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R E S E A R C H A R T I C L E Open Access
Disability, quality of life, productivity
impairment and employer costs of
migraine in the workplace
Toshihiko Shimizu
1*
, Fumihiko Sakai
2
, Hitoshi Miyake
3
, Tomofumi Sone
4
, Mitsuhiro Sato
5
, Satoshi Tanabe
6
,
Yasuhiro Azuma
6
and David W. Dodick
7
Abstract
Background: Migraine is the leading cause of days lost due to disability in the world among people less than 50
years of age. There is a paucity of evidence on the impact of migraine and other headache disorders and the cost
and productivity losses in the workplace.
Methods: Employee population survey assessed prevalence, characteristics, and disability of headache disorders at
a Japanese information technology company. This study was supported by the World Health Organization Western
Pacific Region Office and International Headache Society.
Results: 2458 (1963men, 495 women) out of 2494 responded to the survey that utilized ICHD-3 beta criteria.
Among these, 13% (205 male/123 female) had migraine (M), 53% (1093 male/207 female) had tension-type
headache (TTH) and 4% (61 male/27 female) had migraine and TTH (M/TTH). The number of days when
productivity at work was reduced by half or more because of headache was significantly higher in migraine
compared to TTH. The norm-based scoring of SF-12v2 was significantly lower in M/TTH and M than TTH. The
economic loss due to absenteeism for migraine was calculated to be $ 238.3US$/year/person for day-off and
90.2US$/year/person for half-day off using migraine disability assessment score (MIDAS). The economic loss due to
presenteeism for migraine was calculated to be $ 375.4US$/year/person using MIDAS and 2217US$/year/person
using work productivity and activity impairment questionnaire (WPAI). Furthermore, estimated cost of productivity
loss associated with presenteeism using WPAI was calculated at 21.3 billion US$/year in Japan as a whole.
Conclusions: This study revealed a high prevalence and disease burden among employees with migraine that is
associated with substantial losses in productivity and employer cost. These results support the development and
implementation of workplace programs to improve migraine management in the workplace and reduce the
burden and costs associated with lost workplace productivity.
Keywords: Migraine, Prevalence, Disability, Impact, Economic loss, Presenteeism, Absenteeism, Workplace, Stigma,
Work productivity
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* Correspondence: shimizu-toshi@umin.ac.jp
1
Department of Neurology, Keio University School of Medicine, 35
Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
Full list of author information is available at the end of the article
The Journal of Headache
and Pain
Shimizu et al. The Journal of Headache and Pain (2021) 22:29
https://doi.org/10.1186/s10194-021-01243-5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Introduction
Headache disorders are a public health concern due to
their high prevalence, disability and financial cost to so-
ciety [1]. The World Health Organization estimates that
the three most prevalent neurologic disorders worldwide
are tension-type headache (1.5 billion), migraine (958.8
million) and medication overuse headache (58.5 million)
[2]. The Global Burden of Diseases, Injuries, and Risk
Factors study identified migraine as one of the 10 most
disabling medical disorders in the world and the second
leading cause of global neurological disease burden [3,
4]. In Asian and Oceanian countries, the importance of
better headache care is being recognized as an important
aspect of public health. Headache disorders are associ-
ated with a personal and social burden of pain, disability,
impaired quality of life and financial cost. The estimates
of the financial cost to society from lost work hours and
reduced productivity are massive. Migraine is estimated
to affect 8 million people in Japan and to cost the Japa-
nese economy, in lost productivity, US$ 3 billion every
year [5].
Despite the prevalence and disability associated with
migraine, many may be suffering in silence at work,
resulting in loss of significant productivity in Asian
countries with growing economies [6]. In fact,
population-based studies in North America demon-
strated that presenteeism, which is working while sick,
leads to more lost work time than absenteeism [7]. Ap-
proximately one-third of migraine attacks occur on
workdays and two-thirds of these attacks result in a sub-
stantial loss of productivity [8]. Individuals with chronic
migraine (> 15 headache days per month) experience
four times more productive time lost compared to those
with less frequent migraine attacks [9]. Determining the
prevalence of presenteeism and absenteeism due to
headache disorders in the growing economies of Asia is
vital. Identifying and addressing factors that trigger at-
tacks, providing education on self-management options,
and providing access to standard of care treatments will
help those affected better manage their condition, im-
prove their ability to get to work or stay at work, and
improve their function while at work.
To initiate a public health approach to headache disor-
ders, we deployed a research survey on prevalence rates
and disease burden associated with headache in the
workplace. We focused on an Information Technology
(IT) company in conducting this research. Workers of
IT companies have been engaging in intellectual and
cognitively challenging work and are considered to be a
suitable population for our initial study on the impact
on work productivity as a result of headache disorders.
