Prevalence of headache in Europe: A review for the Eurolight project

Abstract

The main aim of the present study was to do an update on studies on headache epidemiology as a preparation for the multinational European study on the prevalence and burden of headache and investigate the impact of different methodological issues on the results. The study was based on a previous study, and a systematic literature search was performed to identify the newest studies. More than 50% of adults indicate that they suffer from headache in general during the last year or less, but when asked specifically about tension-type headache, the prevalence was 60%. Migraine occurs in 15%, chronic headache in about 4% and possible medication overuse headache in 1-2%. Cluster headache has a lifetime prevalence of 0.2-0.3%. Most headaches are more prevalent in women, and somewhat less prevalent in children and youth. Some studies indicate that the headache prevalence is increasing during the last decades in Europe. As to methodological issues, lifetime prevalences are in general higher than 1-year prevalences, but the exact time frame of headache (1 year, 6 or 3 months, or no time frame stated) seems to be of less importance. Studies using personal interviews seem to give somewhat higher prevalences than those using questionnaires.

Full text

REVIEW ARTICLE
Prevalence of headache in Europe: a review for the Eurolight
project
Lars Jacob Stovner •Colette Andree
Received: 19 January 2010 / Accepted: 15 April 2010 / Published online: 16 May 2010
The Author(s) 2010. This article is published with open access at Springerlink.com
Abstract The main aim of the present study was to do an
update on studies on headache epidemiology as a prepara-
tion for the multinational European study on the prevalence
and burden of headache and investigate the impact of dif-
ferent methodological issues on the results. The study was
based on a previous study, and a systematic literature search
was performed to identify the newest studies. More than
50% of adults indicate that they suffer from headache in
general during the last year or less, but when asked specif-
ically about tension-type headache, the prevalence was 60%.
Migraine occurs in 15%, chronic headache in about 4% and
possible medication overuse headache in 1–2%. Cluster
headache has a lifetime prevalence of 0.2–0.3%. Most
headaches are more prevalent in women, and somewhat less
prevalent in children and youth. Some studies indicate that
the headache prevalence is increasing during the last dec-
ades in Europe. As to methodological issues, lifetime
prevalences are in general higher than 1-year prevalences,
but the exact time frame of headache (1 year, 6 or 3 months,
or no time frame stated) seems to be of less importance.
Studies using personal interviews seem to give somewhat
higher prevalences than those using questionnaires.
Keywords Epidemiology Prevalence Headache 
Migraine Medication overuse
Introduction
The Eurolight project (http://www.eurolight-online.eu)isan
initiative supported by the EC Public Health Executive
Agency launched in May 2007. Its objectives are to bring
together the relevant medical, scientific and lay organi-
zations, and to gather updated reliable comparable infor-
mation regarding migraine, tension-type and chronic
headache. It will be the first data collection on headaches at
EU level focusing on a holistic, patient-driven and scien-
tifically validated approach, aiming to fill in the main holes
in our knowledge by performing comparable studies on
headache prevalence and impact in selected European
countries (Austria, France, Germany, Italy, Lithuania, the
Netherlands, Spain, UK, Ireland and Luxembourg). A pilot
study has already been performed in Luxembourg. The
present review of the prevalence of various headaches in
Europe was performed as a part of the Eurolight project to
assess the current state of knowledge before the data from
the current project are published.
A previous study on the headache prevalence in Europe
covered the data up till 2005 [1]. The present review will
include all previous studies, including relatively recently
published reviews [1–3] with the addition of new relevant
studies that have appeared in the years between 2005 and
2009. The way the research methodology can influence the
results has been thoroughly discussed in some of these and
On behalf of the Eurolight Steering Committee.
L. J. Stovner (&)
Department of Neuroscience, Norwegian National Headache
Centre, Norwegian University of Science and Technology,
7006 Trondheim, Norway
e-mail: lars.stovner@ntnu.no
L. J. Stovner
St. Olavs Hospital, 7006 Trondheim, Norway
C. Andree
CRP Sante
´, Luxembourg City, Luxembourg
C. Andree
Department of Pharmaceutical Sciences,
University of Basel, Basel, Switzerland
123
J Headache Pain (2010) 11:289–299
DOI 10.1007/s10194-010-0217-0

other publications [1,4,5]. The aim of the present article
was to give an update on the prevalence of the most
important headache types in Europe, to identify gaps in our
present knowledge and to analyse some methodological
issues in order to choose an optimal methodology for the
studies to be performed for the EUROLIGHT project.
