Open Access

Treatment of migraine and tension-type headache in Croatia

  • Vlasta Vuković1Email author,
  • Davor Plavec2,
  • Arijana Lovrenčić Huzjan1,
  • Mislav Budišić1 and
  • Vida Demarin1
The Journal of Headache and Pain201011:200

https://doi.org/10.1007/s10194-010-0200-9

Received: 9 September 2009

Accepted: 6 February 2010

Published: 6 March 2010

Abstract

The aim of this study was to assess the treatment patterns of migraine and tension-type headache in the Croatian population. Analysis included the proportion of patients who were taking specific antimigraine therapy and the number of tablets per attack per month, the proportion of patients who were taking prophylactic therapy or using alternative treatment methods and their satisfaction with the treatment. The design of the study was a cross-sectional survey. Self-completed questionnaires were randomly distributed to adults >18 years of age in the Croatian population. A total of 616 questionnaires were analyzed: 115 patients with migraine (M), 327 patients with tension-type headache (TTH), and 174 patients with probable migraine (PM) and TTH. Specific antimigraine therapy was taken by half of patients with migraine: 35.7% of patients used triptans and 21.7% ergotamines. Prophylactic treatment had been used by 13.9% of M, 1.2% of TTH, and 6.9% of PM patients. Alternative methods of treatment were tried by 27% of M and TTH patients. Only 16.8% of patients with M pay regular visits to physicians, while 36.3% never visited a physician. More than half of TTH patients have never visited a physician. The majority of patients are only partially satisfied with their current treatment, and almost one-third are not satisfied. Results of this study indicate that the treatment of primary headaches in Croatia should be improved.

Keywords

MigraineTension-type headacheProbable migraineAcute treatmentProphylactic treatment

Introduction

Studies worldwide continuously show low rates of medical consultations in patients with headache, with visits to neurologists being especially low, even with those patients who are aware of their condition [1, 2]. A large number of migraine patients receive no medical follow-up, think that consultations are useless and that there is no cure for their migraines [3]. Even though migraine is a significant personal and public health problem, it is not effectively managed in clinical practice. Most studies show that in the general population triptans are taken by 3–19% of patients with migraine, while most other patients are taking simple analgesics [26]. In some countries, higher percentages of triptan use have been observed [7]. Preventive treatment is used by a low percentage of migraine patients, with studies showing a range of 6–12.4% [3, 8]. The aim of this study was to assess the patterns of headache treatment in the general population, and to assess medical attendance as well as the level of satisfaction with current therapies offered. Our survey is the first of its kind in the Croatian population.

Methods

This study was part of a population-based study whose aim was to assess the prevalence of migraine (M), probable migraine (PM) and tension-type headache (TTH) as well as patterns of health care in Croatia. The design of the study was a cross-sectional survey of an adult population sample using a self-completed questionnaire. The study population included adults >18 years of age, and the sample represented 4,437,000 Croatian adults. The survey was conducted in four Croatian cities: Zagreb, Split, Osijek, and Dubrovnik. The questionnaires were distributed in general medical practices randomly selected to contain a mix of urban, suburban, and rural settings, as well as range of social classes. In Croatia, 96% of the population is registered with a GP, providing a convenient frame for an indiscriminate sampling of the local population. Randomly selected patients from the GP’s database were asked to fill out the questionnaire.

The questionnaire consisted of three sections:
  • Section 1 consisted of demographic data (age, gender, education, marital status, employment, and city of residence) as well as questions regarding the presence of headache.

  • Section 2 included questions which were designed to define the nature of the headache according to the ICHD-2 [9] criteria for M, PM, and TTH.

  • Section 3 consisted of questions aimed to assess patterns of headache treatment:
    1. (a)

      Have you ever visited a doctor because of your headaches?

       
    2. (b)

      Which doctor(s) have you visited?

       
    3. (c)

      Which therapy do you use for acute headache attacks (respondents were asked to make a list of specific and non-specific therapies, numbers and types of medication, and overall satisfaction with therapy)

       
    4. (d)

      Have you ever used prophylactic therapy?

       
    5. (e)

      Have you ever tried alternative methods of treatment?

       
    6. (f)

      Are you satisfied with your current therapy (on the whole)?

       
    7. (g)

      Which are the main sources from which you receive information regarding health?

       

The questionnaire was designed combining literary sources of similar studies, the IHS classification (second edition) and advice from epidemiologic researchers. On return, the questionnaires were checked for the completeness, and questionnaires containing more than one unanswered question from any of the four sections were excluded from the final analysis. Patients who had definite M and TTH were classified into the M group, and those who had PM and TTH were classified in the PM group. Patients with TTH only were classified into the TTH group. This classification was made because the sampling size was too small to divide the patients into more than three groups. Furthermore, studies worldwide show that most M sufferers will have also TTH, at some point in their lives.

