers, women and children in terms of missing work and school days. There are few studies that show relatively lower prevalence of primary headaches in Africa as compared to Europe and America. There might be many reasons for this lower prevalence. The objective of this study is to determine the prevalence and burden of primary headaches among the Akaki textile factory workers, which may provide data for the local and international level toward the campaign of lifting the burden of headache worldwide. The overall 1-year prevalence of all types of primary headaches was found to be

16.4%, and that of migraine was 6.2%. The prevalence of migraine in females was 10.1% while it was 3.7% in males. The prevalence of tension-type headaches was found to be 9.8%. This was 16.3 % in females as compared to 5.7% in males. The burden of the primary headaches in terms of lost workdays, gross under recognition and absence of effective treatment is tremendous. In conclusion, the prevalence of primary headaches in the Akaki textile mill workers is significant, particularly in females, and the burden is massive, in a place of poverty and ignorance. We recommend the availability and administration of specific therapy to the factory workers with primary headaches, and community based well-designed study for the whole nations rural and urban population. Introduction Headache is one among the most common medical complaints. Various forms of headache, properly called headache disorders, are among the most common disorders of the nervous system. They are pandemic and, in many cases, life-long conditions [1]. As many as 90% of all primary headaches, including migraine, tension-type and cluster headache, fall under few categories. Recurrent headache disorders impose a substantial burden on headache sufferers, family and society [2]. Headache disorders are in the top ten, and possibly the top five, causes of disability worldwide [3]. Although the epidemiology of headache disorders is only partly documented, taken together, headache disorders are extraordinarily common. Population-based studies have mostly focused on migraine, which, although the most frequently studied, is not the most common headache disorder. Other types of headache, such as the more prevalent TTH and sub-types of the more disabling chronic daily headache, have received less attention [1]. The overall prevalence of migraine is estimated to be 1216% percent in North America and Europe [4]. Population-based studies are less available for other chronic headache syndromes, but tension-type headache seems to be more prevalent than migraine [5]. In developed countries, tension-type headache (TTH) alone affects two-thirds of adult males and over 80% of females. Extrapolation from figures for migraine prevalence and attack incidence suggests that 3,000 migraine attacks occur every day for each million of the general population. Less well recognized is the toll of chronic daily headache: up to one adult in 20 has headache, nearly every day or every day [1]. Migraine is more common in boys before the age of puberty but at the age of menarche the incidence of migraine increases in females, and migraine remains more common in women at all post-pubertal ages [2]. Both migraine and tension-type headaches affect women more often than men, while cluster headache is predominantly a disorder of men [5]. Migraine is more common in people from low-income households but less common in African Americans and Asians in the United States. These patterns of prevalence by race are also reflected in international studies, as migraine is most common in North America and Europe and less in Africa and Asia [2]. The recurrent headache disorders have an enormous impact on the individual and society. The individual impact is measured by the frequency and severity of attacks, while the societal burden is measured in terms of lost work and schooldays as well as healthcare utilization [2]. Few population-based studies exist for developing countries where limited funding and large and often rural populations, coupled with the low profile of headache disorders compared with other diseases, prevent the systematic collection of information [1]. There is a scanty data on the prevalence of primary headaches in sub-Saharan Africa in general and Ethiopia in particular. The prevalence of these headaches is very low as compared to Europe and North America. In 2004, the 1-year prevalence of headache from a door-to-door survey of rural south Tanzania was 23.1% (18.8% males and 26.4% females). In this study, the 1-year prevalence of migraine was 5% with a male to female ratio of 1:2.8 and migraine without aura was 1.4% while migraine with aura was 3.6% [6]. From a 1995 study done in Ethiopia, the 1-year prevalence of migraine was 3% (4.2% females and 1.7% males) with a peak age specific rate in the fourth decade [7]. In Hong Kong, another third world country, the estimated prevalence of headaches in 2000 was 12.5% for migraine, 18.7% for tension-type headache and 6.0% for other types of headache [8].

In 2007, in the country of Georgia, Eastern Europe, the 1- year prevalence of migraine was 8.6%, tension-type headache was 20.4% and chronic daily headache was 5.4%, two of whom were overusing acute headache medication [9]. In 2005, in an epidemilogic study in Florianopolis, Brazil, the 1-year prevalence of headache was 80.8%, of migraine 22.1%, of TTH 22.9%, and of CDH 6.4% [10]. In Norway, out of 64,560 participants of a large population-based study in 2000, the overall age-adjusted 1-year prevalence of headache was 38% (46% in women and 30% in men). The prevalence of migraine was 12% (16% in women and 8% in men), and for non-migrainous headache 26% (30% in women and 22% in men). For frequent headache (>6 days per month) and for chronic headache (>14 days per month), the prevalence was 8 and 2%, respectively [11]. The factors for such low prevalence in Africa in general and Ethiopia in particular might be the following: * Headache is under recognized and not diagnosed by many health practitioners in the African set up due to a number of reasons [12]: o Rural people have a great tolerance to pain hence do not report or seek medial attention. o Headache, even if persistent and recurrent, is often perceived as a trivial problem as there are more demanding and basic problems that are given priority. o Most rural headache sufferers come from low socioeconomic segment and are less educated. o Most headache sufferers go for the traditional, religious and herbal medications. * It is not considered as a reason for medical consultation and even the sick people do not know headache as a medical condition * In the studies done so far, there were methodological problems, use of different classifications [like the one by the Ad Hoc Committee (AHC) on the Classification of Headache and the Headache Classification Committee of the International Headache Society (IHS), etc.] and absence of objective laboratory parameters for correlation of the headache data. * The presence of more than one type of primary headaches in a single patient, may have an impact on categorizing the patients even when the IHS criteria is used in the diagnosis of headache by less trained and less experienced health workers. Moreover, this is complicated by the absence of neurologists or headache specialists in most parts of Africa including Ethiopia. * Pain is more tolerated in the African culture than in Western countries. On top of this, diseases are perceived in the magico-religious context where traditional healing plays a big role. * Low incomes, poor infrastructures and inadequate health care coverage make the disease burden of headache different from that in the rich and developed nations. * There could be a genetic difference of Africans from that of Caucasians. Migraine in Africans is not rare as reported in earlier reports. It is, however under recognized and accorded low priority. Its clinical manifestations in Africans are similar to those seen in other populations. It is an under-treated condition where only a low percentage of the sufferers receive specific treatment. The majority of migraine patients resort to herbal and traditional healers [3, 12]. In a world of limited resources for healthcare services and health related research, reliable data on the individual and societal impact of different disorders are crucial for a rational distribution of means [13]. Not only is headache painful, but headache disorders are also disabling [1]. Migraine associated disability remains substantial and pervasive [14]. Worldwide, according to the World Health Organization (WHO), migraine alone is 19th among all causes of years lived with disability (YLDs). Headache disorders impose recognizable burden on sufferers including, sometimes, substantial personal suffering, impaired quality of life and financial cost. Repeated headache attacks, and often the constant fear of the next one, damage family and social life as well as employment. For example, social activity and work capacity are reduced in almost all migraine sufferers and in 60% of TTH sufferers [1].

The disease burden and the costs incurred due to migraine are probably among the highest for the neurological disorders, and is probably high in poor countries as in the rich. For other headaches, reliable data on their impact are still scarce, but these disorders may be as important as migraine because they are more prevalent [13]. While those suffering from headache disorders bear much of the burden, they do not carry it all. Because headache disorders are most troublesome in the productive years (late teens to 50s), estimates of their financial cost to society, principally from lost working hours and reduced productivity, are massive. In the United Kingdom, for example, some 25 million working or school days are lost every year because of migraine alone. TTH, less disabling but more common, and chronic daily headache, less common but more disabling, together cause losses which are almost certainly of at least similar magnitude [1]. In a 2002 study of Italy, among young Italian patients, quality of life was compromised in primary headache and was significantly lower in psychosocial, physical and social functioning [15]. Headache rarely signals serious underlying illness; its public-health importance lies in its causal association with these personal and societal burdens of pain, disability, damaged quality of life and financial cost [1]. The societal impact of headaches is usually measured in economic terms. Direct costs consist primarily of health care utilization. Indirect costs include missed work (i.e., absenteeism) and reduced productivity while at work (i.e., presenteeism) due to headache [2]. Headache is high among causes of consulting medical practitioners. A survey of neurologists found that up to one-third of all their patients consulted because of headache, more than for any other complaint [1]. The direct costs of diagnosing and treating primary headaches are far less than the costs of productivity losses due to headache attacks. As a consequence, improving health care delivery for primary headaches could be cost effective from a societal perspective [2]. The common headache disorders require no special investigation and they are diagnosed and managed with skills that should be generally available to physicians. In theory, therefore, most headaches can be optimally managed in primary care. There are barriers to effective care of these primary headache disorders. These barriers vary throughout the world, but may be classified as clinical, social or political/economic [1]. For the developed nations, there are many cost-effective, efficacious treatments available, but these are limited, unavailable or unaffordable in the developing nations [2, 7, 12]. Headache ought to be a public-health concern. Yet there is good evidence that very large numbers of people troubled by headache do not receive effective care. For example, in representative samples of the general populations of the United States of America and the United Kingdom, only half of those identified with migraine had seen a doctor for headache-related reasons in the previous 12 months, and only twothirds had been correctly diagnosed. Most were solely reliant on over-the-counter medications [1]. Yet the reality is that, for the vast majority of those whose quality of life is spoiled by headache, effective treatment requires no expensive equipments, tests or specialists. The essential components of effective medical management are awareness of the problem, correct recognition and diagnosis, avoidance of mismanagement, appropriate lifestyle modification and informed use of cost-effective pharmaceutical remedies [3]. Top Abstract Introduction >Objective Patients and methods Results Discussion References Objective

The general objective is to determine the prevalence and burden of primary headaches among the textile mills workers in Addis Ababa, Ethiopia Specific objectives are: * To determine the magnitude and prevalence of primary headaches in the textile mills workers * To see the burden of these headaches among the sufferers. * To know the missing working days and hence assess the impact of primary headaches on the productivity in particular and on economy in general. * To assess the care provided to the headache patients (workers) versus the over the counter use and or misuse of drugs for headache. * To generate data on headache prevalence and burden for use by the national and international policy makers on health care.

Patients and methods The study population included all workers in the Akaki textile mill. This cross-sectional prevalence study was conducted among the Akaki textile mill workers from 1 November 2007 to 28 November 2007. It included the entire workers employed by the factory. It is located in Kality, Akaki sub-city of Addis Ababa, about 25 km east of the center. It has 1,300 workers and is about 52 years old, being one of the oldest factories of the country. Data collection was done by the investigator (PI), three nurses and a medical doctor of the factory after training and orientation on primary headaches. Prepared and pre-tested questionnaires were used. The questionnaire was divided into two parts, the first part was on the demographic and personal aspects and the second part dealt with the specific details of headache. Cases with positive history of headache were interviewed and examined by the physician trained in headache medicine, internal medicine and neurology. Subjects were diagnosed in accordance to the most frequent type of headache experienced in the last 1 year, using HIS criteria [16]. Migraine and tension-type headache were diagnosed when all criteria were fulfilled. The diagnosis of probable was made when all but one criterion were fulfilled. Chronic headache was diagnosed when the frequency of headache pain was 180 days per year, based on a question about the frequency of headache. Results Of the 1,300 employees of the Akaki textile mill on job at the time of the interview, 195 did not want to participate in the interview. Out of 1,105 (85%) interviewed, 681 (61.6%) were males and 424 (38.4%) were females. The age ranged from 25 to 77 years with mean of 46.9 7.5. There were two workers beyond the age of 65, working as a cleaner and a guard. Out of the total, 590 (53.4%) were in the age range of 4554 years (Table 1). Of the total study population, 866 (78.4%) were married, of which 260 (30%) were females. The divorce rate was 9.0% (99), of which 87 (87.9%) were females. About 6.7% (74) were widowed of which widows accounted for 79.7 % (59) while widowers were 20.3% (15) (x2 = 185.1, df = 3, P = 0.00000) (Fig. 1). Table 1 The age and sex distribution of the study population Akaki textile mill, Ethiopia, 2007 Fig. 1 Marital status of study population by gender Akaki textile mill, Ethiopia, 2007

Illiteracy rate (did not read or write) of the study population was 9.9% (220), of which 161(73.2%) were females; on the other hand, among 8.5% (94) who had tertiary education 75.5% (71) were males (x2 = 154.6, df = 3, P = 0.0000) (Fig. 2).

Fig. 2

Fig. 2

Educational status of study population by gender, Akaki textile mill, Ethiopia, 2007 Lifetime prevalence of all sorts of headaches was 96.1%, 98.6% in females versus 95.9% in males (adjusted OR = 2.3, 95% confidence interval of 0.905.64). One-year prevalence of all types headaches was 73.2%, in females 79.2% compared 69.5% in males (OR = 1.20, 95% CI = 0.901.63) (Table 2). Table 2 Prevalence of headache in the study population, Akaki textile mill, Ethiopia, 2007 The overall 1-year prevalence of all types of primary headaches was found to be 16.4% (181/1,105). Out of these 181 cases, 114 (63%) with primary headache were females making a prevalence of 26.9% in the females while it was 9.8% in males. This is statistically significant (adjusted OR = 3.13, 95% confidence interval of 2.224.41, P = 0.000). The age specific prevalence was 18.0% in the age group of 4554 years (Tables 2, 4). Table 4 Prevalence headaches by age category, Akaki textile mill, Ethiopia, 2007 According to the International Headache Society criteria, 68 workers were found to have migraine giving a prevalence rate of 6.2%. The prevalence of migraine in females was 10.1% while it was 3.7% in males (adjusted OR = 3.23, 95% CI = 2.114.94, P = 0.000). The age specific prevalence was 7.3 % in the age range of 4554 years. The over all prevalence of migraine without aura was 51 (4.6%) making 75% of the migraine patients. This was 8.5 (36) in females and 2.2% (15) in males (adjusted OR = 4.63, 95% 2.508.58, P = 0.000). The prevalence of migraine with aura was found to be 1.4% and that of probable migraine was found to be 0.1% (Tables 3, 4). Table 3 Table 3 Migraine and tension headache categories by sex, Akaki textile mill, Ethiopia, 2007 The over all prevalence of tension-type headaches was found to be 9.8% (108/1,105). This was 16.3 % in females as compared to 5.7% in males (adjusted OR = 3.14, 95%CI = 1.875.28, P = 0.000). The age specific prevalence was 13.3% in the age group of 2534 years. Frequent episodic tensiontype headache was found to be 4.3%, with 7.1% in females and 2.5% in males (adjusted OR = 3.45, 95% CI of 1.876.35, P = 0.000). The prevalence of infrequent episodic tension headache was 3.5, and 5.2% in females and 2.5% in males (adjusted OR = 2.45, 95% CI = 1.284.70, P = 0.007). Chronic tension-type headache was found to be 1.6 and 3.5% in females and 0.4% in males (adjusted OR = 9.77, 95% CI = 2.8134.00, P = 0.000). Probable tension-type headache was found to be 0.4% (Tables 3, 4). Cluster headache and other trigeminal autonomic cephalalgias were found in five (0.45%) individuals. Table 5 shows the prevalence of headache versus marital status. The widowed ones have the significant higher proportion of all types of headaches followed by the divorced. Table 5 Marital status and prevalence of headache, Akaki textile mill, Ethiopia, 2007 Table 6 shows the prevalence of headaches in educational categories. The general trend of reciprocal relationship of headache and educational levels was found to be evident but this is not significant statistically when confounders are controlled. Table 6 Educational status and prevalence of headache, Akaki textile mill, Ethiopia, 2007 Tables 7 and 8 show the proportion of missing workdays in primary headaches during attacks. Out of 181 workers with primary headaches, 63 (34.8%) miss working days due to headache attacks. This was 60.3% in migraine and 20.4% in tension-type headaches.

Table 7 Primary headaches versus missing working days, Akaki textile mill, Ethiopia, 2007 Table 8 Primary headaches versus missing of workdays, Akaki textile mill, Ethiopia, 2007 Table 9 shows the use of ant-pain medications for attacks of headache. Only one patient, who has migraine with aura, ever used ergot preparation from the specific medications, the only available specific medication in Ethiopia. The most widely used over the counter medicine was acetaminophen tablets. Out of 181 workers with primary headaches, 80.1% used ant-pains intermittently or during every attack. This was 97.1% in migraine and 70.4 % in tension headache. The reasons given for those who did not use medicines were: no lasting remedy or response at all, use of alternatives like traditional medicine and holy water and fear of abuse of drugs. Table 9 Primary headaches versus use of medicine (ant-pain), Akaki textile mill, Ethiopia, 2007 Average age of onset for primary headaches was 25.7 12.4 years, where as it was 21.9 11 for migraine and 27.7 12.2 for tension-type headaches. Out of the average 27.3 7.7 years spent on job in the textile mills, 21.9 12.4 years were with episodes of headache. These workers on average have 13.77 15.5 days of missing work per year. This was 15.6 15.4 days for migraine and 11.2 15.6 days per year for tension-type of headaches. Of the mean 47.3 7.1 years of life, 21.9 12.4 were spent with intermittent episodes of headache. It was 26.8 15.5 years for migraine and 19.24 11.8 years for tension-type headache (Table 10). Table 1 Primary headaches and the burden, Akaki textile mill, Ethiopia, 2007 Discussion Lifetime prevalence of all sorts of headaches in this study is more than 96.0% which is in accordance to the studies done elsewhere [17]. The 1-year prevalence of all kinds of headache was 73%. This is slightly lower than the 1-year prevalence of the 2005 study of Florianopolis in Brazil, which was 80.8% [10]. The 1-year prevalence of migraine, 6.2% in this study is lower than the 2007 prevalence of migraine and probable migraine of Georgia, which was 21.5% where as it was closer to the definite migraine prevalence of 8.5% [9]. The prevalence in this study is within the WHO estimate of 37% in Africa according to the community- based studies [1] but much lower than the global data of 11% [18]. This study showed similar prevalence of migraine to the door-to-door study done in 2004 in rural area of southern Tanzania where the overall 1-year prevalence was 5.0% [6]. In a study done in 1995, in the rural Ethiopian community, 1-year prevalence of migraine, 3.0% was lower than the figure in this study [7]. The reasons for such difference might be that the current study is in an urban setup where people can report and perceive headache as an illness and this study was done in factory employees where as the previous one was in a rural community. Almost similar prevalence of 4.7% was found in a 2000 study from Hong Kong [8]. This study showed much lower prevalence of migraine as compared to the 2005 study of Florianopolis in Brazil, which was 22.1% [10]. In this study, migraine without aura accounted for 75% of the cases with a prevalence of 4.6% and preponderance in females was statistically significant. The low prevalence of migraine with aura 1.4% accounting for 24% of cases with migraine is in agreement with the previous reports from Africa in general and Ethiopia in particular [7, 12]. The 1-year overall prevalence of tension-type headache, 9.8% in this study is lower than the reported prevalence of 20.4% from Georgia [9] and very much lower than the 2007 global estimate of 42% [18]. This is much higher than the 1.7% reported by WHO in some African community based studies [1]. In a 2000 study from Hong Kong, the overall prevalence of tension-type headache of 26.9% was much higher than the present study [8]. In our study, the prevalence of tension-headache was much lower than the 2005 study of Florianopolis in Brazil, which was 22.9% [10]. Chronic tension-type headache in this study found to be 1.6% is in accordance to the WHO figure of 13% in adults and previous report from rural Ethiopia, which was 1.7% [1, 7, 12]. The 1-year prevalence of chronic tension-type headache, which is one of the most disabling headache syndromes, in our study is 3.5% in females and 0.4% in males. This gender difference was statistically significant.

Cluster headache is extremely rare in Africa as reported previously, as well as in this study [1, 7, 12]. Both migraine and tension headache have an enormous burden and impact on the individual family, society and on the nation. This burden is serious in developing countries like Ethiopia where the resources are meager, ignorance and poverty are overwhelming, and infrastructures for healthcare systems are scanty. The cumulative impact over time with a compromised quality of life was enormous on individuals. In this study, cases with primary headache and migraine each lived 21.9 years on average with intermittent attacks of headache while this was more than 19 years for tension headache. The majority of cases with migraine have severe or moderate attacks of headache, photophobia, phonophobia and nausea or vomiting. Although the 1-year prevalence of primary headaches above 16% in this study is much lower than the global estimate 46% and that of Africa 21% [18], only one case of migraine with aura was ever treated with available specific medication of ergot preparation in the past. This shows how serious is the under recognition and under treatment of headaches in the capital city of Ethiopia, Addis Ababa. To complicate the matter, all sufferers in this study did not know that effective treatment exists and the care givers did not diagnose as well treat them. Many migraine sufferers miss work because of their headaches, and reduced productivity as a result of working during the migraine attack is common [2]. In our study, more than 60% with migraine and above 20% with tension headache missed working days and almost all with migraine as well as more than half with tension headache have a reduced work capacity during attacks. This is in agreement with the WHO report [1, 19]. In this study, 34.8% of cases with primary headache had on average 13.77 lost work days per year and this was higher in migraine, about 16 lost working days, and least in tension type, 11 lost working days. This is almost in agreement with the 1995 study from Dares Salaam, Tanzania, which was 11.3 lost workdays per year [20]. The economic impact on workers and their families as well as on the nation is massive especially for a developing country like Ethiopia, where poverty, ignorance and malnutrition are rampant. In conclusion, the prevalence of primary headaches in the Akaki textile mill is significant, particularly in females, and the burden is massive, in a place of poverty and ignorance. We recommend the availability and administration of specific therapy to the factory workers with primary headaches, and community based well-designed study for the whole nations rural and urban population, as suggested in the WHOs Aids for management of common headache disorders in primary care [21]. References 1.World Health Organization (2004) Headache Disorders. Fact sheet N277, March 2004. Accessed 28 June 2007. 2.Munsat TL, Mancall EL, DesLauriers MP (1994) The AAN launches a new education program: CONTINUUM lifelong learning in neurology. Neurology 44:771772 [PubMed]. 3.Steiner TJ (2005) Lifting the burden: the global campaign to reduce the burden of headache worldwide. J Headache Pain 6:373377 [PubMed]. 4.Rasmussen BK (1995) Epidemiology of migraine. Biomed Pharmacother 49:452455 [PubMed]. 5.Rasmussen BK, Jensen R, Schroll M, Olesen J (1991) Epidemiology of headache in a general populationa prevalence study. J Clin Epidemiol 44:11471157 [PubMed]. 6.Dent W, Spiss HK, Helbok R, Matuja WBP, Sheunemann S, Schmutzard E (2004) Prevalence of migraine in a rural area in South Tanzania: a door-to-door survey. Cephalalgia 24:960966 [PubMed]. 7.Tekle Haimanot R, Seraw B, Forsgren L, Ekbom K, Ekstedt J (1995) Migraine, chronic tension type headache and cluster headache in an Ethiopian rural community. Cephalalgia 15:482488 [PubMed]. 8.Cheung Raymond TF (2000) Prevalence of migraine, tension type headache and other headaches in Hong Kong. Headache 40:473479 [PubMed]. 9.Katsarava Z, Kukava M, Mirvelashvili E, Tavadze A, Dzagnidze A, Djibuti M, Steiner TJ (2007) A pilot

methodological validation study for a population-based survey of the prevalences of migraine, tension type headache and chronic daily headache in the country of Georgia. J Headache Pain 8:7782 [PubMed]. 10.Queiroz LP, Barea LM, Blank N (2005) An epidemiological study of headache in Florianopolis, Brazil. Cephalalgia 26:122127 [PubMed]. 11.Hagen K, Zwart JA, Vatten L, Stovner LJ, Bovim G (2000) Prevalence of migraine and non-migrainous headache-head-HUNT, a large population-based study. Cephalalgia 20:900906 [PubMed]. 12.Tekle Haimanot R (2003) Burden of headache in Africa. J Headache Pain 4:S47S54 . 13.Stovner LJ, Hagen K (2006) Prevalence, burden, and cost of headache disorders. Curr Opin Neurol 19:281285 [PubMed]. 14.Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M (2001) Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache 41:646657 [PubMed]. 15. Nodari E, Battistella A, Naccarella C, Vidi M (2002) Quality of life in young Italian patients with primary headache. Headache 42:268274 [PubMed]. 16.Headache Classification Subcommittee of the International Headache Society (2004) The international classification of headache disorders, 2nd edn. Cephalalgia 24:1160. 17.Steiner TJ (2004) Lifting the burden: the global campaign against headache. Lancet Neurol 3:204205 [PubMed]. 18.Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton RB, Scher AI, Steiner TJ, Zwart JA (2007) The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 27:193210 [PubMed]. 19.World Health Organization (2000) WHO report on Headache. Headache Australia, September 2000. http://www.headacheaustralia.org.au/?p=70. Accessed 16 Dec 2007. 20.Mutuja WBP, Mteza LBH, Rwiza HT (1995) Headaches in a non-clinical Population in Dares salaam, Tanzania. A community-based study Headache 35:273276 [PubMed]. 21.Aids for management of common headache disorders in primary care (2007) J Headache Pain 8(S1):147 .

Epidemiology of Tension-Type Headache Brian S. Schwartz, MD, MS; Walter F. Stewart, PhD, MPH; David Simon, MS; Richard B. Lipton, MD JAMA. 1998;279:381-383. Context. Tension-type headache is a highly prevalent condition. Because few population-based studies have been performed, little is known about its epidemiology. Objectives. To estimate the 1-year period prevalence of episodic tension-type headache (ETTH) and chronic tension-type headache (CTTH) in a population-based study; to describe differences in 1-year period prevalence by sex, age, education, and race; and to describe attack frequency and headache pain intensity. Design. Telephone survey conducted 1993 to 1994. Setting. Baltimore County, Maryland. Participants. A total of 13345 subjects from the community.

Main Outcome Measures. Percentage of respondents with diagnoses of headache using International Headache Society criteria. Workdays lost and reduced effectiveness at work, home, and school because of headache, based on self-report. Results. The overall prevalence of ETTH in the past year was 38.3%. Women had a higher 1-year ETTH prevalence than men in all age, race, and education groups, with an overall prevalence ratio of 1.16. Prevalence peaked in the 30- to 39-year-old age group in both men (42.3%) and women (46.9%). Whites had a higher 1-year prevalence than African Americans in men (40.1% vs. 22.8%) and women (46.8% vs 30.9%). Prevalence increased with increasing educational levels in both sexes, reaching a peak in subjects with graduate school educations of 48.5% for men and 48.9% for women. The 1-year period prevalence of CTTH was 2.2%; prevalence was higher in women and declined with increasing education. Of subjects with ETTH, 8.3% reported lost workdays because of their headaches, while 43.6% reported decreased effectiveness at work, home, or school. Subjects with CTTH reported more lost workdays (mean of 27.4 days vs 8.9 days for those reporting lost workdays) and reduced-effectiveness days (mean of 20.4 vs 5.0 days for those reporting reduced effectiveness) compared with subjects with ETTH. Conclusions. Episodic tension-type headache is a highly prevalent condition with a significant functional impact at work, home, and school. Chronic tension-type headache is much less prevalent than ETTH; despite its greater individual impact, CTTH has a smaller societal impact than ETTH.

Brazilian Journal of Medical and Biological Research Print ISSN 0100-879X doi: 10.1590/S0100-879X2003001000021 Braz J Med Biol Res, October 2003, Volume 36(10) 1425-1432 Headache complaints associated with psychiatric comorbidity in a population-based sample I.M. Benseor1, L.F. Tfoli2 and L. Andrade2 Departamentos de 1Clnica Mdica, and 2Psiquiatria, Faculdade de Medicina, Universidade de So Paulo, So Paulo, SP, Brasil Abstract The objective of the present study was to determine the frequency at which people complain of any type of headache, and its relationship with sociodemographic characteristics and psychiatric comorbidity in So Paulo, Brazil. A three-step cluster sampling method was used to select 1,464 subjects aged 18 years or older. They were mainly from families of middle and upper socioeconomic levels livingin in the catchment area of Instituto de Psiquiatria. However, this area also contains some slums and shantytowns. The subjects were interviewed using the Brazilian version of the Composite International Diagnostic Interview version 1.1. (CIDI 1.1) by a lay trained interviewer. Answers to CIDI 1.1 questions allowed us to classify people according to their psychiatric condition and their headaches based on their own ideas about the nature of their illness. The lifetime prevalence of "a lot of problems with" headache was 37.4% (76.2% of which were attributed to use of medicines, drugs/alcohol, physical illness or trauma, and 23.8% attributed to nervousness, tension or mental illness). The odds ratio (OR) for headache among participants with "nervousness, tension or mental illness" was elevated for depressive episodes (OR, 2.1; 95%CI, 1.4-3.4), dysthymia (OR, 3.4; 95%CI, 1.6-7.4) and generalized anxiety disorder (OR, 4.3; 95%CI, 2.1-8.6), when compared with patients without headache. For "a lot of problems with" headaches

attributed to medicines, drugs/alcohol, physical illness or trauma, the risk was also increased for dysthymia but not for generalized anxiety disorder. These data show a high association between headache and chronic psychiatric disorders in this Brazilian population sample. Key words: Headache, Illness attribution, Psychiatric comorbidity, Brazil, Odds ratio Introduction Headache is one of the most common complaints in the general population. It can be bothersome and interfere with routine activities and quality of life (1,2). As is the case for some other high-prevalence pain symptoms, such as those involving the joints, chest, abdomen and back, headache is a complaint that remains poorly understood. In most cases, although extensively investigated by classical clinical and radiographic examinations, no organic cause is found. Some studies have shown that such pain syndromes are associated with common mental disorders and some personality traits (1,3). However, the dilemma of whether psychopathology is the cause or a consequence of chronic pain is still a matter of controversy (3,4). There has been much discussion about a possible relationship between psychological factors and headache for a very long time. In 1937, Wolff (5) defined the "migraine personality" including ambition and perfectionism, mental instability and immaturity, vulnerability to frustrations, and shyness. Several studies at the community level have discussed the frequent association between headache of any type and psychiatric comorbidity (1,6,7). A lot of data have correlated headache and personality traits, especially using patient samples from headache clinics (3,4). The psychiatric diagnoses most commonly associated with headaches are anxiety and depressive disorders (6,8-10), and the personality trait most frequently associated is neuroticism (2,11-13). Ossipova et al. (14) described two cases of migraine without aura, associated with panic attacks. They suggested that a pronounced autonomic dysregulation associated with psychological abnormalities could be related to both disorders, and that this comorbidity increases their severity. Marazziti et al. (15) found that this type of migraine is the most prevalent kind of headache among panic patients. Guidetti et al. (16), studying 100 patients from a Headache Center, found that from the youngest ages onwards, anxiety and depressive disorders represent a considerable clinical problem for both migraine and tension-type headache sufferers. Population-based studies have confirmed this positive association in patient samples. In the Zurich Cohort Study of Young Adults (6) the combination of anxiety disorder and major depression was significantly associated with migraine. In a review paper, Merikangas and Stevens (10) discussed the importance of documenting an association between migraine and other comorbidities as the first step in creating a causal model. Accordingly, an index disease would cause or precipitate the manifestation of comorbid conditions (10). Breslau and Davis (11) and Breslau et al. (12), studying a cohort of young adults, concluded that the presence of migraine increases the risk for depression and anxiety. Using Coxproportional hazards, after 3.5 years of follow-up they found that both migraine and depression increased the risk for the first onset of each other. This favored an explanation of shared mechanisms. However, recent data from the Baltimore Epidemiological Catchment Area Follow-up Study (17) showed a strong cross-sectional relationship between affective disorders and migraine headaches, but no association between previous affective disorder and incident cases of migraine headaches in a prospective manner. There is little information about headache prevalence in Brazil. The only study presenting its association with psychiatric disorders was done on an adult sample (aged 18 years or over) in an urban area of Northeastern Brazil. An odds ratio (OR) of 4.4 was found for the association of headache symptoms and psychiatric comorbidity. Women were more at risk, and the prevalence increased with age (18). Migration, marital status, and low educational levels were associated with a higher frequency of headache. More recent data from a Brazilian sample of high-school students (aged 10-18 years) showed a lifetime prevalence of headache of 93.2%, with a one-year prevalence of 82.9%. Of these headaches, 72.8% were tension-type and 9.9% migraine (19), according to the International Headache Society (IHS) criteria (20). Women had higher rates than men. Sanvito et al. (21) interviewed 595 medical students.

When classifying their headaches according to IHS criteria, they observed that the one-year prevalence for any kind of headache was 40% and that 40.2% of those were migraine. The migraine prevalence was 54% for women and 28.3% for men, and was considered incapacitating by half of the sufferers. No information about psychiatric comorbidity or personality traits was available in these last two studies. We analyzed data from a population-based catchment area mental health survey in the city of So Paulo, Brazil, to determine the prevalence of people complaining of "a lot of problems with" any kind of headache, the relationship with sociodemographic characteristics and the co-occurrence of psychiatric disorders. Material and Methods The study population lived in the catchment area of the University of So Paulo Medical Center, a 2000bed tertiary care facility in So Paulo, the largest city in South America and one of the largest cities in the world (ten million inhabitants). The catchment area included two districts of the city covering a geographic area of 10.5 km2. The population in this area consists mainly of families of middle and upper socioeconomic levels. However, this area also contains some slums and shantytowns. In order to improve the probability of observing young psychotics and old-age psychiatric morbidity, all persons aged 18-24 years and 60 years or older, living in each selected household, were interviewed with a probability equal to one. Of the remaining individuals aged 25-29 years living in the selected household, one was chosen for interview based on the Kish and Frankel selection table (22,23). From the 950 households, 1,906 people were selected to participate in the study based on the three age strata described above. Of these, 442 refused to participate, resulting in a final sample of 1,464 subjects, with an individual response of 76.8%. Psychiatric assessment The psychiatric diagnoses were based on face-to-face interviews. The instrument used was the Brazilian version of the Composite International Diagnostic Interview (CIDI) (24), version 1.1. This is a structured psychiatric interview (25) designed for use by lay interviewers. The instrument provides lifetime, 12- and 1-month prevalence estimates for ICD-10 diagnoses (International Classification of Disease-Related Health Problems, 10th revision, WHO, 1992) (26). For this study, we tested the association of lifetime psychiatric disorders that could be related to headache: depression, anxiety, alcohol and nicotine dependence, somatization, and bulimia. Headache diagnosis The CIDI 1.1 asks whether the person has experienced "a lot of problems with" headache during his/her lifetime and/or has taken any medication for headache, three or more times during a week. Answers to these questions were classified as: i) negative answer; ii) positive answer, but patient did not seek medical help because of symptoms, did not take any medication, or symptoms did not interfere with routine activities; iii) positive answer, but symptoms were caused by medicines, drugs or alcohol; iv) positive answer, but symptoms were the consequence of physical illness or trauma; v) positive answer, but symptoms were the consequence of nervousness, tension, anxiety, depression, mental illness, or no defined diagnosis. Thus, the prevalence rate does not reflect the actual prevalence of headache, but is restricted to people with a lot of problems with headaches (a small portion of all the people with headaches). Data from the CIDI did not allow us to classify headaches according to the IHS criteria (20), but it was possible to consider answers 3 and 4 as headaches attributed by the patient to the use of medication, drugs or alcohol, physical illness or trauma, and answer number 5 as potentially associated with psychiatric disorders. The attributed cause was classified into two categories: lifestyle and/or physical conditions were considered to be the cause of answers 3 or 4, and psychological conditions

were considered to be the cause of answer 5, as used previously by Nimnuan et al. (27). Sociodemographic measurements We considered the effects of several sociodemographic variables such as age, gender, marital status, and educational level (years of education). Age was coded by category, as ranges 18-24, 25-34, 35-44, 45-54, 55-64, and 65 and over. Gender was coded dichotomously (male, female). Marital status was coded as married or not married. Years of education were coded by category as ranges 0-8, 9-11, 12-15, and 16 or more. Statistical analysis Since the data in this report were obtained from a complex stratified sample, they were weighted for differential probabilities of selection and nonresponse. A post-stratification of known population characteristics of sex and regional geographic groupings in the sample age range was also made in order to compensate for discrepancies between the sample and the original census population data. A matrix with the following factors was constructed to calculate the final weighting: age, sex, age strata, number of persons in each stratum by household, and a post-stratification factor. Logistic regression analysis was used to examine the association between demographic factors, psychiatric disorders and the headache symptom. As a result of the complex sample design and weighting, estimates of standard errors based on the usual assumption of equal-probability simple random samples become biased. Thus, standard errors for prevalence and logistic regression coefficients were computed using the jackknife repeated replications method, to adjust for the design effects introduced by the clustering and weighting of observations (22,23). All evaluations of significance were based on two-sided tests using 0.05 as the level of significance. Results The lifetime prevalence for "a lot of problems with" headache of any type for the total sample was 37.4%. Of this, 76.2% was attributed to medicines or drugs/alcohol and to physical illness or trauma (cause attributed to lifestyle and/or physical conditions), and 23.8% was attributed to nervousness, tension or mental illness (cause attributed to psychological conditions). Table 1 shows the lifetime prevalence rates for "a lot of problems with" headache of any type, headache attributed to lifestyle and/or physical conditions, and headache attributed to psychological conditions by gender and age stratum. The lifetime rates for "a lot of problems with" any kind of headache ranged from 19.3% (for men aged 65 years or older) to 56.4% (for women aged 55-64 years), showing that this is a very common symptom. The lifetime frequency of "a lot of problems with" headache attributed to lifestyle and/or physical conditions was higher than the lifetime frequency of "a lot of problems with" headache attributed to psychological conditions, for all ages. This increased with age for men and women up to the age of 64 years (peaking between 55 and 64 years). After this age, we observed a decline for both genders. The frequency of "a lot of problems with" headaches attributed to psychological conditions was higher in women of all ages, except in the 45-54-year age stratum. The lifetime prevalence of "a lot of problems with" headaches attributed to psychological conditions reached a peak in both genders in the age stratum of 25-34 years. After the age of 54 years, the frequency decreased to levels that were similar to those of the 18-24-year age group.

Table 2 shows the OR (controlled for age and gender) for any kind of headache, headache attributed to lifestyle and/or physical conditions, and headache attributed to psychological conditions according to sociodemographic characteristics of the study population. Gender had a major effect, with women being 1.5 to 2.9 times more at risk than men. As we are reporting the lifetime prevalence of symptoms, a pattern of increasing prevalence with age would be expected. This was the case for "a lot of problems with" headaches attributed to lifestyle and/or physical conditions, in which the risk increased with age up to the 55-64-year age stratum and decreased thereafter. This was not the case for "a lot of problems with" headaches attributed to psychological conditions, for which the risk was higher only in the 25-34-year age stratum (OR, 2.1; 95%CI, 1.1-4.0), indicating that this age group was at major risk for the disorders grouped under this heading. There was no effect of years of education or marital status on the risk for "a lot of problems with" headache. Table 2 also shows the OR for the association of headaches and psychiatric comorbidity. The OR for "a lot of problems with" any kind of headache associated with depression was 1.8 (95%CI, 1.3-2.4). However, when we subdivided depression into depressive episode and dysthymia, most of the comorbidity was concentrated in dysthymia (OR, 4.2; 95%CI, 2.3-7.6), in comparison with depressive episodes (OR, 1.9; 95%CI, 1.4-2.5). For anxiety (OR, 2.3; 95%CI, 1.6-3.4), the association was again higher for generalized anxiety disorder (OR, 3.2; 95%CI, 1.5-6.9), which is a more chronic disturbance, in comparison with panic disorder (OR, 1.7; 95%CI, 0.8-3.7) or any kind of phobias (OR, 2.0; 95%CI, 1.42.8). The same pattern was found for "a lot of problems with" headaches attributed to psychological conditions, with slight differences in the OR. For "a lot of problems with" headaches attributed to lifestyle and/or physical conditions, the risk of psychiatric comorbidity was increased for dysthymia (OR, 2.2;

95%CI, 1.1-4.3) but not for generalized anxiety disorder (OR, 1.3; 95%CI, 0.7-2.5). As expected, the OR for association of somatoform disorders and "a lot of problems with" headaches attributed to psychological conditions was very high (OR, 11; 95%CI, 6.1-19.6) because headache due to these conditions could be part of the diagnostic criteria for somatoform disorders. In our sample, for people with somatoform disorders, the most common physical symptoms in order of frequency were headache (44%), followed by chest pain (17.9%), abdominal pain (17.9%), and back pain (16.7%). There was no association between headache and alcohol or nicotine dependence, or bulimia.

Discussion In this cross-sectional study conducted on Brazilian adults, we detected an association between headache and psychiatric disorders. "A lot of problems with" headache is a very prevalent symptom in the general population. At least one in every three persons has had such symptoms at some time in their lives. Because we only assessed headaches of some sort of severity, it is quite probable that these numbers are an underestimate of the actual prevalence of headache in this community. Systematic comparison with previous population-based studies is difficult because of different instruments used to assess headache. Nonetheless, our finding of a 37.4% frequency of lifetime headache is far below the nearly 80% frequency of tension-type headache reported by Rasmussen in Sweden (2) and the 72.8% value reported by Barea et al. (19) for children and adolescents in Brazil, using the IHS

criteria. However, our rate is slightly above the lifetime prevalence of 25.9% of headache complaints reported by Kroenke and Price (1) in the Epidemiologic Catchment Area Program study. As in other studies conducted on the general population (2,18), headache symptoms are both age and gender dependent. "A lot of problems with" headache is more common among women. Headaches that are symptomatic (cause attributed to lifestyle and/or physical conditions, such as headache due to fever, hangover and other lifestyle causes, clinical or neurological disorders) increased with age. The higher prevalence of headaches attributed to nervousness or mental illness in the 25-34-year age stratum may indicate that young age cohorts more frequently experience these types of symptoms. The lack of association of headache symptoms with educational level and marital status also agrees with other population-based studies. In agreement with previous studies (1,9,18,19,27), one of which was conducted on a Brazilian population (18), there was a high comorbidity among people complaining of "a lot of problems with" headache, especially headaches attributed to nervousness or mental illness with depression and anxiety disorders. People with "a lot of problems" with headache have at least a two-fold increased likelihood of having lifetime anxiety or depressive disorder. This association is especially strong with chronic disorders like generalized anxiety disorder and dysthymia. This is in agreement with data from Italian patients with episodic and chronic tension-type headache, described by Guidetti et al. (16). The most common anxiety disorder diagnosed was generalized anxiety disorder (44.7%), and the most common depression disorder was dysthymia (16.6%). These kinds of findings are still scarcely available in the literature because most studies do not subdivide depressive and anxiety disorders into subgroups. There was no association of headache and panic disorder in our sample. However, the lack of significance of this result may have been due to the low prevalence (1.5%) of panic disorder in our sample. The present study has several limitations. First, we did not evaluate the real prevalence of headache in the population sample but the prevalence of "a lot of problems with" headache. Therefore, our data give an underestimate of the real prevalence of headache in the population. Data from a population-based telephone interview survey in Maryland, USA, which included residents 12-29 years of age who reported having had a headache during the previous year, showed that only 26.7% of women and 13.6% of men had ever sought a physician because of the headache problem (28). Most people with headache have episodic tension-type headache, which is sporadic and of mild intensity and have never sought a physician for medical advice about a headache problem. So again, when we asked about "many problems with headaches", these people were probably not included and underestimation was again possible. Second, we did not have the information to classify headache subtypes according to the IHS criteria. However, it is possible to obtain the individual attributed causes of headache by using the answers to the CIDI questions. We were probably preferentially selecting mostly the headaches attributable to psychological conditions as primary tension-type and migraine headaches with no alteration upon physical examination. Most of the headaches attributable to lifestyle and/or physical conditions (those due to medicines, drugs and alcohol, clinical and neurological diseases) would then have been selected as secondary headaches. However, since the IHS criteria were not available in this sample, some kind of misclassification was very likely. This may have influenced our results showing a positive association of headache attributed to lifestyle and/or physical conditions with dysthymia. This would be reflected in some of the primary headaches (migraine or tension-type) being erroneously identified as secondary headaches. According to our definition, headaches due to nervousness or mental sickness were more prevalent between 25 and 44 years of age, an age stratum in which primary headaches are really more prevalent. The clearly greater association between some psychiatric disorders and "primary headaches" is another point that suggests that we made a true assumption in classifying most primary headaches into the group of headaches attributed to psychological conditions. This agrees with previous observations in the literature (5,16,17,19,28,29). The strength of the present study is that the information came from a general population sample and was

collected using standardized interviews to assess psychiatric morbidity. Few studies in the literature have provided data on the relationship between headache and other psychiatric disorders like bulimia, nicotine and alcohol dependence. Most of the available data are about anxiety and depression as a whole. Only a small number of studies have included the subtypes of anxiety (panic disorder, generalized anxiety disorders and phobias) and depression (dysthymia, depressive episode) (30). The results of the present study are not representative of the entire Brazilian population because of the wide variety of cultural and socioeconomic influences in the country. It is clear from our data that headache is correlated with common chronic psychiatric disorders such as generalized anxiety disorders, among anxiety disorders, and dysthymia among depression disorders. There is also a very strong comorbidity between headache and somatoform disorders. Additional studies are needed for a better understanding of the relationships between these disorders. References 1. Kroenke K & Price RK (1993). Symptoms in the community: prevalence, classification, and psychiatric comorbidity. Archives of Internal Medicine, 153: 2474-2480. [ Links ] 2. Rasmussen BK (1995). Epidemiology of headache. Cephalalgia, 15: 45-68. [ Links ]

3. Mongine F, Ferla E & Maccagnani C (1992). MMPI profiles in patients with headache or craniofacial pain: a comparative study. Cephalalgia, 12: 91-98. [ Links ] 4. Mongine F, Defilippi N & Negro C (1997). Chronic daily headache. A clinical and psychological profile before and after treatment. Headache, 37: 83-87. [ Links ] 5. Wolff HG (1937). Personality features and reactions of subjects with migraine. Archives of Neurology and Psychiatry, 37: 895-921. [ Links ] 6. Merikangas KR, Angst J & Isler H (1990). Migraine and psychopathology: results of the Zurich Cohort Study of Young Adults. Archives of General Psychiatry, 47: 849-853. [ Links ] 7. Breslau N, Davis GC & Andreski P (1991). Migraine, psychiatric disorders and suicide attempts: an epidemiological study of young adults. Psychiatry Research, 37: 11-23. [ Links ] 8. Mongine F, Ibertis F & Ferla E (1994). Personality characteristics before and after treatment of different head pain syndromes. Cephalalgia, 14: 368-373. [ Links ] 9. Mitsikostas DD & Thomas AM (1999). Comorbidity of headache and depressive disorders. Cephalalgia, 19: 211-217. [ Links ] 10. Merikangas KR & Stevens DE (1997). Comorbidity of migraine and psychiatric disorders. Neurologic Clinics, 15: 115-123. [ Links ] 11. Breslau N & Davis GC (1992). Migraine, major depression and panic disorder: a prospective epidemiological study of young adults. Cephalalgia, 12: 85-90. [ Links ]

12. Breslau N, Davis GC, Schultz LR & Peterson EL (1994). Migraine and major depression: a longitudinal study. Headache, 34: 387-393. [ Links ] 13. Ziegler DK & Paolo AM (1995). Headache symptoms and psychological profile of headache prone individuals. A comparison of clinic patients and controls. Archives of Neurology, 52: 602-606. [ Links ] 14. Ossipova VV, Kolosova OA & Vein AM (1999). Migraine associated with panic attacks. Cephalalgia, 19: 728-731. [ Links ] 15. Marazziti D, Toni C, Pedri S, Bonuccelli U, Pavese N, Lucetti C, Nuti A, Muratorio A & Cassano GB (1999). Prevalence of headache syndromes in panic disorder. International Clinical Psychopharmacology, 14: 247-251. [ Links ] 16. Guidetti V, Fabrizi P, Giannantoni AS, Napoli L, Bruni O & Trillo S (1998). Headache and psychiatric comorbidity: clinical aspects and outcome in an 8-year follow-up study. Cephalalgia, 18: 455-462. [ Links ] 17. Swartz KL, Pratt LA, Armenian HK, Ching Lee MS & Eaton WW (2000). Mental disorders and the incidence of migraine headaches in a community sample. Archives of General Psychiatry, 57: 945-950. [ Links ] 18. Bastos SB, Almeida-Filho N & Santana VS (1993). Prevalence of headache as a symptom in the urban area of Salvador, Bahia, Brazil. Arquivos Brasileiros de Neuropsiquiatria, 51: 307-312. [ Links ] 19. Barea LM, Tannhauser M & Rotta NT (1996). An epidemiological study of headache among children and adolescents in southern Brazil. Cephalalgia, 16: 545-549. [ Links ] 20. International Headache Society (1988). Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia, 8 (Suppl 7): 1-96. [ Links ] 21. Sanvito WL, Monzillo PH, Peres MF, Martinelli MO, Fera MP, Gouveia DA, Murachovsky J, Salomo WR & Leme RJ (1996). The epidemiology of headache in medical students. Headache, 36: 316-319. [ Links ] 22. Kish L (1965). Survey Sampling. John Wiley & Sons, New York. [ Links ]

23. Kish L & Frankel MR (1970). Balanced repeated replications for standard errors. Journal of the American Medical Association, 65: 1071-1094. [ Links ] 24. Miranda CT, Mari JJ, Ricciardi A & Arruda ME (1990). Patients' reactions to CIDI in Brazil. In: Stefanis CN, Rabavillas AD & Soldatos CR (Editors), Psychiatry: A World in Perspective. Elsevier, Amsterdam, The Netherlands, 133-137. [ Links ] 25. Lopes CS (1994). Reliability of the Brazilian version of the CIDI in a case-control study of risk factors for drug abuse among adults in Rio de Janeiro. Bulletin of the Pan-American Health Organization, 28: 3441. [ Links ]

26. World Health Organization (1992). Mental health and behavioral disorders. In: International Classification of Diseases. 10th revision. World Health Organization, Geneva, Switzerland, 311-387. [ Links ] 27. Nimnuan C, Hotopf M & Wessely S (2001). Medically unexplained symptoms. An epidemiological study in seven specialties. Journal of Psychosomatic Research, 51: 361-367. [ Links ] 28. Breslau N (1998). Psychiatric comorbidity in migraine. Cephalalgia, 18 (Suppl 22): 56-61. [ Links ]

29. Linet MS, Celentano DD & Stewart WF (1991). Headache characteristics associated with physician consultation: a population-based survey. Annals of Preventive Medicine, 7: 40-46. [ Links ] 30. The Italian Collaborative Group for the Study of Psychopathological Factors in Primary Headaches (1999). Psychiatric comorbidity and psychosocial stress in patients with tension-type headache from headache centers in Italy. Cephalalgia, 19: 159-164. [ Links ]

Cephalalgia, 2002, 22, 672-679 Low socio-economic status is associated with increased risc of frequent headache: a prospective study of 22718 adults in Norway. K Hagen, L Vatten, L J Stovner, J-A Zwart, S Krokstad & G Bovim Studiile prevalenei, ce au studiat relaiile dintre statutul socio-economic(SSE) i cefalee prezint rezultate contradictorii. Acesta e primul studio prospective, ce analizeaz relaia dintre SSE i riscul cefaleei. Totalul de 2685 aduli nepredispui s sufere de cefalee au fost clasificai dup SSE dup idea de baz n 1984-1986 i au rspuns la chestionarele de cefalee cu 11 ani mai trziu(1995-1997). Statutul socio-economic dup cum a fost gndit a fost definit(coninea) prin nivelul educaional, ocupaie i venit. Riscul cefaleelor frecvente i al cefaleelor cronice(>6 i 15 zile/lun , respective) , dup cum urmeaz au fost estimate n relaie cu SSE. Cnd s-a definit SSE prin nivelul educaional sau tipul ocupaiei, statutul jos a fost asociat cu riscul crescut al cefaleelor frecvente i cronice ca urmare. Riscul cefaleelor frecvente i cronice descrete cu creterea venitului personal, dar doar n cazul brbailor. Am concluzionat, c persoanele(indivizii) cu un nivel jos al statutului socioeconomic au un risc mai nalt al cefaleelor frecvente i cronice, dect persoanele cu cu un SSE nalt. (Socio-economic status, migraine, chronic headache. Introducere: Inegaliti n morbiditate din cauza diferenelor n statutul socio-economic sunt substaniale n Europa de Vest i n SUA, dar studii al statutului socio-economic i cefaleei conin rezultate contradictorii( ce se contrazic). Studiile clinice raporteaz, c migrena survine mai frecvent printre indivizii inteligeni i cu un nivel de

educaie(studii) nalt, pe cnd studiile populaionale cross-sectional n-au confirmat aceste rezultate. n contrast unii au raportat o cretere a prevalenei cefaleei i migrenei printre grupurile cu venituri mici i nivel jos educaional. Asemenea unei relaii inverse ntre cefalee i SSE statutul socio-economic n-a fost raportat n studiile din afara SUA. Cauza i efectul n-a fost distins n studiile populaionale cross-sectionale i este de preferat un studiu-design prospectiv. n acest studiu prospectiv randomizat cu un numr mare de persoane noi am examinat relaia dintre statutul socio-economic (SSE), msurat n perioada anilor 1984-1986 i riscul ulterior al migrenei, cefaleei nemigrenoase i a cefaleei frecvente(>6 zile cu cefalee/lun) peste 11 ani. De asemenea s-a evaluat asocierea dintre SSE i prevalena cefaleei dup cum a fost estimat n urmtorii 1995-1997. Materiale i metode n Nord-Trondelag County din Norvegia 2 studii populaionale cross-sectionale(the HUNT study)au fost executate. Primul studiu(HUNT-1) a avut loc n 1984-1986, iar al doilea(HUNT-2) n 1995-1997). n HUNT-1 toate persoanele 20 ani au fost invitai i descrii detaliat n studiul populaional de ctre Holmen et al. pe scurt, din 85100 indivizi eligibili, 77310(91%), ce au rspuns la chestionarele, care le-au fost trimise cu invitaii. Participanii au raportat nivelul de educaie, ce-l deineau(6 categorii) i bazndu-ne pe aceast informaie am divizat participanii n 3 categorii,n accord cu durata studiilor : 9ani(coala obligatorie), 10-12 an i 13 ani(nivelul universitar). Participanii au menionat deasemeni ocupaiile lor (10 categorii) i aceast infrmaie a fost utilizat pentru reclasificarea subiecilor(n aproximativ din schema social naional, recomandat n raportul OMS(WHO)(Erikson, Goldthope and Portocarero, EGP). Raionamentul pentru care am preferat aceast schem de clasificare pentru HUNT populaional este dat n alt parte. Participanii sunt reclasificai n 3 categorii : clasa social nalt( clasa I-II EGP social): posture managerial n ntreprinderi publice sau private i profesionitii( lucrtorii cu gulerae albe); clasa social medie(clasa III-IV EGP social): muncitorii , ce efectuiaz munc de rutin nemanual, proprietarii mici, fermierii i pdurarii i ali muncitori autoangajai din producia primar; cea mai joas clas social (clasa V-VII EGP social): tehnicieni necalificai, supraveghetori ai muncitorilor specializai n munci manual, muncitori sei i necalificai(cu gulerae albastre). Datele privind venitul n 1984i 1985 au fost disponibile de la serviciul Norvegian Revenue, prin legarea failurilor cu date printr-un numr de identificarede 11 cifre dat cetenilor norvegieni la natere. Numrul de identificare a fost schimbat nainte de a fi

suplimentat de alte investigaii. Analizele s-au bazat pe venitul aproximativ al salariului pentru pensionare(pensionable salary) n 1984 i 1985. Ca referin venitul mediu n Nord-Trondelag County din Norvegia a fost de9513 (NOK 109071) pentru brbai i de 4173 (NOK 47851) pentru femei(NOK= krona Norvegian; 1 NOK= 0,09 ca i pentru iunie 2002). Ca i pentru educaie i educaie, am divizat participanii n 3 categorii dup venit, unde cel mai jos venit a fost definit ca fiind sub 33 persentile(8267(NOK 94800)la brbai i 1400 (NOK 16050) la femei). Venitul nalt a fost considerat unul mai nalt de 66 persentile(11416(NOK 130900) i 5534 (NOK 63450) printre brbai i femei respective). Ne-am propus s stabilim ul lot de baz fr cefalee . Chestiopnarul HUNT-1 n-a inclus ntrebri privind cefaleea, dar 59471 persoane au rspuns la ntrebarea despre utilizarea analgezicelor(Ct de des ai luat medicamente de uurare a durerii pe parcursul ultimei luni?). n total 41581 au rspuns, c niciodat n-au utilizat analgezice, proporia suferinzilor de cefalee putea fi neglijat. Respondenii, care niciodat n-au utilizat medicamente au fost ceva mai tineri i au avut un venit mai nalt, un niveleducaional i o clas social, legat de profesie n comparaie cu cei care au utilizat analgezice. Printre 4158 1 indivizi , ceniciodat n-au utilizat medicamente-analgesic-free, 7887 au decedat sau s-au mutat din Nord-Trondelag County(caracteristici demogrefice nedisponibile). Acei 33694 disponibili pentru HUNT -2 i n afar de acetea,22718(67%) au rspuns la chestionarul cefaleei. Indivizii, care au rspuns la chestionarul cefaleei tindeau s fie mai tineri(aveau tendina)(55,0 vs 58,6 ani,P<0,0001), cu tendina de a fi femei(47% vs. 44%, P<0,0001), i cu o mai nalt SSE(astare socio-economic), msurat(evaluat prin educaie, ocupaie i venit(P<0,0001), dect acei, care n-au rspuns. Printre 22718 analgesic-freerespondeni, n total 22187 au raportat frecvena cefaleelor. Printre 22718 respondeni au crezut c nu au cefalei n timpul HUNT1, 6317(28%), au raportat, c sufer de cefalee n HUNT-2 (De migren 7% i de cefalei nemigrenoase 21%). n HUNT-2(1995-1997), toi locuitorii cu vrsta20ani au fost invitai, detaliile studiului au fost raportate mai trziu. Pe scurt, participanii au rspuns la 2 chestionare. Clasificarea educaiei i ocupaiei a fost identic cu cea din HUNT1). Datele despre venit a fost oferite de Norvegian Revenue service. Ca referin venitul mediu n 1995 disponibil n Nord-Trondelag County a fost de 13293 (NOK 152414) i 810 (NOK 92909) pentru femei i brbai, respectiv. Am divizat participanii n 3 categorii, n care venitul mai jos de 33 perscentile a fost clasificat ca jos(6471 (NOK 74200) n cazul brbailor i 1143 (NOK 13100) n cazul

femeilor ) i venitul mai nalt de66 persentile a fost clasificat ca nalt(18446 (NOK 211500) n cazul brbailor i 11914 (NOK 136600) n cazul femeilor(printre femei)). n plus, indivizii cu vrsta 69 ani trebuiau s rspund la ntrebarea Ai avut careva problem n acoperirea cheltuielilor pentru alimente, transport, trai etc.?. n chestionar au fost 4 opiuni de rspuns:niciodat, rar, uneori i des. Al doilea chestionar (Q2) n HUNT-2 a anclus 13 ntrebri privind cefaleea i indivizii, ce au rspuns da la ntrebarea Ai suferit de cefalee pe parcursul ultimelor 12 luni? au fost clasificai ca suferinzi de cefalee. Respondenii, care au raportat , c sufer de migren n chestionar au fost diagnosticai ca suferinzi de migren. n plus, indivizii, ce au completat criteriile ulterioare au fost deasemeni diagnossticai ca suferinzi de migren: atacuri dfe cefalee, ce dureaz de la 4 la 72 ore(72 ore pentru acei, care au raportat dereglri(fenomene) vizuale nainte de atac); avea cel puin una din trei caracteristici: character pulsatil, localizare unilateral sau agravare la efort fizic; pe parcursul cefaleei, mcar una din cele ce urmeaz a fost prezent: greaa, fotofobia sau fonofobia. Criteriile noastre pentru migren au fost versiunea modificat a criteriilor pentru migren a Societii Internaionale a Cefaleelor(SIC), cea mai notabil modificare fiind faptul c severitatea durerii nu a fost inclus printre caracteristice durerii(item no. (ii)). Drept urmare, criteriile noastre pentu migren au fost mai puin riguroase n priviina caracteristicelor durerii, necesare diagnozei. Deasemenea criteriile noastre pentru migren erau diferite de cele impuse de SIC, de exmplu, prin neglijarea numrului atacurilor precendente resimite n timpul vieii. Discrepana dintre criteriile noastre pentru migren i cele ale SIC a fost discutat anterior(27). Cefaleea care nu a satisfcut criteriile pentru migren a fost clasificat ca fiind cefalee non-migrenoas. Diagnosele cefaleelor erau de mutual excusive. Migrenoii i non-migrenoii au fost deasemenea clasificai dup frecvena cefaleelor. Deoarece nu a existat o diferena semnificativ dintre categoriile diagnozei(cefaleea migrenoas i non-migrenoas) la fel i n asociere cu SSE, aceste grupuri au fost combinate. Cefaleea frecvent i cronic a fost definit ca cefalee >6 i >14 zile /lun, respectiv. Din 92566 de indivizi invitai , un total de 49948 de subieci(54%) au completat chestionarul asupra cefaleei, unde era disponibil informaia privind venitul. Etica Acest studiu a fost aprobat de ctre Comitetul Regional de Etic n Studiile Medicale i de ctre inspectoratul Norvegian de Date. Validitatea i veridicitatea diagnozei cefaleii

