Chronic headache among general practice out patients in a tertiary care hospital, Eastern Nepal

Abstract

p> Background: The term chronic headache is commonly taken as headache lasting for more than three months. It is common in general practice with minimal research on the topic in Nepal. Objective: To sort out the common diagnoses of chronic headache and to study the clinical features and demographic profile of patients presenting with chronic headache.

Method: A descriptive cross sectional study was conducted (2012 August to 2013 August) at General Practice outpatients in BP Koirala Institute of Health Sciences, a medical university in eastern Nepal. Approval and ethical clearance was taken from Research Committee and Institutional Ethical Review Board. Descriptive statistical analysis was done.

Result: 168 patients constituting 1% of outpatient visits presented due to chronic headache. Mean age was 29.57 years (SD 10.53) and female to male ratio was 3.67. Mean number of days of headache was 19.46 days (SD 4.62). Numerical pain score was reported at 7.1/10 (SD 1.85). The mean duration of presentation was 22 months (SD 11). 40% reported impaired activity of more than one week. Headache was classified as chronic migraine in 20.2%, chronic tension type headache in 16.7%, and chronic daily persistent headache in 11.9%. The diagnosis did not fit into any diagnostic criteria in 51.2% cases.

Conclusion: Chronic headache is common in females and young age group. Patients present late despite significant pain scores. Significant proportion is still unclassified.

Health Renaissance 2015;13(2): 22-29</p

Full text

Bhandari et.al.
Chronic headache
Health Renaissance 2015;13(2): 22-29
22
Chronic headache among general practice out patients in a tertiary care hospital,
Eastern Nepal
R Bhandari
1
, R Bhandari
1
, DR Shakya
2
, R Maskey
3
, M Paudel
1
, R Giri
1
, PP Gupta
1
Department of General Practice and Emergency Medicine
1
, Department of Psychiatry
2
, Department of
Internal Medicine
3
, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
Abstract
Background: The term chronic headache is commonly taken as headache lasting for more
than three months. It is common in general practice with minimal research on the topic in Nepal.
Objective: To sort out the common diagnoses of chronic headache and to study the clinical
features and demographic profile of patients presenting with chronic headache. Method: A
descriptive cross sectional study was conducted (2012 August to 2013 August) at General
Practice outpatients in BP Koirala Institute of Health Sciences, a medical university in eastern
Nepal. Approval and ethical clearance was taken from Research Committee and Institutional
Ethical Review Board. Descriptive statistical analysis was done. Result: 168 patients
constituting 1% of outpatient visits presented due to chronic headache. Mean age was 29.57
years (SD 10.53) and female to male ratio was 3.67. Mean number of days of headache was
19.46 days (SD 4.62). Numerical pain score was reported at 7.1/10 (SD 1.85). The mean
duration of presentation was 22 months (SD 11). 40% reported impaired activity of more than
one week. Headache was classified as chronic migraine in 20.2%, chronic tension type
headache in 16.7%, and chronic daily persistent headache in 11.9%. The diagnosis did not fit
into any diagnostic criteria in 51.2% cases. Conclusion: Chronic headache is common in
females and young age group. Patients present late despite significant pain scores. Significant
proportion is still unclassified.
Keywords: Chronic headache, general practice, Nepal.
Introduction
The term chronic headache has not been
defined formally by the International
Headache Society. But it is commonly taken
as headache lasting for more than three
months.
1,2
Primary daily chronic headaches
major subgroups are chronic migraine,
chronic tension type headache, hemicrania
Address for correspondence
Rabin Bhandari
Additional Professor
Department of GP & EM
B.P. Koirala Institute of Health Sciences, Dharan
Email: bhandari529@yahoo.com
Original Article