Because cognitive impairment has been shown to be a
major source of disability associated with headache at-
tacks, work efficiency is likely to be impaired by
headache [10]. In addition, we believe that quantitative
assessment of the reduction in work productivity and
presenteeism due to headache should be possible in this
homogeneous population.
Methods
Study design and population
This is a cross-sectional survey of workers of IT com-
panies in Asia. Japan, Republic of Korea and the
Philippines participated and conducted the study indi-
vidually with the support of the World Health
Organization Regional Office for the Western Pacific
(WHO-WPRO) and the International Headache Society
(IHS). Studies in these three countries followed the same
protocol accredited by the WHO-WPRO. Since survey
and data analysis are performed in each country, this
study will summarize the findings in Japan.
The survey in Japan was conducted between May and
September 2018 at Fujitsu with the support of the com-
pany’s Health Promotion Headquarters using tablet ter-
minals for internal communications owned by all
employees. The questionnaire survey was conducted
only on the employees who gave their informed consent
on the tablet screen.
The participants in these studies were given a compre-
hensive questionnaire to determine the prevalence of
and the disability caused by migraine and tension-type
headache divided into three parts. The first section of
the questionnaire consisted of sociodemographic ques-
tions, the second part contained questions about health-
related quality of life (HRQoL). The third part included
questions pertaining to the diagnosis of headache, dis-
ease disability and productive loss due to headache. We
also inquired about the reciprocal impact of headache
on the work environment and the work environment on
headache. Furthermore, we examined the health care
utilization for headache and the reasons for consulting
or not consulting among those reporting recurrent head-
ache. We evaluated how to individuals had and are cur-
rently managing their headaches.
For the classification of headaches, questions were pre-
pared based on the diagnostic criteria of the Inter-
national Classification of Headache Disorders (ICHD-3
beta) [11]. In this study, ICHD-3 beta criteria were used
and according to the criteria for medication overuse
headache, “Patients with a pre-existing primary headache
who in association with medication overuse develop a
new type of headache or a marked worsening of their
pre-existing headache that, in either case, meets the cri-
teria for 8.2 Medication-overuse headache (or one of its
subtypes) should be given both this diagnosis and the
diagnosis of the pre-existing headache”. Because we
could not be certain from the questionnaires used
whether a new type of headache or a marked worsening
Shimizu et al. The Journal of Headache and Pain (2021) 22:29 Page 2 of 11
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of a pre-existing headache occurred, we restricted the
analysis to the primary headache disorder type for each
subject.
The 12-item short-form health survey second edition
(SF-12v2) Japanese version was used for analysis of
HRQoL [12,13]. Using the SF-12v2 Japanese version of
the scoring program by iHope International, norm-based
scoring was calculated for eight subscales of SF-12v2.
The subscales are: Physical functioning (PF), daily role
function (body, Role physical; RP), body pain (Bodily
pain; BP), general health (GH), vitality (Vitality; VT), so-
ciety Life function (Social functioning; SF), daily role
function (Mental, Role emotional; RE), mental health
(Mental health; MH).
Furthermore, questions related to the migraine disabil-
ity assessment score (MIDAS) [14,15] and Work Prod-
uctivity and Activity Impairment questionnaire (WPAI)
were used to measure the severity of impact on work
and daily life [16].
To estimate the economic loss due to headache, we
calculated the number of days of headache, moderate or
severe headache, the days off work due to headache, the
half-days off work due to headache, and when work effi-
ciency was reduced to less than half due to headache,
using MIDAS. In addition, the degree to which the head-
ache impacted work productivity was also evaluated on
the WPAI questionnaire. We asked the participants
whether they had the symptoms related to headache dis-
order on days when headaches are not experienced.
The economic loss due to absenteeism and presentee-
ism caused by headache was calculated using the age-
specific wage in the IT industry according to the Basic
Survey on Wage Structure in 2018 by the Ministry of
Health, Labor and Welfare, since this survey was con-
ducted in 2018 [17].
Economic losses due to absenteeism were calculated
for a full day-off and half-day off. The number of day-off
multiplied by the daily wage and the number of half-
days off multiplied by 50% of the daily wage, and these
were converted to annual amounts.
The economic loss due to presenteeism was calculated
by multiplying the number of the days when work prod-
uctivity was reduced to less than half from MIDAS by
wage multiplied by 0.5 and converted to annual amount.
Furthermore, the impact of WPAI on work productivity
was converted into a ratio. This ratio, the number of
days worked with headache and daily wage were multi-
plied, and the result was converted to annual monetary
value. We considered this as the economic loss due to
presentism estimated by WPAI. Because of the absence
of information on the degree of productivity loss per
each day of presenteeism, we assumed that work effi-
ciency was halved, when calculating presenteeism eco-
nomic losses from MIDAS data. Also, we did not ask
WPAI for each headache and the value is the mean of
headache of each subject. Therefore, when calculating
the amount of economic loss due to presenteeism from
WPAI data, we assumed that the degree of work effi-
ciency decline was the same on days with headaches.