Statistical analysis

Data analysis was performed using the STATISTICA for WINDOWS release 6.0. Continuous variables were summarized as mean and standard deviation (SD). Categorical variables were summarized as a number (%). In the statistical analysis, the chi-square and Fisher exact tests were used to compare distribution of categorical variables between subgroups and Student t test to compare continuous variables. Statistic significance was considered at P < 0.05.

Results

Demographic characteristics

The questionnaires were sent to 2,000 inhabitants with 1,542 of them being suitable for analysis (77.1%). Of the total 1,542 respondents, 640 (41.5%) indicated that they suffer from a primary headache at least once within the span of a year. From the sample of 640 respondents, data regarding treatment patterns in the general population were assessed. Among 640 respondents, 115 (88 women, 27 men, mean age 42 ± 14) suffered from M, 327 (215 women, 112 men, mean age 41 ± 14) from TTH, and 174 (138 women, 36 men, mean age 39 ± 14) from PM with or without TTH. A majority of the respondents were married, had high school education, were employed, and resided in a city.

Medical attendance

A small percentage of patients with M visit a doctor regularly (16.8%) (Table 1). A quarter of M and PM patients declared to have visited a doctor several times but with no effect. A doctor was never visited by 36.3% of M patients and 46.6% of PM patients, whereas more than half of patients (55.5%) with TTH have never visited a doctor (P = 0.002). Approximately one-fifth of patients in all three groups visited a doctor once.
Table 1

Medical attendance

Visit to a physician

Migraine

n = 115 (%)

TTH

n = 327 (%)

PM

n = 174 (%)

P value

Never

41 (36.3)

177 (55.5)

81 (46.6)

0.0024

Once

25 (22.1)

66 (20.7)

33 (19.0)

0.0024

Several times

28 (24.8)

42 (13.2)

42 (24.1)

0.0024

Regularly

19 (16.8)

34 (10.7)

18 (10.3)

0.0024

Primary care

57 (49.6)

139 (42.5)

74 (42.5)

0.39

Neurologist

51 (44.4)

53 (16.2)

43 (24.7)

<0.0001

Internal medicine

4 (3.5)

12 (3.7)

8 (4.6)

0.85

Other specialist

10 (8.7)

32 (9.8)

17 (9.8)

0.26

Numbers in parenthesis are percentages

Patients with M have visited a neurologist significantly more as compared with TTH patients (44.4 vs. 16.2%) (P < 0.0001) (Table 1). Almost half of patients with any type of primary headache have visited a primary care physician at least once. Other specialists that headache sufferers visited were internal medicine doctors (24 cases), ophthalmologists (12), ENT specialists (19), rheumatologists (14), psychiatrists (9), cardiologists (2), gynecologists (2), and urologists (1).

Treatment patterns

Medication used, number of tablets taken, overall satisfaction, preventive and alternative therapies are shown in Table 2. A total of 57.4% of respondents with M stated that they are using specific antimigraine therapy such as triptans (sumatriptan or zolmitriptan; 35.6%) or ergotamines (21.8%).
Table 2

Use of specific, non-specific, prophylactic, and alternative therapies in patients with headache, their overall satisfaction, and number of tablets taken according to headache subtype

Medications

Migraine

n = 115 (%)

TTH

n = 327 (%)

PM

n = 174 (%)

P value

Specific

 Sumatriptan

23 (20.0)

1 (0.3)

17 (9.8)

<0.0001

 Zolmitriptan

18 (15.7)

2 (0.6)

7 (4.0)

<0.0001

 Ergotamines

18 (15.7)

3 (0.9)

14 (8.1)

<0.0001

 Dihydroergotamines

7 (6.1)

0

4 (2.3)

0.0001

Do these medications relief pain?

 Yes, if taken on time

29 (67.4)

1 (16.7)

14 (50.0)

0.0007

 Partially

12 (27.9)

2 (33.3)

13 (46.4)

0.0007

 No

2 (4.7)

3 (50.0)

1 (3.6)

0.0007

Number of tablets (specific or non-specific)

Per attack: one

84 (73.0)

296 (90.5)

149 (84.2)

0.0033

Tablets per month, number (range)a

8.6 (4.9–12.2)

5.3 (4.2–6.4)

7.3 (5.4–9.1)

0.0420

Do these medications relief the pain?

