Lifting%20The%20Burden%20The%20Global%20Campaign%20to%20Reduce%20the%20Burden%20of%20Headache%20Worldwide

1
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache Worldwide
Introduction to the Global Campaign TJ Steiner
(UK), for the Global Campaign Committee
The problem Headache disorders are real and often
lifelong illnesses. They are highly prevalent,
affecting men, women and children everywhere, and
they are disabling. In the World Health Report
2001, the World Health Organization ranked
migraine among the top 20 causes in the world of
years of healthy life lost to disability.
Migraine alone is the cause of an estimated
400,000 lost days from work or school every year
per million of the population in developed
countries. Migraine harms family and social
relationships and damages quality of life.
Migraine, however, is only one of the headache
disorders with public-health importance others,
including tension-type headache and the various
chronic daily headaches, together are believed to
be responsible for at least as much disability as
migraine. If this is correct, headache disorders
collectively are in the top ten and possibly
the top five causes of disability worldwide.
Appropriate health care alleviates this burden,
but still it persists everywhere. This is
principally because health systems that should
provide this care do not reach many who need it.
Lifting The Burden envisions a future world in
which headache disorders are recognized
everywhere as real, disabling and deserving of
medical care. In this world, all who need
headache care have access to it, without
artificial barriers.
A new solution Lifting The Burden is a response
to this health-care failure, which has its roots
in education failure. Launched in 2004, Lifting
The Burden is a formal collaboration between the
World Headache Alliance, the International
Headache Society, the European Headache
Federation and the World Health Organization.
The first objective of Lifting The Burden is to
know the size of the headache problem in all
regions of the world. This can be achieved by
bringing out all of the available worldwide
evidence of the burden attributable to headache
and by setting up new studies where the evidence
is lacking or of poor quality. The second
objective is to exploit this evidence, as a means
of persuading governments and other
health-service policy-makers, health-care
providers, people directly affected by headache
and the general population that headache
manifestly should have higher priority for
treatment.
Lifting The Burden is founded on the belief that
the basis of the health-care solution for
headache in most parts of the world is education.
Hence, the third objective is to work with local
policy-makers and other key stakeholders to plan
and implement health-care services for headache
that are appropriate to local systems, resources
and locally-assessed needs. Within these
services, better diagnosis and better care, and
better understanding amongst patients and the
public, will all be fostered through education.
Lifting The Burden believes that most headache
management belongs in primary care, where
education must be supplemented by clinical
management supports if diagnosis and management
are to be optimized. These include diagnostic
aids and algorithms region-based management
guidelines developed by harmonizing existing
guidelines information sheets for patients, to
aid understanding and promote compliance with
treatment and universally acceptable indices of
treatment outcome.
Lifting The Burden gratefully acknowledges
unrestricted financial and/or logistic support
from the following (in alphabetical
order)Allergan Almirall Astra Zeneca Bayer
Healthcare Glaxo SmithKline Janssen-Cilag
Merck, Sharp and Dohme Pfizer
2
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache WorldwideA partnership
in action between the World Health Organization,
World Headache Alliance,International Headache
Society and European Headache Federation
The global burden of headache LJ Stovner
(Norway), K Hagen (Norway), R Jensen (Denmark), Z
Katsarava (Germany), R Lipton (USA), AI Scher
(USA), TJ Steiner (UK), J-A Zwart (Norway)

• BACKGROUND In WHOs World Health Report 2001,
  migraine was ranked 19th among causes of years of
  life lost to disability overall, and 12th in
  women. Other headache disorders were not
  included. The present study1 collates and
  presents all existing evidence of the world
  prevalence and burden of headache disorders.