Hence, the economic loss due to MIDAS may be under-
estimated, while the economic loss due to WPAI may be
overestimated, and the economic loss from presenteeism
in migraine in Japan is estimated to be at least the value
calculated by MIDAS and up to the value calculated by
WPAI. The conversion from Japanese yen to US dollar
was calculated at the conversion rate of 112 yen to one
US dollar.
To estimate the effects of headache on work environ-
ment and work statistically, the answers to the questions,
“Always”,“Often”,“Sometimes”,“Rarely”and “Never”,
were scored as 5, 4, 3, 2, and 1, respectively, and we ana-
lyzed these results using these scores.
Statistical methods
According to the ICHD-3 beta included in the question-
naire of this study, the group was classified into five
groups: a group that satisfies the diagnostic criteria for
migraine (migraine group, migraine; M), a group that
satisfies the diagnostic criteria for tension-type headache
(tension-type headache group, TTH), a group that satis-
fies the diagnostic criteria for migraine and tension-type
headache (M/TTH), a group that does not meet the
diagnostic criteria for migraine or tension-type headache
(HA) and a group that does not have headache (no
headache; NHA).
In the questionnaire survey of this study, the age of
the participants was between 22 and 66 years old and
did not include the younger and older participants.
Therefore, we used this result as the prevalence of head-
ache at working age in Japan for the subsequent analysis
in this study.
Descriptive statistical analyses were performed to com-
pare clinical features and HRQoL among these five
groups. Disease burden and the status of medical con-
sultation were compared among M, TTH, M/TTH and
HA.
For comparison between multiple groups, a post-hoc
test by the Bonferroni was performed after one-way
ANOVA. They are; age, body mass index (BMI),
HRQoL, disease disability, impact of headache, economic
loss due to headache and the effects of headache on
work environment and work.
Frequency data such as working hours and overtime
hours, the symptoms related to headache on days even if
headache does not occur and consultation to the med-
ical institutions was subjected to residual analysis after
chi-square test. For residual analysis, cut-off values of
adjusted residuals was set at ≤−2or≥2.
Shimizu et al. The Journal of Headache and Pain (2021) 22:29 Page 3 of 11
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Logistic regression was conducted using the forced
entry method in order to search for migraine-inducing
factors with the dependent variable as the trigger of mi-
graine or tension-type headache. As explanatory vari-
ables, age, gender, sleep time, overtime hours, computer
hours, lots of work, quota achievement, lack of meals,
lack of water intake, and drinking were used. For all ana-
lyses, p< 0.05 were considered statistically significant.
All statistical results were analyzed based on non-
missing data. Stata (release 15; Light Stone) was used for
analysis.
Results
Responses of participants
We received 2494 responses from the questionnaire.
The analysis was performed on 2458 cases excluding 36
cases lacking the description overtime hours and missing
demographic information on age and gender.
Headache classification and their characteristics
Among 2458 cases, migraine group (M) accounted for
13% and tension-type headache group (TTH) for 53%,
and migraine and tension-type headache group (M/
TTH) is 4% (88 cases, 61 men 3.1%, 27 women 5.5%)
and other headache groups (Headache other than mi-
graine and / or tension-type headache; HA) 15% and
15% (no headache; NHA) group as shown in Table 1.
Statistically, the mean age of M and HA was significantly
younger than TTH (p< 0.001, one-way ANOVA
followed by Bonferroni’s post hoc test). Also, BMI of M
was significantly lower than TTH (p= 0.049, one-way
ANOVA followed by Bonferroni’s post hoc test). There
was no significant difference in the working hours for 1
week and overtime hours for 1 month (supplementary
material; Table 1).
HRQoL
Table 2shows the norm-based scoring of the SF-12v2
Japanese version. In group comparison, RP, BP, VT, SF,
RE and MH scores were significantly lower in M and M/
TTH than TTH and NHA (p< 0.05, one-way ANOVA
followed by Bonferroni’s post hoc test). In addition, GH
was significantly lower in M/TTH than NHA and in M
than TTH and NHA (p< 0.05, one-way ANOVA
followed by Bonferroni’s post hoc test).
Impact of headache on work productivity
In the past 3 months, the average number of headache
days and the number of moderate or severe headache
days were significantly higher for M, M/TTH and HA
than for TTH (p< 0.05, one-way ANOVA followed by
Bonferroni’s post hoc test, Table 3). The average
number of days off for 1 day or half day due to head-
ache in the past 3 months did not differ significantly
between each headache group (Table 3). On the other
hand, the number of the days when work efficiency
was reduced to less than half due to headache were
significantly higher in M and M/TTH than in TTH
(p< 0.05, one-way ANOVA followed by Bonferroni’s
post hoc test, Table 3). The impact of headache on
work productivity was evaluated in 10 steps using
WPAI and significantly higher in M/TTH, M, HA
compared to TTH (p< 0.001, one-way ANOVA
followed by Bonferroni’sposthoctest,Table3).