 Yes

54 (71.1)

211 (79.6)

72 (57.1)

0.0001

 Partially

19 (25.0)

52 (19.6)

49 (38.9)

0.0001

 No

3 (4.0)

2 (0.8)

5 (4.0)

0.0001

Per attack: two

29 (25.2)

81 (24.8)

71 (40.1)

0.0033

Tablets per month, number (range)a

11.3 (1.6–20.1)

5.9 (3.0–8.9)

6.6 (3.7–9.6)

0.2689

Do these medications relief pain?

 Yes

12 (48.0)

56 (78.9)

31 (52.5)

0.0041

 Partially

9 (36.0)

14 (19.7)

23 (39.0)

0.0041

 No

3 (12.0)

1 (1.4)

5 (8.5)

0.0041

Per attack: three

11 (9.6)

15 (4.6)

20 (11.3)

0.0033

Tablets per month, number (range)a

20.1 (0–45.2)

13.5 (0–31.1)

9.4 (0–21.1)

0.6348

Do these medications relief pain?

 Yes

5 (55.6)

10 (71.4)

10 (58.8)

0.5195

 Partially

3 (33.3)

4 (28.6)

6 (35.3)

0.5195

 No

1 (11.1)

0

1 (5.9)

0.5195

Prophylactic treatment

16 (13.9)

4 (1.2)

12 (6.9)

<0.0001

Alternative methods of treatment

 Chiropractics

3 (2.6)

13 (4.0)

12 (6.9)

0.1777

 Acupuncture

10 (8.7)

11 (3.4)

8 (4.6)

0.0673

 Homeopathy

2 (1.7)

4 (1.2)

2 (1.2)

0.8964

 Physical therapy

11 (9.6)

40 (12.2)

17 (9.8)

0.6023

 Autogenic training

4 (3.5)

4 (1.2)

4 (2.3)

0.2980

 Yoga, meditation

8 (7.0)

11 (3.4)

9 (5.2)

0.2528

 Something else

10 (8.7)

40 (12.2)

26 (14.9)

0.3794

 Total

31 (27.0)

89 (27.2)

49 (28.2)

0.9670

Do these methods help?

 Yes

12 (38.7)

53 (59.5)

20 (40.8)

0.5446

 Partially

3 (9.7)

2 (2.2)

2 (4.1)

0.5446

 No

16 (51.6)

34 (38.2)

27 (55.1)

0.5446

aNumbers represent average (range) consumption of tablets per month

Among M patients, 67.4% stated that these medications relieve the pain if taken in time and will partially help in 27.9% of cases.

Patients with M were least likely to take only one tablet for a headache attack as compared with the TTH and PM groups (P = 0.0033). The least-satisfied group of patients was the PM group if they took only one tablet per attack (P = 0.0001).

Two medications per headache attack were most likely to be taken by patients in the PM group (P = 0.003). Most satisfied with two tablets were patients from the TTH group (P = 0.004). Two or three tablets per headache attack were most likely to be taken by patients in the M and PM groups as compared with the TTH group (P = 0.003). Regarding satisfaction with therapy, there was no significant difference among patient groups if they had to use three tablets per attack. Comparing all three groups, patients with M were most likely to take the largest total number of medications for their headache attacks per month.

Prophylactic treatment has been prescribed to 13.9% of M, 1.2% of TTH, and 6.9% of PM patients. Details on the type of prophylactic therapy used were not obtained.

Alternative methods for headache treatment were used by 27% of M and TTH patients; 60% of TTH patients were satisfied with therapies received as were approximately 40% of patients with M and PM. There was no statistical significance among the number of patients who used alternative treatment between the three groups of patients (P > 0.05) (Table 2).

Satisfaction with therapy

Satisfaction with current therapies among our group of patients was not statistically different between subgroups (Table 3). Approximately one quarter of patients or less declared they were completely satisfied, nearly half of the patients were partially satisfied, one-fifth (M and TTH groups) of patients were mostly unsatisfied and 10% or less in each group were not satisfied at all (Table 3).
Table 3

Satisfaction with current therapy (on the whole)

Satisfaction with current therapy

Migraine

n = 115 (%)

TTH

n = 327 (%)

PM

n = 174 (%)

P value

Totally

24 (26.1)

57 (27.9)

25 (19.2)

0.65

Partially

40 (43.5)

91 (44.6)

62 (47.7)

0.65

Mostly not

18 (19.6)

40 (19.6)

31 (23.9)

0.65

Not at all

10 (10.9)

16 (7.8)

12 (9.2)

