Abstract
Background
Chronic headache disorders, especially migraine, are known to cause considerable loss of productivity and negatively affect brain health in the workplace. The present study aims to clarify how common chronic headache disorders are and how much productivity loss they are causing within administrative bodies.
Methods
An intranet-based headache survey was conducted with employees of a city office located in the Tokyo metropolitan area. Headache classification among participants was made according to the ICHD-3 criteria. Headache days, headache intensity, headache-related disability, and productivity loss were analyzed in each headache group. We also explored what factors were linked to the likelihood of seeking medical care for headache.
Results
The response rate was 52.3%, with 1156 men and 764 women. Among individuals who had chronic headache during the 12 months preceding the survey, 116, 95, 93, and 214 had migraine without aura (MO), probable MO (pMO), migraine with aura (MA), and tension-type headache (TTH) as their most severe and distressing headache, respectively (6.0%, 4.9%, 4.8%, and 11.1%, respectively). MO, pMO, and MA were found to have more severe impact on daily activities and work productivity than TTH. Migraine-related presenteeism was proportional to headache frequency and intensity. A total of 63.1% of those who had active chronic headache had never sought care for their headaches, and only 10.4% of them were consulting a healthcare professional. The consultation rate was lower among younger headache sufferers. Migraine features, such as vomiting, photophobia, and worsening by physical activity, were associated with seeking medical care. The annual estimated wage loss due to headache was highest in the MO group, totaling 39,202,191.2 JPY (267,463.9 USD) per year, 81.6% of which was derived from presenteeism. It was estimated that active chronic headache disorders were responsible for 8.6% of the total wage.
Conclusions
Many individuals with chronic headache disorders are underdiagnosed and undertreated within administrative bodies. Compared with TTH, migraine compromises brain health more severely and generates more economic loss. Our data imply that chronic headache disorders, particularly migraine, may lower the quality of public service.
Graphical Abstract
Supplementary Information
The online version contains supplementary material available at 10.1186/s10194-025-02157-2.
Keywords: Chronic headache, Migraine, Brain health, Consultation rate, Economic loss, Presenteeism, Work productivity, Workplace, Administrative body, Calcitonin gene-related peptide (CGRP)
Introduction
Brain health is defined as “the state of brain functioning across cognitive, sensory, social-emotional, behavioural and motor domains, allowing a person to realize their full potential over the life course, irrespective of the presence or absence of disorders” by World Health Organization (https://www.who.int/health-topics/brain-health?utm_source=chatgpt.com#tab=tab_1). To disseminate this tenet, World Brain Day (WBD) is organized by the World Federation of Neurology (WFN) in collaboration with national member societies. How can we make the value of this conceptual construct in everyday medical practice? Migraine and tension-type headache (TTH) are representative primary headache disorders [1, 2]. In developed countries, approximately half of the general population is known to experience active headache disorders, with an estimated prevalence of migraine and TTH of 14.0% and 26.0%, respectively [3]. Although these disorders do not cause direct fatality or noticeable tissue damage, ongoing attacks can impair the functioning of affected individuals [4]. In particular, along with stroke and neonatal encephalopathy, migraine is among the top three causes of disability-adjusted life years (DALYs) for neurological disorders and ranks second among adults aged < 60 years [5]. Since migraine prevalence reaches its maximum during the most economically active stages of life, considerable loss in productivity occurs due to migraine in the workplace worldwide. In a headache survey conducted at a Japanese information technology company, the prevalence of migraine was 13%, and migraine-related economic loss was found to stem mostly from presenteeism at 375.4 USD/year/person [6]. Similar findings were reported at a Turkish automobile company [7]. In a recent survey of palm plantation workers in Cameroon, compared with TTH, migraine was associated with a greater negative impact on work productivity with respect to both absenteeism and presenteeism, with a prevalence of 16.9% [8]. The integrity of neurological function is required to achieve high performance in the workplace. Therefore, we posit that compromised brain health may be rendered tangible by measuring disability burden and productivity or economic losses attributable to chronic headache disorders. Proactive therapeutic interventions for chronic headache disorders, particularly migraine, are crucial for preserving brain health in affected people. Nevertheless, several lines of evidence show that the majority of chronic headache sufferers in Japan have never sought medical care [6, 9–13]. This situation should be addressed, especially because migraine therapy has ushered in a new era with the advent of treatments targeting calcitonin gene-related peptide (CGRP), a 37-amino acid neuropeptide that plays a pivotal role in migraine pathogenesis [14]. Ideally, achieving freedom from migraine should significantly contribute to enhancing brain health. [15].