Criteriile pentru diagnoza cefaleelor au fost validate (27) prin compararea diagnozelor bazate pe informaia din chestionare cu diagnozele puse ntr-o consultaie clinic a unei mostre de participani. Pentru migren, valoarea predictiv pozitiv a diagnozei n baza chestionarului era de 84%, i ansa rectificarea stabilit() era 0.59(95% CI 0.47-0.71), care este considerat bun. Pentru cefaleea non-migrenoas , ct i pentru cefaleea cronic i frecvent, valorile lui erau 0.43,0.44 i 0.50., respectiv,care indic un accord/nelegere moderat(30). Prevelena de un an a migrenei, cefaleii non-migrenoase, cefaleii frecvente i cronice la HUNT-2 era de 12%, 26%, 8% i 2% , respective(29). Analiza statisic Diferenele dntre proporii erau analizate prin testul .Valorile lui P< 0.05 erau

considerate statisctic semnificative. n analizele multiple i variate, utiliznd regresia logic multipl, noi am folosit informaia despre SSE(anii de educaie, statutul professional, i venitul) n HUNT-1 pentru a estima riscul relativ al cefaleei , la fel dup cum este nregistrat n succesorul HUNT-2. Riscul relativ a fost calculat pentru migren, cefaleea non-migrenoas, i cefaleea frecvent i cronic. Noi am evaluat poteniala ncurcare(buimceal)dup vrst(categorii de cte 5 ani), indexul de mas corporal(BMI), fumatul current(da/nu), consumul de alcool(3 categorii) i activitatea fizic(3 categorii). Precizia riscului relativ a fost analizat cu interval de ncredere de 95%(CI). Analizele statisctice au fost petrecute utiliznd Pachetul Statistic pentru tiinele Sociale(PSS), versiunea 8.0(PSS Inc., Chicago, IL, SUA). Rezultate Pe cnd cefaleea non-frecvent nu a prezentat vreo legtur cu SSE, un nivel jos al SSE definit de nivelul de educaie i ocupaie, n prim-plan , era asociat cu un risc crescut al cefaleelor frecvente i cronice. Acest lucru era evident pentru ambele sexe , ct i pentu cefaleea migrenoas i non-migrenoas. Deaoarece nu a existat vreo diferen n categoriile de diagnosticare (cefalee migrenoas i non-mogrenoas) la fel i n asociere cu SSE, aceste grupuri au fost combinate,dup cum este prezentat n tab. 1. Printre indivizii cu mai puin de 10 ani de educaie, riscul relativ pentru ambele cefalei frecvente i cronice era 1.8(95%I-intervalul de ncredere CI1.5-2.4 i 1.21.8, respectiv) n comparaie cu indivizii cu cel puin de 13 ani de educaie. Acest risc mai nalt al cefaleelore frecvente printre indivizii cu educaie mai proast(nivel mai jos)era mai evident printre indivizii mai tinrei de 60 ani(fig 1. Clasa social joas definit de profesie era deasemenea asociat cu un risc crescut pentru cefaleea frecvent la ambele sexe i pentru cefaleea crnic a femei(tab 1) evident n toate grupele de vrst. Un SSE jos, definit de venit era deasemenea legat de un risc marit

pentru cefalee frecvente i cornice , dar numai ntre brbai(tab.1 ). Ajustrile pentru IMC, fumat, comsumul de alcool sau activitatea fizic nu a schimbat rezultatele menionate mai sus. Deasemenea n analiza intra-secional(cross-)(tab 2), un SSE jos era asociat cu prevalena mai nalt a cefaleelor frecvente i cronice , evident att pentru migren ct i pentru cefaleea non-migrenoas. n mediu, indivizii cu mai puin de 10 ani de educaie aveau o prevalena mai nalt cu 90% a cefaleelor frecvente (OR=19.5% CI 1.7-2.1)i o prevalen cu 70 % mai nalt pentru cefaleea cronic(OR=1.7, 95% CI 1.4-2.0) n comparaie cu acei cu educaie superioar(>= 13 ani). n mod similar,clasa social joas definit de tipul profesiei i venit era asociat cu o frecven mai nalt a cefaleii frecvente i cronice, evident pentru ambele sexe. O prevalen nalt a cefaleii frecvente i cronice a fost deasmena descoperit printre cei care nu aveau o profesie anume(studeni/elevi,gospodari sau pensionari )(tab2). O analiz ulterioar a dezvluit c o legtur strins dintre pensia de invaliditate i cefaleea frecvent poate explica cel puin parial aceste rezultate(nu sunt prezentate date). n final, frecvena cefaleelor frecvente i cronice era dublu mai nalt la indivizii care au prezentat probeme economice n comparaie cu cei care experimentau foarte rar sau niciodat asfel de probleme(tab 2). Discuii n acest studiu prospectiv, un SSE jos, definit de nivelul educaiei i profesie ca un prim-plan a fost asociat cu un risc crescut al cefaleiilor frecvente i cronice 11 ani mai trziu. Aceasta era evident pentru ambele sexe i pentru migren la fel ct i pentru cefaleea non-mogrenoas. Riscul cefaleii frecvente i cronice descretea odat cu creterea venitului individual, dar numai n cazul brbailor. Deasemenea, n partea intra-secional a studiului, SSE-ul jos era asociat cu cefaleea frecvent i cronic. Nici un studiu precedent privitor la SSE i cefalee nu a avut un design prospectiv. Totui, numai partea intra-secional a studiului nostru poate fi comparat cu studiile anterioare. Rezultatele prezente difer de cteva din acele studii, care au descoperit o prevaln destul de uniform printre categoriile de educaie(811,14,15,19), clasa profesional(8-10,15,19)sau venit(5-7,16-18). Descoperirea noastr principal , este totui, n concordan cu studiile din SUA. Scher et al. (25) a raportat c cefaleea fecvent definit cu 180 sau mai multe cefalei pe an era mai pevalent la cei cu un nivel jos de educaie, i Stewart et al.(20) a descoperit c cefaleea era mai frecvent la migrenoi a grupele cu venitul cel mai mic. Pe cnd SSE jos a fost asociat cu un risc crescut al cefaleei frecvente i cronice, noi nu am gsit vreo relaie ntre cefalea non-frecvent i SSE. n concordan, Schwartz et al. (31) a raportat o cretere a prevalenei cefaleii de tip tensional cronice odat cu descreterea nivelului de educaie, pe cnd prevalena CTT episodice a

descrescut. Rezultatele noastre indic c SSE este legat de frecvena cefaleii mai mult dect de tipul cefaleei. Lipsa unei diferene dintre 2 categorii diagnostic poate reflecta c aceste 2 tipuri de cefalei mpart aceiai factori de risc. Totui, ea poate deasemenea refecta o acuratee sczut a diagnozei (27) i faptul c muli dintre migrenoi au i CTT. n studiile intra-secionale, relaia dintre cauz i effect nu pate fi distins , n timp ce informaia despre educaie, profesie sau venit este prezentat n acelai timp ca informaie n baza creia este obinut cefaleea. n accord cu acest fapt , o relaie invers dintre pevalena cefaleii i SSE poate fi explicat de interferena cefaleii cu reuitele colare i cariera profesional, dup cum este sugerat n modeul social selectat(32,33). n studiul nostru prospectiv informaia despre SSE era obinut ntr-o populaie presupus fr cefalee. Totui, era mai puin probabil c cefaleea a interferat cu eduaia sau cariera profesional ntr-un prim-plan. Rezulatele noastre indic c ali factori asociai cu un SSE jos, precum stresul, malnutriia sau ngrijirea medical necorespunztoare, poate influena riscul cefaleii(modelul social al cauzelor)(32,33). mpotriva acestui fapt, cineva ar putea declara c ajustarea pentu factoii sociali precum fumatul i activitatea fizic nu a schimbat rezultatele noastre. Nectnd la acest lucru, informaia din baza chestionarului despre fumat, consumul de alcool i activitatea fizic poate fi considerat cu atenie , deoarece aceste date nu au fost validate. Prin urmare , ali factori nemsurai relatai cu cu SSE ar putea confunda informaia. Unii participani ar putea fi schimbat SSE lor n decursul celor 11 ani urmtori, de exemplu finisa studiile superioare(mai ales persoanele mai tinere) , sau schimba mrimea venitului i a statutului profesional. Deoarece informaia asupra SSE era disponibil n ambele HUNT-1 i HUNT-2, cineva ar putea considera c ajustarea riscului estimeaz schimbarea pentru SSE n perioada imediat urmtoare. Aceasta este totui incorect , avnd n vedere c informaia despre SSE pentru HUNT-2 a fost acumulat n acelai timp cu rspunsurile din chestionarul de cefalee. Pentru a fi relevant n aceast ntrebare , este absolute necesar ca informaia despre dezvluire s fie obinut nainte de evoluia cefaleii. ntrebrile cu privire la cefalee nu au fost incluse n HUNT-1 i statutul cefaleii n primplan a trebuit s fie determinat indirect prin utilizarea informaiei despre folosirea analgezicelor. Conform acestui fapt, noi a trebuit s presupunem c cei care nu au consumat medicamente anti-cefalgice n ultima lun pe durata HUNT-1 nu sufereau de dureri de cap. Totui a fost raportat c anumii pacieni nu i atenueaz cefaleea prin medicamente(34-37). Dac noi am inclus un numr substanial de indivizi ca o baz a suferinzilor de cefalei , aceasta ar fi putut influena rezultatele noastre, dar este dificil de a susine o anumit direcie. Totui, este rezonabil de a presupune c populaia care nu administreaz analgezice reprezint o problem aparte , avnd n vedere c nu a fost

gsit vreo relaie ntre SSE i cefaleea non-frecvent. Identificarea unei populaii complet lipsite de cefalee este grea, deoarece majoritatea chestionailor au fi avut cefalei n timpul ultimului an.(38) Totui, pare rezonabil c populaia noastr antimedicamentoas ntr-o prim faz avea probleme minore cu cefaleeile comparative cu cealalt populaie. Noi nu am avut vreo informaie de ce pacienii au utilizat analgezice n HUNT-1. Fiindc a trebuit s excludem idivizii cu toate condiiile durerii rezultate din administrarea analgezicelor, cineva ar putea specula dc oare excluderea pacienilor ce nu administreaz pastile din studio ar fi putut influena rezultatele noastre. Totui, deasemenea printre utilizatorii de analgezice un SSE jos n prim-plan era asociat cu riscul crescut al cefaleii frecvente i cronice(nu sunt artate date). Astfel, includerea pacienilor ce nu primesc analgezice n studiul nostru n grupa persoanelor de risc, cel mai probabil nu ar fi influenat rezultatele noastre. n HUNT-1, 70% din persoanele invitate au rspuns la ntrebarea despre utilizare analgezicelor i de asemenea 70% din indivizi au fost invitai pentu HUNT-2, au rspuns la chestionarul cefaleei. Dei rata de participare a fost nalt, n-am putut stpni posibila deviere al selecionrii. Indivizii, care au rspuns la chestionarul cefaleei au fost foarte tineri, tindeau s fie femei( n majoritate femei) i aveau un SSE mai nalt dect acei, ce n-au rspuns . Astfel, generalizarea rezultatelor noastre privind acei , ce n-au participat poate fi efectuat cu precauie. Riscul cefaleelor frecvente crete printre persoanele cu nivel jos de educaie de ambele sexe, mai proeminent la pers .cu vrsta <60 . Astfel, nivelul educaional nu pare a fi un indicator puternic al SSE printre persoanele nscute naintea celui deal rzboi mondial II-lea Rzboi Mondial ori, ca alternativ SSE nu influieneaz prevalena cefaleelor frecvente la pacienii n vrst. A fost (gsit)un risc nalt al cefaleelor frecvente , asociat cu un nivel jos de venit. n analiza cross- secional, aceasta a fost adevrat pentru ambele sexe, dar n partea prospectiv a studiului, el a fost gsit doar printre brbai. O msurare mai exact pentru SSE este venitul gospodriei ajustat la numrul membrilor familiei(gospodriei). n particular acesta ar putea fi un indicator mai sensibil pentru femei, dar din pcate aceast informaie n-a fost disponibil. Este de asemenea o asociere ntre problemele economice expuse desinestttor i cefaleele frecvente. Astfel, pare a fi rezonabil s presupunem, c nivelul jos economic reflect problemele financiare. Unii pot specula, c astfel de problem induc un stress nalt psiho-social, ce cauzeaz cefaleea frecvent n grupurile cu nivel economic jos. Prevalena cefaleei frecvente i cronice a fost nalt printre indivizii, care aveau SSE neclasificabil, definit de ocupaie, mai evident n grupul persoanelor , care

primesc pensie de incapacitate. Aceast cercetare a fost surprinztoare, deoarece foarte puini subieci primesc pensie de incapacitate n Nord-Trondelag din cauza cefaleei, acesta sugeraz, c alte patologii dect cefaleea pot fi accentuate, cnd se efectuiaz aplicaia pentru pensie de desabilitate. Exist o dovad, c e mai bine s defineti statutul ocupaiei femeii pe baza statutului ocupaiei partenerului su . Totui n studiul present, clasa social joas , definit doar de ocupaie a fost asociat cu un risc nalt al cefaleelor frecvente deasemenea i printre femei. Deoarece SSE pare a fi un predictor destul de puternic al cefaleelor frecvente, este important s fie considerat acest factor n studiile pacienilor cu cefalei frecvente i cronice . Dac SSE difer printre grupuri, diferenele n frecvena cefaleei pot fi ateptate i rezultatele trebuie ajustate la SSE. Trei tipuri de msurare al SSE s-au aplicat n acest studio, toate avnd avantaje i dezavantaje, dar toate probabil reflect(careva) diferite aspect al SSE. n concluzie , statutul socio-economic jos ca punct de pornire a fost asociat cu un risc crescut al cefaleelor frecvente cu 11 ani mai trziu, evident pentru ambele migren i cefaleea nemigrenoas. Asumnd faptul, c participanii au fost relative fr cefalee din start, este puin probabil, c cefaleea interfer cu funcia educaional sau ocupaional. S-ar prea important s identificm mai ndeaproape care factori interacioneaz (sunt n relaie) cu SSE jos, sunt responsabili de riscul crescut al cefaleelor frecvente.
Factors Associated With Low Socioeconomic Status Increase The Prevalence Of Migraines In Adolescents, New Study Shows Main Category: Headache / Migraine Also Included In: Pediatrics / Children's Health Article Date: 07 Jul 2007 - 7:00 PDT Adolescents from low-income families are much more likely to suffer from migraine headaches than teens from wealthier households, according to researchers at the Albert Einstein College of Medicine of Yeshiva University. The findings, published in Neurology, suggest that factors associated with low socioeconomic status --stress, poor diet and limited access to medical care, for example -- increase the prevalence of migraines in young people. But when the Einstein researchers focused on those teens without a strong family predisposition for migraines, they found that household income was strongly associated with migraine prevalence: In families with annual incomes of less than $22,500, the prevalence of migraines in teens was 4.4 percent; by contrast, the migraine prevalence among teens in households earning $90,000 or more was only 2.9 percent. "It would seem that for those teens who have a genetic predisposition for migraine, the stressful life events related to income don't matter," says Dr. Bigal. "They're more likely than other teens to get migraine regardless of their socioeconomic status, since they are predisposed. But for teens without a strong predisposition, reflected by the absence of migraine in first-degree relatives, family income factors into the prevalence of migraine, particularly among those teens whose families have low income." Dr. Bigal notes that this finding correlates with migraine prevalence for adults, which is consistently higher among people with lower income and less education. "Our study also suggests that we should explore environmental risk factors, such as stressful events and

nutrition, as they relate to low income and migraine to understand how we might reduce the occurrence of migraine among these individuals." -----------------------------------------------------------------------------------------------------------------Article Date: 23 Sep 2007 - 0:00 PDT Herd P, Goesling B, House JS. Socioeconomic position and health: the differential effects of education versus income on the onset versus progression of health problems. J Health Soc Behav 48(3), 2007.

"Those with less education are more likely to develop health problems and those with low incomes who already have health problems are more likely to see their health worsen," said lead author Pamela Herd, a University of Wisconsin-Madison sociologist. The study appears in the September issue of the Journal of Health and Social Behavior and examines how health differences in the United States often relate to people's socioeconomic status. Herd and colleagues say education influences occupation, income and wealth and with higher education comes healthier behaviors, such as good diet, increased physical activity, reduced stress and better use of preventive and therapeutic healthcare. The authors used data collected from 1986 to mid-2002 in the "Americans' Changing Lives Study," which conducted four waves of interviews of adults who were 25 years old and older. Herd and colleagues analyzed data for 8,287 participants. They looked at two groups of health problems: chronic conditions and functional limitations or disabilities. Compared with those with a college degree, the odds of having health problems were 81 percent higher for those without a high school diploma and 56 percent greater for those with a high school diploma. When comparing income, the researchers found that those with incomes of less than $10,000 had a 35 percent greater chance of developing health problems than those who made more than $30,000. In addition, those with incomes less than $10,000 had a 195-percent greater chance that their health problems would get worse. -----------------------------------------------------------------------------------------------------------------------------Cigarette Smoking Among Adults in the USA Main Category: Smoking / Quit Smoking Article Date: 01 Jun 2004 - 10:00 PDT This report summarizes the results of that analysis, which indicated that, in 2002, approximately 22.5% of adults were current smokers. Although this prevalence is slightly lower than the 22.8% prevalence among U.S. adults in 2001 and substantially lower than the 24.1% prevalence in 1998, the rate of decline has not been at a sufficient pace to achieve the 2010 national health objective. Cigarette smoking prevalence rates varied substantially across population subgroups (Table). The prevalence of smoking was higher among men (25.2%) than women (20.0%) and inversely related to age, from 28.5% for those aged 18--24 years to 9.3% for those aged >65 years. Among racial/ethnic groups, Asians (13.3%) and Hispanics (16.7%) had the lowest prevalence, and American Indians/Alaska Natives had the highest (40.8%). Current smoking prevalence also was higher among adults living below the poverty level* (32.9%) than among those at or above the poverty level (22.2%). During 1983--2002, the gap in smoking prevalence between those living below the poverty line and those living at or above it increased from 8.7 percentage

points to 10.7 percentage points (Figure 1). By education level, smoking prevalence was highest among adults who had earned a General Educational Development diploma (42.3%) and lowest among those with graduate degrees (7.2%). Women with undergraduate (10.5%) or graduate degrees (6.4%) and men with graduate degrees (7.8%) also had smoking prevalence rates below the overall U.S. 2010 objective. During 1983--2002, the largest decreases in smoking prevalence occurred among adults with a college degree (10.0 percentage points) and those with some college education (9.3 percentage points); those with a high school diploma (6.6 percentage points) and those with less than a high school education (5.8 percentage points) showed the smallest decreases. During this period, the gap in smoking prevalence between adults who had graduated from college and those with less than a high school education increased from 14.0 percentage points in 1983 to 18.2 percentage points in 2002 (Figure 2). Similar patterns occurred in the percentage of ever smokers who had quit among different educational groups. The percentage of ever smokers who had quit was highest for those with college degrees, followed by persons with some college education. High school graduates and those with less than high school education had the lowest percentage of ever smokers who had quit. The gap between adults with a college degree and those with less than a high school education increased from 19.0 percentage points in 1983 to 25.9 percentage points in 2002. Editorial Note: The findings in this report indicate that 1) the socioeconomic status of U.S. adults is inversely related to their likelihood of smoking and 2) during 1983--2002, the gap in smoking prevalence by socioeconomic status did not narrow and might have widened. These findings underscore the need for targeted interventions that can better reach persons of lower socioeconomic status. Persons of low socioeconomic status have less access to health care than those of high socioeconomic status (3). ----------------------------------------------------------------------------------------------------------------------------------

Lifetime Prevalence of Migraine and Other Headaches Lasting 4 or More Hours: The Atherosclerosis Risk in Communities (ARIC) Study Authors: Perry Carson A.L.; Rose K.M.; Sanford C.P.; Ephross S.A.; Stang P.E.; Hunt K.J.; Brown C.A.; Szklo M. Source: Headache: The Journal of Head and Face Pain, Volume 44, Number 1, January 2004 , pp. 2028(9) Abstract: Objective.To evaluate the lifetime prevalence of migraine and other headaches lasting 4 or more hours in a population-based study of older adults. Background.Migraine and other headaches not fulfilling migraine criteria are common afflictions. Yet

the health and social effects of these conditions have not been fully appreciated, particularly among older adults. Methods.The study included 12 750 participants in the Atherosclerosis Risk in Communities (ARIC) Study from 4 US communities. Prevalence estimates of a lifetime history of migraine and other headaches lasting 4 or more hours were obtained for race and gender groups. A cross-sectional analysis was done to assess the relationship between headache type, by aura status, and various sociodemographic and health-related indices. Results.Compared to education beyond high school, having completed less than 12 years of education was significantly associated with an increased occurrence of migraine with aura (prevalence odds ratio [POR], 1.47; 95% confidence interval [CI], 1.08 to 2.01). Family income less than $16 000, compared to family income of $75 000 or greater, was significantly associated with migraine with aura (POR, 1.68; 95% CI, 1.07 to 2.64), migraine without aura (POR, 1.56; 95% CI, 1.14 to 2.14), and other headaches with aura (POR, 1.89; 95% CI, 1.14 to 3.13). The prevalence odds ratio was higher in each headache category, particularly for those with an aura, for those with hypertension versus normotension and for those who perceived their general health as poor compared to those whose perception was excellent. Conclusions.A lifetime history of migraine with aura and other headaches with aura was more common among whites, women, and younger participants. Further investigation of headaches lasting 4 or more hours, particularly by aura status, is warranted. ---------------------------------------------------------------------------------------------------------------Cardiovascular risk factors and migraine: The GEM population-based study. Articles Neurology. 64(4):614-620, February 22, 2005. Scher, A I. PhD; Terwindt, G M. MD, PhD; Picavet, H S.J. PhD; Verschuren, W M.M. MD, PhD; Ferrari, M D. MD, PhD; Launer, L J. PhD Abstract: Background: Migraine, particularly with aura, is a risk factor for early-onset ischemic stroke. The underlying mechanisms are unknown, but may in part be due to migraineurs having an increased risk profile for cardiovascular disease. In this study, the authors compare the cardiovascular risk profile of adult migraineurs to that of nonmigraineurs. Methods: Participants (n = 5,755, 48% men, age 20 to 65 years) are from the Genetic Epidemiology of Migraine (GEM) study, a population-based study in the Netherlands. A total of 620 current migraineurs were identified: 31% with aura (MA), 64% without aura (MO), and 5% unclassified. Controls were 5,135 individuals without lifetime migraine. Measured cardiovascular risk factors included blood pressure (BP), serum total and high-density lipoprotein cholesterol (TC, HDL), smoking, oral contraceptive use, and the Framingham risk score for myocardial infarction or coronary heart disease (CHD) death. Results: Compared to controls, migraineurs were more likely to smoke (OR = 1.43 [1.1 to 1.8]), less likely to consume alcohol (OR = 0.58 [0.5 to 0.7]), and more likely to report a parental history of early myocardial infarction. Migraineurs with aura were more likely to have an unfavorable cholesterol profile (TC >= 240 mg/dL [OR = 1.43 (0.97 to 2.1)], TC:HDL ratio > 5.0 [OR = 1.64 (1.1 to 2.4)]), have elevated BP (systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg [OR = 1.76 (1.04 to 3.0)]), and report a history of early onset CHD or stroke (OR = 3.96 [1.1 to 14.3]); female migraineurs with aura were more likely to be using oral contraceptives (OR = 2.06 [1.05 to 4.0]). The odds of having an elevated Framingham risk score for CHD were approximately doubled for the migraineurs with aura.

Conclusions: Migraineurs, particularly with aura, have a higher cardiovascular risk profile than individuals without migraine. -----------------------------------------------------------------------------------------------------------------------------Impact of comorbidity on headache-related disability. Saunders K, Merikangas K, Low NC, Von Korff M, Kessler RC. Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA. saunders.k@ghc.org OBJECTIVE: To assess and compare the extent to which comorbid conditions explain the role disability associated with migraine and other severe headaches. METHODS: A probability sample of US adults (n = 5,692) was interviewed. Presence of headaches, other chronic pain conditions, and chronic physical conditions was assessed in a structured interview administered by trained interviewers. Diagnostic criteria for migraine were based on the International Headache Society classification. Mental disorders were ascertained with the Composite International Diagnostic Interview that collected diagnostic criteria according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Role disability was assessed with World Health Organization Disability Assessment Schedule questions about days out of role and days with impaired role functioning. RESULTS: Eighty-three percent of migraineurs and 79% of persons with other severe types of headache had some form of comorbidity. Compared with headache-free subjects, migraineurs were at significantly increased risk for mental disorders (odds ratio [OR] 3.1), other pain conditions (OR 3.3), and physical diseases (OR 2.1). Compared with headache-free subjects, persons with nonmigraine headache were also at significantly increased risk for mental disorders (OR 2.0), other pain conditions (OR 3.5), and physical diseases (OR 1.7). Migraineurs experienced role disability on 25.2% of the last 30 days compared with 17.6% of the days for persons with nonmigraine headaches and 9.7% of the days for persons without headache. Comorbid conditions explained 65% of the role disability associated with migraine and all of the role disability associated with other severe headaches. CONCLUSIONS: Comorbidity is an important factor in understanding disability among persons with headache. ----------------------------------------------------------------------------------------------------------------Pathophysiology and Treatment of Migraine and Related Headache Article Last Updated: Sep 4, 2008 Soma Sahai, MD, Director of Neurology Ambulatory Clinics, LAC and USC Medical Center; Assistant Professor, Department of Neurology, University of Southern California Coauthor(s): David Y Ko, MD, Associate Professor, Laboratory Director, Department of Neurology, University of Southern California Medical Center Headache is a pervasive symptom and the most common problem neurologists encounter in their clinical practices. It affects an estimated 60-80% of Americans at any time. The history of headache can be traced almost to the beginning of the history of humankind. The first description of headache dates back to the third millennium BCE. Headache has been written about extensively since the time of the Babylonian civilization. Migraine headache and hemicrania are discussed in the Bible. Some famous historical figures (eg, Napoleon) are known to have had terrible headaches. Prevalence Migraine affects 17% of females and 6% of males in the United States.3 Before puberty, both the

prevalence and incidence of migraine are higher in boys than in girls. In individuals older than 12 years, the prevalence increases in both males and females, and the incidence declines in individuals older than 40 years, except for women in perimenopause. The overall prevalence is higher in females than in males. The female-to-male ratio increases from 2.5:1 at puberty to 3.5:1 at age 40 years, after which it declines. The incidence of migraine with aura peaks in boys at around age 5 years and in girls at around age 12-13 years. The incidence of migraine without aura peaks in boys at age 10-11 years and in girls at age 14-17 years. The incidence of migraine in females of reproductive age has increased over the last 20 years, probably due to more awareness of the condition. In the United States, white women have the highest incidence of migraine, whereas Asian women have the lowest incidence. Moreover, low socioeconomic status is associated with migraine. Currently, 1 of 6 American women has migraine headaches. Genetics Approximately 70% of patients have a first-degree relative with a history of migraine. The risk of migraine is increased 4-fold in relatives of people who have migraine with aura. However, no genetic basis has been identified for common migraine, although it generally demonstrates a maternal inheritance pattern.

J am acad Nurse Pract. 2007 jul, 19(7):378-82. Prevalence and management of headache in a university undergraduate population. Curry K, Green R Scopul: scopul acestui studiu pilot a fost explorarea incidenei, morbiditii i managementul cefaleelor la studenii universitari, fr master. Autorii au explorat de asemeni alegerea medicaiei de uurare pentru cefalei n efortul de a ajuta potenialele necesiti privind educaia pacienilor n privina unui management eficient al cefaleei. Sursa datelor: Datele au fost colectate dintr-un lot convenional de 104 studeni. Headache Assessment Quiz a fost utilizat pentru a msura tipul i severitatea cefaleei i a colecta date privind managementul simptomelor. Concluzii: Majoritatea studenilor supravegheai au raportat, c au suportat cefalei de intensitate moderat sau severe. 16% din respondeni au indicat, c cefaleele lor s-au intercalat cu activitile lor zilnice(uzuale),n timp ce 92,5% au raportat utilizarea preparate neprescrise de uurare doar pentru managementul cefaleei. Cunotinele privind prevenirea cefaleei i tratamentul lor lipsea n acest grup. Aplicarea practic: cefaleea este un simptom des ntlnit la persoanele de vrsta universitar.Urmtoarele cercetri trebuie s determine incidena tipurior specifice ale cefaleelor. Medicii de familie sunt provocai s se adreseze pacienilor , educndu-i pentru a ajuta pacienii s-i diagnostice mi bine tipurile de cefalee.
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1.Am J Med. 2005 Mar; 118 Suppl 1:3S-10S.

The epidemilogy of migraine. Lipton RB, Bigal ME. Acest articol pledeaz pentru revizuirea epidemiologiei i a factorilor de risc pentru migren n studiile populaionale, ct i a patternului de ngrijire medical acordat. Dauna i costul migrenei, ct i factorii de risc pentru progresarea patologiei date de asemenea se discut. n pofida faptului, c migrena este o cauz extrem de remarcabil al dizabilitii(incapacitii) temporare de munc, multe persoane, ce aveau asemenea cefalei incapacitante, nu s-au adresat niciodat dup ajutor la medic. Prevalena e cea mai nalt la femei, la persoanele cu vrsta de 25-55 ani i n sfrit nSUA, la persoanele cu un buget mic(din gospodrii cu buget mic). Totui, prevalena este nalt n alte grupuri, n afara acestui grup cu risc nalt. ntr-un subgrup de pacieni, migrena poate fi o patologie progresiv. ---------------------------------------------------------------------------------------------------------------------------------2. Headache. 2005 Apr;45 Suppl 1:S3-S13. Migraine: epidemiologyimpact, and risc factors for progression. Lipton RB, Bigal ME. Migrena este o patologie cronic i uneori progresiv, ce se caracterizeaz prin episoade recurente de cefalee i simptome asociate. Acest articol scote n eviden epidemiologia migrenei i factorii de risc al migrenei, descrii n studiile populaionale i discut impactul patologiei i costul socio-economic al migrenei . cu un an nainte de pubertate, migrena e mai rspndit printre biei, dect printre fete. Dar odat cu pubertatea, migrena e mai prevalent la fete i n urmtorii 10 ani, femeile sufer de migren practic de 2 ori mai des dect bieiii. Vrvul prevalenei la ambele sexe este n cei mai productivi ani ale vieii adulte(25-55 ani) i n SUA este cea mai nalt la persoanele cu un statut economic jos. Costul direct al migrenei include costul medicaiei migrenei i cheltuielile de ingrijire medical. Costul indirect asociat cu migrena include productivitatea redus datorat absenteismului i reducerea performanelor pe timpul lucrului. Evidena recent sugereaz, c subgrupele pacienilor cu migren po avea o patologie clinic progresiv. Viitoarele studii epidemilogice trebuie focusate asupra identificrii pacienilor, care au un risc major de progresare i n asistarea impactului strategiilor de intervenire asupra progresrii bolii. 3. Curr Med Res Opin. 2001; 17 Suppl 1:S4-S12 Epidemilogy and economic impact of migraine. Lipton RB, Stewart WF, Scher AI.

Migrena este o patologie foarte rspndit, ce afecteaz circa 11% din populaia adult a rilor vestice. Prevalena e cea mai nalt n anii de productivitate maxim de la 25 la55 ani. Prevalena e mai nalt la femei dect la brbain toi anii dup pubertate, dar proporia pe sexe variaz cu anii. n SUA, prev. migr. e mai nalt la persoane cu nivel jos de educaie, probabil din cauza, c migrena interfer cu coala i munca. Majoritatea migrenoilor i soluioneaz cefaleele lor fr recomandarea convenional a medicului i n general i trateaz atacurile prin medicaie abuziv.Costul indirect depete cu mult costul tratamentului, crend oportuniti pentru intervenii eficiente dup cost. Impactul migrenei asupra sntii publice este substanial datorit prevalenei sale nalte i a disabilitii(proieminente) considerabile temporare. Incapacitatea masiv, produs de migren este o important sarcin de tratament. Vrvul prevalenei la ambele sexe este n cei mai productivi ani ale vieii adulte(25-55 ani) i n SUA este cea mai nalt la persoanele cu un statut economic jos 4. Pharmaco economics. 2004;22(15):985099. Economic impact of migraine and other episodic headaches in France: data from the GRIM2000 study. Pradalier A, Auray JP, EI Hasnaoui A et al. Introducere: Migrena este o patologie prevalent i incapacitant, care afecteaz nviii lor productive, ce genereaz o povar economic , ce afecteaz att societatea , ct i sistemul de ngrijire a sntii. Costul anual direct al migrenei n Frana a fost evaluat timp de 10 ani precedeni i studiul dat elucideaz aceste date. Obiective: Obiectivele acestui studiu au fost determinarea costului economic (costului direct) al migrenei i ale altor cefalei episodice n Frana, bazate pe un studiu de cefalee populaional, GRIM(Groupe de researche Interdisciplinaire sur la Migraine). Design: Din grupul de populaie reprezentativ de 10,585 de pers15 ani din Frana n 1999, 1486 pers., ce au avut cefalee au fot identificate, intervievate privind utilizarea resuselor de ngrijire de sntate n 6 luni precedente. Aplicnd costul uni la datele obinute, costul (n valoarea a.1999), a fost determinat de consultaia medicului, spitalizarea, medicamentele utilizate i testele de laborator i evoluat din perspectiva ngrijirii snttii. Informaia despre absenteism i pierderea productivitii s-a dedus din (a derivat) din chestionarul Migraine Disability Assessment Score(MIDAS). Rezultate: Prevalena migrenei(incluznd ptologiile migrenoase) a fost determinat ca fiind de 17%. Costul direct total anual a fost estimat la 128 Euro pentru o persoan n 1999, ce corespunde cu 1044 milioane de Euro, fiind extapolat la suferinzii de migren cu vrsta 15 ani. Aproximativ 2/3 din acest cost a fost acoperit(asigurat)de sistemul de securitate social(698 milioane de Euro; 85 Euro de persoan). Costul total direct anual

al altor forme de cefalee episodic a fost mult maijos- la 28 Euro de persoan( costul securitii sociale este de 18 Euro); cu o prevalen de 9,2%, costul anual naional direct pentru alte forme a cefaleelor episodice alctuiete 124 milioane Euro. Principalul element al costului a u fost consultaiile medicilor. Totui s-a depistat, c multe persoane n-au fost consultai niciodat de medici din cauza cefaleei lor i automedicaia a contribuit substanial la costul tratamentului(a doua cauz de cretere a costului migrenei). Costul per individ devine exorbitant odat cu creterea severitii cefaleelor. Concluzii: Costul direct de ngrijire medical al migrenei nu a crescut semnificativ pe parcursul ultimei decade. O mic minoritate de persoane cu cefaleele cele mai severe au consumat majoritatea resurselor predestinate migrenei, pe cnd majoritatea persoanelor au provocat un cost direct relativ jos. Costul direct anual n Frana pentru migren este aproximativ de 10 ori mai nalt, dect pentru alte patologii episodice. 4.a.Socio-economic impact of migraine and headaches in France Auray JP Societatea internaional de cefalee are ghiduri(ndrumtoare) clar definite diagnostic, cecclasific cefaleele n 3 categorii. Acum este bine cunoscut, c cefaleele exercit un efect considerabil asupra calitii vieiii supra studiilor, activitilor familiale sau individuale , i impactul economic nu e deloc de neglijat. Un studiu extins, ce a fost efectuat pe un lot de 10582 pers.adulte din Frana, a fost ndeplinit n 1999. Rezultatele au demonstrat o prevalen de 17,3% pentru migren i aproximativ 30% pentru cefalei. Cheltuiala bneasc medie pentru un pacient cu cefalee este de circa 220 Euro, s-a mprit dup cum urmeaz: 10% pentru consultaia medicului-generalist, 11% pentru evalurile de laborator, 17% pentru consultaiile specialitului, 18% pentu medicamente i 44% costul tratamentului n spital. Aceast divizare depinde n mare msur de categoria cefaleei. Dei cele mai acute cefalei afecteaz cel mai mult calitatea vieii, activitile colare i profesionale nu sunt afectate n aceia msur. 5.Curr Neurol Neurosci Rep. 2004 Mar;4(2):98-104 The epidemiology and impact of migraine. Bigal ME, Lipton RB, Stewart WF. S-a scos n eviden epidemiologia descriptiv, dauna patologiei, patternul diagnostic i tratament. n acest articol s-a focusat atenia asupra epidemiologiei i a daunei migrenei probabile, subtipul migrenei,cnd doar o particularitate clinic lipsete. La ncheere sau descris strategiile de mbuntire a ngrijirii medicale impuse de migren i migrena probabil. Cu toate c migr. este o binecunoscut cauz a dizabilitii temporare , muli migrenoi ,chiar i acei cu cefalei incapacitante n-au consultat niciodat medicul din aceast cauz. Nu n ultimul rnd prevalen n alte grupuri dect aceste grupuri cu risc

nalt. Migrena probabil este o form prevalent al migrenei i asemeni migrenei cu i fr aur ea produce descretere calitii vieii i sporirea incapacitii relative la subiecii controlai. 6.Pharmaco economics. 2004;22(9):591-603. The burden of migraine in Spain: beyond direct costs. Badia X, Magaz S, Gutierrez L, Galvan J. Obiective: ESTIMAREA PAGUBEI ECONOMICE AL MIGRENEI N SPANIA din perspective sociale. Metode: Costul anual direct( medicamentele, trat. de ambulator, cons. specialistului i vizitele ambulanei) i indirect(zilele lipsite de la serviciu i capacitatea redus de munc) pe anul 2001 au fos calculate, utiliznd modul de abordare al prevalenei. Metoda capitalului uman a fost utilizat la calcularea costului indirect. Sursele utilizate epidemiologice au fost publicate , utiliznd criteriile de diagnostic ale SIC(Societii Internaionale de Cefalee) di baza de date oficial i neoficial. Rezultate: Populaia Spaniei cu migren a fost estimat a fi de 3,617,600 pacieni, 92,5% fiind n vrsta apt de munc. Povara economic a migrenei a fost de aproximativ 1076 milioane Euro. Costul direct reprezenta doar 32,0% dinpovara total(344 milioane de Euro), 39,2% au fost pentru vizita la medicul-generalist, 28,7% pentru vizitele la specialist, 20,5% pentru vizitele ambulanei la domiciliu i mai departe 11,7% pentru medicamentele prescrise specifice migrenei(serotonin 5HT(1B/1d)receptor agonist Costul indirect a fost estimat n 732 milioane Euro anual, reprezentnd 453,55 Euro pentru un pacient apt de munc(ce muncete ) cu migren. Concluzii: Ca i nmulte alte ri dezvoltate, migrena reprezint o povar economic considerabil n Spania, n special n termeniiproductivitii pierdute. Deci activitile trebuie specific direcionate spre reducerea costului indirect , i spre tratamente eficiente, care ar reduce semnificativ pierderea productivitii trebuie date publicitii(promovate n public).

Tulburri de somn i veghe La ntrebarea privind dereglrile de somn (insomnii) n decursul ultimului an: Des au rspuns 144 persoane fr cefalee(11,7%din 1226) i 316ptts. cu cefalee(22% din 1439)(P<0,001), deci suferinzii de cefalee au avut de 2,2 ori mai des tulburri de somn fa de lotul de control.

Din respondenii cu cefalee- 118ptts. au fost suferinzi de migren(22,1% din534), iar cu CTT-87ptts.(17,79%din 489). Migrenoii n acest grup au fost de 1,4 ori mai muli dect suferinzi de CTT. Foarte des, practic permanent au avut tulburri de somn 25 pers. convenional sntoase(2% din1226) i 51ptts. cu cefalee(3,55 din 1439)(P<0,05), resondenii cu cefalee fiind dublu mai numeroi n acest caz. Din cei cu cefalee-13 ptts.(2,43% din 534)au fost respondenii cu migren, iar 14ptts.(2,86% din 489)- cei cu CTT. n cazul dereglrilor foarte frecvente de somn att migrenoii, ct i suferinzii de CTT sunt afectai n egal msur. Att n cazul tulburrilor de somn frecvente, ct i n cazul celor foarte frecvente n grupul respondenilor cu cefalee majoritatea o ocup persoanele cu cefalei primare. Caracterul tulburrilor de somn a fost:
1. Adormire dificil-100 respondeni fr cefalee(59,2% din 1226) i 262ptts. cu cefalee(71,4% din 1439)(P<0,01); de 2,6 ori mai frecvent sufer de aceast problem persoanele cu cefalee.

Suferinzii de cefalee s-au divizat astfel: 74(73,3%din 489) cu CTT.

90 ptts.(68.7% din 534) cu migren;

2. Somn superficial-54 respondeni fr cefalee(32% din 1226) i 123ptts. cu cefalee(33,5% din 1439)(P>0,05); de 2,3 ori mai frecvent au somn superficial persoanele cu cefalee.

Suferinzii de cefalee s-au divizat astfel: 34(33,7%din 489) cu CTT.

41 ptts.(31,3% din 534) cu migren;

3.Treziri frecvente n cursul nopii- 83 respondeni fr cefalee(49,1% din 1226) i 161ptts. cu cefalee(43,9% din 1439)(P>0,05); de 2 ori mai frecvent sufer de treziri frecvente n cursul nopii persoanele cu cefalee. Suferinzii de cefalee s-au divizat astfel: 65 ptts.(49,6% din 534) cu migren; 58(57,4%din 489) cu CTT majoritatea o alctuiesc cei cu migren. 4.Vise frecvente-17 respondeni fr cefalee(10,1% din 1226) i 48ptts. cu cefalee(13,1% din 1439)(P>0,05); practic de 3 ori mai frecvent au vise frecvente n cursul nopii persoanele cu cefalee. Suferinzii de cefalee s-au divizat astfel: 17 ptts.(13% din 534) cu migren; 11(11%din 489) cu CTT, majoritatea o alctuiesc cei cu migren.

5.Vise neplcute-25 respondeni fr cefalee(14,8% din 1226) i 68ptts. cu cefalee(18,5% din 1439)(P>0,05); de 2,7 ori mai frecvent au vise neplcute n cursul nopii persoanele cu cefalee.

Suferinzii de cefalee s-au divizat astfel: 21 ptts.(16% din 534) cu migren; 17(16,8%din 489) cu CTT, majoritatea o alctuiesc cei cu migren. 6.Comaruri-12 respondeni fr cefalee(7,1% din 1226) i 37ptts. cu cefalee(10,1% din 1439)(P>0,05); de 3,1 ori mai frecvent au comaruri noaptea persoanele cu cefalee. Suferinzii de cefalee s-au divizat astfel: 12 ptts.(9,2% din 534) cu migren; 6(6%din 489) cu CTT, au fost de 2 ori mai muli respondeni cu migren dect cu CTT. 7.Dimineaa trezire e dificil-18 respondeni fr cefalee(10,7% din 1226) i 59ptts. cu cefalee(16,1% din 1439)(P>0,05); practic de 3,3 ori mai frecvent trezirea e dificil dimineaa la persoanele cu cefalee. Suferinzii de cefalee s-au divizat astfel: 21 ptts.(16% din 534) cu migren; 15(15%din 489) cu CTT, majoritatea o alctuiesc cei cu migren. 8.Dimineaa trezirea e devreme- 61 respondeni fr cefalee(36,1% din 1226) i 124ptts. cu cefalee(33,8% din 1439)(P>0,05); de 2 ori mai des se trezesc devreme dimineaa persoanele cu cefalee. Suferinzii de cefalee s-au divizat astfel: 38 ptts.(29% din 534) cu migren; 31(30,7% din 489) cu CTT, majoritatea o alctuiesc cei cu migren.

Fenomene n timpul somnului: 1.Sforie- 572 respondeni fr cefalee(64,7% din 1226) i 689ptts. cu cefalee(63,9% din 1439)(P>0,05); de 1,2 ori mai frecvent sforie n timpul somnului persoanele cu cefalee. Suferinzii de cefalee s-au divizat astfel: 228 ptts.(59,4% din 534) cu migren; 266(70,74%din 489) cu CTT, majoritatea o alctuiesc suferinzii de CTT. 2.Se oprete uneori respiraia-53 respondeni fr cefalee(6% din 1226) i 74ptts. cu cefalee(6,9% din 1439)(P>0,05); practic de 1,4 ori mai frecvent persoanelor cu cefalee li se oprete uneori respiraia. Suferinzii de cefalee s-au divizat astfel: 16 ptts.(4,2% din 534) cu migren; 32(8,5%din 489) cu CTT, suferinzii de CTT au astfel de probleme de 2 ori dect cei cu migren. 3.Strig n timpul somnului- 73 respondeni fr cefalee(8,3% din 1226) i 128ptts. cu cefalee(12% din 1439)(P>0,05); practic de 1,8 ori mai frecvent persoanele cu cefalee strig n timpul somnului . Suferinzii de cefalee s-au divizat astfel: 48 ptts.(12,5% din 534) cu migren; 35(9,3%din 489) cu CTT, resp. Cu migren alctuiesc majoritatea n acest caz.

Au avut somnolen n timpul zilei: 1.Des- 193 respondeni fr cefalee(15,7% din 1226) i 287ptts. cu cefalee(20% din 1439)(P<0,01); practic de 1,5 ori mai frecvent persoanele cu cefalee au avut somnolen n timpul zilei des. Suferinzii de cefalee s-au divizat astfel: 112ptts.(21% din 534) cu migren; 82(17%din 489) cu CTT, resp. Cu migren alctuiesc majoritatea n acest caz.

2. Foarte des-27 respondeni fr cefalee(2,2% din 1226) i 37ptts. cu cefalee(2,6% din 1439)(P>0,05); practic de 1,4 ori mai frecvent persoanele cu cefalee au avut somnolen n timpul zilei foarte des. Suferinzii de cefalee s-au divizat astfel: 8(1,64%din 489) cu CTT, resp. 13ptts.(2,4% din 534) cu migren;

3. Aproape permanent-11 respondeni fr cefalee(0,9% din 1226) i 9ptts. cu cefalee(0,6% din 1439)(P>0,05); practic de 1,4 ori mai frecvent persoanele cu cefalee au avut somnolen n timpul zilei foarte des. Suferinzii de cefalee s-au divizat astfel: 2ptts.(0,4% din 534) cu migren; 3(0,6%din 489) cu CTT, resp.

Sursa 10 : Tension type, the forgotten headache: how to recognize

this common, but

undertreated condition.

Postgrad Med 2002; vol 111(4): 25-50. Aproximativ 80% din populatie suporta uneori cefalei de tip tensional. S-a estimat prevalenta de 1 an la 86% de femei si 63% de barbati( in mediu), ce e foarte probabil, ca au suportat cefalei de tip tensional, decat nu.(1a): ( Rasmussen BK, Jensen R,Schroll M, et al. Epidemiology of headache in a general population: a prevalence study. J Clin. Epidemiol. 1991; 44(11); 1147-57) Cefaleea este una din principalele 10 acuze ale pacientilor, cunoscute in practica medicinei primare si 47% din cefalei il are cefaleea de tip tensional(3a): A study of headache in North American primary care: report from the Ambulatory Sentinel Practice Network.

J R Coll Gen Pract 1987; 37(302): 400-3) Pe parcursul copilariei nu exista o predominare al barbatilor sau al femeilor pentru cefalei de tip tensional, dar pe parcursul vietii adulte e mult mai frecvent traita de femei ( proportia femei- barbati e 5:4)(4a): Friedman A P, de sola Pool N, von Storch T J. Tension headache.JAMA 1953: 151: 174-7)
Indata ce cefaleea de tip tensional este dupa 20 ani la 40% din persoanele afectate, la varsta de 20-40 ani- la 40% pers, si intre 40-50 ani la 18%(3a).

Trei procente din populatia generala(5% din femei si25 de barbati) traiesc experienta cefaleei de tip tensional , definind mai mult de 180 zile cu cefalee pe an(1a) . Prevalenta cefaleei de tip tensional creste cu anii; inversul e adevarat pentru cefaleea de tip tensional episodica. Concluzie: Progresele recente obtinute in tratamentul migrenei umbreste interesul fata de cefaleea de tip tensional, cel mai prevalent tip de tulburare cefalgica. Din cauza prevalentei inalte a cefaleei de tip tensional si al spectrului larg de disabilitate, cefaleea de tip tensional e cel mai important tip de cefalee, din punctul de vedere al reducerii productivitatii muncii, calitatii vietii si al impactului socio- economic. Sursa 11: November/ december 2004 issue of headache. Costul direct medical de ingrijire al migrenei-asa ca medicatia si vizitele la doctor in SUA a crescut peste 1 mlrd de dolari pe an. Mai este si costul indirect, ce include timpul pierdut de lucru, studii sau activitatile din timpul liber. Acordarea medicatiei, care previne migrena, daca folosirea ei ar fi dirijata, ar putea reduce considerabil costul tratamentului migrenei.
Acordarea medicatiei, care previne migrena, daca folosirea ei ar fi dirijata, ar putea reduce considerabil costul tratamentului migrenei.

Autorii asambleaza lista preturilor la 70 de preparate preventive, demonstrand gasirea sau apropierea de standard in reducerea producerii cefaleei cu 50% la 50% din pacientii tratati. Sugestia articolului include alegerea preparatelor generice, cand e posibil,utilizand doze mari,fata de multiplele tablete mici, pilulele taiate,

alegerea preparatelor, care de asemenea trateaza alte conditii ca tensiunea ridicata arteriala sau depresia. Sursa 12: Burden of Migraine in the United States: Disability and Economic costs.

Archives of Internal Medicine

Vol.159, pp 813-818,April 26, 1999 X. Henry Hu et al.
Migrena este o patologie disabilitanta raspandita, dar povara ei economica nu este cuantificata adecvat.

Autorii si-au propus sa estimeze povara migrenei in SUA cu respectare disabilitatii si al costului economic. Disabilitatea a fost exprimata prin zile de aflare la pat. Sarcina tratamentului aplicat la migrena a fost utilizarea costului direct, evaluat la calculator. Abordarea capitalului uman a fost utilizata in estimarea costului indirect.. Rezultate; Migrenosii necesita 3,8 zile la pat pentru barbati si 5,6 zile la pat pentru femei in fiecare an, rezultand un total de 112 mlrd zile, petrecute la pat pe an. Costul migrenei pentru angajatorii din SUA atinge cifra de aproximativ 13 mlrd pe an din cauza absenteismului si al functionarii defectuoase a lucrului; ingroparea a 8 mlrd a fost direct pe parcursul zilelor omise(lipsite). Pacientii de ambele sexe cu varsta intre 30 si 49 ani cauzeaza un cost indirect inalt, in comparatie cu pacientii tineri sau varstnici. Costul medical anual direct pentru ingrijirea migrenei a fost estimat la aproximativ 1 mlrd si aproape 100 dolari au fost cheltuiti pentru diagnosticul pacientului,vizitele la medicul de familie au alcatuit circa 60% din tot costul; in contrast, costul vizitelor departamentului de urgenta a alcatuit mai putin de 1% din costul direct. Concluzii: Povara economica a migrenei afecteaza pacientii si patronii lor sub forma zilelor petrecute la pat si prin pierderea productivitatii. Variate ecranizari(modalitati) ale regimului de tratament trebuiau sa evaluieze si sa identifice oportunitatile reducerii poverii patologiei date.

S 1: Impactul migrenei: defectarea functiei: 1. Incapacitatea efectuarii lucrului casnic macar 1 zi in ultimele 3 luni- 76%. 2. Productivitatea efectuarii lucrului casnic: redusa mai mult sau cu 50%67% 3. Lipsa de la activitatile familiale sau sociale- 59% 4. Productivitatea la serviciu/scoala redusa mai mult sau cu 50%- 51% Nediagnosticarea si diagnosticele pierdute
In pofida prevalentei sale si al impactului, cat si al disponibilitatii unui tratament sigur si eficient, migrena e frecvent nediagnosticata.

. Un studiu a determinat, ca proportia migrenosilor, care au scapat diagnosticul a descrescut doar cu 52% intre 1989 si 1999, cu 52% din suferinzi ramasi nediagnosticati. . Un alt studiu a descoperit, ca printre 3074 pacienti, care au corespuns criteriilor IHS pentru migrena, doar 1642(53,4%) au recunoscut cefaleea lor drept migrena. Cefaleea de la stres(n= 345) si cefaleea de la sinusite (n= 365) au fost etichetate ca cel mai frecvent eronat raportate. Studiile au demonstrat, ca mai putin de jumatate din bolnavii de migrena, au cautat ingrijiri pentru cefaleea lor, in majoritatea cazurilor deoarece ei credeau, ca nimic nu poate fi facut. Doar 295 din migrenosi, incluzandu-i pe acei, care s-au autotratat sunt pe deplin satisfacuti de tratamentul lor. Persoanele, ce au raportat nesatisfactia, privind tratamentul dureriilor de cap s-au plans, ca usurarea durerii n-a durat prea mult (87%), de repetarea cefaleelor lor (71%) si de efectul secundar al medicamentelor, ce ia necajit (35%).

Interesant, ca intensitatea durerii a descrescut semnificativ in migrena, cand ea ramanea neschimbata, oricare tip de cefalee.

Spuse impreuna aceste constatari erau in favoarea unui management mai bun al atacurilor de migrena., cand istoria naturala a patologiei ramanea neschimbata. In acelasi studiu a fost introdus MIDAS score pentru masurarea costului indirect al cefaleei. In 2000 proportia cu MIDAS, gradurile III si IV au fost 12,4%, care alcatuiau prevalenta migrenei, solicitau atentia medicilor 1,6%. Patologia migrenoasa are o magnitudine al consecintelor similara in termenii zilelor pierdute din cauza cefaleei( 11,5% de gradul III-IV, pe cand altele tipuri ale cefaleelor aupe departe mai putine consecinte la acest indicator( doar 2,1% de gradul III si IV). Deci, necatand la progresul in managementul cefaleelor, migrena ramane in 2001 patologia cu cea mai mare povara economica. In viitor va fi primordiala luarea in consideratie a tuturor factorilor, ce interfera cu povara economica al cefaleelor, daca dorim sa realizam descresterea acestei poveri. Dupa parerea autorilor o cale buna e gasirea unor astfel de lucrari ca trialul publicat de Lipton et al, compararea ingrijirii stratificate, versus strategiile de ingrijire- pasi pentru migrena, care controlau majoritatea acestor factori.

Sursa 13: R Zivadinov, K Willheim, D Sepic-Grahovac, et al

Depart. Of Clinical Medicineand neurology. Cephalalgia 2003; 23: 336-343. Monitorizarea atenta al factorilor triggeri a cefaleei pot fi un pas important in tratamentul lor, deoarece evitarea lor poate micsora frecventa si severitatea atacurilor. Mai mult ca atat, ele pot furniza rezolvarea etiologiei cefaleelor. Grija principala a studiului in cauza a fost estimarea prevalentei cefaleei de tip tensional si stabilirea frecventei factorilor precipitanti la subiectii cu migrena si cefalee de tip tensional la populatia adulta dinBacar, district al Coastei si Gorski Kotar,Croatia. Un alt scop al studiului a fost examenarea relatiei dintre factorii precipitanti si migrena si cefaleea de tip tensional si cu subtipurile migrenei( migrena cu aura si migrena fara aura). Cei mai frecventi factori provocatori pentru migrena de ambele tipuri si cefaleea de tip tensional au fost stresul si calatoriile frecvente.

Stresul a fost asociat cu migrena, pe cand activitatea fizica cu CTT(cefaleea de tip tensional). La fel calatoriile frcvente, unele alimente sau schimbarile meteo au o asociere vadita pozitiva cu MA( migrena cu aura). Prezentul studiu a demonstrat, ca atacurile provocate de triggeri au fost frecvente in ambele cazuri, la migrenosi si la cei cu CTT. De-a lungul vietii migrenosii suporta atacuri de cefalee, precedate de factori-trigger mai frecvent decat pacientii cu CTT. MA e mai des asociata cu factorii declansatori, decat migrena fara aura. Sursa 14: North Staffordshire Headache Survey:development, reliability and validity of a questionnaire for use in a general population survey. H F Boardman,E Thomas et al. Cefalalgia 2003; 23: 325-331.

Scopul acestui studiu al cefaleei din regiunea North Staffordshire a fost masurarea efectului si impactului cefaleelor, utilizarii medicamentelor si al ajutorului medical intr-o populatie generala-mostra.
Consultantii pe cefalei au raportat o frecventa mai importanta, durata si severitate al cefaleelor, decat la populatia generala-mostra, sugerand o validitate bine construita. Rezultatele studiului indica, ca chestionarul este un instrument de incredere si valid in colectarea datelor, privind cefaleele la populatia generala. Sursa 15: Beghi E, Monticelli M L,Amoruso L et al. Prevalence, characteristics, and patterns of health care use for chronic headache in two areas of Italy. Results of a questionnaire interview in general practice. Cephalalgia 2003; 23: 175-182. S-a incercat definirea prevalentei, trasaturilor clinice si al severitatii cefaleei cronice intre 2 grupuri afiliate de practicieni-generalisti si ilustrarea diagnosticarii si al modalitatilor de lucru al serviciului terapeutic. Grupurile de medici-generalisti au incercat clasificarea cefaleelor in acord cu criteriile IHS. Diagnosticul pus, admiterea in spital, adresarea la centrele de cefalee si modalitatile de tratament trebuiau sa fie in corelatie cu severitatea cefaleei.

S-a stabilit, ca cefaleea cronica e frecventa printre indivizii din practica generala. Cunoasterea mai buna a criteriilor IHS poate fi in relatie directa cu costul managementului. Sursa 16: Epidemiological and clinical characteristics of migraine and tension type headache in 1146 females in Kayseri, Turkey. E Koseoglu, M Nacaret et al. Cephalalgia 2003; 23:381-388. Prevalenta migrenei a fost apreciata statistic mai inalta intre varsta de 35-44 la cei licentiati, la persoanele, ce locuiesc in localitatile urbane. Prevalenta CTT a fost mai inalta la grupurile de persoane ca varsta cuprinse intre45-64 ani. Pacientii cu CTT cronica au fost gasiti mai mari de varsta, decat cei cu CTT episodica si mai frecvent la persoanele cu un nivel educational mai scazut. Sursa 17; Richard B Lipton, Neurology. 2003; 61: 375-382 Richard B Lipton a alcatuit un test, numit ID Migraine din 3 iteme: 1.A limitat oare cefaleea activitatea Dvs pentru o zi sau mai mult in ultimele 3 luni? 2.Aveti greturi sau vome, cand aveti cefalee? 3. Va deranjeaza lumina , cand aveti cefalee? Criteriile IHS au stat la baza chestionarului semistructurat. Sensibilitatea pentru cele 3 iteme a fost 0,81(95% confidence interval), specificitatea a fost 0,75(95%), valoarea pozitiva predictiva a fost 0,93 (95%), iar credibilitatea test-retest a fost buna(Kappa 0,68(95%). Sexul, varsta, prezenta altor cefalei in comorbiditate si statutul de diagnostic anterior nau afectat sensibilitatea si specificitatea acestui test. Dr Lipton a spus: Folositi disponibilitatea tratamentului efectiv, utilizarea metodelor de screening pot reprezenta un pas important in reducerea impactului acestei maladii. Sursa 18 : Evaluating the economic costs of migraine. Jean Francois Dartiques, Philippe Michel, Patrik Henry J Headache Pain(2003)4: s 63- s 66. Hu et al au calculat costul direct anual al migrenei , care ajunge in SUA la 1 mlrd de dolari, iar costul anual al zilelor absentate de la serviciu- la 8 mlrd, iar estimarea costului productivitatiireduse in SUA- la 5 mlrd dolari. In orice caz factorii, ce interfera cu relatia dintre migrena si cost sunt:

1. 2. 3. 4. 5. 6.

Eficacitatea primului tratament. 2. Personalitatea migrenosilor. Comorbiditatea. Migrena. Increderea in eficienta sistemului de ingriire a sanatatii. Atitudinea doctorului- generalist.

Un mare procent al migrenosilor niciodata n-au consultat un medic din cauza migrenei,de la 19% la 76% in acord cu tara, varsta, genul si severitatea patologiei. Multi migrenosi adopta o strategie de colaborare cu durerea, nu necesita ingrijire si nu fac abuz de medicamente. In Franta( asa cum se raporteaza si in alte tari), 65% din migrenosi cred, ca migrena nu va fi tratata niciodata, 43% considera, ca nu poti face nimic impotriva migrenei si 52% cred, ca medicina ortodoxala nu este eficienta. Atitudinea medicilor, serviciului medical primar si eficacitatea primului tratament de asemenea influienteaza costul. Dupa prima consultatie multi pacienti nu mai revin la terapeutul lor sau la neurologul lor. Edmeads a analizat in Canada rationamentul: 55% din pacienti sunt satisfacuti de tratament si nu necesita consultatii din nou; 17% nu se reantorc din cauza problemelor cu medicatia si 38% pleaca de la doctorii lor si considera, ca ei n-au fost luati in serios. De fapt Packard demonstra cu 22 de ani in urma, ca cel mai mare neajuns al consultatiilor migrenosilor este pentru acesti pacienti obtinerea explicatiilor si linistirii,intrucat cel mai mare neajuns al doctorilor era obtinerea usurarii durerii. S-a observat o discrepanta dintre povara obiectiva si subiectiva, ce sugereaza, ca impactul public(social) al sanatatii publice e mai mic decat asupra persoanei in parte. Migrenosii pot suferi silentios si lucra pe parcursul atacurilor de migrena. O alta explicatie, ce nu se exclude e ca migrenosii pot adopta o atitudine de strategie compensatorie pentru dereglarile de sanatate, altele, decat cele de migrena: cand ei lipsesc de la serviciu din cauza cefaleelor, ei pot minimaliza absentele lor pentru alte dereglari de sanatate. Deoarece in studiul MIGACCESS ei evaluau controlul medical anterior direct de 6 luni in autorapoartele zilelor spitalizarii, al departamentului de urgenta si vizitele medicilor de familie. Rezultatele erau putin diferite de studiul Francez, pe cand diferentele dintre migrenosi si nonmigrenosi au fost mai putin pronuntate pentru medicii de familie si departamentul vizitelor de urgenta si au ramas semnificative dupa egalarea comorbiditatilor. Aceeas situatie s-a observat pentru pierderea productivitatii. Discrepantele dintre studii pot fi explicate prin metodologiile diferite, in particular pentru criteriile diagnostice ale

migrenei, dar diferentele intre sistemele de ingrijire a sanatatii Francez si cel American si increderea in eficacitatea sistemelor e cert cea mai relevanta explicatie. Un alt tip de comparatie poate fi util pentru studierea consecintelor progresului in managementul migrenei asupra impactului acestei patologii. Pe parcursul ultimilor 10 ani diverse noi tratamente pentru migrena au devenit disponibile si constientizarea migrenei a fost imbunatatita. In patologia cu atacuri recurente eficacitatea strategiei de tratament mai bune se poate asocia cu descresterea prevalentei migrenei, datorita descresterii duratei acestei patologii. De fapt unele studii sugereaza, ca prevalenta migrenei poate fi in crestere, dar autorii admit, ca aceasta crestere poate fi datorata unui management de diagnostic mai bun la etapa primara a ingrijirii medicale. Doua studii recente al prevalentei in SUA si in Franta, care au fost efectuate pe mostre reprezentative nationale la telefon sau prin interviuri face-to-face, nu confirma aceasta crestere si demonstreaza exact aceeas rata la intervalul de 10 ani:12,1% in 1989 si 12,6% in1999 in SUA pentru migrena clasificata conform criteriilor IHS si 8,1% in 1990 si 7,9% in 2000 in Franta pentru migrena , clasificata conform criteriilor IHS. In studiul Francez al prevalentei doua caracteristiciale cefaleei au fost comparate la intervalul de 10 ani, in acord cu tipurile cefaleei

1. S VII: Richard B. Lipton. Better Screening Test for Migraine CME

Neurology. 2003; 61: 375-382 2. S VI: E Koseoglu, M Nacar et al Epidemiological and clinical characteristics of migraine and tension type headache in 1146 females in Kayseri, Turkey. Cefalalgia 2003; 23: 381-388. 3. SVII: J.F. Dartiques, P. Henry. Evaluating the economic costs of migraine: interest of a comparative approach. J Headache Pain (2003) 4: S63-S66. 4. S I: J. B. Bjorner, M. Kosinski et al. Calibration of an item pool for assessing the burden of headaches; An application of item response theory to the Headache Impact Test. Quality of Life Research 12: 913-933, 2003. S II: J. B. Bjorner, M. Kosinski et al.

The feasibility of applying item response theory to measures of migraine impact: A re-analysis of three clinical studies. Quality of Life Research 12: 887-902, 2003. 5. SIII: Zivadinov R, Wilheim K et al. Migraine and tension type headache in Croatia; a population- based survey of precipitating factors. Cefalalgia 2003; 23: 336-343. 6. SXII: R. Camarda. R. Monastero. Prevalence of primary headaches in Italian elderly: preliminary data from the Zabut Aging Project. Neurol Sci(2003) 24: S 122-S 124. 7. S : Iannacero, Cannistra 8. S XIV: Rapoport AM, Sheftell FD. A management Guide for Practiners. Philadelfia: 2001(1996) 9. S XVI: N. V. Patel, Pharm D et al. Prevalence and impact of migraine and probable migraine in a health plan. 2004

Reference

Year

Country

Age, years 18-65

Study design Men Questionnaire Personal interview

Prevalence% Women ? ?