0.65

Sources of health information

As an information source, patients with M and PM were more likely to visit a specialist such as a neurologist or internal medicine specialist (P = 0.005), and gain information regarding headaches from internet (P = 0.002) or medical books (P = 0.0008) as compared with patients with TTH. Patients with TTH are more likely to gain information from family and friends (P = 0.02) or mass media (P = 0.0001) as compared with M patients (Table 4).
Table 4

Sources of health information

Sources of health information

Migraine

n = 115 (%)

TTH

n = 327 (%)

PM

n = 174 (%)

P value

Primary care physician

56 (48.7)

129 (39.5)

86 (49.4)

0.0535

Specialist (neurologist and internal medicine)

21 (18.3)

25 (7.7)

23 (13.2)

0.0049

Family friends

28 (24.4)

123 (37.6)

55 (31.6)

0.0288

Journals

38 (33.0)

181 (55.4)

78 (44.8)

0.0001

TV and radio

34 (29.6)

155 (47.4)

61 (35.1)

0.0008

Internet

24 (20.9)

36 (11.0)

37 (21.3)

0.0027

Medical books

27 (23.5)

50 (15.3)

51 (29.3)

0.0008

None

1 (0.9)

4 (1.2)

0

0.3471

Other

8 (7.0)

4 (1.2)

6 (3.5)

0.0064

Discussion

Medical attendance

Worldwide population-based epidemiologic surveys have consistently demonstrated that the majority of M sufferers are not currently consulting their physicians about their problem and that many have never even consulted a physician [1018].

Studies in Canada, Denmark, The Netherlands, and USA have shown that 55–70% of M patients sought initial treatment from primary care physicians [10, 12, 15]. A UK study showed that 20% of M sufferers never visited a doctor and among those who did almost 50% felt that the physician did not help [13]. In Sweden, 27% of patients with M visited a doctor (6% regularly and 21% occasionally) with 60% being satisfied with their treatment [16]. In Austria, 39.6% never visited a doctor, 30.8% once, 16.8% occasionally, and 12.8% regularly [18]. Two studies from France indicated that 59% had visited a doctor; in one study 70% were not satisfied with initial treatment after their first visit, with 48% being satisfied in the other study. Among those who had never visited a doctor 87% were from MIDAS I group and even 68% were from MIDAS IV group [3, 19]. A study that encompassed data from six South American countries stated that 59% of patients had never visited a doctor [20]. In Europe, patients usually need to be referred to a specialist by their primary care physician, and about 5–15% will visit a specialist [15, 21, 22].

Many M sufferers who do consult physicians for M relief do not receive a correct diagnosis. In a US study, 40% of M sufferers stated that they had not been diagnosed as having M even after consultation with a physician [12]. Only 45% of migraineurs who sought medical treatment for their migraines were correctly diagnosed [23].

Results of our study are similar to studies from other countries regarding physician visit. Due to a M headache, 63.7% of M patients have visited a physician at least once, but only 16.8% pay regular visits. One quarter of M and PM patients have visited a physician several times, but have not been satisfied with treatment. For M, 4–5% of patients have seen an internal medicine doctor, and nearly 10% of headache sufferers have visited other specialists.

In our study, 43–50% of patients had visited a GP, among those 44.4% with M had also visited a neurologist and only 16.2% with TTH (P < 0.0001). The reason for the high percentage of patients visiting a neurologist is probably because in Croatia, a prescription for triptans requires a neurologist’s approval. This is probably a major obstacle for a proportion of patients who cannot find the time to visit a specialist, or have difficulties with making an appointment. In Croatia, 96% of the population has “basic health insurance” covering visits to GPs and a minor part of costs for medical examinations or medications. The “additional health insurance” costs between 130 and 214 Euros per year (depending on the amount of the salary or pension), and covers the majority of cost for medical examinations and drugs. A patient who is not paying the “additional insurance” will pay 16.5 Euros for a visit to a neurologist. There is a so-called “list A” for medications which are fully covered and a “list B” which are partially covered by the health insurance. The three available triptans in Croatia (sumatriptan, zolmitriptan, and rizatriptan) are reimbursed by health insurance: sumatriptan tablets 50 mg are fully reimbursed (“list A”) and for others (sumatriptan nasal spray, zolmitriptan, and rizatriptan melting disks or tablets- “list B”) there is an additional surcharge of approximately 3–8 Euros per package. A prescription for triptans, however, is not necessary, but at a cost of between 9 and 31 Euros per package, the costs for triptans are high. The average salary in Croatia is approximately 730 Euros, and the unemployment rate is now 14%. Therefore, if the patient does not have the “additional health insurance” the costs for visits to a neurologist and for triptans are rather high.