Methodology
Literature search
A comprehensive literature search was performed to iden-
tify population-based studies of headache and migraine.
Searches were performed with PubMed using the expres-
sions ‘‘migraine epidemiology’’, ‘‘headache epidemiology’’
and ‘‘migraine prevalence’’ or ‘‘headache prevalence’’ for
each European country. References in relevant publications
have also been examined. Only studies in English, German,
French or Spanish were considered.
Data extraction
The information extracted was the country of origin, year
of publication, population characteristics and the preva-
lence estimates for headache, migraine, tension-type
headache (TTH) and chronic headache, both overall and for
each gender, and for various age categories.
Case definitions
Only studies where the headache diagnoses are made
according to the International Classification of Headache
Disorders, first edition (ICHD-1) from 1988 [6]or
according to ICHD-2 from 2004 [7] have been used. This
classification has later been incorporated in the Interna-
tional Classification of Diseases (ICD-10) [8]. Hence, we
have included epidemiologic studies that have appeared
after 1988 on migraine (ICD-10 diagnosis G43) and TTH
(G44.2), the two types that affect the great majority of
headache patients. For migraine, we have not distinguished
between migraine with (G43.1) and without (G43.0) aura.
This differentiation can reliably be made only in studies
using personal interview, preferably by a headache spe-
cialist. In addition, it is not known whether the two types
differ markedly with regard to the patients’ suffering and
subsequent economic consequences. For practical reasons,
the diagnosis in most headache epidemiologic studies has
been made according to somewhat modified criteria, and
such studies have also been included.
In order to comprise all headache patients, we have also
included epidemiologic studies that have investigated
headache in general. The term ‘‘headache’’ is not, however,
defined in the ICHD classifications, and we have therefore
included studies on headache prevalence that appeared
before 1988. For TTH, the term ‘‘chronic’’ has been
applied to patients who have this type of headache for
C15 days per month on average for C3 months (ICHD-1
and -2). In many headache studies, a similar definition has
been given to patients with headache, irrespective of
whether it is of the tension type or not. We have also
gathered data on ‘‘chronic headache’’ (i.e. C15 days per
month or ‘‘daily’’ headache) to assess the prevalence of
these patients who are probably most incapacitated by their
condition. A subgroup of these patients are overusing acute
medication, a condition termed ‘‘Medication overuse
headache’’ (MOH) in the IDHD-2. We have also collected
data on this frequent and possibly preventable condition.
Source populations
For our purpose, we have included only studies performed
on the whole population or a representative sample of the
whole population within a certain age range in a commu-
nity, town or country. We have accordingly not included
studies based on selected populations (clinic based, in
workplaces, among university students, etc.). Since the
primary school is obligatory in all European countries,
studies on headache in children and youth based on schools
have been included.
Period prevalences
For many patients, headache is troublesome only in certain
phases of life. For this reason, most headache epidemio-
logical studies have asked the subjects on headache within a
limited time span, usually the last year. The 1-year preva-
lence figure indicates the proportion of the population that
has an active disease, which is more relevant than lifetime
prevalence for health economic calculations. Data on life-
time prevalence are also considered less reliable due to recall
problems, at least in the elderly. In children and adolescents,
one may assume that the lifetime and 1-year prevalences are
not very different. The studies with 3-month or not specified
timeframe has also been included since these time frames
will also give a fairly accurate estimate of the proportion of
the population with headache in the relatively recent past,
usually not very different from the 1-year prevalence.