In the present study, we delineate how common primary headache disorders are and how much they affect work productivity among employees of the Ichikawa City Office. Ichikawa is a Japanese city with a population of approximately 500,000 and is located in an area adjacent to Tokyo. A survey conducted in 1988 reported that 77% of civil servants in a London government department had experienced headaches in the previous 12 months [16], suggesting that headaches could threaten the quality of civil service. Since then, little has been known about the impact of chronic headache disorders within administrative bodies. Our data shed light on the overlooked aspect of headache-induced productivity loss in modern society.
Methods
Study design and objectives
This cross-sectional survey of employees of the Ichikawa City Office was conducted via the Ichikawa City Office-operated intranet system between August 22, 2024 and September 30, 2024. All employees received an email inviting them to participate in the survey. Of these, approximately 80% were clerical workers, and the remainder were technical workers, employees at fire stations or welfare facilities. Only those who provided informed consent were permitted to proceed to the online headache survey described below. Ethical approval for the present study was obtained from the Tokyo Dental College Ichikawa General Hospital Ethics Committee (Authorization number: I 24–05). This was a voluntary survey, and all participants provided informed consent prior to participation on the condition that their data would be anonymized.
The primary objective of this study was to estimate the frequency of major primary headache disorders, which included migraine, TTH, and cluster headache, as the most severe and distressing headache for participants. We also sought to clarify the headache characteristics, treatment status, and estimated annual economic loss resulting from headache-induced productivity loss among all Ichikawa City Office employees.
Headache diagnosis, headache management, and medical consultation status
The contents of the questionnaire are provided in Supplementary Document 1. In the first part of the questionnaire, we collected demographic information about the age group, sex, height, and weight of each participant. Next, the participants were asked whether they were experiencing active chronic headache, which had occurred for 3 months or longer in the past 12 months, or if they had experienced such headache attacks prior to that period. Headaches due to alcohol hangover were excluded. If participants had more than one type of headache, the questionnaire asked them to answer only about the most severe and distressing type. The participants were asked to report the onset, characteristics, frequency, and intensity of headache and the presence of nausea/vomiting, photophobia, phonophobia, visual field defects, and scintillating scotomas. Headache intensity was reported according to the Numeric Rating Scale (NRS; 0–10), with higher scores indicating greater intensity. In the present study, NRS scores of 1–4, 5–7, and 8–10 were categorized as mild, moderate, and severe, respectively. The items of the questionnaire were strategically designed to classify migraine without aura (MO) and TTH according to the diagnostic criteria of the International Classification of Headache Disorders (ICHD-3). If headache characteristics fulfilled all but one of the criteria A–D for 1.1 Migraine without aura, the headache was classified as probable migraine without aura (pMO). Those who reported visual defects and scintillating scotomas preceding their headache were diagnosed with migraine with aura (MA). For the diagnosis of cluster headache, the index features included higher headache intensity (numeric rating scale (NRS) ≥ 7), a short duration of headache attacks (≤ 3 h), and cranial autonomic symptoms, such as nasal discharge and tearing. We also asked how participants with chronic headache managed their symptoms and whether they had ever sought or were currently seeking medical care for their headache. The utilization of over-the-counter (OTC) and prescribed medications was also reported.
Disability and productivity loss due to headache
The impact of headaches during and between attacks on daily life was evaluated. The questionnaire asked whether headaches interfered with daily activities or made them feel the need to lie down. With respect to the interictal burden of headache, the participants were asked whether they were reluctant to plan social or leisure activities because they might have a headache attack. The impact of headache on work productivity was measured by work productivity and activity impairment (WPAI) scale. The number of hours missed from work during the previous 7 days because of headache-associated problems was used to quantify absenteeism. Presenteeism is defined as the problem of workers being on the job but not fully functioning because of illness or other medical conditions [17]. Accordingly, the questionnaire asked participants to rate how much their headaches affected their productivity while working over the previous 7 days, using a scale from 0 (no effect) to 10 (completely impaired). Economic loss from absenteeism was calculated by multiplying missed working hours due to headache by the participant's hourly wage. Presenteeism losses were calculated by multiplying the number of headache days (excluding days missed from work) by the participant’s daily wage and their self-reported score of productivity impairment due to headache. Data were analyzed by decade-based age group and sex, for which wage data were available from the Ichikawa City Office. The wage data provided represent mean values across all role types (e.g. clerical workers and technical staff). The actual number of employees by decade-based age group and sex was also obtained. The population proportions of headache sufferers were estimated from the sample data with 95% confidence intervals (CIs). The number of headache days per month was represented by the mean value of each frequency interval. All values were converted to annual estimates.