Satisfaction with treatment

One study showed that the main reasons were dissatisfaction with treatment or feeling that the physician was ignorant about, or not interested in solving the problem [10]. In a population-based study in the United States, only 29% of M sufferers reported that they were “very satisfied” with their usual acute treatment [24].

Our study showed that when specifically asked for satisfaction with treatment so far, the results of the proportion of patients in each group was similar: one-fifth to one quarter of patients being completely satisfied, nearly half of patients stated that they were partially satisfied, and approximately 30% were mostly or completely unsatisfied. Patients attending headache clinics were more satisfied with treatments provided than patients visiting community care physicians [25].

These data should be analyzed for use in future studies to show subgroups of patients and their reasons for dissatisfaction with current therapies. Targeting untreated groups will help establish better health care plans in Croatia. Our study has shown that the main information source are mass media (journals 55.4% and TV or radio 47.4%), whereas information from the internet and from medical books is still restricted to a smaller number of health seekers.

Use of acute treatment

Triptans are widely recommended for M since studies have shown that their use increases productivity at work and improves the quality of life of M sufferers [26]. However, studies worldwide show that the majority of M patients are using OTCs and the minority is using triptans [26, 17, 27, 28]. This is largely influenced by the physician who is treating the patient. A study from Singapore showed that community care physicians treat patients with triptans far less than do physicians in headache clinics [25].

In our study, 57.4% of M patients stated that they are currently using or have tried specific M treatment: 35.7% used triptans and 21.8% used ergotamines or dihydroergotamines. According to Croatian guidelines for headache treatment [29], analgesics and triptans should be the first line for M treatment, while ergotamines can be recommended with some exceptions. However, our results show that a large number of patients are still using ergotamines. Reasons for this are probably due to the fact that these drugs were previously used as specific treatment, and patients have a lack of information regarding new drugs such as triptans. Another reason is that ergotamines are somewhat less expensive as compared to triptans: a price for 20 tablets of combined ergotamine with paracetamol and caffeine is 7 Euros; however, they are not available as OTC drugs and are not a prescription drug in Croatia (they can only be purchased abroad). The least expensive are NSAIDs; the price varies between 1 and 3 Euros for ten tablets.

In our study, 67.4% of M patients were satisfied with specific medications if taken on time and only 4.7% were not satisfied. Studies showed that intra-individual consistency to oral triptan response is 40–50% in 3/3 M attacks [30]. Efficacy, adverse events, costs, and physician’s knowledge have a major influence on triptan consumption.

Results of our study showed that patients with M were taking significantly more tablets per month for M attacks as compared with TTH patients. In the group of patients who were taking one tablet per month, 71.1% of M patients were satisfied with their treatment and an additional 25% were partially satisfied, whereas the percentage of satisfied patients who must take two or three medications was 48 and 55.6% respectively. In the TTH group, approximately 70–80% of all patients (taking 1, 2 or 3 tablets per attack) were satisfied with treatment. These results indicate that the more medications the patients must take per headache attack, the less likely they are to be satisfied with their efficacy. This study was not designed to provide data on medication overuse in the general population; therefore, these data is not available. A study from the USA showed that half of the patients use OTC drugs for the acute M attack despite the fact that 73% of them require a second dose or product; patients using a triptan were less likely to require a second dose or product [31]. A survey comparing the consumption of analgesics over the past 20 years in nine countries showed that in half of countries analyzed the consumption of analgesics has increased significantly, and it has remained constant or showed a minor increase in the others [32].

Use of prophylactic treatment

In our study, 13.9% of patients have used prophylactic therapy for M. The details regarding the type and duration of prophylactic therapy were not obtained. A French study showed that only 6% of M patients are currently taking prophylaxis, among those 22% were in MIDAS III or IV group [3]. Another population-based study in France showed that only 0.3% of M patients and 1.4% with PM are taking prophylactic treatment [27]. A study from the USA showed that 12.4% of patients with M are taking prophylaxis [8] and 7.9% of PM patients, even though this percentage should be higher based on patients’ characteristics [33]. In Australia, 8.3% of patients were taking prophylactic medication [34]. In a Canadian study, only 31% of patients with severe or chronic M were taking prophylactic treatment [7]. More than half of patients on prophylaxis, especially <40 years of age, tend to discontinue the therapy within 3 months [35].