Results
Headache
Headache in general has been reported in 49 studies
(Table 1), whereof 34 have concerned headache during
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Table 1 Studies on headache prevalence
Country (year) Reference Time frame Method NAge range (years) Headache Chronic headache
M F Total M F Total
Adults or all ages
Austria (2003) Lampl [37] 1-y P.i. 997 C15 43.6 54.6 49.4
Croatia (2001, 2003) Zivadinov [38,49] L.t. P.i. 3,794 15–65 65.2
Denmark (1991) Rasmussen [10] 1-y P.i. 740 25–64 3
Denmark (1991) Rasmussen [10] L.t. P.i. 740 25–64 93 99 96
Finland (1981) Nikiforow [45] 1-y P.i. 200 [15 69 83 77
Finland (1981) Nikiforow [45] L.t. P.i. 200 [15 91
France (1992) Henry [51] L.t. Q 4,204 5–65 35
France (2002) Henry [20] N.s. Q 10,585 C15 29.2 3.0
France (2003) Lanteri-Minet [17] L.t. Q 10,585 C15 1.6 4.2 3
France (1996) Michel [46] 3-m Q 9,411 [18 39.0 58.0 49
Germany (1994) Gobel [52] L.t. Q 4,061 C18 71.4
Germany (2009) Pfaffenrath [61] 6-m P.i. 7,417 C20 49.5
Germany (2009) Radke [62] 1-y T.i. 7,341 C18 53.0 66.6 60.2
Georgia (2009) Katsarava [12] 1-y P.i. 1,145 C16 46.3 7.6
Greece (1996) Mitsikostas [18] 1-y Q 3,501 15–75 19.0 40.0 29 2.1 6.8 4.5
Italy (1988) D’Alessandro [47] 1-y Q 1,154 [7 35.3 46.2 46
Netherlands (2006) Wiendels [13] 3-m Q 16,232 25–55 3.7
Norway (2000) Hagen [15] 1-y Q 51,383 C20 29.6 45.7 37.7 1.7 2.8 2.4
Norway (2008) Grande [22] 1-y Q 20,598 30–44 2.9
Norway (2008) Russell [43] 1-y Q 21,800 20–80 69.6 84.0 77.2
Portugal (1995) Pereira Monteiro [53] L.t. Q 2,008 All ages 88.6 4.1
Spain (1999) Castillo [14] 1-y Q 2,253 [14 1.0 8.7 4.7
Spain (1994) Laı
´nez [50] L.t. P.i. 2,231 16–65 86.7
Sweden (2001) Dahlof [42] 1-y Q 1,668 18–74 50 76 63
Sweden (2006) Molarius [63] 3-m Q 43,770 18–79 10.4 22.9 16.7
Turkey (2005) Boru [64] L.t P.i. 1,835 15–45 70.9
UK (1975) Waters [65] 1-y Q 1,718 [21 63.5 78.4 71.0
UK (2005) Boardman [48] 1-y Q 1,589 18–90 76
UK (1977) Crisp [66] L.t. Q 727 [7 35.3 46.2
UK (2003) Boardman [67] L.t. Q 1,662 C18 90.2 94.4 92.6
UK (2003) Boardman [67] 3-m Q 1,662 C18 62.0 76.8 70.3
Children and youth
Finland (1983) Sillanpa
¨a
¨[68] 1-y Q 3,784 13 79.8 84.2 82.0
Finland (1994) Metsa
¨honkala [69] 1-y Q 3,580 8–9 36.5
Finland (1991) Sillanpaa [70] 1-y Q 4,405 5 19.5
Finland (1994) Metsa
¨honkala [69] L.t. Q 3,580 8–9 36.5
Germany (2004) Roth-Isigkeit [71] 3-m Q 735 10–18 58.9 73.1 66
Italy (1995) Raieli [72] 1-y P.i. 1,445 11–14 19.9 28.1 23.9
Norway (2004) Zwart [19] 1-y Q 8,255 13–19 69.4 84.2 76.8 0.2 0.8 0.5
Serbia (2007) Milanovic [73] L.t. P.i. 1,259 7–12 32.8
Sweden (2004) Laurell [33] 1-y Q 1,850 7–15 39.3 50.3 44.8
Sweden (1962) Bille [74] L.t. Q 8,993 7–15 58 59.3 58.7
Turkey (2005) Bugdayci [75] N.s. P.i. 5,777 8–16 46.2 52.8 49.2 1.5
Turkey (2007) Akyol L.t. Q 7,721 9–17 79.6 87.1 83.4
Turkey (2006) Karli [76] 1-y Q 2,387 12–17 45.1 59.8 52.2
Turkey (2006) Unalp [77] N.s. Q 2,384 14–18 36 53 46
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the last year or less (here summarized as ‘‘current
headache’’, also including studies where timeframe were
not stated). Calculating the mean of all the studies
comprising more than 205,000 adult participants, current
headache occurred in 53% of adults (61% among women
and 45% among men). The prevalence in the 12 studies
restricted to children and youth, including [37,000 par-
ticipants, was the same (53%), but the only two studies
on the elderly, from Italy, showed a somewhat lower
figure (36%). The total lifetime prevalence of headache
among adults was as expected higher than that of current
headache (77%).