Statistical analysis
Numerical data are presented as the means with standard deviations (SDs) or 95% confidence intervals (CIs). The normality of the data distribution was assessed using D'Agostino's K-square test. Between-group comparisons were conducted using analysis of variance (ANOVA) or the Kruskal–Wallis U test, as appropriate, followed by post hoc tests. When we performed a multiple comparisons test, a multiplicity-adjusted p value for each comparison was computed. We applied the Dunnett or Dunn (nonparametric) multiple comparisons test. Categorical variables were analyzed using Fisher’s exact test. To identify predictors of medical consultations among individuals with active chronic headache, odds ratios for current medical consultation were calculated for predetermined variables using Fisher’s exact test. Additionally, stepwise logistic regression analysis was performed to develop a predictive model for current medical consultation. Statistical analyses were performed using GraphPad Prism 10 (GraphPad Software, Boston, MA, USA) or SPSS Statistics 29 (IBM, Armonk, NY, USA), depending on the type of statistical analysis. We considered two-tailed p values < 0.05 to indicate statistical significance.
Results
Demographic data and headache diagnoses of the participants
A total of 3682 employees of the Ichikawa City Office were invited to participate in this survey. Among them, 1926 (52.3%) provided informed consent and completed the questionnaire, with 1156 men (60.0%) and 764 women (39.7%). Six respondents did not disclose their sex (Table 1). The age group distribution of the participants is shown in Table 1. The mean body mass index (BMI) was 22.8 ± 3.3. Active chronic headache, defined as described above, was reported by 605 participants (31.4%), while 163 participants (8.5%) did not experience current chronic headache but had a history of chronic headache prior to the past 12 months. Among the individuals with current active chronic headache, 116, 95, 93, and 214 had MO, pMO, MA, and TTH, respectively (6.0%, 4.9%, 4.8%, and 11.1%, respectively) as their most severe and distressing headache. No patients met the criteria for cluster headache. We were not able to establish a headache diagnosis in the remaining 87 participants.
Table 1.
Demographic characteristics of study participants
| N = 1926 | |
|---|---|
| Age groups, n (%) | |
| 20–29 | 237 (12.3) |
| 30–39 | 421 (21.9) |
| 40–49 | 414 (21.5) |
| 50–59 | 615 (31.9) |
| 60–69 | 231 (12.0) |
| 70– | 8 (0.4) |
| Sex, n (%) | |
| Male | 1156 (60.0) |
| Female | 764 (39.7) |
| Not specified | 6 (0.3) |
| BMI, mean (SD) | 22.8 (3.3) |
| Headache history | |
| Current | 605 (31.4) |
| Past | 163 (8.5) |
| Never | 1158 (60.1) |
The demographic characteristics of each headache group are presented in Table 2. There was a significant difference in age group distribution between the MO and TTH groups, with individuals in the MO group being younger than those in the TTH group (p = 0.0136, Fisher’s exact test). The proportion of individuals aged 20–29 years was significantly greater in the MO group than in the TTH group (p = 0.0266, Fisher’s exact test). The proportions of females were significantly greater in the MO and pMO groups than in the TTH group (p < 0.0001 and p = 0.0189, respectively, Fisher’s exact test).
Table 2.