The annual economic loss per person due to absentee-
ism was higher in M compared to M/TTH, TTH, HA
for day off and half day off holidays, but showed no sig-
nificant difference (Table 4). The annual economic loss
per person due to presenteeism calculated by the results
of MIDAS and WPAI were significantly higher in M and
M/TTH than in TTH (p< 0.01, one-way ANOVA
followed by Bonferroni’s post hoc test, Table 4).
In addition, symptoms related to headache on days
even if headache does not occur were observed in 40%
of M, 15% of TTH, 41% of M/TTH and 34% of HA, and
they were significantly higher than expected in M/TTH,
M, HA (p< 0.05, chi-square statistics followed by the
analysis of residuals, Fig. 1). These symptoms included
anxiety, depressive state, difficult to concentrate and
sensitive to light (supplementary material; Table 2).
Among these symptoms, difficulty to concentrate, feeling
tired and stiff shoulders were frequently observed.
Table 1 Headache classification
M TTH M/TTH HA NHA Total p-value
Number, n (%) 328 (13) 1300 (53) 88 (4) 360 (15) 382 (15) 2458
male, n 205 1093 61 265 339 1963
female, n 123 207 27 95 43 495
Age (years), mean (SD) 44.5 (8.6) 46.9 (8.7) 45.5 (8.3) 44.2 (9.6) 46.0 (10.8) < 0.001
a
BMI (kg/m
2
), mean (SD) 23.0 (3.7) 23.7 (3.7) 23.4 (3.7) 23.2 (3.5) 23.5 (3.6) 0.049
a
Continuous variables are reported as mean (standard deviation [SD]) for non-missing observations
Mmigraine group, TTH tension-type headache group, M/TTH a group that satisfies the diagnostic criteria for migraine and tension-type headache, HA a group that
does not meet the diagnostic criteria for migraine or tension-type headache, NHA a group that does not have headache, BMI body mass index
a
One-way ANOVA
Shimizu et al. The Journal of Headache and Pain (2021) 22:29 Page 4 of 11
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Effects of headache on work environment and work
were shown in Table 5. M, M/TTH and HA showed sig-
nificantly higher values compared to TTH for lack of
understanding of headaches in the workplace, impaired
relationships due to headaches and burdening bosses
and colleagues with headaches (p< 0.01, one-way
ANOVA followed by Bonferroni’s post hoc test). Fur-
thermore, M and M/TTH showed significantly higher
values compared to TTH and HA to lose their energy to
work and not to concentrate on work due to headache
(p< 0.01, one-way ANOVA followed by Bonferroni’s
post hoc test).
In logistic regression with tension-type headache as a
control, age, gender, lack of sleep, completion of work
and skipping meals were correlated significantly with oc-
currence of migraine (p< 0.05), and it is suggested that
these may be factors associated with migraine (Table 6).
Consultation to the medical institutions and treatment for
headache
As shown in Fig. 2, 5 % of M answered that they “con-
sult regularly”, 1% of TTH, and none of M/TTH.
“Previously visited the hospital (now discontinued)”was
23% for M, 10% for TTH, and 30% for M/TTH, and
this was significantly higher than expected in M and
M/TTH (p< 0.001, chi-square statistics followed by
the analysis of residuals). “Never visited the medical
institution”was 72% for M, 89% for TTH, and 70%
for M/TTH. In addition, only 5% of M patients were
prescribed acute medicines and 2% were prescribed
preventive drugs.
The most common reason for not seeing a medical in-
stitution was because they did not consider their head-
aches severe enough to require a consultation (57% of
M, 76% of TTH and 61% of M/TTH). However, only
35% of M, 21% of TTH and 41% of M/TTH thought
they could manage their own headache.
As for the self-care of headache, “lying down”was 66%
in M, 41% in TTH, 59% in M/TTH, and “use over the
counter”was 67% in M, 36% in TTH and 69% in M/
TTH. “Lying down”and “use over the counter”were sig-
nificantly higher than expected in M and M/TTH (p<
0.001, chi-square statistics followed by the analysis of
residuals).