Migraine
The studies on migraine are presented in Table 2. The
mean prevalence of current migraine among [170,000
adults was 14.7% (8% in men and 17.6% in women). In
studies restricted to children and youth ([36,000 partici-
pants), the prevalences were lower (9.2% for all, 5.2% in
boys and 9.1% in girls). Lifetime prevalences were higher
(16, 11 and 20%, respectively).
Most studies only report the prevalence of ‘‘strict
migraine’’, i.e. cases that comply with all the criteria of
either migraine without (ICHD-2 1.1) or with aura
(ICHD-2 1.2). However, if also probable migraine
(ICHD-2 1.6), i.e. cases which fulfil all but one of the
criteria, is included, the proportion with migraine is
almost doubled [9].
TTH
Nineteen studies have reported the TTH prevalences
(Table 3). Overall, the prevalence of current TTH among
[66,000 adults was 62.6%, and chronic TTH (i.e. on
C15 days per month) occurred in 3.3%. Much lower fig-
ures (current TTH 15.9%, chronic TTH 0.9%) were found
in the nine studies among almost 25,000 children and
youth.
Chronic headache and MOH
The definitions of chronic headache varied considerably
among studies. Only two studies used the same criteria for
chronicity as with chronic TTH ([180 days/year [10]or
[14 days/month for more than 3 months during the last
year [11]). Most other studies used a definition of C15 days
per month [12–16] or simply daily headache [17–19].
The 1-year prevalence of current chronic daily headache
was 4.0% (mean of 8 studies) [10,12,14,15,18,20–22]. A
similar figure (4.4%) was found in one study restricted to
the elderly [16], but in studies on children and youth, the
figure was lower (0.5% among 13–19-year-old in Norway),
and 1.5% among 8–16-year-old in Turkey. The highest
figure (7.6%) was found among adults in Georgia [12].
Medication overuse is frequent among those with chronic
headache, and possible medication overuse headache (i.e.
headache C15 days per month and use of medication
C3 months) was found to affect 0.9% in Georgia [12] and
1% of adults in Spain [14,23]. In the HUNT studies in
Norway from the 1990s the prevalence was 1% in adults
[24] and 0.5% in adolescents [25], whereas a more recent
study showed 1.7% [26]. In Germany, a recent study
demonstrated a prevalence of 2% [27].
Cluster headache
In comparison to migraine and TTH, cluster headache is
rare, and to make the diagnosis from questionnaires alone
has never been validated. Therefore, the prevalence should
preferably be made by personal interview and examination
by a neurologist in a large population. A lifetime preva-
lence of 0.326% was found in a study in which the diag-
nosis was made by face-to-face interview by a headache
expert among more than 1,800 inhabitants of a Norwegian
rural community [28]. This is similar to the figure (0.279%)
found in an Italian town among [10,000 patients regis-
tered in the lists of general practitioners, the sample
being representative of the general population [29].