METHODS A comprehensive Medline search for
population-based studies of headache and migraine
used the search terms headache epidemiology or
migraine epidemiology or headache prevalence or
migraine prevalence. References listed in
relevant publications were also examined. All
identified articles were screened for various
aspects of methodology and design, and type of
content, in order to select methodologically
adequate studies of interest for our purpose.
Population-based studies applying 1988 or 2004
International Headache Society criteria for
migraine and tension-type headache (TTH), and
also studies on headache in general and on
chronic daily headache (CDH), were included.
Figure 1. Prevalence of adults with an active
headache disorder (ie, during last year or less)
RESULTS Of 107 studies deemed methodologically
adequate and relevant, most were from Western
Europe and North America and most concerned
migraine (see map). Relatively few studies
concerned TTH (figure 1) and no studies, or
studies of only limited value for the present
purpose, existed for large and populous areas
such as mainland China, India, countries of the
former USSR and large parts of Africa.
Globally, 46 of adults had an active headache
disorder, with 1-year prevalences of 42 for TTH,
11 for migraine and 3 for CDH
Figure 2. Headache burden
(figure 1). There were marked differences between
continents, and all headache types seemed least
prevalent in Africa. Applying various formulae
to calculate the burden of illness from
prevalence, headache frequency (mean headache
days per person in the population), intensity
and/or duration (where such data existed), we
found that the worldwide disability attributable
to TTH was larger than that due to migraine
(figure 2).
CONCLUSIONS 1. Although studies are lacking for
important regions of the world, it is clearly
documented that headache is a major health
problem on all continents. 2. There are
differences in headache prevalence between the
continents, but at present it is impossible to
know if these are real or due to methodological
differences between studies. 3. TTH appears to
impose greater burden on the population than
migraine, and the disability due to all headache
is therefore almost certainly at least twice that
of migraine. 4. If correct, these calculations
bring headache disorders collectively into the 10
most disabling conditions worldwide, and into the
5 most disabling for women.
1 Stovner LJ et al. The global burden of
headache a documentation of headache prevalence
and disability worldwide. Cephalalgia.
200727193-210
3
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache WorldwideA partnership
in action between the World Health Organization,
World Headache Alliance, International Headache
Society and European Headache Federation
Prevalence of primary headache disorders in the
Republic of Georgia Z Katsarava
(Germany/Georgia), M Kukava (Georgia), A
Dzagnidze (Georgia), E Mirvelashvili (Georgia), M
Djibuti (Georgia), R Jensen (Denmark),LJ Stovner
(Norway) and TJ Steiner (UK)
A Collaboration between Lifting The Burden and
theRussian Linguistic Subcommittee of the
International Headache Society
AIM To estimate the prevalences of migraine,
tension-type Headache (TTH) and chronic daily
headache (CDH) in the Republic of Georgia.
BACKGROUND The Republic of Georgia is located
in the Caucasus. Its total population in 2000 was
4.4 million, 53 urban and 47 rural, with 1.5
million inhabitants in the Capital city, Tbilisi.
No data currently exist on the prevalence and
impact of headache disorders in the countries of
the former Soviet Union.