Bhandari et.al.
Chronic headache
Health Renaissance 2015;13(2): 22-29
23
continua and new persistent daily
headache.
1,2,3
Among these chronic migraine
(sub classified as complication of migraine)
and chronic tension type (evolving from
episodic migraine) need to be present for
more than 15 days per month.
2
Chronic
headache is a common problem in both
specialist care and primary care setting
4
and
contributes to low quality of life. It is also a
cause of social and economic burden.
1,6
The
global prevalence of headache is estimated
at 47%.
6
General practitioners frequently see
the patient with headache first.
7,8
Literature
from South East Asian countries like India
and Pakistan have shown tension type
headache and migraine to be the commonest
cause for chronic headache.
9,10
Researches
on headache from Nepal are limited with
none on chronic headache in general
practice. Headache diagnoses have been
found among common diagnostic correlates
in diagnostic profile studies of psychiatric
patients of our hospital in different settings,
such as referred out-patients,
11
child and
adolescent out-patients
12
and mass health
camp settings.
13
We conducted a study in the general practice
outpatient department with an aim to sort out
the common diagnoses of chronic headache
and to study the clinical features and
demographic profile of patients presenting
with chronic headache.
Methods
A descriptive cross sectional study was
conducted among the patients presenting
with chronic headache to the General
Practice outpatient at B.P. Koirala Institute of
Health Sciences (BPKIHS) over one year
from 2012 August to 2013 August. The
general practice outpatients see an average
of 100 unsorted case mix per day.
All patients presenting with complains of
chronic headache were included and
interviewed by one of the researchers using a
pre formed questionnaire. The patients were
managed by their respective physicians and
researchers did not interfere with patients’
plan of management. The term chronic was
defined as duration of more than three
months and diagnostic criteria from ‘The
international classification of headache
disorder, 2nd edition (ICHD 2)
3
was used to
classify headache.
Severity of headache was assessed using
numerical scale from one to ten.
Other variables studied were demographic
profile and clinical features. Patients were
also called for a one time follow up within one
month.
Informed consent was taken from all the
patients and strict confidentiality was
maintained during one on one interview.
Approval for the study and ethical clearance
was taken from Research Committee and
Institutional Ethical Review Board, BPKIHS.

Bhandari et.al.
Chronic headache
Health Renaissance 2015;13(2): 22-29
24
SPSS and EPI info software was used for
statistical analysis. Categorical variables
were presented as percentages with 95% CI.
Numerical variables were presented as mean
with standard deviation (95% CI with lower
and upper bound values). Cross tabulation of
gender, marital status (unmarried, married,
separated) occupation (housewife, students,
others) and educational status (illiterate, upto
10 years of school, more than 10 years of
school) was done among different subtypes
of headache.
Results
A total of 168 patients presented with chronic
headache over a period of 1 year, accounting
for 1% of total general outpatient visits. The
mean age of the patients under study was
29.57 years (SD 10.53). The female: male
ratio was 3.67. Majority were married (60%,
95%CI 53-68). Occupation was listed as
housewives by 51% (95%CI 43-59) and
students by 26% (95% CI 19-33). Majority of
patients had chosen to visit hospital
themselves (95%, 95% CI 91-98), 4 patients
were referred from other hospitals. (Table 1)
Table 1: Characteristics of patients under
study (n=168)
Age Mean 29.57 years
(SD 10.53, 95% CI 27.97-
31.18)
Sex Male 21.4%
Female 78.6%
Occupation Housewife 51.2%
Students 26.2%
Others 22.6%
Education Illiterate 22.6%
Up to 10 years 53.6%
More than 10 years 23.8%
Marital status
Married 60.7%
Unmarried 35.7%
Separated 3.6%
Religion Hindu 76.8%
Buddhism 8.9%
Christian 10.1%
Kirati 4.2%
The mean duration of headache before
consultation by a doctor was 22 months (SD
11). The mean number of days with
headache per month was 19.46 days (SD
4.62). Impairment of routine work due to
headache was reported by 78 patients (46%,
95% CI 39-54). In this group, the average
number of days off work per month was 3.67
days per month(SD 5.32, minimum 0,
maximum 21).The mean score for pain
(numerical scale) was 7.1 (SD 1.85).
The headache was classified as chronic
migraine in 34 patients (20.2%), chronic
tension type headache in 28 (16.7%) and
chronic daily persistent headache in 20

Bhandari et.al.
Chronic headache
Health Renaissance 2015;13(2): 22-29
25
(11.9%). Patients did not fit into any
diagnostic criteria in 86 (51.2%) cases.
The mean age was 33.62 years (SD 9.368,
95% CI 30.35-36.89) in chronic migraine,
26.11 (SD 5.412, 95% CI 24.01-28.21) in
tension type headache, 27.55 (SD 8.870,
95% CI 23.40-31.70) in chronic persistent
daily headache and 29.57 (SD 12.066, 95%
CI 26.98-32.16) in unclassified group.
The mean duration to doctors visit was 26.41
months (SD 9.897, 95% CI 22.96-29.860) in
chronic migraine, 21.64 (SD 9.569, 95% CI
17.93-25.35) in tension type headache, 19.80
(12.639, 95% CI 13.88-25.72) in daily
persistent headache and 21.41 (SD 11.289,
95% CI 18.99-23.83) in the unclassified
group.
The mean pain score was 7.79 (SD 1.175,
95% CI 7.38-8.20) for chronic migraine, 7.36
(SD 1.569, 95% CI 6.75-7.97) for tension type
headache, 6.9 (SD 2.360, 95% CI 5.8-8.00)
for daily persistent headache and 6.79 (SD
1.965, 95 CI 6.37-7.21) for the unclassified
group.
Different subtypes of chronic headache were
cross tabulated with gender, educational
status, marital status and occupation. Marital
status and occupation showed statistical
significance when compared with the
subtypes of headaches. Gender and
education did not show statistical
significance. (See table 2)
Table 2: Comparison of headache classification and population characteristics
Characteristics
Chronic
Migraine
(34)
Chronic
Tension
type
(28)
Chronic
persistent
daily (20)
Unclassified
(86)
P value
Gender
Male
Female
5 (14.7%)
29 (85.3%)
9 (32.1%)
19 (67.9%)
5 (25%)
15 (75%)
17 (21.4%)
69 (80.2%)
0.374
Education
Illiterate
<10 years
>10 years
8 (23.5%)
18 (52.9%)
8 (23.5%)
4 (14.3%)
13 (46.4%)
11 (39.3%)
4 (20%)
12 (60%)
4 (20%)
22 (25.6%)
47 (54.7%)
17 (42.5%)
0.514