Demographic and headache characteristics in each headache group
| MO | pMO | MA | TTH | |
|---|---|---|---|---|
| N = 116 | N = 95 | N = 93 | N = 214 | |
| Age groups, n (%) | ||||
| 20–29 | 25 (21.6) | 13 (13.7) | 12 (12.9) | 26 (12.1) |
| 30–39 | 31 (26.7) | 19 (20.0) | 23 (24.7) | 51 (23.8) |
| 40–49 | 32 (27.6) | 26 (27.4) | 17 (17.9) | 47 (22.0) |
| 50–59 | 23 (19.8) | 32 (33.7) | 33 (34.7) | 70 (32.7) |
| 60–69 | 5 (4.3) | 5 (5.3) | 8 (8.4) | 20 (9.3) |
| Sex, n (%) | ||||
| Male | 23 (19.8) | 35 (36.8) | 40 (43.0) | 110 (51.4) |
| Female | 93 (80.2) | 60 (63.2) | 52 (55.9) | 103 (48.1) |
| Not specified | 0 | 0 | 1 (1.1) | 1 (0.5) |
| BMI, mean (SD) | 21.4 (3.2) | 22.7 (3.8) | 22.2 (3.4) | 22.6 (3.4) |
| Age of onset, n (%) | ||||
| < 10 | 29 (25.0) | 22 (23.2) | 2 (2.2) | 53 (24.8) |
| 10–19 | 30 (25.9) | 23 (24.2) | 25 (26.9) | 14 (6.5) |
| 20–29 | 16 (13.8) | 9 (9.5) | 20 (21.5) | 32 (15.0) |
| 30–39 | 5 (4.3) | 5 (5.3) | 14 (15.1) | 22 (10.3) |
| 40– | 2 (1.7) | 6 (6.3) | 12(12.9) | 9 (4.2) |
| Unknown | 34 (29.3) | 30 (31.6) | 20 (21.5) | 84 (39.3) |
| Frequency of headaches, n (%) | ||||
| < 1/month | 3 (2.4) | 9 (9.5) | 11 (11.8) | 22 (10.3) |
| 1/month | 14 (11.1) | 12 (12.6) | 12 (12.9) | 30 (14.0) |
| 2–4/month | 43 (34.1) | 36 (37.9) | 33 (34.7) | 85 (39.7) |
| 5–8/month | 25 (19.8) | 15 (15.8) | 13 (14.0) | 30 (14.0) |
| 9–14/month | 17 (13.5) | 11 (11.6) | 7 (7.5) | 18 (8.4) |
| 15/month– | 11 (8.7) | 8 (8.4) | 10 (10.8) | 15 (7.0) |
| Not specified | 3 (2.4) | 4 (4.2) | 7 (7.5) | 14 (6.5) |
| Headache Pain Intensity, NRS, mean (SD) | 6.6 (1.5) | 6.4 (1.9) | 5.8 (2.0) | 4.3 (1.9) |
| Headache Pain Intensity, NRS, n (%) | ||||
| 1 | 0 | 0 | 0 | 5 (2.3) |
| 2 | 0 | 1 (1.1) | 3 (3.2) | 26 (12.1) |
| 3 | 4 (3.4) | 9 (9.5) | 13 (14.0) | 51 (23.8) |
| 4 | 4 (3.4) | 9 (9.5) | 10 (10.8) | 40 (18.7) |
| 5 | 19 (16.3) | 10 (10.5) | 21 (22.6) | 32 (15.0) |
| 6 | 27 (23.2) | 10 (10.5) | 7 (7.5) | 29 (13.6) |
| 7 | 26 (22.4) | 30 (31.6) | 17 (18.3) | 16 (7.5) |
| 8 | 31 (26.7) | 17 (17.9) | 17 (18.3) | 11 (5.1) |
| 9 | 1 (0.9) | 5 (5.3) | 2 (2.2) | 1 (0.5) |
| 10 | 4 (3.4) | 4 (4.2) | 3 (3.2) | 1 (0.5) |
Headache characteristics and headache-induced impairment in daily activities
The distributions of headache frequency and intensity in each headache group are shown in Table 2 and Supplementary Fig. 1. The most common frequency range was 2–4/month across all the groups. A headache frequency of ≥ 15 days per month was observed in 8.7%, 8.4%, 10.8%, and 7.0% of individuals in the MO, pMO, MA, and TTH groups, respectively (Table 2, Supplementary Fig. 1). With respect to headache intensity, NRS scores were significantly higher in the MO, pMO, and MA groups than in the TTH group (6.6 ± 1.5, 6.4 ± 1.9, and 5.8 ± 2.0 vs. 4.3 ± 1.9, respectively, p < 0.0001, the Kruskal–Wallis test followed by Dunn’s multiple comparisons test, Table 2). However, no differences in NRS scores were observed among age groups (p = 0.7074, Kruskal–Wallis test) (Supplementary Fig. 2). The proportions of individuals reporting that headache interfered with daily activities “sometimes”, “often”, or “always” were significantly greater in the MO, pMO, and MA groups than in the TTH group (95.7%, 90.5%, and 84.9% vs. 58.9%, respectively, p < 0.0001, Fisher’s exact test) (Fig. 1). A significantly greater proportion of individuals in the MO, pMO, and MA groups reported that they felt the need to lie down during headache attacks 'sometimes,' 'often,' or 'always' compared to those in the TTH group (93.1% [p = 0.0002], 90.5% [p = 0.0066], 92.5% [p = 0.0011] vs. 77.5%, respectively, Fisher’s exact test) (Fig. 1). Moreover, a significantly greater proportion of individuals in the MO, pMO, and MA groups worried about planning social or leisure activities because they might have a headache compared to those in the TTH group (25.0% [p < 0.0001], 18.9% [p = 0.0051], and 19.4% [p = 0.0048] vs. 7.5%, respectively, Fisher’s exact test). Across all the headache groups, those who were worried about doing so reported a significantly greater impact of their headache on their regular daily activities, other than working at a job, compared with those who were not worried (Table 3).