Table 2 Norm-based scoring of SF-12v2
M TTH M/TTH HA NHA p-value
a
Physical functioning, mean (SD) 50 (10) 51 (10) 49 (11) 50 (10) 51 (10) 0.472
Role physical, mean (SD) 46 (11) 49 (10) 45 (11) 47 (11) 50 (9) < 0.001
Bodily pain, mean (SD) 43 (11) 50 (10) 45 (10) 47 (11) 52 (11) < 0.001
General health, mean (SD) 48 (10) 51 (8) 48 (9) 49 (10) 53 (9) < 0.001
Vitality, mean (SD) 46 (9) 48 (8) 44 (10) 47 (8) 50 (9) < 0.001
Social functioning, mean (SD) 49 (10) 51 (9) 48 (10) 50 (10) 51 (9) < 0.001
Role emotional, mean (SD) 43 (11) 47 (10) 44 (11) 44 (11) 50 (9) < 0.001
Mental health, mean (SD) 44 (10) 48 (9) 44 (10) 45 (10) 49 (10) < 0.001
Continuous variables are reported as mean (SD) for non-missing observations
Mmigraine group, TTH tension-type headache group, M/TTH a group that satisfies the diagnostic criteria for migraine and tension-type headache, HA a group that
does not meet the diagnostic criteria for migraine or tension-type headache, NHA a group that does not have headache
a
One-way ANOVA
Table 3 Number of headache days and working days affected by headache in 3 months, and the impact of headaches on work
productivity by WPAI
M TTH M/TTH HA p-value
a
Headache (days), mean (SD) 5.5 (8.4) 2.4 (6.5) 6.4 (12.3) 3.9 (10.4) < 0.001
Severe Headache (days), mean (SD) 1.9 (3.6) 0.5 (2.4) 1.6 (2.6) 1.1 (4.6) < 0.001
One day off (days), mean (SD) 0.3 (0.9) 0.1 (1.2) 0.2 (0.5) 0.1 (0.6) 0.084
Half day off (days), mean (SD) 0.2 (1.6) 0.1 (0.9) 0.1 (0.4) 0.1 (0.5) 0.081
Reduced productivity (days), mean (SD) 1.0 (2.4) 0.2 (1.3) 0.8 (2.1) 0.5 (2.3) < 0.001
The impact of headaches on work productivity
WPAI score, mean (SD) 4.7 (2.7) 2.0 (2.1) 4.1 (2.8) 3.5 (2.6) < 0.001
Continuous variables are reported as mean (SD) for non-missing observations
Mmigraine group, TTH tension-type headache group, M/TTH a group that satisfies the diagnostic criteria for migraine and tension-type headache, HA a group that
does not meet the diagnostic criteria for migraine or tension-type headache, WPAI work productivity and activity impairment questionnaire
a
One-way ANOVA
Shimizu et al. The Journal of Headache and Pain (2021) 22:29 Page 5 of 11
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Discussion
This study revealed a high prevalence and disease bur-
den among employees with migraine that is associated
with substantial losses in productivity and employer cost.
Amongst the 2458 respondents (98.5% of those sur-
veyed) 17% had migraine, and compared to individuals
with no headache or tension-type headache, people with
migraine had significantly more missed workdays, and
experienced a greater impact on work productivity,
physical and mental health and economic cost to the
employer.
Presenteeism is defined as an individual’s loss of work
productivity due to health conditions and the symptoms
of a disease. In a study involving 7959 employees evalu-
ated over a 4-year period, 22 health conditions were
studied for their effect on daily productivity of
employees at a large health care system. The conditions
with the highest estimated daily productivity loss and
annual cost per person were chronic back pain, mental
illness, general anxiety, migraine or severe headaches,
neck pain, and depression. Allergies and migraine or se-
vere headaches had the highest estimated annual com-
pany cost [18]. Their result indicates that 16% of
workforce presenteeism may be due to migraine with a
cost of US $240 billion dollars per year. Furthermore,
according to the Japan National Health and Wellness
Survey of pooled commercial data, migraine patients
have been reported to experience significantly higher
presenteeism than controls in Japan [19].
Our study focused on migraine and demonstrated that
presenteeism causes more economic loss than absentee-
ism. Based on our findings, we can predict the annual
Table 4 Annual economic loss per person due to absenteeism and presenteeism
M TTH M/TTH HA p-value
a
Absenteeism (calculated by MIDAS)
Day off (US$), mean (SD) 238.3 (739.9) 82.9 (1142) 153.9 (409.2) 123.0 (511.0) 0.080
Half day off (US$), mean (SD) 90.2 (462.7) 30.1 (431.3) 40.2 (163.7) 47.8 (209.3) 0.111
Presenteeism
Calculated by MIDAS (US$), mean (SD) 375.4 (1039) 70.9 (533.8) 324.1 (878.1) 191.1 (967.1) < 0.001
Calculated by WPAI (US$), mean (SD) 2217 (4497) 562.1 (266) 2621 (6077) 1267 (4356) < 0.001
Continuous variables are reported as mean (SD) for non-missing observations
Mmigraine group, TTH tension-type headache group, M/TTH a group that satisfies the diagnostic criteria for migraine and tension-type headache, HA a group that
does not meet the diagnostic criteria for migraine or tension-type headache, MIDAS migraine disability assessment score, WPAI work productivity and activity
impairment questionnaire
a
One-way ANOVA
Fig. 1 Symptoms related to headache disorder on days when headaches are not experienced. M, migraine group; TTH, tension-type headache
group; M/TTH, a group that satisfies the diagnostic criteria for migraine and tension-type headache; HA, a group that does not meet the
diagnostic criteria for migraine or tension-type headache
Shimizu et al. The Journal of Headache and Pain (2021) 22:29 Page 6 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
economic loss due to migraine in Japan as a whole. The
age range of respondents in this study was 25 and 65
and according to statistics from the Statistics Bureau of
the Ministry of Internal Affairs and Communications,
the number of working people between the ages of 25
and 65 in Japan in 2018 is 52,400,000 [20]. Using eco-
nomic loss due to migraine and working population data
from the Statistics Bureau of Japan, the annual economic
loss due to presenteeism is US $3.3 billion, calculated
from the number of days when work efficiency has fallen
to less than half due to headaches using MIDAS. On the
other hand, the annual economic loss due to presentee-
ism using WPAI is estimated to be US $21.3 billion. In
addition, the annual economic loss due to absenteeism
estimated by MIDAS was calculated to be US $2.7 bil-
lion in total, with the loss due to one day off being US
$2.0 billion and the loss due to half day off being US
$0.7 billion.