Lipton al[VII]

et 2003

USA

2003 Koseoglu et al[VI]

Turkey(Kay 15-87 seri)

2003 France, SA

Face-to face interview, clinical exam and interview

Cu aura-7,3 Fara aura-5,2

Dartiques, 2003 Henry[VIII]

18-65 Denmarc, USA 15-65 Croatia 65 Italy 18-65 Italy

Questionnaire

Total 11

Bjorner, Kosinski 2003 et al[I,II]

Face-to face interview or door to- door interview

14,8

22,9 Total 19

Zivadinov, 2001 Wilheim et al[III] 2001

Face-to face interview or door to- door interview

Total 4,6

Camarda et al[XII]

Questionnaire

18

9,3 Total 11,4 Migr probab35( total)

Iannacero, Cannistra 2004 USA 18-65 Questionnaire Migr certa19,2

Migrena certa-6,6 total-14,7

Patel M.V,Pharm et a[XVI]

Migr probabilaMigr 15,9 probab 12,6 ila15,9 Total-14,6%

Prevalena migrenei i cefaleei de tip tensional n localitile rurale i urbane din Republica Moldova
Obiective: Scopul acestui studiu a fost estimarea prevalenei cefaleelor primare (migrenei

i cefaleei de tip tensional) i stabilirea frecvenei factorilor- triggeri la subiecii aduli (15-65 ani) cu acest tip de cefalei in localitile urban(mun Chiinu) i rural(Hanceti) din Republica Moldova. Acesta este primul studiu epidemiologic al migrenei i cefaleei de tip tensional din Republica Moldova, efectuat in conformitate cu Criteriile Clasificrii Internaionale a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee in anul 2004. Metode: Studiul populaiei a constat din 2665 ceteni aduli (15-65 ani) din municipiul " door-to-door de o echip de medici- neurologi special pregtii( N. Testemianu) in perioada : mai-iunie, septembrie-

Chiinu i or. Hnceti din Republica Moldova. Studiul a fost efectuat utiliznd metodele de intervievare face-to-face", Stat de Medicin i Farmacie rezideni in neurologie, de colaboratori tiinifici al Catedrei de Neurologie al Universitii de octombrie 2005, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee . Rata de participare a fost de 84%(2665persoane). din 3165 persoane contactate .Toi participanii au fost evaluai asupra istoricului durerii de cap n conformitate cu criteriile Societii Internaionale a Durerii de Cap. Au fost diagnosticai cu cefalee-1439(65.5%). Diagnosticul specialiti n cefalei. Rezultate: Au fost diagnosticai 534 de persoane cu migren. Prevalena migrenei la femei era de 16,81% i prevalena migrenei la brbai e de 3,22%, i de 20,03% la ambele sexe. Cea mai mare prevalena a migrenei a fost depistat la persoanele cu vrsta 20-29ani-124ptts.(4,6%); 40-49 ani-113ptts.(4,24%). Printre cei 534 de migrenoi activi, 448(16,81%) erau femei i 86(3,22%)- brbai. Cu cefalee de tip tensional au fost diagnosticai 489 persoane (18,34%). Prevalena cefaleei de tip tensional la femei era de 11,1% i prevalena CTT la brbai e de 7,24% , i de 18,34% la ambele sexe. tipurilor de cefalee s-a stabilit ulterior de neurologi

Cea mai mare prevalena a cefaleei de tip tensional a fost depistat la persoanele cu vrsta 2029ani- 102 ptts.(3,8%); 50-59 ani-97ptts.(3,6%). Printre cei 489 de persoane cu cefalee de tip tensional activi, 296(11,1%) erau femei i 193(7,24%)- brbai; Concluzii: Prevalena migrenei si cefaleei de tip tensional n cadrul populaiei din Repunlica Moldova a demonstrat rate aproximativ similare cu cele raportate la rile nvecinate , precum Italia i Frana,Croaia i Turcia. Cuvinte cheie: migren, cefalee de tip tensional,epidemiologie, prevalen, interviuface-toface", " door-to-door. Abrevieri: MFA- migren fr aur, MCA- migren cu aur, MCAFA- migren cu aur i fr aur, CTT-cefalee de tip tensional. Materiale i metode: Studiu randomizat face-to-face", " door-to-door a populaiei adulte din localitile urban i rural (cetenii (15-65 ani) din municipiul Chiinu i or. Hnceti) din Republica Moldova prin intermediul chestionarului structurat, elaborat de profesorul I.Moldovanu in 2004, in conformitate cu Criteriile Clasificrii Internaionale a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee din anul 2004. Cercetatare efectuat sub conducerea profesorului I.Moldovanu in anul 2005 n coordonare cu Societatea Internaional de Cefalee(International Headache Society) cu selectarea eantionuluiChiinu-Hnceti. In studiu au fost inclui 2665 respondeni cu varsta cuprins intre 15-65 ani, rata de participare a fost de 84% din 3165 persoane contactate . Toi participanii au fost evaluai asupra istoricului durerii de cap n conformitate cu criteriile Societii Internaionale a Cefalee. Din totalul de 2665 de persoane au rspuns afirmativ la intrebare privind prezena cefaleelor1439, ce constituie 54%, 1226 din cei cercetai-46% n- au avut cefalee . Dac cefaleea era declarat, li se adresau ntrebri, privind caracteristicele cefaleelor lor i relatarea unor astfel de date cum ar fi: frecvena, durata, triggerii(factorii declanatori), simptomele nsoitoare, dereglrile de somn, istoricul familial, tratamentele suportate pn acum etc. Cei care au fost diagnosticai cu cefalee- 1439(54%) au fot intervievai de o echip de medicineurologi special pregtii( rezideni in neurologie, de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu) in perioada : maiiunie, septembrie-octombrie 2005, de un grup de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu i rezideni in neurologie, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee. Diagnosticul ulterior al tipurilor de cefalee s-a stabilit

ulterior de neurologi specialiti n cefalei. Chestionarul care a fost utilizat in acest studiu include 145 intrebri, care vizeaz urmtoarele aspecte de baz: aspecte socio-demografice, depistarea factorilor- declanatori ai migrenei i cefaleei de tip tensional, caracteristici clinice detaliate, tratamente farmacologice, date medicoeconomice, comorbiditatea, gradul de incapacitate(MIDAS i HIT), impactul cefaleelor i estimarea prezenei abuzului medicamentos. Analiza statistic a datelor chestionarelor s-a efectuat utilizand SPSS , varianta 12. Dup ntrebrile introductive privind vrsta, nivelul economic i educaional, statutul matrimonial i profesional, persoanele au fost interogate despre prezena oricror patologii cronice, diagnosticate de medicul-generalist i au avut vreo cefalee important, care atrage atenia(deranjant) n perioada ultimului an. A fost gsit partea prevalenei migrenei i al cefaleei de tip tensional . Prevalena migrenei i cefaleei de tip tensional: n lotul mixt(brbai +femei). 448 femei+86 brbai= 534 ptts. cu migren-20,03% din numrul total al persoanelor chestionare- 2665; 534ptts- 37,10% din 1439 pers cu cefalee; 296 femei+193 brbai= 489 ptts. cu CTT- 18,34% din numrul total al persoanelor chestionare- 2665; 489ptts- 33,98% din 1439 pers cu cefalee. Dat fiind, c cefaleea constituie o problem major de sntate, fiind inclus de Organizaia Mondial a Sntii(OMS) in lista primelor 10 cauze de incapacitate la ambele sexe i a primelor 5 cauze de incapacitate la femei, lipsa unui studiu epidemiologic al prevalenei cefaleelor primare in Republica Moldova s-a impus necesitatea imperativ a efecturii acestuia. Prin intermediul acestei cercetri s-a evaluat relaia dintre prevalena tipurilor de cefalee i proprietile cefaleelor pacienilor, aa ca vrsta , nivelul educaional i economic, statutul matrimonial i profesional, locul de reedin i compararea caracteristicelor clinice printre subtipurile cefaleei analizat. Tipurile cefaleelor migrenoase i particularitile socio-demografice. Au fost diagnosticai 534(20%) persoane cu migren. Prevalena migrenei la femei era de 16,81%(...% intervalul de ncredere, de la ... la ...) i prevalena migrenei la brbai e de 3,22% (...% interval de ncredere ,de la ... la...), i de 20,03%(...%, ...) la ambele sexe. Cea mai mare Corelaia dintre caracteristicele clinice i severitatea cefaleei a fost

prevalena a migrenei a fost depistat la persoanele cu vrsta 20-29ani-124ptts.(4,6%); 40-49 ani-113ptts.(4,24%). Printre cei 534 de migrenoi activi, 448(16,81%) erau femei i 86(3,22%)brbai. Prevalena( de 1 an) migrenei a fost de 20%(534ptts.), cuprinznd ...%(...) migr.cu aur i ...% (...)-migr. fr aur. Prevalena migrenei a fost gsit statistic mai nalt la grupul de vrst de 20-29ani-124ptts.(4,6%); 40-49 ani-113ptts.(4,24%); 50-59 ani -104 ptts(19,48%) (P<0.01)i mai joas la grupul de peste 65 ani-37ptts.(6,93%)(P<0.01), n comparaie cu alte grupuri. Cefaleea de tip tensional i particularitile socio-demografice. Prevalena (de 1 an) CTT a fost gsit de 18,34% %(489 persoane), incluznd... (...% )episodic i ...(...%)-tipul cronic al cefaleei. Cea mai mare prevalena a cefaleei de tip tensional a fost depistat la persoanele cu vrsta 2029ani- 102ptts.(3,8%)(P<0,05); 50-59 ani-97ptts.(3,6%)(P<0,01). Printre cei 489 de persoane cu cefalee de tip tensional activi, 296(11,1%) erau femei i 193(7,24%)- brbai; (Pacienii cu CTT cronic au fost gsii a fi cu mult mai n vrst dect cei cu forme episodice)?( Media de vrst SD pentruCTT episodic i cronic:......, ... ..., P...). 1587 femei au fost intervievate, 1050(39,4%) din ele au suportat migrena sau CTT n decursul ultimului an. Din 1078 brbai intervievai-389 (39,4%) din ei au avut migrena sau CTT n decursul ultimului an.

Rezultate Trsturile socio-demografice ale migrenei i CTT: vrsta, nivelul educaional , statutul matrimonial i locul de trai au fost demonstrate n Tab.1. Tab.1. Trsturile socio- demografice a tuturor persoanelor intervievate i a pacienilor cu cefalee.
Parametri demografici Vrsta(ani) 15-19 20-29 30-39 298(11,2%) 647(24,3%) 493(18,5%) 55 (10,3%) 124 (23,22%) 101 (18,91%) 49(10,02%) 102(20,86%) 75(15,34%) socio- Toate persoanele Pacienii migren(n=534) cu Pacienii CTT(n=489) cu

intervievate(n=2665)

40-49 50-59 60-65 Nivelul educaional jos mediu superior Statutul matrimonial Cstorit() Celibatar()(singur()) Divorat Vduv

486(18,2%) 443(16,6%) 298(11,2%)

113 (21,16%) 104(19,48%) 37(6,93)

96(19,63%) 97(19,84%) 70(14,31%)

1150(43,2%) 503(18,9%) 1012(38%) 1834(68,8%) 586(22%) 121(4,5%) 124(4,7)

226 (42,32%) 100 (18,73%) 208 (38,95%) 118 (13,8%) 17 (9,5%) 8 (7,0%)

217(44,38%) 82 (16,77%) 190 (38,85%) 160 (18,7%) 28 (15,7%) 28 (24,3%)

Locul de trai Localitate urban Localitate rural 1301(48,8%) 1364(51,2%)

Tab.2Repartiia dup vrst a persoanelor cu migren i cefalee de tip tensional versus persoanele fr cefalee( convenional sntoase sau lot de control). Majoritatea o alctuiesc persoanele cu vrsta cuprins ntre 20-29 ani, att n lotul persoanelor convenional sntoase, ct i n lotul celor cu migren. Diferene statistice se observ la grupurile de vrst 40-49; 50-59; 60-65 ani

Persoanele CTT(20-29 ani) 102p.-3,8% n total;

cu P<0,05

Persoanele sntoase(20-29 ani) 327p.-12,27% din 2665p.chestionate n total; 26,7% din 1226 cefalee. p. fr P> 0,05

Persoanelecu migren(20-29 ani) 124p.-4,6% n total; 8,6%- din tot. de 1439ptts. cefalee; 23,22%- din 534 ptts. cu migren. cu din

din

2665p.chestionate

2665p.chestionate

7,08%- din tot. de 1439ptts. cefalee; 20,86%- din 489 ptts. cu CTT cu

Persoanele sntoase(40-49 ani) 193p.-7,24% din 2665p.chestionate n total; 15,74% 1226p. cefalee din fr P<0,01

Persoanelecu migren(40-49 ani) 113p.-4,24% n total; 7,8%- din tot. de 1439ptts. cefalee; 21,16%- din 534 ptts. cu migren. cu din

2665p.chestionate

Persoanele CTT(50-59 ani) 97p.-3,6% n total;

cu P<0,01

Persoanele sntoase(50-59 ani) 175p.-6,56% din 2665p.chestionate n total; 14,27% 1226p. cefalee din fr P< 0,01

Persoanelecu migren(50-59 ani) 104p.-3,9% n total; 7,23%- din tot. de 1439ptts. cefalee; 19,48%- din 534 ptts. cu migren. cu din

din

2665p.chestionate

2665p.chestionate

6,7%- din tot. de 1439ptts. cefalee; 19,84%- din 489 ptts. cu CTT cu

Persoanele sntoase(60-65 ani) 144p.-5,4% n total; din P< 0,01

Persoanelecu migren(60-65 ani) 37p.-1,38% n total; din

2665p.chestionate

2665p.chestionate

1587 femei au fost intervievate, 1050(39,4%) din ele au suportat migrena sau CTT n decursul ultimului an. Din 1078 brbai intervievai-389 (39,4%) din ei au avut migrena sau CTT n decursul ultimului an. Cum se repartizeaza dup sex persoanele cu migren si CTT? P. cu Migren: CTT: Brbai-16,1% 39,5% Femei-83,9% (P<0,002) Femei-60,5% ( P<0,001) BrbaiP. cu

Raportul femei/brbai la persoanele , ce sufer de migren este de 5,16, Iar la cei cu CTT raportul femei/brbai -1,53. n lotul persoanelor cu Migren fumeaz-14%, iar din cei cu CTT-21,1%(P<0,01) Nu fumeaz-86% (P<0.02) Sunt mai muli nefumtori n cazul respondenilor cu migren-86%, fa de 78,9% din cei cu CTT. S-a depistat prezena maladiilor endocrine la persoanele cu Migren n 9% cazuri fa de 5,1% din cei cu CTT(p<0,05) 4,1% din cei diagnosticai cu migren au menionat, c sufer de maladii nu fumeaz-78,9%

oncologice, iar din cei cu CTT doar 2%(P<0,05). n timpul atacului de cefalee nu-i pot ndeplini activitile zilnice 3,6 % din totalul pers. cu Migren i 0,6% din cei cu CTT(P<0,001). Durerea de cap este nsoit de nausee diagnosticate cu Migren i La 2,7% din respondeii, ce sufer de Cefalee de tip tensional(P<0,05). sau vom la 5,1% din persoanele

Triggerii cefaleei la persoanele cu Migren i CTT(rspuns spontan):

Factorii declanatori cel mai frecvent nominalizai(rspuns spontan) de ctre respondenii cu: MIgren tensional 3.Menstruaia- 3,8% 0,5% 4.Stresul sau ncetarea stresului-34,8% ncetarea stresului-26,9% 6.Obosela-23,9% 36,8% 21.Altceva-4,3% 7,8% 1.foamea-3,4% 2. alcoolul-1,9% 5.Somn insufficient-1,7% insufficient-1,1% 7.Incordarea psihic-2,6% psihic-4,1% 11. Lumini intense sau soare-5,5% sau soare-3,9% 17.Schimbri meteo-14,1% meteo-14,1% ----------------------------------------------------------------------------------------------------------------------------------------Triggerii migrenei i cefaleei de tip tensional dup interviu: Persoanele cu migren menioneaz foamea n 28,7% cazuri, iar cei cu CTT-n20,3% (P<0,01) Alcoolul ca factor declanator al migrenei a fost indicat de 27,3% din intervievai i doar de 13,1% din cei cu Cefalee de tip tensional (P<0,001) (P>0,05) 17.Schimbri (P>0,05) 11. Lumini intense (P>0,05) 7.Incordarea (P>0,05) (P>0,05) (P>0,05) 1.foamea-1,6% 2. alcoolul-2,3% 5.Somn (P<0,05) 21.Altceva(P<0,001) 6.Obosela(P<0,05) 4.Stresul sau (P<0,001) 3.MenstruaiaCefalee de tip

Menstruaia ca factor-trigger a fost menionat de 23% de migrenoi i de 9% din persoane cu CTT(P<0,001) Stresul sau ncetarea stresului a fost nominalizat ca trigger de 81,5% din

respondenii cu migren i de 70,8% din cei cu CTT!!! Oboseala este prezent ca factor-trigger la 74,9% din migrenoi i la 80,4% din cei cu cefalee de tip tensional(P<0,05)!!! Mirosurile puternice cauzeaz cefaleea la 23% din intervievaii cu migren i la 7,4% din cei cu CTT(P<0,001) Luminile intense sau soarele provoac migrena la 44,6%din suferinzi i la 22,9% de intervievai cu Cefalee de tip tensional(P<0,001) Sunetele puternice sunt triggerii Migrenei n 38,4% din cazuri, iar la cei cu CTT- la 13,1% din suferinzi(P<0,001) Somnul profund sau prea mult somn este nominalizat ca trigger n 23,2% n cazul respondenilor cu migren i n 13,1% cazuri de CTT(P<0,001) Schimbrile meteo migrenoi i la au fost menionate ca factori- declanatori la 64,8% din

57,3% din persoanele cu Cefalee de tip tensional(P<0, 05).

Comportamentul n timpul durerii de cap(rspuns spontan:

3.Continu activitile zilnice- 4% din respondenii, ce sufer de migren i 9,3% din cei cu CTT(P<0,001). 5.Iau medicamente-54,3% din migrenoi i 41,7% din intervievaii cu Cefalee de tip tensional(P<0,001). Comportamentul n timpul durerii de cap(rspuns dup chestionare): Merg la aer- 10,3% din persoanele cu migren i 30,5% din respondenii cu

CTT(P<0,001).

Privesc televizorul-7,9% din respodenii, ce sufer de migren i 27,2% din cei cu CTT(P<0,001)

Continu activitile obinuite-28,8% din intervievaii-migrenoi i 61,85% din respondenii, ce sufer de cefalee de tip tensional(P<0,001).

Fac masaj la cap 17,4% din cei cu migren i 23,1% din cei cu CTT(P<0,05).

Iau medicamente- 77,5% din respondenii ce sufer de migren i 57,1% din persoanele cu CTT(P<0,001).

Prefer repaosul la pat 77,5% din migrenoi i 53,8% din cei cu CTT(P<0,001).

Aleg o odaie ntunecoas-38,4 din cei, ce sufer de Migren i 8,2% din respondenii cu Cefalee de tip tensional(P<0,001). P.39. Antecedente eredo-colaterale Cineva din rudele apropiate sufer ( a suferit) de dureri de cap similare? n cazul respondenilor cu migren-69,9% au menionat prezena rudelor cu dureri similare, iar din cei cu cefalee de tip tensional -58,5% (P<0,001). 3. 52,8% din suferinzii de migren i 46,1%din cei cu CTT au numit mama, care a avut sau are cefalei similare(P>0,05). 5. sora sau fratele au fost menionai n cazul a 9,8% din respondenii cu migren i de 7,4% din cei cu CTT(P>0,05). 12. feciorul sa fiica au fost nominalizai n cazul a 14,3% din migrenoi i de 16% din cei, ce sufer de CTT(P>0,05). 2,2% din migrenoi i 11,5% din cei cu CTT- au indicat alte persoane din anturaj(P<0,001).

Dup chestionare 62,2% din suferinzii de Migren au lucru(P<0,01).

numit mama, ca avnd

dureri similare de cap i 50,7% din respondenii cu CTT au menionat acelai

Soul a fost numit ca suferind de cefalei de acelai tip de 13,9% din migrenoi i de 20,3% din cei cu cefalee de tip tensional(P<0,05). Altcineva a fost nominalizat de 3,2% din cei cu Migren i de 10,1% din cei cu

CTT(P<0,001).

P.40 Cefaleea i somnul diurn. Se ntmpl ca n timpul durerii de cap ziua s reuii s adormii (cu sau fr medicamente)? N-au reuit s adoarm ziua, n timpul cefaleei respondenii cu migren n 36% cazuri, iar cei cu CTT n28,2% cazuri(P<0,01). Durerea poate s dispar dup trezire? Durerea de cap persist dup trezirea din somnul diurn la 14,9% din cei cu

migren i la doar 5,15 din respondenii cu cefalee de tip tensional(P<001), pe cnd la 85,1% din migrenoi i 94,9% din respondenii cu CTT cefaleea dispare. Comorbiditatea algic n cursul ultimului an: Durerile abdominale au nsoit cefaleea la 12,7% din respondenii cu migren i la 8,8% din cei cu CTT(P<0,05). Durerea n regiunea lombar(n ale) a fost nominalizat de 34,6% din suferinzii de migren i de 28% din cei cu cefalee de tip tensional8P<0,05). Anxietatea generalizat Prezena anxietii la respondenii cu Migren a fost indicat ca frecvent n 27,3% cazuri , iar la respondenii cu Cefalee de tip tensional-n20,4% cazuri, foarte des, practic permanent, respectiv n 4,3% i 1,8% n ambele gupuri(P<0,05).

Au menionat n calitate de fenomene frecvente(sau foarte frecvente) adiionale durerii de cap greaa i discomfortul abdominal persoanele cu migren n 14,2% de cazuri, iar cei cu CTT- n 3,7% cazuri(P<0,001).

Comentarii: Acesta a fost primul studiu epidemiologic al migrenei i al cefaleei de tip tensional i a subtipurilor acesteia din Republica Moldova, efectuat n baza criteriilor operaionale al SIC(Societii Internaionale de Cefalee). Exist cteva aspecte ale procedurii noastre metodologice care trebuie luate n consideraie. Studiile epdemiologice asupra migrenei n care au fost aplicate metodele de intervievareface-to-face", " door-to-door sunt rare. Acest metod a colectrii de date este probabil mai sensibil n definirea cazurilor de migren i cefalee de tip tensional dect interviurile telefonice sau chestionarele prin pot. Un interviu clinicface-toface" rmne referin-standart pentru diagnosticarea cefaleelor primare n absena oricror indicatori neuroradiologici sau biologici. ntr-un studiu bazat pe populaia dintr-o comunitate , problema major este de a petrece un interviu direct cu participanii cu scopul de a clarifica semnele i simptomele MCA i a MFA ,ct i al CTT i astfel de a mbunti excactitatea diagnosticului. Alt surs major de variaii n studiile cu interviuri fa-n-fa este acordul intra i interobservatorilor n rndurile intervievatorilor. n evaluarea de fa, noi am petrecut , nainte de a ncepe studiul , un curs de instruire de 1 lun care implica o echip de medici- neurologi special pregtii( rezideni in neurologie, colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu), condui de ctre medicii specialiti n cefalei. n plus nainte de demararea procesului de colectare a datelor , neurologii seniori au petrecut o consulataie lunar , ntlnindu-se cu intervievatorii pentru a stabiliza o diagnoz final a migrenei i al cefaleei de tip tensional i a subtipurlor acestora. O astfel de abordare minimalizez potenialele devieri de diagnosticare i contribuie la obinerea unei informaii ct mai veridice asupra prevalenei migrenei i caefaleei de tip tensional. n afar de aceasta, iterviul nostru de identificare a fost deasemena petrecut pentru a introduce o ntreag mostr de pacieni negativi (1226p.- fr cefalee) n baza clinic. Dup cum cunoatem, trebuie notat c doar Rasmussen et al1 i Stewart et al18 au administrat un interviu de diagnosticare ntregului grup de intervievai. Deaceea , noi considerm c c stabilirea definiiei cazului nostru este precis i senzitiv. Mostra de intervievai ai studiului nostru bazat pe populaie costituia 2665p.(84%) din totalul de rezideni. Rata de participare n cadrul studiului nostru a fost mai nalt de ct cele prezentate n studiile recent publicate care prevedeau interviuri fa-n-fa asupra migrenei, dar era n concordan cu studiile raportate anterior. Cu acordul celorlali autori, noi am identificat 54% de respondeni pozitivi la cefalee n mostra clinic de participani . prevalena pe via a migrenei era nalt, n special printre femei cu vrsta 40-49 ani i 60-65(38.1% i 37.5%, respectiv). Aceste rate sunt aproximativ similare cu cele raportate n rile nvecinate , precum Frana i Italia Croaia i

Turcia , dar puin mai joase dect cele raportate n rile nordice din Europa. Totui, este bine stabilit c migrena este mai frecvent ntlnit la femei dect la brbai, evidena arat c ratele da la femeie la brbat variaz considerabil n dependen de vrst ; prevalena crete din adolescen pn la 40 ani i descrete apoi, mai ales la brbai. Exist probail o anumit influien a factorului hormonal asociate cu genul femenin care pot explica predominarea la femei mai n vrst de 60 de ani, dup cum a sugerat Stewart et al. Descoperirile noastre aprob aceats ipotez. Ratele noatre pentru prevalena pe durata unui an erau similare cu ratele obinute ntr- un studiu-exemplu american. Prevalena de 1 an n dependen de vrst a artat un tipar bimodal cu vrful n grupele de vrst 20-29, 40-49 i 50-59 de ani pentru ambele sexe. Cauza exact pentru o prevalen de vrf n grupul cel mai tnr nu este clar. Dup cum a presupus un studiu Korean, o explicaie posibil poate fi sindromul stresului printre elevii de liceu care se pregtesc de examenele de intrare la universitate. n studiul nostru , noi am subclasificat cei 534 de migrenoi activi, n dependen de subtipul lor. Majoritatea(...%) aveau MFA, urmai de cei cu MCA(...%) i MCAFA(...%). Ratele noastre sunt puin mai joase det cele raportate n studiul GEM care prevedea MFA i MCAFA(...% i ...%, respectiv),dar mai nalte pentru rata de MCA(...%). Posibil diferenele de studiu pentru MCA, MFA i MCAFA pot fi explicate de descoperirea i clasificarea lor, avnd in vedere c n studiul GEM numai o parte din respondenii negativi au fost interogai.). Aceste descoperiri sunt n concordan cu un studiu epidemiologic din Ungaria, asupra MFA i MCA , recent publicat . n studiul de fa, noi am observat o predominan n cazul femeilor n toate cele 3 grupe dup cum era sugerat i de ceilali autori. Unii autori au sugerat c MCA i MFA au probabil diferita etiologii. n studiul d fa, noi am ncercat s investigm diferenele dintre caracteristicile clinice a migrenoilor pe via pentru cei cu migren cu i fr aur, ct i cele ale pacienilor cu cefalee de tip tensional.( Ratele de la femeie la brbat erau semnificativ mai nalte la pacienii afectai de MCA(P=.03). Majoritatea migrenoilor cu aur au resimit atacuri mai frecvente i mai severe cu simptomele nsoitare generale. Aceste descoperiri pot susine ipoteza c MCA i MFA sunt du entiti clinice diferite. Grupul amestecat (MCAFA) poate fi un alt grup distinct de migrenoi, iar aura la pacienii afectai de MCAFA probabil are o baz diferit det cea la migrenoii cu MCA. Noi am identificat numai 6.9% de migrenoi activi afectai de MCAFA. Aceast rat este mai joas dect ratele raportate de studiul GEM . pentru a investiga epidemiologia analitic descriptiv i clinic a MCA, MFA i MCAFA ,) ar fi important de standardizat o procedur de scanare a investigaiilor i a subclasificrii pentru a putea fi folosit n studiile din viitor. Studiile care vor urma trebuie s estimeze ratele reale ale prevalenei migrenei i ale cefaleei de tip tensional n populaia Moldovei.

S XXXII Headache: The Journal of Head and Face Pain Vol 42 P. 963-November 2002. Issue 10 Prevalence and Clinical Characteristics of Headache in a Rural community in Oman. Dirk Deleu,MD et al. Obiective: mbuntirea studiului prospectiv epidemiologic al cefaleelor n comunitatea rural Oman, evaluarea prevalenei, profilului simptomelor i utilizarea patternului de ngrijire medical. Metode: Utilizarea studiului door-to door de estimare a prevalenei, care a fost bazat pe chestionarul structurat de evaluare a cefaleei, care efectuiaz diagnosticarea migrenei i CTT n acord cu criteriile IHS(Societii Internaionale a Cefaleelor)efectuat pe 1158 persoane. Rezultate:Prevalena nefinisat(preventiv)pe via i pe durata de 1 an al cefaleei a fost de 83,6% i de 78,8% respectiv,cu preponderen la femei. Prevalena de 1 an al migrenei i CTT a fost de 10,1% i 11,2% respectiv. Nu este o diferen semnificativ dup gen(sex) n prevalena migrenei (4,5% la femei i 5,6% la brbai), dar CTT a fost de 2,6% ori mai frecv. la femei(3,1% la brbai i 8,1% la femei). Prevalena de 1 an al cefaleelor frecvente a fost de 5,4%, 48% din respondeni au cerut asisten medical, privind cefaleea i 79% au utilizat medicaia, iar 40% din ei-automedicaia. Concluzii: Acest studiu prospectiv a demonstrat, c prevalena cefaleei este la fel de nalt n aceast comunitate. Migrena i CTT au o prevalen similar, dar distribuia dup sex e diferit de cea dinrile din Vest. Prevalena CTT ests substanial mai joas dect cea observat n alte pri ale lumii. Cefaleele frecvente au fost la fel de des ntlnite ca i n alte studii asemntoare n lume. Utilizarea analgezicelor, ct i abuzul probabil de asemenea coexist cu cefaleea, deoarece automedicaia mai este destul de rspndit.

S XXX Curr. Pain Headache Rep. 2003 Dec;7(6):455-9. Diagnosis, epidemiology and impact of tension-type headache. Jensen R. Dei CTT este cea mai prevalent cefalee i afecteaz 78% din populaia dgeneral, impactul substanial individual i social asociat cu aceast cefalee primar este trecut cu vederea(neglijat). n contrast cu migrena , concentrarea asupra CTT este limitat. Muli pacieni cu forme de Ctt cronic, care afecteaz 3% din populaie sunt lsai (abandonai) fr orice trataent specific.

CTT cronic difer de forma episodic prin frecven, lipsa efectului la majoritatea strategiilor de tratament, mai mult abuz medicamentos i o mai mare scdere(pierdere) a calitii vieii. Zilnic sau aproape(practic) zilnic deasemenea constituie o problem de diagnostic i tratament i separarea( deosebirea) CTT cronic de migren(cefaleea migrenoas) i de cefaleea indus de medicaie este o provocare, deoarece strategiile manageriale sunt complet diferite. Un beneficiu considerabil pentru societate este obinerea unor strategii specifice, ce vor conduce la reducerea n cantitate al absenteismului pe motiv de boal i a mbuntirii abilitilor de munc. Impactul supra pacienilor afectai i asupra calitii vieii familiilor lor de asemenea pot fi mbuntite prin accepterea general a patologiei(recunoaterea ei) i prin dezvoltarea unei strategii specifice de tratament.

S XXXI CNS DRUGS: 2005; 19(6): 483-97 Medication overuse headache in patients with primary headache disorders: epidemiology, management and pathogenesis. Dowson AJ, Dodick DW, Limmroth V. Cefaleea indus de abuzul medicamentos(CIAM) sau MOH- medication overuse headache este o problem medical frecvent ntlnit, dac e asociat cu o stare de boal de lung durat i cu o disabilitate considerabil(scdere considerabil a capacitii de munc). CIAM afecteaz pacienii cu cefalei primare(migrena, CTT i combinaia migrenei i a CTT), ceea, ce schimb patternul cefaleelor zilnice sau aproape zilnice pe o perioad de ani sau zeci de ani, nsoind abuzul medicaiilor simptomatice a cefaleelor. Abuzul medicamentos Medicamentele utilizate n exces includ analgezicele, alcaloizii ergotaminici, triptanele(serotonin 5HT(1/1D) receptorii agonitilor ) i medicamentele, ce conin barbiturice, codein, cafein, tranchilizantele i analgezicele mixte. Pacienii afectai au de obicei un istoric de lung durat de cefalei primare, medicaia abuzivi cefaleea indus de abuzul medicamentos pn la adresarea la medicul-generalist pentru ngrijiri medicale(dup ajutor). Pacienii cu CIAM(Cefaleea indus de abuzul medicamentos) sunt ndreptai n centre specializate, unde sunt retrase medicamentele, ce au fost utilizate n abuz i li se aplic un tratament de retractare al simptomelor(n tratamentul n staionar i ambulator), profilaxia cefaleelor i limitarea utilizrii medicaiei simptomatice acute.

Majoritatea pacienilor rspund la acest tratament, dei prognoza nu este mereu una bun, 50% pot cdea, se pot ntoarce) n starea sau perioada iniial n urmtorii 5 ani. Cea mai bun strategie practicat n prezent este prevenirea abuzului medicamentos n primul rnd prin educaia pacienilor i formal abordarea managerial dirijat(?) n medicina primar(prespitaliceasc), ce const n tratarea cefaleelor primare pn la transformarea lor CIAM. Calitatea evidenei clinice al CIAM este suboptimal i pe departe cercetrile biologice(?) i clinice (solicitate) necesit urgent un ajutor de facilitare a managementului acestor pacieni, mai eficient n viitor.

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J Headache Pain 2003 Epidemiology of migraine Gian Camillo Manzoni, Paola Torelli Prevalena de 1 an al migrenei n populaia general a rilor vestice variaz de la 4% la 9% la brbai i de la 11% la 25% la femei. Brbai(%) Mattson et al.[8]2000 sweden(40-74 ani) Dahlof et al. [9]2001 Sweden(18-74) Lipton et al. [10]2001 SUA(12) Henry et al. [12]2002 France(15) Lipton et al. [11]2002 SUA(18-65) 9,5 6,5 4,0 6,0 Femei (%) 18,0 16,7 18,2 11,2 17,2

Non-Western countries(rile, ce nu sunt situate n vest) Bank, Marton [17]2000 Hungary(15-80) Zivadinov et al [18]2001 Croaia(15-65) Kececi,Dener[18 ]2002 Turkey(7) S XXXII Eur J Epidemiol. 2005; 20(3): 243-9. Has the prevalence of migraine and tension-type headache changed over a 12-year period? A Danish population survei. Lyngberg AC, Rasmussen BK, Jorgensen T, Jensen R. Rata de participare a fost de 75%. 4,3 12,3 7,9 10,7 18,0 17,0

Prevalena migrenei nu s-a schimbat semnificativ(11-15%), pe cnd prevalena CTT(79-87%) n special CTT frecvent(29-37%) a crescut semnificativ. Prevalena CTT cronice(2-5%) tinde spre cretere. Proporia migrenoilor cu migren de 14 zile i mai mult pe an e n cretere(12-38%). Genul feminin a fost un factor de risc pentru ambele tipuri de cefalei primare. Majoritatea migrenoilor(9294%) de asemenea au raportat coexistena CTT(asocierea). Concluzii: Prevalena CTT, dar nu i al migrenei este n cretere. Creterea frecvenei migrenei i a CTT sugereaz un nalt impact individual i social al cefaleelor

primare acum, ca i 12 ani n urm.

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J. Headache Pain(2003)4: S 55-S 58 General disease costing principles. Amalia Donia sofio, Franco Mazzuca, Francesco S Mennini Studiile recente au demonstrat, c n rile UE(Uniunii Europene)zilele pierdute de lucru n rezultatul migrenei( din cauza migrenei) variaz de la 1,9 la 3,2 la pacient pe an. n toate studiile, indiferent de naionalitate femeile au ntietatea net fa de brbai( women stay away from worc more often than men). Capacitatea muncii scade cu 70% la aceti subieci. Costul spitalizrii peste tot (universally)reprezint doar o mic parte din costul total de management al migrnei: rata spitalizrii e mai mic de 10% i variaz de la 2% n Danemarca la 7% n SUA. Pentru introducere: Cefaleea este un simptom foarte cunoscut, care poate avea un impact profund asupra calitii vieii. Dou patologii, cele mai cunoscute cefalei primare, migrena i cefaleea de tip tensional au o prevalen unianual 11%i 40% la populaia adult. Patologiile au condiii heterogene, care rezult ntr-un spectru al disabilitii n interiorul i printre diferii indivizi. Dei exist tratamente eficiente pentru muli pacieni cu migren, ea este acum slab cunoscut i slab tratat. Evaluarea dizabilitii la cefalee e important pentru formarea prerii privind terapia acut i preventiv. Cteva chestionare standartizate pentru migren i impactul cefaleei au fost descoperite. Acest tip de chestionare au cel puin 2 utilizri poteniale: 1.Evaluarea grupurilor, rezultatul evalurii studiilor clinice.

Surse la sfrit: Cefaleea este un simptom extrem de rspndit, care poate avea un impact profund asupra funcionrii oamenilor i asupra calitii vieiilor.

Dou cele mai frecvent ntlnite cefalei primare: migrena i cefaleea de tip tensional cu o prevalen de 1 an de 11%[Breslau N, Rasmussen BK. The impact of migraine:Epidemiology, risk factors, and comorbidities. Neurology 2001; 56: S4-S12] i 40% [Schwarz BS, Stewart WF, Simon D, Lipton RB: Epidemiology of tension- type headache. JAMA 1998; 279: 381-383] n populaia adult. Patologiile, ce au condiii heterogene, rezult n spectru de dizabiliti n interiorul i printre diferite persoane[Stewart WF,Shechter A, Lipton RB. Migraine heterogenity.Disability, pain intensity, and attack frequency and duration. Neurology 1994; 44. S 24-39 ]. Dei exist tratamente eficiente pentru majoritatea nediagnosticat i netratat ndeajuns. n evaluarea patologiei cefalalgice este important luarea deciziilor privind tratamentul acut i preventiv. Chestionarul HIT[Headache Impact Test] include ntrebri privind durerea, funcionarea social, oboseala, suprarea emoional, capacitatea de nsuire i sntate mintal. n MIDAS se include informaia despre timpul de munc pierdut, munca casnic sau ntreruperea activitii n ultimele 3 luni. Criterii de selectare: 1.Vrsta 18-65 ani. 2.Reedin permanent(ca s poat fi contactai) 3. A avut o cefalee cu 4 sptmni nainte de interviu(nu din cauza mahmurelii, rcelii sau gripei). Respondenii trebuia s poat: 1. S poat liber conversa n englez; 2. S poat fi intervievai fizic i mental. Rata de participare- 71%. Prevalena cefaleei n 4 sptmni precedente a fost de 45,7%. Durata interviului a fost 21,5 min.(17-27 min.). Din persoanele, ce nu au raportat, c au avut cefalee n cele 4 sptmni precedente, 35% au spus, c au avut cefalee n ultimele 3 luni. Quality of life research 12: 913-933, 2003 Calibration of an item pool for assesing the burden of headaches: An response theory to the Headache Impact Test(HIT TM). -----------------------------------------------------------------------------------------------------------------------------------------Nippon Rinsho.2005.oct; 63(10):1705-11. [ Epidemiology of headache] Ocuma H, Kitagawa Y. n articol s-a discutat epidemiologia cefaleelor cronice. application of item pesonal, pacienilor cu migren, ea mai rmine

Cefaleea e omniprezent(wide spread i o problem costisitoare al sntii publice Rar cine n-a suferit de cefalee: La brbai prevalena pe via e de 93%, iar la femei de 99%. Aproximativ 8,4 mln oameni n Japonia dup servicii medicale. E important s se recunoasc incidena variatelor tipuri de cef. Cronice, diagnosticarea i tratarea lor corect. n acest articol a fost elucidat incidena, factorii provocatori, prevalena regional i dependena de vrst al incidenei fiecrui tip de cefalee cronic. sufer de migren i 22 mln. Au cefalee de tip tensional.

Nectnd la dauna, costul i dizabilitatea cauzat de cefalee, muli pacieni cu cefalei nu se adreseaz

Prevalence and Clinical Characteristics of Headache in Medical students in Oman Dirk Deleu, MD et al. (Headache2001;41:798-804) Au fost completate chestionare: 151-brbai(37,5%) 252 femei(62,5%). Prevalena pe via i pe durata ultimului an al cefaleei a fost -98,3% i 96,8% respectiv. Un istoric pozitiv familial de cefalee a fost gsit la 57,6% studeni. Rata de prevalen a migrenei i a CTT a fost gsit asemntoare(12,2%) cu o diferen a distribuiei printre sexe:6,6% din brbai i 15,5% din femei- sufereau de migren, n timp ce 13,9% din brbai i 11,1% din femei aveau cefalee de tip tensional. Doar 23,3% din studeni au cerut asistena medical pe parcursul episoadelor de cefalee i 80,3% au primit medicamente: 24,6% au primit medicamente prescrise, iar 72,4%- medicamente neprescrise8automedicaia) i doar 2,5% au apelat la remedii tradiionale. Probabil utilizarea analgezicelori abuzul lor coexist cu cefaleea la studenii Universitii Sultan Oaboos , ntruct majoritatea lor se bizuiepe medicaia neprescris.

Cefalalgia, 2003,23,381-388. Epidemilogical and clinical characteristics of migraine and tension type headache in 1146 females in Kayseri, Turkey. E Koseoglu , M Nacar et al. Au fost investigate unele caracteristici epidemiologice i clinice ale migrenei i cefaleei de tip tensional i a subtipurilor lor la populaia feminin a Turciei(1146 femei adulte). S-a cercetat relaia dintre severitatea cefaleei i caracteeristicele clinice. Prevalena migrenei a fost apreciat statistic mai nalt la grupul de vrsta de 35-44 ani i la cele, ce aveau studii superioare(P<0,001), cstorite(P<0,01) i care locuiesc la ora(n localitile urbane) (P<0,01).

Cefaleea de tip tensional a fost gsit mai nalt la grupul de vrst(persoanele) de 45-64 ani(P<0,05). Pacienii cu CTT cronic au fost gsii mai n vrst dect cei cu forme episodice(P<0,01) i mai frecveent la persoanele cu nivel mai jos de educaie(P<0,05). Prezena i impactul activitilor zilnice din cauza severitii cefaleei a fost gsit ca fiind cauzat de agravare n rezultatul activitilor fizice(P=0,001) la CTT, fr caracteristici clinice la cefaleea migrenoas i lund n consideraie c toi pacienii cu cefalee de natur pulsatil(P<0,05), ce se agraveaz la activiti fizice (P=0,001), greaa(P<0,01), voma(P<0,05) i fonofobie(P<0,05). Introducere: Sunt numeroase studii privind cefaleea, dar relativ puine studii efectuate n rile Asiatice. Este raportat c factorii de risc rasiali, culturali i cei , ce in de mediu joac un rol important n cercetrile epidemiologice. Acest studiu a fost petrecut ntr-o ar in Asia, ai crei populaie aparine rasei albe. Studii, ce in n special de femei sunt de asemenea relativ puine. ntr-un studiu epidemiologic al cefaleei n Turcia , ce a fost tiprit ca un abstract, a fost efectuat pe un lot de 2007 persoane, prevalena de 1 an al migrenei i a CTT a fost declarat ca fiind de 16,4% i 31,7% respectiv(2), dar caracteristicele clinice ale cefaleelor nu au fost evaluate. Acest studiu este primul studiu bazat pe populaie i detaliat al cefaleelor i a caracteristicelor clinice pe baza criteriilor Societ .Interna. a Cefaleelor la populaia de femei din Turcia. S-au cercetat prevalena de 1 an, datele socio- demografice o caracteristicele migrenei, ale cefaleei de tip tensional. Mareriale i metode Acest studiu a fost executat pn la final n provincia Kaisery pe populaia feminin mai mare de 14 ani , n numr de 375441. Cea mai mic mostr a fost calculat de 1100 persoane(95% interval confedenial, SD:1,6%) s-a estimat prevalena migrenei la 8%. 1300 de femei cu vrsta cuprins ntre 15-87 ani au fost selectate randomizat dup cluster i metoda mostrei sistematice n regiune, utiliznd cartela casnic din centrele primare de sntate, n cere figureaz datele despre toi locuitorii din regiune; 1146 din aceste femei au putut fi contactate . Simptomele au fost evaluate prin interviul face to face structurat, bazat pe criteriile SIC(Societii internaionale a Cefaleelor)- IHS. naintea fiecrui interviu, obiectivele stdiului au fost descrise i a fost obinut acordul(consimmntul). Toate femeile i-au declarat acordul de a fi implicate n studiu. Studiul a fost acceptat de Comitetul de Etic al Universitii Erciyes. Dup ntrebrile introductive privind vrsta, nivelul economic i educaional, statutul matrimonial i profesional, persoanele au fost interogate despre prezena oricror patologii cronice, diagnosticate de medicul-generalist i au avut vreo cefalee important, care atrage atenia(deranjant) n perioada ultimului an. Dac cefaleea era declarat, li se adresau ntrebri, privind caracteristicele cefaleelor lor i

relatarea unor astfel de date cum ar fi: frecvena, durata, triggerii(factorii declanatori), simptomele nsoitoare, dereglrile de somn, istoricul familial, tratamentele suportate pn acum etc. Interviul a fost executat de ctre studenii- medici, pregtii pentru a lucra n policlinica cefalalgic. Dup interviu tipurile de cefalee a fost determinate n acord cu criteriile IHS n interviu de neurologi i de studeni. Diagnosticarea altor patologii s-a bazat pe decizia medicului generalist(de familie). Alte cauze ale cefaleelor, cum ar fi sinusitele, hipertensiunea au fost considerate i evaluate pentru probabilitatea de a fi cauze ale cefaleelor. n 15 cazuri (1,31%) din cazuri cefaleea a fost considerat ca fiind cauzat de aceste patologii. A fost gsit partea prevalenei migrenei cu aur(MWA) i a migrenei fr aur(MWOA), al cefaleei de tip tensional episodic i cronic. Evaluarea relaiei dintre prevalena tipurilor de cefalee i proprietile cefaleelor pacienilor, aa ca vrsta , nivelul educaional i economic, statutul matrimonial i profesional, locul de reedin i compararea caracteristicelor clinice printre subtipurile cefaleei, a fost dobndit caracteristicele clinice i severitatea Spearman. Rezultate Trsturile socio-demografice ale migrenei i CTT: vrsta, nivelul educaional i economic, statutul matrimonial i profesional, locul de trai au fost demonstrate n Tab.1. Tab.1. Trsturile socio- demografice cefalee. Parametri demografici Vrsta(ani) 15-24 25-34 35-44 45-64 > 65 Nivelul educaional <5 ani 5 ani 8 ani 11 ani 312 526 99 126 33 (10,5%) 72 (13,7%) 6 (6,0%) 11 (8,7%) 57 (18,2%) 96 (18,2%) 19 (19,2%) 22 (17,4%) 289 311 253 228 65 23 (8,0%) 48 (15,4%) 41 (16,2%) 29 (12,7%) 2 (3,0%) 46 (15,9%) 55 (17,7%) 47 (18,5%) 59 (29,9%) 9 (13,8%) socioToate persoanele Pacienii migren(n=143) cu Pacienii CTT(n=216) cu a tuturor persoanelor intervievate i a pacienilor cu cefaleei de Corelaia dintre

a fost analizat, utiliznd analiza scalei corelaiei

intervievate(n=1146)

>11 ani Statutul matrimonial Cstorit Celibatar(singur) Divorat Statutul profesional Gospodin casnic

83

21 (25,8%)

22 (26,5%)

853 178 115

118 (13,8%) 17 (9,5%) 8 (7,0%) 1

160 (18,7%) 28 (15,7%) 28 (24,3%) 18 0(18,4%) 2 36( 21,0%)

975

16(11,9%)

171 Angajat Locul de trai Localitate urban Localitate rural 636 510

7(15,8%)

97 (15,2%) 46 (9,0%)

123(19,3%) 93 (18,2%)

Tipurile cefaleelor migrenoase i particularitile socio-demografice. 1146 femei au fost intervievate. 359(31,3%) din ei au experimentat(suportat) migrena sau CTT n decursul ultimului an. Prevalena de 1 an al migrenei a fost de 12,5%(143ptts.), cuprinznd 7,3%(84) migr.cu aur i

5,2%(59)-migr. fr aur. Prevalena migrenei a fost gsit statistic mai nalt la grupul de vrst de 35-44 ani i mai joas la grupul de peste 65 ani, n comparaie cu alte grupuri ( /16,38, P<0,01).Cefaleea migrenoas s-a

depistat ca fiind cu cea mai nalt prtevalen la persoanele cu cel mai nalt nivel educaional, ci studii universitare( urbane( /19,59, P<0,001), femeile mritate( /6,04, P<0,05) i la cele, care locuiau n localitile

/9,5,P<0,01). Totui statutul profesional i nivelul economic nu erau n legtur semnificativ

cu cefaleea de tip migrenos.

Cefaleea de tip tenional i particularitile socio-demografice.

Prevalena de 1 an al CTT a fost gsit de 18,8%(216 persoane), incluznd 144(12,5% )- episodic i 72(6,3%)-tipul cronic al cefaleei. Cea mai nalt prevalena a CTT a fost gsit la grupul de vrst de 45-64 ani( /10,34, P<0,05).

Pacienii cu CTT cronic au fost gsii a fi cu mult mai n vrst dect cei cu forme episodice( Media de vrst SD pentruCTT episodic i cronica: 41,1115,57, 35,85 12,91, P<0,01). Lund n consideraie nivelul educaional, CTT cronic a fost gsit ca cea mai prevalent ( cel mai jos nivel educaional. Frecvena atacurilor de cefalee. Aproximativ 73,4% din pacienii cu migren au 1-4 atacuri pe lun, pe cnd restul trec prin> 4 atacuri pe lun. 55 pacieni migrenoi(38,5% din toi pacienii cu migren; 21- cu (MWA)migren 14- (MWOA) migren fr aur au cel puin 180 atacuri pe an. Lund n consideraie, c la CTT, 31,9% au 1-3 atacuri de cefalee pe lun i 68,1% din pacieni sufer de cefalee minim 1 dat pe sptmn; 33,3% din pacieni au cel puin 180 atacuri de cefalee de tip tensional pe an. Durata cefaleei. n acord cu criteriile Societii Internaionale de Cefalee(IHS), durata acceptabil a atacului de migren la pacientul netratat e de 4-72 ore. 22 pacieni (15,4%)cu migren au avut durata atacurilor < 4ore. Dar toi aceti pacieni au utilizat tratamentul medicamentos pentru atacurile lor de cefalee. Acest studiu arat(demostreaz, c cea mai rspndit(comun durat al atacurilor de migren(71,3%) a fost ntre 4 i 24 ore. n CTT atacurile s-au sfrit n cadrul(dup)mai multor ore(51,9%), au continuat pe parcursul zilei(22,2%), au durat 1-3 zile(14,8%) i 3-7 zile la (11%)din pacieni. CTT episodic difer de tipul cronic prin aceea, c atacurile de obicei au o durat mai scurt, 15 min.cteva ore( 10,52, P<0,05). cu aur, /6,83, P<0,05) la persoanele cu

Caracterul cefaleei. Pulsaia a fost observat la 88,8% din migrenoi pe cnd la 62,0% din pacienii cu CTT aveau senzaie de presiune, ncordare(Tab.2); 53,1% din pacienii cu migren au avut cefalee unilateral. Cefaleea bilateral a fost raportat n 72,7% din pacienii cu CTT. La 82,5% din pacienii cu migren i 43,5% din pacienii cu CTT, cefaleea a fost agravat de activiti fizice de rutin. Caracteristicele tipurilor migrenei cu aur i fr aur au fost demonstrate n Tab.2 Compararea acestor caracteristici cu frecvent n migrena cu aur( Caracteristicele CTT cronic i episodic au fost prezentate n Tab.3. N-au fost diferene statistice( test) ntre cele 2 tipuri de cefalei tensionale. test a demonstrat caracterul pulsatil, care a fost gsit mai

Simptome nsoitoare.(concomitente, asociate).

Fonofobia(85,3%) a fost cel mai frecvent simptom al migrenei, nsoit de grea(80,4%) i fotofobie(77,6%). Voma a fost observat la 44,8% din pacienii cu migren, n( MWA)- migrena cu aur , cea mai comun aur au fost manifestrile vizuale, incluznd scintilaia sau distorsia (modificarea ) imaginii, hemianopsia i ntunecarea vederii(81,8%), urmat (nsoit) de tinitus/vertije(67,1%), simptome senzoriale(34,3%) i afazia(15,4%). n cazurile de CTT, fonofobia a fost de asemenea cel mai des simptom nsoitor. Greaa a fost observat la 40,7%, iar fotofobia la 14,4% din pacieni. Simptomele nsoitoare ale migrenei cu i fr aur au fost artate(prezentate, demonstrate) n Tab.4, iar cele de cefalee de tip tensional episodic i cronic n Tab. 5 Cu respectarea acestor constatri, n-a fost difereniat statistica ntre migrena cu i fr aur.

Totui, cnd comparaia similar a fost fcut ntre subtipurile cefaleei de tip tensional, simptomele de grea ( ( au fost gsite ca cele mai frecvente n cefaleea cronic de tip tensional.

Tab.3 Caracteristicele cefaleei de tip tensional cronice i episodice

Bilaterali Tipurile CTT tatea% Natura presiune, strangulare% de fizic

Agr avarea la efort pactul

Im asupra activitii zilnice

CTT cronic

73,6

34,7

45,8

33,3

CTT episodic

70,1

39,6

45,1

38,2

Tab.4 Simptomele nsoitoare ale migrenei cu i fr aur.

F Tipurile migrenei Greaa(%) Voma(%) onofobia(%) obia(%)

Fotof

Migrena cu aur(MWA)

81,0

47,6

89,2

82,1

Migrena fr aur(%)

83,1

40,7

79,6

71,2

Factorii trigger (declanatori) Cei mai frecveni factori declanatori ai atacurilor de cefalee au fost stresul(la migren-81,8%; la

cefaleea de tip tensional-83,3%), privarea de somn(la migren-52,4%; la cefaleea de tip tensional53,2%), graba sau foamea(la migren-37,1%; la cefaleea de tip tensional-39,4%), factorii hormonali ca menstruaia(la migren-35,6%; la cefaleea de tip tensional-24,5%), sarcina(la migren-16,1%; la cefaleea de tip tensional-6,0%. Diverse alimente nu joac vre-un rol semnificativ ca factor declanator la pacienii cu migren(cacavalul0%, ciocolata-1,4%) . 32,2% din persoane cu migren cu aur i 42,4% din cei cu migren fr aur au fost raportate ca cefalei provocate de menstruaie. La compararea acestor date nu s-au gsit diferene statistice.

5 pacieni(3,5- migrenoi: 3- cu migr. cu aur, 2- cu migr.fr aur) au fost raportai cu cefalei de tip migrenos relatate doar la menstruaie, iat de ce ei sunt considerai pacieni cu migrena menstrual pur.

Impactul asupra activitilor zilnice. Activitile zilnice de rutin sunt afectate la 77,6% din pacienii cu migren i la 37,5% din pacienii cu CTT, din cauza severitii cefaleei. Cu respectarea acestui factor o diferen nesemnificativ a fost gsit ntre migrena cu i fr aur sau ntre cefaleea de tip tensional episodic i cronic. La pacienii cu CTT , comparnd prezena impactului asupra sctivitilor zilnice cu caracteristicele cefaleei i simptomele nsoitoare, a fost gsit legtura(relativ)intre impactul asupra activitilor i agravarea la efort fizic(activiti fizice)(Spearman p: 0,27, P= 0,001). Cnd o comparaie asemntoare efectuat la pacienii cu cefalee de tip migrenos nu a fost gsit vre-o relaie. n cazul altor pacieni cu cefalee, caracterul pulsatil(P>0,05), agravarea la efort fizic(activiti fizice) (P<0,001), simptomele nsoitoare de grea(P<0,01), vom(P<0,05), fotofobia(P<0,05), au fost gsite pentru a fi relatat impactul cefaleei asupra activitilor zilnice n analiza gradului de corelaie a lui Spearman. afost

Tab.5 Simptomele nsoitoare ale cefaleei de tip tensional cronice i episodice. F Tipurile CTT Greaa(%) Voma(%) onofobia(%) obia(%) Fotof

CTT cronic

52,8

13,0

61,1

19,4

CTT episodic

34,7

10,0

45,8

12,5

Somnul i cefaleea. n studiul nostru lipsa somnului(privarea de somn)a fost raportat la 23% de migrenoi i la 20,8% de pacieni cu CTT. Relaiile pacient- medic 75,5% din pacienii cu migren i 56,7% din cei cu cefalee de tip tensional au fost consultai n privina durerii lor de cap(cefaleei lor).

51% din migrenoi tiu despre migrena lor. Msuri de tratament Partea utilizrii medicamentelor la pacienii migrenoi a fost gsit a fi-90,9%, n timp, ce la pacienii cu cefalee de tip tensional-63,4%. O alt msur important este aflarea n singurtate ntr-o odaie i somnul cefaleea de tip tensional-66,7%), masajul compresele reci sau calde (la migren-10,5%; la cefaleea de tip tensional-6,0%). Istoricul familial 43,4% din migrenoi aveau un istoric familial similarcefaleelor(48,8% migr. cu aur;35,6% migr. fr aur) , n timp, ce istoricul pozitiv familial a fost raportat la 32,9% din cei cu CTT. Reieind din(respectnd) acestea nu a fost gsit o diferen semnificativ ntre tipurile cefalei. Discuii Acesta este studiul bazat pe femeile cu cefalee din Turcia. Noi am ncercat s evalum caracteristicele socio-dmografice i clinice ale cefaleelor de tip tenional i cele de tip migrenos. n cele, ce urmeaz noi am clasificat cefaleele de tip tenional i cele de tip migrenos n episodice i cronice, iar la migren- cu aur i fr aur. Caracteristicele clinice ale simptomelor nsoitoare au fost evaluate la toate subtipurile cefaleelor i comparate ntre ele . Atitudinea pacienilor fa de cefalee a fost investigat. (la migren-86,0%; la

(la migren-38,5%; la cefaleea de tip tensional-31,0%),

Femeile i cefaleele. Ce trebuie s tim? C oameni au migren? Conform datelor Studiului II American al Migrenei (National Headache Foundation. American

Migraine Study II: Migraine in the Unaited States. Burden of illness and patterns of treatment). Sunt 28 mln persoane, care sufer de migren >12 ani(12+) n SUA, din care 21 mln- femei, 7 mlnbrbai. O gospodin casnic din 4 a suferit cel puin 1 atac de migren. Majoritatea persoanelor, ce sufer de migren sunt cu vrsta cuprins ntre 25-55 ani. Din diagnozele de cefalee-98%(Conform Landmark Study) o alctuies migrenele, 0,4%-CTT, cefaleele secundare-1%. Ce este Migrena? Conform datelor OMS i World Federation of Neurology:

Atacuri recurente(repetitive)de cefalee A. Cel puin 5 atacuri, ce corespund criteriilor B-D B. Atacurile de cefalee au durata 4-72 ore fiecare( fr tratament sau dup tratament fr succes C. Cefaleea are cel puin 2 din urmtoarele caracteristici: 1. localizare unilateral 2. caracter pulsatil 3. intensitate moderat sau sever 4. agravare de sau evitarea activitii fizice de rutin(ex., mersul sau urcatul scrilor). D.n timpul durerii de cap apare cel puin una din urmtoarele: 1.grea i vom 2.fotofobie i fonofobie E. Nu este atribuit altor afeciuni.

Pacienii au deseori mai mult de un singur tip de atac migrenos: . Migrena matinal . Migrena de durat lung . Migrena cu grea/ vom . Migrena cu evoluie lent . Migrena cu escaladare rapid . Migrena menstrual Medicii au de difereniat diverse tipuri de cefalee: . Migrena cu/fr aur . Migrena cronic .Cefaleea benign .Cefaleea de tip tensional . Cefaleea primar cluster .Aura fr cefalee .Cefaleea menstrual .Cefaleele mixte .Statusul migrenos Ce putei simi nainte sau pe parcursul atacului de migren: 1.Greuri 9.Fonofobie 2.Vome 3.Diaree 4.Transpiraie 10.Tensiuni ale scalpului 11.Paliditate 12.Pulsaii la tmple

5.Mini reci 6.Sensibilitate la lumin 7.Obnubilare 8.Dureri n reg. cervical Triggerii migrenei: 1.Stresul 2.Schimbarea regimului de somn 3.Schimbrile meteo(vremii) 4.Lumina puternic sau licritoare 5.Buturi alcoolice 6.Schimbri hormonale Femeile i migrena

13.Dureri(senzaii) de presiune 14.Vertije 15.Dificulti de vorbire sau concentrare

. 70% din femei vor meniona asocierea (agravarea) cefaleelor n legtur cu ciclul menstrual. .60% din femei(raporteaz )vor comunica diminuarea(uurarea)cefaleelor sarcinii(poate fi neadevrat) . . 40% din femei vor suporta primul atac de migren n timpul sarcinii sau imediat dup aceea. . 70% din femei au rar migren dup menopauz. . Multe femei menioneaz agravarea( nrutirea) cefaleelor n timpul menopauzei. Definiii . Migrena menstrual(7-8%) . Migrena asociat cu menstruaia Impactul sarcinii asupra migrenei . 60-70% au rare cazuri de migren, n special n trimestrele II i III. . 4-8% din femei au simit agravarea simptomelor. . 10% din cazurile de migren ncep n timpul sarcinii. . Patternul cefaleelor revine la normal aproape imediat dup natere. [Aube M. Neurology 1999; 53(S1): S26-S28] Impactul migrenei sarcinii asupra sarcinii . Migrena nsi nu influieneaz fertilitatea . .Migrena nu interfer cu sarcina sau nu afecteaz ftul pe parcursul

[Aube M. Neurology 1999; 53(S1): S26-S28 Silberstein SD.Neurologic Clinics 1997; 15(1): 209-231]

Concluzii: .Cefaleele migrenoase pot fi provocate de diveri factori, incluznd schimbrile hormonale. .Pentru migrena menstrual utilizarea focal a medicaiei poate fi util. .Patternul cefaleei se poate schimba odat cu sarcina sau menopauza. .Multe medicamente pentru migren sunt prezente n laptle matern. .Exist multe opiuni pentru uurarea migrenei- ntreab-i medicul, care e cea mai optim pentru tine.

Hormonii sexuali i durerea de cap Exist o legtur ntre estrogeni i progesteron, hormonii sexuali feminini i migren. Migrena apare mai frecvent la femei adulte(18%), dect la brbai(6%) i totui are o prevalen egal la copii. Migrena evoluiaz mai des n a doua decad cu incidena de vrf survenit n adolescen. Migrena n legtur cu menstruaia(migr.menstr.,MM) ncepe la menarhe n 33% din femeile afectate. Migr.menstr.are loc n majoritatea cazurilor n timpul menstruaiei la multe femei cu migren i exclusiv cu menstruaie(migrena real menstrual, TMM)la unele. Migr.menstr. poate fi asociat cu unele plngeri(boli) somatice care apar nainte i persist deseori n timpul menstruaiilor, precum greaa,durerea de spate, sni dureroi i crampe i apariii asemntoare, cauzate de nivelul sczut al hormonilor sexuali. Ca urmare, migrena premenstrual poate fi asociat Sindromului premenstrual(PMS),care este diferit de simptomele fizice a perioadei premenstruale i este probabil cauzat indirect de scderea nivelului progesteronului(vezi mai jos). Migrena care apare n timpul (mai mult dect)menstruaiei, nu este de obicei asociat cu PMS n caracteristica simptomelor ei de baz, severitatea ei i daunele rezultate. Migrena se poate agrava n timpul primului trimestru al sarcinii i,dei multe femei scap de durerea de cap n timpul ultimelor dou semestre, 23% nu au schimbri n migrena lor. MM de obicei evoluiaz la graviditate, posibil cu scopul de a susine nivelul nalt de estrogen. Schimbul hormonal cu estrogeni poate exacerba migrena i contraceptivele orale (OCs)pot schimba caracterul i frecvena ei.

Prevalena migrenei scade odat cu avansarea n vrst,dar totui poate reveni sau agrava la menopauz. Schimbrile, ce apar n tabloul cefaleei cu utilizarea Ocs i n timpul menarhei, menstruaieigraviditii sau menopauzei sunt legate de schimbrile nivelului de estrogen. Acest fenomen sugeraz o relaie dintrecefaleele migrenoase i schimbrile nivelului hormonilor sexuali. Aceast discuie va acoperi partea endocrinologic a ciclului menstrual, neurofarmacologia estrogenilor i a progesteronului; definiia, epideiologiai patogeneza migrenei menstruale i apropierea de terapia pentru durerile de cap, legate de hormoni, n particular acele asociate ciclului menstrual, menopauza i utilizarea contraceptivelor orale. -----------------------------------------------------------------------------------------------------------------------------------------Fraze utile Cefaleea este un simptom simit de oameni. Ne bazm pe expunerile personale, privind frecvena, durata i durerea suportat. Problema o alctuiete lipsa unui standard de aur pentru msurarea experienei de cefalee a oamenilor, ea reflect necesitatea de a ne baza pe teste indirecte de validare, precum consultaiile primare i secundare. S-a utilizat chestionarul versiunea 1, care cuprinde 16 ntrebri privind impactul migrenei asupra funcionrii i strii de bine.(Din discursul d-lui Profesor sau a D-nei Stela ). Cefaleea la femei Nippon Rinsho.2005 Oct;63(10): 1786-90. [Headache in female] Douchi T.