Table 1 continued
Country (year) Reference Time frame Method NAge range (years) Headache Chronic headache
M F Total M F Total
UK (1977) Deubner [78] 1-y Q 600 10–20 74.4 81.5 78.0
UK (1994) Abu-Arefeh [79] 1-y Q 2,165 5–15 66
Elderly
Italy (2001) Prencipe [16] 1-y P.i. 833 C65 36.6 62.1 51 2.5 6 4.4
Italy (2003) Camarda [80] 1-y P.i. 1,031 C65 16.5 26.3 21.8
1-y 1-year prevalence, 3-m 3-month prevalence, 6-m 6-month prevalence, L.t. lifetime prevalence, N.s. prevalence not stated, P.i. personal
interview, T.i. telephone interview, Qquestionnaire, Mmales, Ffemales
292 J Headache Pain (2010) 11:289–299
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Table 2 Studies on migraine prevalence
Country (year) Reference Time frame Method NAge range (years) Migraine
M F Total
Adults or all ages
Austria (2003) Lampl [37] 1-y P.i. 997 C15 6.1 13.8 10.2
Croatia (2001) Zivadinov [38] 1-y P.i. 3,794 15–65 13 20.2 16.7
Croatia (2001, 2003) Zivadinov [38,49] L.t. P.i. 3,794 15–65 14.8 22.9 19
Denmark (1991) Rasmussen [10] 1-y P.i. 740 25–64 6 15 10
Denmark (1991) Rasmussen [10] L.t. P.i. 740 25–64 8 25 16.1
Denmark (1995) Russell [81] L.t. Q 4,061 40 12 24 18
Denmark (2005) Lyngberg [36] 1-y P.i. 207 25–36 5.4 23.5 15.5
Denmark (2006) Russell [44] 1-y Q 28,195 12–41 13.9 24.3 19.1
France (1992) Henry [51] L.t. Q 4,204 5–65 6.1 17.6 12.1
France (2002) Henry [20] N.s. Q 10,585 C15 10 23 17
France (2005) Lante
´ri-Minet [9] N.s. Q 10,532 C18 6.3 15.7 11.2
France (1996) Michel [46] 3-m Q 9,411 [18 8 18 15
Germany (1994) Gobel [52] L.t. Q 4,061 C18 22 32 27.5
Germany (2009) Pfaffenrath [61] 6-m P.i. 7,417 C20 11.4
Germany (2009) Radke [62] 1-y T.i. 7,341 C18 5.3 15.6 10.6
Georgia (2009) Katsarava [12] 1-y P.i. 1,145 C16 15.6
Hungary (2000) Bank [40] 1-y Q 813 15–80 2.7 6.9 9.6
Netherlands (1999) Launer [41] 1-y Q 6,491 20–65 7.5 25 16.3
Netherlands (1999) Launer [41] L.t. Q 6,491 20–65 13.3 33 23.2
Norway (2000) Hagen [15] 1-y Q 51,383 C20 7.5 15.6 11.6
Norway (2006) Sjaastad [82] N.s. P.i. 1,838 18–65 17.5 28.4 23.0
Norway (2008) Russell [43] L.t. Q 21,800 20–80 18.1 34.1
Portugal (1995) Pereira Monteiro [53] L.t. Q 2,008 All 8.8
Spain (1994) Laı
´nez [50] L.t. P.i. 2,231 16–65 8 17 12
Sweden (2000) Mattsson [83] L.t. Q 722 40–74 31
Sweden (2000) Mattsson [83] 1-y Q 728 40–74 18
Sweden (2001) Dahlo
¨f[42] 1-y Q 1,668 18–74 9.5 16.7 13.2
Sweden (2006) Molarius [63] 3-m Q 43,770 18–79 2.4 5.5 4.0
Switzerland (1994) Merikangas [39] 1-y P.i. 379 29–30 24.6
Turkey (2005) Boru [64] L.t. P.i. 1,835 15–45 15.8
Turkey (2005) Celik [55] L.t. P.i. 386 [14 9.3 29.3 19.9
Turkey (2002) Kececi [56] L.t. P.i. 947 C7 7.9 17.1 12.5
UK (2003) Steiner [57] 1-y T.i. 4,007 16–65 7.6 18.3 14.3
Children and youth
Finland (1994) Metsa
¨honkala [69] L.t. Q 3,580 8–9 3 2.3 2.7
Germany (2007) Fendrich [84] 3-m Q 3,324 12–15 4.4 9.3 6.9
Germany (2009) Heinrich [85] 6-m Q 2,553 9–14 13.1
Greece (1999) Mavromichalis [86] 1-y Q 3,509 4–15 5.2 7.3 6.2
Italy (1995) Raieli [72] 1-y P.i. 1,445 11–14 2.7 3.3 3.0
Norway (2004) Zwart [19] 1-y Q 8,255 13–19 4.8 9.1 7.0
Serbia (2007) Milanovic [73] L.t. P.i. 1,259 7–12 2.1 4.6 3.3
Sweden (2004) Laurell [33] 1-y Q 1,850 7–15 9.8 12.2 11.0
Turkey (2005) Bugdayci [75] N.s. P.i. 5,777 8–16 10.4
Turkey (2004) Zencir [87] N.s. Q 2,490 11–18 6.7 11.0 8.8
Turkey (2006) Karli [76] 1-y Q 2,387 12–17 14.5
Turkey (2007) Akyol [88] L.t. Q 7,721 9–17 7.8 11.7 9.7
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Questionnaires or telephone interviews were used to screen