PROJECT DESIGN Pilot Phase During a small
pilot we established and tested the methodology.
Medical residents with a structured questionnaire
visited adjacent households in Tbilisi to
interview a pre-defined target of 100
biologically unrelated subjects. All respondents
reporting headache in the previous year, as well
as random 20 non-headache controls, were examined
by a neurologist. The response rate was 70. The
questionnaire had sensitivities of 89 for
migraine and 67 for TTH (overall kappa 0.74).
Population based validation of the questionnaire
In second step we validated a Georgian language
self-administered questionnaire in a
population-derived sample of 186 subjects with
headache, recruited randomly during the first
stage of the pilot. All subjects completed the
questionnaire and then were examined by one of
two headache-experienced neurologists who were
blind to the questionnaires. Sensitivities and
specificities were, respectively, 0.75 and 0.96
for migraine, 0.79 and 0.86 for TTH, and 0.61 and
0.84 for migraineTTH (kappa 0.68). Main
study Using similar door-to-door methodology, we
surveyed two populations one urban, in Tbilisi
(n1,136), and one rural, in the eastern region
of Kakheti (n565). These yielded 1,298
biologically unrelated adults (gt16 years) of whom
722 (56) were women. Mean age was 4513 years.
PRINCIPAL FINDINGS To the screening question
Have you had headache in the last year not
related to a cold, flu, hangover or head injury?
616 (48) subjects replied yes. The estimated
1-year prevalence of migraine was 13 (n169 95
CI 1214), of TTH 33 (n422 95 CI 3134) and
of CDH 8 (n105 95 CI 7-9). 583 subjects
used acute medication for their headaches. The
vast majority took combination analgesics and
none used triptans. 39 subjects (3 of the total
sample) overused acute headache medication. None
of the respondents had seen a neurologist for
headache, and none was receiving preventative
drugs.
CONCLUSIONS This is the first population-based
estimate of the prevalence of primary headache
disorders in a country of the former Soviet
Union. Migraine and tension-type headache have
prevalences similar to those found elsewhere.
Chronic daily headache is somewhat more
prevalent. The study reveals that no headache
service exists in the Republic of Georgia, which
may explain the high prevalence of chronic daily
headache, including probable medication-overuse
headache.
4
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache WorldwideA partnership
in action between the World Health Organization,
World Headache Alliance, International Headache
Society and European Headache Federation
Eurolight A CONSORTIUM of 24 public bodies,
patient organisations, scientific organisations,
hospitals and headache experts from 15 different
European countries Colette Andrée
(CH/Luxembourg), Guy Dargent (EC/Luxembourg),
Marie-Lise Lair (Luxembourg)
A European initiative supported by a grant of the
EC Public Health Executive Agencyand promoted by
the Centre of Public Research Luxembourg in
partnership with Lifting The Burden
Primary headaches in Europe It is estimated that
more than 50 million Europeans suffered from
migraine during the last year, and lost 180
million days from work or school. The estimated
cost was in excess of 20 billion. Data on other
headache disorders are few but the most common,
tension-type headache, probably accounts for even
greater losses. Health sector policy makers are
constrained in their ability to take decisions on
effective measures to reduce the impact of
headache disorders on those affected directly,
on their families and colleagues, on their carers
in the case of children, and on society because
knowledge of this impact on each of these is very
incomplete. Knowledge is needed for action in
Europe

• Eurolight
• Launched in May 2007, Eurolight is a response to
  this need. Its methods were developed and tested
  in a pilot study in Luxembourg (figure 1).
• Eurolight
• is the first consortium of stakeholders to
  collect data on headache at EU level, bringing
  together relevant medical, scientific and lay
  organizations
• will study the general population prevalence of
  headache disorders in Lithuania, a country in a
  part of eastern Europe where epidemiological data
  are lacking
• will survey mostly patient populations in 10
  representative European countries, using similar
  methods in each to produce comparable findings
  throughout
• will gather qualitative as well as quantitative
  data that describe impact, in a broad sense, of
  each headache disorder of public-health
  importance migraine, tension-type headache and
  chronic daily headache
• will assess personal suffering, consequences for
  work, education and family life, and the needs
  for better disease management
• will produce systematic data to complement
  epidemiological evidence of the burden of
  headache in Europe
• is holistic, patient-driven and respectful of
  scientifically validated methods

