title: Primary headache disorders in the adult general population of Pakistan - a cross sectional nationwide prevalence survey.
abstract: BACKGROUND
  The large geographical gaps in our knowledge of the prevalence and burden of headache disorders include almost all of Eastern Mediterranean Region (EMR). We report a nationwide population-based study in Pakistan, an EMR country with the sixth largest population in the world, conducted as a project within the Global Campaign against Headache.
  
  
  METHODS
  We surveyed six locations from the four provinces of Pakistan: Punjab, Sindh, Khyber Pakhtunkhwa and Baluchistan. We randomly selected and visited rural and urban households in each. One adult member (18-65 years) of each household, also randomly selected, was interviewed by a trained non-medical interviewer from the same location using a previously-validated structured questionnaire translated into Urdu, the national language. We estimated 1-year prevalences of the headache disorders of public-health importance and examined their associations with demographic variables using multivariate analysis.
  
  
  RESULTS
  There were 4223 participants (mean age 34.4 ± 11.0 years; male 1957 [46.3%], female 2266 [53.7%]; urban 1443 [34.2%], rural 2780 [65.8%]). Participation proportion was 89.5%. Headache in the previous year was reported by 3233 (76.6% [95% CI: 75.3-77.8%]). The age- and gender-adjusted 1-year prevalence of migraine was 22.5% [21.2-23.8%] (male 18.0% [16.8-19.2%], female 26.9% [25.6-28.2%]), of tension-type headache (TTH) 44.6% [43.1-46.1%] (male 51.2% [49.7-52.7%], female 37.9% [36.4-39.4%]), of probable medication-overuse headache 0.7% [0.5-1.0%] (male 0.7% [0.5-1.0%], female 0.8% [0.5-1.1%]) and of other headache on ≥15 days/month 7.4% [6.6-8.2%] (male 4.4% [3.8-5.0%], female 10.4% [9.5-11.3%]). Migraine was more prevalent in females by a factor of 3:2 although this association barely survived (P = 0.039) after correcting for other factors. TTH was more prevalent in males by about 4:3 (P = 0.026). All headache and migraine were age-related, peaking in the age group 40-49 years; TTH peaked a decade earlier. Higher education (P = 0.004) and income (P = 0.001) were negatively associated with prevalence of migraine.
  
  
  CONCLUSIONS
  With three quarters of its population affected, headache disorders must be on the public-health agenda of Pakistan. Worldwide, these disorders are the third leading cause of disability; information from specific enquiry into the burden attributable to headache disorders in this country is needed to inform health policy and priority-setting, and will be reported soon.
authors.affiliation: Headache Research Foundation of Pakistan, Karachi, Pakistan.|Department of Surgery, University of Texas at San Antonio, San Antonio, TX, USA.
authors.forename: A A
authors.initials: AA
authors.lastname: Herekar
authors.affiliation: Headache Research Foundation of Pakistan, Karachi, Pakistan.|Dow University of Health Sciences, Karachi, Pakistan.
authors.forename: A
authors.initials: A
authors.lastname: Ahmad
authors.affiliation: Headache Research Foundation of Pakistan, Karachi, Pakistan.|Dow University of Health Sciences, Karachi, Pakistan.
authors.forename: U L
authors.initials: UL
authors.lastname: Uqaili
authors.affiliation: Headache Research Foundation of Pakistan, Karachi, Pakistan.|Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida College of Medicine, Gainesville, FL, USA.
authors.forename: B
authors.initials: B
authors.lastname: Ahmed
authors.affiliation: Headache Research Foundation of Pakistan, Karachi, Pakistan.|Dow University of Health Sciences, Karachi, Pakistan.
authors.forename: J
authors.initials: J
authors.lastname: Effendi
authors.affiliation: Headache Research Foundation of Pakistan, Karachi, Pakistan.|Department of Medicine, University of Nevada, Las Vegas, USA.
authors.forename: S Z
authors.initials: SZ
authors.lastname: Alvi
authors.affiliation: Aga Khan Medical College, Aga Khan Medical University Hospital, Karachi, Pakistan.
authors.forename: M A
authors.initials: MA
authors.lastname: Shahab
authors.affiliation: School of International and Public Affairs, Columbia University, New York, NY, USA.
authors.forename: U
authors.initials: U
authors.lastname: Javed
authors.affiliation: Headache Research Foundation of Pakistan, Karachi, Pakistan.|Department of Neurology, Baqai Medical University, Karachi, Pakistan.
authors.forename: A D
authors.initials: AD
authors.lastname: Herekar
authors.affiliation: Department of Pathology and Microbiology Department at Dow University of Health Sciences, Karachi, Pakistan.
authors.forename: Rafiq
authors.initials: R
authors.lastname: Khanani
authors.affiliation: Department of Neuroscience, Norwegian University of Science and Technology (NTNU), Edvard Griegs Gate, NO-7491, Trondheim, Norway. t.steiner@imperial.ac.uk.|Division of Brain Sciences, Imperial College London, London, UK. t.steiner@imperial.ac.uk.
authors.forename: T J
authors.initials: TJ
authors.lastname: Steiner
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D051270:Headache Disorders, Primary / Q000453:epidemiology*; D051271:Headache Disorders, Secondary / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008881:Migraine Disorders / Q000453:epidemiology; D010154:Pakistan / Q000453:epidemiology; D015995:Prevalence; D018781:Tension-Type Headache / Q000453:epidemiology; D055815:Young Adult
keywords: Eastern Mediterranean Region; Epidemiology; Global campaign against headache; Headache disorders; Medication-overuse headache; Migraine; Pakistan; Population-based survey; Prevalence; Tension-type headache