Fig. 1.
Frequency of negative impact of headache (interfering with daily activities and feeling the need to lie down) in each headache group. Blue: never, Orange: rarely, Gray: sometimes, Yellow: often, Green: always). The number of respondents in each headache group is shown in parentheses
Table 3.
Interactal burden and impact on non-job daily activities in each headache group
| Headache Group | Worrying about planning | N (%) | Impact on non-job daily activities (SD) | p |
|---|---|---|---|---|
| MO | Yes | 29 (25.2) | 5.8 (3.0) | 0.0002 |
| No | 86 (74.8) | 3.4 (2.5) | ||
| pMO | Yes | 17 (18.9) | 4.3 (2.3) | 0.0053 |
| No | 73 (81.1) | 2.4 (2.6) | ||
| MA | Yes | 17 (19.5) | 5.6 (2.5) | < 0.0001 |
| No | 70 (80.5) | 2.4 (2.5) | ||
| TTH | Yes | 16 (7.8) | 4.2 (2.7) | 0.0002 |
| No | 188 (92.2) | 1.7 (1.8) |
Headache management and healthcare resource utilization
Among the 605 individuals with active chronic headache, 382 (63.1%) had never sought care for their headaches, and only 63 (10.4%) were consulting a healthcare professional at the time of the survey. The remaining 160 individuals had discontinued seeing their physicians. Regardless of headache diagnosis, the majority of patients reported utilizing over-the-counter (OTC) analgesics (81.0%, 62.1%, 58.1%, and 55.1% in the MO, pMO, MA, and TTH groups, respectively) to relieve their headaches (Fig. 2). Compared with TTH, migraine was associated with a higher consultation rate at the time of survey (10.3% [p = 0.1919], 17.9% [p = 0.0028], 17.2% [p = 0.0047], and 6.2% in MO, pMO, MA, and TTH, respectively, Fisher’s exact test). With respect to prescribed medications, only a small proportion of active migraine sufferers used triptans (10.3%, 8.4%, and 8.6% in the MO, pMO, and MA groups, respectively). Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as loxoprofen and ibuprofen, were commonly prescribed (10.3%, 10.5%, and 18.3% in the MO, pMO, and MA groups, respectively). The use of migraine preventives was uncommon (6.0%, 8.4%, and 8.6% in the MO, pMO, and MA groups, respectively).
Fig. 2.
Headache management patterns among individuals with active chronic headache disorders. The data are shown for all participants (All) and separately for each headache group (MO, pMO, MA, and TTH). Data are presented as percentage points in each category
Factors relevant to seeking medical care
We sought to determine which clinical features were linked to seeking medical care among individuals with active chronic headache. In this analysis, we examined the proportion of individuals who were seeking medical care at the time of the survey. According to the univariate analysis, severe headache intensity (NRS: 8–10) significantly increased the likelihood of seeking medical care compared with that associated with mild headache intensity (NRS: 1–4) (odds ratio [OR]: 2.46, 95% confidence interval [CI]: 1.18–4.83, p = 0.0133). In logistic regression analyses in which age group, sex, and headache frequency were used as covariates, vomiting, photophobia, and worsening by physical activity were found to be associated with seeking medical care (Fig. 3A). On the other hand, the frequency of feeling the need to lie down did not influence the likelihood of seeking medical care (Fig. 3B). The frequency of interference with daily activities due to headache tended to increase the likelihood of seeking medical care, although this difference was not statistically significant (p = 0.3669, Fisher’s exact test) (Fig. 3B). A stepwise logistic regression analysis revealed that age (older people were more likely to seek medical care), photophobia, and worsening physical activity were significant predictors of seeking medical care (Supplementary Table 2).
Fig. 3.