Figure 1. Control of migraine in two population
samples data from the Luxembourg pilot
Eurolights over-arching objective to provide a
justification that headache should be high
amongst health-care priorities in Europe
For more information Tel [phone] Fax
41 61 423 1082 www.eurolight-online.org
5
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache WorldwideA partnership
in action between the World Health Organization,
World Headache Alliance,International Headache
Society and European Headache Federation
Completing the burden map TJ Steiner (UK) and LJ
Stovner (Norway), for the Global Burden Working
Group
Introduction To build knowledge of the world
burden of headache, the first objective of
Lifting The Burden, the Global Burden Working
Group has collated all existing prevalence data
for headache disorders, adding to those on
migraine already assimilated into the World
Health Report 2001. The result is headache maps
of the world, which highlight areas of very
deficient knowledge in large and populous
areas. These gaps in our knowledge should be
filled, requiring new epidemiological studies in
priority areas.
Georgia The Republic of Georgia has been the
testing ground to develop a door-to-door
methodology for population surveys in countries
whose infra-structure does not support other
methods of contact. A burden-of-headache study is
under analysis. Africa The continent of Africa
is a huge area where knowledge of the burden of
headache is almost totally lacking. A local group
in South Africa has commenced plans for a
population-based study there, again sampling
urban and rural populations, and acknowledging
ethnic diversity which may be relevant. If
successful, these plans will be extended to
selected countries in both East Africa and
West Africa.
China China is a high priority because of its
size and because the prevalence of headache there
is almost certainly underestimated (adversely
affecting the estimate of global burden). A local
Working Group has been formed and a protocol is
under development for a population-based survey
in six regions of China, including Tibet, each
to include urban and rural areas.
India In India, the prevalence of headache
disorders may be high but good epidemiological
data do not exist. This country is also a high
priority because of its size. A local Working
Group has set out detailed proposals for a
population-based study of urban and rural
populations in and around Jaipur, Mumbai, Kolkata
and Bangalore.
Russia This country is a large area of Europe and
Asia with little knowledge of headache burden. A
local Working Group has come together with the
support also of the IHS Russian Linguistic
Subcommittee. Plans are being laid for a
population-based survey sampling urban and rural
populations in 22 areas of Russia which will be
representative of the entire country.
Once these epidemiological studies and estimates
of burden attributable to headache are complete,
Lifting The Burden expects to have demonstrated
unequivocally that headache disorders
collectively are in the top 10 causes of
disability in the world.
6
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache WorldwideA partnership
in action between the World Health Organization,
World Headache Alliance,International Headache
Society and European Headache Federation
Atlas of headache disorders T Dua (Switzerland),
for the Headache Atlas Working Group
Introduction There is considerable evidence that
the global burden of headache disorders is high.
However, little is known about the resources
available to meet this burden. In order to fill
this knowledge gap, an international survey is
being carried out within the framework of World
Health Organization (WHO) Project Atlas and as
part of Lifting The Burden. The two documents
previously published within this framework for
neurological disorders are Atlas country
resources for neurological disorders and Atlas
epilepsy care in the world. Objective The aim
of this survey is to collect information on the
epidemiology of headache disorders, their impact
on society, the availability of resources to
provide treatment, and the current management
practices worldwide. It is envisaged that the
Atlas of headache disorders will be a key tool to
inform policy development and to support national
and regional advocacy initiatives. Data
collection A group of international experts
identified areas where there was a need to
collect information and put together a draft
questionnaire with accompanying glossary. This
questionnaire was validated and feedback from
this exercise was used to derive the final
version of the questionnaire to be sent to all
the countries.
The questionnaire is divided into three sections
neurologist version, primary-care version and
patient version, to be filled by a neurologist or
other secondary-care headache specialist, a
primary-care physician and a patient (or
representative of a patient advocacy group)
respectively. Multiple sources have been drawn
upon to identify respondents from the countries
members of the World Headache Alliance, the
International Headache Society and the European
Headache Federation key members of national
neurological societies identified through the
World Federation of Neurology contacts developed
during the production of the Neurology Atlas and
Epilepsy Atlas contacts in other countries known
to respondents and literature search. Data
collection began in November 2006 and a total of
474 focal points have been contacted in 169
countries. Currently we have received data from
58, 39 and 39 countries for neurologist,
primary-care and patient versions respectively.
Are you from a country with an absence of data
(shown in grey) and able to assist in data
collection? If so, please contact the Lifting The
Burden booth.