the population, and suspected cases were interviewed by a
headache specialist to confirm the diagnosis. These high
prevalences are also supported by recent data from a
Swedish twin registry study giving a lifetime prevalence of
around 0.2% [30]. In Germany, suspected cluster headache
cases detected by a questionnaire and interviewed by a
neurologist in a population-based study revealed a preva-
lence of 0.12% [31]. In Georgia, one case was found in
door-to-door survey among 1,145 individuals, which cor-
responds to 0.09% [32].
Increase in headache
By studying headache prevalence with an interval of some
years in the same community and using the same method, it
may be possible to study time-trends in headache preva-
lence. A study from Sweden indicates a marked increase of
Table 3 Studies on the prevalence of tension-type headache
Country (year) Reference Time frame Method NAge range
(years)
TTH Chronic TTH
M F Total M F Total
Adults
Croatia (2001, 2003) Zivadinov [49] L.t. P.i. 3,794 15–65 32.3 37.1 34.8
Denmark (1991) Rasmussen [10] 1-y P.i. 740 25–64 63 86 74
Denmark (1991) Rasmussen [10] L.t. P.i. 740 25–64 69 88 78 3.0
Denmark (2005) Lyngberg [36] 1-y P.i. 207 25–36 81.5 90.4 86.5 4.8
Denmark (2006) Russell [44] 1-y Q 28,195 12–41 78.9 92.5 86.0 0.5 1.3 0.9
Georgia (2009) Katsarava [12] 1-y P.i. 1,145 C16 37.3 3.8
Germany (1994) Gobel [52] L.t. Q 4,061 C18 37 39 38 3.0 3.0 3.0
Germany (2009) Pfaffenrath [61] 6-m P.i. 7,417 C20 31.5 1.25
Germany (2009) Radke [62] 1-y T.i. 7,341 C18 53.0 66.6 60.2
Norway (2008) Grande [22] 1-y Q 20,598 30–44 1.6 3.7 2.8
Portugal (2005) Pereira Monteiro [53] L.t. Q 2,008 All ages 48.7 4.1
Turkey (2003) Koseoglu [89] 1-y P.i. 1,146 45–64 18.8 6.3
Children/youth
Finland (2002) Anttila [90] N.s. Q 1,135 12 12.2 0
Germany (2007) Fendrich [84] 3-m Q 3,324 12–15 19.1 21.2 20.2 0.2
Norway (2004) Zwart [19] 1-y Q 8,255 13–19 12.5 23.2 18.0
Serbia (2007) Milanovic [73] L.t. P.i. 1,259 7–12 0.9 1.7 1.3
Sweden (2004) Laurell [33] 1-y Q 1,850 7–15 7.9 11.8 9.8
Turkey (2005) Bugdayci [75] N.s. P.i. 5,777 8–16 24.7 1.5
Turkey (2004) Kaynak Key [91] N.s. Q 2,226 17–21 14.3 22.7 20.35 0.8 2.8 1.9
Turkey (2006) Unalp [77] 1-y Q 2,384 14–18 5.7
For abbreviations see Table 1
Table 2 continued
Country (year) Reference Time frame Method NAge range (years) Migraine
M F Total
Turkey (2006) Unalp [77] 1-y Q 2,384 14–18 9.6
UK (1994) Abu-Arefeh [79] 1-y Q 2,165 5–15 9.7 11.5 10.6
Elderly
Italy (2001) Prencipe [16] 1-y P.i. 833 C65 7.4 13.8 11
Italy (2003) Camarda [80] 1-y P.i. 1,031 C65 2.3 6.4 4.6
For abbreviations see Table 1
294 J Headache Pain (2010) 11:289–299
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both headache and migraine in schoolchildren over a per-
iod of 40 years [33], and in a Finnish community there was
a significant increase among 8-year-old children in head-
ache (and abdominal pain) over a 10-year period [34]. In
another Finnish study, three population-based studies on
migraine and other headaches among 7-year-old children
conducted in 1974, 1992 and 2002 with almost identical
study design indicated increased incidence rates both of
headaches in general (incidence in the 3 years: 58, 156,
278/1,000 person-years) and migraine (20, 59 and 133)
[35]. Among young adults (25–36 years) in Denmark, there
was over a 12-year period a significant increase in TTH,
particularly the frequent type. There was also a significant
increase in the proportion with relatively frequent
migraine, but the increase for migraine in general was not
significant [36].