O corelaie semnificant se observ ntre prevalena cefaleei(cefaleei de tip tensional i migrenei), ct i astfel de variabile ca vrsta i genul(sexul). Prevalena migrenei la femeile de vrst reproductiv e de 4-5 ori mai nalt dect la brbai. Totui, prevalena migrenei nu difer dup sex naintea pubertii. Viaa femeii include perioada de pn la pubertate, pubrtatea, perioada reproductiv(graviditatea , naterea, puerperium), perioada menopauzei i postmenopauza. Pe parcursul acestei perioade, nivelul estrogenului seric se schimb dinamic. Chiar n timpul ciclului menstrual, nivelul estradiolului seric se schimb dinamic. Aceste schimbri difer completamente(definitiv) de schimbrile nivelului seric al testosteronului la brbai. Cefaleea sau migrena pe parcursul ciclului menstrual perioadei menstruaiei. se observ mult mai frecvent pe parcursul

Totui, prevalena cefaleei imigrenei devine mai joas dup menopauz. Aceste cercetri sugeraz, c evenimentul(fenomenul )cefaleei sanguin. este n parte asociat cu scderea nivelului estradiolului n serul

Prevalena migrenei i cefaleei de tip tensional n localitile rurale i urbane din Republica Moldova.
Obiective: Scopul acestui studiu a fost de a estima prevalena cefaleelor primare (migrenei i cefaleei de tip tensional) i stabilirea frecvenei factorilor- triggeri la subiecii aduli (15-65 ani) cu acest tip de cefalei in localitile urban(mun Chiinu) i rural(Hanceti) din Republica Moldova. Acesta este primul studiu epidemiologic al migrenei i cefaleei de tip tensional din Republica Moldova, efectuat in conformitate cu Criteriile Clasificrii Internaionale a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee in anul 2004. Metode: Studiul Hnceti populaieia constat din cetenii (15-65 ani) din municipiul Chiinu i or. din Republica Moldova. Studiul asupra populaiei a fost efectuat utiliznd

metodele de intervievare fa-n-fa , u cu u. Rata de participare a fost de 73%. Toi participanii au fost evaluai asupra istoriei durerii de cap n conformitate cu criteriile Societii Internaionale a Durerii de Cap. Cei care au fost diagnosticai cu cefalee(65.5%) au fot intervievai de ctre studenii antrenai n medicin, utiliznd un chestinar detaliat focusat pe migren. Materiale i metode: Studiu randomizatface-to-face", " door-to-door a populaiei adulte din localitile urban i rural (cetenii (15-65 ani) din municipiul Chiinu i or. Hnceti) din Republica Moldova prin intermediul chestionarului structurat, elaborat de Profesorul I.Moldovanu in 2004, in conformitate cu Criteriile Clasificrii Internaionale a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee din anul 2004. Cercetatare efectuat sub conducerea profesorului I.Moldovanu in anul 2005 n coordonare cu Societatea Internaional de Cefalee(International Headache Society) cu selectarea eantionului-Chiinu-Hnceti. In studiu au fost inclui 2665 respondeni cu varsta cuprins intre 15-65 ani, rata de participare a fost de 84% din 3165 persoane contactate . Toi participanii au fost evaluai

asupra istoriei durerii de cap n conformitate cu criteriile Societii Internaionale a Cefalee. Cei care au fost diagnosticai cu cefalee- 1439(54%) au fot intervievai de ctre studenii antrenai n medicin, utiliznd un chestionar detaliat focusat pe cefalei. Chestionarea a fost efectuat de o echip de medici neurologi special pregtii( rezideni in neurologie, de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu) in perioada : mai-iunie, septembrie-octombrie 2005 de un grup de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu i rezideni in neurologie, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee(IHS). Chestionarul care a fost utilizat in acest studiu include 145 intrebri, care vizeaz urmtoarele aspecte de baz: aspecte socio-demografice, depistarea factorilordeclanatori ai migrenei i cefaleei de tip tensional, caracteristici clinice detaliate, tratamente farmacologice, date medico-economice, comorbiditatea, gradul de incapacitate(MIDAS i HIT), impactul cefaleelor i estimarea prezenei abuzului medicamentos.

Din totalul de 2665 de persoane au rspuns afirmativ la intrebare privind prezena cefaleelor- 1439, ce constituie 54% , 1226 din cei cercetai-46% n- au avut cefalee . Dup ntrebrile introductive privind vrsta, nivelul economic i educaional, statutul matrimonial i profesional, persoanele patologii cronice, diagnosticate de au fost interogate despre prezena oricror medicul-generalist i au avut vreo cefalee

important, care atrage atenia(deranjant) n perioada ultimului an. Din totalul de 2665 de persoane au rspuns afirmativ la intrebare privind prezena cefaleelor- 1439, ce constituie 54% , 1226 din cei cercetai-46% n- au avut cefalee . Dac cefaleea era declarat, li se adresau ntrebri, privind caracteristicele cefaleelor lor i relatarea unor astfel de date cum ar fi: frecvena, durata, triggerii(factorii declanatori), simptomele nsoitoare, dereglrile de somn, istoricul familial, tratamentele suportate pn acum etc. Interviul a fost executat de policlinica cefalalgic. ctre studenii- medici, pregtii pentru a lucra n

Dup interviu tipurile de cefalee a fost determinate n acord cu criteriile IHS n interviu de neurologi i de studeni. Diagnosticarea altor patologii s-a bazat pe decizia medicului generalist(de familie).

Alte cauze ale cefaleelor, cum ar fi sinusitele, hipertensiunea au fost considerate i evaluate pentru probabilitatea de a fi cauze ale cefaleelor. n 15 cazuri (1,31%) din cazuri cefaleea a fost considerat ca fiind cauzat de aceste patologii.

A fost gsit partea prevalenei migrenei i al cefaleei de tip tensional . Prevalena migrenei i cefaleei de tip tensional: a) n lotul mixt(brbai +femei). 448 femei+86 brbai= 534 ptts. cu migren-20,03% din numrul total al persoanelor chestionare- 2665; 534ptts- 37,10% din 1439 pers cu cefalee; 296 femei+193 brbai= 489 ptts. cu CTT- 18,34% din numrul total al persoanelor chestionare- 2665; 489ptts- 33,98% din 1439 pers cu cefalee.

Evaluarea relaiei dintre prevalena tipurilor de cefalee i proprietile cefaleelor pacienilor, aa ca vrsta , nivelul educaional i economic, statutul matrimonial i profesional, locul de reedin i compararea caracteristicelor clinice printre subtipurile cefaleei, a fost dobndit de Corelaia dintre caracteristicele clinice i severitatea cefaleei a fost analizat, utiliznd analiza scalei corelaiei Spearman.

Chestionarul care a fost utilizat in acest studiu include 145 intrebri, care vizeaz urmtoarele aspecte de baz: aspecte socio-demografice, depistarea factorilordeclanatori ai migrenei i cefaleei de tip tensional, caracteristici clinice detaliate, tratamente farmacologice, date medico-economice, comorbiditatea, gradul de incapacitate(MIDAS i HIT), impactul cefaleelor i estimarea prezenei abuzului medicamentos. Analiza statistic a datelor chestionarelor s-a efectuat utilizand SPSS , varianta 12. Dat fiind, c cefaleea constituie o problem major de sntate, fiind inclus de Organizaia Mondial a Sntii(OMS) in lista primelor 10 cauze de incapacitate la ambele sexe i a primelor 5 cauze de incapacitate la femei, lipsa unui studiu epidemiologic al prevalenei cefaleelor primare in Republica Moldova a impus necesitatea imperativ a efecturii acestuia. Rezultate Trsturile socio-demografice ale migrenei i CTT: vrsta, nivelul educaional i economic, statutul matrimonial i profesional, locul de trai au fost demonstrate n Tab.1.

Tab.1. Trsturile socio- demografice pacienilor cu cefalee.

Parametri demografici Vrsta(ani) 15-19 20-29 30-39 40-49 50-59 60-65 298(11,2%) 647(24,3%) 493(18,5%) 486(18,2%) 443(16,6%) 298(11,2%) socio- Toate

a tuturor persoanelor intervievate i a

persoanele Pacienii migren(n=534)

cu Pacienii CTT(n=489)

cu

intervievate(n=2665)

55 (10,3%) 124 (23,22%) 101 (18,91%) 113 (21,16%) 104(19,48%) 37(6,93)

49(10,02%) 102(20,86%) 75(15,34%) 96(19,63%) 97(19,84%) 70(14,31%)

Nivelul educaional jos mediu superior Statutul matrimonial Cstorit() Celibatar() (singur()) Divorat Vduv 121(4,5%) 124(4,7) 8 (7,0%) 28 (24,3%) 1834(68,8%) 586(22%) 118 (13,8%) 17 (9,5%) 160 (18,7%) 28 (15,7%) 1150(43,2%) 503(18,9%) 1012(38%) 226 (42,32%) 100 (18,73%) 208 (38,95%) 217(44,38%) 82 (16,77%) 190 (38,85%)

Locul de trai Localitate urban Localitate rural 1301(48,8%) 1364(51,2%)

Din ei: Nu erau incadrai in cimpul muncii- 829 respondeni- 31,1% Munc intelectual indeplineau- 1120 chestionai-42% Munceau fizic- 708 intervievai- 26,6%.

Dup nivelul educaiei: intervievai,

jos- 43,2%:

coala primar au absolvit-o 18,2% din

cei

coala profesional- 25%, mediu- 18,9% : Studii liceale -5,6%, Studii postliceale- 13,2%, superior -48,5%: Universitatea au absolvit-o 35,3% din respondeni i Studii postuniversitare- 2,6% din 2665 persoane chestionate.

Tabagismul: fumtori- 623(23,4%), iar nefumatori-2042(76,6%).

Dup starea material i condiii de trai- 15% din respondeni au menionat, c au un trai decent, 69,8%- considerau, c au condiii de trai medii i au bani doar pentru strictul necesar, iar 15,2%-c au condiii nefavorabile de trai i nu le ajung bani nici pentru strictul necesar.

2 Repartiia dup sex a persoanelor cu convenional sntoase

cefalee versus cele fr cefalee

Numrul total al persoanelor chestionare- 2665- 100%,

Din 2665: Femei- 1587- 59,55% Brbai-1078- 40,45% Rspuns la p.2: Din 2665 : cefalei); 66,16% din totalul femeilor chestionate(1587). Cu cefalee- 1439ptts-54%(din totalul de2665 intervievai: Femei- 1050- 39,4% (din2665 intervievai); 73% (din 1439 cu

Brbai- 389-14,6% (din 2665p); 27% (din 1439 cu cefalei); 36,08% din totalul de brbai chestionai(1078).

Fr cefalee-1226- 46%(din totalul de2665 intervievai): Femei - 537- 20,15% (din2665 intervievai); 43% (din 1226 fr cefalei). Brbai- 689-25,85% (din 2665p); 56,2% (din 1226 fr cefalei).

Din 1050 femei cu cefalee- 39,4% (din2665 intervievai) ( 66,16% din 1587- totalul femeilor chestionate) :

448 femei au migren-16,81% din tot. 2665p. chestionate, 42,67% din 1050- femei cu cefalee, 28,23% di totalul de 1587 femei chestionate, 31,13% din 1439-totalul ptts. cu cefalee 296 femei au cefalee de tip tensional-11,1% din tot. 2665p. chestionate, 28,19% din 1050- femei cu cefalee, 18,65% di totalul de 1587 femei chestionate, 20,57% din 1439-totalul ptts. cu cefalee

Din 389 brbai cu cefalee-14,6% (din 2665p); ( 36,08% din 1078- totalul brbailor chestionai): 86 brbai au migren-3,22% din tot.a 2665p. chestionate, 22,11% din 389 brbai cu cefalee, 7,98% din totalul de 1078 brbai chestionai, 5,98% din 1439-totalul ptts. cu cefalee; 193 brbai au cefalee de tip tensional-7,24% din tot. 2665p. chestionate,

49,61% din 389 brbai cu cefalee, 17,9% din totalul de 1078 brbai chestionai, 13,41% din 1439-totalul ptts. cu cefalee.

Tab.1. P.1Repartiia dup vrst a persoanelor cu migren i cefalee de tip tensional versus persoanele fr cefalee( convenional sntoase sau lot de control). Majoritatea o alctuiesc persoanele cu vrsta cuprins ntre 20-29 ani, att n lotul persoanelor convenional sntoase, ct i n lotul celor cu migren. Diferene statistice se observ la grupurile de vrst 40-49; 50-59; 60-65 ani.

Persoanele CTT(20-29 ani) 102p.-3,8% n total;

cu P<0,05

Persoanele sntoase(20-29 ani) 327p.-12,27% n total; 26,7% din 1226 cefalee. p. fr din P> 0,05

Persoanelecu migren(20-29 ani) 124p.-4,6% n total; 8,6%- din tot. de 1439ptts. cefalee; 23,22%- din 534 ptts. cu migren. cu din

din

2665p.chestionate

2665p.chestionate

2665p.chestionate

7,08%- din tot. de 1439ptts. cefalee; 20,86%- din 489 ptts. cu CTT cu

Persoanele sntoase(40-49 ani) 193p.-7,24% n total; 15,74% din 1226p. fr cefalee din P<0,01

Persoanelecu migren(40-49 ani) 113p.-4,24% n total; 7,8%- din tot. de 1439ptts. cefalee; cu din

2665p.chestionate

2665p.chestionate

21,16%- din 534 ptts. cu migren.

Persoanele CTT(50-59 ani) 97p.-3,6% n total;

cu P<0,01

Persoanele sntoase(50-59 ani) 175p.-6,56% n total; 14,27% din 1226p. fr cefalee din P< 0,01

Persoanelecu migren(50-59 ani) 104p.-3,9% n total; 7,23%- din tot. de 1439ptts. cefalee; 19,48%- din 534 ptts. cu migren. cu din

din

2665p.chestionate

2665p.chestionate

2665p.chestionate

6,7%- din tot. de 1439ptts. cefalee; 19,84%- din 489 ptts. cu CTT cu

Persoanele sntoase(60-65 ani) 144p.-5,4% n total; 11,75% din 1226p. fr cefalee. din P< 0,01

Persoanelecu migren(60-65 ani) 37p.-1,38% n total; 2,57%- din tot. de 1439ptts. cefalee; 6,93%din 534 cu din

2665p.chestionate

2665p.chestionate

ptts. cu migren.

Tipurile cefaleelor migrenoase i particularitile socio-demografice.

1146 femei au fost intervievate. 359(31,3%) din ei au experimentat(suportat) migrena sau CTT n decursul ultimului an. Prevalena de 1 an al migrenei a fost de 12,5%(143ptts.), cuprinznd 7,3%(84) migr.cu aur i 5,2%(59)-migr. fr aur. Prevalena migrenei a fost gsit statistic mai nalt la grupul de vrst de 35-44 ani i mai joas la grupul de peste 65 ani, n comparaie cu alte grupuri ( persoanele cu cel mai nalt nivel educaional, ci studii universitare( femeile mritate( /16,38, P<0,01).Cefaleea migrenoas s-a depistat ca fiind cu cea mai nalt prtevalen la /19,59, P<0,001), /6,04, P<0,05) i la cele, care locuiau n localitile urbane( erau n legtur

/9,5,P<0,01). Totui statutul profesional i nivelul economic nu semnificativ cu cefaleea de tip migrenos.

Cefaleea de tip tensional i particularitile socio-demografice.

Prevalena de 1 an al CTT a fost 144(12,5% )- episodic i 72(6,3%)-tipul cronic al cefaleei.

gsit de 18,8%(216 persoane), incluznd

Cea mai nalt prevalena a CTT a fost gsit la grupul de vrst de 45-64 ani( /10,34, P<0,05). Pacienii cu CTT cronic au fost gsii a fi cu mult mai n vrst dect cei cu forme episodice( Media de vrst SD pentruCTT episodic i cronica: 41,1115,57, 35,85 12,91, P<0,01). Lund n consideraie nivelul educaional, CTT cronic a fost gsit ca cea mai prevalent ( /6,83, P<0,05) la persoanele cu cel mai jos nivel educaional.

Cum se repartizeaza dup sex persoanele cu migren si CTT? P. cu Migren: CTT: Brbai-16,1% 39,5% Femei-83,9% (P<0,002) Femei-60,5% ( P<0,001) BrbaiP. cu

Raportul femei/brbai la persoanele , ce sufer de migren este de 5,16, Iar la cei cu CTT raportul femei/brbai -1,53.

n lotul persoanelor cu Migren fumeaz-14%, iar din cei cu CTT-21,1%(P<0,01) Nu fumeaz-86% (P<0.02) Sunt mai muli nefumtori n cazul respondenilor cu migren-86%, fa de 78,9% din cei cu CTT. S-a depistat prezena maladiilor endocrine la persoanele cu Migren n 9% cazuri fa de 5,1% din cei cu CTT(p<0,05) 4,1% din cei diagnosticai cu migren au menionat, c sufer de maladii nu fumeaz-78,9%

oncologice, iar din cei cu CTT doar 2%(P<0,05). n timpul atacului de cefalee nu-i pot ndeplini activitile zilnice 3,6 % din totalul pers. cu Migren i 0,6% din cei cu CTT(P<0,001). Durerea de cap este nsoit de nausee diagnosticate cu Migren i La 2,7% din respondeii, ce sufer de Cefalee de tip tensional(P<0,05). sau vom la 5,1% din persoanele

Triggerii cefaleei la persoanele cu Migren i CTT(rspuns spontan): Factorii declanatori cel mai frecvent nominalizai(rspuns spontan) de ctre respondenii cu: MIgren tensional 3.Menstruaia- 3,8% 0,5% 4.Stresul sau ncetarea stresului-34,8% ncetarea stresului-26,9% 6.Obosela-23,9% 36,8% 21.Altceva-4,3% 7,8% 1.foamea-3,4% (P>0,05) 1.foamea-1,6% (P<0,05) 21.Altceva(P<0,001) 6.Obosela(P<0,05) 4.Stresul sau (P<0,001) 3.MenstruaiaCefalee de tip

2. alcoolul-1,9% 5.Somn insufficient-1,7% insufficient-1,1% 7.Incordarea psihic-2,6% psihic-4,1% 11. Lumini intense sau soare-5,5% sau soare-3,9% 17.Schimbri meteo-14,1% meteo-14,1%

(P>0,05) (P>0,05)

2. alcoolul-2,3% 5.Somn

(P>0,05)

7.Incordarea

(P>0,05)

11. Lumini intense

(P>0,05)

17.Schimbri

----------------------------------------------------------------------------------------------------------------------------------------Triggerii migrenei i cefaleei de tip tensional dup interviu: Persoanele cu migren menioneaz foamea n 28,7% cazuri, iar cei cu CTT-n20,3% (P<0,01) Alcoolul ca factor declanator al migrenei a fost indicat de 27,3% din intervievai i doar de 13,1% din cei cu Cefalee de tip tensional (P<0,001) Menstruaia ca factor-trigger a fost menionat de 23% de migrenoi i de 9% din persoane cu CTT(P<0,001) Stresul sau ncetarea stresului a fost nominalizat ca trigger de 81,5% din

respondenii cu migren i de 70,8% din cei cu CTT!!! Oboseala este prezent ca factor-trigger la 74,9% din migrenoi i la 80,4% din cei cu cefalee de tip tensional(P<0,05)!!! Mirosurile puternice cauzeaz cefaleea la 23% din intervievaii cu migren i la 7,4% din cei cu CTT(P<0,001) Luminile intense sau soarele provoac migrena la 44,6%din suferinzi i la 22,9% de intervievai cu Cefalee de tip tensional(P<0,001) Sunetele puternice sunt triggerii Migrenei n 38,4% din cazuri, iar la cei cu CTT- la 13,1% din suferinzi(P<0,001) Somnul profund sau prea mult somn este nominalizat ca trigger n 23,2% n cazul respondenilor cu migren i n 13,1% cazuri de CTT(P<0,001)

Schimbrile meteo migrenoi i la

au fost menionate

ca factori- declanatori la 64,8% din

57,3% din persoanele cu Cefalee de tip tensional(P<0, 05).

Comportamentul n timpul durerii de cap(rspuns spontan:

3.Continu activitile zilnice- 4% din respondenii, ce sufer de migren i 9,3% din cei cu CTT(P<0,001). 5.Iau medicamente-54,3% din migrenoi i 41,7% din intervievaii cu Cefalee de tip tensional(P<0,001). Comportamentul n timpul durerii de cap(rspuns dup chestionare): Merg la aer- 10,3% din persoanele cu migren i 30,5% din respondenii cu

CTT(P<0,001).

Privesc televizorul-7,9% din respodenii, ce sufer de migren i 27,2% din cei cu CTT(P<0,001)

Continu activitile obinuite-28,8% din intervievaii-migrenoi i 61,85% din respondenii, ce sufer de cefalee de tip tensional(P<0,001).

Fac masaj la cap 17,4% din cei cu migren i 23,1% din cei cu CTT(P<0,05).

Iau medicamente- 77,5% din respondenii ce sufer de migren i 57,1% din persoanele cu CTT(P<0,001).

Prefer repaosul la pat 77,5% din migrenoi i 53,8% din cei cu CTT(P<0,001).

Aleg o odaie ntunecoas-38,4 din cei, ce sufer de Migren i 8,2% din respondenii cu Cefalee de tip tensional(P<0,001). P.39. Antecedente eredo-colaterale

Cineva din rudele apropiate sufer ( a suferit) de dureri de cap similare? n cazul respondenilor cu migren-69,9% au menionat prezena rudelor cu dureri similare, iar din cei cu cefalee de tip tensional -58,5% (P<0,001). 3. 52,8% din suferinzii de migren i 46,1%din cei cu CTT au numit mama, care a avut sau are cefalei similare(P>0,05). 5. sora sau fratele au fost menionai n cazul a 9,8% din respondenii cu migren i de 7,4% din cei cu CTT(P>0,05). 12. feciorul sa fiica au fost nominalizai n cazul a 14,3% din migrenoi i de 16% din cei, ce sufer de CTT(P>0,05). 2,2% din migrenoi i 11,5% din cei cu CTT- au indicat alte persoane din anturaj(P<0,001).

Dup chestionare 62,2% din suferinzii de Migren au lucru(P<0,01).

numit mama, ca avnd

dureri similare de cap i 50,7% din respondenii cu CTT au menionat acelai

Soul a fost numit ca suferind de cefalei de acelai tip de 13,9% din migrenoi i de 20,3% din cei cu cefalee de tip tensional(P<0,05). Altcineva a fost nominalizat de 3,2% din cei cu Migren i de 10,1% din cei cu

CTT(P<0,001).

P.40 Cefaleea i somnul diurn. Se ntmpl ca n timpul durerii de cap ziua s reuii s adormii (cu sau fr medicamente)? N-au reuit s adoarm ziua, n timpul cefaleei respondenii cu migren n 36% cazuri, iar cei cu CTT n28,2% cazuri(P<0,01). Durerea poate s dispar dup trezire?

Durerea de cap persist

dup trezirea din somnul diurn la 14,9% din cei cu

migren i la doar 5,15 din respondenii cu cefalee de tip tensional(P<001), pe cnd la 85,1% din migrenoi i 94,9% din respondenii cu CTT cefaleea dispare. Comorbiditatea algic n cursul ultimului an: Durerile abdominale au nsoit cefaleea la 12,7% din respondenii cu migren i la 8,8% din cei cu CTT(P<0,05). Durerea n regiunea lombar(n ale) a fost nominalizat de 34,6% din suferinzii de migren i de 28% din cei cu cefalee de tip tensional8P<0,05). Anxietatea generalizat Prezena anxietii la respondenii cu Migren a fost indicat ca frecvent n 27,3% cazuri , iar la respondenii cu Cefalee de tip tensional-n20,4% cazuri, foarte des, practic permanent, respectiv n 4,3% i 1,8% n ambele gupuri(P<0,05).

Au menionat n calitate de fenomene frecvente(sau foarte frecvente) adiionale durerii de cap greaa i discomfortul abdominal persoanele cu migren n 14,2% de cazuri, iar cei cu CTT- n 3,7% cazuri(P<0,001).

Prevalence and Clinical Characteristics of Headache in Medical students Oman Dirk Deleu, MD et al. (Headache2001;41:798-804) Au fost completate chestionare: 151-brbai(37,5%) 252 femei(62,5%).

in

Prevalena pe via i pe durata ultimului an al cefaleei a fost -98,3% i 96,8% respectiv. Un istoric pozitiv familial de cefalee a fost gsit la 57,6% studeni. Rata de prevalen a migrenei i a CTT a fost gsit asemntoare(12,2%) cu o diferen a distribuiei printre sexe:6,6% din brbai i 15,5% din femei- sufereau de migren, n timp ce 13,9% din brbai i 11,1% din femei aveau cefalee de tip tensional. Doar 23,3% din studeni au cerut asistena medical pe parcursul episoadelor de cefalee i 80,3% au primit medicamente: 24,6% au primit medicamente prescrise, iar 72,4%- medicamente neprescrise8automedicaia) i doar 2,5% au apelat la remedii tradiionale.

Probabil utilizarea analgezicelori abuzul lor coexist cu cefaleea la studenii Universitii Sultan Oaboos , ntruct majoritatea lor se bizuiepe medicaia neprescris.

Cefalalgia, 2003,23,381-388. Epidemilogical and clinical characteristics of migraine and tension type headache in 1146 females in Kayseri, Turkey. E Koseoglu , M Nacar et al. Au fost investigate unele caracteristici epidemiologice i clinice ale migrenei i cefaleei de tip tensional i a subtipurilor lor la populaia feminin a Turciei(1146 femei adulte). S-a cercetat relaia dintre severitatea cefaleei i caracteeristicele clinice. Prevalena migrenei a fost apreciat statistic mai nalt la grupul de vrsta de 35-44 ani i la cele, ce aveau studii superioare(P<0,001), cstorite(P<0,01) i care locuiesc la ora(n localitile urbane)(P<0,01). Cefaleea de tip tensional a fost gsit mai nalt la grupul de vrst(persoanele) de 4564 ani(P<0,05). Pacienii cu CTT cronic au fost gsii mai n vrst dect cei cu forme episodice(P<0,01) i mai frecveent la persoanele cu nivel mai jos de educaie(P<0,05). Prezena i impactul activitilor zilnice din cauza severitii cefaleei a fost gsit ca fiind cauzat de agravare n rezultatul activitilor fizice(P=0,001) la CTT, fr caracteristici clinice la cefaleea migrenoas i lund n consideraie c toi pacienii cu cefalee de natur pulsatil(P<0,05), ce se agraveaz la activiti fizice (P=0,001), greaa(P<0,01), voma(P<0,05) i fonofobie(P<0,05). Introducere: Sunt numeroase studii privind cefaleea, dar relativ puine studii efectuate n rile Asiatice. Este raportat c factorii de risc rasiali, culturali i cei , ce in de mediu joac un rol important n cercetrile epidemiologice. Acest studiu a fost petrecut ntr-o ar in Asia, ai crei populaie aparine rasei albe. Studii, ce in n special de femei sunt de asemenea relativ puine. ntr-un studiu epidemiologic al cefaleei n Turcia , ce a fost tiprit ca un abstract, a fost efectuat pe un lot de 2007 persoane, prevalena de 1 an al migrenei i a CTT a fost declarat ca fiind de 16,4% i 31,7% respectiv(2), dar caracteristicele clinice ale cefaleelor nu au fost evaluate.

Acest studiu este primul studiu bazat pe populaie i detaliat al cefaleelor i a caracteristicelor clinice pe baza criteriilor Societ .Interna. a Cefaleelor la populaia de femei din Turcia. S-au cercetat prevalena de 1 an, datele socio- demografice o caracteristicele migrenei, ale cefaleei de tip tensional. Mareriale i metode Acest studiu a fost executat pn la final n provincia Kaisery pe populaia feminin mai mare de 14 ani , n numr de 375441. Cea mai mic mostr a fost calculat de 1100 persoane(95% interval confedenial, SD:1,6%) s-a estimat prevalena migrenei la 8%. 1300 de femei cu vrsta cuprins ntre 15-87 ani au fost selectate randomizat dup cluster i metoda mostrei sistematice n regiune, utiliznd cartela casnic din centrele primare de sntate, n cere figureaz datele despre toi locuitorii din regiune; 1146 din aceste femei au putut fi contactate . Simptomele au fost evaluate prin interviul face to face structurat, bazat pe criteriile SIC(Societii internaionale a Cefaleelor)- IHS. naintea fiecrui interviu, obiectivele stdiului au fost descrise i a fost obinut acordul(consimmntul). Toate femeile i-au declarat acordul de a fi implicate n studiu. Studiul a fost acceptat de Comitetul de Etic al Universitii Erciyes. Dup ntrebrile introductive privind vrsta, nivelul economic i educaional, statutul matrimonial i profesional, persoanele au fost interogate despre prezena oricror patologii cronice, diagnosticate de medicul-generalist i au avut vreo cefalee important, care atrage atenia(deranjant) n perioada ultimului an. Dac cefaleea era declarat, li se adresau ntrebri, privind caracteristicele cefaleelor lor i relatarea unor astfel de date cum ar fi: frecvena, durata, triggerii(factorii declanatori), simptomele nsoitoare, dereglrile de somn, istoricul familial, tratamentele suportate pn acum etc. Interviul a fost executat de policlinica cefalalgic. ctre studenii- medici, pregtii pentru a lucra n

Dup interviu tipurile de cefalee a fost determinate n acord cu criteriile IHS n interviu de neurologi i de studeni. Diagnosticarea altor patologii s-a bazat pe decizia medicului generalist(de familie). Alte cauze ale cefaleelor, cum ar fi sinusitele, hipertensiunea au fost considerate i evaluate pentru probabilitatea de a fi cauze ale cefaleelor. n 15 cazuri (1,31%) din cazuri cefaleea a fost considerat ca fiind cauzat de aceste patologii.

A fost gsit partea prevalenei migrenei cu aur(MWA) i a migrenei fr aur(MWOA), al cefaleei de tip tensional episodic i cronic. Evaluarea relaiei dintre prevalena tipurilor de cefalee i proprietile cefaleelor pacienilor, aa ca vrsta , nivelul educaional i economic, statutul matrimonial i profesional, locul de reedin i compararea caracteristicelor clinice printre subtipurile cefaleei, a fost dobndit de Corelaia dintre caracteristicele clinice i severitatea cefaleei a fost analizat, utiliznd analiza scalei corelaiei Spearman. Rezultate Trsturile socio-demografice ale migrenei i CTT: vrsta, nivelul educaional i economic, statutul matrimonial i profesional, locul de trai au fost demonstrate n Tab.1. Tab.1. Trsturile socio- demografice pacienilor cu cefalee.
Parametri demografici Vrsta(ani) 15-24 25-34 35-44 45-64 > 65 Nivelul educaional <5 ani 5 ani 8 ani 11 ani >11 ani Statutul matrimonial Cstorit Celibatar(singur) Divorat Statutul profesional 853 178 115 118 (13,8%) 17 (9,5%) 8 (7,0%) 160 (18,7%) 28 (15,7%) 28 (24,3%) 312 526 99 126 83 33 (10,5%) 72 (13,7%) 6 (6,0%) 11 (8,7%) 21 (25,8%) 57 (18,2%) 96 (18,2%) 19 (19,2%) 22 (17,4%) 22 (26,5%) 289 311 253 228 65 23 (8,0%) 48 (15,4%) 41 (16,2%) 29 (12,7%) 2 (3,0%) 46 (15,9%) 55 (17,7%) 47 (18,5%) 59 (29,9%) 9 (13,8%) socio- Toate

a tuturor persoanelor intervievate i a

persoanele Pacienii migren(n=143)

cu Pacienii CTT(n=216)

cu

intervievate(n=1146)

Gospodin casnic

975

116(11,9%)

180(18,4%)

Angajat Locul de trai Localitate urban Localitate rural

171

27(15,8%)

36(21,0%)

636 510

97 (15,2%) 46 (9,0%)

123(19,3%) 93 (18,2%)

Tipurile cefaleelor migrenoase i particularitile socio-demografice. 1146 femei au fost intervievate. 359(31,3%) din ei au experimentat(suportat) migrena sau CTT n decursul ultimului an. Prevalena de 1 an al migrenei a fost de 12,5%(143ptts.), cuprinznd 7,3%(84) migr.cu aur i 5,2%(59)-migr. fr aur. Prevalena migrenei a fost gsit statistic mai nalt la grupul de vrst de 35-44 ani i mai joas la grupul de peste 65 ani, n comparaie cu alte grupuri ( persoanele cu cel mai nalt nivel educaional, ci studii universitare( femeile mritate( /16,38, P<0,01).Cefaleea migrenoas s-a depistat ca fiind cu cea mai nalt prtevalen la /19,59, P<0,001), /6,04, P<0,05) i la cele, care locuiau n localitile urbane( erau n legtur

/9,5,P<0,01). Totui statutul profesional i nivelul economic nu semnificativ cu cefaleea de tip migrenos.

Cefaleea de tip tenional i particularitile socio-demografice.

Prevalena de 1 an al CTT a fost 144(12,5% )- episodic i 72(6,3%)-tipul cronic al cefaleei.

gsit de 18,8%(216 persoane), incluznd

Cea mai nalt prevalena a CTT a fost gsit la grupul de vrst de 45-64 ani( /10,34, P<0,05). Pacienii cu CTT cronic au fost gsii a fi cu mult mai n vrst dect cei cu forme episodice( Media de vrst SD pentruCTT episodic i cronica: 41,1115,57, 35,85 12,91, P<0,01). Lund n consideraie nivelul educaional, CTT cronic a fost gsit ca cea mai prevalent ( /6,83, P<0,05) la persoanele cu cel mai jos nivel educaional.

Frecvena atacurilor de cefalee. Aproximativ 73,4% din pacienii cu migren au 1-4 atacuri pe lun, pe cnd restul trec prin> 4 atacuri pe lun. 55 pacieni migrenoi(38,5% din toi pacienii cu migren; 21- cu (MWA)migren cu aur, 14- (MWOA) migren fr aur au cel puin 180 atacuri pe an. Lund n consideraie, c la CTT, 31,9% au 1-3 atacuri de cefalee pe lun i 68,1% din pacieni sufer de cefalee minim 1 dat pe sptmn; 33,3% din pacieni au cel puin 180 atacuri de cefalee de tip tensional pe an.

Durata cefaleei. n acord cu criteriile Societii Internaionale de Cefalee(IHS), durata acceptabil a atacului de migren la pacientul netratat e de 4-72 ore. 22 pacieni (15,4%)cu migren au avut durata atacurilor < 4ore. Dar toi aceti pacieni au utilizat tratamentul medicamentos pentru atacurile lor de cefalee. Acest studiu arat(demostreaz, c cea mai rspndit(comun durat al atacurilor de migren(71,3%) a fost ntre 4 i 24 ore. n CTT atacurile s-au sfrit n cadrul(dup)mai multor ore(51,9%), au continuat pe parcursul zilei(22,2%), au durat 1-3 zile(14,8%) i 3-7 zile la (11%)din pacieni. CTT episodic difer de tipul cronic prin aceea, c atacurile de obicei au o durat mai scurt, 15 min.-cteva ore( 10,52, P<0,05).

Caracterul cefaleei. Pulsaia a fost observat la 88,8% din migrenoi pe cnd la 62,0% din pacienii cu CTT aveau senzaie de presiune, ncordare(Tab.2); 53,1% din pacienii cu migren au avut cefalee unilateral. Cefaleea bilateral a fost raportat n 72,7% din pacienii cu CTT. La 82,5% din pacienii cu migren i 43,5% din pacienii cu CTT, cefaleea a fost agravat de activiti fizice de rutin. Caracteristicele tipurilor migrenei cu aur i fr aur au fost demonstrate n Tab.2 Compararea acestor caracteristici cu gsit mai frecvent n migrena cu aur( Caracteristicele CTT cronic i episodic au fost prezentate n Tab.3. N-au fost diferene statistice( test) ntre cele 2 tipuri de cefalei tensionale. test a demonstrat caracterul pulsatil, care a fost

Simptome nsoitoare.(concomitente, asociate).

Fonofobia(85,3%) a fost cel mai frecvent simptom al migrenei, nsoit de grea(80,4%) i fotofobie(77,6%). Voma a fost observat la 44,8% din pacienii cu migren, n( MWA)- migrena cu aur , cea mai comun aur au fost manifestrile vizuale, incluznd scintilaia sau distorsia (modificarea ) imaginii, hemianopsia i ntunecarea vederii(81,8%), urmat (nsoit) de tinitus/vertije(67,1%), simptome senzoriale(34,3%) i afazia(15,4%). n cazurile de CTT, fonofobia a fost de asemenea cel mai des simptom nsoitor. Greaa a fost observat la 40,7%, iar fotofobia la 14,4% din pacieni. Simptomele nsoitoare ale migrenei cu i fr aur au fost artate(prezentate, demonstrate) n Tab.4, iar cele de cefalee de tip tensional episodic i cronic n Tab. 5 Cu respectarea acestor constatri, n-a fost difereniat statistica ntre migrena cu i fr aur.

Totui, cnd comparaia similar a fost fcut ntre subtipurile cefaleei de tip tensional, simptomele de grea ( de tip tensional. ( au fost gsite ca cele mai frecvente n cefaleea cronic

Tab.3 Caracteristicele cefaleei de tip tensional cronice i episodice

Bilate Tipurile CTT ralitatea% Natura de gravarea presiune, efort fizic strangulare%

A la mpactul asupra activitii zilnice 33,3

CTT cronic

73,6

34,7

45,8

CTT episodic

70,1

39,6

45,1

38,2

Tab.4 Simptomele nsoitoare ale migrenei cu i fr aur.

Tipurile migrenei

Greaa(%)

Voma(%)

F Fot onofobia(%) ofobia(%)

Migrena aur(MWA) Migrena aur(%)

cu 81,0

47,6

89,2

82,1

fr 83,1

40,7

79,6

71,2

Factorii trigger (declanatori) Cei mai frecveni factori declanatori ai atacurilor de cefalee au fost stresul(la migren81,8%; la cefaleea de tip tensional-83,3%), privarea de somn(la migren-52,4%; la cefaleea de tip tensional-53,2%), graba sau foamea(la migren-37,1%; la cefaleea de tip tensional-39,4%), factorii hormonali ca menstruaia(la migren-35,6%; la cefaleea de tip tensional-24,5%), sarcina(la migren-16,1%; la cefaleea de tip tensional-6,0%. Diverse alimente nu joac vre-un rol semnificativ ca factor declanator la pacienii cu migren(cacavalul-0%, ciocolata-1,4%) . 32,2% din persoane cu migren cu aur i 42,4% din cei cu migren fr aur au fost raportate ca cefalei provocate de menstruaie. La compararea acestor date nu s-au gsit diferene statistice. 5 pacieni(3,5- migrenoi: 3- cu migr. cu aur, 2- cu migr.fr aur) au fost raportai cu cefalei de tip migrenos relatate doar la menstruaie, iat de ce ei sunt considerai pacieni cu migrena menstrual pur. Impactul asupra activitilor zilnice. Activitile zilnice de rutin sunt afectate la 77,6% din pacienii cu migren i la 37,5% din pacienii cu CTT, din cauza severitii cefaleei. Cu respectarea acestui factor o diferen nesemnificativ a fost gsit ntre migrena cu i fr aur sau ntre cefaleea de tip tensional episodic i cronic. La pacienii cu CTT , comparnd prezena impactului asupra sctivitilor zilnice cu caracteristicele cefaleei i simptomele nsoitoare, a fost gsit legtura(relativ)intre impactul asupra activitilor i agravarea la efort fizic(activiti fizice)(Spearman p: 0,27, P= 0,001). Cnd o comparaie asemntoare afost efectuat la pacienii cu cefalee de tip migrenos nu a fost gsit vre-o relaie. n cazul altor pacieni cu cefalee, caracterul pulsatil(P>0,05), agravarea la efort fizic(activiti fizice) (P<0,001), simptomele nsoitoare de grea(P<0,01), vom(P<0,05), fotofobia(P<0,05), au fost gsite pentru a fi relatat impactul cefaleei asupra activitilor zilnice n analiza gradului de corelaie a lui Spearman.

Tab.5 Simptomele nsoitoare ale cefaleei de tip tensional cronice i episodice. F Fot onofobia(%) ofobia(%)

Tipurile CTT

Greaa(%)

Voma(%)

CTT cronic

52,8

13,0

61,1

19,4

CTT episodic

34,7

10,0

45,8

12,5

Somnul i cefaleea. n studiul nostru lipsa somnului(privarea de somn)a fost raportat la 23% de migrenoi i la 20,8% de pacieni cu CTT. Relaiile pacient- medic 75,5% din pacienii cu migren i 56,7% din cei cu cefalee de tip tensional au fost consultai n privina durerii lor de cap(cefaleei lor). 51% din migrenoi tiu despre migrena lor. Msuri de tratament Partea utilizrii medicamentelor la pacienii migrenoi a fost gsit a fi-90,9%, n timp, ce la pacienii cu cefalee de tip tensional-63,4%. O alt msur important este aflarea n singurtate ntr-o odaie i somnul (la migren86,0%; la cefaleea de tip tensional-66,7%), masajul (la migren-38,5%; la cefaleea de tip tensional-31,0%), compresele reci sau calde (la migren-10,5%; la cefaleea de tip tensional-6,0%). Istoricul familial 43,4% din migrenoi aveau un istoric familial similarcefaleelor(48,8% migr. cu aur;35,6% migr. fr aur) , n timp, ce istoricul pozitiv familial a fost raportat la 32,9% din cei cu CTT. Reieind din(respectnd) acestea nu a fost gsit o diferen semnificativ ntre tipurile cefalei. Discuii Acesta este studiul bazat pe femeile cu cefalee din Turcia. Noi am ncercat s evalum caracteristicele socio-dmografice i clinice ale cefaleelor de tip tenional i cele de tip

migrenos. n cele, ce urmeaz noi am clasificat cefaleele de tip tenional i cele de tip migrenos n episodice i cronice, iar la migren- cu aur i fr aur. Caracteristicele clinice ale simptomelor nsoitoare au fost evaluate la toate subtipurile cefaleelor i comparate ntre ele . Atitudinea pacienilor fa de cefalee a fost investigat.

Un sondaj bazat pe populaie: Prevalena migrenei n Croaia

Obiective: Scopul acestui studiu a fost de a estima prevalena migrenei printre adulii din Croaia. Acesta este primul studiu epidemiologic asupra migrenei din Croaia n care a fost aplicat criteriul operaional de diagnosticare al Societii Internaionale a Durerilor de cap. Metode: Studiul populaiei a constat din toi cetenii (15-65 ani) din Bakar, o regiune a Coastei i a Gorski Kotar, din Croaia. Studiul asupra populaiei a fost efectuat utiliznd metodele de intervievare fa-n-fa , u cu u. Rata de participare a fost de 73%. Toi participanii au fost evaluai asupra istoriei durerii de cap n conformitate cu criteriile Societii Internaionale a Durerii de Cap. Cei care au fost diagnosticai cu cefalee(65.5%) au fot intervievai de ctre studenii antrenai n medicin, utiliznd un chestinar detaliat focusat pe migren. Rezultate: Au fost diagnosticai 720 de migrenoi, cu migren pe via. Prevalena pe durata vieii a migrenei era 22.9%(95% intervalul de ncredere, de la 20.9 la 25.1) la femei i 14.8%(95% interval de ncredere ,de la 13.1 la 16.8) la brbai, i 19%(95%, 17.6-20.5) la ambele sexe. Cea mai mare prevalena pe duarata vieii a fost depistat la femeile cu vrsta 40-49 ani(38.1%). Printre cei 636 de migrenoi activi, 399(62.7%) erau femei i 237(37.3%) brbai; 55.8% aveau migren cu aur i 6.9% aveau ambele tipuri(cu aur i fr). Prevalena migrenei, a migrenei cu aur i a migrenei cu aura i fr, pe durata unui an, la femei era de 18%, 11.3%,8.6% i 3.2%, respectiv. La brbai, prevalena migrenei, a migrenei cu aur i a migrenei cu aura i fr, pe durata unui an, era 12.3%, 7.3%,3% i 0.7%, respectiv. Concluzii: Prevalena migrenei n cadrul populaiei din aceste regiuni a Croaiei a demonstrat rate aproximativ similare cu cele raportate la rile nvecinate , precum Italia i Frana. Studiile viitoare trebuie s fie proiectate pentru a estima ratele prevalenei migrenei n toat populaia Croaiei. Cuvinte cheie: migren,. Epidemiologie, prevalen, interviufa-n-fa, u cu u Abrevieri: MFA migren fr aur, MCA migren cu aur, MCAFA migren cu aur i fr aur,

Migrena este una din cele mai des ntlnite tipuri de cefalee n parctica general i impactul general socio-economic a acestei maldii asupra comunitii este considerabil. (1-3) un numr mare de studii n baza comunitii asupra prevalenei migrenei au fost publicate. O metaanaliy recent efectuat de Stewart et al6 a sugerat c variaiile mari n ratele prevalenei printre studiile luate n consideraie sunt explicate de diferenele mari n definirea cazurilor i profilurile sociodemografice ale subiecilor selctai pentru studiu. Introducerea criteriiilor pentru migren a Societii Internaionale a Cefaleelor(SIC) a fost un pas major pentru modernizarea standardizrii diagnozelor cefaleelor. Recent, cteva studii sociale asupra prevalenei au utilizat criteriile SIC pentru migren. Majoritate lor au fost efectuate n baza sondajelor prin telefon sau scrisori pentru a diagnosticarea chestionailor cu cefalee din cadrul cantitii de populaie selecionate pentru studiu. ; studiile epidemiologice cu interviuri fa-n-fa sau u cu u sunt destul de rare, deoarece ele implic costuri economice foarte mari. Noi am efectuat un studiu epidemiologicfa-n-fa, u cu u asupra migrenei i subtipurilor acesteia , utiliznd criteriul de diagnosticare a SIC, asupra populaiei Croaiei. Scopul acestui studiu a fost de a determina prevalena migrenei i a subtipurilor ei printr-un studiu social n cadrul adulilor din Croaia, pentru a analiza posibilele variaii de sex i vrst i de a compara aceste descoperiri cu cele obinute n alte ri. Materiale i metode Studiul a fost petrecut n Bakar, regiune a Coastei i Gorski Kotar, Croaia, care este situat de-a lungul coastei de est a prii de nord a mrii Adriatice. Studiul populaiei era constituit din toi locuitorii Bakar-ului cu vrsta 15- 65 ani pe 31 decembrie , 1998(5137 rezideni). Pe parcursul anului 1999, un total de 3794 de indivizi(73.3%) din toi rezidenii de 15-65 ani, au participat la acest studiu(fig. 1). Nu a exista o diferen semificativ ntre participani, n priviina sexului sau vrstei. totui, participanii au fost considerai reprezentativi pentru ntreaga populaiei selectat.Dup aprobarea din partea Consiliului Municipal din Bakar, adresele i nr de telefon a tuturor potenialilor participani pentru interogare au fost obinute din centrul local de statistic. Rezidenii au fost contactai prin telefon sau personal i cei care acceptau s participe, erau intervievai la domiciliu. A fost identificat un numr total de 1379 (26.7%)de persoane care au refuzat s participe(fig.1). principalele motive de a nu participa erau neprecizarea sau eroarea numerelor de telefon sau a adreselor(901 rezideni, 65.3%) i refuzul de a participa la studiu(479 rezideni, 34.7%). Fiecarui participant i-a fost efectuat un interviu fa-n-fa, u cu u, de ctre doi neurologi seniori(K:W i D.S-G) ai Centrului Clinic de Neurologie a Universitii din Rjieka,

Croaia , specialiti n diagnosticarea i tratamentul cefaleii, cu scopul de a obine ct mai multe date posibile asupra istoriei sociodemografice, fiziologice, medicale i detaliate a cefaleii. Toi participanii au semnat un acord general nainte de a ncepe studiul. Chestionarul a fost petrecut pentru a evalua ntreaga populaie asupra prezenei migrenei n baza criteriilor SIC i era structurat n doua seturi de ntrebri diferite. Primul set prevedea datele socidemografice, fiziologice, medicale i a istorieie cefaleii. n baza acestor ntrebri ,respondenii cu cefalei au fost divizai n cei care au avut o cefalee( cu excepia) sau sau o cefalee acut n ultimile 12 luni , i durerea era mai sever de 5 puncte pe scara de 10 puncte, i cei care au nregistrat cel puin o cefalee n ultimul an, dar durerea era apreciat cu nu mai mult de 4 puncte pe scara zecimal i au experimentat unul din zece simptome ale aurei vizuale. Al doilea set de ntrebri a fost aplicat numai n cazul respondenilor pozitivi i coninea un chestionar mai detaliat care se focusa pe simptomele migrenei cu aur aa cum erau specificate n criteriile SIC . Interviul a fost petrecut i chestionarele au fost completate de ctre 12 studeni medicali dup o perioad necesar de training condus de investigatorii specilaizai n migren, atunci cnd afost obinut aprobarea unui supervizor adecvat n echipa intervievatorilor.La sfritul periodei de training , validarea procedurii de scanare se petrecea cu intervievatorii incontieni de diagnoza clinic a 200 de pacieni care erau urmarii profilactic de ctre Clinica Neurologic a Uniersitii din Rjieka.Acordul Inter i intraobservatorilor n cadrul reelei a fost 0.85(rangul , 0.65 la 0.92) i 0.84(0.68 la 0.88), repectiv. Sensibilitatea procedurii de descoperirea cazului a fost 0.92(rangul, 0.58 la 0.99). Diagnoza final a migrenei, migrenei cu aur(MCA) sau a migrenei fr aur (MFA) a fost efectuat de neurologii seniori (K.W., D.S-G.,A.J., M-B.). 39 de respondeni pozitivi (0.16%) au fost atribuii iniial grupei de migrenoi dar respondenii au fost reclasificai ca nemigrenoi dup o revedere necesar efectuat de neurologii seniori; totui aceti subieci nu au fost luai n consideraie n studiul prevalenei migrenei i subtipurilor acesteia. Prevalena pe via a migrenei a fost estimat n baza celor care au avut vreodat migren conform criteriilor SIC- cel pui dou tipuri diferite de atacuri de MCA sau cel puin cinci atacuri de MFA. Prevalena migrenei pe durata unu an includea subiecii care au avut cel puin un atac de migren nultimul an(subiecii activi). Datele prevalenei pentru MCA i MFA , i migren att cu ct i frr aur (MCFA) sunr prezentate numai pentru subiecii activi, deaoarece ei sunt mai puin probabili de a fi expui nclinaiei de rechemare. Urmtoarea informaie au fost colectat pentru subiecii cu MCA i MFA pe via: sex, vrst, frecvena i durata atacurilor , caracteristicile clinice a migrenei (locaie, caracter i intensitatea durerii) i fenomele asociative (grea, vom). Analiza statistic a fost petrecut utiliznd Pachetul Statistic pentru tiine Sociale(PSS), versiunea 10.0. Noi am utilizat testul X2(x la ptrat) i testul Student t era asemntor, pentru a determina dac diferena dintre dou sau mai multe frecvene era semnificativ. 95% a

intervalului de confiden au fost calculate folosind o aproximaie binominal a distribuiei Poisson dup metoda sugerat(propus) de Schoenberg. Datele demografice au fost obinute din Centrul Statistic din Bakar, regiune a Coastei i a Gorski Kotar, Croaia.

Rezultate: din cei 3794 de participani , 2475 (65.2%) au fost indentificai ca fiind responendi cu cefalee i 1319 far cefalee(fig.1). un total de 720 de pacieni cu migren pe via a fost identificat (451 femei i 269 brbai). Printre 636 de migrenoi n faza activ, 399(62.7%) au fost femei i 237 brbai(37.3%); 55.8% aveau MFA; #%:% aveau MCA i 6.9% aveau MCAFA. Trei pacieni din grupa pacienilor n faza acut nu au putut fi clasificai cu certitudine n una din aceste 3 grupe, astfel nct ei au fost atribuii grupei MCAFA. Prevelena pe via- Prevalena pe via a migrenei era 22.9% (95%interval de confinden, 20.9 la 25.1%) pentru femei, 14.8% la brbai (95% intervalul de confiden, 13.1 la 16.8%) i 19%(95% IC, 17.6 la 20.5) pentru amble sexe(tabel1). Printre femei, cea mai nalt prevalen specific vrstei a fost n intervalul de vrst 40-49 ani i 60-65 ani(38.1% i 37.5%, repectiv). Printre brbai,topul prevalenei pe via a fost n grupele de 15-19 i 40-49 (29.5%i 22.7%, respectiv). Prevalena pe 1 an- Prevalena pe parcusrsul unui an a fost de 20.2%(95% IC, 18.9la 21.5) la femei, 13%(95%IC, 12.1 la 13.8) la brbai i 16.7%(95%IC, 15.6 la 17.7) la ambele sexe considerate nmpreun(tabel 2).Distribuirea prevalenei specifice vrstei n toat populaia, a dovedit un patern bimodal cu vrful n grupul de vrste 15-19 i 40-49. Prevalena pe parcursul unui an a MFA era de 11.3%(95% IC,9.8 la 13) pentru femei, 7.3% la barbai i 9.2% la ambele sexe. Prevalena pe durata unui an a MCA era 8.6% la femei, 3% la brbai i 5.9& la ambele sexe. Prevalena pe durata unui an a MCAFA era de 2.2% la femei, 0.7% la brbai i 5.9% la ambele sexe. Ratele prevalenei specifice vrstei sau sexului a MCA i MFA sunt artate n figura 2. Caracteristicile clinice a migrenei cu aur i frr aur pe via- Caracteristicile clinice a MCA i MFA la migrenoii pe via sunt artate n tabelul 3. pacieii afectai de MCA au prezentat diferene semnificante cnd au fost comparai cu pacienii cu MFA n priviina frecvenei i severitii atacurilor, frecvena durerii deranjante, i prezena simptomelor generale asociai. Ratele de la femeie la brbat erau mai nalte la pacienii cu MCA (2.1:1.5, P=.03). Comentarii: Acesta a fost primul studiu epidemiologic al migrenei i subtipurilor acesteia din Croaia, efectuat n baza criteriilor operaionale al SIC. Exist cteva aspecte ale procedurii noastre metodologice care trebuie luate n consideraie. Studiile epdemiologice asupra migrenei n care au fost aplicate metodele de intervievare fa-n-fa, u cu u sunt rare. Acest metod a colectrii de date este probabil mai sensibil n definirea cazurilor de migren dect interviurile telefonice sau chestionarele prin pot. Un interviu clinic fa-n-fa rmne referin-standart pentru diagnosticarea migrenei n absena oricror indicatori neuroradiologici

sau biologici. ntr-un studiu bazat pe populaia dintr-o comunitate , problema major este de a petrece un interviu direct cu participanii cu scopul de a clarifica semnele i simptomele MCA i a MFA , i astfel de a mbunti excactitatea diagnosticii. Alt surs major de variaii n studiile cu interviuri fa-n-fa este acordul intra i interobservatorilor n rndurile intervievatorilor. n evaluarea de fa, noi am petrecut , nainte de a ncepe studiul , un curs de instruire de 1 lun care implica 12 studeni medicali condui de ctre medicii specialiti n migren. n plus, pe parcursul procesului de colectare a datelor , neurologii seniori petreceau o consulataie lunar , ntlnindu-se cu intervievatorii pentru a stabiliza o diagnoz final a migrenei i subtipurlor acesteia. O astfel de abordare minimalizez potenialele devieri de diagnosticare i contribuie la obinerea unei informaii ct mai veridice asupra prevalenei migrenei. n afar de aceasta, iterviul nostru de identificare a fost deasemena petrecut pentru a introduce o ntreag mostr de pacieni negativi (2475) n baza clinic. Dup cum cunoatem, trebuie notat c doar Rasmussen et al1 i Stewart et al18 au administrat un interviu de diagnosticare ntregului grup de intervievai. Deaceea , noi considerm c c stabilirea definiiei cazului nostru este precis i senzitiv. Mostra de intervievai ai studiului nostru bazat pe populaie costituia 73.3% din totalul de rezideni. Rata de participare n cadrul studiului nostru a fost puin mai nalt de ct cele prezentate n studiile recent publicate care prevedeau interviuri fa-n-fa asupra migrenei, dar era n concordan cu studiile raportate anterior. Cu acordul celorlali autori, noi am identificat 65% de respondeni pozitivi la cefalee n mostra clinic de participani . prevalena pe via a migrenei era nalt, n special printre femei cu vrsta 40-49 ani i 60-65(38.1% i 37.5%, respectiv). Aceste rate sunt aproximativ similare cu cele raportate n rile nvecinate , precum Frana i Italia , dar puin mai joase dect cele raportate n rile nordice din Europa. Totui, este bine stabilit c migrena este mai comun la femei dect la brbai, evidena arat c ratele da la femeie la brbat variaz considerabil n dependen de vrst ; prevalena crete din adolescen pn la 40 ani i descrete apoi ,mai ales la brbai. Exist probail o anumit influien a factorului hormonal asociate cu genul femenin care pot explica predominarea la femei mai n vrst de 60 de ani, dup cum a sugerat Stewart et al. Descoperirile noastre aprob aceats ipotez. Ratele noatre pentru prevalena pe durata unui an erau similare cu ratele obinute n dou studii de talie naional i un studiuexemplu american. Prevalena de 1 an n dependen de vrst a artat un tipar bimodal cu vrful n grupele de vrst 15-19 i 40-49 de ani pentru ambele sexe. Cauza exact pentru o prevalen de vrf n grupul cel mai tnr nu este clar , lund n consideraie c doar 11.9% din toat mostra intervievat aparinea acestei categorii. Dup cum a presupus un studiu Korean, o explicaie posibil poate fi sindromul stresului printre elevii de liceu care se pregtesc de examenele de intrare la universitate. n studiul nostru , noi am subclasificat cei 636 de migrenoi activi, n dependen de subtipul lor. Majoritatea(55.8%) aveau MFA, urmai de cei cu MCA(35.2%) i MCAFA(6.9%). Ratele noastre sunt puin mai joase det cele raportate n studiul GEM care prevedea MFA i MCAFA(63.9% i 13.9%, respectiv),dar mai nalte pentru rata de MCA(17.9%). Posibil diferenele de studiu pentru MCA, MFA i MCAFA pot fi explicate de descoperirea i clasificarea lor, avnd in vedere c n studiul GEM numai o

parte din respondenii negativi au fost interogai. Majoritate pacienilor notri care suferea de MFAaveau 15-19, pe cnd migrenoii cu aur artau un vrf la vrsta de 30-39 ani (fig2). Aceste descoperiri sunt n concordan cu un studiu epidemiologic din Ungaria, asupra MFA i MCA , recent publicat . n studiul de fa, noi am observat o predominan n cazul femeilor n toate cele 3 grupe dup cum era sgerat i de ceilali autori. Unii autori au sugerat c MCA i MFA au probabil diferita etiologii. n studiul d fa, noi am ncercat s investigm diferenele dintre caracteristicile clinice a migrenoilor pe via pentur cei cu migren cu i fr aur(tabel 3). Ratele de la femeie la brbat erau semnificant mai nalte la pacienii afectai de MCA(P=.03). Majoritatea migrenoilor cu aur au resimit atacuri mai frecvente i mai severe cu simptomele nsoitare generale. Aceste descoperiri pot susine ipoteza c MCA i MFA sunt du entiti clinice diferite. Grupul amestecat (MCAFA) poate fi un alt grup distinct de migrenoi, iar aura la pacienii afectai de MCAFA probabil are o baz diferit det cea la migrenoii cu MCA. Noi am identificat numai 6.9% de migrenoi activi afectai de MCAFA. Aceast rat este mai joas dect ratele raportate de studiul GEM . pentru a investiga epidemiologia analitic descriptiv i clinic a MCA, MFA i MCAFA , ar fi important de standardiza o procedur de scanare a investigaiilor i a subclasificrii oentru a putea fi folosit n studiile din viitor. Studiile care vor urma trebuie s estimeze ratele reale a le prevalenei migrenei n populaia Croat.

Raportul doctorandei Catedrei de Neurologie a USMF N. Testemianu Crciun Cristina privind lucrul asupra tezei de doctor n tiine medicale socio-economic." Rezumat: Actualitatea problemei cefaleelor primare e justificat prin prevalena nalt a migrenei-1315% i a cefaleei de tip tensional de 40-60% din numrul total al populaiei i impactul social i personal important al acestora. Cefaleea reprezint cel mai frecvent simptom neurologic pentru care pacienii se prezint la medic, ea a fost inclus de OMS n lista celor 10 cauze cele mai rspndite de incapacitate la ambele sexe i primelor 5 la femei. Elucidarea aspectelor epidemiologice i socio-economice ar permite obinerea unui tablou real al prevalenei cefaleelor primare n Republica Moldova i ar putea fi elaborate strategii adecvate att n aspect clinic, diagnostic i de tratament, ct i managerial. Monitorizarea atent a factorilor- declanatori a cefaleelor poate avea un rol i "Epidemiologia cefaleelor primare n mediul rural i urban din Republica Moldova. Impactul

important in tratamentul lor, deoarece evitarea acestora poate micora frecvena severitatea atacurilor de cefalee i poate duce la depistarea etiologiei cefaleelor.

Prevalena- numrul total de bolnavi prezeni la o populaie ntr-o perioad de timp(1 an, life-time). Inciden- cte cazuri noi au aprut ntr-o unitate de timp(1 an). Scopul studiului: Estimarea prevalenei cefaleelor primare (migrenei i cefaleei de tip Moldova . Un alt obietiv important al studiului dat a fost examinarea relaiei dintre factorii declanatori i migren, cefalee de tip tensional, cat i cu subtipurile migrenei: migrena cu aur i migrena fr aur, ct i evidenierea particularitilor clinice a diferitor tipuri de cefalee, cunoaterea incidenei acestora i compararea rezultatelor cu cele prezente n alte ri. In anul 1988,Sociataea Internaional a Cefaleeii a publicat prima clasificare a tulburrilor cefalgice, divizind toate tipurile de cefalee in : 23 24 primare(neasociate unei leziuni cerebrale clinic identificate) secundare(condiionate de o maladie neurologic sau somatic) tensional) i stabilirea frecvenei factorilor- triggeri la subiecii aduli (15-65 ani) cu acest tip de cefalei in localitile urban(mun Chiinu) i rural(Hanceti) din Republica

Ea a devenit un standard pentru diagnosticarea cefaleei. Acumularea cunotinelor in domeniul cefaleelor,cunoaterea mai bun a fiziopatologiei acestora, precum i descrierea de noi entiti clinice a condus la necesitatea revizuirii acestei clasificri. Ediia adoua a Clasificrii Internaionale a Tulburrilor Cefalgice a aprut in ianuarie 2004, fiind complex, bine ierarhizat, astfel inct s fie util cercettotilor i clinicienilor, prezentnd o clasificare ampl i sistematizarea a 200 de forme ale cefaleei. In acelai an ea a fost tradus in limba roman in Republica Moldova la Catedra de Neurologie a Universitii de Stat de Medicin i Farmacie Nicolae Testemianu . Criteriile de diagnostic stricte i exacte expuse in clasificare ofer posibilitatea aprecierii unui diagnostic corect tiinific, fondat pe abordarea medicinei bazate pe dovezi. In raportul OMS din a. 2000 dup gradele de severitate a diferitor patologii, pacienii cu atacuri severe de migren au fost considerai mai afectai decat cei cu psihoze active, demene, sau cei cu tetraplegie. Privind numrul de ani trii cu disabilitate( YLDs), cauzat de variate patologii, migrena depete locul 19 in lume i locul 9 la femei(Maters et al 2002). Migrena este o form relativ sever de cefalee, ce survine in form de atacuri, de obicei cu

durata de la 4 ore pan la 72 ore (3 zile), fiind acompaniat de astfel de fenomene disabilitante ca : nausea(greurile) sau vomele, intolerana sever a luminii, sunetelor, mirosurilor i al micrii corpului. Cefaleea de tip tensional este de obicei mai puin incapacitant ca migrena i cu mai puine fenomene insoitoare. Acest tip de cefalee nu a fost considerat in raportul OMS cel mai important, dar datorit fatului, c este cel mai prevalent tip de cefalee i are tendina de a deveni cronic la o substanial parte a pacienilor, consecinele individuale i sociale a Cefaleei de tip tensional pot fi la fel de semnificative, ca i cele ale migrenei. Alte forme relativ rare aa ca cefaleea in ciorchine(Cluster), poate fi chiar mai incapacitant ca migrena pe timpul atacului. Fr a ine cont de diagnostic, pentru majoritatea pacienilor, consecina este, c funcia normal e intrerupt de episoade de cefalee cu intervale neregulate i imprevizibile, iar aceasta poate impune severe limitri in viaa lor cotidian, la studii, munc i pe parcursul timpului de odihn. Toate acestea i faptul, c patologiile date par a fi extrem de prevalente in toat lumea, le face importante din punctul perspectivei economice. Materiale i metode: Studiu randomizatface-to-face", " door-to-door prin intermediul chestionarului structurat, elaborat de Profesorul I.Moldovanu in 2004, in conformitate cu Criteriile Clasificrii Internaionale Chiinu-Hnceti. In studiu au fost inclui 2665 respondeni cu varsta cuprins intre 15-65 ani, care au alctuit 84% din 3165 persoane contactate . Chestionarea a fost efectuat in perioada : mai-iunie, septembrie-octombrie 2005 de un grup de colaboratori tiinifici al Catedrei de Neurologie al Universitii de Stat de Medicin i Farmacie N. Testemianu i rezideni in neurologie, cercetare efectuat sub controlul profesorului I.Moldovanu n coordonare cu Societatea Internaional de Cefalee(IHS). Din totalul de 2665 de persoane au rspuns afirmativ la intrebare privind prezena cefaleelor- 1439, ce constituie 54% , 1226 din cei cercetai-46% n- au avut cefalee . Chestionarul care a fost utilizat in acest studiu include 145 intrebri, care vizeaz urmtoarele aspecte de baz:aspecte socio-demografice depistarea factorilor- declanatori ai a Tulburrilor Cefalalgice editat de Societatea Internaional de Cefalee in anul 2004.Selectarea eantionului-

migrenei i cefaleei de tip tensional,caracteristici clinice detaliate, tratamente farmacologice, date medico-economice , comorbiditatea, gradul de incapacitate(MIDAS i HIT),impactul cefaleelor i estimarea prezenei abuzului medicamentos. Analiza datelor chestionarelor s-a efectuat utilizand SPSS , varianta 12. Dat fiind, c cefaleea constituie o problem major de sntate, fiind inclus de Organizaia Mondial a Sntii(OMS) in lista primelor 10 cauze de incapacitate la ambele sexe i a primelor 5 cauze de incapacitate efecturii acestuia . Rezultate: Datele privind repartizarea tipurilor maladiilor cefalalgice sunt indicate in tabelului de mai jos: Tipul cefaleei Migren Cefaleea de tip tensional Migrena cronic CTT cronic Cefalee mixt Cefaleea mixt cronic Migrena probabil CTT probabil Migrena cronic probabil CTT cronic probabil Cefalee mixt probabil Cefalee mixt cronic probabil Cefalee secundar Numrul suferinde 441 421 93 68 73 43 61 54 44 49 41 24 26 persoanelor Prevalena(%)(din pers.) 16,5% 15,8% 3,5% 2,6% 2,7% 1,6% 2,3% 2,0% 1,7% 1,8% 1,5% 0,9% 1% 2665 la femei, lipsa unui studiu epidemiologic al a impus necesitatea imperativ a prevalenei cefaleelor primare in Republica Moldova

Dup frecvena atacurilor pe lun Migrena-1-4 zile- 173p. CTT-1-4 zile-185p.