A Clinical features linked to the likelihood of seeking medical care. Data are presented as forest plots, with each bar representing the mean and corresponding 95% confidence interval of the odds ratio for each clinical feature. Numerical data are presented on the right. B Effects of the frequency of negative impact of headache (interfering with daily activities and feeling the need to lie down) on the frequency of patients currently seeking medical care. The vertical axis indicates the proportion of individuals currently seeking medical care. The horizontal axis indicates the frequency with which their headache interferes with daily activities (blue) and makes them feel the need to lie down (brown)
Productivity loss due to headache in the workplace
We compared the impact of headache on work productivity among the headache groups using WPAI metrics. With respect to absenteeism, the number of missed hours due to headache per week did not differ among the headache groups (0.84 ± 3.96, 0.08 ± 0.44, 0.41 ± 1.97, and 0.20 ± 1.87 in the MO, pMO, MA, and TTH groups, respectively; p = 0.838, Kruskal–Wallis test; Fig. 4A). In terms of presenteeism, work productivity was significantly more compromised in the MO, pMO, and MA groups than in the TTH group (3.2 ± 2.5 [p < 0.0001], 2.5 ± 2.5 [p = 0.0131], and 2.5 ± 2.6 [p = 0.018] vs. 1.5 ± 1.9, respectively; Kruskal–Wallis test followed by Dunn’s test; Fig. 4B). The impact of headache on work productivity increased with headache frequency and intensity in individuals with migraine (MO, pMO, and MA) (Fig. 5A). These correlations were less robust in those with TTH (Fig. 5B).
Fig. 4.
A Missed hours due to headache per week in each headache group. The data are presented as box-and-whisker plots. Between-group comparison was performed by Kruskal–Wallis test. B Missed hours due to headache per week in each headache group. The data are presented as box-and-whisker plots. Between-group comparison was performed by Kruskal–Wallis test followed by Dunn’s test. The number of respondents in each headache group is shown in the parentheses
Fig. 5.
Correlations of the impact of headache on work productivity with headache frequency and intensity in patients with migraine (A) and TTH (B). On the left, the data are presented as box-and-whisker plots. Statistical analyses were performed by Kruskal–Wallis test followed by Dunn’s test (left) and Pearson’s test (right). For migraine, the combined data from the MO, pMO, and MA groups were analyzed
Based on the wage data provided by the Ichikawa City Office, we estimated headache-associated economic loss (lost wage) in each headache group. The annual estimated wage loss due to headache was highest in the MO group, totaling 39,202,191.2 JPY (267,463.9 USD) per year, 81.6% of which was derived from presenteeism (Fig. 6A and 6B, Table 4). The annual estimated wage loss per capita in the MO group was 355,828.9 JPY (2,427.7 USD) (Table 4). The detailed data for each headache group are presented in Table 4. It was estimated that active chronic headache disorders were responsible for 8.6% of the total wage.
Fig. 6.
Economic loss due to chronic headache disorders among employees of Ichikawa City Office. A On the left hand, gross annual estimates of wage loss in each headache group. On the right hand, the breakdown into the presenteeism (light green) and absenteeism (sky blue) portions is shown. B Annual estimates of wage loss per capita in each headache group. The amounts are indicated in 10,000JPY
Table 4.
Annual estimated wage loss due to headache in each headache group (in JPY)
| Headache Group | Total | Per capita | ||||
|---|---|---|---|---|---|---|
| Mean | 95% CI | Mean | 95% CI | |||
| Lower | Upper | Lower | Upper | |||
| MO | 39,202,191.2 | 20,487,060.1 | 57,917,322.3 | 355,827.9 | 185,955.6 | 525,700.2 |
| pMO | 18,481,664.3 | 7,170,299.0 | 29,793,029.7 | 229,673.9 | 89,106.2 | 370,241.6 |
| MA | 23,266,730.1 | 9,874,946.1 | 36,658,514.1 | 274,281.7 | 116,411.6 | 432,151.9 |
| TTH | 27,486,097.6 | 16,757,831.1 | 38,214,364.1 | 142,586.6 | 86,932.7 | 198,240.4 |
| Grand total | 108,436,683.3 | 54,290,136.3 | 162,583,230.2 | - | - | - |
Discussion
The present study revealed that only 10.4% of individuals suffering from active chronic headache sought medical care for their headache among employees of Ichikawa City Office. The frequencies of MO, pMO, MA, and TTH reported as the most severe and distressing headache experienced in the past 12 months were 6.0%, 4.9%, 4.8%, and 11.1%, respectively. Compared with TTH, migraine has been shown to cause greater disability and impact work productivity. The impact of headache extended to the interictal period and adversely affected the regular daily activities outside of work, which was more pronounced in individuals with migraine than in those with TTH. Migraine caused greater economic loss than TTH, as measured by wage loss. More than 80% of headache-associated economic loss was found to be derived from presenteeism. Our findings underpin that protecting brain health in employees must include the recognition and treatment of chronic headache disorders to maintain a healthy, productive workforce. To the best of our knowledge, this is the first study to provide a quantitative assessment of work productivity loss within an administrative body.