• Table 1 Data to be included in the Atlas of
  Headache Disorders
• National Professional/Patient Associations
• Epidemiology
• Diagnosis and assessment
• Treatment
• Human resources
• Impact on society
• Information/data collection system
• Issues of care of people with headache disorders

Data organization and presentation Data are
organized into eight major themes (table 1). They
will be presented at global and WHO region levels
in the form of maps or graphics or as written
text. For each of the themes, specific
limitations will be highlighted. These must be
kept in mind when interpreting the data. The
Atlas of headache disorders will also include
brief reviews of selected topics, which summarize
medical, lifestyle, social and economic issues
affecting people with headache disorders.
Conclusion It is hoped that the Atlas of headache
disorders will stimulate global and national
programmes in the headache field. It will be a
reference for health professionals, planners and
policy makers at national and international
levels, helping them plan, develop and provide
better care and services for people with headache
disorders throughout the world.
7
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache WorldwideA partnership
in action between the World Health Organization,
World Headache Alliance,International Headache
Society and European Headache Federation
Management aids for primary care TJ Steiner (UK),
for the Diagnostic Aids Working Group,Patient
Information Writing Committee and Outcome
Measures Working Group
Introduction Medical management of headache
disorders, for the vast majority of people
affected by them, can and should be carried out
in primary care. It does not require specialist
skills. Nonetheless, non-specialists throughout
the world may have received limited training in
the diagnosis and treatment of headache. As
Lifting The Burden moves towards interventional
projects, planning and implementing health-care
solutions for headache in various world regions,
primary-care physicians will need support to
provide best care based on timely and correct
diagnosis. Through several working groups,
Lifting The Burden is developing a range of
management aids expressly to assist primary-care
physicians faced with these very common
disorders. The aim is to benefit both physicians
and patients. Whilst physicians are helped to
deliver care more efficiently and more
cost-effectively, there should be better outcomes
for the many people with headache who need
medical treatment.
Outcome measures Assessment of a headache
disorder as a prelude to planning best management
requires more than diagnosis there should be
some measure of its impact on the patients life
and lifestyle. There are many ways in which
recurrent or persistent headache can damage life.
Finding a simple measure to summarize these,
whilst being equally applicable to all of the
common headache disorders, is a challenge. The
MIDAS instrument developed by Stewart and Lipton
has proved extremely useful with a simple
concept it estimates active time lost through
the disabling effect of headache, and expresses
the result in a number with intuitively
meaningful units (hours). The Headache and Lost
Time (HALT) index is a direct and close
derivative of MIDAS developed by Lifting The
Burden to use wording that is more easily
translated. Whenever treatment is started, or
changed, follow-up ensures that optimum treatment
has been established or it recognizes that it
has not, and identifies further changes that may
be needed. It is not always easy to know whether
or not the outcome achieved by an individual
patient is the best that he or she can reasonably
expect. For the non-specialist, one question that
sometimes arises is What further effort, in
hope of a better outcome, is justified? A second
question, which follows if it is thought that
more should be done, may be What is it that
needs changing? A working group is developing
the Headache Under-Response to Treatment (HURT)
index, an outcome measure designed to aid
management by suggesting answers to these two
questions. This index is currently undergoing
validation.
Diagnostic aids The Diagnostic Aids Working
Group, in collaboration with the Chairman of
the IHS Classification Sub-committee, has
produced a core cut-down version of
International Classification of Headache
Disorders, 2nd edition (ICHD-II). In time,
region-specific variations will be developed for
use around the world. Later, this Group will
formulate diagnostic algorithms. Patient
information leaflets Headache management is
facilitated if the patient understands his or her
headache disorder and the treatment being
proposed for it. Compliance is improved and a
better outcome is likely. Explanation takes time,
which is often not available. A writing group is
developing a series of Patient Information
Leaflets to be handed to patients at the time of
diagnosis. The group includes an international
review panel of headache specialists,
primary-care physicians and patient
representatives whose task is to ensure
cross-cultural relevance in these leaflets. Those
already produced include leaflets on each of the
four important headache disorders in primary care
(migraine, tension-type headache, cluster
headache and medication-overuse headache). A
fifth explains some of the relationships
between female hormones and headache, which
commonly raise questions from patients.
INTERNATIONAL CLASSIFICATIONofHEADACHE
DISORDERS2nd edition
These management aids are published in J
Headache Pain 2007 8 (suppl 1)
8
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache WorldwideA partnership
in action between the World Health Organization,
World Headache Alliance,International Headache
Society and European Headache Federation
Translation protocols Michele Peters (UK), for
the Translations Working Group