Migrena-5-14 zile-291p. Migrena>sau egal 15 zile-70p.

CTT-5-14 zile-235p. CTT >sau egal 15 zile-69p.

Din totalul de 2665 respondeni- 1587(59%) au fost femei, brbai au fost- 1078(40,5%), Din numrul persoanelor cu dureri de cap, femei au fost 1050- 73%, brbai- 38927%.

48,8% din cei intervievai locuiau in mun Chiinu, respectiv- 51,2%- in Hinceti. Divizarea dup starea matrimonial a respondenilor a avut loc astfel: Cstorii- 1834- 68,8%, celibatari- 586-22%, divorai-121- 4,5%, vduvi-124-4,7%. Dup varst persoanele chestionate aveau: 15-24 ani- 629p.- 23,6% 25-34 ani- 610p.- 22,89% 35-44 ani- 432p.- 16,21% 45-54 ani-486p.-18,23% 55- 65 ani- 508p.- 19,06%

Din ei: Nu erau incadrai in cimpul muncii- 829 respondeni- 31,1% Munc intelectual indeplineau- 1120 chestionai-42% Munceau fizic- 708 intervievai- 26,6%. Dup nivelul educaiei: intervievai, coala profesional- 25%, jos- 43,2%: coala primar au absolvit-o 18,2% din cei

mediu- 18,9% : Studii liceale -5,6%, Studii postliceale- 13,2%, superior -48,5%: Universitatea au absolvit-o 35,3% din respondeni i Studii postuniversitare- 2,6% din 2665 persoane chestionate.

Tabagismul: fumtori- 623(23,4%), iar nefumatori-2042(76,6%).

Dup starea material i condiii de trai- 15% din respondeni au menionat, c au un trai decent, 69,8%- considerau, c au condiii de trai medii i au bani doar pentru strictul necesar, iar 15,2%-c au condiii nefavorabile de trai i nu le ajung bani nici pentru strictul necesar.

Cefaleea este una din acuzele cele mai frecvente in practica medical, constituind o problem major a sntii publice cu un impact indvidual i social mare, , avind ca rezultat pierderea productivitii, limitarea activitii i deteriorarea calitii vieii, date confirmat de cercetrile epidemiologice actuale. Circa 45 de mln de americani au cefalee cronic,dintre care, 20 de mln sunt femei . (NWHJK) Rata prevalenei cefaleelor este aproximativ 1 din 6 sau 16.54% ,adic 45 mln de persoane din Statele Unite. Cefaleea este omniprezent i este o problem costisitoare a sntii publice in Japonia . Conform datelor prezentate( Ocuma H., Kitagawa Y. 2005),prevalena cefaleei pe via e aproximativ de 93% la brbai i 99% la femei. Aproximativ 8.4 mln de oameni in Japonia sufer de migren i 22 mln au cefalee de tip tensional.

n pofida faptului impactului personal i economic, ct i disabilitatea cauzat de cefalee, muli pacieni cu cefalee nu se adreseaz dup servicii medicale. Studiile populaionale sunt in majoritaea lor focusate asupra migrenei deoarece ea a fost mai des studiat,dar ea nu este cea mai frecvent intilnit patologie cefalalgic. In rile dezvoltate doar CTT afecteaz 2/3 din brbai i mai mult de 80%din femei. Extrapolarea din datele privind prevalena migrenei i a incidenei atacurilor, prezint c 3000 de atacuri de migren au loc zilnic pentru fiecare 1 mln din populaia general. Adic mai mult de 1 adult din 20 are cefalee aproape zilnic sau chiar zilnic. Conform datelor Organizaiei Mondiale a Sntii,migrena se afl pe locul 19 printre maladiille incapacitante. Patologia cefalalgic impune o povar considerabil asupra suferinzilor, incluzind afectarea calitii vieii, suferina substanial personal periodic i costul financiar . Repetarea atacurilor de cefalee, urmate de o frecvent sau permanent fric, dauna pricinuit vieii de familie,vieii sociale i serviciului constitue impactul patologiei cefalalgice. Spre exemplu activitatea social i capacitatea de lucru sunt reduse aproape la toi suferinzii de migren i la 60% din cei cu CTT. Migrena e intilnit la toate rasele. Totui evidena curent sugereaz , c prevalena migrenei este mai inalt la cei de ras alb decit la asiatici i africani.

ara 1. Canada 2. SUA 3.Peru 4.Britania 6.Malasia 7.Arabia Saudit

Prevalena 15% 11% 32% 11% 9% 3%

ara 8.Frana 9.Norvegia 10.Danemarca 11.Japonia 12.Hong Kong 13.Etiopia

Prevalena 12% 9% 17% 8% 1.5% 3%

Un efort de lung durat de a face fa patologiilor cefalgice persoanele cu migren sever sau cefalei severe decit la indivizii sntoi.

poate de asemenea

predispune persoanele fa de alte patologii . De exemplu, depresia e de 3 ori mai des intilnit la

De obicei cu debutul in pubertate, migrena afectez majoritar persoanele cu virsta cuprins intre 35 i 45 de ani, dar le poate crea probleme i persoanelor mult mai tinere, inclusiv copiilor. Studiile Americane i Europene demonstreaz c in fiecare an 6-8% din brbai i 15-18% dintre femei au migren . Un pattern similar se vede in America Central i de Sud. In urma cercetrilor din Puerto Rico,spre exemplu, s-a constatat prevalena migrenei de 6% la brbai i 17% la femei. Un Studiu efectuat in Turcia dezvluie o i mai mare prevalen in aceast ar: 10% la brbai i 22% la femei. Cea mai inalt rat pretutindeni la femei (de 2-3 ori mai mare decit la brbai) este cea hormonal condiionat. Migrena este aadar mai puin prevalent ,dar totui frecvent , in Asia(3% la brbai i ? 0% la femei ) i in Africa(3-7% in studiile bazate pe comunitate). Studii majore nu au fost inc petrecute.

Incidence and prevalence of some neurological conditions (rates per 100,000) Incidence: number of new cases per 100,000 that develop each year

Condition

Prevalence: total number of people per 100,000

Source

Alzheimer's disease/dementia

25,000 per 100,000 in over 65 year olds per 100,000 27 new cases in year 2000 Migraine 400 100,000(1)

1,000

Alzheimer's Society based on ONS population estimate 1996

CJD

Alzheimer's Society

vCJD

101 cases since 1995

Alzheimer's Society

per

15,000 (8,000,000)

1. Steiner TJ et al Epidemiology of migraine in England. Cephalalgia 2. Olesen J, Goadsby PJ, Cluster Headache and related conditions in Olesen J (Ed) Frontiers in Headache Research Vol 9 OUP 1999 3. Goadsby PJ, Lipton RB. A review of paroxysmal hemicaranias Brain 1997; 120:193-209 4. Silberstein SD et al, Headaches in Primary Care Oxford/Isis Medical Media 1999

Cluster Headache 4 per 100,000 (2) Headache Paroxysmal Hemicrania (3) Chronic Migraine (4) Chronic tensiontype headache (4) Headache Motor neurone disease

100

10

3,000

144 (85,000)

MS Society and MS Research Trust - estimates based on UK area studies and international data Dowsett E G, Richardson J The Epiemiology of Myalgic Encephalomyelitis (ME) in the UK 1919 - 1999 Evidence submitted to the All Party Parliamentary Group of MPs on ME 23.11.99 Parkinson's Disease Society - advice from medical adviser

Myalgic Encephalomyelitis (ME)

300 - 500

Parkinson's disease

200

Last edited: 2/2/2004 2003-4 World Health Organization - UK Collaborating Centre

DIAGNOZELE MIGRENA SI CTT 1+3 SI 2+4

Total N 2. sexul barbat 279 % 27,3 72,7 100

Migrene simpla+cron N 86 448 534 % 16,1 83,9 100

CTT simpla+cronica N 193 296 489 % 39,5 60,5 100 U fiser -8,52299 P <0.001

femeie 744 Total 1023

8,522988 <0.002

Cum se repartizeaza dup sex persoanele cu migren si CTT? P. cu Migren: CTT: Brbai-16,1% 39,5% Femei-83,9% ( P<0,001) (P<0,002) P. cu BrbaiFemei-60,5%

Raportul femei/brbai la persoanele , ce sufer de migren este de 5,16, Iar la cei cu CTT raportul femei/brbai -1,53

8. Fumatu l

da nu

178 845 1023

17,4 82,6 100

75 459 534

14 86 100

103 386 489

21,1 -2,99606

<0.01

78,9 2,996058 <0.02 100

Total

n lotul persoanelor cu Migren fumeaz-14%, iar din cei cu CTT-21,1%(P<0,01) Nu fumeaz-86% (P<0.02) Sunt mai muli nefumtori n cazul respondenilor cu migren-86%, fa de 78,9% din cei cu CTT. nu fumeaz-78,9%

18. Maladii endocrin e

1 2

73 950 1023

7,1 92,9 100

48 486 534

9 91 100

25 464 489

5,1 94, 9 100

2,45708 5 -2,45708

<0.05 <0.06

Total

S-a depistat prezena maladiilor endocrine la persoanele cu Migren n 9% cazuri fa de 5,1% din cei cu CTT(p<0,05) 20. Maladii onco 1 2 Total

32 991 1023

3,1 96,9 100

22 512 534

4,1 95,9 100

10 479 489

2 98 100

1,981026 <0.05 -1,98103 <0.05

4,1% din cei diagnosticai cu migren au menionat, oncologice, iar din cei cu CTT doar 2%(P<0,05). x23 0 1 Total 1001 22 1023 97,8 2,2 100 515 19 534 96,4 3,6 100 486 3 489

c sufer de maladii 99,4 3,62213 <0.001 0,6 100 3,62213 <0.001

n timpul atacului de cefalee nu-i pot ndeplini activitile zilnice 3,6 % din totalul pers. cu Migren i 0,6% din cei cu CTT(P<0,001). x25 0 1 Total 983 40 1023 96,1 3,9 100 507 27 534 94,9 5,1 100 476 13 489 97,3 -2,00448 2,7 100 <0.05

2,004485 <0.05

Durerea de cap este nsoit de nausee diagnosticate cu Migren i

sau vom

la 5,1% din persoanele

La 2,7% din respondeii, ce sufer de Cefalee de tip tensional(P<0,05).

Triggerii cefaleei la persoanele cu Migren i CTT(rspuns spontan):

37. dcappro v 1,76129 3 -0,41956 3,76835 4 2,57428 9 0,77163 -4,2368 -2,22844

1 2 3 4 5 6 21

23 19 20 280 13 272 54 904

2,5 2,1 2,2 31 1,4 30,1 6 100

16 9 18 163 8 112 20 469

3,4 1,9 3,8 34,8 1,7 23,9 4,3 100

7 10 2 117 5 160 34 435

1,6 2,3 0,5 26, 9 1,1 36, 8 7,8 100

>0.05 >0.05 <0.001 <0.05 >0.05 <0.001 <0.05

Total

Factorii declanatori cel mai frecvent nominalizai(rspuns spontan) de ctre respondenii cu:

MIgren tensional 3.Menstruaia- 3,8% 0,5% (P<0,001) (P<0,05)

Cefalee de tip 3.Menstruaia4.Stresul sau 6.Obosela21.Altceva-

4.Stresul sau ncetarea stresului-34,8% ncetarea stresului-26,9% 6.Obosela-23,9% 36,8% 21.Altceva-4,3% 7,8% 1.foamea-3,4% 2. alcoolul-1,9% 5.Somn insufficient-1,7% insufficient-1,1% 7.Incordarea psihic-2,6% psihic-4,1% 11. Lumini intense sau soare-5,5% sau soare-3,9% 17.Schimbri meteo-14,1% meteo-14,1%

(P<0,001) (P<0,05)

(P>0,05) (P>0,05) (P>0,05) (P>0,05) (P>0,05) (P>0,05)

1.foamea-1,6% 2. alcoolul-2,3% 5.Somn 7.Incordarea 11. Lumini intense 17.Schimbri

-----------------------------------------------------------------------------------------------------------------------------------------

Triggerii migrenei i cefaleei de tip tensional dup interviu:

d3701 0 1 Total 769 254 1023 75,2 24,8 100 381 153 534 71,3 28,7 100 388 101 489 79,3 -2,97241 <0.01 20,7 2,972413 <0.01 100

Persoanele cu migren menioneaz foamea n 28,7% cazuri, iar cei cu CTT-n20,3% (P<0,01) d3702 0 813 79,5 388 72,7 425 86,9 -5,73328 <0.001

2 Total

210 1023

20,5 100

146 534

27,3 100

64 489

13,1 5,733275 <0.001 100

Alcoolul ca factor declanator al migrenei a fost indicat de 27,3% din intervievai i doar de 13,1% din cei cu Cefalee de tip tensional (P<0,001) d3703 0 3 854 169 83,5 16,5 409 125 76,6 23,4 445 44 91 9 -6,39788 <0.001

6,397875 <0.001

Menstruaia ca factor-trigger a fost menionat de 23% de migrenoi i de 9% din persoane cu CTT(P<0,001) d3704 0 4 242 781 23,7 76,3 99 435 18,5 81,5 143 346 29,2 -4,03429 <0.001

70,8 4,034294 <0.001

Stresul sau ncetarea stresului a fost nominalizat ca trigger de 81,5% din respondenii cu migren i de 70,8% din cei cu CTT!!!

d3706 0 6

230 793

22,5 77,5

134 400

25,1 74,9

96 393

19,6 80,4

2,11289 2,11289

<0.05 <0.05

Oboseala este prezent ca factor-trigger la 74,9% din migrenoi i la 80,4% din cei cu cefalee de tip tensional(P<0,05)!!! d3708 0 8 864 159 84,5 15,5 411 123 77 23 453 36 92,6 -7,17924 7,4 <0.001

7,179237 <0.001

Mirosurile puternice cauzeaz cefaleea la 23% din intervievaii cu migren i la 7,4% din cei cu CTT(P<0,001) d3711 0 11 673 350 65,8 34,2 296 238 55,4 44,6 377 112 77,1 -7,42284 <0.001

22,9 7,422843 <0.001

Luminile intense sau soarele provoac migrena la 44,6%din suferinzi i la 22,9% de intervievai cu Cefalee de tip tensional(P<0,001) d3713 0 13 754 269 73,7 26,3 329 205 61,6 38,4 425 64 86,9 -9,52161 <0.001

13,1 9,521612 <0.001

Sunetele puternice sunt triggerii Migrenei n 38,4% din cazuri, iar la cei cu CTT- la 13,1% din suferinzi(P<0,001) d3714 0 835 81,6 410 76,8 425 86,9 -4,2244 <0.001

14

188

18,4

124

23,2

64

13,1 4,224399 <0.001

Somnul profund sau prea mult somn este nominalizat ca trigger n 23,2% n cazul respondenilor cu migren i n 13,1% cazuri de CTT(P<0,001) d3717 0 17 397 626 38,8 61,2 188 346 35,2 64,8 209 280 42,7 2,46007 <0.05 57,3 2,46007 <0.05

Total

1023

100

534

100

489

100

Schimbrile meteo migrenoi i la

au fost menionate ca factori- declanatori la 64,8% din 57,3% din persoanele cu Cefalee de tip tensional(P<0, 05).

Comportamentul n timpul durerii de cap(rspuns spontan:

DIAGNOZELE MIGRENA SI CTT 1+3 SI 2+4 Total N comport 0 1 2 3 4 5 6 7 8 9 Total 102 25 1 65 16 483 258 6 1 43 1000 % 10,2 2,5 0,1 6,5 1,6 48,3 25,8 0,6 0,1 4,3 100 20 525 3,8 100 21 6 285 134 5 4 1,1 54,3 25,5 1 N 45 9 Migrene simpla+cron % 8,6 1,7 CTT simpla+cronica N 57 16 1 44 10 198 124 1 1 23 475 % 12 3,4 0,2 9,3 2,1 41,7 26,1 0,2 0,2 4,8 100 -1,77211 -1,72747 -1,41292 -3,42796 -1,27444 3,99335 7 -0,21656 1,75069 4 -1,41292 -0,77975 >0.05 >0.05 >0.05 <0.001 >0.05 <0.001 >0.05 >0.05 >0.05 >0.05

3.Continu activitile zilnice- 4% din respondenii, ce sufer de migren i 9,3% din cei cu CTT(P<0,001). 5.Iau medicamente-54,3% din migrenoi i 41,7% din intervievaii cu Cefalee de tip tensional(P<0,001).

Comportamentul n timpul durerii de cap(rspuns dup chestionare): d3801 0 1 Total 819 204 1023 80,1 19,9 100 479 55 534 89,7 10,3 100 340 149 489 69,5 8,255631 <0.001 30,5 -8,25563 100 <0.001

Merg la aer- 10,3% din CTT(P<0,001).

persoanele cu migren i 30,5% din respondenii cu

d3802

0 2

848 175

82,9 17,1

492 42

92,1 7,9

356 133

72,8 27,2

8,427462 -8,42746

<0.001 <0.001

Privesc televizorul-7,9% din respodenii, ce sufer de migren i 27,2% din cei cu CTT(P<0,001)

d3803

0 3

567 456

55,4 44,6

380 154

71,2 28,8

187 302

38,2 61,8

10,80193 -10,8019

<0.001 <0.001

Continu activitile obinuite-28,8% din intervievaii-migrenoi i 61,85% din respondenii, ce sufer de cefalee de tip tensional(P<0,001).

d3804

0 4

817 206

79,9 20,1

441 93

82,6 17,4

376 113

76,9 23,1

2,271193 -2,27119

<0.05 <0.05

Fac masaj la cap 17,4% din cei cu migren i 23,1% din cei cu CTT(P<0,05).

d3805

0 5

330 693

32,3 67,7

120 414

22,5 77,5

210 279

42,9 57,1

-7,02788 7,027876

<0.001 <0.001

Iau medicamente- 77,5% din respondenii ce sufer de migren i 57,1% din persoanele cu CTT(P<0,001).

d3806

0 6

346 677

33,8 66,2

120 414

22,5 77,5

226 263

46,2 53,8

-8,08886 8,088861

<0.001 <0.001

Prefer repaosul la pat 77,5% din migrenoi i 53,8% din cei cu CTT(P<0,001).

d3807

0 7

778 245

76,1 23,9

329 205

61,6 38,4

449 40

91,8 8,2

-12,0755 12,0755

<0.001 <0.001

Aleg o odaie ntunecoas-38,4 din cei, ce sufer de Migren i 8,2% din respondenii cu Cefalee de tip tensional(P<0,001).

P.39. Antecedente eredo-colaterale Cineva din rudele apropiate sufer ( a suferit) de dureri de cap similare?
DIAGNOZELE MIGRENA SI CTT 1+3 SI 2+4 Total N rudele Total Nu 1 Da 2 364 659 1023 % 35,6 64,4 100 Migrene simpla+cron N 161 373 534 % 30,1 69,9 100 CTT simpla+cronica N 203 286 489 % 41,5 58,5 100 -3,81054 3,810541 <0.001 <0.001

n cazul respondenilor cu migren-69,9% au menionat prezena rudelor cu dureri similare, iar din cei cu cefalee de tip tensional -58,5% (P<0,001). 3. 52,8% din suferinzii de migren i 46,1%din cei cu CTT au numit mama, care a avut sau are cefalei similare(P>0,05). 5. sora sau fratele au fost menionai n cazul a 9,8% din respondenii cu migren i de 7,4% din cei cu CTT(P>0,05). 12. feciorul sa fiica au fost nominalizai n cazul a 14,3% din migrenoi i de 16% din cei, ce sufer de CTT(P>0,05).
14 Total 39 625 6,2 100 8 356 2,2 100 31 269 11,5 100 -4,87963 <0.001

2,2% din migrenoi i 11,5% din cei cu CTT- au indicat alte persoane din anturaj(P<0,001).

d3903 Total

0 3

282 377 659

42,8 57,2 100

141 232 373

37,8 62,2 100

141 145 286

49,3 50,7 100

-2,95798 2,957979

<0.01 <0.01

Dup chestionare 62,2% din suferinzii de Migren au numit mama, ca avnd dureri similare de cap i 50,7% din respondenii cu CTT au menionat acelai lucru(P<0,01).

d3913

0 13

549 110

83,3 16,7

321 52

86,1 13,9

228 58

79,7 20,3

2,171417 -2,17142

<0.05 <0.05

Soul a fost numit ca suferind de cefalei de acelai tip de 13,9% din migrenoi i de 20,3% din cei cu cefalee de tip tensional(P<0,05).
d3914 0 618 93,8 361 96,8 257 89,9 3,653072 <0.001

14 Total

41 659

6,2 100

12 373

3,2 100

29 286

10,1 100

-3,65307

<0.001

Altcineva a fost nominalizat de 3,2% din cei cu Migren i de 10,1% din cei cu CTT(P<0,001).

P.40 Cefaleea i somnul diurn. Se ntmpl ca n timpul durerii de cap ziua s reuii s adormii (cu sau fr medicamente)?
somnziua Total Da 1 Nu 2 693 330 1023 67,7 32,3 100 342 192 534 64 36 100 351 138 489 71,8 28,2 100 -2,67378 2,673782 <0.01 <0.01

N-au reuit s adoarm ziua, n timpul cefaleei respondenii cu migren n 36% cazuri, iar cei cu CTT n28,2% cazuri(P<0,01). Durerea poate s dispar dup trezire?
dispdure Total Da 1 Nu 2 624 69 693 90 10 100 291 51 342 85,1 14,9 100 333 18 351 94,9 5,1 100 -4,43538 4,435381 <0.001 <0.001

Durerea de cap persist dup trezirea din somnul diurn la 14,9% din cei cu migren i la doar 5,15 din respondenii cu cefalee de tip tensional(P<001), pe cnd la 85,1% din migrenoi i 94,9% din respondenii cu CTT cefaleea dispare. Comorbiditatea algic n cursul ultimului an:
p.80_07 Total 0 7 912 111 1023 89,1 10,9 100 466 68 534 87,3 12,7 100 446 43 489 91,2 8,8 100 -2,01945 2,019452 <0.05 <0.05

Durerile abdominale au nsoit cefaleea la 12,7% din respondenii cu migren i la 8,8% din cei cu CTT(P<0,05).
p.80_12 Total 0 12 701 322 1023 68,5 31,5 100 349 185 534 65,4 34,6 100 352 137 489 72 28 100 -2,27682 2,276817 <0.05 <0.05

Durerea n regiunea lombar(n ale) a fost nominalizat de 34,6% din suferinzii de migren i de 28% din cei cu cefalee de tip tensional8P<0,05). Anxietatea generalizat
p.81 0 20 2 9 1,7 11 2,2 -0,5789 >0.05

Nu sau foarte rar 1 Rar Des 2 3

361 364 246

35,3 35,6 24

152 204 146

28,5 38,2 27,3

209 160 100

42,7 32,7 20,4

-4,76056 1,83823 2,592837

<0.001 >0.05 <0.05

f. des, practic permanent 4 Total

32 1023

3,1 100

23 534

4,3 100

9 489

1,8 100

2,374464

<0.05

Prezena anxietii la respondenii cu Migren a fost indicat ca frecvent n 27,3% cazuri , iar la respondenii cu Cefalee de tip tensional-n20,4% cazuri, foarte des, practic permanent, respectiv n 4,3% i 1,8% n ambele gupuri(P<0,05).

0 7 Total

250 28 278

89,9 10,1 100

145 24 169

85,8 14,2 100

105 4 109

96,3 3,7 100

-3,13902 3,139021

<0.001 <0.001

Au menionat n calitate de fenomene frecvente(sau foarte frecvente) adiionale durerii de cap greaa i discomfortul abdominal persoanele cu migren n 14,2% de cazuri, iar cei cu CTT- n 3,7% cazuri(P<0,001).

Obiective:
1.Care este prevalena migrenei i cefaleei de tip tensional a) n lotul mixt(brbai +femei). b) n loturi separate(cef n lume, Europa- Stovner) - brbai ; femei. 2. Din lotul de: Femei- care este% de pers. cu cefalee. Brbai- care este% de pers. cu cefalee. 3 Se discut tot, ce este publicat la tema dat:explicaii i comparaii cu datele noastre Rspuns la p.1 Prevalena migrenei i cefaleei de tip tensional: a) n lotul mixt(brbai +femei). 448 femei+86 brbai= 534 ptts. cu migren-20,03% din numrul total al persoanelor chestionare- 2665; 534ptts- 37,10% din 1439 pers cu cefalee;

296 femei+193 brbai= 489 ptts. cu CTT- 18,34% din numrul total al persoanelor chestionare- 2665; 489ptts- 33,98% din 1439 pers cu cefalee.

Comentarii:
Tab. 1. P.2 Repartiia dup sex a persoanelor cu cefalee versus cele fr cefalee convenional sntoase Numrul total al persoanelor chestionare- 2665- 100%,

Din 2665: Femei- 1587- 59,55% Brbai-1078- 40,45% Rspuns la p.2: Din 2665 : cefalei); 66,16% din totalul femeilor chestionate(1587). Brbai- 389-14,6% (din 2665p); 27% (din 1439 cu cefalei); 36,08% din totalul de brbai chestionai(1078). Cu cefalee- 1439ptts-54%(din totalul de2665 intervievai: Femei- 1050- 39,4% (din2665 intervievai); 73% (din 1439 cu

Fr cefalee-1226- 46%(din totalul de2665 intervievai): Femei - 537- 20,15% (din2665 intervievai); 43% (din 1226 fr cefalei). Brbai- 689-25,85% (din 2665p); 56,2% (din 1226 fr cefalei).

Din 1050 femei cu cefalee- 39,4% (din2665 intervievai) ( 66,16% din 1587- totalul femeilor chestionate) :

448 femei au migren-16,81% din tot. 2665p. chestionate,

42,67% din 1050- femei cu cefalee, 28,23% di totalul de 1587 femei chestionate, 31,13% din 1439-totalul ptts. cu cefalee 296 femei au cefalee de tip tensional-11,1% din tot. 2665p. chestionate, 28,19% din 1050- femei cu cefalee, 18,65% di totalul de 1587 femei chestionate, 20,57% din 1439-totalul ptts. cu cefalee

Din 389 brbai cu cefalee-14,6% (din 2665p); ( 36,08% din 1078- totalul brbailor chestionai): 86 brbai au migren-3,22% din tot.a 2665p. chestionate, 22,11% din 389 brbai cu cefalee, 7,98% din totalul de 1078 brbai chestionai, 5,98% din 1439-totalul ptts. cu cefalee; 193 brbai au cefalee de tip tensional-7,24% din tot. 2665p. chestionate, 49,61% din 389 brbai cu cefalee, 17,9% din totalul de 1078 brbai chestionai, 13,41% din 1439-totalul ptts. cu cefalee.

Tab.1. P.1Repartiia dup vrst a persoanelor cu migren i cefalee de tip tensional versus persoanele fr cefalee( convenional sntoase sau lot de control). Majoritatea o alctuiesc persoanele cu vrsta cuprins ntre 20-29 ani, att n lotul persoanelor convenional sntoase, ct i n lotul celor cu migren. Diferene statistice se observ la grupurile de vrst 40-49; 50-59; 60-65 ani.

Persoanele CTT(20-29 ani) 102p.-3,8%

cu P<0,05

Persoanele sntoase(20-29 ani) 327p.-12,27% din P> 0,05

Persoanelecu migren(20-29 ani) 124p.-4,6% din

din

2665p.chestionate

n total; 7,08%- din tot. de 1439ptts. cefalee; 20,86%- din 489 ptts. cu CTT cu

2665p.chestionate n total; 26,7% din 1226 cefalee. p. fr

2665p.chestionate n total; 8,6%- din tot. de 1439ptts. cefalee; 23,22%- din 534 ptts. cu migren. cu

Persoanele sntoase(40-49 ani) 193p.-7,24% n total; 15,74% din 1226p. fr cefalee din P<0,01

Persoanelecu migren(40-49 ani) 113p.-4,24% n total; 7,8%- din tot. de 1439ptts. cefalee; 21,16%- din 534 ptts. cu migren. cu din

2665p.chestionate

2665p.chestionate

Persoanele CTT(50-59 ani) 97p.-3,6% n total;

cu P<0,01

Persoanele sntoase(50-59 ani) 175p.-6,56% n total; 14,27% din 1226p. fr cefalee din P< 0,01

Persoanelecu migren(50-59 ani) 104p.-3,9% n total; 7,23%- din tot. de 1439ptts. cefalee; 19,48%- din 534 ptts. cu migren. cu din

din

2665p.chestionate

2665p.chestionate

2665p.chestionate

6,7%- din tot. de 1439ptts. cefalee; 19,84%- din 489 ptts. cu CTT cu

Persoanele

Persoanelecu

sntoase(60-65 ani) 144p.-5,4% n total; 11,75% din 1226p. fr cefalee. din

P< 0,01

migren(60-65 ani) 37p.-1,38% n total; 2,57%- din tot. de 1439ptts. cefalee; 6,93%din 534 cu din

2665p.chestionate

2665p.chestionate

ptts. cu migren.

Caracteristicile epidemiologice si clinice a migrenei si cefaleei de tip tensional in cazul a 1146 de femei din Kayseri, Turcia

Kseoglu E., Naar M., Talaslioglu A., etinkaya F.

Caracteristici epidemiologice si clinice ale migrenei si a cefaleei de tip tensional in cazul a 1146 de femei din Kayseri, Turcia. Cephalalgia 2003 ; 23 :381-338. London ISSN 0333-1024

In populatia feminina a Turciei (1146 de femei adulte), au fost investigate unele caracteristici epidemiologice si clinice ale migrenei si cefaleei de tip tensional si unele subtipuri ale lor. Relatia intre severitatea durerii de cap si caracteristicile clinice au fost investigate amanuntit. Statisticile arata o raspandire mai mare a migrenei la grupul de varsta intre 35 si 44 de ani (P<0.01), la cei cu studii superioare (P<0.001), la cei casatoriti (P<0.01) precum si la persoanele care locuiesc in localitati urbane. Cefaleea de tip tensional a fost apreciata ca fiind mai inalta la grupul de varsta cuprins intre 45 si 64 de ani (P<0.05). Sa constatat ca pacientii cu cefalee cronica (P<0.01) sunt mult mai avansati in varsta

comparativ celor cu cefalee de tip tensional de tip episodic si deseori sunt cu un nivel de educatie scazut (P<0.05). Prezenta impactului asupra activitatii lor zilnice datorat severitatii durerilor de cap a fost legata de agravarea starii fizice (P=0.001) in cazul cefaleei de tip tensional, fara caracteristici clinice ale durerii de cap migrenoase si considerand toti pacientii cu dureri de cap pulsatile (P<0.05), agravarea starii fizice (P=0.001), greturi (P<0.01), vome (P<0.05), si phonofobie (P<0.05). Migrena, cefalee de tip tensional, populatia feminina, Turcia.

Introducere

Exista multe studii epidemiologice a durerilor de cap, dar relativ putine sunt efectuate in tarile asiatice. Aceasta relateaza faptul ca factorii de risc de ordin rasial, cultural si cel al mediului inconjurator joaca un rol important in cercetarile epidemiologice(1). Acest studiu a fost efectuat intr-o tara asiatica, a carei populatie apartine rasei Caucaziene. Studiile, in special cele cu privire la femei, sunt si ele relativ putine la numar. Un studiu epidemiologic a durerilor de cap din Turcia, publicat sub forma de rezumat, efectuat in cazul a 2007 de persoane, arata o raspandire a migrenei si cefaleei de tip tensional (CTT) in decursul unui an de 16.4% si respectiv 31.7%(2). Dar caracteristicile clinice ale cefaleelor n-au fost evaluate. Acesta este primul studiu detaliat, bazat pe cercetari masive a cefaleei si caracteristicile sale clinice bazate pe Sistemul International al Cefaleei (criteriul IHS) in populatia feminina a Turciei. Prevalenta de 1 an, date socio-demografice si caracteristicile migrenei, CTT si subtipurile cefaleei de tip tensional au fost investigate. De asemenea, a fost apreciata si corelatia dintre caracteristicile clinice si severitatea cefaleei.

Materiale si metode

Studiul a fost efectuat in provincia Kayseri avand ca obiect de cercetare femei in varsta mai mare de 14 ani, in cazul a 375 441 de persoane. Marimea-mostra minima a fost calculata ca fiind cea de 1100 de persoane (95% interval confidential, SD: 1.6%) prevalenta migrenei estimata la 8%. 1300 de femei intre varsta de 15 si 87 de ani au fost selectate la intamplare dupa grup si metodele de sistematizare din regiune, folosind registrul civil in centrele de sanatate primare, care au inregistrari a tuturor locuitorilor a regiunilor; 1146 din aceste femei a putut fi contactate pentru studiu. Simptomele durerii de cap au fost evaluate prin intervievarea structurata fata-n fata, bazata pe criteriul IHS (3) . Inaintea fiecarui interviu era descris obiectivul studiului si era primit acordul verbal de a participa. Studiul a fost aprobat de Comitetul Etic al Universitatii Erciyes. In urma unor intrebari introductive cu privire la varsta, nivelul educational si economic, statutul marital si profesional, indivizii au fost intrebati daca medicii generalisti au depistat vre-o boala cronica si cel mai important, daca au avut dureri de cap bine resimtite (discomfortante) pe parcursul anului trecut. In cazul in care durerea de cap era raportata, li se puneau intrebari pe marginea caracteristicilor durerilor de cap si intrebari legate de cele din urma, cum ar fi frecventa, durata, factorii declansatori, simptomele concomitente, dereglari ale somnului, istoricul familiei, tratamentele facute, etc.

Intervievarile erau executate de studentii la medicina, antrenati in acest subiect prin lucrul la policlinicile de studiere a cefaleelor. Dupa intervievare, tipurile de dureri de cap au fost determinate dupa criteriul IHS in interviurile dintre neurologi si studenti. Diagnosticile altor boli erau bazate pe deciziile generalistilor din centrul primar al sanatatii. Alte cauze ale durerii de cap, ca sinusitele si hipertensiunea au fost luate in consideratie si evaluate ca posibilitate a existentei cauzei migrenei. In 15 (1,31 %) dintre cazuri durerea de cap era gasita de a fi cauzata de aceste boli. Proportia prevalentei migrenei cu aura (MWA) si a migrenei fara aura (MWOA), tipul episodic si cel cronic CTT au fost depistate. Evaluarea relatiei dintre prevalenta tipurilor de cefalee si proprietatile pacientilor cu cefalee, cum ar fi varsta, nivelul educational si economic, statutul marital si profesional, aria rezidentiala si comparatia caracteristicilor clinice dintre severitatea durerii de cap au fost evaluate folosind sirul Spearman al analizelor corelative.

Rezultatele

Proprietatile socio-demografice ale pacientilor CTT si pacientilor migrenosi: varsta, nivelul educational si economic, statutul marital si profesional, aria rezidentiala sunt prezentate in Tabelul nr.1

Tebelul 1 Particularitatile socio-demografice a tuturor persoanelor intervievate si pacientilor cu cefalee

Persoane intervievate (n=1146) Varsta (ani) 15-24 25-34 35-44 45-64 >65 Nivelul educational <5 ani 5 ani 8 ani 11 ani >11 ani Statutul marital Casatorite Celibatare Divortate Statutul profesional Femei de casa Lucratoare Resedinta Urban 636 975 171 853 178 115 312 526 99 126 83 289 311 253 228 65

Pacienti cu migrena (n=143)

Pacientii CTT (n=216)

23 (8.0%) 48 (15.4%) 41 (16.2%) 29 (12.7%) 2 (3.0%)

46 (15.9%) 55 (17,7%) 47 (18.5%) 59 (25.9%) 9 (13.8%)

33 (10.5%) 72 (13.7%) 6 (6.0%) 11 (8,7%) 21 (25.8%)

57 (18.2%) 96 (18.2%) 19 (19.2%) 22 (17.4%) 22 (26.5%)

118 (13.8%) 17 (9.5%) 8 (7.0%)

160 (18.7%) 28 (15.7%) 28 (24.3%)

116 (11.9%) 27 (15.8%)

180 (18.4%) 36 (21.0%)

97 (15.2%)

123 (19.3%) 93 (18.2%)

Rural 510 46 (9.0%) Durerea de cap de tip migrenos si aspectele socio-demografice

1146 de femei au fost intervievate. 359 (31.1%) dintre ele au suportat migrena sau cefaleea de tip tensional pe parcursul ultimului an. Prevalenta migrenei timp de un an a fost de 12.5% (143 de pacienti), inclunzand 7,3 % (84) MWA si 5.2% (59) MWOA. Prevalenta migrenei a fost gasita ca fiind statistic mai inalta in grupul de persoane cuprinse intre 35-44 de ani si mai joasa in grupul de persoane cu varsta mai mare de 65 de ani, comparativ cu alte grupe (2: 16.38, P<0.01). O prevalenta mai mare a durerii de cap migrenoase a fost determinata la persoanele cu un nivel educational relativ mai inalt, universitar (2: 6.04, P<0.05) precum si la cei care au locuit in zonele urbane (2: 9.5, P<0.01). Totusi, in cazul statutului profesional si situatia economica nu au fost gasite tangente semnificative cu prezenta durerilor de cap de tip migrenos.

Cefaleea de tip tensional si aspectele socio-demografice

Prevalenta de un an al CCT a fost gasita de 18.8% (216 persoane) incluzand 144 (12.5%) tip episodic si 72 (6.3%) cu tip cronic al cefaleei. Prevalenta CTT a fost gasita mai inalta la grupul de varsta 45-64 de ani (2: 10.34, P<0.05). Cefaleea de tip tensional cronica a fost gasita semnificativ mai mare decat cea de tip episodic (media de varsta SD pentru tipul cronic si episodic al cefaceei de tip tensional: 41.11 15.57, 35.85, 12.91, P<0.01). Cu respectarea studiilor, tipul cronic al cefaleei a fost gasit cel mai prevalent (2: 6.83, P<0.05). La persoanele cu nivel cel mai scazut de studii.

Frecventa atacurilor de cefalee

Aproximativ 73.4% din pacientii cu migrena au 1-4 atacuri pe luna, pe cand restul trec prin >4 atacuri pe luna. 55 de pacienti migrenosi (38.5% din toti migrenosii; 21 MWA, 14 MWOA) au cel putin 180 de atacuri pe an. Luand in consideratie, ca la cefalee de tip tensional 31.9% de pacienti au 1-3 cefaleei pe luna si 68.1% din pacienti sufera de cefalee minim 1 data pe saptamana; 33.3% din pacienti au cel putin 180 de atacuri pe an, de cefalee de tip tensional.

Durata cefaleei

In acord cu criteriile Societatii Internationale ale Cefaleei, durata acceptata a atacului de migrena la pacientul netratat e de 4-72 ore. 22 de pacienti (15.4%) cu migrena au avut durata <4 ore, dar toti acesti pacienti au utilizat tratamentul medicamentos pentru atacurile lor de cefalee. Acest studiu demonstreaza ca cea mai raspandita durata a

atacurilor de migrena (71.3%) a fost intre 4-24 ore. In cefalee de tip tensional, atacurile s-au sfarsit in cadrul mai multor ore (51.9%, au continuat pe parcursul zilei 22.2%, au durat de la 1-3 zile (14.8%) si de la 3-7 zile la 11.1% din pacienti). Cefalee de tip tensional episodica difera de tipul cronic prin aceea ca atacurile de obicei au durata mai scurta, 15 min. - cateva ore (2: 10.52, P<0.05).

Caracteristica cefaleei

Pulsatia a fost observata la 88.8% din migrenosi si 62.0% din pacientii cu cefalee de tip tensional, pe cand pacientii aveau senzatii de presiune/inclestare.

Tabelul 2 Caracteristicile migrenei cu aura si fara aura

Unilateralitatea

Caracterul pulsatil

Agravarea la efort fizic

Impactul asupra activitatilor zilnice % 78.6 76.2

% MWA 54.8

% 83.3

% 78.6 89.8

MWOA 49.2 96.6 Nota: MWA Migrena cu aura; MWOA - Migrena fara aura.

53.1% din pacientii cu migrena au avut cefalee unilaterala. Cefalee bilaterala a fost raportata la 72.7% din pacientii cu cefalee de tip tensional. La 82.5% din pacientii cu migrena si 43.3% din pacientii cu cefalee de tip tensional, cefaleea a fost agravata de activitati fizice de rutina.

Caracteristicile tipurilor migrenei cu aura si fara aura au fost demonstrate in Tabelul 2. Compararea acestor caracteristici cu 2 test a demonstrat caracterul pulsativ, care a fost gasit mai frecvent in migrena cu aura. (2: 4.88, P<0.005). Caracteristicile cefaleei de tip tensional cronica si episodica au fost prezentate in Tabelul 3. N-au fost diferente statistice (2 test) intre cele doua tipuri de cefalei tensionale.

Tabelul 3 Caracteristicile cefaleei de tip tensional cronice si episodice Bilateralitatea Caracterul de presiune/inclestar e Impactul asupra activitatilor zilnice % 33.3 38.2

Agravarea la efort fizic

% Cronica Episodica 73.6 70.1

% 34.7 39.6

% 45.8 45.1

Simptome insotitoare

Phonofobia 85.3% a fost cel mai frecvent simptom al migrenei insotit de greata (80.4%) si photofobia 177.6%. Voma a fost observata la 44.8% din pacientii cu migrena in MWA, cea mai comuna aura au fost dereglarile vizuale, incluzind scintilatia sau distorsia imaginii, hemianopsia si intunecarea vederii (81.8%), insotita de tinitus/vertije (67.1%), simptome senzoriale (34.3%) si afazie (15.4%). In cazurile de cefalee de tip tensional, phofobia a fost de asemenea cel mai des simptom insotitor. Greata a fost observata la 40.7% din pacienti, iar photofobia la 14.4% din pacienti. Simptomele insotioare ale migrenei cu si fara aura, au fost demonstrate in Tabelul 4, iar cele de cefalee de tip tensional episodice si cronice in Tabelul 5. In ceea ce priveste aceste constatari, n-a fost diferenta statistica intre migrena cu si fara aura. Totusi, cand comparatia similara a fost facuta intre subtipurile cefaleei de tip tensional, simptomele de greata (2: 6.48, P<0.001), voma (2: 5.12, P<0.05) si phonofobie (2: 4.48, P<0.005), au fost gasite ca cele mai frecvente in cefaleea cronica de tip tensional.

Tabelul 4 Simptomele insotitoare ale migrenei cu si fara aura Greata % MWA 81.0 Voma % 47.6 Phofobia % 89.2 79.6 Photofobia % 82.1 71.2

MWOA 83.1 40.7 Nota: MWA Migrena cu aura; MWOA - Migrena fara aura.

Factorii trigger (declansatori)

Cei mai frecventi factori declansatori ai atacurilor de cefalee au fost stresul (la migrena 81.8%; la cefalee de tip tensional 83.3%), privarea de somn (la migrena 37.1%, cefalee de tip tenional 39.4%), factorii hormonali ca menstruatia (la migrena 35.6%, cefalee de tip tensional 24.5%), sarcina (la migrena 16.1%, cefalee de tip tensional 6.0%). Diverse alimente nu joaca vre-un rol semnificativ ca factor declansator la pacientii cu migrena (cascavalul 0%, ciocolata 1.4%). 32.2% a migrenei cu aura si 42.4% a migrenei fara aura au fost raportate ca cefalei provocate de menstruatie. Cand comparam aceste frecvente, ele au fost gasite din punct de vedere statistic neschimbate. 5 pacienti (3.5% migrenosi; 3 MWA, 2 MWOA) au fost raportati cu cefalee de tip migrenos, relatate doar la menstruatie, iata de ce ei sunt considerati pacienti cu migrena menstruala pura.

Impactul asupra activitatilor zilnice

Activitatile zilnice de rutina au fost afectate in 76.6% de migrena 37.5% din pacientii cu cefalee de tip tensional, din cauza severitatii cefaleei. In ceea ce priveste acest factor, o diferenta nesemnificativa a fost gasita intre migrena cu si fara aura sau intre cefalee de tip tensional cronica si episodica. La pacientii cu cefalee de tip tensional comparand prezenta impactului asupra activitatilor zilnice cu caracteristicile cefaleei si simptomele insotitoare a fost gasita legatura intre impactul asupra activitatilor si agravarea lor la efort fizic (Spearman p:0.27, P=0.001). Cand o comparatie asemanatoare a fost efectuata la pacientii cu cefalee de tip migrenos n-a fost gasita vre-o relatie. In cazul altor pacienti cu cefalee, caracterul pulsatil (P<0.005), agravarea la eforturi fizice (P<0.01), simptomele insotitoare de greata (P<0.001), voma (P<0.05), si photofobia (P<0.05) au fost gasite pentru a relata impactul cefaleei asupra activitatilor zilnice in analizele gradului de corelatie al lui Spearman.

Tabelul 5 Simptomele insotitoare ale cefaleei de tip tensional cronice si episodice

Greata % Cronica Episodica 52.8 34.7

Voma % 13.0 10.0

Phofobia % 61.1 45.8

Photofobia % 19.4 12.5

Somnul si cefaleea In studiul nostru lipsa somnului a fost raportata la 23% de migrenosi si 20.8% de pacienti de tip tensional.

Relatiile pacient medic 75.5% din pacientii cu migrena si 56.7% din cei cu cefalee de tip tensional au fost consultati de medicul generalist in privinta durerii lor de cap. 51% din migrenosi stiu despre migrena lor.

Masuri de tratament Partea utilizarii medicamentelor la pacientii migrenosi a fost identificata pana la 90.9%, in timp ce la pacientii cu cefalee de tip tensional 63.4%. O alta masura importanta este aflarea in singuratate intr-o odaie si somnul (la migrena 86.0%, CTT 66.7%), masajul (migrena 38.5%, CTT 31.0%), compresele reci sau fierbinti (migrena 10.5%, CTT 6.0%).

Istoricul familial 43.4% din migrenosi aveau un istoric familial cu cefalei similare (48.8% migrena cu aura, 35.6% migrena fara aura), in timp ce istoricul pozitiv familial a fost raportat la 32.9% din pacientii cu CTT. Reisend din acestea, nu a fost gasita o diferenta semnificativa intre tipurile de cefalee.

Discutii Acesta este studiul epidemiologic al populatiei bazat pe femeile cu cefalee din Turcia. Noi am incercat sa evaluam caracteristicile socio-demografice si clinice ale cefaleelor de tip tensional si cele de tip migrenos. In cele ce urmeaza noi am clasificat cefaleele de tip tensional si cele de tip migrenos in episodice si cronice, iar la migrena cu aura si fara aura. Caracteristicile clinice ale simptomelor insotitoare au fost evaluate la toate subtipurile cefaleelor si comparate intre ele. Atitudinea pacientilor fata de cefalee a fost investigata si ea. Indicii de corespundere criteriului IHS in toate tipurile si subtipurile au fost considerate si comparate. Orice necorespundere semnificativa intre subtipuri a fost evaluata. Relatia dintre caracteristicile durerilor de cap si simptomele insotitoare, si impactul asupra activitatilor zilnice au fost special studiate in tipurile cefaleelor si pacientii cu dureri de cap. Ca rezultat, luand in consideratie toti pacientii cu cefalee, am identificat relatii statistice semnificative intre unele caracteristici si simptomele insotitoare cu severitatea durerii de cap. Aceste caracteristici si simptome insotitoare au fost tipic asociate cu cefaleea migrenoasa; pulsatii, agravarea starii fizice, greturi, vome, phonofobia. La cefalee de tip tensional, severitatea a fost asociata cu agravarea starii fizice. Constatarea aceasta era in conformitate cu lucrarea lui Lavados si a lui Tenhamm (4), in care ei indicau ca agravarea cefaleei cu migrarea durerii la cefalee nu sunt discriminatori specifici ai sindromurilor de cefalee, ci posibil ca erau mai mult legate de severitatea durerii. Nici o legatura de acest fel nu a fost gasita la tipul cefaleelor migrenoase. Migrena este de obicei unilaterala, pulsatila, de la moderat pana la sever ca intensitate, si deseori asociata cu greturi, photofobie si phonofobie. Intr-un studiu realizat anterior asupra pacientilor cu migrena fara aura intr-un spital universitar din Turcia (5), 58% sufereau de dureri pulsatile, 74% aveau dureri de cap unilaterale. Agravarea prin activitati fizice de rutina a fost gasita in proportie de 96% in cadrul studiului mentionat. Rezultatele noastre (pulsatia 96.6%, dureri unilaterale 49.2% la pacienti cu MWOA) se deosebesc de acest studiu, posibil datorita diferentei de studiu a populatiei. Caracteristicile clinice a migrenei au fost gasite relativ similare cu cele din tarile vestice (6,7). Cel mai mic coeficient de cazuri unde se intalneste asa simptom ca voma, intalnit in Korea si Ungaria, nu a fost confirmat de cercetarile noastre (8,9). Am depistat un coeficient semnificativ mai mare al pulsatiei in MWOA comparativ cu MWA. Acest fapt nu a fost confirmat nicaieri in alta parte. Russell et al.(10) au declarat ca ei s-au retinut sa faca o analiza statistica comparativa intre MWOA si MWA din motivul ca exista o diferenta in criteriul de includere. Insa noi credem ca manifestarea pulsatiei la MWA se datoreaza patofiziologiei. Depresia corticala raspandita si schimbarile fluxului sanguin celebral sunt responsabile de aura migrenei. Aceste

procese pot cauza dureri din ambele parti a capului prin conexiuni centrale (11). Aria rostrala a creierului are un rol central si determinant in migrena (12). Este de-a dreptul plauzibil de considerat daca proiectiile de la aceste zone centrale a creierului spre cortex participa la initierea aurei si schimbarile vasculare a migrenei (11), precum si daca ele cauzeaza o astfel de diferenta a durerii la alte subtipuri ale migrenei. Cefaleea de tip tensional este caracterizata de o prezenta bilaterala, presiune/inclestare, domoala sau moderata ca intensitate, si de obicei, nu este agravata de activitatile fizice de rutina (13). Coeficientul indicat de noi privind cefaleele insotite de presiune/inclestare (38%) a fost determinat ca fiind mai mic comparativ cu cele indicate in lucrarile anterioare (52%-73.8%) (4,8). Un coeficient inalt al caracterului unilateral a fost indicat (28.7%) pentru acest tip de cefalee. Prezenta unui inalt coeficient al exacerbarii activitatilor fizice (45.4%), fapt prezentat in cateva studii recente (7, 14-16). In studiul nostru, photofobia a fost anuntata in 14.8% de cazuri la pacienti cu CTT. Aceasta descoperire este in corespundere cu alte studii (17, 18). N-am depistat un coeficient inalt al photofobiei (82%) indicat de Vanagait si Stovner (19). In evaluarea criteriului de diagnosticare IHS, unii autori cum sunt Messinger et al. (20) au sugerat evaluarea separata a criteriului in loc de cea traditionala, a tuturor criteriilor laolalta. Ei au raportat ca suprapunerea diagnosticilor in cazul migrenei si cefaleei de tip tensional ar putea fi diminuata daca simptomele cefaleei, cum sunt intensitatea, durata, calitatea, agravarea prin activitati fizice, nu ar fi folosite impreuna pentru a construi un criteriu comun, ci fiecare simptom ar fi tratat ca un criteriu separat (21). Unii autori au propus ca intensitatea durerii sa fie cel mai important dintre cele patru caracteristici ale durerii la migrena fara aura. Astfel, aceasta poate ajuta in diferentierea migrenei fara aura si CTT (18, 21). In acest studiu, noi am gasit o relatie dintre severitatea intensitatii durerii si cateva alte caracteristici migrenoase, facand o analiza a situatiei tuturor pacientilor. Insa, n-am fi putut constata nici o relatie intre pacientii cu cefalee migrenoasa si CTT, considerate aparte una de alta. Aceasta constatare a relevat ca atunci cand durerea devine mai severa, ea capata caracteristici migrenoase, cum ar fi pulsatia, agravarea starii fizice, greturi, vome si phonofobia. Totusi, caracterul unilateral si photofobia nu au fost determinate ca fiind datorate intensitatii durerii. Comparand CTT cronic si episodic, greturile, vomele si phonofobia au fost gasite ca mai des intalnite in cazul CTT cronice. Aceasta descoperire este considerata in corespundere cu criteriul IHS, conform caruia simptomele apar mai ales la CTT cronice. Prevalenta migrenei studiata timp de un an corespunde rezultatelor altor studii (22). Insa noi am depistat mai multi pacienti MWA decat MWOA, faptul care este surprinzator de contradictoriu fata de rezultatele altor studii (2, 10, 21, 23). Prezenta aurei face ca

MWA sa fie mai usor depistata. Exista si o problema diferentiala mai cu seama intre cefaleea de tip tensional episodica si migrena fara aura (24, 25). De asemenea, uneori aceste doua tipuri de cefalee pot coexista la unul si acelasi pacient (26, 27). In asa caz, in studiul efectuat de noi, pacientii s-ar fi putut plange doar de cefaleea de tip tensional, care probabil este mai frecventa si retinuta ca cea mai deranjanta, ca raspuns la intrebarea: Aveti dureri de cap pronuntate, care deranjeaza?. Prevalenta CTT de un an a fost similara celor prezentate in alte studii (8, 28). Prevalenta cefaleei de tip tensional cronice a fost depistata in 2-3% de cazuri conform studiilor precedente (6, 28). Coeficientul de prevalenta CTT cronica prezentata de noi, a fost mai inalt (6.3%) comparativ cu cele, similare studiului efectuat mai devreme in Turcia (2). In studiul nostru, prevalenta migrenei a fost mai inalta la grupul de varsta 35-44 de ani si respectiv mai joasa la grupul de varsta mai mare de 65 de ani. Acest fapt corespunde rezultatelor multor studii (14, 29-34). Rata mai mare a migrenei la femeile de varsta reproductiva, comparativ cu femeile de alte varste a fost legata de prezenta oestrogenului (35). Inainte se sugera ideea ca migrena este asociata cu inteligenta sporita si clasa sociala (9). Mai tarziu, in unele studii, a fost regasita tot mai des la pacientii cu un nivel mai jos de educatie si o situatie economica mai slaba (1, 6, 10, 36-39). Am depistat o rata mai mare a prevalentei migrenei la pacienti cu studii si casatoriti. Totusi, statutul profesional si nivelul economic nu au fost gasite sa aiba legatura cu rata prevalentei migrenei. In studiul efectuat de noi, prevalenta a fost gasita a fi mai mare in zonele urbane, opus rezultatelor prezentate de Martin et al. (40). In majoritatea studiilor, aria rezidentiala nu a fost corelata cu prevalenta. In literatura de specialitate, multe studii prezinta teoria ca prevalenta CTT este cea mai mare intre 30 si 39 de ani si apoi scade cu inaintarea in varsta (7, 28, 41). In cercetarile noastre, prevalenta CTT a fost determinata a fi mai mare la grupul de varsta 45-64 de ani. Aceasta descoperire poate fi atribuita unur stresuri sociale in viata familiala a grupului de varsta respectiv. Nu am putut identifica nici o legatura intre alte proprietati socio-demografice si prevalenta CTT, in conformitate cu alte studii (42). Am observat ca tipul de CTT cronic se intalneste la cei varstnici si cu mai putine studii, ceea ce coincide cu descoperirea facuta de Schwartz et al. (28). In literatura, aproape jumatate din persoane care sufera de migrena si mai mult de 80% de persoane cu CTT au recunoscut ca nu au contactat un medic generalist pentru cefalee (22). In cazul femeilor si pacientilor suferinzi de migrena, procentul de prezentare la consultatii au fost declarate a fi mai mare (43). Procentul de prezentare la

consultatii la medicii generalisti a fost mai mare decat cel indicat in studiile precedente, fapt datorat posibil studiului nostru care se efectueaza la femei. Am avut cateva limitari in studiul nostru. Rasmussen et al.(29) a indicat ca modul in care sunt puse intrebarile despre cefalee, cum ar fi Suferiti de dureri de cap? sau Ati avut vre-odata dureri de cap? ar putea influenta rezultatele studiilor epidemiologice. Presupunem ca utilizarea cuvintelor a suferi de a fost indicata sa aiba o prevalenta mai mica decat utilizarea verbului aveti. Aceeasi idee este aplicata, in studiul nostru, si intrebarii Aveti dureri de cap pronuntate, care deranjeaza?. Am pus intrebari detaliate despre caracterul celor mai suparatoare dureri de cap subiectilor. Aceasta exprimare ar putea fi confundata de unii pacienti, care sufera de mai multe tipuri de dureri de cap si ar putea influenta prevalentele. Aceasta insa este o problema generala in incercarile de a face o clasificare a pacientilor in grupuri, conform tipurilor de cefalee. Intervievarile sunt o metoda preferata in cercetarile masive (44). In acest studiu, studentii la medicina, antrenati de neurologi, au efectuat intervievari, iar deciziile finale asupra cazurilor intalnite au fost luate atat de neurologi cat si de studenti. Totusi, ar fi fost mai bine daca cei care intervievau pacientii sa fi fost neurologi specializati in obiectul cefaleelor. Studiul a fost efectuat in exclusivitate la femei, deoarece stabilirea unui contact cu ele a fost mai usoar decat in cazul barbatilor si pentru ca ele pot fi mai usor gasite acasa. De altfel, femeile sunt o categorie speciala si importanta in studierea cefaleelor.

Concluzie Aceste cercetari, bazate pe cercetari masive, a avut ca obiect de studiu caracteristicile clinice si factorii socio-demografici in manifestarea migrenei, CTT si a subtipurilor lor. Credem ca aceste cercetari sunt de asemenea interesante, deoarece discutarea simptomelor clinice si relatia lor cu severitatea durerii este actuala.

-------------------------------------------------------------------------------------------------------------------------------S 111 European Journal of Neurology 2005.12(suppl 1)59-62. Original Article Cost of migraine and other headaches in Europe. Costul migrenei i a altor cefalei n Europa. J.Berg and L.J. Stovner

Cu mai bune(mai optime), dar mai costisitoare opiuni de tratament devenite mai accesibile pe parcursul ultimilor 10- 15 ani migrena i alte patologii cefalalgice au devenit subiectul unui interes considerabil pentru economia sntii i perspectivele sntii publice. n raportul OMS, din 2000 grade de severitate a diferitor patologii, pacienii cu atacuri severe de migren au fost considerai mai afectai dect cei cu psihoze active, demene sau cei cu tetraplegie. Privind numrul de ani trii cu disabilitate(ILDs), cauzate de variate patologii mondiale, migrena depete numrul 19 ( numrul 9 la femei(printre femei))(Maters et al. 2002). Migrena e o form relativ sever de cefalee, ce survine n form de atacuri, de obicei cu durata ntre 4 ore i 3 zile, acompaniat(nsoit) de fenomene dizabilitante ca greaa sau vomele, intolerana sever a luminii, sunetelor, mirosurilor i al micrilor corpului. Cefaleea de tip tensional e de obicei mai puin dizabilitant ca migrena i cu mai puine fenomene asociate( de acompaniere, de nsoire). Acest tip de cefalee nu a fost considerat n raportul OMS cel mai impotant( mai presus de orice), dar deoarece el este cel mai prevalent tip de cefalee i de asemenea are tendina de a deveni cronic la o substanial parte a pacienilor, consecinele individuale i sociale ale CTT pot fi la fel de semnificative ca i cele ale migrenei. Alte forme relativ rare, aa ca cefaleea n ciorchine(cluster), poate fi chiar mai disabilitant dect migrena pe timpul atacului. Fr a ine cont de diagnoz consecina pentru majoritatea suferinzilor este, c funcia normal este ntrerupt de episoade de cefalee cu intervale neregulate i imprevizibile, iar aceasta poate impune severe limitri n viaa cotidian, la coal, munc i pe parcursul timpului de odihn. Aceasta i faptul, c patologiile date par a fi extrem de prevalente n toat lumea, le face importante din punctul perspectivei economice. Faptul, c cefaleele predomin la femei i c suferinzii de dureri de cap au o ateptare a vieii normale poate explica de ce pacienilor cu cefalee nu li s-a acordat atenia i resursele, pe care ei le merit. Prezentul studiu(cercetare) este o ncercare de a calcula costul patologiilor cefalalgice n Europa, bazat pe studiu epidemiologic i economic. Metodologia Cercetrile studiilor epidemiologice relevante au fost descrise anterior n revistele studiilor epidemilogice al cefaleelor n Europa(Stovner et al.) Studiile epidemiologice privind cefaleea i migrenele sunt accesibile pentru majoritatea rilor Europei de Vest, dar sunt foarte puine studii pentru Europa de Est i cele privind cefaleea de tip tensional.