Methodological analyses
To explore to which degree the method of data collection
in epidemiologic studies is important for the results, we
compared the mean prevalence of studies in adults using
either personal interview or questionnaire. For 1-year
prevalences (both sexes) of migraine, the mean of the five
studies using personal interview [10,36–39] was 15.3%,
compared to 14.0% in the five studies using questionnaires
[15,40–44]. For headache in general, the total prevalence
seemed to be higher in the three studies using personal
interview [12,37,45] than in the eight studies using
questionnaires [15,18,20,42,43,46–48] (57.6 vs. 40.6%).
For lifetime prevalences of headache in general, the mean
prevalence was somewhat higher in the four studies using
personal interview [10,45,49,50] than in the four using
questionnaires [51–54] (84.7 vs. 71.9%). However, for
lifetime prevalences of migraine, the mean of the five
studies using personal interview [10,38,50,55,56] was
somewhat lower than in the four studies using question-
naires [41,51–53] (15.9 vs. 17.9%).
As to the effect of using different timeframes in the
studies, there was little difference between the migraine
prevalence in those studies in which the timeframe was not
stated [9,51] compared to the studies asking about head-
ache during the last year [10,15,36,37,40–42,49,57]
(12.9 vs. 13.0%).
Discussion
Aggregating studies that have used different methods of
data collection and somewhat variable timeframes for
headache (during the last year or less), the present survey
indicates that more than 50% of the population in Europe
are current headache sufferers, and almost 15% suffer from
migraine. During the last years, more attention has been
drawn to the importance of TTH on the public health, and it
seems that [60% suffer from this headache type. It is a
paradox that the prevalence of TTH is higher than that of
headache in general. Probably, this has to do with the way
studies were performed. More detailed questions in studies
aimed at making specific diagnoses may elicit higher
positive rates than studies using only general questions
about headache. Chronic headache (i.e. on more than
15 days per month) seems to affect around 4% of the adult
population, and MOH 1–2%. For cluster headache, the 1-
year prevalence is not known, but the lifetime prevalence
seems to be around 0.2–0.3%. Other primary headaches are
even rarer, and the prevalence of these has not been esti-
mated in population-based studies. The prevalence of
headache and migraine is higher among women than
among men [1]. In children and youth, the migraine
prevalence is lower than among adults, but the prevalence
of headache in general seems to be as high. Several studies
also indicate a marked increase in headache prevalence
over the decades, particularly in studies on children and
youth, and also in one study on adults.
In this report, we have only considered the main primary
headaches. One reason for this is that reasonably certain
diagnosis of secondary headache requires extensive clinical
and medical investigations, and often follow-up, which is
not feasible in most population-based epidemiologic stud-
ies. An exception to this is medication overuse headache
(MOH) since relatively many studies attempt to estimate
the prevalence of those that might have this condition
(‘‘possible MOH’’), although a certain diagnosis of this
requires both treatment and follow-up. Secondary head-
aches due to serious diseases with a grave prognosis are
quite rare although secondary headaches related to more
trivial causes, like fever or hangover, occur relatively often
[58].