Although individuals with chronic headache disorders are aware of high disability, they are unlikely to seek medical care [6, 9–13]. Our analysis showed that migrainous features (worsening by physical activity, vomiting, and photophobia) increased the likelihood of seeking medical care. Nevertheless, the current consultation rate among individuals with migraine was found to be only 10–17%, implying that the effect size of migrainous features for prompting a medical consultation was relatively small. A remarkable finding was that their behavior was not affected by the frequency of headache-induced disabilities. This contrasts with the findings of a medical claims-based study conducted in Japan, which is likely to reflect the situation in the general population [18]. Our questionnaire did not ask about the reason for not seeking medical care. In a previous survey conducted at a Japanese information technology company, 57% of individuals with migraine were shown to consider their headaches not severe enough to require a medical consultation [6]. Our logistic regression analysis revealed that younger people tended not to seek medical care. This phenomenon cannot be explained by differences in headache intensity (Supplementary Fig. 2). Although younger people are more susceptible to migraine, they may be too attached to their job to find an opportunity to seek medical care. With respect to migraine management, the proportion of people relying on OTC analgesics was high, especially in the MO group. Approximately 60% of Japanese patients with migraine were reported to use OTC analgesics in the OVERCOME [Japan] study [19]. The wide availability of OTC analgesics in Japan is very likely to be relevant to the low rate of seeking medical care. OTC analgesics have been shown to be effective in relieving headaches with good cognitive and behavioral effects [20]. However, they are not only a suboptimal treatment choice but also increase the risk of developing medication-overuse headache (MOH) [21]. This information should be provided to migraine sufferers more thoroughly. On the other hand, our data revealed low utilization of triptans and migraine preventives, which is unfortunate because our data revealed that one-third to one-half of individuals with migraine in our cohort experienced more than four headache days per month and would likely benefit from migraine-specific therapy [15] (Table 2). As a rule, all residents living in Japan are covered by health insurance, and even CGRP-targeting antibodies can be used only if a traditional migraine preventive drug fails due to ineffectiveness, intolerance, or safety concerns (https://www.mhlw.go.jp/content/12404000/000768564.pdf). Therefore, restrictive health policies are unlikely to constitute a significant barrier to appropriate treatment. Several lines of evidence show that CGRP-targeting antibodies improve migraine-induced productivity loss [22–25]. In Japan, one dose of CGRP-targeting antibody costs patients approximately 14,000 JPY. On the assumption that CGRP-targeting antibody therapy reduces migraine days by half, our data showed that this treatment would be cost effective. Under the wage system of the Ichikawa City Office, five doses of a CGRP-targeting antibody would be equivalent to economic loss due to absenteeism in individuals with MO. To increase the consultation rate, we need to increase public awareness of recent progress in migraine therapy. Concomitantly, education on the diagnosis and management of primary headache disorders among healthcare providers is imperative.
Our study supports previous findings that chronic headache disorders cause economic loss mostly from presenteeism in the workplace [26]. Many individuals are likely to remain at work while enduring headache symptoms. Our data demonstrated that the negative impact of headache on work efficiency is positively correlated with the frequency and intensity of headache, which highlights the need to manage headache symptoms appropriately to enhance work productivity. Consistent with previous studies, our data show that migraine causes greater productivity loss and interictal burden than TTH. The present study revealed that chronic headache disorders, especially migraine, remain underdiagnosed and undertreated and reduce functionality within an administrative body, thus potentially compromising the quality of public service to local residents. Because similar situations are likely to exist ubiquitously, this problem should be addressed at the global level. The effective execution of administrative work depends on physical, mental, and social well-being, as emphasized in the concept of brain health [27]. The elevated anxiety, reduced quality of life, and impaired productivity can be interpreted as evidence that chronic headache, especially migraine, imposes a broad burden on neurological and psychological well-being. To maintain the brain health of individuals with chronic headache disorders, simply encouraging them to consult a physician is not sufficient. The implementation of comprehensive migraine education and management programs in the workplace, including instructions for lifestyle improvement, has been shown to reduce absences and increase work productivity [28, 29]. To achieve the goal of enhancing societal productivity, we should introduce such in-house educational systems in collaboration with administrative bodies and corporations. Additionally, industrial physicians should provide headache treatment themselves or refer headache sufferers to headache specialists. These activities would increase awareness of headache disorders among workers. This is important, especially for city servants, because they may be directly involved in healthcare administration for citizens.