Doar studiile bazate pe populaie cu date epidemiologice privind cefaleea n general , migrena i cefaleea de tip tensional au fost incluse n studiu(overview). Caatare nu sunt studii(virtual), ce ar avea date despre incidena cefaleelor i aproape toate studiile au prezentat rata prevalenei(de 3 luni, de 1 an sau pe via). Majoritatea studiilor au utilizat ratele prevalenei de un an ( pe 1 an), parametrul, ce indic proporia populaiei cu patologie activ(prezent), ce este mai relevant pentru calcularea consecinelor economice. Privind migrena i cefaleea de tip tensional doar studiile aprute dup ncercarea(advent) publicrii n 1988 al criteriilor de diagnostic de Societatea Internaional de Cefalei(IHS) au fost discutate(luate n consideraie). Datele extrase din acest studiu au fost prevalena general i distribuia printre sexe i diverse grupuri de vrst i de fiecare dat accesibile datele despre prevalena cefaleei cronice(definite ca cefalee, ce dureaz > 15 zile pe lun sau e zilnic), frecvena cefaleei(numrul zilelor pe lun sau pe an) i absenteismul la serviciu. Cercetrile metodologiei i a rezultatelor studiilor economice de sntate au fost deasemenea descrise detaliat anterior(Berg, 2004). Bazate pe studiera literaturii studiilor, ce conin date despre costul migrenelor i a altor cefalei, 11 studii Europene, care au evaluat costurile direct i indirect al migrenei au fost identificate. Trei din aceste studii au fost excluse din cercetare din moment ce ele nu au utilizat perspectivele sociale. N-au fost gsite studii, ce ar analiza costul cefaleei de tip tensional sau alte cefalei nemigrenoase. n concluzie costul estimat pentru migren a fost accesibil pentru Frana(Mchel et al., 1993,1999),Germania(Neubauer and Ujlaky, 2002), Niderlanda(Van Roijen et al., 195), Spania(Lainez, 2003), Suedia(Bjork and Roos, 1991) i din Marea Britanie(Blau and Drummond, 1991; Cull et al., 1992). n general majoritatea studiilor au fost efectuate nainte de 1995, nsemnnd, c impactul clasei triptanelor asupra ambelor- costului direct i indirect nu a fost inclus n acest studiu. Deoarece aceste medicamente probabil(posibil) au dus la creterea costului medical direct, aceasta ar putrea duce la salvarea termenilor sau ameliora productivitatea. Deoarece nu sunt studii bazate pe populaie, privind costul patologiilor, care au condus la aprecierea potenialelor schimbri n distribuia costului, rezultat din patternul nou de tratament. Toate identificrile costurilor estimate s-au bazat pe prevalen, dar au fost altfel primite(derivate, extrase prin amestecarea metodologiilor).Costul direct a fost mai

frecvent calculat, utiliznd modurile de abordare cele mai inferioare, n timp ce costul indirect a fost mai des obinut prin metoda de vrf. n cazul migrenei vizitele pacienilor de ambulator i tratamentul farmacologic s explice(s justifice majoritatea costurilor medicale directe .(?) Studiile bazate pe populaie, analiznd costul indirect au utilizat de obicei chestionare pentru estimarea impactului migrenei, privind lipsa de la lucru i producivitatea. N-au fost identificate studii, care ar statifica costul dup vrst sau severitate bolii.Datele costurilor au suferit inflaie n jurul anului2004 cu indicele de pre al consumatorului i schimbat n Euro, ajustat la puterea de cumprare (Eurostat, 2004 a,b; European Central Bank, 2004). Rezultate Lund n consideraie datele epidemiologice, au fost gsite mari variaii n prevalena att a migrenei, ct i a cefaleei n diferite ri Europene(Tab.1). Durerea de cap i migrena au prevalat n grupurile de vrst de la 20 pnla 50 ani la ambele sexe i aici era o preponderen feminin clar n tote grupurile de vrst, cu excepia copiilor. Selectnd articole, care includeau grupuri de vrst de cel puin 25-65 ani, a fost gsit media prevalenei de 1 an a durerii de cap ca fiind-51%(61%- femei; 44%Brbai), a migrenei-14%(17%- femei, 8%- brbai), a durerii cronice de cap4%(6%-femei, 2%- brbai). Deoarece a fost efectuat numai un studiu, care percepea prevalena de 1 an al CTT la aduli, nu a putut fi calculat media pentru acest tip de dureri de cap. Deseori a fost dificil de comparat datele despre durerea de cap din diferite studii, dar pare , c att migrenoii,ct i cei cu CTT au dureri de cap n medie 30 de zile pe an. Relativ recent i studiile bazate pe populaie au indicat, c 14-15% din persoanele adulte au absentat de la serviciu din cauza durerii de cap n Danemarca(Rasmussen et al.,1992) i n Anglia(Boardman et al., 2003), i numrul zilelor absentate de la serviciu erau de la 1100 pn la 1300 zile pentru 1000 de angajai pe an n aceste studii . Dac se iau n considerie studiile, ce vizeaz(au de afacere) consecinele economice a durerii de cap, a fost gsit, c costul anual, estimat pentru migren variaz substanial n dependen de 1 din 6 ri, unde au fost percepute(efectuate), ncepnd cu 100 Euro pentru un pacient n Suedia pn la 900 Euro n Germania. (Tab. 2.)

Numrul zilelor cu eficacitatea lucrului redus au fost estimate ca fiind de 4 ori mai mare(Boardman et al., 2003) i totui rezultat ntr-o pierdere de timp de lucru chiar mai mare dect zilele absentate . Cauzele majore pentru aceste variaii nu sunt corecte n diferite metodologii i ani de referin. Marea majoritate a costurilor totale, ntre 72% i 98% sunt din cauza pierderii productivitii, sub forma absenei de la serviciu i o medie a nivelului eficacitii de 65%. n timpul lucrului cu migrena, care duce la pierderea a mai mult de 4,1 zile pentru un pacient. Costurile raportate la genuri, femeile tind s piard mai multe zile lucrtoare dect brbaii, dar costurile indirecte sunt similsre pentru salarii mai joase i fora de participare printre femei. Discutarea(dezbaterea) Principalele dificulti a datelor epidemiologice sunt lipsa de studii n pri mari a Europei(n particular n Est) i a puinelor informaii despre cefalei de tip tensional, care este i cel mai frecvent tip de durere de cap. Cea din urm deficien este compensat de datele bune despre cefalei n general, dup ce se poate aprecia rezonabil c diferena dintre prevalena cefaleei i cea a migrenei pentru un nalt grad(>80%) const din pacienii cu CTT. Analiznd variaiile n prevalena durerii de cap dintre diferite studii i ri, pare, c cea mai mare parte, dac nu n ntregime, din aceast variaie poate fi asociat ca diferene de metodologie. Factorii metodologici importani par a fi vrsta i compoziia n dependen de sex a populaiei, tipul prevalenei perioadei( un an versus prevalena pe via), i cile criteriilor Societii Internaionale de studiere a cefaleei(IHS) sunt implimentate n studiu. Frazarea exact a ntrebrii ecranizate(?) este foarte important, dup cum ratele prevalenei cefaleei sunt n general mult mai nalte n studii, utiliznd o ntrebare neutr(Ai avit dureri de cap?) dect n studiile cu o ntrebare referitoare la gradul cefaleei sau a frecvenei cefaleei.(Ai suferit vreo dat o durere de cap, Ai avut mai mult de 3 cefalei n ultimul timp X?, etc. ). Avnd n vedere faptul, c este imposibil de corectat aceste diferene metodologice n mod sistematic, nimeni nu poate concluziona cu precizie faptul, c acestea sunt variaii reale n prevalena cefaleei de-a lungul coninutului. Deci pentru calcularea costurilor durerii de cap bazate numai pe date epidemiologice pentru orice ar n particular, probabil este mai corect de a folosi datele sumare pe prevalena dat n selectarea rezultatelor . O problem principal n informaiile despre cost accesibile n Europa i n State este c ele se refer doar la migren. Spre cunotina noastr nici un studiu nu a cuprins costurile CTT sau a cefaleelor nemigrenoase ca informaii( pentru date). Aceasta conine un gol major n cercetrile curente, de cnd Ctt afecteaz o proporie mult mai mare a populaiei, dect o face migrena i totui un component major al costurilor cefaleei nu poate fi estimat cu precizie. Pe deasupra

studiile costurilor de boal n cazul migrenei identificate pe parcursul acestui sondaj s-a bazat n principiu pe datele obinute n 1995, nsemnnd, c majoritate costului estimeaz , c nu s-au identificat schimbri recente n strategiile de management(control) a pacientului, incluznd utilizarea medicamentelor cu triptan. n medie, se pare datele disponibile despre pre n Europa se afl sub estimarea costurilor actuale. Pe de-o parte estimarea cea mai aproape de nivelul minim, n general folosit pentru costurile directe poart riscul subestimrii sau neglijrii itemii relevani a costurilor, n timp ce costurile indirecte au o sensibilitate nalt la metoda de calculare utilizat, care variaz pe parcursul studiilor. Totui, estimrile conservative luate din studiile relevante constituie pragul minim al costului. n fnal, majoritatea studiilor despre cost nu au inclus copii i adolesceni n evalurile sale, nsemnnd, c costurile introduse de acest segment a pacienilor nu snt implicate. Oferind disponibilitatea limitat a studiilor moderne i surprinztoare de cost al bolii pentru majoritatea rilor Europene, oricare estimare al impactului total al migrenei i a altor cefalei n Europa trebuiau s fie interpretate ca cele mai bune presupuneri, bazate pe o eviden disponibil(util) i presupuneri rezonabile. Totalitatea diferenelor absolute i relative a preurilor ntre ri trebuie ajustate, calea prin care serviciul de sntate e finanat i furnizat e i mai greu de evaluat. Cea mai reuit cale de extrapolare din datele existente este utilizarea mediei celor mai reprezentative estimri a costului ca baz. Pentru migren, estimrile relevante a costurilor sunt din Marea Britanie, Germania(ajustate cu utilizarea ratei salariale n loc de venitul total intern familial pentru costul indirect ) i Frana (ajustate, adaptate) cu utilizarea mediei dintre Marea Britanie i costurile adaptate din Germania cu productivitatea redus de munc).Studiul Danez nu a fost inclus datorit utilizrii metodei neclare de apreciere a costului. Astfel costul anual mediu e de 590 Euro pentru un pacient cu migren poate fi asumat de aceste trei ri europene. De aici sunt 14% de migrenoi printre aduli, costul anualtotal al acestei patologii n rile date poate fi estimat de numrul adulilor n populaie0,14 590 Euro. O estimare i mai aproximativ pentru costul cefaleei, mai degrab dect migrena singur(n parte poate fi obinut prin utilizarea rezultatelor din Danemarca (Rasmussen et al., 1992) i Marea Britanie(Boardman et al.) studiile bazate pe populaie, care la un loc (mpreun) demonstreaz, c n jurul a 1100-1300 zile la 1000 de persoane, ce lucreaz, au lupsit de la serviciu din cauza cefasaleei n fiecare an. Cercetrile Britanice de asemeni sugereaz c numrul zilelor cu reducerea eficacitii (n= 5213) e aproximativ de 4 ori mai mare dect numrul zilelor omise(lips) (n=1327).

Dac cineva presupune, c eficiena lucrului a fost redus (s-a redus) cu o treime pe parcursul acestor zile( privete secia rezultatelor) de aici rezult, ca adaos la 1700 zile de munc pierdute(i.e)din totalul a 3000 zile pentru 1000 de lucrtori au fost probabil pierdute din cauza cefaleei n fiecare an. Productivitatea pierdut din cauza cefaleei a putut fi calculat(estimat) dup aceea n baza a 3 zile pierdute pe an pentru toi angajaii, care, spre exemplu n germania au rezultat din costul indirect de 18 Euro pe an din cauza cefaleei. Presupunnd acestea, pentru estimrile ajustate pntru migren, costul direct constituie aproximativ 8% din costul indirect, costul total pentru pacienii cefalalgici(fr corespundere cu diagnoza) pot fi apoi aproximate pe baza ratei prevalenei 51%n populaia general. Utiliznd estimrile din Frana, Germania, Marea Britanie costul total pentru pacienii cefalalgici putea fi astfel estimat brut la 425 Euro pe an(din care 394 Euro ar fi costul indirect i 32 E.- costul medical direct. Totui, deoarece aceste date s-au bazat pe estimri aproximative a costului cefaleei d tip tensional, costul total al cefaleelor poate fi scopul(centrul) viitoarelor cercetri i nu va fi utilizat la estimarea costului patologiei creierului la aceast etap. Concluzii n sumar, migrena cu prevalena de 1 an de 14% la populaia adult pare s determine costul de 590 de Euro pe an pentru pacient n rile Vest-Europene. Nu au fost gsite date despre costuri pentru Europa n privina cefaleei n general i deci estimarea costului agregat(?) se centreaz pe migren. Dei costul unui pacient pentru alte tipuri de cefalei pare a fi ceva mai jos dect cel pentru migren, costurile ntregii societi pentru cefalee sunt, desigur, mult mai mari dect ceea, ce poate fi calculat n baza datelor migrenei, n timp, ce cefaleea afecteaz n general 50% din populaie n fiecare an. Ambele costuri i datele prevalenei trebuie, totui , considerate (ca date curente cu cele mai bune aproximri) asupra epidemiologiei i a costului migrenei i a altor dureri de cap(suferine). n plus datele despre costuri nu sunt recente i nu iau n consideraie evoluiile(descoperirile) recente n managementul durerilor de cap. Prin urmare este nevoie de a avea studii recente i bazate pe nelegerea populaiei, care includ toate costurile, care rezult din cauza migrenei i a altor cefalei. Sunt necesare i alte studii din ri aflaten afara majoritii pieelor farmaceutice din Europa de vest. La un nivel metodologic, o apropiere standartizat i s sperm mai de

ndejde(ncredere) asupra costului de boal ar facilita o viitoare hotrre asupra fondrii cercetrilor de cefalei i managementul lor. Pentru noi msuri severe de(soluionare a problemei) urgen a durerii de cap, ar fi important de neles cum sunt relatate costurile la severitatea bolii, astfel nct strategiile de management pot fi specificate pentru fiecare subpopulaie. n special viitoarele analize a diferito r msuri(date) ale productivitii sunt necesare pentru a permite o evaluare real a costurilor indirecte, care constituie ...(?) atacului migrenei. n acest context, ar fi interesant de neles costurile intangibile a condiiei prin conducerea cercetrilor asupra scorurilor utilitare pentru diferite nivele ale severitii i a costurilor relatate calitii anilor de via , pierdui din cauza migrenei.

S XXXII Headache: The Journal of Head and Face Pain Vol 42 P. 963-November 2002. Issue 10 Prevalence and Clinical Characteristics of Headache in a Rural community in Oman. Dirk Deleu,MD et al. Obiective: mbuntirea studiului prospectiv epidemiologic al cefaleelor n comunitatea rural Oman, evaluarea prevalenei, profilului simptomelor i utilizarea patternului de ngrijire medical. Metode: Utilizarea studiului door-to door de estimare a prevalenei, care a fost bazat pe chestionarul structurat de evaluare a cefaleei, care efectuiaz diagnosticarea migrenei i CTT n acord cu criteriile IHS(Societii Internaionale a Cefaleelor)efectuat pe 1158 persoane. Rezultate:Prevalena nefinisat(preventiv)pe via i pe durata de 1 an al cefaleei a fost de 83,6% i de 78,8% respectiv,cu preponderen la femei. Prevalena de 1 an al migrenei i CTT a fost de 10,1% i 11,2% respectiv. Nu este o diferen semnificativ dup gen(sex) n prevalena migrenei (4,5% la femei i 5,6% la brbai), dar CTT a fost de 2,6% ori mai frecv. la femei(3,1% la brbai i 8,1% la femei). Prevalena de 1 an al cefaleelor frecvente a fost de 5,4%, 48% din respondeni au cerut asisten medical, privind cefaleea i 79% au utilizat medicaia, iar 40% din eiautomedicaia. Concluzii: Acest studiu prospectiv a demonstrat, c prevalena cefaleei este la fel de nalt n aceast comunitate.

Migrena i CTT au o prevalen similar, dar distribuia dup sex e diferit de cea dinrile din Vest. Prevalena CTT ests substanial mai joas dect cea observat n alte pri ale lumii. Cefaleele frecvente au fost la fel de des ntlnite ca i n alte studii asemntoare n lume. Utilizarea analgezicelor, ct i abuzul probabil de asemenea coexist cu cefaleea, deoarece automedicaia mai este destul de rspndit.

S XXX Curr. Pain Headache Rep. 2003 Dec;7(6):455-9. Diagnosis, epidemiology and impact of tension-type headache. Jensen R. Dei CTT este cea mai prevalent cefalee i afecteaz 78% din populaia dgeneral, impactul substanial individual i social asociat cu aceast cefalee primar este trecut cu vederea(neglijat). n contrast cu migrena , concentrarea asupra CTT este limitat. Muli pacieni cu forme de Ctt cronic, care afecteaz 3% din populaie sunt lsai (abandonai) fr orice trataent specific. CTT cronic difer de forma episodic prin frecven, lipsa efectului la majoritatea strategiilor de tratament, mai mult abuz medicamentos i o mai mare scdere(pierdere) a calitii vieii. Zilnic sau aproape(practic) zilnic deasemenea constituie o problem de diagnostic i tratament i separarea( deosebirea) CTT cronic de migren(cefaleea migrenoas) i de cefaleea indus de medicaie este o provocare, deoarece strategiile manageriale sunt complet diferite. Un beneficiu considerabil pentru societate este obinerea unor strategii specifice, ce vor conduce la reducerea n cantitate al absenteismului pe motiv de boal i a mbuntirii abilitilor de munc. Impactul supra pacienilor afectai i asupra calitii vieii familiilor lor de asemenea pot fi mbuntite prin accepterea general a patologiei(recunoaterea ei) i prin dezvoltarea unei strategii specifice de tratament.

S XXXI CNS DRUGS: 2005; 19(6): 483-97

Medication overuse headache in patients epidemiology, management and pathogenesis. Dowson AJ, Dodick DW, Limmroth V.

with

primary

headache

disorders:

Cefaleea indus de abuzul medicamentos(CIAM) sau MOH- medication overuse headache este o problem medical frecvent ntlnit, dac e asociat cu o stare de boal de lung durat i cu o disabilitate considerabil(scdere considerabil a capacitii de munc). CIAM afecteaz pacienii cu cefalei primare(migrena, CTT i combinaia migrenei i a CTT), ceea, ce schimb patternul cefaleelor zilnice sau aproape zilnice pe o perioad de ani sau zeci de ani, nsoind abuzul medicaiilor simptomatice a cefaleelor. Abuzul medicamentos Medicamentele utilizate n exces includ analgezicele, alcaloizii ergotaminici, triptanele(serotonin 5HT(1/1D) receptorii agonitilor ) i medicamentele, ce conin barbiturice, codein, cafein, tranchilizantele i analgezicele mixte. Pacienii afectai au de obicei un istoric de lung durat de cefalei primare, medicaia abuzivi cefaleea indus de abuzul medicamentos pn la adresarea la mediculgeneralist pentru ngrijiri medicale(dup ajutor). Pacienii cu CIAM(Cefaleea indus de abuzul medicamentos) sunt ndreptai n centre specializate, unde sunt retrase medicamentele, ce au fost utilizate n abuz i li se aplic un tratament de retractare al simptomelor(n tratamentul n staionar i ambulator), profilaxia cefaleelor i limitarea utilizrii medicaiei simptomatice acute. Majoritatea pacienilor rspund la acest tratament, dei prognoza nu este mereu una bun, 50% pot cdea, se pot ntoarce) n starea sau perioada iniial n urmtorii 5 ani. Cea mai bun strategie practicat n prezent este prevenirea abuzului medicamentos n primul rnd prin educaia pacienilor i formal abordarea managerial dirijat(?) n medicina primar(prespitaliceasc), ce const n tratarea cefaleelor primare pn la transformarea lor CIAM. Calitatea evidenei clinice al CIAM este suboptimal i pe departe cercetrile biologice(?) i clinice (solicitate) necesit urgent un ajutor de facilitare a managementului acestor pacieni, mai eficient n viitor.

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J Headache Pain 2003

Epidemiology of migraine Gian Camillo Manzoni, Paola Torelli Prevalena de 1 an al migrenei n populaia general a rilor vestice variaz de la 4% la 9% la brbai i de la 11% la 25% la femei. Brbai(%) Mattson et al.[8]2000 sweden(40-74 ani) Dahlof et al. [9]2001 Sweden(18-74) Lipton et al. [10]2001 SUA(12) Henry et al. [12]2002 France(15) Lipton et al. [11]2002 SUA(18-65) 9,5 6,5 4,0 6,0 Femei (%) 18,0 16,7 18,2 11,2 17,2

Non-Western countries(rile, ce nu sunt situate n vest) Bank, Marton [17]2000 Hungary(15-80) Zivadinov et al [18]2001 Croaia(15-65) Kececi,Dener[18 ]2002 Turkey(7) S XXXII Eur J Epidemiol. 2005; 20(3): 243-9. Has the prevalence of migraine and tension-type headache changed over a 12-year period? A Danish population survei. Lyngberg AC, Rasmussen BK, Jorgensen T, Jensen R. Rata de participare a fost de 75%. Prevalena migrenei nu s-a schimbat semnificativ(11-15%), pe cnd prevalena CTT(7987%) n special CTT frecvent(29-37%) a crescut semnificativ. Prevalena CTT cronice(2-5%) tinde spre cretere. Proporia migrenoilor cu migren de 14 zile i mai mult pe an e n cretere(12-38%). Genul feminin a fost un factor de risc pentru ambele tipuri de cefalei primare. Majoritatea migrenoilor(92-94%) de asemenea au raportat coexistena CTT(asocierea). Concluzii: Prevalena CTT, dar nu i al migrenei este n cretere. Creterea frecvenei migrenei i a CTT sugereaz un nalt impact individual i social al cefaleelor primare acum, ca i 12 ani n urm. 4,3 12,3 7,9 10,7 18,0 17,0

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J. Headache Pain(2003)4: S 55-S 58 General disease costing principles. Amalia Donia sofio, Franco Mazzuca, Francesco S Mennini Studiile recente au demonstrat, c n rile UE(Uniunii Europene)zilele pierdute de lucru n rezultatul migrenei( din cauza migrenei) variaz de la 1,9 la 3,2 la pacient pe an. n toate studiile, indiferent de naionalitate femeile au ntietatea net fa de brbai( women stay away from worc more often than men). Capacitatea muncii scade cu 70% la aceti subieci. Costul spitalizrii peste tot (universally)reprezint doar o mic parte din costul total de management al migrnei: rata spitalizrii e mai mic de 10% i variaz de la 2% n Danemarca la 7% n SUA.

Pentru introducere: Cefaleea este un simptom foarte cunoscut, care poate avea un impact profund asupra calitii vieii. Dou patologii, cele mai cunoscute cefalei primare, migrena i cefaleea de tip tensional au o prevalen unianual 11%i 40% la populaia adult. Patologiile au condiii heterogene, care rezult ntr-un spectru al disabilitii n interiorul i printre diferii indivizi. Dei exist tratamente eficiente pentru muli pacieni cu migren, ea este acum slab cunoscut i slab tratat. Evaluarea dizabilitii la cefalee e important pentru formarea prerii privind terapia acut i preventiv. Cteva chestionare standartizate pentru migren i impactul cefaleei au fost descoperite. Acest tip de chestionare au cel puin 2 utilizri poteniale: 1.Evaluarea grupurilor, rezultatul evalurii studiilor clinice.

Surse la sfrit: Cefaleea este un simptom extrem de rspndit, care poate avea un impact profund asupra funcionrii oamenilor i asupra calitii vieiilor. Dou cele mai frecvent ntlnite cefalei primare: migrena i cefaleea de tip tensional cu o prevalen de 1 an de 11%[Breslau N, Rasmussen BK. The impact of migraine:Epidemiology, risk factors, and comorbidities. Neurology 2001; 56: S4S12] i 40% [Schwarz BS, Stewart WF, Simon D, Lipton RB: Epidemiology of tension- type headache. JAMA 1998; 279: 381-383] n populaia adult. Patologiile, ce au condiii heterogene, rezult n spectru de dizabiliti n interiorul i printre diferite persoane[Stewart WF,Shechter A, Lipton RB. Migraine heterogenity.Disability, pain intensity, and attack frequency and duration. Neurology 1994; 44. S 24-39 ]. Dei exist tratamente eficiente pentru majoritatea rmine nediagnosticat i netratat ndeajuns. pacienilor cu migren, ea mai

n evaluarea patologiei cefalalgice este important luarea deciziilor privind tratamentul acut i preventiv. Chestionarul HIT[Headache Impact Test] include ntrebri privind durerea, funcionarea pesonal, social, oboseala, suprarea emoional, capacitatea de nsuire i sntate mintal. n MIDAS se include informaia despre timpul de munc pierdut, munca casnic sau ntreruperea activitii n ultimele 3 luni. Criterii de selectare: 1.Vrsta 18-65 ani. 2.Reedin permanent(ca s poat fi contactai) 3. A avut o cefalee cu 4 sptmni nainte de interviu(nu din cauza mahmurelii, rcelii sau gripei). Respondenii trebuia s poat: 1. S poat liber conversa n englez; 2. S poat fi intervievai fizic i mental. Rata de participare- 71%.

Prevalena cefaleei n 4 sptmni precedente a fost de 45,7%. Durata interviului a fost 21,5 min.(17-27 min.). Din persoanele, ce nu au raportat, c au avut cefalee n cele 4 sptmni precedente, 35% au spus, c au avut cefalee n ultimele 3 luni. Quality of life research 12: 913-933, 2003 Calibration of an item pool for assesing the burden of headaches: An application of item response theory to the Headache Impact Test(HIT TM). -----------------------------------------------------------------------------------------------------------------------------------------

Nippon Rinsho.2005.oct; 63(10):1705-11. [ Epidemiology of headache] Ocuma H, Kitagawa Y. n articol s-a discutat epidemiologia cefaleelor cronice. Cefaleea e omniprezent(wide spread i o problem costisitoare al sntii publice Rar cine n-a suferit de cefalee: La brbai prevalena pe via e de 93%, iar la femei de 99%. Aproximativ 8,4 mln oameni n Japonia sufer de migren i 22 mln. Au cefalee de tip tensional. Nectnd la dauna, costul i dizabilitatea cauzat de cefalee, muli pacieni cu cefalei nu se adreseaz dup servicii medicale. E important s se recunoasc incidena variatelor tipuri de cef. Cronice, diagnosticarea i tratarea lor corect. n acest articol a fost elucidat incidena, factorii provocatori, prevalena regional i dependena de vrst al incidenei fiecrui tip de cefalee cronic.

Prevalence and Clinical Characteristics of Headache in Medical students Oman Dirk Deleu, MD et al. (Headache2001;41:798-804) Au fost completate chestionare: 151-brbai(37,5%) 252 femei(62,5%).

in

Prevalena pe via i pe durata ultimului an al cefaleei a fost -98,3% i 96,8% respectiv.

Un istoric pozitiv familial de cefalee a fost gsit la 57,6% studeni. Rata de prevalen a migrenei i a CTT a fost gsit asemntoare(12,2%) cu o diferen a distribuiei printre sexe:6,6% din brbai i 15,5% din femei- sufereau de migren, n timp ce 13,9% din brbai i 11,1% din femei aveau cefalee de tip tensional. Doar 23,3% din studeni au cerut asistena medical pe parcursul episoadelor de cefalee i 80,3% au primit medicamente: 24,6% au primit medicamente prescrise, iar 72,4%- medicamente neprescrise8automedicaia) i doar 2,5% au apelat la remedii tradiionale. Probabil utilizarea analgezicelori abuzul lor coexist cu cefaleea la studenii Universitii Sultan Oaboos , ntruct majoritatea lor se bizuiepe medicaia neprescris.

Cefalalgia, 2003,23,381-388. Epidemilogical and clinical characteristics of migraine and tension type headache in 1146 females in Kayseri, Turkey. E Koseoglu , M Nacar et al. Au fost investigate unele caracteristici epidemiologice i clinice ale migrenei i cefaleei de tip tensional i a subtipurilor lor la populaia feminin a Turciei(1146 femei adulte). S-a cercetat relaia dintre severitatea cefaleei i caracteeristicele clinice. Prevalena migrenei a fost apreciat statistic mai nalt la grupul de vrsta de 35-44 ani i la cele, ce aveau studii superioare(P<0,001), cstorite(P<0,01) i care locuiesc la ora(n localitile urbane)(P<0,01). Cefaleea de tip tensional a fost gsit mai nalt la grupul de vrst(persoanele) de 4564 ani(P<0,05). Pacienii cu CTT cronic au fost gsii mai n vrst dect cei cu forme episodice(P<0,01) i mai frecveent la persoanele cu nivel mai jos de educaie(P<0,05). Prezena i impactul activitilor zilnice din cauza severitii cefaleei a fost gsit ca fiind cauzat de agravare n rezultatul activitilor fizice(P=0,001) la CTT, fr caracteristici clinice la cefaleea migrenoas i lund n consideraie c toi pacienii cu cefalee de natur pulsatil(P<0,05), ce se agraveaz la activiti fizice (P=0,001), greaa(P<0,01), voma(P<0,05) i fonofobie(P<0,05). Introducere: Sunt numeroase studii privind cefaleea, dar relativ puine studii efectuate n rile Asiatice.

Este raportat c factorii de risc rasiali, culturali i cei , ce in de mediu joac un rol important n cercetrile epidemiologice. Acest studiu a fost petrecut ntr-o ar in Asia, ai crei populaie aparine rasei albe. Studii, ce in n special de femei sunt de asemenea relativ puine. ntr-un studiu epidemiologic al cefaleei n Turcia , ce a fost tiprit ca un abstract, a fost efectuat pe un lot de 2007 persoane, prevalena de 1 an al migrenei i a CTT a fost declarat ca fiind de 16,4% i 31,7% respectiv(2), dar caracteristicele clinice ale cefaleelor nu au fost evaluate. Acest studiu este primul studiu bazat pe populaie i detaliat al cefaleelor i a caracteristicelor clinice pe baza criteriilor Societ .Interna. a Cefaleelor la populaia de femei din Turcia. S-au cercetat prevalena de 1 an, datele socio- demografice o caracteristicele migrenei, ale cefaleei de tip tensional. Mareriale i metode Acest studiu a fost executat pn la final n provincia Kaisery pe populaia feminin mai mare de 14 ani , n numr de 375441. Cea mai mic mostr a fost calculat de 1100 persoane(95% interval confedenial, SD:1,6%) s-a estimat prevalena migrenei la 8%. 1300 de femei cu vrsta cuprins ntre 15-87 ani au fost selectate randomizat dup cluster i metoda mostrei sistematice n regiune, utiliznd cartela casnic din centrele primare de sntate, n cere figureaz datele despre toi locuitorii din regiune; 1146 din aceste femei au putut fi contactate . Simptomele au fost evaluate prin interviul face to face structurat, bazat pe criteriile SIC(Societii internaionale a Cefaleelor)- IHS. naintea fiecrui interviu, obiectivele stdiului au fost descrise i a fost obinut acordul(consimmntul). Toate femeile i-au declarat acordul de a fi implicate n studiu. Studiul a fost acceptat de Comitetul de Etic al Universitii Erciyes. Dup ntrebrile introductive privind vrsta, nivelul economic i educaional, statutul matrimonial i profesional, persoanele au fost interogate despre prezena oricror patologii cronice, diagnosticate de medicul-generalist i au avut vreo cefalee important, care atrage atenia(deranjant) n perioada ultimului an. Dac cefaleea era declarat, li se adresau ntrebri, privind caracteristicele cefaleelor lor i relatarea unor astfel de date cum ar fi: frecvena, durata, triggerii(factorii declanatori), simptomele nsoitoare, dereglrile de somn, istoricul familial, tratamentele suportate pn acum etc.

Interviul a fost executat de policlinica cefalalgic.

ctre studenii- medici, pregtii

pentru a

lucra n

Dup interviu tipurile de cefalee a fost determinate n acord cu criteriile IHS n interviu de neurologi i de studeni. Diagnosticarea altor patologii s-a bazat pe decizia medicului generalist(de familie). Alte cauze ale cefaleelor, cum ar fi sinusitele, hipertensiunea au fost considerate i evaluate pentru probabilitatea de a fi cauze ale cefaleelor. n 15 cazuri (1,31%) din cazuri cefaleea a fost considerat ca fiind cauzat de aceste patologii. A fost gsit partea prevalenei migrenei cu aur(MWA) i a migrenei fr aur(MWOA), al cefaleei de tip tensional episodic i cronic. Evaluarea relaiei dintre prevalena tipurilor de cefalee i proprietile cefaleelor pacienilor, aa ca vrsta , nivelul educaional i economic, statutul matrimonial i profesional, locul de reedin i compararea caracteristicelor clinice printre subtipurile cefaleei, a fost dobndit de Corelaia dintre caracteristicele clinice i severitatea cefaleei a fost analizat, utiliznd analiza scalei corelaiei Spearman. Rezultate Trsturile socio-demografice ale migrenei i CTT: vrsta, nivelul educaional i economic, statutul matrimonial i profesional, locul de trai au fost demonstrate n Tab.1. Tab.1. Trsturile socio- demografice pacienilor cu cefalee.
Parametri demografici Vrsta(ani) 15-24 25-34 35-44 45-64 > 65 Nivelul educaional <5 ani 5 ani 8 ani 312 526 99 33 (10,5%) 72 (13,7%) 6 (6,0%) 57 (18,2%) 96 (18,2%) 19 (19,2%) 289 311 253 228 65 23 (8,0%) 48 (15,4%) 41 (16,2%) 29 (12,7%) 2 (3,0%) 46 (15,9%) 55 (17,7%) 47 (18,5%) 59 (29,9%) 9 (13,8%) socio- Toate

a tuturor persoanelor intervievate i a

persoanele Pacienii migren(n=143)

cu Pacienii CTT(n=216)

cu

intervievate(n=1146)

11 ani >11 ani Statutul matrimonial Cstorit Celibatar(singur) Divorat Statutul profesional Gospodin casnic

126 83

11 (8,7%) 21 (25,8%)

22 (17,4%) 22 (26,5%)

853 178 115

118 (13,8%) 17 (9,5%) 8 (7,0%)

160 (18,7%) 28 (15,7%) 28 (24,3%)

975

116(11,9%)

180(18,4%)

Angajat Locul de trai Localitate urban Localitate rural

171

27(15,8%)

36(21,0%)

636 510

97 (15,2%) 46 (9,0%)

123(19,3%) 93 (18,2%)

Tipurile cefaleelor migrenoase i particularitile socio-demografice. 1146 femei au fost intervievate. 359(31,3%) din ei au experimentat(suportat) migrena sau CTT n decursul ultimului an. Prevalena de 1 an al migrenei a fost de 12,5%(143ptts.), cuprinznd 7,3%(84) migr.cu aur i 5,2%(59)-migr. fr aur. Prevalena migrenei a fost gsit statistic mai nalt la grupul de vrst de 35-44 ani i mai joas la grupul de peste 65 ani, n comparaie cu alte grupuri ( persoanele cu cel mai nalt nivel educaional, ci studii universitare( femeile mritate( /16,38, P<0,01).Cefaleea migrenoas s-a depistat ca fiind cu cea mai nalt prtevalen la /19,59, P<0,001), /6,04, P<0,05) i la cele, care locuiau n localitile urbane( erau n legtur

/9,5,P<0,01). Totui statutul profesional i nivelul economic nu semnificativ cu cefaleea de tip migrenos.

Cefaleea de tip tenional i particularitile socio-demografice.

Prevalena de 1 an al CTT a fost 144(12,5% )- episodic i

gsit de 18,8%(216 persoane), incluznd

72(6,3%)-tipul cronic al cefaleei. Cea mai nalt prevalena a CTT a fost gsit la grupul de vrst de 45-64 ani( /10,34, P<0,05). Pacienii cu CTT cronic au fost gsii a fi cu mult mai n vrst dect cei cu forme episodice( Media de vrst SD pentruCTT episodic i cronica: 41,1115,57, 35,85 12,91, P<0,01). Lund n consideraie nivelul educaional, CTT cronic a fost gsit ca cea mai prevalent ( /6,83, P<0,05) la persoanele cu cel mai jos nivel educaional.

Frecvena atacurilor de cefalee. Aproximativ 73,4% din pacienii cu migren au 1-4 atacuri pe lun, pe cnd restul trec prin> 4 atacuri pe lun. 55 pacieni migrenoi(38,5% din toi pacienii cu migren; 21- cu (MWA)migren cu aur, 14- (MWOA) migren fr aur au cel puin 180 atacuri pe an. Lund n consideraie, c la CTT, 31,9% au 1-3 atacuri de cefalee pe lun i 68,1% din pacieni sufer de cefalee minim 1 dat pe sptmn; 33,3% din pacieni au cel puin 180 atacuri de cefalee de tip tensional pe an.

Durata cefaleei. n acord cu criteriile Societii Internaionale de Cefalee(IHS), durata acceptabil a atacului de migren la pacientul netratat e de 4-72 ore. 22 pacieni (15,4%)cu migren au avut durata atacurilor < 4ore. Dar toi aceti pacieni au utilizat tratamentul medicamentos pentru atacurile lor de cefalee. Acest studiu arat(demostreaz, c cea mai rspndit(comun durat al atacurilor de migren(71,3%) a fost ntre 4 i 24 ore. n CTT atacurile s-au sfrit n cadrul(dup)mai multor ore(51,9%), au continuat pe parcursul zilei(22,2%), au durat 1-3 zile(14,8%) i 3-7 zile la (11%)din pacieni. CTT episodic difer de tipul cronic prin aceea, c atacurile de obicei au o durat mai scurt, 15 min.-cteva ore( 10,52, P<0,05).

Caracterul cefaleei. Pulsaia a fost observat la 88,8% din migrenoi pe cnd la 62,0% din pacienii cu CTT aveau senzaie de presiune, ncordare(Tab.2); 53,1% din pacienii cu migren au avut cefalee unilateral. Cefaleea bilateral a fost raportat n 72,7% din pacienii cu CTT. La 82,5% din pacienii cu migren i 43,5% din pacienii cu CTT, cefaleea a fost agravat de activiti fizice de rutin. Caracteristicele tipurilor migrenei cu aur i fr aur au fost demonstrate n Tab.2

Compararea acestor caracteristici cu gsit mai frecvent n migrena cu aur(

test a demonstrat caracterul pulsatil, care a fost

Caracteristicele CTT cronic i episodic au fost prezentate n Tab.3. N-au fost diferene statistice( test) ntre cele 2 tipuri de cefalei tensionale.

Simptome nsoitoare.(concomitente, asociate).

Fonofobia(85,3%) a fost cel mai frecvent simptom al migrenei, nsoit de grea(80,4%) i fotofobie(77,6%). Voma a fost observat la 44,8% din pacienii cu migren, n( MWA)- migrena cu aur , cea mai comun aur au fost manifestrile vizuale, incluznd scintilaia sau distorsia (modificarea ) imaginii, hemianopsia i ntunecarea vederii(81,8%), urmat (nsoit) de tinitus/vertije(67,1%), simptome senzoriale(34,3%) i afazia(15,4%). n cazurile de CTT, fonofobia a fost de asemenea cel mai des simptom nsoitor. Greaa a fost observat la 40,7%, iar fotofobia la 14,4% din pacieni. Simptomele nsoitoare ale migrenei cu i fr aur au fost artate(prezentate, demonstrate) n Tab.4, iar cele de cefalee de tip tensional episodic i cronic n Tab. 5 Cu respectarea acestor constatri, n-a fost difereniat statistica ntre migrena cu i fr aur.

Totui, cnd comparaia similar a fost fcut ntre subtipurile cefaleei de tip tensional, simptomele de grea ( de tip tensional. ( au fost gsite ca cele mai frecvente n cefaleea cronic

Tab.3 Caracteristicele cefaleei de tip tensional cronice i episodice

Bilate Tipurile CTT ralitatea% Natura de gravarea presiune, efort fizic strangulare%

A la mpactul asupra activitii zilnice 33,3

CTT cronic

73,6

34,7

45,8

CTT episodic

70,1

39,6

45,1

38,2

Tab.4 Simptomele nsoitoare ale migrenei cu i fr aur.

Tipurile migrenei

Greaa(%)

Voma(%)

F Fot onofobia(%) ofobia(%)

Migrena aur(MWA) Migrena aur(%)

cu 81,0

47,6

89,2

82,1

fr 83,1

40,7

79,6

71,2

Factorii trigger (declanatori) Cei mai frecveni factori declanatori ai atacurilor de cefalee au fost stresul(la migren81,8%; la cefaleea de tip tensional-83,3%), privarea de somn(la migren-52,4%; la cefaleea de tip tensional-53,2%), graba sau foamea(la migren-37,1%; la cefaleea de tip tensional-39,4%), factorii hormonali ca menstruaia(la migren-35,6%; la cefaleea de tip tensional-24,5%), sarcina(la migren-16,1%; la cefaleea de tip tensional-6,0%. Diverse alimente nu joac vre-un rol semnificativ ca factor declanator la pacienii cu migren(cacavalul-0%, ciocolata-1,4%) . 32,2% din persoane cu migren cu aur i 42,4% din cei cu migren fr aur au fost raportate ca cefalei provocate de menstruaie. La compararea acestor date nu s-au gsit diferene statistice. 5 pacieni(3,5- migrenoi: 3- cu migr. cu aur, 2- cu migr.fr aur) au fost raportai cu cefalei de tip migrenos relatate doar la menstruaie, iat de ce ei sunt considerai pacieni cu migrena menstrual pur. Impactul asupra activitilor zilnice. Activitile zilnice de rutin sunt afectate la 77,6% din pacienii cu migren i la 37,5% din pacienii cu CTT, din cauza severitii cefaleei. Cu respectarea acestui factor o diferen nesemnificativ a fost gsit ntre migrena cu i fr aur sau ntre cefaleea de tip tensional episodic i cronic. La pacienii cu CTT , comparnd prezena impactului asupra sctivitilor zilnice cu caracteristicele cefaleei i simptomele nsoitoare, a fost gsit legtura(relativ)intre

impactul asupra activitilor i agravarea la efort fizic(activiti fizice)(Spearman p: 0,27, P= 0,001). Cnd o comparaie asemntoare afost efectuat la pacienii cu cefalee de tip migrenos nu a fost gsit vre-o relaie. n cazul altor pacieni cu cefalee, caracterul pulsatil(P>0,05), agravarea la efort fizic(activiti fizice) (P<0,001), simptomele nsoitoare de grea(P<0,01), vom(P<0,05), fotofobia(P<0,05), au fost gsite pentru a fi relatat impactul cefaleei asupra activitilor zilnice n analiza gradului de corelaie a lui Spearman.

Tab.5 Simptomele nsoitoare ale cefaleei de tip tensional cronice i episodice. F Fot onofobia(%) ofobia(%)

Tipurile CTT

Greaa(%)

Voma(%)

CTT cronic

52,8

13,0

61,1

19,4

CTT episodic

34,7

10,0

45,8

12,5

Somnul i cefaleea. n studiul nostru lipsa somnului(privarea de somn)a fost raportat la 23% de migrenoi i la 20,8% de pacieni cu CTT. Relaiile pacient- medic 75,5% din pacienii cu migren i 56,7% din cei cu cefalee de tip tensional au fost consultai n privina durerii lor de cap(cefaleei lor). 51% din migrenoi tiu despre migrena lor. Msuri de tratament Partea utilizrii medicamentelor la pacienii migrenoi a fost gsit a fi-90,9%, n timp, ce la pacienii cu cefalee de tip tensional-63,4%. O alt msur important este aflarea n singurtate ntr-o odaie i somnul (la migren86,0%; la cefaleea de tip tensional-66,7%), masajul (la migren-38,5%; la cefaleea de tip tensional-31,0%), compresele reci sau calde (la migren-10,5%; la cefaleea de tip tensional-6,0%).

Istoricul familial 43,4% din migrenoi aveau un istoric familial similarcefaleelor(48,8% migr. cu aur;35,6% migr. fr aur) , n timp, ce istoricul pozitiv familial a fost raportat la 32,9% din cei cu CTT. Reieind din(respectnd) acestea nu a fost gsit o diferen semnificativ ntre tipurile cefalei. Discuii Acesta este studiul bazat pe femeile cu cefalee din Turcia. Noi am ncercat s evalum caracteristicele socio-dmografice i clinice ale cefaleelor de tip tenional i cele de tip migrenos. n cele, ce urmeaz noi am clasificat cefaleele de tip tenional i cele de tip migrenos n episodice i cronice, iar la migren- cu aur i fr aur. Caracteristicele clinice ale simptomelor nsoitoare au fost evaluate la toate subtipurile cefaleelor i comparate ntre ele . Atitudinea pacienilor fa de cefalee a fost investigat.

Femeile i cefaleele. Ce trebuie s tim? C oameni au migren? Conform datelor Studiului II American al Migrenei (National Headache Foundation. American Migraine Study II: Migraine in the Unaited States. Burden of illness and patterns of treatment). Sunt 28 mln persoane, care sufer de migren >12 ani(12+) n SUA, din care 21 mln- femei, 7 mln- brbai. O gospodin casnic din 4 a suferit cel puin 1 atac de migren. Majoritatea persoanelor, ce sufer de migren sunt cu vrsta cuprins ntre 25-55 ani. Din diagnozele de cefalee-98%(Conform Landmark Study) o alctuies migrenele, 0,4%CTT, cefaleele secundare-1%. Ce este Migrena? Conform datelor OMS i World Federation of Neurology: Atacuri recurente(repetitive)de cefalee A. Cel puin 5 atacuri, ce corespund criteriilor B-D

B. Atacurile de cefalee tratament fr succes

au durata 4-72 ore fiecare( fr tratament sau dup

C. Cefaleea are cel puin 2 din urmtoarele caracteristici: 1. localizare unilateral 2. caracter pulsatil 3. intensitate moderat sau sever 4. agravare de sau evitarea activitii fizice de rutin(ex., mersul sau urcatul scrilor). D.n timpul durerii de cap apare cel puin una din urmtoarele: 1.grea i vom 2.fotofobie i fonofobie E. Nu este atribuit altor afeciuni.

Pacienii au deseori mai mult de un singur tip de atac migrenos: . Migrena matinal . Migrena de durat lung . Migrena cu grea/ vom . Migrena cu evoluie lent . Migrena cu escaladare rapid . Migrena menstrual Medicii au de difereniat diverse tipuri de cefalee: . Migrena cu/fr aur . Migrena cronic .Cefaleea benign .Cefaleea de tip tensional . Cefaleea primar cluster .Aura fr cefalee .Cefaleea menstrual .Cefaleele mixte .Statusul migrenos Ce putei simi nainte sau pe parcursul atacului de migren:
1.Greuri 9.Fonofobie

2.Vome 3.Diaree 4.Transpiraie

10.Tensiuni ale scalpului 11.Paliditate 12.Pulsaii la tmple

5.Mini reci 6.Sensibilitate la lumin 7.Obnubilare 8.Dureri n reg. cervical Triggerii migrenei: 1.Stresul 2.Schimbarea regimului de somn 3.Schimbrile meteo(vremii) 4.Lumina puternic sau licritoare 5.Buturi alcoolice 6.Schimbri hormonale Femeile i migrena

13.Dureri(senzaii) de presiune 14.Vertije 15.Dificulti de vorbire sau concentrare

. 70% din femei vor meniona asocierea (agravarea) cefaleelor n legtur cu ciclul menstrual. .60% din femei(raporteaz )vor comunica diminuarea(uurarea)cefaleelor parcursul sarcinii(poate fi neadevrat) . pe

. 40% din femei vor suporta primul atac de migren n timpul sarcinii sau imediat dup aceea. . 70% din femei au rar migren dup menopauz. . Multe femei menopauzei. Definiii . Migrena menstrual(7-8%) . Migrena asociat cu menstruaia Impactul sarcinii asupra migrenei . 60-70% au rare cazuri de migren, n special n trimestrele II i III. . 4-8% din femei au simit agravarea simptomelor. . 10% din cazurile de migren ncep n timpul sarcinii. . Patternul cefaleelor revine la normal aproape imediat dup natere. [Aube M. Neurology 1999; 53(S1): S26-S28] Impactul migrenei sarcinii asupra sarcinii menioneaz agravarea( nrutirea) cefaleelor n timpul

. Migrena nsi nu influieneaz fertilitatea . .Migrena nu interfer cu sarcina sau nu afecteaz ftul

[Aube M. Neurology 1999; 53(S1): S26-S28 Silberstein SD.Neurologic Clinics 1997; 15(1): 209-231]

Concluzii: .Cefaleele migrenoase pot fi provocate de diveri factori, incluznd schimbrile hormonale. .Pentru migrena menstrual utilizarea focal a medicaiei poate fi util. .Patternul cefaleei se poate schimba odat cu sarcina sau menopauza. .Multe medicamente pentru migren sunt prezente n laptle matern. .Exist multe opiuni pentru uurarea migrenei- ntreab-i medicul, care e cea mai optim pentru tine.

Hormonii sexuali i durerea de cap Exist o legtur ntre estrogeni i progesteron, hormonii sexuali feminini i migren. Migrena apare mai frecvent la femei adulte(18%), dect la brbai(6%) i totui are o prevalen egal la copii. Migrena evoluiaz mai des n a doua decad cu incidena de vrf survenit n adolescen. Migrena n legtur cu menstruaia(migr.menstr.,MM) ncepe la menarhe n 33% din femeile afectate. Migr.menstr.are loc n majoritatea cazurilor n timpul menstruaiei la multe femei cu migren i exclusiv cu menstruaie(migrena real menstrual, TMM)la unele. Migr.menstr. poate fi asociat cu unele plngeri(boli) somatice care apar nainte i persist deseori n timpul menstruaiilor, precum greaa,durerea de spate, sni dureroi i crampe i apariii asemntoare, cauzate de nivelul sczut al hormonilor sexuali. Ca urmare, migrena premenstrual poate fi asociat Sindromului premenstrual(PMS),care este diferit de simptomele fizice a perioadei premenstruale i este probabil cauzat indirect de scderea nivelului progesteronului(vezi mai jos). Migrena care apare n

timpul (mai mult dect)menstruaiei, nu este de obicei asociat cu PMS n caracteristica simptomelor ei de baz, severitatea ei i daunele rezultate. Migrena se poate agrava n timpul primului trimestru al sarcinii i,dei multe femei scap de durerea de cap n timpul ultimelor dou semestre, 23% nu au schimbri n migrena lor. MM de obicei evoluiaz la graviditate, posibil cu scopul de a susine nivelul nalt de estrogen. Schimbul hormonal cu estrogeni poate exacerba migrena i contraceptivele orale (OCs)pot schimba caracterul i frecvena ei. Prevalena migrenei scade odat cu avansarea n vrst,dar totui poate reveni sau agrava la menopauz. Schimbrile, ce apar n tabloul cefaleei cu utilizarea Ocs i n timpul menarhei, menstruaieigraviditii sau menopauzei sunt legate de schimbrile nivelului de estrogen. Acest fenomen sugeraz o relaie dintrecefaleele migrenoase i schimbrile nivelului hormonilor sexuali. Aceast discuie va acoperi partea endocrinologic a ciclului menstrual, neurofarmacologia estrogenilor i a progesteronului; definiia, epideiologiai patogeneza migrenei menstruale i apropierea de terapia pentru durerile de cap, legate de hormoni, n particular acele asociate ciclului menstrual, menopauza i utilizarea contraceptivelor orale. ----------------------------------------------------------------------------------------------------------------------------------------Fraze utile Cefaleea este un simptom simit de oameni. Ne bazm pe expunerile personale, privind frecvena, durata i durerea suportat. Problema o alctuiete lipsa unui standard de aur pentru msurarea experienei de cefalee a oamenilor, ea reflect necesitatea de a ne baza pe teste indirecte de validare, precum consultaiile primare i secundare. S-a utilizat chestionarul versiunea 1, care cuprinde 16 ntrebri privind impactul migrenei asupra funcionrii i strii de bine.(Din discursul d-lui Profesor sau a D-nei Stela ).

Cefaleea la femei
Nippon Rinsho.2005 Oct;63(10): 1786-90. [Headache in female] Douchi T.

O corelaie semnificant se observ ntre prevalena cefaleei(cefaleei de tip tensional i migrenei), ct i astfel de variabile ca vrsta i genul(sexul). Prevalena migrenei la femeile de vrst reproductiv e de 4-5 ori mai nalt dect la brbai. Totui, prevalena migrenei nu difer dup sex naintea pubertii. Viaa femeii include perioada de pn la pubertate, pubrtatea, perioada reproductiv(graviditatea , naterea, puerperium), perioada menopauzei i postmenopauza. Pe parcursul acestei perioade, nivelul estrogenului seric se schimb dinamic. Chiar n timpul ciclului menstrual, nivelul estradiolului seric se schimb dinamic. Aceste schimbri difer completamente(definitiv) de schimbrile nivelului seric al testosteronului la brbai. Cefaleea sau migrena pe parcursul ciclului menstrual se observ mult mai frecvent pe parcursul perioadei menstruaiei. Totui, prevalena cefaleei imigrenei devine mai joas dup menopauz. Aceste cercetri sugeraz, c evenimentul(fenomenul )cefaleei este n parte asociat cu scderea nivelului estradiolului n serul sanguin.

1.Am J Med. 2005 Mar; 118 Suppl 1:3S-10S. The epidemilogy of migraine. Lipton RB, Bigal ME. Acest articol pledeaz pentru revizuirea epidemiologiei i a factorilor de risc pentru migren n studiile populaionale, ct i a patternului de ngrijire medical acordat. Dauna i costul migrenei, ct i factorii de risc pentru progresarea patologiei date de asemenea se discut. n pofida faptului, c migrena este o cauz extrem de remarcabil al dizabilitii(incapacitii) temporare de munc, multe persoane, ce aveau asemenea cefalei incapacitante, nu s-au adresat niciodat dup ajutor la medic. Prevalena e cea mai nalt la femei, la persoanele cu vrsta de 25-55 ani i n sfrit nSUA, la persoanele cu un buget mic(din gospodrii cu buget mic). Totui, prevalena este nalt n alte grupuri, n afara acestui grup cu risc nalt. ntr-un subgrup de pacieni, migrena poate fi o patologie progresiv. 2. Headache. 2005 Apr;45 Suppl 1:S3-S13. Migraine: epidemiologyimpact, and risc factors for progression. Lipton RB, Bigal ME.

Migrena este o patologie cronic i uneori progresiv, ce se caracterizeaz prin episoade recurente de cefalee i simptome asociate. Acest articol scote n eviden epidemiologia migrenei i factorii de risc al migrenei, descrii n studiile populaionale i discut impactul patologiei i costul socio-economic al migrenei . cu un an nainte de pubertate, migrena e mai rspndit printre biei, dect printre fete. Dar odat cu pubertatea, migrena e mai prevalent la fete i n urmtorii 10 ani, femeile sufer de migren practic de 2 ori mai des dect bieiii. Vrvul prevalenei la ambele sexe este n cei mai productivi ani ale vieii adulte(25-55 ani) i n SUA este cea mai nalt la persoanele cu un statut economic jos. Costul direct al migrenei include costul medicaiei migrenei i cheltuielile de ingrijire medical. Costul indirect asociat cu migrena include productivitatea redus datorat absenteismului i reducerea performanelor pe timpul lucrului. Evidena recent sugereaz, c subgrupele pacienilor cu migren po avea o patologie clinic progresiv. Viitoarele studii epidemilogice trebuie focusate asupra identificrii pacienilor, care au un risc major de progresare i n asistarea impactului strategiilor de intervenire asupra progresrii bolii. 3. Curr Med Res Opin. 2001; 17 Suppl 1:S4-S12 Epidemilogy and economic impact of migraine. Lipton RB, Stewart WF, Scher AI. Migrena este o patologie foarte rspndit, ce afecteaz circa 11% din populaia adult a rilor vestice. Prevalena e cea mai nalt n anii de productivitate maxim de la 25 la55 ani. Prevalena e mai nalt la femei dect la brbain toi anii dup pubertate, dar proporia pe sexe variaz cu anii. n SUA, prev. migr. e mai nalt la persoane cu nivel jos de educaie, probabil din cauza, c migrena interfer cu coala i munca. Majoritatea migrenoilor i soluioneaz cefaleele lor fr recomandarea convenional a medicului i n general i trateaz atacurile prin medicaie abuziv.Costul indirect depete cu mult costul tratamentului, crend oportuniti pentru intervenii eficiente dup cost. Impactul migrenei asupra sntii publice este substanial datorit prevalenei sale nalte i a disabilitii(proieminente) considerabile temporare. Incapacitatea masiv, produs de migren este o important sarcin de tratament. 4. Pharmaco economics. 2004;22(15):985099. Economic impact of migraine and other episodic headaches in France: data from the GRIM2000 study. Pradalier A, Auray JP, EI Hasnaoui A et al. Introducere: Migrena este o patologie prevalent i incapacitant, care afecteaz nviii lor productive, ce genereaz o povar economic , ce afecteaz att societatea , ct i sistemul de ngrijire a sntii. Costul anual direct al migrenei n Frana a fost evaluat timp de 10 ani precedeni i studiul dat elucideaz aceste date.

Obiective: Obiectivele acestui studiu au fost determinarea costului economic (costului direct) al migrenei i ale altor cefalei episodice n Frana, bazate pe un studiu de cefalee populaional, GRIM(Groupe de researche Interdisciplinaire sur la Migraine). Design: Din grupul de populaie reprezentativ de 10,585 de pers15 ani din Frana n 1999, 1486 pers., ce au avut cefalee au fot identificate, intervievate privind utilizarea resuselor de ngrijire de sntate n 6 luni precedente. Aplicnd costul uni la datele obinute, costul (n valoarea a.1999), a fost determinat de consultaia medicului, spitalizarea, medicamentele utilizate i testele de laborator i evoluat din perspectiva ngrijirii snttii. Informaia despre absenteism i pierderea productivitii s-a dedus din (a derivat) din chestionarul Migraine Disability Assessment Score(MIDAS). Rezultate: Prevalena migrenei(incluznd ptologiile migrenoase) a fost determinat ca fiind de 17%. Costul direct total anual a fost estimat la 128 Euro pentru o persoan n 1999, ce corespunde cu 1044 milioane de Euro, fiind extapolat la suferinzii de migren cu vrsta 15 ani. Aproximativ 2/3 din acest cost a fost acoperit(asigurat)de sistemul de securitate social(698 milioane de Euro; 85 Euro de persoan). Costul total direct anual al altor forme de cefalee episodic a fost mult maijos- la 28 Euro de persoan( costul securitii sociale este de 18 Euro); cu o prevalen de 9,2%, costul anual naional direct pentru alte forme a cefaleelor episodice alctuiete 124 milioane Euro. Principalul element al costului a u fost consultaiile medicilor. Totui s-a depistat, c multe persoane n-au fost consultai niciodat de medici din cauza cefaleei lor i automedicaia a contribuit substanial la costul tratamentului(a doua cauz de cretere a costului migrenei). Costul per individ devine exorbitant odat cu creterea severitii cefaleelor. Concluzii: Costul direct de ngrijire medical al migrenei nu a crescut semnificativ pe parcursul ultimei decade. O mic minoritate de persoane cu cefaleele cele mai severe au consumat majoritatea resurselor predestinate migrenei, pe cnd majoritatea persoanelor au provocat un cost direct relativ jos. Costul direct anual n Frana pentru migren este aproximativ de 10 ori mai nalt, dect pentru alte patologii episodice. 4.a.Socio-economic impact of migraine and headaches in France Auray JP Societatea internaional de cefalee are ghiduri(ndrumtoare) clar definite diagnostic, cecclasific cefaleele n 3 categorii. Acum este bine cunoscut, c cefaleele exercit un efect considerabil asupra calitii vieiii supra studiilor, activitilor familiale sau individuale , i impactul economic nu e deloc de neglijat. Un studiu extins, ce a fost efectuat pe un lot de 10582 pers.adulte din Frana, a fost ndeplinit n 1999. Rezultatele au demonstrat o prevalen de 17,3% pentru migren i aproximativ 30% pentru cefalei. Cheltuiala bneasc medie pentru un pacient cu cefalee este de circa 220 Euro, s-a mprit dup cum urmeaz: 10% pentru consultaia medicului-generalist, 11% pentru

evalurile de laborator, 17% pentru consultaiile specialitului, 18% pentu medicamente i 44% costul tratamentului n spital. Aceast divizare depinde n mare msur de categoria cefaleei. Dei cele mai acute cefalei afecteaz cel mai mult calitatea vieii, activitile colare i profesionale nu sunt afectate n aceia msur. 5.Curr Neurol Neurosci Rep. 2004 Mar;4(2):98-104 The epidemiology and impact of migraine. Bigal ME, Lipton RB, Stewart WF. S-a scos n eviden epidemiologia descriptiv, dauna patologiei, patternul diagnostic i tratament. n acest articol s-a focusat atenia asupra epidemiologiei i a daunei migrenei probabile, subtipul migrenei,cnd doar o particularitate clinic lipsete. La ncheere sau descris strategiile de mbuntire a ngrijirii medicale impuse de migren i migrena probabil. Cu toate c migr. este o binecunoscut cauz a dizabilitii temporare , muli migrenoi ,chiar i acei cu cefalei incapacitante n-au consultat niciodat medicul din aceast cauz. Nu n ultimul rnd prevalen n alte grupuri dect aceste grupuri cu risc nalt. Migrena probabil este o form prevalent al migrenei i asemeni migrenei cu i fr aur ea produce descretere calitii vieii i sporirea incapacitii relative la subiecii controlai. 6.Pharmaco economics. 2004;22(9):591-603. The burden of migraine in Spain: beyond direct costs. Badia X, Magaz S, Gutierrez L, Galvan J. Obiective: ESTIMAREA PAGUBEI ECONOMICE AL MIGRENEI N SPANIA din perspective sociale. Metode: Costul anual direct( medicamentele, trat. de ambulator, cons. specialistului i vizitele ambulanei) i indirect(zilele lipsite de la serviciu i capacitatea redus de munc) pe anul 2001 au fos calculate, utiliznd modul de abordare al prevalenei. Metoda capitalului uman a fost utilizat la calcularea costului indirect. Sursele utilizate epidemiologice au fost publicate , utiliznd criteriile de diagnostic ale SIC(Societii Internaionale de Cefalee) di baza de date oficial i neoficial. Rezultate: Populaia Spaniei cu migren a fost estimat a fi de 3,617,600 pacieni, 92,5% fiind n vrsta apt de munc. Povara economic a migrenei a fost de aproximativ 1076 milioane Euro. Costul direct reprezenta doar 32,0% dinpovara total(344 milioane de Euro), 39,2% au fost pentru vizita la medicul-generalist, 28,7% pentru vizitele la specialist, 20,5% pentru vizitele ambulanei la domiciliu i mai departe 11,7% pentru medicamentele prescrise specifice migrenei(serotonin 5HT(1B/1d)receptor agonist Costul indirect a fost

estimat n 732 milioane Euro anual, reprezentnd 453,55 Euro pentru un pacient apt de munc(ce muncete ) cu migren. Concluzii: Ca i nmulte alte ri dezvoltate, migrena reprezint o povar economic considerabil n Spania, n special n termeniiproductivitii pierdute. Deci activitile trebuie specific direcionate spre reducerea costului indirect , i spre tratamente eficiente, care ar reduce semnificativ pierderea productivitii trebuie date publicitii(promovate n public).

6.J am acad Nurse Pract. 2007 jul, 19(7):378-82. Prevalence and management of headache in a university undergraduate population. Curry K, Green R Scopul: scopul acestui studiu pilot a fost explorarea incidenei, morbiditii i managementul cefaleelor la studenii universitari, fr master. Autorii au explorat de asemeni alegerea medicaiei de uurare pentru cefalei n efortul de a ajuta potenialele necesiti privind educaia pacienilor n privina unui management eficient al cefaleei. Sursa datelor: Datele au fost colectate dintr-un lot convenional de 104 studeni. Headache Assessment Quiz a fost utilizat pentru a msura tipul i severitatea cefaleei i a colecta date privind managementul simptomelor. Concluzii: Majoritatea studenilor supravegheai au raportat, c au suportat cefalei de intensitate moderat sau severe. 16% din respondeni au indicat, c cefaleele lor s-au intercalat cu activitile lor zilnice(uzuale),n timp ce 92,5% au raportat utilizarea preparate neprescrise de uurare doar pentru managementul cefaleei. Cunotinele privind prevenirea cefaleei i tratamentul lor lipsea n acest grup. Aplicarea practic: cefaleea este un simptom des ntlnit la persoanele de vrsta universitar.Urmtoarele cercetri trebuie s determine incidena tipurior specifice ale cefaleelor. Medicii de familie sunt provocai s se adreseze pacienilor , educndu-i pentru a ajuta pacienii s-i diagnostice mi bine tipurile de cefalee. Split W and Szdlowska M. Tension Type Headache in Diabetes Mellitus. Headache Quaterly.1998; 9:145-148. Obiective: Acest studiu a fost creat pentru evaluarea frecvenei cefaleei de tp tensional n diabetul zaharat, ca ntotdeauna natura corelaiei dintre durata patologiei, vrsta pacienilor i coexistena complicaiilor diabetului. Pacieni: Au fost implicai 71 pacieni cu diabet zaharat insulin-dependent(IDDM) i 154 pacieni cu diabet zaharat insulin-independent(NIDDM). Grupul comparativ a constat din 120 de persoane.