Use of alternative treatment

Alternative methods of treatment in our study have been used by approximately one quarter of patients in all three groups of patients. Approximately 40% of patients with M and PM were satisfied with alternative methods, whereas in the TTH group this percentage was even higher, at 60%. Studies from other countries show that patients relatively frequently reach for alternative methods for headache treatment: approximately one-third of patients in Italy, Switzerland, and Singapore tried at least one method [25, 36, 37]. Analysis of patients who visited a specialized headache clinic revealed that even 84% tried one or more alternative methods and 60% of those stated that these methods were efficient [38]. American studies observed an increase in the proportion of patients seeking alternative methods for headache treatment [39].

Study limitations

This study has several limitations. First, the data were collected by a questionnaire; it is possible that the data obtained from a face-to-face interview would, to some extent, be different. Second, the data regarding the number of specific acute M treatment and OTC drugs were provided as a total number of used medication and not in separate groups. Furthermore, details about types of prophylactic treatments were not provided due to the limited number of questions asked. Finally, due to a rather small sample size our results need to be further validated.

Conclusion

Health care systems must aim to satisfactorily manage the majority of M patients by primary care physicians [21], and more severe cases should have easy access to neurologists, preferably headache specialists. Results of our study regarding treatment patterns of primary headaches in Croatia are similar to other countries worldwide, with certain differences. Current health care laws in Croatia probably influence the treatment of M sufferers. We believe that current health care policies in Croatia regarding headache management should be revised to offer an easier approach; patients with headache should be encouraged to visit physicians more regularly, and public information should be more accessible. Such activities are under way, and in near future we expect improvement in headache care in Croatia. We hope that the results of our study will help to improve the management of primary headaches in Croatia.

Declarations

Conflict of interest

None.

Authors’ Affiliations

(1)
University Department of Neurology, University Hospital “Sestre milosrdnice”
(2)
Research Department, Children’s Hospital “Srebrnjak”