• Introduction
• As Lifting The Burden sets objectives and plans
  activities worldwide, the documents it develops
  in English must be made accessible in many
  languages. Initially 11 other languages are given
  priority, which collectively are used by half the
  world (table 1).
• The importance of rigorous translation of written
  materials used in medical management is
  increasingly recognized and advocated 1,2.
  Translation procedures, such as those by
  Guillemin et al 3, are internationally
  recognized and underpin recommendations for good
  translation practices for headache 1.
  Quality-controlled translations following
  standardized protocols increase the likelihood of
  linguistic and conceptual equivalence between the
  translated products, and are essential if
  questionnaires are to be comparable
  cross-culturally and if lay or professional
  instruments are to be of equal value in different
  languages.
• Documents for Translation
• Lifting the Burden creates three different types
  of document
• Lay documents (eg, patient information leaflets)
• Technical documents including information for
  professionals (eg, management guidelines)
• Hybrid documents aimed at people with headache
  but to be used either in clinical practice or
  in research (eg, outcome measures).

• The Translation Protocols
• Three translation protocols were written, one for
  each type of document. The procedure for each
  protocol (figure 1) aims to avoid making
  translation unnecessarily onerous yet not
  compromise on rigour.
• Similarities between protocols are
• A co-ordinator who is a native speaker of the
  target language selects the translators,
  oversees the translations and reports to the
  Translations Working Group
• Translators are native speakers of the target
  language
• At least one forward translator must be a
  headache or medical expert
• Two forward semantic and conceptual translations
  
• Production from these of a consensus translated
  version
• A quality assessment by members of the
  respective target audience
• Production of a report, including all translated
  versions and any translation difficulties.
• Differences between the three translation
  protocols include
• The co-ordinator for the hybrid translations
  must have technical knowledge (ie, able to
  understand the concepts underlying the
  instrument to be translated) and the
  co-ordinator for the technical translations must
  be a headache expert
• Production of one back translation only for
  hybrid documents
• For hybrid and lay documents, the quality
  assessment also includes a linguistic review.
• The Translation Procedure
• All translations of Lifting The Burden materials
  should follow one or other of these protocols as
  closely as possible.

Table 1 Campaign Languages
Arabic Hindi/Urdu
Bengali Italian
Mandarin Japanese
English Portuguese
French Russian
German Spanish
Figure 1 Translation Procedure
ORIGINAL
FIRST FORWARD TRANSLATION
SECOND FORWARD TRANSLATION
RECONCILIATION
HYBRID
LAY AND TECHNICAL
BACK TRANSLATION
REVIEW
QUALITY ASSESSMENT
FINAL TRANSLATION
TRANSLATION REPORT
The Translations Working Group A Lifting The
Burden working group was formed whose members
were either translation specialists or
knowledgeable about translation issues and the
Global Campaign (Box 1). Their task was to
develop protocols that would ensure the rigour
and quality of translations whilst being
pragmatic and suitable for use in different
cultures.

• Box 1 Translations Working Group
• Michele Peters (chairman), University of Oxford,
  Oxford, UK
• José M Bertolote, World Health Organization,
  Geneva, Switzerland
• Caroline Houchin, Oxford Outcomes, Oxford, UK
• Taj Kandoura, Oriental Institute, University of
  Oxford, Oxford, UK
• Timothy J Steiner, Imperial College London,
  London, UK.