In the present study, analyses were conducted in each headache group, enabling comparisons between MO and MA. Importantly, such a distinction has not been made in any of the studies focusing on headache characteristics and work productivity loss among workers with migraine [6–8, 26]. Our data revealed that clinical characteristics, such as headache frequency, headache intensity and accompanying symptoms, were milder in patients with MA than in those with MO. Congruently, the economic loss per capita was found to be lower in patients with MA. There have been controversies over whether MOs and MAs are distinct clinical entities or subtypes of the same disorder. They differ in genetics, age of onset, hormonal influences, and future vascular risk [30]. The hypothalamus is now considered an important migraine generator [31]. On the other hand, cortical spreading depolarization/depression (CSD), which underlies migraine aura [32], is a fundamentally different neural abnormality—and this may contribute to qualitatively different headache presentations. Consistent with our data, epidemiological studies have reported milder headache phenotypes [33, 34], which might explain the less marked effect of MA on economic loss. In this context, we should consider the influence of the ICHD-3 criteria of MA, which do not define the characteristics of headache apart from the temporal association.
There are several limitations to the present study. First, the response rate of our questionnaire was 52.3%, which was lower than that reported in similar previous studies [8]. We should consider a potential for overrepresentation of symptomatic individuals due to voluntary participation. However, the estimated prevalence of migraine in the present study was consistent with previous findings, which supports the validity of our data sampling. Second, as this study relied on self-reported data, it is susceptible to recall bias, resulting in uncertainty in headache diagnosis. For example, what respondents understood as visual aura might be false because we sometimes encounter patients who mistake photophobia for visual aura. The duration and development of visual aura was not thoroughly confirmed in the survey. Moreover, our questionnaire was not able to identify individuals with cluster headaches, although its prevalence is 41–381 individuals per 100,000 [35]. Our inability to capture cluster headache may be due to the combined effect of the transient nature of episodic cluster headache and recall bias. In the present study, we utilized higher headache intensity (numeric rating scale (NRS) ≥ 7)), a short duration of headache attacks (≤ 3 h), and cranial autonomic symptoms as diagnostic criteria for cluster headache. More robust criteria might be necessary to diagnose cluster headache in questionnaire-based surveys. Third, to minimize the burden on respondents, our questionnaire asked them only about their most severe and distressing headache. We should bear in mind that there are individuals who have multiple headache types. In this way, we likely underestimated the prevalence of TTH because migraine sufferers have been shown to have TTH at a similar rate to that of the general population. Lastly, regarding the generalizability of our findings, urban public sector employees may differ in both health behaviors and job structure from individuals in rural settings or the private sector, which could limit external validity. Despite these limitations, the present study provides important evidence that chronic headache disorders are a threat to brain health within an administrative body in contemporary society.
Conclusions
The present study revealed that chronic headache disorders, particularly migraine, are common even among people working in administrative bodies. This unfavorable situation is likely to result in considerable harm to society as well as tax waste. To solve this problem, every measure should be taken to prompt medical consultations, especially among young people suffering from migraine. This principle should align with the practice of brain health. In this context, the WBD activity would facilitate the dissemination of the tenet that chronic headache disorders pose a threat to brain health across society.
Supplementary Information
Acknowledgements
The authors thank staff at the Department of Public Health and Medical Services, Ichikawa City Office for their kind cooperation with the present study.
Authors’ contributions
MS conceived the present study and asked for assistance from staff at the Department of Public Health and Medical Services, Ichikawa City Office. All authors participated in the study design and interpretation of study results and in the drafting, critical revision, and approval of the final version of the manuscript. RT supervised the statistical analyses.
Funding
The present study was supported by a research fund from Tokyo Dental College.
Data availability
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval for the present study was obtained from the Tokyo Dental College Ichikawa General Hospital Ethics Committee (Authorization number: I 24–05). This was a voluntary survey, and all participants provided informed consent prior to participation on the condition that their data would be anonymized.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.