References

  1. De Diego EV, Lanteri-Minet M (2005) Recognition and management of migraine in primary care: influence of functional impact measured by the headache impact test (HIT). Cephalalgia 25:184–190 10.1111/j.1468-2982.2004.00820.xPubMedView ArticleGoogle Scholar
  2. Linde M, Dahlof C (2004) Attitudes and burden of disease among self-considered migraineurs—a nation-wide population-based survey in Sweden. Cephalalgia 24:455–465 10.1111/j.1468-2982.2004.00703.x, 1:STN:280:DC%2BD2c3ls1yjtA%3D%3DPubMedView ArticleGoogle Scholar
  3. Lucas C, Chaffaut C, Artaz MA, Lantéri-Minet M (2005) FRAMIG 2000: medical and therapeutic management of migraine in France. Cephalalgia 25:267–279 10.1111/j.1468-2982.2004.00851.x, 1:STN:280:DC%2BD2M7kt1WktA%3D%3DPubMedView ArticleGoogle Scholar
  4. MacGregor EA, Brandes J, Eikermann A (2003) Migraine prevalence and treatment patterns: the global migraine and zolmitriptan evaluation survey. Headache 43:19–26 10.1046/j.1526-4610.2003.03004.xPubMedView ArticleGoogle Scholar
  5. Lucas C, Auray JP, Gaudin AF et al (2004) Use and misuse of triptans in France: data from the GRIM2000 population survey. Cephalalgia 24:197–205 10.1111/j.1468-2982.2003.00651.x, 1:STN:280:DC%2BD2c7js1OqsA%3D%3DPubMedView ArticleGoogle Scholar
  6. Lohman JJ, van der Kuy-de Ree MM, on behalf of the Group of Co-operating Pharmacists Sittard-Geleen and its environs (2005) Patterns of specific antimigraine drug use-a study based on the records of 18 community pharmacies. Cephalalgia 25:214–218 10.1111/j.1468-2982.2004.00843.x, 1:STN:280:DC%2BD2M%2FmtVyqtQ%3D%3DPubMedView ArticleGoogle Scholar
  7. Jelinski SE, Becker WJ, Christie SN, Giammarco R, Mackie GF, Gawel MJ et al (2006) Clinical features and pharmacological treatment of migraine patients referred to headache specialists in Canada. Cephalalgia 26:578–588 10.1111/j.1468-2982.2005.01077.x, 1:STN:280:DC%2BD283ltVCktg%3D%3DPubMedView ArticleGoogle Scholar
  8. Diamond S, Bigal ME, Silberstein S, Loder E, Reed M, Lipton RB (2007) Patterns of diagnosis and acute and preventive treatment for migraine in the United States: results from the American Migraine Prevalence and Prevention Study. Headache 47:355–363PubMedGoogle Scholar
  9. Headache Society (2004) The international classification of headache disorders. Cephalalgia 24(Suppl 1):1–160Google Scholar
  10. Micieli G (1993) Suffering in silence. In: Edmeads J (ed) Migraine: a brighter future. Cambridge Medical Publications, Worthing, pp 1–7Google Scholar
  11. Edmeads J, Findlay H, Tugwell P, Pryse-Phyllips W, Nelson RF, Murray TJ (1993) Impact of migraine and tension-type headache on life-style, consulting behavior, and medication use: a Canadian population survey. Can J Neurol Sci 20:131–137 1:STN:280:DyaK3szislamsQ%3D%3DPubMedGoogle Scholar
  12. Lipton RB, Stewart WF, Simon D (1998) Medical consultation for migraine: results from the American Study. Headache 38:87–96 10.1046/j.1526-4610.1998.3802087.x, 1:STN:280:DyaK1c7ptVKlug%3D%3DPubMedView ArticleGoogle Scholar
  13. Lipton RB, Stewart WF, Liberman J (1999) Patterns of healthcare utilization for migraine in England. Cephalalgia 19:305Google Scholar
  14. Lipton RB, Scher AI, Steiner TJ et al (2003) Patterns of health care utilization for migraine in England and in the United States. Neurology 60:441–448 10.1001/archneur.60.3.441, 1:STN:280:DC%2BD3s%2FmvV2ktA%3D%3DPubMedView ArticleGoogle Scholar
  15. Rasmussen BK, Jensen R, Olesen J (1992) Impact of headache on sickness absence and utilization of medical services: a Danish population study. J Epidemiol Community Health 46:443–446 10.1136/jech.46.4.443, 1:STN:280:DyaK3s%2Flslamtg%3D%3DPubMed CentralPubMedView ArticleGoogle Scholar
  16. Dahlöf C, Linde M (2001) One-year prevalence of migraine in Sweden: a population-based study in adults. Cephalalgia 21:664–671 10.1046/j.1468-2982.2001.00218.xPubMedView ArticleGoogle Scholar
  17. Takeshima T, Ishizaki K, Fukuhara Y et al (2004) Population-based door-to-door survey of migraine in Japan: the Daisen study. Headache 44:8–19 10.1111/j.1526-4610.2004.04004.xPubMedView ArticleGoogle Scholar
  18. Lampl C, Buzath A, Baumhackl U, Klingler D (2003) One-year prevalence of migraine in Austria: a nation-wide survey. Cephalalgia 23:280–286 10.1046/j.1468-2982.2003.00509.x, 1:STN:280:DC%2BD3s7pslWgug%3D%3DPubMedView ArticleGoogle Scholar
  19. Russell MB, Olesen J (1996) Migrainous disorder and its relation to migraine without aura and migraine with aura. A genetic epidemiologic study. Cephalalgia 16:431–435 10.1046/j.1468-2982.1996.1606431.x, 1:STN:280:DyaK2s%2Flsl2hsQ%3D%3DPubMedView ArticleGoogle Scholar
  20. Morillo LE, Alarcon F, Aranaga N et al (2005) Prevalence of migraine in Latin America. Headache 45:106–117 10.1111/j.1526-4610.2005.05024.xPubMedView ArticleGoogle Scholar