Bhandari et.al.
Chronic headache
Health Renaissance 2015;13(2): 22-29
26
Marriage
Unmarried
Married
Separated
5 (14.7%)
25 (73.5%)
4 (11.8%)
12 (42.9%)
16 (57.1%)
0
8 (40%)
12 (60%)
0
35 (40.7%)
49 (57%)
2 (2.3%)
0.021
Chi
Square
14.959 (6)
Occupation
Housewife
Student
Others
24 (70.6%)
0
10 (29.4%)
10 (35.7%)
10 (35.7%)
8 (28.6%)
8 (40%)
6 (30%)
6 (30%)
44 (51.2%)
28 (32.6%)
14 (16.3%)
0.005
Chi
square
18.757(6)
A onetime follow up within a month was
planned. It was attended by 16.7% patients.
During the follow up visit of these patients the
mean numerical pain score had decreased by
3.11 (SD 1.72).
Discussion
Headache is also one of common condition
presenting to primary health care, with
estimates of 3-4%
14,15,16
of population
suffering from chronic headache. Most of the
data are extrapolated from western
population. 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.
6
Our study provides a snapshot
of chronic headache in the general practice
outpatient department (OPD) of a country
with predominantly rural population. The
patients presenting to general practice OPD
in our institute is reflective of primary care
setting combined with referred patients from
outside. It is first contact to hospital in a large
number of presentations. Chronic headache
formed 1% of our OPD presentation which is
lesser than population estimates. However,
actual number of patients is probably higher.
Many patients with headache may visit the
specialty clinics directly.
4,8
A fractions of
patient also visits the local pharmacies,
auxiliary health workers, local practitioners
including complementary and alternative
medicine
8
before visiting the hospital. The
same practice could also explain the long
wait (22 months) before a patient contacted a
doctor for the problem. Difficult geopolitical
conditions of our country may also have
contributed to seemingly lower prevalence
and delayed presentation of the patients.
The predominant age involved was young
with impaired routine activity reported by
more than 50% of patients. Gender wise,
females were common. Similar findings for
headache in general including chronic
headache have been reported.
4,7-9,15,17,18

Bhandari et.al.
Chronic headache
Health Renaissance 2015;13(2): 22-29
27
However, the gender ratio of 3.6 reported in
our study is comparatively higher than
reported previously. Females are socio
culturally more vulnerable with lower literacy
rates. So, they may be prone to present late
to doctors with more complex presentations
in our set up.
Chronic migraine and chronic tension type
headache have been reported as commonest
chronic headache types.
9,10,15,17,18
Although
the diagnosis of chronic migraine, chronic
tension type headache and persistent daily
headache were almost evenly distributed in
our study, the proportion of unclassified
headache was almost 50%. This is in contrast
to study by Agarwal et al
18
reporting 1.9%
unclassified headache but compares
favorably to Beghi et al
4
who reported 27%
unclassified chronic headache by general
practitioners overall, and 78% in Southern
Italy. Irrespective of the headache category
all the patients reported moderate to severe
chronic pain and a significant proportion had
impaired regular activity needing attention.
When called for follow up, only 17% attended
the follow up. This suggests a further scope
for research involving the community level
workers in the management of complex
problems like long standing headaches. In
countries like Nepal with uneven distribution
of health resources,
19
it allows an opportunity
to train and coordinate chronic pain care with
local health workers.
Limitation
The study has tried to provide a snapshot of
chronic headache picture in general practice
outpatients and may not be reflective of larger
populations.
Conclusions
Chronic Headache is common in young
females. The patients often present late to
hospitals. A signification proportion was
unclassified. Coordinated and continued care
of chronic pain involving local community
workers may be useful as the case mix is
largely unclassified, present late to a doctor
and has low follow up rate.
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