Rezultate: Cu CTT au fost diagnosticai 18% din pacienii cu diabet zaharat insulindependent(IDDM) i 21%cu diabet zaharat insulin-independent(NIDDM). n majoritatea cazurilor debutul cefaleei a coincis cu instalarea diabetului. Numrul anual al cefaleelor a fost de 4 ori mai mare dect n grupul de control. La persoanele, la care cefaleele au aprut nainte de manifestrile diabetului, instalarea patologiei de asemenea a condus la o cretere semnificativ a numrului anual al zilelor cu cefalee. Nu a fost gsit corelaia dintre cefalei i durata diabetului, glicemia de 24 ore i coexistena complicaiilor diabetului. Concluzii: Diabetul zaharat a avut un efect important n creterea anual a cefaleei de tip tensional. Cefaleea de tip tensional cronic a fost prezent semnificativ mai des n diabet dect la persoanele din grupul de control. Vrsta, la care cefaleele apar la pacienii cu diabet zaharat insulin-independent(NIDDM) difer smnificativ de grupurilestudiate rmase.

Tension-Type Headache and other PRIMARY HEADACHE DISORDERS Aromaa M, Sillanpaa ML, Rautava P, Helenius H. Childhood headache at school entry: A controlled clinical study. Neurology 1998;50:1729-1736. Obiective: Obiectivul nostru a fost studierea prevalenei diferitor tipuri de cefalei, caracterizarea i triggerii cefaleelor la copii din Finlanda din coala primar. Metode: Au fost chestionate 1.132 familii cu copii de 6 ani. Copiii cu cefalei, ce afectau activitile lor zilnice(n=96) i un grup de copii de control asimptomatic (n=96) au participat n interviul clinic i examinare. Rezultate: Copiii cu cefalee au avut considerabil mai des bruxism(odds ratio[OR], 1,9; 95% CI, 1,0 la 3,4), durere la locul de inserare a muchilor occipitali(OR, 4,8; 95% CI, 1,8 la 1,7), dureri n regiunea jonciunii temporo- mandibulare(OR, 2,8; 95% CI, 1,3 la 6,0). Deasemenea ei aveau mai des ru de mare (OR, 3,4; 95% CI, 1,7 la 6,7) dect copii din grupul de control. Consumul ngheatei (OR, 5,3; 95% CI, 1,4 la 20,3), fric(OR, 3,7; 95% CI, 1,2 la 11,2) i anxietatea (OR, 3,2; 95% CI, 1,0 la 10,8) au provocat(au fost triggerii) cefaleelor mai des la migrenoi dect la copiii cu cefalee de tip tensional . Copii cu migren au menionat de asemenea mai frecvent durerile abdominale (OR, 5,6; 95% CI, 1,7 la 18,1) i altele (OR, 3,5; 95% CI, 1,2 la 9,8) simultan cu cealeea i ei au utilizat medicamente pentru stoparea durerii mai des(OR, 3,1; 95% CI, 1,0 la 9,5).

Concluzii: Clasificarea cefleei la copii poate fi mbuntit prin palparea zonei de inserie a muchilor occipitali i n regiunea jonciunii temporo- mandibulare, i pentru distingereaistoricului evenimentelor triggeri i a simptomelor nsoitoare(concurente). Vingen JV, Stovner LJ. Photophobia and phonopfobia in tension-type and cervicogenic headache. Cephalalgia 1998;18:313-318. Discomfortul indus de lumin i sunete i pragul durerii au fost msurate la 26 pacini cu cefalee cervicogenic, la 40 de pacieni cu CTT i la 100 de persoane fr cefalee- de control. Nici ntr-un caz din grupul cu cefalee privind photophobia and phonopfobia nau fost gsite diferene semnificative, dar ambele au fost semnificativ mai sensibile la lumin i sunete dect grupul de control(P<0,001), chiar dac pacienii au fost testai n perioada fr cefalee(P<0,05). CTT episodic i cronic a avut prag similar

Obiective:
1.Care este prevalena migrenei i cefaleei de tip tensional a) n lotul mixt(brbai +femei). b) n loturi separate(cef n lume, Europa- Stovner) - brbai ; femei. 2. Din lotul de: Femei- care este% de pers. cu cefalee. Brbai- care este% de pers. cu cefalee. 3 Se discut tot, ce este publicat la tema dat:explicaii i comparaii cu datele noastre Rspuns la p.1 Prevalena migrenei i cefaleei de tip tensional: a) n lotul mixt(brbai +femei). 448 femei+86 brbai= 534 ptts. cu migren-20,03% din numrul total al persoanelor chestionare- 2665; 534ptts- 37,10% din 1439 pers cu cefalee; 296 femei+193 brbai= 489 ptts. cu CTT- 18,34% din numrul total al persoanelor chestionare- 2665; 489ptts- 33,98% din 1439 pers cu cefalee.

Comentarii:

Tab. 1. P.2 Repartiia dup sex a persoanelor cu cefalee versus cele fr cefalee convenional sntoase Numrul total al persoanelor chestionare- 2665- 100%,

Din 2665: Femei- 1587- 59,55% Brbai-1078- 40,45% Rspuns la p.2: Din 2665 : cefalei); 66,16% din totalul femeilor chestionate(1587). Brbai- 389-14,6% (din 2665p); 27% (din 1439 cu cefalei); 36,08% din totalul de brbai chestionai(1078). Cu cefalee- 1439ptts-54%(din totalul de2665 intervievai: Femei- 1050- 39,4% (din2665 intervievai); 73% (din 1439 cu

Fr cefalee-1226- 46%(din totalul de2665 intervievai): Femei - 537- 20,15% (din2665 intervievai); 43% (din 1226 fr cefalei). Brbai- 689-25,85% (din 2665p); 56,2% (din 1226 fr cefalei). Din 1050 femei cu cefalee- 39,4% (din2665 intervievai) ( 66,16% din 1587- totalul femeilor chestionate) :

448 femei au migren-16,81% din tot. 2665p. chestionate, 42,67% din 1050- femei cu cefalee, 28,23% di totalul de 1587 femei chestionate, 31,13% din 1439-totalul ptts. cu cefalee 296 femei au cefalee de tip tensional-11,1% din tot. 2665p. chestionate, 28,19% din 1050- femei cu cefalee, 18,65% di totalul de 1587 femei chestionate, 20,57% din 1439-totalul ptts. cu cefalee

Din 389 brbai cu cefalee-14,6% (din 2665p); ( 36,08% din 1078- totalul brbailor chestionai): 86 brbai au migren-3,22% din tot.a 2665p. chestionate, 22,11% din 389 brbai cu cefalee, 7,98% din totalul de 1078 brbai chestionai, 5,98% din 1439-totalul ptts. cu cefalee; 193 brbai au cefalee de tip tensional-7,24% din tot. 2665p. chestionate, 49,61% din 389 brbai cu cefalee, 17,9% din totalul de 1078 brbai chestionai, 13,41% din 1439-totalul ptts. cu cefalee. Tab.1. P.1Repartiia dup vrst a persoanelor cu migren i cefalee de tip tensional versus persoanele fr cefalee( convenional sntoase sau lot de control). Majoritatea o alctuiesc persoanele cu vrsta cuprins ntre 20-29 ani, att n lotul persoanelor convenional sntoase, ct i n lotul celor cu migren. Diferene statistice se observ la grupurile de vrst 40-49; 50-59; 60-65 ani.

Persoanele CTT(20-29 ani) 102p.-3,8% n total;

cu P<0,05

Persoanele sntoase(20-29 ani) 327p.-12,27% n total; 26,7% din 1226 cefalee. p. fr din P> 0,05

Persoanelecu migren(20-29 ani) 124p.-4,6% n total; 8,6%- din tot. de 1439ptts. cefalee; 23,22%- din 534 ptts. cu migren. cu din

din

2665p.chestionate

2665p.chestionate

2665p.chestionate

7,08%- din tot. de 1439ptts. cefalee; 20,86%- din 489 ptts. cu CTT cu

Persoanele sntoase(40-49 ani) P<0,01

Persoanelecu migren(40-49 ani)

193p.-7,24% n total;

din

113p.-4,24% n total;

din

2665p.chestionate

2665p.chestionate

15,74% din 1226p. fr cefalee

7,8%- din tot. de 1439ptts. cefalee; 21,16%- din 534 ptts. cu migren. cu

Persoanele CTT(50-59 ani) 97p.-3,6% n total;

cu P<0,01

Persoanele sntoase(50-59 ani) 175p.-6,56% n total; 14,27% din 1226p. fr cefalee din P< 0,01

Persoanelecu migren(50-59 ani) 104p.-3,9% n total; 7,23%- din tot. de 1439ptts. cefalee; 19,48%- din 534 ptts. cu migren. cu din

din

2665p.chestionate

2665p.chestionate

2665p.chestionate

6,7%- din tot. de 1439ptts. cefalee; 19,84%- din 489 ptts. cu CTT cu

Persoanele sntoase(60-65 ani) 144p.-5,4% n total; 11,75% din 1226p. fr cefalee. din P< 0,01

Persoanelecu migren(60-65 ani) 37p.-1,38% n total; 2,57%- din tot. de 1439ptts. cefalee; 6,93%din 534 cu din

2665p.chestionate

2665p.chestionate

ptts. cu migren.

Planul tezei de doctor n tine medicale I Introducere: 1.Actualitatea temei i gradul de studiere ai acesteia. 2. Scopul i obiectivele tezei. 3.Noutatea tiinific a rezultatelor obinute. 4. Semnificaia teoretic i valoarea aplicativ a lucrrii. 5. Aprobarea rezultatelor. II Coninutil propriu-zis:
a) Valoarea rezultatelor obinute, a investigaiilor sale. b) Locul lor n contextul cercetrilor de profil din ar i din lume. c) Compararea lor cu rezultatele obinute n centrele tiinifice de excelen i cu cele de performan la zi. III ncheiere: 1. Sinteza rezultatelor obinute. 2. Concluziile i recomandrile; 3. Bibliografia.

4. Adnotarea (pn la 2 pagini )n limbile romn, englez i rus; 5. Lista abrevierilor utilizate.

Durerea de cap 1. Intensitatea durerilor de cap. 2. 3. 4. Frecvena lor. Simptomele nsoitoare. Simptomele uor resimite: 1)neurologice 2) emoionale 3)autonomice 4)motivaionale i de comportament; simptome nedurerooase nsoitoare ale migrenei.

Fenomenul cefaleelor cronice Condiionat de un ir de factori nemedicali, sociali, culturali, economici, etc.. Prevalen- Ci pacieni cu migren avem n momentul dat. Inciden-Cte cazuri noi au aprut ntr-o unitate de timp()ntr-o unitate de msur de timp).

Un sondaj bazat pe populaie: Prevalena migrenei n Croaia

Obiective: Scopul acestui studiu a fost de a estima prevalena migrenei printre adulii din Croaia. Acesta este primul studiu epidemiologic asupra migrenei din Croaia n care a fost aplicat criteriul operaional de diagnosticare al Societii Internaionale a Durerilor de cap. Metode: Studiul populaiei a constat din toi cetenii (15-65 ani) din Bakar, o regiune a Coastei i a Gorski Kotar, din Croaia. Studiul asupra populaiei a fost efectuat utiliznd metodele de intervievare fa-n-fa , u cu u. Rata de participare a fost de 73%. Toi participanii au fost evaluai asupra istoriei durerii de cap n conformitate cu criteriile Societii Internaionale a Durerii de Cap. Cei care au fost diagnosticai cu cefalee(65.5%) au fot intervievai de ctre studenii antrenai n medicin, utiliznd un chestinar detaliat focusat pe migren. Rezultate: Au fost diagnosticai 720 de migrenoi, cu migren pe via. Prevalena pe durata vieii a migrenei era 22.9%(95% intervalul de ncredere, de la 20.9 la 25.1) la femei i 14.8%(95% interval de ncredere ,de la 13.1 la 16.8) la brbai, i 19%(95%, 17.6-20.5) la ambele sexe. Cea mai mare prevalena pe duarata vieii a fost depistat la femeile cu vrsta 40-49 ani(38.1%). Printre cei 636 de migrenoi activi, 399(62.7%) erau femei i 237(37.3%) brbai; 55.8% aveau migren cu aur i 6.9% aveau ambele tipuri(cu aur i fr). Prevalena migrenei, a migrenei cu aur i a migrenei cu aura i fr, pe durata unui an, la femei era de 18%, 11.3%,8.6% i 3.2%, respectiv. La brbai, prevalena migrenei, a migrenei cu aur i a

migrenei cu aura i fr, pe durata unui an, era 12.3%, 7.3%,3% i 0.7%, respectiv. Concluzii: Prevalena migrenei n cadrul populaiei din aceste regiuni a Croaiei a demonstrat rate aproximativ similare cu cele raportate la rile nvecinate , precum Italia i Frana. Studiile viitoare trebuie s fie proiectate pentru a estima ratele prevalenei migrenei n toat populaia Croaiei. Cuvinte cheie: migren,. Epidemiologie, prevalen, interviufa-n-fa, u cu u Abrevieri: MFA migren fr aur, MCA migren cu aur, MCAFA migren cu aur i fr aur, Migrena este una din cele mai des ntlnite tipuri de cefalee n parctica general i impactul general socio-economic a acestei maldii asupra comunitii este considerabil. (1-3) un numr mare de studii n baza comunitii asupra prevalenei migrenei au fost publicate. O metaanaliy recent efectuat de Stewart et al6 a sugerat c variaiile mari n ratele prevalenei printre studiile luate n consideraie sunt explicate de diferenele mari n definirea cazurilor i profilurile sociodemografice ale subiecilor selctai pentru studiu. Introducerea criteriiilor pentru migren a Societii Internaionale a Cefaleelor(SIC) a fost un pas major pentru modernizarea standardizrii diagnozelor cefaleelor. Recent, cteva studii sociale asupra prevalenei au utilizat criteriile SIC pentru migren. Majoritate lor au fost efectuate n baza sondajelor prin telefon sau scrisori pentru a diagnosticarea chestionailor cu cefalee din cadrul cantitii de populaie selecionate pentru studiu. ; studiile epidemiologice cu interviuri fa-n-fa sau u cu u sunt destul de rare, deoarece ele implic costuri economice foarte mari. Noi am efectuat un studiu epidemiologicfa-n-fa, u cu u asupra migrenei i subtipurilor acesteia , utiliznd criteriul de diagnosticare a SIC, asupra populaiei Croaiei. Scopul acestui studiu a fost de a determina prevalena migrenei i asubtipurilor ei printr-un studiu social n cadrul adulilor din Croaia, pentru a analiza posibilele variaii de sex i vrst i de a compara aceste descoperiri cu cele obinute n alte ri.

Materiale i metode Studiul a fost petrecut n Bakar, regiune a Coastei i Gorski Kotar, Croaia, care este situat de-a lungul coastei de est a prii de nord a mrii Adriatice. Studiul populaiei era constituit din toi locuitorii Bakar-ului cu vrsta 15- 65 ani pe 31 decembrie , 1998(5137 rezideni). Pe parcursul anului 1999, un total de 3794 de indivizi(73.3%) din toi rezidenii de 15-65 ani, au participat la acest studiu(fig. 1). Nu a exista o diferen semificativ ntre participani, n priviina sexului sau vrstei. totui, participanii au fost considerai reprezentativi pentru ntreaga populaiei selectat.Dup aprobarea din partea Consiliului Municipal din Bakar, adresele i nr de telefon a tuturor potenialilor participani pentru interogare au fost obinute din centrul local de statistic. Rezidenii au fost contactai prin telefon sau personal i cei care acceptau s participe, erau intervievai la domiciliu. A fost identificat un numr total de 1379 (26.7%)de persoane care au refuzat s participe(fig.1). principalele motive de a nu participa erau neprecizarea sau eroarea numerelor de telefon sau a adreselor(901 rezideni, 65.3%) i refuzul de a participa la studiu(479 rezideni, 34.7%). Fiecarui participant i-a fost efectuat un interviu fa-n-fa, u cu u, de ctre doi neurologi seniori(K:W i D.S-G) ai Centrului Clinic de Neurologie a Universitii din Rjieka, Croaia , specialiti n diagnosticarea i tratamentul cefaleii, cu scopul de a obine ct mai multe date posibile asupra istoriei sociodemografice, fiziologice, medicale i detaliate a cefaleii. Toi participanii au semnat un acord general nainte de a ncepe studiul. Chestionarul a fost petrecut pentru a evalua ntreaga populaie asupra prezenei migrenei n baza criteriilor SIC i era structurat n doua seturi de ntrebri diferite. Primul set prevedea datele socidemografice, fiziologice, medicale i a istorieie cefaleii. n baza acestor ntrebri ,respondenii cu cefalei au fost divizai n cei care au avut o cefalee( cu excepia) sau sau o cefalee acut n ultimile 12 luni , i durerea era mai sever de 5 puncte pe scara de 10 puncte, i cei care au nregistrat cel puin o cefalee n ultimul an, dar durerea era apreciat cu nu mai mult de 4 puncte pe scara zecimal i au experimentat unul din zece simptome ale aurei vizuale. Al doilea set de ntrebri a fost aplicat numai n cazul respondenilor pozitivi i coninea un chestionar mai detaliat care se focusa pe simptomele migrenei cu aur aa cum erau specificate n criteriile SIC . Interviul a fost petrecut i chestionarele au fost completate de ctre 12 studeni medicali dup o perioad necesar de training condus de investigatorii specilaizai n

migren, atunci cnd afost obinut aprobarea unui supervizor adecvat n echipa intervievatorilor. La sfritul periodei de training , validarea procedurii de scanare se petrecea cu intervievatorii incontieni de diagnoza clinic a 200 de pacieni care erau urmarii profilactic de ctre Clinica Neurologic a Uniersitii din Rjieka.Acordul Inter i intraobservatorilor n cadrul reelei a fost 0.85(rangul , 0.65 la 0.92) i 0.84(0.68 la 0.88), repectiv. Sensibilitatea procedurii de descoperirea cazului a fost 0.92(rangul, 0.58 la 0.99). Diagnoza final a migrenei, migrenei cu aur(MCA) sau a migrenei fr aur (MFA) a fost efectuat de neurologii seniori (K.W., D.SG.,A.J., M-B.). 39 de respondeni pozitivi (0.16%) au fost atribuii iniial grupei de migrenoi dar respondenii au fost reclasificai ca nemigrenoi dup o revedere necesar efectuat de neurologii seniori; totui aceti subieci nu au fost luai n consideraie n studiul prevalenei migrenei i subtipurilor acesteia. Prevalena pe via a migrenei a fost estimat n baza celor care au avut vreodat migren conform criteriilor SIC- cel pui dou tipuri diferite de atacuri de MCA sau cel puin cinci atacuri de MFA. Prevalena migrenei pe durata unu an includea subiecii care au avut cel puin un atac de migren nultimul an(subiecii activi). Datele prevalenei pentru MCA i MFA , i migren att cu ct i frr aur (MCFA) sunr prezentate numai pentru subiecii activi, deaoarece ei sunt mai puin probabili de a fi expui nclinaiei de rechemare. Urmtoarea informaie au fost colectat pentru subiecii cu MCA i MFA pe via: sex, vrst, frecvena i durata atacurilor , caracteristicile clinice a migrenei (locaie, caracter i intensitatea durerii) i fenomele asociative (grea, vom). Analiza statistic a fost petrecut utiliznd Pachetul Statistic pentru tiine Sociale(PSS), versiunea 10.0. Noi am utilizat testul X2(x la ptrat) i testul Student t era asemntor, pentru a determina dac diferena dintre dou sau mai multe frecvene era semnificativ. 95% a intervalului de confiden au fost calculate folosind o aproximaie binominal a distribuiei Poisson dup metoda sugerat(propus) de Schoenberg. Datele demografice au fost obinute din Centrul Statistic din Bakar, regiune a Coastei i a Gorski Kotar, Croaia.

Rezultate:

din cei 3794 de participani , 2475 (65.2%) au fost indentificai ca fiind responendi cu cefalee i 1319 far cefalee(fig.1). un total de 720 de pacieni cu migren pe via a fost identificat (451 femei i 269 brbai). Printre 636 de migrenoi n faza activ, 399(62.7%) au fost femei i 237 brbai(37.3%); 55.8% aveau MFA; #%:% aveau MCA i 6.9% aveau MCAFA. Trei pacieni din grupa pacienilor n faza acut nu au putut fi clasificai cu certitudine n una din aceste 3 grupe, astfel nct ei au fost atribuii grupei MCAFA.

Prevelena pe via- Prevalena pe via a migrenei era 22.9% (95%interval de confinden, 20.9 la 25.1%) pentru femei, 14.8% la brbai (95% intervalul de confiden, 13.1 la 16.8%) i 19%(95% IC, 17.6 la 20.5) pentru amble sexe(tabel1). Printre femei, cea mai nalt prevalen specific vrstei a fost n intervalul de vrst 40-49 ani i 60-65 ani(38.1% i 37.5%, repectiv). Printre brbai,topul prevalenei pe via a fost n grupele de 15-19 i 40-49 (29.5%i 22.7%, respectiv). Prevalena pe 1 an- Prevalena pe parcusrsul unui an a fost de 20.2%(95% IC, 18.9la 21.5) la femei, 13%(95%IC, 12.1 la 13.8) la brbai i 16.7%(95%IC, 15.6 la 17.7) la ambele sexe considerate nmpreun(tabel 2).Distribuirea prevalenei specifice vrstei n toat populaia, a dovedit un patern bimodal cu vrful n grupul de vrste 15-19 i 40-49. Prevalena pe parcursul unui an a MFA era de 11.3%(95% IC,9.8 la 13) pentru femei, 7.3% la barbai i 9.2% la ambele sexe. Prevalena pe durata unui an a MCA era 8.6% la femei, 3% la brbai i 5.9& la ambele sexe. Prevalena pe durata unui an a MCAFA era de 2.2% la femei, 0.7% la brbai i 5.9% la ambele sexe. Ratele prevalenei specifice vrstei sau sexului a MCA i MFA sunt artate n figura 2. Caracteristicile clinice a migrenei cu aur i frr aur pe via- Caracteristicile clinice a MCA i MFA la migrenoii pe via sunt artate n tabelul 3. pacieii afectai de MCA au prezentat diferene semnificante cnd au fost comparai cu pacienii cu MFA n priviina frecvenei i severitii atacurilor, frecvena durerii deranjante, i prezena simptomelor generale asociai. Ratele de la femeie la brbat erau mai nalte la pacienii cu MCA (2.1:1.5, P=.03).

Comentarii:

Acesta a fost primul studiu epidemiologic al migrenei i subtipurilor acesteia din Croaia, efectuat n baza criteriilor operaionale al SIC. Exist cteva aspecte ale procedurii noastre metodologice care trebuie luate n consideraie. Studiile epdemiologice asupra migrenei n care au fost aplicate metodele de intervievare fa-n-fa, u cu u sunt rare. Acest metod a colectrii de date este probabil mai sensibil n definirea cazurilor de migren dect interviurile telefonice sau chestionarele prin pot. Un interviu clinic fa-nfa rmne referin-standart pentru diagnosticarea migrenei n absena oricror indicatori neuroradiologici sau biologici. ntr-un studiu bazat pe populaia dintr-o comunitate , problema major este de a petrece un interviu direct cu participanii cu scopul de a clarifica semnele i simptomele MCA i a MFA , i astfel de a mbunti excactitatea diagnosticii. Alt surs major de variaii n studiile cu interviuri fa-n-fa este acordul intra i interobservatorilor n rndurile intervievatorilor. n evaluarea de fa, noi am petrecut , nainte de a ncepe studiul , un curs de instruire de 1 lun care implica 12 studeni medicali condui de ctre medicii specialiti n migren. n plus, pe parcursul procesului de

colectare a datelor , neurologii seniori petreceau o consulataie lunar , ntlnindu-se cu intervievatorii pentru a stabiliza o diagnoz final a migrenei i subtipurlor acesteia. O astfel de abordare minimalizez potenialele devieri de diagnosticare i contribuie la obinerea unei informaii ct mai veridice asupra prevalenei migrenei. n afar de aceasta, iterviul nostru de identificare a fost deasemena petrecut pentru a introduce o ntreag mostr de pacieni negativi (2475) n baza clinic. Dup cum cunoatem, trebuie notat c doar Rasmussen et al1 i Stewart et al18 au administrat un interviu de diagnosticare ntregului grup de intervievai. Deaceea , noi considerm c c stabilirea definiiei cazului nostru este precis i senzitiv. Mostra de intervievai ai studiului nostru bazat pe populaie costituia 73.3% din totalul de rezideni. Rata de participare n cadrul studiului nostru a fost puin mai nalt de ct cele prezentate n studiile recent publicate care prevedeau interviuri fa-n-fa asupra migrenei, dar era n concordan cu studiile raportate anterior. Cu acordul celorlali autori, noi am identificat 65% de respondeni pozitivi la cefalee n mostra clinic de participani . prevalena pe via a migrenei era nalt, n special printre femei cu vrsta 40-49 ani i 60-65(38.1% i 37.5%, respectiv). Aceste rate sunt aproximativ similare cu cele raportate n rile nvecinate , precum Frana i Italia , dar puin mai joase dect cele raportate n rile nordice din Europa. Totui, este bine stabilit c migrena este mai comun la femei dect la brbai, evidena arat c ratele da la femeie la brbat variaz considerabil n dependen de vrst ; prevalena crete din adolescen pn la 40 ani i descrete apoi ,mai ales la brbai. Exist probail o anumit influien a factorului hormonal asociate cu genul femenin care pot explica predominarea la femei mai n vrst de 60 de ani, dup cum a sugerat Stewart et al. Descoperirile noastre aprob aceats ipotez. Ratele noatre pentru prevalena pe durata unui an erau similare cu ratele obinute n dou studii de talie naional i un studiu-exemplu american. Prevalena de 1 an n dependen de vrst a artat un tipar bimodal cu vrful n grupele de vrst 15-19 i 40-49 de ani pentru ambele sexe. Cauza exact pentru o prevalen de vrf n grupul cel mai tnr nu este clar , lund n consideraie c doar 11.9% din toat mostra intervievat aparinea acestei categorii. Dup cum a presupus un studiu Korean, o explicaie posibil poate fi sindromul stresului printre elevii de liceu care se pregtesc de examenele de intrare la universitate. n studiul nostru , noi am subclasificat cei 636 de migrenoi activi, n dependen de subtipul lor. Majoritatea(55.8%) aveau MFA, urmai de cei cu MCA(35.2%) i MCAFA(6.9%). Ratele noastre sunt puin mai joase det cele raportate n studiul GEM care prevedea MFA i MCAFA(63.9% i 13.9%, respectiv),dar mai nalte pentru rata de MCA(17.9%). Posibil diferenele de studiu pentru MCA, MFA i MCAFA pot fi explicate de descoperirea i clasificarea lor, avnd in vedere c n studiul GEM numai o parte din respondenii negativi au fost interogai. Majoritate pacienilor

notri care suferea de MFAaveau 15-19, pe cnd migrenoii cu aur artau un vrf la vrsta de 30-39 ani (fig2). Aceste descoperiri sunt n concordan cu un studiu epidemiologic din Ungaria, asupra MFA i MCA , recent publicat . n studiul de fa, noi am observat o predominan n cazul femeilor n toate cele 3 grupe dup cum era sgerat i de ceilali autori. Unii autori au sugerat c MCA i MFA au probabil diferita etiologii. n studiul d fa, noi am ncercat s investigm diferenele dintre caracteristicile clinice a migrenoilor pe via pentur cei cu migren cu i fr aur(tabel 3). Ratele de la femeie la brbat erau semnificant mai nalte la pacienii afectai de MCA(P=.03). Majoritatea migrenoilor cu aur au resimit atacuri mai frecvente i mai severe cu simptomele nsoitare generale. Aceste descoperiri pot susine ipoteza c MCA i MFA sunt du entiti clinice diferite. Grupul amestecat (MCAFA) poate fi un alt grup distinct de migrenoi, iar aura la pacienii afectai de MCAFA probabil are o baz diferit det cea la migrenoii cu MCA. Noi am identificat numai 6.9% de migrenoi activi afectai de MCAFA. Aceast rat este mai joas dect ratele raportate de studiul GEM . pentru a investiga epidemiologia analitic descriptiv i clinic a MCA, MFA i MCAFA , ar fi important de standardiza o procedur de scanare a investigaiilor i a subclasificrii oentru a putea fi folosit n studiile din viitor. Studiile care vor urma trebuie s estimeze ratele reale a le prevalenei migrenei n populaia croat.

Filed In: 1. Headaches & Migraines

Puff, Puff, Puff Throb, Throb, Throb Smoking and Headaches: Another Reason To Quit Join the Discussion "it bothers me to the point that I will leave a place if there a too many smokers or smokers in a nonsmoking area who are smoking. I'll cancel my order in a restaurant and leave if I have to. I refuse to have a HA..." Roni Related Resources Become a "Trigger Detective" Is it Migraine? Tension? What? Are you a ClusterHead? From Other Guides

 Quitter's Toolbox The Big Quit Day Daily Tips Ash Kickers Forum

As many other headache sufferers, I'm part of another large group smokers who logically know we should quit for better health, but just haven't been able to do so. Oh, like so many people, I've quit at least a dozen times. You've been there, too? I though so. The difference this time is that my headaches have become so huge a problem to my daily life that the issue has finally snagged my full attention. Let's remind ourselves of some of the commonly known risks of smoking that are fairly obvious in relation to headaches: * increased blood pressure * circulation problems * increased risk of stroke * increased risk of heart disease * inflammation of the sinus cavities * inflammation of the nasal passages When you start looking for a more direct correlation between smoking or second hand smoke and headaches, the research is quite obliging in extending our list of reasons to quit. The list continues: * Smoking and second hand smoke is a major trigger for many headaches, particularly migraines and cluster headaches. * Smoking is a significant block to reduction of chronic daily headache. Studies have shown that abstinence from smoking nearly eliminated headaches in some sufferers of chronic daily headache. * Smoking increases carbon dioxide, decreases oxygen delivery to the brain, and actually be directly toxic to the brain in some instances. Talk about a headache trigger! * Smoking reduces the effectiveness many, if not all, of our headache treatments. Then, there's the one that we all know intellectually even if we tend not to admit it, even to ourselves: * Smoking weakens our bodies. It weakens our immune systems, our circulatory systems, our nervous systems, our entire bodies. If we want to control our headaches, the kindest thing we can do for ourselves is to control and rid ourselves of the habit of and addiction to smoking. In no way do I mean to imply that quitting smoking will be easy or something to be taken lightly. It may well be necessary to ask your doctor and/or pharmacist for assistance. * It also helps to have support, so rather than just stopping here, I'll close with links to two About forums where you can go to talk with others who understand: -------------------------------------------------------------------------------------------------------------------------------------Headache: The Journal of Head and Face Pain Volume 36 Issue 9, Pages 561 - 564

Published Online: 24 Feb 2002 Copyright 2008 American Headache Society * Get Sample Copy * Recommend to Your Librarian * Save journal to My Profile * Set E-Mail Alert * Email this page * Print this page * RSS web feed (What is RSS?) Published on behalf of the American Headache Society American Headache Society Go to Society Site < Previous Abstract | Next Abstract > Save Article to My Profile Download Citation

Abstract | Full Text: PDF (39k) | Related Articles | Citation Tracking An Epidemiological Study of Headaches Among Medical Students in Athens Dr. D.D. Mitsikostas, MD 1 2 * ; Dr. S. Gatzonis, MD 1 ; Dr. A. Thomas, MD 1 ; Dr. N. Kalfakis, MD 1 ; Dr. A. llias, MD 1 ; Dr. C. Papageoergiou, MD 1 1 Department of Neurology, Aeginition Hospital, Athens, Greece Naval Hospital, Athens, Greece. 2 Department of Neurology Athens

Correspondence to Dr. Dimos-Dimitrios Mitsikostas, Department of Neurology, Athens Naval Hospital, 70 Dinokratous Str., Athens 115 21, Greece. Copyright American Headache Society KEYWORDS headache migraine tension-type headache prevalence epidemiology students Greece ABSTRACT In order to study the prevalence of frequent headaches among the medical students of Athens University, an epidemiological survey was carried out among 588 medical students (318 men and 270 women), with mean age 23.5 years. Two questionnaires were designed for the study: one general, consisting of 10 questions and a second one, specific for headache sufferers, consisting of 117 questions. All those with headache who voluntarily completed the two questionnaires also underwent a neurological examination. Thirty point eight percent of men and 50.3% of women reported various headache attacks during the previous 6 months (39.6% in both sexes). However, only the 11.9% of students (from both sexes) reported that they suffered from disturbing headaches. The 6-month prevalence of migraine was 2.4% and 9.5% for tension-type headache (in both sexes). Cluster headache was not traced. The prevalence of nonclassifiable headaches (according to the criteria of the International Headache Society) was 0.85%. Headache was correlated to sex (more frequent among women) and anxiety level (Hamilton scale for anxiety). Headache prevalence was not correlated to smoking and social class.

Accepted for publication February 8, 1996. -------------------------------------------------------------------------------------------------------------------------------------European Journal of Neurology Volume 13 Issue 11, Pages 1233 - 1238 Published Online: 17 Jul 2006 2008 European Federation of Neurological Societies * Get Sample Copy * Recommend to Your Librarian * Save journal to My Profile * Set E-Mail Alert * Email this page * Print this page * RSS web feed (What is RSS?) The Official Journal of the European Federation of Neurological Societies (EFNS) European Federation of Neurological Societies (EFNS) Go to Society Site < Previous Abstract | Next Abstract > Save Article to My Profile Download Citation

Abstract | References | Full Text: HTML, PDF (153k) | Related Articles | Citation Tracking Headache prevalence related to smoking and alcohol use. The Head-HUNT Study A. H. Aamodt a,b , L. J. Stovner a,b , K. Hagen a,b , G. Brthen b and J. Zwart a,b,c a Norwegian National Headache Centre, Trondheim University Hospital ; b Department of Neuroscience, Faculty of Medicine, Norwegian University of Science and Technology ; and c Norwegian Centre for Spinal Disorders, Norwegian University of Science and Technology, Trondheim, Norway Correspondence to Dr Anne Hege Aamodt, Norwegian National Headache Centre, Trondheim University Hospital, N-7006 Trondheim, Norway (tel.: +477 386 8420; fax: +477 386 7581; e-mail: anne.hege.aamodt@ntnu.no). Copyright 2006 EFNS KEYWORDS alcohol epidemiology headache migraine smoking ABSTRACT The aim of this study was to examine a possible association between smoking, alcohol and headache in a large population-based cross-sectional study. A total of 51 383 subjects completed a headache questionnaire and constituted the 'Head-HUNT' Study. Questionnaire-based information on smoking was available in 95% and on alcohol in 89% of the individuals. Associations were assessed in multivariate

analyses, estimating prevalence odds ratios (ORs) with 95% confidence intervals (CI). Prevalence rates for headache were higher amongst smokers compared with never smokers, most evident for those under 40 years smoking more than 10 cigarettes per day (OR 1.5, 95% CI 1.31.6). Passive smoking was also associated with higher headache prevalence. For alcohol use, there was a tendency of decreasing prevalence of migraine with increasing amounts of alcohol consumption compared with alcohol abstinence. Only with regard to symptoms indicating alcohol overuse, a positive association with frequent headache was found. The association between headache and smoking found in the present study raises questions about a causal relationship, e.g. that smoking causes headache or that it allays stress induced by headache. The observed negative association between migraine and alcohol consumption is probably explained by the headache precipitating properties of alcohol. Received 12 September 2005 Accepted 18 November 2005 --------------------------------------------------------------------------------------------------------------------Migraine and Ovarian Sex Hormones, Clinical Abstracts Source: Headache: The Journal of Head and Face Pain, Volume 47, Number 2, February 2007 , pp. 341344(4) Publisher: Blackwell Publishing --------------------------------------------------------------------------------------------------------------------Elsevier Article Locator Help

You have requested access to the following article: Epidemiology, co-morbidity, and impact on health-related quality of life of self-reported headache and musculoskeletal pain a gender perspective . European Journal of Pain , Volume 8 , Issue 5 , Pages 435 - 450 K . Bingefors , D . Isacson To view this article, please choose one of your preferred Elsevier websites: Access to the full-text of this article will depend on your personal or institutional entitlements. Preferred Websites The ScienceDirect Web Site Full text on Elsevier Health Sciences imprints, theclinics.com, and ophsource.org MD Consult read help Article via MD Consult Article via ScienceDirect Article via Elsevier Health Sciences - Elsevier

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Abstract

Background. Headache and musculo-skeletal pain are major public health problems. Substantial proportions of the general population report that they experience pain problems that affect their work, daily living and social life. Epidemiological studies have consistently shown that the prevalence of most pain conditions is higher in women than in men. Design. Cross-sectional survey in the county of Uppland, Sweden, 1995. Five thousand four hundred and four completed the questionnaire (response RATE=68%). In these analyses for persons aged 2064 years 4506 were included. Results. Back pain (22.7%) and shoulder pain (21.0%) were the most commonly reported medical problems in the population with pain in arms/legs (15.7%) in fifth and headache (12.5%) in eight place. Major gender differences were found. The prevalence of pain conditions, especially headache, was higher among women. Women reported more severe pain. Co-morbidity between pain conditions and psychiatric and somatic problems was higher among women. Health-related quality of life (SF-36) differed by gender and type of pain condition. The physical dimensions of HRQoL were more affected by headache among men; psychological dimensions were more affected among women. Among both men and women, pain conditions were associated with poorer socioeconomic conditions and life-style factors but there were gender differences. Education and unemployment were important only among men while economical difficulties, half-time work and being married were associated with pain among women. Obesity, early disability retirement, long time sick-leave and lack of exercise were associated with pain conditions generally. Factors associated with pain conditions were unevenly distributed between genders. Conclusion. There are major differences between men and women in the prevalence and severity of selfreported pain in the population. Biological factors may explain some of the differences but the main explanation is presumably gender disparities in work, economy, daily living, social life and expectations between women and men. Although improved working conditions are of importance, deeper societal changes are needed to reduce the inequities in pain experiences between women and men. ----------------------------------------------------------------------------------------------------------------------------------Full Text DE-97-003 SEX AND GENDER-RELATED DIFFERENCES IN PAIN AND ANALGESIC RESPONSE NIH GUIDE, Volume 26, Number 23, July 18, 1997 RFA: DE-97-003 P.T. 34 Keywords: Pain

National Institute of Dental Research National Institute for Nursing Research National Institute on Drug Abuse National Cancer Institute Office of Research on Women's Health Letter of Intent Receipt Date: August 25, 1997 Application Receipt Date: September 25, 1997 PURPOSE The National Institute of Dental Research (NIDR), National Institute of Nursing Research (NINR), National Institute on Drug Abuse (NIDA), National Cancer Institute (NCI), and the Office of Research on Women's Health (ORWH) invite research grant applications to identify significant sex- or gender- related differences in analgesic response and to characterize fundamental biological or biobehavioral mechanisms underlying male/female differences in response to nociceptive stimuli or clinical pain. Both animal and human studies are encouraged. This initiative is expected to yield new insights which may ultimately lead to more targeted, effective, and safe approaches for treating acute or chronic clinical pain and preventing pain-related disability in both men and women. HEALTHY PEOPLE 2000 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of "Healthy People 2000," a PHS-led national activity for setting priority areas. This RFA is related to the priority areas of chronic disabling conditions and oral health, as well as the cross-cutting issue of women's health. Potential applicants may obtain a copy of "Healthy People 2000" (Full Report: Stock No. 017-001-00474-0) or "Healthy People 2000" (Summary Report: Stock No. 017-001-00473-1) through the Superintendent of Documents, Governing Printing Office, Washington, DC 20402-9325 (telephone 202- 512-1800). ELIGIBILITY REQUIREMENTS

Applications may be submitted by either domestic or foreign for-profit and non-profit organizations, public and private, such as universities, colleges, hospitals, laboratories, units of state or local governments, and eligible agencies of the Federal Government. Awards in connection with this RFA will be made to foreign institutions only for research of exceptional merit, scientific promise, or need, in accordance with PHS policy governing such awards. Foreign institutions are not eligible to apply for First Independent Research Support and Transition (FIRST) awards. Applications from minority individuals and women are encouraged. MECHANISM OF SUPPORT The mechanisms of support utilized will be the individual research project (R01) and the FIRST (R29) award. Responsibility for the planning, direction and execution of the proposed project remains solely that of the applicant. The total project period for an application submitted in response to this RFA may not exceed five years. Typically, a maximum of three years of support will be provided for R01 applications. This RFA is a one-time solicitation for new and competing renewal awards. Future competitive renewal applications will compete with all investigator-initiated applications and will be reviewed according to customary referral and review procedures. FUNDS AVAILABLE The estimated total funds (direct and indirect costs) available for the first year of support for awards under this RFA will be $2,400,000. The NIDR, NINR, NIDA, NCI, and the ORWH each plan to support or contribute toward the support of projects. Pending receipt of a sufficient number of applications of high scientific merit, the agencies intend to fund a total of approximately eight to ten grants in response to this RFA in FY98. Applications may not request more than three percent annual increases for inflation over subsequent years. Usual PHS policies governing grants administration and management will apply. Although this program is provided for in the financial plans of the NIDR, NINR, NIDA, NCI, and the ORWH, awards pursuant to this RFA are contingent upon the availability of funds for this purpose. Funding beyond the first and subsequent years of the grant will be contingent upon satisfactory progress

during the preceding years and the availability of funds. RESEARCH OBJECTIVES Background The terminology used throughout this RFA encompasses both solely biological factors influencing differential pain or analgesic responses observed in male and female animals or humans (i.e., sex-related differences) and the interactions between biological factors and differential cultural expectancies, socialization, or experiential factors influencing pain or analgesic response in men and women (gender-related differences). Recent reviews of sex and gender differences related to pain highlight important questions that need additional study (Unruh, 1996; Fillingim and Maixner, 1995; Berkely, 1996; Miaskowski, 1996). In general, the existing research literature on experimentally-induced pain suggests that women tend to show lower pain thresholds, assign higher ratings of pain intensity to the same stimulus, and to discontinue pain- inducing tasks earlier (i.e., show lower pain tolerance) than do men. However, gender-related differences observed in response to experimentally-induced cutaneous pain are relatively small and are most reliably observed in response to mechanical or electrical (but not thermal) nociceptive stimuli. Animal studies also suggest that female rats, as compared with males, show enhanced discrimination of nociceptive stimuli, and are more likely to show persisting pain behaviors after experiencing procedures which can lead to neuropathic pain. Several recent studies indicate that gonadectomy in both males and females decreases nociceptive thresholds, and that the administration of testosterone to gonadectomized males, as well as females, increases the antinociceptive effects of morphine. Other studies indicate sex-related differences in the underlying neurochemical mediation of stress-induced analgesia, the development of which is sensitive to the hormonal environment during early post-natal development. Several studies suggest that cyclical or pregnancy-related hormonal variations, as well as the use of exogenous hormones, influence pain. For example, data from both animal and human studies indicate marked

endorphin-mediated increases in pain thresholds in pregnant females during the final days of gestation. Findings from a recent epidemiological study using a large, longitudinal data set obtained from a health maintenance organization indicated that post-menopausal estrogen use was associated with a 77% increase in the odds of referral for treatment of temporomandibular disorder (jaw) pain, even when patients' overall patterns of health care utilization had been controlled for statistically. Use of oral contraceptives was also significantly, though less strongly, associated with an increased probability of referral for treatment of temporomandibular disorder pain. Clinically, gender differences have been noted in the prevalence of a number of pain syndromes. Women, for example, show a higher prevalence of fibromyalgia, temporomandibular joint disorders, and rheumatoid arthritis, while cluster headaches, duodenal ulcers, and ankylosing spondylitis are more prevalent in men. In general, given the same diagnosis, women report greater pain intensity, indicate higher numbers of painful sites, and are more likely to use over-the-counter pain medications. In contrast, studies focusing on patterns of health care delivery suggest that health care professionals managing post-operative and cancer pain tend to provide less potent analgesic coverage for women as compared with men. In adolescence and early adulthood, women report higher levels of recurrent pain than do men. It has not been determined whether sexrelated differences in natural occurring experiences which generate pain (e.g., menstruation, pregnancy, parturition) may favor the development of biological or behavioral changes altering pain sensitivity or analgesic response. Also, many questions remain regarding the mechanisms through which hormonal variations influence pain behaviors and response to analgesics. Few studies have focused on sex-specific differences in analgesic response. However, a recent study indicates that drugs activating kappa opioid receptors produce more powerful, persisting post-operative pain relief in females as compared with males. This and related work suggests the possibility that fundamental differences may exist in pain modulatory systems, or in interactions between sex hormones and pharmacological agents impacting upon pain and analgesic response.

Scope of Research Sought This initiative focuses upon expanding our understanding of biologically significant differences between males and females in response to experimentally-induced or clinical pain or analgesics and the underlying mechanisms through which such differences occur. It is recognized that pain is a multidimensional phenomenon, including physiological, behavioral, sensory, cognitive, affective, and sociocultural factors. While this initiative emphasizes biological determinants of differential pain and analgesic responses, studies which integrate biological and environmental or sociobehavioral factors are specifically encouraged. Examples of some pertinent areas and research topics are listed below. This list is intended to be illustrative, not exhaustive. Topics are not presented in a priority order: o animal or human studies which characterize relationships between hormonal function and analgesic or pain response; o studies to improve methodologies for studying hormonal and other sex-related biological variables impacting on nociceptive or analgesic response; o studies characterizing mechanisms underlying male/female differences in analgesic or nociceptive response, including studies at the molecular or genetic level; o studies evaluating male/female differences in pain modulatory systems or elucidating the role of cyclical hormonal variations in pain modulatory systems or analgesic response; o studies to clarify biobehavioral mechanisms underlying differences between men and women in pain thresholds, pain ratings, and pain tolerance; o studies evaluating sex or gender-related differences in malignant or non-malignant visceral pain, responses to analgesic regimens, or mechanisms underlying visceral pain;

o studies clarifying gender-related differences in "break-through" pain associated with malignant or non-malignant chronic pain conditions. Studies to develop or test new analgesics or epidemiological studies evaluating gender-related differences in the prevalence of various clinical disorders, pain symptoms, or health care utilization are considered outside the scope of this RFA and will be returned without review. INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS It is the policy of the NIH that women and members of minority groups and their sub-populations must be included in all NIH supported biomedical and behavioral research projects involving human subjects, unless a clear and compelling rationale and justification is provided that inclusion is inappropriate with respect to the health of the subjects or the purpose of the research. This policy results from the NIH Revitalization Act of 1993 (Section 492B of Public Law 103-43). Investigators proposing research involving human subjects should read the "NIH Guidelines For Inclusion of Women and Minorities as Subjects in Clinical Research," which have been published in the Federal Register of March 20, 1994 (FR 59 14508-14513) and in the NIH Guide for Grants and Contracts of Vol. 23, No. 11, March 28, 1994. LETTER OF INTENT Prospective applicants are asked to submit a letter of intent on or before August 25, 1997. The letter should include a descriptive title of the proposed research, the name, address, and telephone number of the Principal Investigator, the identities of other key personnel and participating institutions, and the number and title of the RFA to which the application responds. Although a letter of intent is not required, is not binding, and does not enter into the review of a subsequent application, the information that it provides will assist in planning for the timely review of applications. Receipt of such letters will allow Institute staff to estimate the potential review workload and make review plans which will avoid possible conflict of interest.

The letter of intent should be addressed to Dr. Patricia Bryant at the address and telephone number listed under INQUIRIES and will be distributed promptly to co-sponsoring agencies. APPLICATION PROCEDURES Applications are to be submitted on the grant application form PHS 398 (rev. 5/95). Applications kits are available at most institutional offices of sponsored research and may be obtained from the Division of Extramural Outreach and Information Resources, National Institutes of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone 301/435-0714, email: ASKNIH@odrockm1.od.nih.gov. Applications for the FIRST Award (R29) must include at least three sealed letters of reference attached to the face page of the original application. FIRST Award (R29) applications submitted without the required number of reference letters will be considered incomplete and will be returned without review. Individuals must also comply with the 1994 NIH Guidelines for FIRST awards and the Just-in-Time procedures announced in the NIH Guide on March 29, 1996. The RFA label available in the PHS 398 application form kit must be affixed to the bottom of the face page of the original and the original must be placed on top of the entire package. Failure to use this label or failure to follow the mailing instructions outlined below could result in delayed processing of the application such that it may not reach the review committee in time for review. In order to identify the application as a response to this RFA, the RFA title "SEX AND GENDER-RELATED DIFFERENCES IN PAIN AND ANALGESIC RESPONSE" and number DE-97-003 must be typed in item 2 of the face page of the application form and the YES box must be checked. Specific attention should be given to efforts to contain costs and ensure cost-competitive implementation of the project's research goals. Investigators are also encouraged to examine the potential for securing supplementary funds for the project from non-NIH sources, such as foundations or industry. If additional financial support from non-NIH sources is planned to complement or expand the research proposed for support by the NIH, the applicant should explain how such activities will further the goals of the project and make it

more cost-effective. Awardees will be expected to update this information on an annual basis. Applicants from institutions which have a General Clinical Research Center (GCRC) funded by the NIH National Center for Research Resources may wish to identify the GCRC as a resource for conducting the proposed research. In such a case, a letter of agreement from either the GCRC program director or principal investigator could be included with the application. Submit a signed, typewritten original of the application, including the Checklist, and three signed photocopies, in one package to: DIVISION OF RESEARCH GRANTS NATIONAL INSTITUTES OF HEALTH 6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710 BETHESDA, MD 20892-7710 BETHESDA, MD 20817 (for express/courier service) At the time of submission, two additional copies of the application must also be sent to: Dr. H. George Hausch Chief, Scientific Review Branch Division of Extramural Research National Institute of Dental Research Natcher Building, Room 4AN-44F 45 Center Drive MSC 6402 Bethesda, MD 20892-6402 Applications must be received by September 25, 1997. All applications received after that date will be returned to the applicant without review. REVIEW CONSIDERATIONS Upon receipt, applications will be reviewed for completeness by DRG and responsiveness by relevant program and review staff. Incomplete and/or unresponsive applications will be returned without further consideration.

Applications that are complete and responsive to the RFA will be evaluated for scientific and technical merit by a special emphasis panel convened by the Scientific Review Branch, NIDR. As part of the initial merit review, a process may be used by the initial review group in which applications will be determined to be competitive or non- competitive based on their scientific merit relative to other applications received in response to the RFA. Applications judged to be competitive will be discussed and assigned a priority score. Applications deemed non- competitive will be withdrawn from further consideration; the principal investigator/program director and the official signing for the applicant organization will be notified. Factors to be considered in the evaluation of the scientific merit of applications will be similar to those used in the review of traditional research project grant applications and will include: the novelty, originality, and feasibility of the approach; the training, experience, and research competence of the investigator(s); the adequacy of experimental design; the accessibility and appropriateness of study populations and facilities. Secondary review of the applications will be conducted by advisory boards or councils of sponsoring NIH institutes. AWARD CRITERIA Funding decisions will be made on the basis of scientific and technical merit as determined by peer review, program priorities, and the availability of funds. Applicants should also be aware that, in addition to scientific merit, program priorities and program balance, the total cost of the research proposed will be considered by program staff and the relevant advisory board or council in making funding recommendations. When applications have similar scientific merit, but vary in cost- competitiveness, program staff may select the more cost-competitive application for funding. INQUIRIES Staff welcomes requests for this RFA and welcomes opportunities to answer questions applicants have. Please direct inquiries regarding programmatic issues to:

Patricia S. Bryant, Ph. D. Division of Extramural Research National Institute of Dental Research Natcher Building, Room 4AN 18A 45 Center Drive MSC 6402 Bethesda, MD 20892-6402 Telephone: (301) 594-2095 FAX: (301) 480-8318 e-mail: BryantP@de45.nidr.nih.gov Mary D. Leveck, Ph. D., RN Scientific Program Administrator National Institute of Nursing Research Building 45, Rm 3AN-12 MSC 6300 Bethesda, MD 20892-6300 Telephone: (301) 594-5963 FAX: (301) 480-8260 email: mleveck@ep.ninr.nih.gov David A. Thomas, Ph. D. Division of Basic Research Behavioral Neurobiology Research Branch National Institute on Drug Abuse 5600 Fishers Lane, Rm 10A-10 Rockville, MD 20857 Telephone: (301) 443-6975 FAX: (301)594-6043 email:dt78k@nih.gov Claudette Varricchio, D.S.N., R.N. Division of Cancer Prevention and Control National Cancer Institute 6130 Executive Plaza N. - Rm 300 Rockville, MD 20892-7340 Telephone: (301) 496-8541 FAX: (301) 496-8667 email:cv9h@nih.gov Joyce Rudick Office of Research on Women's Health National Institutes of Health

Bldg 1, Rm 201 Telephone: (301) 402-1770 FAX: (301) 402-1798 email:RudickJ@od1tm1.od.nih.gov Direct inquiries regarding fiscal issues to: Mr. Martin R. Rubinstein Grants Management Office National Institute of Dental Research Natcher Building, Room 4AN-44A 45 Center Drive MSC 6402 Bethesda, MD 20892-6402 Telephone: (301) 594-4800 email: Rubinstein@DE45.nidr.nih.gov Mr. Jeff Carow Grants Management Office National Institute of Nursing Research Building 45 Rm 3AN12 - MSC 6301 Bethesda, MD 20892-6301 Telephone: (301) 594-5974 FAX: (301) 480-8256 email: jcarow@ep.ninr.nih.gov Dr. Gary Fleming Chief, Grants Management Branch National Institute on Drug Abuse 5600 Fishers Lane, Rm 8A-54 Rockville, MD 20857 Telephone: (301) 443-6710 FAX: 30`-594-6847 email:gf6@nih.gov Mr. Robert E. Hawkins Team Leader, Grants Administration Branch National Cancer Institute Executive Plaza S - Rm 243 6130 Executive Blvd Bethesda, MD 20892 Telephone 301-496-7800

FAX: 301-496-8601 email: rh60d@nih.gov SCHEDULE Letter of Intent Receipt Date: August 25, 1997 Application Receipt Date: September 25, 1997 Scientific Review Date: January/February, 1998 Advisory Council Date: May, 1998 Earliest Possible Award Date: July 1, 1998 AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance No. 93.121. Awards are made under authorization of the Public Health Service Act, Title IV, Part A (Public Law 78-410, as amended by Public Law 99-158, 42 USC 241 and 285) and administered under PHS grants policies and Federal Regulations 42 CFR 52 and 45 CFR Part 74. This program is not subject to the intergovernmental review requirements of Executive Order 12372 or Health Systems Agency review. The PHS strongly encourages all grant and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of a facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people. REFERENCES Berkley, K.J. Sex differences in pain Behav. Brain Sci. (in press) Gear, R. W. Miaskowski, C, Gordon, N., Paul, S, Heller, P, & Levine, J. Kappa opioids produce significantly greater analgesia in women than in men Nature 1996 2 1248-1250. Fillingim, R. B. & Maixner, W. Gender differences in the responses

to noxious stimuli Pain Forum 1995 4 209-221. Islam, A.K. Cooper, M. L.& Bodnar, R.M. Interactions among aging, gender, and gonadectomy effects upon morphine antinociception in rats Physio. Behav.1993 54 45-53 LeResche, L. Saunders, K, VonKorff, M., Barlow, W, and Dworkin, S. Use of exogenous hormones and risk of temporomandibular disorders Pain 1997 69 153-160. Unruh, A M. Gender variations in clinical pain experience Pain 1996 65 123-167. . Return to RFAs Index Return to NIH Guide Main Index Office of Extramural Research (OER) - Home Page Research (OER) Institutes of Health (NIH) 9000 Rockville Pike Bethesda, Maryland 20892 Department of Health and Human Services (HHS) Department of Health and Human Services (HHS) - Home Page USA.gov - Government Made Easy Office of Extramural National

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Abstract

The objectives of this study were to determine the prevalence and characteristics of recurrent headaches and to investigate the sociodemographic differences between high school students with or without recurrent headaches from Izmir, Turkey. Multistep, stratified, cluster sampling method was used in this analytic, school-based cross-sectional study. Twenty-one schools were selected randomly, and 2384 preparatory, first-, second-, and third-grade high school students from 84 different classrooms constituted the study cohort. The prevalence of recurrent headaches was 45.7% (1090/2384). Female students had a significantly higher headache frequency than males (P = 0.000). No significant relationship was evident between age and headache (P = 0.065). Also, there were no significant differences between the adolescents with or without headache for variables such as parental divorce (P = 0.052), existence of a step parent (P = 0.32), people with whom the students live at home (P = 0.186), number of siblings (P = 0.37), and maternal and paternal educational levels (P = 0.62 and P = 0.15, respectively). Headache frequency was higher when the income level of the students family was lower (P = 0.016). Among the students who had headaches, 53.3% had a medication, 37.3% were referred to a physician, and in 27.2% of them a diagnosis was established. School absenteeism with a ratio of 26.5% was a common problem among the students with headaches. These results indicate that approximately one half of Turkish high school students have recurrent headaches which reduce the quality of their lives. -------------------------------------------------------------------------------------------------------------------------------------Headache: The Journal of Head and Face Pain Volume 37 Issue 2, Pages 95 - 101 Published Online: 19 Jan 2002 Copyright 2008 American Headache Society * Get Sample Copy * Recommend to Your Librarian

* Save journal to My Profile * Set E-Mail Alert * Email this page * Print this page * RSS web feed (What is RSS?) Published on behalf of the American Headache Society American Headache Society Go to Society Site < Previous Abstract | Next Abstract > Save Article to My Profile Download Citation

Abstract | Full Text: PDF (131k) | Related Articles | Citation Tracking Prevalence of Migraine and Headache in a High-Altitude Town of Peru: A Population-Based Study Assia S. Jaillard, MD Dr 1 * ; Pilar Mazetti, MD Dr 2 ; Edwin Kala, MD Dr 3 1 Department of Clinical and Biological Neuro-sciences, Centre Hospitalier Universitaire de Grenoble. France ; 2 The Instituto de Ciencias Neurologicas. Hospital Santo Toribio Lima, Peru 3 Hospital Provincial, Cuzco, Peru (Dr. Kala). Correspondence to Dr. Assia S. Jaillard, Stroke Unit, Clinique Neurologique, Department of Clinical and Biological Neurosciences, BP 217 38043 Grenoble, Cedex 9, France. Copyright American Headache Society KEYWORDS migraine headache epidemiology altitude Peru ABSTRACT A door-to-door population-based epidemiological study of the prevalence of migraine and headache in a sample of 3246 people older than 15 years of age was carried out in Cuzco, a high-altitude town in the Peruvian Andes, located at 3380 meters. Among the 3246 screened people, there were 172 cases of migraine and 930 cases of headache, yielding a crude 1-year prevalence of 5.3% for migraine (2.3% among men and 7.8% among women) and 28.7% for headache (17.5% among men and 38.2% among women). Our results suggest that migraine prevalence in Cuzco is close to that of other developing countries, whereas headache prevalence may be higher than in other developing countries. Multivariate logistic regression suggested that both migraine and headache were related to the female sex, age, and anxiety and/or depression. This study suggests that migraine is a relatively common disorder in Cuzco, but does not show any difference which could be significantly related to altitude. In contrast, our results suggest that headache may be more frequent at high altitude than at sea level. -------------------------------------------------------------------------------------------------------------------------------------J Headache Pain. 2008 April; 9(2): 119128. Published online 2008 February 19. doi: 10.1007/s10194-008-0024-z.