Although migraine is classically described as a chronic
disease with paroxysmal or episodic manifestations, the
presence and burden of persistent symptoms between
attacks, including photophobia and cognitive dysfunc-
tion, has been reported [21]. An anti-CGRP antibody re-
cently approved by the FDA in the United States has
been reported to improve these interictal symptoms
[22]. Our questionnaire also showed that 40% of those
with migraine have interictal symptoms, and the impact
of these symptoms on work was significantly higher in
the migraine compared to the tension-type headache
group. This suggests that migraine may have an impact
on work efficiency and economic losses even on days
without headache. In addition, our questionnaire survey
revealed that 98% of migraine sufferers had never been
treated with preventive medications. It has also been re-
ported that many migraine patients use over-the-counter
instead of prescription medication in East Asia [23].
Therefore, in order to improve the economic loss due to
migraine, it is important to improve awareness around
the availability and importance of using preventive treat-
ments that reduce attack frequency and improve interic-
tal burden in those patients with an unmet treatment
need.
The impact of migraine in the workplace has also been
correlated with the frequency of days with headache [24,
25]. For those with frequent headache (10–14 days per
month), the estimated number of days per year missing
from work is 2 days while there is 46 days with reduced
productivity (presenteeism). This loss in productivity ac-
counts for approximately 20% of the work year. Higher
numbers for missed and lost productive days per year
Table 5 Effects of headache on work environment and work
M TTH M/TTH HA p-value
a
Lack of understanding, mean (SD) 2.0 (1.2) 1.4 (0.8) 2.0 (1.1) 1.7 (1.1) < 0.001
Have difficulty with human relations, mean (SD) 1.5 (0.8) 1.2 (0.5) 1.4 (0.8) 1.3 (0.7) < 0.001
Burden on others, mean (SD) 1.6 (0.8) 1.2 (0.5) 1.5 (0.8) 1.4 (9.8) < 0.001
Lack energy, mean (SD) 2.8 (1.0) 1.8 (9.9) 2.7 (0.9) 2.3 (1.0) < 0.001
Not able to concentrate, mean (SD) 2.8 (1.0) 1.9 (0.9) 2.8 (0.9) 2.3(1.0) < 0.001
Continuous variables are reported as mean (SD) for non-missing observations
Mmigraine group, TTH tension-type headache group, M/TTH a group that satisfies the diagnostic criteria for migraine and tension-type headache, HA a group that
does not meet the diagnostic criteria for migraine or tension-type headache
a
One-way ANOVA
Table 6 Factors that may be associated with migraine
Odds Ratio Std. Err. z P> |z| 95% CI
Age 0.9791165 0.0073349 −2.82 0.005 0.9648455–0.9935987
Gender 0.3635942 0.0525101 −7.01 0 0.2739598–0.4825553
Lack of sleep 2.045667 0.2924829 5.01 0 1.545728–2.707304
Overtime work 0.9279385 0.1740869 −0.4 0.69 0.6424341–1.340324
Long time PC use 1.237306 0.2033557 1.3 0.195 0.8965589–1.707557
Too much work 0.984432 0.188815 −0.08 0.935 0.6759654–1.433663
Completed project 2.14913 0.7591344 2.17 0.03 1.075459–4.294687
Skipping meal 1.730537 0.4820394 1.97 0.049 1.002489–2.987324
Dehydration 1.161006 0.2004847 0.86 0.387 0.8276512–1.628627
Alcohol intake 1.198216 0.184249 1.18 0.24 0.8864343–1.619661
CI confidence interval, Std. Err standered error, PC personal computer
Shimizu et al. The Journal of Headache and Pain (2021) 22:29 Page 7 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
for those with more than 15 headache days per month
are 3.5 days and 87 days respectively, accounting for 38%
of the work year [24]. Furthermore, it is reported that
patients with chronic migraine experienced greater im-
pairment and less productivity than those with episodic
migraine, according to WPAI scores in Japan [26]. Our
data also illustrates that the number of days with pres-
enteeism was significantly higher in chronic migraine
compared with episodic migraine.