  21. Holmes W, Laughey W, MacGregor AE et al (1999) Headache consultation and referral patterns in one UK general practice. Cephalalgia 19:328–329Google Scholar
  22. Van Roijen L, Essink-Bot ML, Koopmanschap MA, Michel BC, Rutten FF (1995) Societal perspective on the burden of migraine in the Netherlands. Pharmacoeconomics 7:170–179 10.2165/00019053-199507020-00008PubMedView ArticleGoogle Scholar
  23. Stang PE, Von Korff M (1994) The diagnosis of headache in primary care: factors in the agreement of clinical and standardized diagnoses. Headache 34:138–142 10.1111/j.1526-4610.1994.hed3403138.x, 1:STN:280:DyaK2c3lvFGrtg%3D%3DPubMedView ArticleGoogle Scholar
  24. Lipton RB, Stewart WF (1999) Acute migraine therapy: do doctors understand what patients with migraine want from therapy. Headache 39(Suppl 2):20–26 10.1111/j.1526-4610.1999.00006.xView ArticleGoogle Scholar
  25. Soon YY, Siow HC, Tan CY (2005) Assessment of migraineurs referred to a specialist headache clinic in Singapore: diagnosis, treatment strategies, outcomes, knowledge of migraine treatments and satisfaction. Cephalalgia 25:1122–1132 10.1111/j.1468-2982.2005.00969.x, 1:STN:280:DC%2BD2MnisFarsw%3D%3DPubMedView ArticleGoogle Scholar
  26. Dahlöf C, Bouchard J, Cortelli P, Heywood J, Jansen JP, Pham S et al (1997) A multinational investigation of the impact of subcutaneous sumatriptan. II Health-related quality of life. Pharmacoeconomics 11(Suppl 1):24–34 10.2165/00019053-199700111-00005PubMedView ArticleGoogle Scholar
  27. Lantéri-Minet M, Valade D, Géraud G, Chautard MH, Lucas C (2005) Migraine and probable migraine—results of FRAMIG 3, a French nationwide survey carried out according to the 2004 IHS classification. Cephalalgia 25:1146–1158 10.1111/j.1468-2982.2005.00977.xPubMedView ArticleGoogle Scholar
  28. Panconesi A, Pavone E, Vacca F, Vaiani M, Banfi R (2008) Triptans in Italian population: a drug utilization study and a literature review. J Headache Pain 9:71–76 10.1007/s10194-008-0020-3PubMed CentralPubMedView ArticleGoogle Scholar
  29. Demarin V, Vuković V, Lovrenčić-Huzjan A, Lušić I, Jančuljak D, Wilheim K et al (2005) Evidence based guidelines for treatment of primary headaches. Report of the Croatian Neurovascular Society. Acta Clin Croat 44:139–183Google Scholar
  30. Ferrari MD, Goadsby PJ, Roon KI, Lipton RB (2002) Triptans (serotonin, 5-HT1B/1D agonists) in migraine: detailed results and methods of meta-analysis of 53 trials. Cephalalgia 22:633–658 10.1046/j.1468-2982.2002.00404.x, 1:STN:280:DC%2BD38njtlehtw%3D%3DPubMedView ArticleGoogle Scholar
  31. MacGregor EA, Brandes J, Gendolla A, Gianmarco R (2004) Migraine treatment strategies: the global Migraine and Zolmitriptan Evaluation (MAZE) survey—phase IV. Curr Med Res Opin 20:1777–1783 10.1185/030079904X10142PubMedView ArticleGoogle Scholar
  32. Diener HC, Schneider R, Aicher B (2008) Per-capita consumption of analgesics: a nine-country survey over 20 years. J Headache Pain 9:225–231 10.1007/s10194-008-0046-6PubMed CentralPubMedView ArticleGoogle Scholar
  33. Silberstein S, Loder E, Diamond S, Reed ML, Lipton RB, AMPP Advisory Group (2007) Probable migraine in the United States: results of the American Migraine and Prevention (AMPP) study. Cephalalgia 27:220–234Google Scholar
  34. Stark RJ, Valenti L, Miller GC (2007) Management of migraine in Australian general practice. Med J Aust 187:142–146PubMedGoogle Scholar
  35. Rahimtoola H, Buurma H, Tijssen CC, Leufkens HG, Egberts ACG (2003) Migraine prophylactic medication usage patterns in the Netherlands. Cephalalgia 23:293–301 10.1046/j.1468-2982.2003.00494.x, 1:STN:280:DC%2BD3s3ivFaktw%3D%3DPubMedView ArticleGoogle Scholar
  36. Rossi P, Lorenzo MG, Faroni J, Cesarino F, Di Lorenzo C, Nappi G (2005) Prevalence, pattern and predictors of use of complementary and alternative medicine (CAM) in migraine patients attending a headache clinic in Italy. Cephalalgia 25:493–506 10.1111/j.1468-2982.2005.00898.x, 1:STN:280:DC%2BD2MzgvVWguw%3D%3DPubMedView ArticleGoogle Scholar
  37. Gantenbein AR, Kozak S, Agosti F, Agosti R, Isler H (2006) Headache patients in primary care and tertiary care unit in Zürich, Switzerland. Cephalalgia 26:1451–1457 10.1111/j.1468-2982.2006.01225.x, 1:STN:280:DC%2BD28notFGltA%3D%3DPubMedView ArticleGoogle Scholar
  38. von Peter S, Ting W, Scrivani S, Korkin E, Okvat H, Gross M et al (2002) Survey on the use of complementary and alternative medicine among patients with headache syndromes. Cephalalgia 22:395–400 10.1046/j.1468-2982.2002.00376.xView ArticleGoogle Scholar
  39. Eisenberg DM, Davis SL, Ettner S, Appel S, Wilkey S, van Rompany M et al (1998) Trends in alternative medicine use in the United States, 1990–97. JAMA 280:1569–1575 10.1001/jama.280.18.1569, 1:STN:280:DyaK1M%2Fjs1WnsQ%3D%3DPubMedView ArticleGoogle Scholar

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