References 1. Peters M, Passchier J. Translating
Instruments for cross-cultural studies in
headache research. Headache 2006 46 82-91. 2.
Wild D, Grove A, Martin M, Eremenco S, McElroy S,
Verjee-Lorenz A, Erikson P. Principles of good
practice for the translation and cultural
adaptation process for patient-reported outcomes
(PRO) measures Report of the ISPOR task force
for translation and cultural adaptation. Value in
Health 2005 8 94-104 3. Guillemin F, Bombardier
C, Beaton D. Cross-cultural adaptation of
health-related quality of life measures
literature review and proposed guidelines.
Journal of Clinical Epidemiology 1993
461417-1432
9
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache WorldwideA partnership
in action between the World Health Organization,
World Headache Alliance, International Headache
Society and European Headache Federation
A new headache service inthe Republic of
Georgia Z Katsarava (Germany/Georgia), M Kukava
(Georgia), A Dzagnidze (Georgia), E Mirvelashvili
(Georgia), M Djibuti (Georgia), R Jensen
(Denmark),LJ Stovner (Norway) and TJ Steiner (UK)
A Collaboration between Lifting The Burden and
theRussian Linguistic Subcommittee of the
International Headache Society
AIM To establish a new headache service in the
Republic of Georgia and investigate its impact on
headache-related disability, overall health and
quality of life of people with headache. BACKGROUN
D The Republic of Georgia is selected for the
first interventional project of Lifting The
Burden. Its population in 2000 was 4.4 million,
53 urban and 47 rural 1.5 million inhabitants
are in the Capital, Tbilisi.

• No headache service currently exists in the
  country. A recent epidemiological survey showed
  that the prevalences of primary headache
  disorders were similar to those in Europe and
  USA. It furthermore revealed that people with
  headache neglect their illness, not considering
  headache as a medical problem.
• PROJECT DESIGN
• Three headache clinics will be established
• Tbilisi, Capital city with 1.5 million
  inhabitants an EHF level 2-3 clinic, with one
  consultant neurologist supported by two
  neurologists, one nurse and one physiotherapist
• Batumi, city with 250,000 inhabitants a level
  1-2 clinic with one consultant neurologist
  supported by one neurologist and one nurse
• Sachkhere, town with 20,000 inhabitants a level
  1 clinic with one neurologist and one nurse.
• Headache services
• will be offered primarily to the inhabitants of
  the catchments areas (4,000 households, or 10,000
  people) of each clinic. All patients will receive
  cost-free headache services for 3 months, and
  must then make payment for their further care and
  medications. This is the exit strategy, designed
  to assess sustainability.
• Month 1
• First contact with doctor history and
  examination, diagnosis, treatment plan, headache
  diary, educational materials, drugs if needed
  (domperidone and aspirin or ibuprofen).
• Month 2
• Follow-up contact with doctor review of headache
  diary, review of treatment, further drugs as
  required (domperidone, aspirin or ibuprofen,
  triptan tablets up to 2 doses free, but
  additional doses at 2 Lari per tablet, atenolol
  or propranolol or amitriptyline).
• Month 3
• Follow-up contact with nurse (or doctor if
  necessary) review of headache diary, drugs as
  for month 2.

Evaluation will be after 6 months and 1 year in
all compliant patients and in 10 of
non-compliant patients. Outcome
variables 1) headache days per month, recorded
in headache diaries 2) headache-related
disability (lost active time) and outcome
assessed by Lifting The Burdens HALT and HURT
indices 3) overall wellbeing assessed by SF
12 4) patient satisfaction assessed by
questionnaire developed in Glostrup Headache
Centre, University of Copenhagen 5) social
benefit assessed in health economic terms
6) service quality using measures developed by
Tanaka Business School, Imperial College
London 7) willingness to pay.
PRINCIPAL HYPOTHESIS that development of a
headache service according to EHF recommendations
and standards requires a relatively low initial
investment and results in an effective and
sustainable service which reduces
headache-related disability and improves overall
health of people with headache.
10
Lifting The BurdenThe Global Campaign toReduce
the Burden of Headache WorldwideA partnership
in action between the World Health Organization,
World Headache Alliance,International Headache
Society and European Headache Federation
Visit the new Campaign website

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www.l-t-b.org