A recent study assessed the impact of a migraine care
support program offered by a healthcare company as a
complimentary service to medical care for its Swiss
based employees and their family members living with
migraine [27]. The study results demonstrated that edu-
cational and counseling support program within an em-
ployee population can significantly decrease migraine-
related disability and promote disease self-management
among employees. Fujitsu, the participating company of
this study, has initiated an employee migraine wellness
program with GPAC (Global Patient Advocacy Coali-
tion) of the International Headache Society [28].
Stigma is an established construct in the social sci-
ences that describes a characteristic, trait, or diagnosis
that is used to discredit an individual and leads to preju-
dice, discrimination, and loss of status [29]. The stigma
faced by employees with migraine is substantial, and like
in our study, stigma contributes to the burden and eco-
nomic loss due to migraine. In this study, individuals
with migraine reported a significant lack of understand-
ing of headache in the workplace, impaired relationships
due to headache, and guilt about burdening bosses and
colleagues with headaches. In addition, the most com-
mon reason for not seeking medical consultation was
that they did not consider their headache disorder severe
enough to require a consultation. Stigma and lack of
awareness of burden of migraine may well explain our
data that 72% of individuals did not seek medical con-
sultation for migraine despite the fact that 63% of pa-
tients indicated that they could not cope with their
illness.
Our results are consistent with the stigmatizing atti-
tudes of those who surround people with migraine.
Using the Stigma Scale for Chronic Migraine (SSCI),
stigma associated with chronic migraine has been found
to be higher than other neurological diseases including
stroke, epilepsy, multiple sclerosis, Parkinson’s disease,
motor neuron disease, and epilepsy [30,31]. In a recent
study, more than 40% of people who knew at least one
person with migraine felt that people with migraine use
their illness as an excuse to avoid family, work, or school
commitments and/or exaggerate their symptoms. More
than one third (36%) believed that someone’s migraine
attacks are caused by their own unhealthy behavior and
approximately one-third of people believed those with
migraine make things difficult for their co-workers
(29%) [30,32]. These attitudes and beliefs were consist-
ent among all individuals surrounding a person with
migraine including co-workers, friends, and family mem-
bers. Employers also harbor stigma toward those with
migraine. Only 22% consider migraine to be a “serious
Fig. 2 Consultation to the medical institutions. M, migraine group; TTH, tension-type headache group; M/TTH, a group that satisfies the
diagnostic criteria for migraine and tension-type headache
Shimizu et al. The Journal of Headache and Pain (2021) 22:29 Page 8 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
enough reason for an employee to be absent from work”,
lower than for any other reason, including depression,
anxiety, stress, the flu, or the common cold [33]. These
data highlight the importance of ensuring that any
disease-related education with a workforce also target
people without migraine to create a better understand-
ing of the prevalence and impact of this disease on their
co-workers.
There are several limitations that should be noted in
this study. This research is conducted through the com-
pany’s tablet terminal. Since all employees have termi-
nals, there is no restriction on access to the
questionnaire. However, since participation in the ques-
tionnaire was voluntary, ascertainment bias is a risk as
only those with an interest in headache, especially those
affected, would participate. For this reason, questions re-
garding daily quality of life were included so that people
without headache may have been more interested to par-
ticipate. In addition, the diagnosis of migraine was not
confirmed by a physician. However, the diagnostic por-
tion of the questionnaire included all criteria from
ICHD-3 beta, and this methodology is commonly used
in population-based studies of headache and migraine.
Despite these limitations, the high prevalence and dis-
ease burden among employees with migraine in this
study provide the basis and a mandate for measures de-
signed to screen employees for disabling headache and
provide appropriate education and care. The substantial
losses in productivity and high employer costs also sup-
port the development and implementation of workplace
programs to raise awareness and understanding, reduce
stigma, improve migraine management and reduce the
burden and costs associated with lost workplace
productivity.
Conclusions
This employee population survey revealed a high preva-
lence and disease burden of migraine that is associated
with substantial losses in productivity and employer cost.
In employees with migraine, presenteeism causes more
economic loss than absenteeism. These results support
the development and implementation of workplace pro-
grams to improve migraine management in the work-
place and reduce the burden and costs associated with
lost workplace productivity.