Most of the studies on headache prevalence so far stems
from Western Europe. There are only a few studies from
Eastern Europe (Georgia, Croatia, Serbia and Hungary). In
addition, there are still relatively few studies on TTH. Most
studies this far concern headache in general and migraine.
As to the methodological issues, we have tried to
compare the results from the studies using different
methods of data collection. Only for migraine and head-
ache in general in adults could meaningful comparisons be
made; in TTH or in children or elderly, there were too few
studies available. In general, the figures obtained with
personal interview were somewhat higher than those
obtained with questionnaire. For migraine, the difference
between the two methods was around 10% (15.4 vs 14.0%)
for 1-year prevalence, but almost 30% for lifetime preva-
lence (22.2 vs. 15.9%). For headache in general, the dif-
ference in 1-year prevalence was 30% (57.6 vs 40.6%), but
J Headache Pain (2010) 11:289–299 295
123

for this category, there were only three studies using per-
sonal interview, which will make the estimates less accu-
rate. For lifetime prevalences, the figure based on
questionnaire studies was 15% lower (84.7 vs. 71.9%).
These differences may also reflect variations in the how the
ICHD-2 criteria are applied as most questionnaire studies
use somewhat modified criteria, whereas studies based on
personal interviews tend to use strict criteria. In sum,
personal interview seem to be a somewhat more sensitive
method for obtaining data on headache suffering, and
questionnaires are likely to underestimate prevalences to
some degree.
It has previously been demonstrated that the way the
introductory screening question is asked makes a great
difference in headache prevalence. Quite predictably, a
neutral screening question (e.g. ‘‘have you had headache/
migraine…’’) will give markedly higher estimates than
questions specifying some degree/severity/frequency of
headache suffering (e.g. ‘‘have you suffered from head-
ache/migraine’’, ‘‘have you had severe headache…?’’,
‘‘have you had repeated episodes of headache…?’’, etc.)
[1]. In order to obtain answers from as many headache
sufferers as possible in epidemiologic studies, it is there-
fore probably better to use a neutral screening question,
and then ask additional questions on headache severity,
frequency, duration and impact to define groups of head-
ache sufferers that are of clinical and economical impor-
tance [1].
The ways the ICHD criteria are applied and which
diagnoses are included are also of great importance. It has
been found that the prevalence of migraine almost doubles
if the diagnosis probable migraine (i.e. patients fulfilling all
migraine criteria except one) is included [9,20,51,59].
Among the European studies, the highest migraine preva-
lences has been found in a yet unpublished study from
Luxembourg (29%) performed by one of the authors (CA).
This study has used the ‘‘ID migraine’’ [60] which is a
screening instrument consisting of only three questions.
This instrument has been validated against the ICHD-2
criteria in clinical settings, showing a high sensitivity and
somewhat lower specificity. Probably, this method will
include many patients with probable migraine, and thereby
it will tend to show higher prevalence compared to the
studies using strict ICHD criteria for definite migraine.
The problem of multiple headache types occurring in the
same patient may create large problems in headache epi-
demiologic studies. Generally, it is considered that with
personal interview and examination, many different head-
aches can be diagnosed. With interview performed by
trained personnel, migraine and TTH can be differentiated
in the same person, but with questionnaires, it is usually
wise to let the patient answer the questionnaire based on
the altogether most bothersome headache [4].
Conclusions
The present study indicates that 50% of Europeans have an
active headache disorder. However, there are large varia-
tions, and part of this variation is caused by methodological
differences between studies. Around 15% seem to suffer
from migraine, 4% have chronic headache and possibly 1–
2% medication overuse headache. During their lifetime,
0.2–0.3% has had cluster headache. Headaches are pre-
valent in both sexes and in all age groups, but women
between 20 and 50 years are those who have the highest
prevalences. Data on TTH is still too scarce in Europe, and
data on prevalence of any headache is lacking from most of
Eastern Europe.
As to the method to be used in headache epidemiologic
studies, personal interview will give the most reliable
diagnoses and the highest prevalence estimates, but when
the aim was to diagnose only the most bothersome of the
headaches occurring in one person, questionnaires seem to
perform quite well. A neutral screening question supple-
mented with questions on headache severity and frequency
will probably be the most sensitive method.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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