PMCID: PMC2276239 Copyright Springer-Verlag 2008 Prevalence and burden of primary headache in Akaki textile mill workers, Ethiopia Getahun Mengistu Takele,corresponding author1 Redda Tekle Haimanot,1 and Paolo Martelletti2 1School of Medicine, Department of Neurology, Addis Ababa University, Addis Ababa, Ethiopia 2Master in Headache Medicine, 2nd School of Medicine and Surgery, Sapienza University of Rome, Italy, Rome Getahun Mengistu Takele, Phone: +251-911-647580, Email: getahaau@yahoo.com. corresponding authorCorresponding author. Received December 24, 2007; Revised January 30, 2008; Accepted February 4, 2008. Top >Abstract Introduction Objective Patients and methods Results Discussion References Abstract Headache disorders are the most common complaints worldwide. Migraine, tension-type and cluster headaches account for majority of primary headaches and impose a substantial burden on the individual, family or society at large. The burden is immense on workers, women and children in terms of missing work and school days. There are few studies that show relatively lower prevalence of primary headaches in Africa as compared to Europe and America. There might be many reasons for this lower prevalence. The objective of this study is to determine the prevalence and burden of primary headaches among the Akaki textile factory workers, which may provide data for the local and international level toward the campaign of lifting the burden of headache worldwide. The overall 1-year prevalence of all types of primary headaches was found to be 16.4%, and that of migraine was 6.2%. The prevalence of migraine in females was 10.1% while it was 3.7% in males. The prevalence of tension-type headaches was found to be 9.8%. This was 16.3 % in females as compared to 5.7% in males. The burden of the primary headaches in terms of lost workdays, gross under recognition and absence of effective treatment is tremendous. In conclusion, the prevalence of primary headaches in the Akaki textile mill workers is significant, particularly in females, and the burden is massive, in a place of poverty and ignorance. We recommend the availability and administration of specific therapy to the factory workers with primary headaches, and community based well-designed study for the whole nations rural and urban population. Top Abstract >Introduction Objective Patients and methods Results Discussion References Introduction

Headache is one among the most common medical complaints. Various forms of headache, properly called headache disorders, are among the most common disorders of the nervous system. They are pandemic and, in many cases, life-long conditions [1]. As many as 90% of all primary headaches, including migraine, tension-type and cluster headache, fall under few categories. Recurrent headache disorders impose a substantial burden on headache sufferers, family and society [2]. Headache disorders are in the top ten, and possibly the top five, causes of disability worldwide [3]. Although the epidemiology of headache disorders is only partly documented, taken together, headache disorders are extraordinarily common. Population-based studies have mostly focused on migraine, which, although the most frequently studied, is not the most common headache disorder. Other types of headache, such as the more prevalent TTH and sub-types of the more disabling chronic daily headache, have received less attention [1]. The overall prevalence of migraine is estimated to be 1216% percent in North America and Europe [4]. Population-based studies are less available for other chronic headache syndromes, but tension-type headache seems to be more prevalent than migraine [5]. In developed countries, tension-type headache (TTH) alone affects two-thirds of adult males and over 80% of females. Extrapolation from figures for migraine prevalence and attack incidence suggests that 3,000 migraine attacks occur every day for each million of the general population. Less well recognized is the toll of chronic daily headache: up to one adult in 20 has headache, nearly every day or every day [1]. Migraine is more common in boys before the age of puberty but at the age of menarche the incidence of migraine increases in females, and migraine remains more common in women at all post-pubertal ages [2]. Both migraine and tension-type headaches affect women more often than men, while cluster headache is predominantly a disorder of men [5]. Migraine is more common in people from low-income households but less common in African Americans and Asians in the United States. These patterns of prevalence by race are also reflected in international studies, as migraine is most common in North America and Europe and less in Africa and Asia [2]. The recurrent headache disorders have an enormous impact on the individual and society. The individual impact is measured by the frequency and severity of attacks, while the societal burden is measured in terms of lost work and schooldays as well as healthcare utilization [2]. Few population-based studies exist for developing countries where limited funding and large and often rural populations, coupled with the low profile of headache disorders compared with other diseases, prevent the systematic collection of information [1]. There is a scanty data on the prevalence of primary headaches in sub-Saharan Africa in general and Ethiopia in particular. The prevalence of these headaches is very low as compared to Europe and North America. In 2004, the 1-year prevalence of headache from a door-to-door survey of rural south Tanzania was 23.1% (18.8% males and 26.4% females). In this study, the 1-year prevalence of migraine was 5% with a male to female ratio of 1:2.8 and migraine without aura was 1.4% while migraine with aura was 3.6% [6]. From a 1995 study done in Ethiopia, the 1-year prevalence of migraine was 3% (4.2% females and 1.7% males) with a peak age specific rate in the fourth decade [7]. In Hong Kong, another third world country, the estimated prevalence of headaches in 2000 was 12.5% for migraine, 18.7% for tension-type headache and 6.0% for other types of headache [8]. In 2007, in the country of Georgia, Eastern Europe, the 1- year prevalence of migraine was 8.6%, tension-type headache was 20.4% and chronic daily headache was 5.4%, two of whom were overusing acute headache medication [9]. In 2005, in an epidemilogic study in Florianopolis, Brazil, the 1-year prevalence of headache was 80.8%, of migraine 22.1%, of TTH 22.9%, and of CDH 6.4% [10]. In Norway, out of 64,560 participants of a large population-based study in 2000, the overall age-adjusted 1year prevalence of headache was 38% (46% in women and 30% in men). The prevalence of migraine was 12% (16% in women and 8% in men), and for non-migrainous headache 26% (30% in women and 22% in men). For frequent headache (>6 days per month) and for chronic headache (>14 days per month), the prevalence was 8 and 2%, respectively [11]. The factors for such low prevalence in Africa in general and Ethiopia in particular might be the following:

* Headache is under recognized and not diagnosed by many health practitioners in the African set up due to a number of reasons [12]: o Rural people have a great tolerance to pain hence do not report or seek medial attention. o Headache, even if persistent and recurrent, is often perceived as a trivial problem as there are more demanding and basic problems that are given priority. o Most rural headache sufferers come from low socioeconomic segment and are less educated. o Most headache sufferers go for the traditional, religious and herbal medications. * It is not considered as a reason for medical consultation and even the sick people do not know headache as a medical condition * In the studies done so far, there were methodological problems, use of different classifications [like the one by the Ad Hoc Committee (AHC) on the Classification of Headache and the Headache Classification Committee of the International Headache Society (IHS), etc.] and absence of objective laboratory parameters for correlation of the headache data. * The presence of more than one type of primary headaches in a single patient, may have an impact on categorizing the patients even when the IHS criteria is used in the diagnosis of headache by less trained and less experienced health workers. Moreover, this is complicated by the absence of neurologists or headache specialists in most parts of Africa including Ethiopia. * Pain is more tolerated in the African culture than in Western countries. On top of this, diseases are perceived in the magico-religious context where traditional healing plays a big role. * Low incomes, poor infrastructures and inadequate health care coverage make the disease burden of headache different from that in the rich and developed nations. * There could be a genetic difference of Africans from that of Caucasians. Migraine in Africans is not rare as reported in earlier reports. It is, however under recognized and accorded low priority. Its clinical manifestations in Africans are similar to those seen in other populations. It is an under-treated condition where only a low percentage of the sufferers receive specific treatment. The majority of migraine patients resort to herbal and traditional healers [3, 12]. In a world of limited resources for healthcare services and health related research, reliable data on the individual and societal impact of different disorders are crucial for a rational distribution of means [13]. Not only is headache painful, but headache disorders are also disabling [1]. Migraine associated disability remains substantial and pervasive [14]. Worldwide, according to the World Health Organization (WHO), migraine alone is 19th among all causes of years lived with disability (YLDs). Headache disorders impose recognizable burden on sufferers including, sometimes, substantial personal suffering, impaired quality of life and financial cost. Repeated headache attacks, and often the constant fear of the next one, damage family and social life as well as employment. For example, social activity and work capacity are reduced in almost all migraine sufferers and in 60% of TTH sufferers [1]. The disease burden and the costs incurred due to migraine are probably among the highest for the neurological disorders, and is probably high in poor countries as in the rich. For other headaches, reliable data on their impact are still scarce, but these disorders may be as important as migraine because they are more prevalent [13]. While those suffering from headache disorders bear much of the burden, they do not carry it all. Because headache disorders are most troublesome in the productive years (late teens to 50s), estimates of their financial cost to society, principally from lost working hours and reduced productivity, are massive. In the United Kingdom, for example, some 25 million working or school days are lost every year because of migraine alone. TTH, less disabling but more common, and chronic daily headache, less common but more disabling, together cause losses which are almost certainly of at least similar magnitude [1]. In a 2002 study of Italy, among young Italian patients, quality of life was compromised in primary headache and was significantly lower in psychosocial, physical and social functioning [15]. Headache rarely signals serious underlying illness; its public-health importance lies in its causal association with these personal and societal burdens of pain, disability, damaged quality of life and

financial cost [1]. The societal impact of headaches is usually measured in economic terms. Direct costs consist primarily of health care utilization. Indirect costs include missed work (i.e., absenteeism) and reduced productivity while at work (i.e., presenteeism) due to headache [2]. Headache is high among causes of consulting medical practitioners. A survey of neurologists found that up to one-third of all their patients consulted because of headache, more than for any other complaint [1]. The direct costs of diagnosing and treating primary headaches are far less than the costs of productivity losses due to headache attacks. As a consequence, improving health care delivery for primary headaches could be cost effective from a societal perspective [2]. The common headache disorders require no special investigation and they are diagnosed and managed with skills that should be generally available to physicians. In theory, therefore, most headaches can be optimally managed in primary care. There are barriers to effective care of these primary headache disorders. These barriers vary throughout the world, but may be classified as clinical, social or political/economic [1]. For the developed nations, there are many cost-effective, efficacious treatments available, but these are limited, unavailable or unaffordable in the developing nations [2, 7, 12]. Headache ought to be a public-health concern. Yet there is good evidence that very large numbers of people troubled by headache do not receive effective care. For example, in representative samples of the general populations of the United States of America and the United Kingdom, only half of those identified with migraine had seen a doctor for headache-related reasons in the previous 12 months, and only twothirds had been correctly diagnosed. Most were solely reliant on over-the-counter medications [1]. Yet the reality is that, for the vast majority of those whose quality of life is spoiled by headache, effective treatment requires no expensive equipments, tests or specialists. The essential components of effective medical management are awareness of the problem, correct recognition and diagnosis, avoidance of mismanagement, appropriate lifestyle modification and informed use of cost-effective pharmaceutical remedies [3]. Top Abstract Introduction >Objective Patients and methods Results Discussion References Objective The general objective is to determine the prevalence and burden of primary headaches among the textile mills workers in Addis Ababa, Ethiopia Specific objectives are: * To determine the magnitude and prevalence of primary headaches in the textile mills workers * To see the burden of these headaches among the sufferers. * To know the missing working days and hence assess the impact of primary headaches on the productivity in particular and on economy in general. * To assess the care provided to the headache patients (workers) versus the over the counter use and or misuse of drugs for headache. * To generate data on headache prevalence and burden for use by the national and international policy makers on health care.

Top Abstract Introduction Objective >Patients and methods Results Discussion References Patients and methods The study population included all workers in the Akaki textile mill. This cross-sectional prevalence study was conducted among the Akaki textile mill workers from 1 November 2007 to 28 November 2007. It included the entire workers employed by the factory. It is located in Kality, Akaki sub-city of Addis Ababa, about 25 km east of the center. It has 1,300 workers and is about 52 years old, being one of the oldest factories of the country. Data collection was done by the investigator (PI), three nurses and a medical doctor of the factory after training and orientation on primary headaches. Prepared and pre-tested questionnaires were used. The questionnaire was divided into two parts, the first part was on the demographic and personal aspects and the second part dealt with the specific details of headache. Cases with positive history of headache were interviewed and examined by the physician trained in headache medicine, internal medicine and neurology. Subjects were diagnosed in accordance to the most frequent type of headache experienced in the last 1 year, using HIS criteria [16]. Migraine and tension-type headache were diagnosed when all criteria were fulfilled. The diagnosis of probable was made when all but one criterion were fulfilled. Chronic headache was diagnosed when the frequency of headache pain was 180 days per year, based on a question about the frequency of headache. Data quality was checked and crosschecked by the PI. The collected data were processed with a computer Epi-Info version 2002 and SPSS 11.0 software packages. Chi-square, OR, P value and 95% Confidence interval were used for analysis. Ethical consideration The proposal was submitted to the Faculty Research and Publication Committee (FRPC) of Addis Ababa University Faculty of Medicine for necessary processes as per rules and regulations. It was approved on 5 October 2007. Institutional ethical clearance was obtained. Informed consent was obtained from the study participants. Dissemination of results The results and outputs of the study will be published in the national or international Journals and copies will be given to MOH, AAU-RPO, Faculty of Medicine Library and NGOs Top Abstract Introduction Objective Patients and methods >Results

Discussion References Results Of the 1,300 employees of the Akaki textile mill on job at the time of the interview, 195 did not want to participate in the interview. Out of 1,105 (85%) interviewed, 681 (61.6%) were males and 424 (38.4%) were females. The age ranged from 25 to 77 years with mean of 46.9 7.5. There were two workers beyond the age of 65, working as a cleaner and a guard. Out of the total, 590 (53.4%) were in the age range of 4554 years (Table 1). Of the total study population, 866 (78.4%) were married, of which 260 (30%) were females. The divorce rate was 9.0% (99), of which 87 (87.9%) were females. About 6.7% (74) were widowed of which widows accounted for 79.7 % (59) while widowers were 20.3% (15) (x2 = 185.1, df = 3, P = 0.00000) (Fig. 1). Table 1 Table 1 The age and sex distribution of the study population Akaki textile mill, Ethiopia, 2007 Fig. 1 Fig. 1 Marital status of study population by gender Akaki textile mill, Ethiopia, 2007 Illiteracy rate (did not read or write) of the study population was 9.9% (220), of which 161(73.2%) were females; on the other hand, among 8.5% (94) who had tertiary education 75.5% (71) were males (x2 = 154.6, df = 3, P = 0.0000) (Fig. 2). Fig. 2 Fig. 2 Educational status of study population by gender, Akaki textile mill, Ethiopia, 2007 Lifetime prevalence of all sorts of headaches was 96.1%, 98.6% in females versus 95.9% in males (adjusted OR = 2.3, 95% confidence interval of 0.905.64). One-year prevalence of all types headaches was 73.2%, in females 79.2% compared 69.5% in males (OR = 1.20, 95% CI = 0.901.63) (Table 2). Table 2 Table 2 Prevalence of headache in the study population, Akaki textile mill, Ethiopia, 2007 The overall 1-year prevalence of all types of primary headaches was found to be 16.4% (181/1,105). Out of these 181 cases, 114 (63%) with primary headache were females making a prevalence of 26.9% in the females while it was 9.8% in males. This is statistically significant (adjusted OR = 3.13, 95% confidence interval of 2.224.41, P = 0.000). The age specific prevalence was 18.0% in the age group of 4554 years (Tables 2, 4). Table 4 Table 4 Prevalence headaches by age category, Akaki textile mill, Ethiopia, 2007 According to the International Headache Society criteria, 68 workers were found to have migraine giving a prevalence rate of 6.2%. The prevalence of migraine in females was 10.1% while it was 3.7% in males (adjusted OR = 3.23, 95% CI = 2.114.94, P = 0.000). The age specific prevalence was 7.3 % in the age range of 4554 years. The over all prevalence of migraine without aura was 51 (4.6%) making 75% of the migraine patients. This was 8.5 (36) in females and 2.2% (15) in males (adjusted OR = 4.63, 95% 2.50 8.58, P = 0.000). The prevalence of migraine with aura was found to be 1.4% and that of probable migraine was found to be 0.1% (Tables 3, 4). Table 3 Table 3 Migraine and tension headache categories by sex, Akaki textile mill, Ethiopia, 2007 The over all prevalence of tension-type headaches was found to be 9.8% (108/1,105). This was 16.3 % in

females as compared to 5.7% in males (adjusted OR = 3.14, 95%CI = 1.875.28, P = 0.000). The age specific prevalence was 13.3% in the age group of 2534 years. Frequent episodic tension-type headache was found to be 4.3%, with 7.1% in females and 2.5% in males (adjusted OR = 3.45, 95% CI of 1.876.35, P = 0.000). The prevalence of infrequent episodic tension headache was 3.5, and 5.2% in females and 2.5% in males (adjusted OR = 2.45, 95% CI = 1.284.70, P = 0.007). Chronic tension-type headache was found to be 1.6 and 3.5% in females and 0.4% in males (adjusted OR = 9.77, 95% CI = 2.8134.00, P = 0.000). Probable tension-type headache was found to be 0.4% (Tables 3, 4). Cluster headache and other trigeminal autonomic cephalalgias were found in five (0.45%) individuals. Table 5 shows the prevalence of headache versus marital status. The widowed ones have the significant higher proportion of all types of headaches followed by the divorced. Table 5 Table 5 Marital status and prevalence of headache, Akaki textile mill, Ethiopia, 2007 Table 6 shows the prevalence of headaches in educational categories. The general trend of reciprocal relationship of headache and educational levels was found to be evident but this is not significant statistically when confounders are controlled. Table 6 Table 6 Educational status and prevalence of headache, Akaki textile mill, Ethiopia, 2007 Tables 7 and 8 show the proportion of missing workdays in primary headaches during attacks. Out of 181 workers with primary headaches, 63 (34.8%) miss working days due to headache attacks. This was 60.3% in migraine and 20.4% in tension-type headaches. Table 7 Table 7 Primary headaches versus missing working days, Akaki textile mill, Ethiopia, 2007 Table 8 Table 8 Primary headaches versus missing of workdays, Akaki textile mill, Ethiopia, 2007 Table 9 shows the use of ant-pain medications for attacks of headache. Only one patient, who has migraine with aura, ever used ergot preparation from the specific medications, the only available specific medication in Ethiopia. The most widely used over the counter medicine was acetaminophen tablets. Out of 181 workers with primary headaches, 80.1% used ant-pains intermittently or during every attack. This was 97.1% in migraine and 70.4 % in tension headache. The reasons given for those who did not use medicines were: no lasting remedy or response at all, use of alternatives like traditional medicine and holy water and fear of abuse of drugs. Table 9 Table 9 Primary headaches versus use of medicine (ant-pain), Akaki textile mill, Ethiopia, 2007 Average age of onset for primary headaches was 25.7 12.4 years, where as it was 21.9 11 for migraine and 27.7 12.2 for tension-type headaches. Out of the average 27.3 7.7 years spent on job in the textile mills, 21.9 12.4 years were with episodes of headache. These workers on average have 13.77 15.5 days of missing work per year. This was 15.6 15.4 days for migraine and 11.2 15.6 days per year for tension-type of headaches. Of the mean 47.3 7.1 years of life, 21.9 12.4 were spent with intermittent episodes of headache. It was 26.8 15.5 years for migraine and 19.24 11.8 years for tension-type headache (Table 10). Table 10 Top Table 10 Primary headaches and the burden, Akaki textile mill, Ethiopia, 2007

Abstract Introduction Objective Patients and methods Results >Discussion References Discussion Lifetime prevalence of all sorts of headaches in this study is more than 96.0% which is in accordance to the studies done elsewhere [17]. The 1-year prevalence of all kinds of headache was 73%. This is slightly lower than the 1-year prevalence of the 2005 study of Florianopolis in Brazil, which was 80.8% [10]. The 1-year prevalence of migraine, 6.2% in this study is lower than the 2007 prevalence of migraine and probable migraine of Georgia, which was 21.5% where as it was closer to the definite migraine prevalence of 8.5% [9]. The prevalence in this study is within the WHO estimate of 37% in Africa according to the community- based studies [1] but much lower than the global data of 11% [18]. This study showed similar prevalence of migraine to the door-to-door study done in 2004 in rural area of southern Tanzania where the overall 1-year prevalence was 5.0% [6]. In a study done in 1995, in the rural Ethiopian community, 1-year prevalence of migraine, 3.0% was lower than the figure in this study [7]. The reasons for such difference might be that the current study is in an urban setup where people can report and perceive headache as an illness and this study was done in factory employees where as the previous one was in a rural community. Almost similar prevalence of 4.7% was found in a 2000 study from Hong Kong [8]. This study showed much lower prevalence of migraine as compared to the 2005 study of Florianopolis in Brazil, which was 22.1% [10]. In this study, migraine without aura accounted for 75% of the cases with a prevalence of 4.6% and preponderance in females was statistically significant. The low prevalence of migraine with aura 1.4% accounting for 24% of cases with migraine is in agreement with the previous reports from Africa in general and Ethiopia in particular [7, 12]. The 1-year overall prevalence of tension-type headache, 9.8% in this study is lower than the reported prevalence of 20.4% from Georgia [9] and very much lower than the 2007 global estimate of 42% [18]. This is much higher than the 1.7% reported by WHO in some African community based studies [1]. In a 2000 study from Hong Kong, the overall prevalence of tension-type headache of 26.9% was much higher than the present study [8]. In our study, the prevalence of tension-headache was much lower than the 2005 study of Florianopolis in Brazil, which was 22.9% [10]. Chronic tension-type headache in this study found to be 1.6% is in accordance to the WHO figure of 13% in adults and previous report from rural Ethiopia, which was 1.7% [1, 7, 12]. The 1-year prevalence of chronic tension-type headache, which is one of the most disabling headache syndromes, in our study is 3.5% in females and 0.4% in males. This gender difference was statistically significant. Cluster headache is extremely rare in Africa as reported previously, as well as in this study [1, 7, 12]. Both migraine and tension headache have an enormous burden and impact on the individual family, society and on the nation. This burden is serious in developing countries like Ethiopia where the resources are meager, ignorance and poverty are overwhelming, and infrastructures for healthcare systems are scanty. The cumulative impact over time with a compromised quality of life was enormous on individuals. In this study, cases with primary headache and migraine each lived 21.9 years on average with intermittent attacks of headache while this was more than 19 years for tension headache. The majority of cases with migraine have severe or moderate attacks of headache, photophobia, phonophobia and nausea or vomiting.

Although the 1-year prevalence of primary headaches above 16% in this study is much lower than the global estimate 46% and that of Africa 21% [18], only one case of migraine with aura was ever treated with available specific medication of ergot preparation in the past. This shows how serious is the under recognition and under treatment of headaches in the capital city of Ethiopia, Addis Ababa. To complicate the matter, all sufferers in this study did not know that effective treatment exists and the care givers did not diagnose as well treat them. Many migraine sufferers miss work because of their headaches, and reduced productivity as a result of working during the migraine attack is common [2]. In our study, more than 60% with migraine and above 20% with tension headache missed working days and almost all with migraine as well as more than half with tension headache have a reduced work capacity during attacks. This is in agreement with the WHO report [1, 19]. In this study, 34.8% of cases with primary headache had on average 13.77 lost work days per year and this was higher in migraine, about 16 lost working days, and least in tension type, 11 lost working days. This is almost in agreement with the 1995 study from Dares Salaam, Tanzania, which was 11.3 lost workdays per year [20]. The economic impact on workers and their families as well as on the nation is massive especially for a developing country like Ethiopia, where poverty, ignorance and malnutrition are rampant. In conclusion, the prevalence of primary headaches in the Akaki textile mill is significant, particularly in females, and the burden is massive, in a place of poverty and ignorance. We recommend the availability and administration of specific therapy to the factory workers with primary headaches, and community based well-designed study for the whole nations rural and urban population, as suggested in the WHOs Aids for management of common headache disorders in primary care [21]. Acknowledgments This epidemiological work represents the final dissertation held at the Master in Headache Medicine by Dr. Getahun Mengistu Takele, during the Academic year 20062007 at Sapienza University of Rome. Dr. Mengistus scholarship has been granted by Sapienza University (00109592.2.4.1.40.2 to the author P.M.) in favor of the WHOs Global Campaign Lifting the Burden. The author G.M.T. is indebted to Dr. Worash Getaneh, geologist from Addis Ababa University, Department of Earth and Environmental Sciences for his ever-unreserved effort in accessing the Internet and encouraging the first author. He did allow his office and personal computer use day and night and sacrificed his time despite many commitments. We thank also Dr. Mihela Zebenigus, neurologist in the Department of Neurology of Addis Ababa University for her continuous support. Finally we are grateful to the participants and management of Akaki textile without which this study would not have been successful. Conflict of interest None. Top Abstract Introduction Objective Patients and methods Results Discussion >References References

1. World Health Organization (2004) Headache Disorders. Fact sheet N277, March 2004. Accessed 28 June 2007. 2. Munsat TL, Mancall EL, DesLauriers MP (1994) The AAN launches a new education program: CONTINUUM lifelong learning in neurology. Neurology 44:771772 [PubMed]. 3. Steiner TJ (2005) Lifting the burden: the global campaign to reduce the burden of headache worldwide. J Headache Pain 6:373377 [PubMed]. 4. Rasmussen BK (1995) Epidemiology of migraine. Biomed Pharmacother 49:452455 [PubMed]. 5. Rasmussen BK, Jensen R, Schroll M, Olesen J (1991) Epidemiology of headache in a general population a prevalence study. J Clin Epidemiol 44:11471157 [PubMed]. 6. Dent W, Spiss HK, Helbok R, Matuja WBP, Sheunemann S, Schmutzard E (2004) Prevalence of migraine in a rural area in South Tanzania: a door-to-door survey. Cephalalgia 24:960966 [PubMed]. 7. Tekle Haimanot R, Seraw B, Forsgren L, Ekbom K, Ekstedt J (1995) Migraine, chronic tension type headache and cluster headache in an Ethiopian rural community. Cephalalgia 15:482488 [PubMed]. 8. Cheung Raymond TF (2000) Prevalence of migraine, tension type headache and other headaches in Hong Kong. Headache 40:473479 [PubMed]. 9. Katsarava Z, Kukava M, Mirvelashvili E, Tavadze A, Dzagnidze A, Djibuti M, Steiner TJ (2007) A pilot methodological validation study for a population-based survey of the prevalences of migraine, tension type headache and chronic daily headache in the country of Georgia. J Headache Pain 8:7782 [PubMed]. 10. Queiroz LP, Barea LM, Blank N (2005) An epidemiological study of headache in Florianopolis, Brazil. Cephalalgia 26:122127 [PubMed]. 11. Hagen K, Zwart JA, Vatten L, Stovner LJ, Bovim G (2000) Prevalence of migraine and non-migrainous headache-head-HUNT, a large population-based study. Cephalalgia 20:900906 [PubMed]. 12. Tekle Haimanot R (2003) Burden of headache in Africa. J Headache Pain 4:S47S54 . 13. Stovner LJ, Hagen K (2006) Prevalence, burden, and cost of headache disorders. Curr Opin Neurol 19:281285 [PubMed]. 14. Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M (2001) Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache 41:646657 [PubMed]. 15. Nodari E, Battistella A, Naccarella C, Vidi M (2002) Quality of life in young Italian patients with primary headache. Headache 42:268274 [PubMed]. 16. Headache Classification Subcommittee of the International Headache Society (2004) The international

classification of headache disorders, 2nd edn. Cephalalgia 24:1160. 17. Steiner TJ (2004) Lifting the burden: the global campaign against headache. Lancet Neurol 3:204205 [PubMed]. 18. Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton RB, Scher AI, Steiner TJ, Zwart JA (2007) The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 27:193210 [PubMed]. 19. World Health Organization (2000) WHO report on Headache. Headache Australia, September 2000. http://www.headacheaustralia.org.au/?p=70. Accessed 16 Dec 2007. 20. Mutuja WBP, Mteza LBH, Rwiza HT (1995) Headaches in a non-clinical Population in Dares salaam, Tanzania. A community-based study Headache 35:273276 [PubMed]. 21. Aids for management of common headache disorders in primary care (2007) J Headache Pain 8(S1):1 47 . Articles from Springer Open Choice are provided here courtesy of Springer ------------------------------------------------------------------------------------------------------------------------------------Vol. 279 No. 5, February 4, 1998 JAMA Online Features Brief Report TABLE OF CONTENTS

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Epidemiology of Tension-Type Headache Brian S. Schwartz, MD, MS; Walter F. Stewart, PhD, MPH; David Simon, MS; Richard B. Lipton, MD JAMA. 1998;279:381-383. Context. Tension-type headache is a highly prevalent condition. Because few population-based studies have been performed, little is known about its epidemiology. Objectives. To estimate the 1-year period prevalence of episodic tension-type headache (ETTH) and chronic tension-type headache (CTTH) in a population-based study; to describe differences in 1-year period prevalence by sex, age, education, and race; and to describe attack frequency and headache pain intensity. Design. Telephone survey conducted 1993 to 1994. Setting. Baltimore County, Maryland. Participants. A total of 13345 subjects from the community. Main Outcome Measures. Percentage of respondents with diagnoses of headache using International Headache Society criteria. Workdays lost and reduced effectiveness at work, home, and school because of headache, based on self-report. Results. The overall prevalence of ETTH in the past year was 38.3%. Women had a higher 1-year ETTH prevalence than men in all age, race, and education groups, with an overall prevalence ratio of 1.16. Prevalence peaked in the 30- to 39-year-old age group in both men (42.3%) and women (46.9%). Whites had a higher 1-year prevalence than African Americans in men (40.1% vs. 22.8%) and women (46.8% vs 30.9%). Prevalence increased with increasing educational levels in both sexes, reaching a peak in subjects with graduate school educations of 48.5% for men and 48.9% for women. The 1-year period prevalence of CTTH was 2.2%; prevalence was higher in women and declined with increasing education. Of subjects with ETTH, 8.3% reported lost workdays because of their headaches, while 43.6% reported decreased effectiveness at work, home, or school. Subjects with CTTH reported more lost workdays (mean of 27.4 days vs 8.9 days for those reporting lost workdays) and reduced-effectiveness days (mean of 20.4 vs 5.0 days for those reporting reduced effectiveness) compared with subjects with ETTH. Conclusions. Episodic tension-type headache is a highly prevalent condition with a significant functional impact at work, home, and school. Chronic tension-type headache is much less prevalent than ETTH;

despite its greater individual impact, CTTH has a smaller societal impact than ETTH. --------------------------------------------------------------------------------------------------------------------------------------

Brazilian Journal of Medical and Biological Research Print ISSN 0100-879X doi: 10.1590/S0100-879X2003001000021 Braz J Med Biol Res, October 2003, Volume 36(10) 1425-1432 Headache complaints associated with psychiatric comorbidity in a population-based sample I.M. Benseor1, L.F. Tfoli2 and L. Andrade2 Departamentos de 1Clnica Mdica, and 2Psiquiatria, Faculdade de Medicina, Universidade de So Paulo, So Paulo, SP, Brasil Abstract

Introduction Material and Methods Results Discussion References Correspondence and Footnotes Abstract The objective of the present study was to determine the frequency at which people complain of any type of headache, and its relationship with sociodemographic characteristics and psychiatric comorbidity in So Paulo, Brazil. A three-step cluster sampling method was used to select 1,464 subjects aged 18 years or older. They were mainly from families of middle and upper socioeconomic levels living in the catchment area of Instituto de Psiquiatria. However, this area also contains some slums and shantytowns. The subjects were interviewed using the Brazilian version of the Composite International Diagnostic Interview version 1.1. (CIDI 1.1) by a lay trained interviewer. Answers to CIDI 1.1 questions allowed us to classify people according to their psychiatric condition and their headaches based on their own ideas about the nature of their illness. The lifetime prevalence of "a lot of problems with" headache was 37.4% (76.2% of which were attributed to use of medicines, drugs/alcohol, physical illness or trauma, and 23.8% attributed to nervousness, tension or mental illness). The odds ratio (OR) for headache among participants with "nervousness, tension or mental illness" was elevated for depressive episodes (OR, 2.1; 95%CI, 1.4-3.4), dysthymia (OR, 3.4; 95%CI, 1.6-7.4) and generalized anxiety disorder (OR, 4.3; 95%CI, 2.1-8.6), when compared with patients without headache. For "a lot of problems with" headaches attributed to medicines, drugs/alcohol, physical illness or trauma, the risk was also increased for dysthymia but not for generalized anxiety disorder. These data show a high association between headache and chronic psychiatric disorders in this Brazilian population sample. Key words: Headache, Illness attribution, Psychiatric comorbidity, Brazil, Odds ratio Introduction Headache is one of the most common complaints in the general population. It can be bothersome and interfere with routine activities and quality of life (1,2). As is the case for some other high-prevalence pain symptoms, such as those involving the joints, chest, abdomen and back, headache is a complaint that remains poorly understood. In most cases, although extensively investigated by classical clinical and radiographic examinations, no organic cause is found. Some studies have shown that such pain syndromes are associated with common mental disorders and some personality traits (1,3). However, the dilemma of whether psychopathology is the cause or a consequence of chronic pain is still a matter of controversy (3,4). There has been much discussion about a possible relationship between psychological factors and headache for a very long time. In 1937, Wolff (5) defined the "migraine personality" including ambition and perfectionism, mental instability and immaturity, vulnerability to frustrations, and shyness. Several studies at the community level have discussed the frequent association between headache of any type and psychiatric comorbidity (1,6,7). A lot of data have correlated headache and personality traits, especially using patient samples from headache clinics (3,4). The psychiatric diagnoses most commonly associated with headaches are anxiety and depressive disorders (6,8-10), and the personality trait most frequently associated is neuroticism (2,11-13). Ossipova et al. (14) described two cases of migraine without aura, associated with panic attacks. They suggested that a pronounced autonomic dysregulation associated with psychological abnormalities could be related to both disorders, and that this comorbidity increases their severity. Marazziti et al. (15) found that this type of migraine is the most prevalent kind of headache among panic patients. Guidetti et al. (16),

studying 100 patients from a Headache Center, found that from the youngest ages onwards, anxiety and depressive disorders represent a considerable clinical problem for both migraine and tension-type headache sufferers. Population-based studies have confirmed this positive association in patient samples. In the Zurich Cohort Study of Young Adults (6) the combination of anxiety disorder and major depression was significantly associated with migraine. In a review paper, Merikangas and Stevens (10) discussed the importance of documenting an association between migraine and other comorbidities as the first step in creating a causal model. Accordingly, an index disease would cause or precipitate the manifestation of comorbid conditions (10). Breslau and Davis (11) and Breslau et al. (12), studying a cohort of young adults, concluded that the presence of migraine increases the risk for depression and anxiety. Using Coxproportional hazards, after 3.5 years of follow-up they found that both migraine and depression increased the risk for the first onset of each other. This favored an explanation of shared mechanisms. However, recent data from the Baltimore Epidemiological Catchment Area Follow-up Study (17) showed a strong cross-sectional relationship between affective disorders and migraine headaches, but no association between previous affective disorder and incident cases of migraine headaches in a prospective manner. There is little information about headache prevalence in Brazil. The only study presenting its association with psychiatric disorders was done on an adult sample (aged 18 years or over) in an urban area of Northeastern Brazil. An odds ratio (OR) of 4.4 was found for the association of headache symptoms and psychiatric comorbidity. Women were more at risk, and the prevalence increased with age (18). Migration, marital status, and low educational levels were associated with a higher frequency of headache. More recent data from a Brazilian sample of high-school students (aged 10-18 years) showed a lifetime prevalence of headache of 93.2%, with a one-year prevalence of 82.9%. Of these headaches, 72.8% were tension-type and 9.9% migraine (19), according to the International Headache Society (IHS) criteria (20). Women had higher rates than men. Sanvito et al. (21) interviewed 595 medical students. When classifying their headaches according to IHS criteria, they observed that the one-year prevalence for any kind of headache was 40% and that 40.2% of those were migraine. The migraine prevalence was 54% for women and 28.3% for men, and was considered incapacitating by half of the sufferers. No information about psychiatric comorbidity or personality traits was available in these last two studies. We analyzed data from a population-based catchment area mental health survey in the city of So Paulo, Brazil, to determine the prevalence of people complaining of "a lot of problems with" any kind of headache, the relationship with sociodemographic characteristics and the co-occurrence of psychiatric disorders. Material and Methods The study population lived in the catchment area of the University of So Paulo Medical Center, a 2000bed tertiary care facility in So Paulo, the largest city in South America and one of the largest cities in the world (ten million inhabitants). The catchment area included two districts of the city covering a geographic area of 10.5 km2. The population in this area consists mainly of families of middle and upper socioeconomic levels. However, this area also contains some slums and shantytowns. In order to improve the probability of observing young psychotics and old-age psychiatric morbidity, all persons aged 18-24 years and 60 years or older, living in each selected household, were interviewed with a probability equal to one. Of the remaining individuals aged 25-29 years living in the selected household, one was chosen for interview based on the Kish and Frankel selection table (22,23). From the 950 households, 1,906 people were selected to participate in the study based on the three age strata described above. Of these, 442 refused to participate, resulting in a final sample of 1,464 subjects, with an individual response of 76.8%. Psychiatric assessment

The psychiatric diagnoses were based on face-to-face interviews. The instrument used was the Brazilian version of the Composite International Diagnostic Interview (CIDI) (24), version 1.1. This is a structured psychiatric interview (25) designed for use by lay interviewers. The instrument provides lifetime, 12- and 1-month prevalence estimates for ICD-10 diagnoses (International Classification of Disease-Related Health Problems, 10th revision, WHO, 1992) (26). For this study, we tested the association of lifetime psychiatric disorders that could be related to headache: depression, anxiety, alcohol and nicotine dependence, somatization, and bulimia. Headache diagnosis The CIDI 1.1 asks whether the person has experienced "a lot of problems with" headache during his/her lifetime and/or has taken any medication for headache, three or more times during a week. Answers to these questions were classified as: i) negative answer; ii) positive answer, but patient did not seek medical help because of symptoms, did not take any medication, or symptoms did not interfere with routine activities; iii) positive answer, but symptoms were caused by medicines, drugs or alcohol; iv) positive answer, but symptoms were the consequence of physical illness or trauma; v) positive answer, but symptoms were the consequence of nervousness, tension, anxiety, depression, mental illness, or no defined diagnosis. Thus, the prevalence rate does not reflect the actual prevalence of headache, but is restricted to people with a lot of problems with headaches (a small portion of all the people with headaches). Data from the CIDI did not allow us to classify headaches according to the IHS criteria (20), but it was possible to consider answers 3 and 4 as headaches attributed by the patient to the use of medication, drugs or alcohol, physical illness or trauma, and answer number 5 as potentially associated with psychiatric disorders. The attributed cause was classified into two categories: lifestyle and/or physical conditions were considered to be the cause of answers 3 or 4, and psychological conditions were considered to be the cause of answer 5, as used previously by Nimnuan et al. (27). Sociodemographic measurements We considered the effects of several sociodemographic variables such as age, gender, marital status, and educational level (years of education). Age was coded by category, as ranges 18-24, 25-34, 35-44, 45-54, 55-64, and 65 and over. Gender was coded dichotomously (male, female). Marital status was coded as married or not married. Years of education were coded by category as ranges 0-8, 9-11, 12-15, and 16 or more. Statistical analysis Since the data in this report were obtained from a complex stratified sample, they were weighted for differential probabilities of selection and nonresponse. A post-stratification of known population characteristics of sex and regional geographic groupings in the sample age range was also made in order to compensate for discrepancies between the sample and the original census population data. A matrix with the following factors was constructed to calculate the final weighting: age, sex, age strata, number of persons in each stratum by household, and a post-stratification factor. Logistic regression analysis was used to examine the association between demographic factors, psychiatric disorders and the headache symptom. As a result of the complex sample design and weighting, estimates of standard errors based on the usual assumption of equal-probability simple random samples become biased. Thus, standard errors for prevalence and logistic regression coefficients were computed using the jackknife repeated replications method, to adjust for the design effects introduced by the clustering and weighting of observations (22,23). All evaluations of significance were based on two-sided tests using 0.05 as the level of significance.

Results The lifetime prevalence for "a lot of problems with" headache of any type for the total sample was 37.4%. Of this, 76.2% was attributed to medicines or drugs/alcohol and to physical illness or trauma (cause attributed to lifestyle and/or physical conditions), and 23.8% was attributed to nervousness, tension or mental illness (cause attributed to psychological conditions). Table 1 shows the lifetime prevalence rates for "a lot of problems with" headache of any type, headache attributed to lifestyle and/or physical conditions, and headache attributed to psychological conditions by gender and age stratum. The lifetime rates for "a lot of problems with" any kind of headache ranged from 19.3% (for men aged 65 years or older) to 56.4% (for women aged 55-64 years), showing that this is a very common symptom. The lifetime frequency of "a lot of problems with" headache attributed to lifestyle and/or physical conditions was higher than the lifetime frequency of "a lot of problems with" headache attributed to psychological conditions, for all ages. This increased with age for men and women up to the age of 64 years (peaking between 55 and 64 years). After this age, we observed a decline for both genders. The frequency of "a lot of problems with" headaches attributed to psychological conditions was higher in women of all ages, except in the 4554-year age stratum. The lifetime prevalence of "a lot of problems with" headaches attributed to psychological conditions reached a peak in both genders in the age stratum of 25-34 years. After the age of 54 years, the frequency decreased to levels that were similar to those of the 18-24-year age group. Table 2 shows the OR (controlled for age and gender) for any kind of headache, headache attributed to lifestyle and/or physical conditions, and headache attributed to psychological conditions according to sociodemographic characteristics of the study population. Gender had a major effect, with women being 1.5 to 2.9 times more at risk than men. As we are reporting the lifetime prevalence of symptoms, a pattern of increasing prevalence with age would be expected. This was the case for "a lot of problems with" headaches attributed to lifestyle and/or physical conditions, in which the risk increased with age up to the 55-64-year age stratum and decreased thereafter. This was not the case for "a lot of problems with" headaches attributed to psychological conditions, for which the risk was higher only in the 25-34-year age stratum (OR, 2.1; 95%CI, 1.1-4.0), indicating that this age group was at major risk for the disorders grouped under this heading. There was no effect of years of education or marital status on the risk for "a lot of problems with" headache. Table 2 also shows the OR for the association of headaches and psychiatric comorbidity. The OR for "a lot of problems with" any kind of headache associated with depression was 1.8 (95%CI, 1.3-2.4). However, when we subdivided depression into depressive episode and dysthymia, most of the comorbidity was concentrated in dysthymia (OR, 4.2; 95%CI, 2.3-7.6), in comparison with depressive episodes (OR, 1.9; 95%CI, 1.4-2.5). For anxiety (OR, 2.3; 95%CI, 1.6-3.4), the association was again higher for generalized anxiety disorder (OR, 3.2; 95%CI, 1.5-6.9), which is a more chronic disturbance, in comparison with panic disorder (OR, 1.7; 95%CI, 0.8-3.7) or any kind of phobias (OR, 2.0; 95%CI, 1.42.8). The same pattern was found for "a lot of problems with" headaches attributed to psychological conditions, with slight differences in the OR. For "a lot of problems with" headaches attributed to lifestyle and/or physical conditions, the risk of psychiatric comorbidity was increased for dysthymia (OR, 2.2; 95%CI, 1.1-4.3) but not for generalized anxiety disorder (OR, 1.3; 95%CI, 0.7-2.5). As expected, the OR for association of somatoform disorders and "a lot of problems with" headaches attributed to psychological conditions was very high (OR, 11; 95%CI, 6.1-19.6) because headache due to these conditions could be part of the diagnostic criteria for somatoform disorders. In our sample, for people with somatoform disorders, the most common physical symptoms in order of frequency were headache (44%), followed by chest pain (17.9%), abdominal pain (17.9%), and back pain (16.7%). There was no association between headache and alcohol or nicotine dependence, or bulimia. Discussion In this cross-sectional study conducted on Brazilian adults, we detected an association between headache and psychiatric disorders. "A lot of problems with" headache is a very prevalent symptom in the general population. At least one in every three persons has had such symptoms at some time in their lives. Because we only assessed headaches of some sort of severity, it is quite probable that these numbers are an underestimate of the actual prevalence of headache in this community. Systematic

comparison with previous population-based studies is difficult because of different instruments used to assess headache. Nonetheless, our finding of a 37.4% frequency of lifetime headache is far below the nearly 80% frequency of tension-type headache reported by Rasmussen in Sweden (2) and the 72.8% value reported by Barea et al. (19) for children and adolescents in Brazil, using the IHS criteria. However, our rate is slightly above the lifetime prevalence of 25.9% of headache complaints reported by Kroenke and Price (1) in the Epidemiologic Catchment Area Program study. As in other studies conducted on the general population (2,18), headache symptoms are both age and gender dependent. "A lot of problems with" headache is more common among women. Headaches that are symptomatic (cause attributed to lifestyle and/or physical conditions, such as headache due to fever, hangover and other lifestyle causes, clinical or neurological disorders) increased with age. The higher prevalence of headaches attributed to nervousness or mental illness in the 25-34-year age stratum may indicate that young age cohorts more frequently experience these types of symptoms. The lack of association of headache symptoms with educational level and marital status also agrees with other population-based studies. In agreement with previous studies (1,9,18,19,27), one of which was conducted on a Brazilian population (18), there was a high comorbidity among people complaining of "a lot of problems with" headache, especially headaches attributed to nervousness or mental illness with depression and anxiety disorders. People with "a lot of problems" with headache have at least a two-fold increased likelihood of having lifetime anxiety or depressive disorder. This association is especially strong with chronic disorders like generalized anxiety disorder and dysthymia. This is in agreement with data from Italian patients with episodic and chronic tension-type headache, described by Guidetti et al. (16). The most common anxiety disorder diagnosed was generalized anxiety disorder (44.7%), and the most common depression disorder was dysthymia (16.6%). These kinds of findings are still scarcely available in the literature because most studies do not subdivide depressive and anxiety disorders into subgroups. There was no association of headache and panic disorder in our sample. However, the lack of significance of this result may have been due to the low prevalence (1.5%) of panic disorder in our sample. The present study has several limitations. First, we did not evaluate the real prevalence of headache in the population sample but the prevalence of "a lot of problems with" headache. Therefore, our data give an underestimate of the real prevalence of headache in the population. Data from a population-based telephone interview survey in Maryland, USA, which included residents 12-29 years of age who reported having had a headache during the previous year, showed that only 26.7% of women and 13.6% of men had ever sought a physician because of the headache problem (28). Most people with headache have episodic tension-type headache, which is sporadic and of mild intensity and have never sought a physician for medical advice about a headache problem. So again, when we asked about "many problems with headaches", these people were probably not included and underestimation was again possible. Second, we did not have the information to classify headache subtypes according to the IHS criteria. However, it is possible to obtain the individual attributed causes of headache by using the answers to the CIDI questions. We were probably preferentially selecting mostly the headaches attributable to psychological conditions as primary tension-type and migraine headaches with no alteration upon physical examination. Most of the headaches attributable to lifestyle and/or physical conditions (those due to medicines, drugs and alcohol, clinical and neurological diseases) would then have been selected as secondary headaches. However, since the IHS criteria were not available in this sample, some kind of misclassification was very likely. This may have influenced our results showing a positive association of headache attributed to lifestyle and/or physical conditions with dysthymia. This would be reflected in some of the primary headaches (migraine or tension-type) being erroneously identified as secondary headaches. According to our definition, headaches due to nervousness or mental sickness were more prevalent between 25 and 44 years of age, an age stratum in which primary headaches are really more prevalent. The clearly greater association between some psychiatric disorders and "primary headaches" is another point that suggests that we made a true assumption in classifying most primary headaches into the group of headaches attributed to psychological conditions. This agrees with previous observations in the literature (5,16,17,19,28,29).

The strength of the present study is that the information came from a general population sample and was collected using standardized interviews to assess psychiatric morbidity. Few studies in the literature have provided data on the relationship between headache and other psychiatric disorders like bulimia, nicotine and alcohol dependence. Most of the available data are about anxiety and depression as a whole. Only a small number of studies have included the subtypes of anxiety (panic disorder, generalized anxiety disorders and phobias) and depression (dysthymia, depressive episode) (30). The results of the present study are not representative of the entire Brazilian population because of the wide variety of cultural and socioeconomic influences in the country. It is clear from our data that headache is correlated with common chronic psychiatric disorders such as generalized anxiety disorders, among anxiety disorders, and dysthymia among depression disorders. There is also a very strong comorbidity between headache and somatoform disorders. Additional studies are needed for a better understanding of the relationships between these disorders. References 1. Kroenke K & Price RK (1993). Symptoms in the community: prevalence, classification, and psychiatric comorbidity. Archives of Internal Medicine, 153: 2474-2480. [ Links ] 2. Rasmussen BK (1995). Epidemiology of headache. Cephalalgia, 15: 45-68. [ Links ]

3. Mongine F, Ferla E & Maccagnani C (1992). MMPI profiles in patients with headache or craniofacial pain: a comparative study. Cephalalgia, 12: 91-98. [ Links ] 4. Mongine F, Defilippi N & Negro C (1997). Chronic daily headache. A clinical and psychological profile before and after treatment. Headache, 37: 83-87. [ Links ] 5. Wolff HG (1937). Personality features and reactions of subjects with migraine. Archives of Neurology and Psychiatry, 37: 895-921. [ Links ] 6. Merikangas KR, Angst J & Isler H (1990). Migraine and psychopathology: results of the Zurich Cohort Study of Young Adults. Archives of General Psychiatry, 47: 849-853. [ Links ] 7. Breslau N, Davis GC & Andreski P (1991). Migraine, psychiatric disorders and suicide attempts: an epidemiological study of young adults. Psychiatry Research, 37: 11-23. [ Links ] 8. Mongine F, Ibertis F & Ferla E (1994). Personality characteristics before and after treatment of different head pain syndromes. Cephalalgia, 14: 368-373. [ Links ] 9. Mitsikostas DD & Thomas AM (1999). Comorbidity of headache and depressive disorders. Cephalalgia, 19: 211-217. [ Links ] 10. Merikangas KR & Stevens DE (1997). Comorbidity of migraine and psychiatric disorders. Neurologic Clinics, 15: 115-123. [ Links ] 11. Breslau N & Davis GC (1992). Migraine, major depression and panic disorder: a prospective

epidemiological study of young adults. Cephalalgia, 12: 85-90.

[ Links ]

12. Breslau N, Davis GC, Schultz LR & Peterson EL (1994). Migraine and major depression: a longitudinal study. Headache, 34: 387-393. [ Links ] 13. Ziegler DK & Paolo AM (1995). Headache symptoms and psychological profile of headache prone individuals. A comparison of clinic patients and controls. Archives of Neurology, 52: 602-606. [ Links ] 14. Ossipova VV, Kolosova OA & Vein AM (1999). Migraine associated with panic attacks. Cephalalgia, 19: 728-731. [ Links ] 15. Marazziti D, Toni C, Pedri S, Bonuccelli U, Pavese N, Lucetti C, Nuti A, Muratorio A & Cassano GB (1999). Prevalence of headache syndromes in panic disorder. International Clinical Psychopharmacology, 14: 247-251. [ Links ] 16. Guidetti V, Fabrizi P, Giannantoni AS, Napoli L, Bruni O & Trillo S (1998). Headache and psychiatric comorbidity: clinical aspects and outcome in an 8-year follow-up study. Cephalalgia, 18: 455-462. [ Links ] 17. Swartz KL, Pratt LA, Armenian HK, Ching Lee MS & Eaton WW (2000). Mental disorders and the incidence of migraine headaches in a community sample. Archives of General Psychiatry, 57: 945-950. [ Links ] 18. Bastos SB, Almeida-Filho N & Santana VS (1993). Prevalence of headache as a symptom in the urban area of Salvador, Bahia, Brazil. Arquivos Brasileiros de Neuropsiquiatria, 51: 307-312. [ Links ] 19. Barea LM, Tannhauser M & Rotta NT (1996). An epidemiological study of headache among children and adolescents in southern Brazil. Cephalalgia, 16: 545-549. [ Links ] 20. International Headache Society (1988). Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia, 8 (Suppl 7): 1-96. [ Links ] 21. Sanvito WL, Monzillo PH, Peres MF, Martinelli MO, Fera MP, Gouveia DA, Murachovsky J, Salomo WR & Leme RJ (1996). The epidemiology of headache in medical students. Headache, 36: 316-319. [ Links ] 22. Kish L (1965). Survey Sampling. John Wiley & Sons, New York. [ Links ]

23. Kish L & Frankel MR (1970). Balanced repeated replications for standard errors. Journal of the American Medical Association, 65: 1071-1094. [ Links ] 24. Miranda CT, Mari JJ, Ricciardi A & Arruda ME (1990). Patients' reactions to CIDI in Brazil. In: Stefanis CN, Rabavillas AD & Soldatos CR (Editors), Psychiatry: A World in Perspective. Elsevier, Amsterdam, The Netherlands, 133-137. [ Links ] 25. Lopes CS (1994). Reliability of the Brazilian version of the CIDI in a case-control study of risk factors for drug abuse among adults in Rio de Janeiro. Bulletin of the Pan-American Health Organization, 28: 34-

41.

[ Links ]

26. World Health Organization (1992). Mental health and behavioral disorders. In: International Classification of Diseases. 10th revision. World Health Organization, Geneva, Switzerland, 311-387. [ Links ] 27. Nimnuan C, Hotopf M & Wessely S (2001). Medically unexplained symptoms. An epidemiological study in seven specialties. Journal of Psychosomatic Research, 51: 361-367. [ Links ] 28. Breslau N (1998). Psychiatric comorbidity in migraine. Cephalalgia, 18 (Suppl 22): 56-61. [ Links ]

29. Linet MS, Celentano DD & Stewart WF (1991). Headache characteristics associated with physician consultation: a population-based survey. Annals of Preventive Medicine, 7: 40-46. [ Links ] 30. The Italian Collaborative Group for the Study of Psychopathological Factors in Primary Headaches (1999). Psychiatric comorbidity and psychosocial stress in patients with tension-type headache from headache centers in Italy. Cephalalgia, 19: 159-164. [ Links ]

---------------------------------------------------------------------------------------------------The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms and Conditions (click here) 2008 UpToDate, Inc. Patient information: Headache causes and diagnosis in adults Authors Zahid H Bajwa, MD R Joshua Wootton, MDiv, PhD Section Editor Jerry W Swanson, MD Deputy Editors Leah K Moynihan, RNC, MSN John F Dashe, MD, PhD

Last literature review version 16.2: 2008 | This topic last updated: 8, 2007 (More) INTRODUCTION Headache is one of the most common medical complaints. Headaches can be quite debilitating, although the vast majority are not due to life threatening disorders. Approximately 90 percent of headaches are caused by one of three syndromes (show table 1): * Migraine headache * Tension-type headaches * Cluster headaches The causes and diagnosis of headaches are discussed here. A summary of headache treatments is also available. (See "Patient information: Headache treatment in adults"). A discussion of headaches in children is available separately. (See "Patient information: Headache in children"). MIGRAINE HEADACHES Between 12 and 16 percent of people in the United States experience migraines, making it the second most common type of headache after tensiontype headaches (See "Tension type headache" below). Migraines have well-defined periods of head pain and other symptoms, separated by periods during which there are no symptoms. These attacks frequently begin in the morning, but can occur at any time. Symptoms The pain of a migraine headache usually begins gradually, intensifies over minutes to one or more hours, and resolves gradually at the end of the attack. The headache is typically dull, deep, and steady when mild to moderate in severity; it becomes throbbing or pulsatile when severe. Migraine headaches are worsened with moving the head rapidly, light, sneezing, straining, constant motion, or physical exertion; many migraine sufferers try to get relief by lying down in a darkened, quiet room. In 60 to 70 percent of people, the pain occurs on only one side of the head. In adults, a migraine headache usually lasts a few hours, but can last from four to 72 hours. Migraine headaches are often accompanied by nausea and vomiting, as well as sensitivity to light and noise. Between 10 and 20 percent of people with migraine also experience nasal stuffiness and runny nose, tearing, or changes in skin tone or body temperature. The symptoms of a migraine attack may be severe and alarming but in most cases there are no lasting health effects when the attack ends. Aura About 20 percent of people with migraines experience visual or other neurologic symptoms prior to the onset of headache; this is called an aura. The aura may include flashing lights or bright spots, zigzag lines, loss of part of the field of vision, numbness or tingling in the fingers of one hand, lips, tongue, or lower face. Auras may also involve other senses and can occasionally cause temporary muscle weakness or changes in speech; these symptoms can mimic a stroke or transient ischemic attack (TIA). A person can have several types of aura symptoms that vary with the headache attack. Aura symptoms typically last five to 20 minutes and rarely last more than 60 minutes with the headache occurring soon after the aura stops. Muscle-related auras may last longer

Migraine triggers Many conditions are potential triggers of migraine headache. A partial list appears in the table (show table 2). Migraines can be triggered by stress, worry, menstrual periods, birth control pills, physical exertion, fatigue, lack of sleep, hunger, head trauma, and certain foods or drinks that contain chemicals such as nitrites, glutamate, aspartate, tyramine. Certain medications and chemicals can also trigger a migraine, including nitroglycerin (used to treat chest pain), estrogens, hydralazine (used to treat high blood pressure), perfumes, smoke, and organic solvents with a strong odor. Headache diary Persons who have frequent or severe headaches may benefit from keeping a headache diary over the course of one month. This can be used to determine the characteristics of the headaches, what triggers them, and what makes them better. A sample diary is included here (show figure 1). Migraines in women Migraines occur about three times more commonly in women than in men. Estrogen has a variable effect on the frequency and severity of a woman's migraines; some women who take oral contraceptives (which contain estrogen) or hormone replacement therapy experience worsening headaches, while others improve. Similarly, some women have an increasing headache pattern during pregnancy while others have diminished headache intensity. Menstrual migraines are migraine headaches that occur around the beginning of a woman's menstrual period (usually two days before to three days after the period begins). Women with menstrual migraine may also have migraines at other times during the month. Most often, there is no migraine aura associated with menstrual migraines, even if the woman usually has aura at other times. Menstrual migraines are thought to be triggered by the normal decrease in estrogen levels that occurs before the menstrual period begins. Menstrual migraines tend to be longer lasting, more severe, and more resistant to treatment than other types of migraine. Migraine variants Some types of migraine have specific symptoms that distinguish them from a typical migraine. * Hemiplegic migraine is characterized by loss of movement and sensation on one half of the body that usually last longer than the headache itself. Complete recovery may take weeks; permanent weakness can occur after multiple attacks. There is a form of hemiplegic migraine, familial hemiplegic migraine (FHM), that is inherited, although this condition is rare. * Basilar-type migraine predominantly affects young women and children. Symptoms may include any combination of double vision, vertigo (sensation of movement or spinning), difficulty hearing, pain in the toes or fingers, double vision, ringing ears, difficulty with balance, and altered consciousness (show table 3). * Migraine aura without headache is characterized by migraine aura that occurs without headache. It may be confused with a stroke or transient ischemic attack (TIA), especially in older persons (see "Aura" above). In one study, 38 percent of patients had migraines with aura as well as migraine aura without a headache.

* Migrainous vertigo is the term used to describe vertigo (a sense of spinning or dizziness) that accompanies a migraine headache. TENSION TYPE HEADACHE Symptoms Symptoms of tension type headaches (TTH) include pressure or tightness around both sides of the head or neck, mild to moderate pain that is steady and does not throb, and pain that is not worsened by activity. Pain can increase or decrease in severity over the course of the headache. There may be tenderness in the muscles of the head, neck, or shoulders. People with TTH often note a feeling of mental stress or tension before their headache. Unlike migraine, tension headaches occur without other symptoms such as nausea, vomiting, sensitivity to lights and sounds, or an aura. However, some people have symptoms of both tension and migraine headache. Clinicians characterize TTH based upon their frequency into three subtypes: infrequent episodic (occurring less than once per month), frequent episodic (occurring one to 14 times per month), and chronic (occurring 15 or more days per month). People with frequent or chronic TTH often overuse over-the-counter and prescription medications in an attempt to treat their pain. This can lead to medication-overuse headaches (see "Medication-overuse headache" below). CLUSTER HEADACHE Cluster headaches are severe, debilitating headaches that occur repeatedly for weeks to months at a time, followed by periods with no headache. Cluster headaches are relatively uncommon, affecting less than one percent of people. In contrast to migraine, men are affected more commonly than women, with a peak age of onset of 25 to 50 years. Symptoms The pain of cluster headache begins quickly without any warning and reaches a peak within a few minutes. The headache is usually deep, excruciating, continuous, and explosive in quality, although occasionally it may be pulsatile and throbbing. The attack may occur up to eight times per day but is usually short in duration (between 15 minutes and three hours). The pain typically begins in or around the eye or temple; less commonly it starts in the face, neck, ear, or side of the head. The pain is always on one side; it remains on the same side of the head during a single cluster, but can switch sides during the next cluster in a small percentage of people. Most people with cluster headache are restless and may pace or rock back and forth when an attack is in progress. Cluster headaches are associated with eye redness and tear production on the side of the pain, a stuffy and runny nose, sweating, a pale appearance, and possibly drooping of the eyelid. Some persons are light sensitive in the eye on the affected side. Other neurologic symptoms are rare. Alcohol can bring on a cluster headache in more than 50 percent of persons who suffer with cluster headaches; this sensitivity to alcohol stops when the cluster ends. Types of cluster headache The frequency of attacks depends upon the type of cluster: * Episodic cluster headaches are most common, occurring in 80 to 90 percent of patients

suffering from this disorder. They are characterized by pain around the eye that occurs one to three times per day over a four to eight week period, followed by an average pain-free interval of six months to one year. The remission may last for years. * Chronic cluster headaches are characterized by cluster headaches that do not resolve. Either form of cluster headache can transform into the other. Attacks of pain tend to recur at the same hour each day for the duration of a single cluster, typically between 9:00 pm and 9:00 am. Most people experience one cluster per year, but this is not predictable. Family history Cluster headaches can begin at any age. People with cluster headaches are more likely to have family members who also have cluster headaches. First-degree relatives (sibling, child) have a 14-fold increased risk while second-degree relatives (grandchild) have a twofold increased risk of cluster headaches. CHRONIC DAILY HEADACHE Some people develop very frequent headaches, as frequent as every day in some cases. When a headache is present for more than 15 days per month for at least three months, it is described as a chronic daily headache. Chronic daily headache is not a type of headache but a category that includes frequent headaches of various kinds. Most people with chronic daily headache have migraine or tension-type headache as the underlying type of headache. The person may have started out having an occasional migraine or tension-type headache, but the headaches became more frequent over months or years. Some people with frequent headache use headache medications too often, which may lead to the development of "medication-overuse headache" (see "Medication-overuse headache" below). Medication-overuse headache Medication-overuse headache (MOH) may occur in people who have frequent migraine, cluster, or tension-type headaches, which leads them to overuse pain medications. A vicious cycle occurs whereby frequent headaches cause the person to take medication frequently (often over-the-counter), which then causes a rebound headache as the medications wear off, causing more medication use, and so on. MOH is a possible diagnosis in people who have frequent or daily headaches despite (or because of) the regular use of headache medications. Overuse of any number of pain medications can contribute to the development of MOH, including acetaminophen (Tylenol), butalbital-aspirin-caffeine (Fiorinal), butalbital-acetominophen-caffeine (Fioricet, Esgic) ergotamines, opioids, triptans, and other combinations of medications. To avoid medication-overuse headache, pain medications should not be used more than nine days per month. Preventive medications may be needed for people who have headaches more frequently. (See "Patient information: Headache treatment in adults" in the section on medication overuse headache). OTHER TYPES OF HEADACHE There are a number of other causes of headache. Giant cell (temporal) arteritis This condition is an inflammation of blood vessels that typically occurs in people ages 50 and older. It can cause mild or severe headaches, often with fatigue, generalized aches and pain, and night sweats. Temporary or permanent visual loss is a potential complication. Giant cell arteritis responds to treatment with glucocorticoids such as prednisone. Sinus headache Although frequently diagnosed, recurrent headaches related to sinusitis are

uncommon. Many, if not most, people diagnosed with sinus headaches actually have migraine headaches. True sinus headache is associated with at least two of the following features: * Nasal pus * Facial pain, pressure, congestion, and fullness * Nasal blockage and discharge * Fever * Decreased or absent ability to smell Sinus-related pain usually lasts for several days (unlike a typical migraine) and does not cause nausea, vomiting, or sensitivity to noise or light (as seen in migraine). Guidelines for the diagnosis and treatment of sinus headache are presented in table 4 (show table 4) [1,2]. Post-trauma headaches Headaches that occur within one to two days after a head injury are relatively common. Most people report a generalized dull, aching, constant discomfort that worsens intermittently. Other common symptoms include vertigo (sensation of spinning), lightheadedness, inability to concentrate, problems with memory, becoming tired quickly, and irritability. Post-trauma headaches may continue for up to a few months, although anyone with a headache that does not begin to improve within a week or two after a traumatic event should be evaluated. DIAGNOSIS Clinicians typically use a person's description of their headache, in combination with an examination, to determine the type of headache. Some people have more than one type of headache. Most people do not need x-rays or imaging tests, although a clinician may recommend a CT scan (or MRI) in some circumstances, for example, if symptoms are not typical of a specific headache syndrome, if there are any danger signs (see "Danger signs" below), or if there are any abnormalities seen during the examination. Other possible reasons for brain imaging include: * Headaches that steadily worsen despite treatment * A sudden change in the pattern of headaches * Signs or symptoms that suggest that another medical condition may be causing symptoms DANGER SIGNS The vast majority of headaches are not life threatening. However, anyone with the following signs or symptoms should seek medical attention immediately. * A sudden, severe, persistent headache that becomes severe within a few seconds or minutes, or that could be described as "the worst headache of your life" * A severe headache associated with a fever or stiff neck * Headache associated with a seizure, personality changes, confusion, or loss of consciousness * Headache that begins quickly after strenuous exercise or minor trauma

* A new headache associated with neurologic symptoms (eg, weakness, numbness, impaired vision). While migraine headaches can sometimes cause these symptoms, a person should be evaluated urgently the first time these symptoms appear. People with persistent or frequent headaches, headaches that interfere with normal activities, or a change in a previous headache pattern should be seen by a healthcare provider during normal office hours. Headaches and brain tumor Headaches occur in approximately 50 percent of people who have brain tumors. However, headaches are very common and brain tumors are rarely found in people who are evaluated for headaches. Many people with brain tumors have chronic headaches that are worse with bending over or occur with nausea and vomiting, although these symptoms can also occur with headaches not related to a brain tumor. TREATMENT The treatment of headaches is discussed in a separate topic review. (See "Patient information: Headache treatment in adults"). WHERE TO GET MORE INFORMATION Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation. This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information. Some of the most pertinent include: Patient Level Information: Patient information: Headache treatment in adults Patient information: Headache in children Professional Level Information: Evaluation of headache in adults Acute treatment of migraine in adults Approach to the patient with headache syndromes other than migraine Cervicogenic headache Headache; migraine; and stroke Nonpharmacologic therapy of headache Pathophysiology; clinical features; and diagnosis of spontaneous low cerebrospinal fluid pressure headache Pathophysiology; clinical manifestations; and diagnosis of migraine in adults Preventive treatment of migraine in adults Thunderclap headache Basilar-type migraine Estrogen-associated migraine Etiology; clinical manifestations; and diagnosis of aneurysmal subarachnoid hemorrhage

Headache in pregnancy A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. * National Library of Medicine (www.nlm.nih.gov/medlineplus/healthtopics.html) * American Council for Headache Education (ACHE) (856) 423-0258 (800) 255-2243 (www.achenet.org) * American Headache Society (856) 423-0043 (www.ahsnet.org) * International Headache Society (www.i-h-s.org) [1-5] Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Cady, RK, Dodick, DW, Levine, HL, et al. Sinus headache: a neurology, otolaryngology, allergy, and primary care consensus on diagnosis and treatment. Mayo Clin Proc 2005; 80:908. 2. Levine, HL, Setzen, M, Cady, RK, et al. An otolaryngology, neurology, allergy, and primary care consensus on diagnosis and treatment of sinus headache. Otolaryngol Head Neck Surg 2006; 134:516. 3. Dodick, DW. Clinical practice. Chronic daily headache. N Engl J Med 2006; 354:158. 4. MacGregor, EA, Hackshaw, A. Prevalence of migraine on each day of the natural menstrual cycle. Neurology 2004; 63:351. 5. Silberstein, SD. Practice parameter: evidence-based guidelines for migraine headache (an evidencebased review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology 2000; 55:754. 2008 UpToDate, Inc. All rights reserved. | Terms of Use |Support Tag: [ecapp1103p.utd.com89.28.98.99-93D935928C-11] Licensed to: UpToDate Patient Preview

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