Abbreviations
ANOVA: Analysis of variance; BMI: Body mass index; BP: Bodily pain;
CGRP: Calcitonin gene-related peptide; FDA: Food and drug administration;
GH: General health; GPAC: Global patient advocacy coalition; HA: Headache;
HRQoL: Health-related quality of life; ICHD-3 beta: International classification
of headache disorders 3rd edition beta version; IHS: International headache
society; IT: Information technology; M: Migraine; MIDAS: Migraine Disability
Assessment Score; MH: Mental health; M/TTH: Migraine and tension-type
headache; NHA: No headache; PF: Physical functioning; RE: Role emotional;
RP: Role physical; SD: Standard deviation; SF: Social functioning; SF-12v.2: The
12-item short-form health survey second edition; SF-36: The 36-item short-
form health survey; TTH: Tension-type headache; VT: Vitality; WHO: World
Health Organization; WHO-WPRO: World Health Organization Regional Office
for the Western Pacific; WPAI: Work Productivity and Activity Impairment
Questionnaire
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s10194-021-01243-5.
Additional file 1: Table S1. Working hours/ week and overtime
working hours/month.
Additional file 2: Table S2. Symptoms related to headache on days
when headaches are not experienced.
Acknowledgements
Not applicable.
Authors’contributions
FS, TS and DWD conceived and designed the study. FS prepared the
technical support from WHO-WPRO and International Headache Society. TS,
FS, TS and DWD designed the questionnaire. MS, ST, YA and HM acquired
data, and all authors had interpreted the raw data. All authors reviewed and
revised the draft of the manuscript and approved the final version.
Funding
This study was supported by a grant of the international research
cooperation promotion project from the Japan Public Health Association.
The funding was used for statistical analysis and license fees for SF-12 Japa-
nese second edition. Japanese Patient Advocacy Coalition for Headache sup-
ported the fee for article-processing charges.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the research ethics review committee of the
National Institute of Public Health in Japan (National Institute of Public
Health Research Ethics Review Committee No. NIPH-IBRA #12151). It has also
been approved by the WHO-WPRO ethics review committee in July 2017.
Participation in this study was entirely voluntary by employees, and the com-
pany did not force them to participate in this study. The questionnaire in this
study was programmed to collect only epidemiological data and not include
any personal data. The data was strictly managed by a personal information
manager.
Consent for publication
Not applicable.
Competing interests
The authors declared the following potential conflicts of interest with
respect to the research, authorship, and/or publication of this article: FS
reports consulting for Amgen, Eli Lilly and Otsuka. DWD reports the
following conflicts within the past 12 months: Consulting: AEON, Amgen,
Clexio, Cerecin, Allergan, Alder, Biohaven, Linpharma, Promius, Eli Lilly,
eNeura, Novartis, Impel, Theranica, WL Gore, Nocira, XoC, Zosano, Upjohn
(Division of Pfizer), Pieris, Revance, Equinox. Honoraria: CME Outfitters, Curry
Rockefeller Group, DeepBench, Global Access Meetings, KLJ Associates,
Majallin LLC, Medlogix Communications, Miller Medical Communications,
Southern Headache Society (MAHEC), WebMD Health/Medscape, Wolters
Kluwer, Oxford University Press, Cambridge University Press. Research
Support: Department of Defense, National Institutes of Health, Henry Jackson
Foundation, Sperling Foundation, American Migraine Foundation, Patient
Centered Outcomes Research Institute (PCORI). Stock Options/Shareholder/
Patents/Board of Directors: Aural analytics (options), ExSano (options), Palion
(options), Healint (Options), Theranica (Options), Second Opinion/Mobile
Health (Options), Epien (Options/Board), Nocira (options), Ontologics
Shimizu et al. The Journal of Headache and Pain (2021) 22:29 Page 9 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
(Options/Board), King-Devick Technologies (Options/Board), Precon Health
(Options/Board). Patent 17189376.1–1466:vTitle: Botulinum Toxin Dosage
Regimen for Chronic Migraine Prophylaxis. TS, TS, MS, ST, YA and HM de-
clared no potential conflicts of interest with respect to the research, author-
ship, and/or publication of this article.
Author details
1
Department of Neurology, Keio University School of Medicine, 35
Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
2
The Saitama
International Headache Center, 6-11-1 Honmachi-Higashi, Chuo-ku, Saitama
338-8577, Japan.
3
Corporate Executive Officer VP, Head of Health Promotion
Unit at Fujitsu Co. Ltd, 4-1-1 Kamikodanaka , Nakahara-ku, Kawasaki 211-8588,
Japan.
4
National Institute of Public Health, 2-3-6 Minami, Wako-shi, Saitama
351-0197, Japan.
5
Fujitsu General Limited, 3-3-17 Suenaga, Takatsu-ku,
Kawasaki 213-8502, Japan.
6
Health Promotion Unit at Fujitsu Co. Ltd, 4-1-1
Kamikodanaka, Nakahara-ku, Kawasaki 211-8588, Japan.
7
Mayo Clinic College
of Medicine, 13400 E Shea Blvd, Scottsdale, AZ, USA.
Received: 3 October 2020 Accepted: 12 April 2021
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