Economic impact of primary headaches in Turkey: a university hospital based study: part II

Abstract

This study was planned to investigate the economic impact of headache on Turkish headache sufferers attending a tertiary care outpatient headache clinic. A total of 937 headache patients were included in this study and questioned using a questionnaire for the profile of patients and headache, quality of life of patients and economic impact of headache. The median total direct cost was found to be 88.0 USD and the median total cost was 160.7 USD. The drug treatment cost was the highest item followed by the specialist outpatient care cost. The average lost and inefficient work/school days was 1.5 (0-45) and 8.4 (0-100) days for one year. It was shown that loss of productivity was higher for migraine without aura group when compared with the episodic and chronic tension-type headache groups. The results of this nationwide university hospital based study methshowed that headache, especially migraine, has considerable economic impact on patients.[PUBLICATION ABSTRACT]

J Headache Pain (2006) 7:7582

DOI 10.1007/s10194-006-0273-7 ORIGINALNecdet KarlMehmet Zarifolu

Mustafa Erta

Sabahattin Saip

Vesile ztrkebnem Bak

Cavit Boz

Deniz Seluki

Atilla Ouzhanolu

Mnife Neyal

Aksel SivaCeyla rke

Hakan Kaleaas

Tlay Kansu

Yakup Sarca

Nebahat Tademir

Nevzat UzunerEconomic impact of primary headaches

in Turkey: a university hospital based study:

part IIReceived: 27 January 2006Accepted in revised form: 27 February 2006

Published online: 15 March 2006N. Karl () M. ZarifoluDepartment of Neurology,

School of MedicineUniversity of Uludag

16059 Gorukle, Bursa, Turkey

e-mail: [email protected]

Tel.: [phone]

Fax: [phone]M. ErtaIstanbul School of Medicine,

University of stanbulS. Saip A. SivaCerrahpaa School of Medicine,

University of stanbulV. ztrkSchool of Medicine,University of Dokuz Eyll. Bak Y. SarcaSchool of Medicine,University of ukurovaC. BozSchool of Medicine,University of Karadeniz TechnicD. SelukiSchool of Medicine,University of Celal BayarA. OuzhanoluSchool of Medicine,University of PamukkaleM. NeyalSchool of Medicine,University of GaziantepC. rkeSchool of Medicine,University of GaziH. KaleaasSchool of Medicine,University of MersinT. KansuSchool of Medicine,University of HacettepeN. TademirSchool of Medicine, University of DicleN. UzunerSchool of Medicine,University of OsmangaziAbstract This study was planned

to investigate the economic impact

of headache on Turkish headache

sufferers attending a tertiary care

outpatient headache clinic.A total of 937 headache patients

were included in this study

and questioned using

a questionnaire for the profile of

patients and headache, quality of

life of patients and economic

impact of headache. The median

total direct cost was found to be88.0 USD and the median total

cost was 160.7 USD. The drug

treatment cost was the highest

item followed by the specialist

outpatient care cost. The average

lost and inefficient work/school

days was 1.5 (045) and 8.4

(0100) days for one year.

It was shown that loss of productivity was higher for migraine

without aura group when compared with the episodic and chronic tension-type headache groups.

The results of this nationwide

university hospital based study76showed that headache, especially

migraine, has considerable economic impact on patients.Key words Headache Tensiontype headache Migraine

Economic impact Loss of work

daysIntroductionHeadache is one of the most common complaints, with a

lifetime prevalence of 95% for women and 90% for men[1]. Migraine has a 1-year prevalence rate of 10%12%

and a lifetime prevalence rate of 12%18%, which is ageand gender-dependent in community-based studies from

different parts of the world [2]. The lifetime prevalence of

migraine in Turkey was defined as 8% in males and 17%

in females in a nationwide epidemiological survey [3].

The prevalence of tension-type headache (TTH) was

found to be 31.7% in this survey [3]. The International

Headache Society (IHS) defined the criteria for all

headache types, mainly migraine and TTH [4], which is

pathophysiologically less understood but more frequent,

with a 1-year prevalence rate of 60%, than migraine [5].Although treatment modalities have improved in recent

years, headache, particularly migraine, continues to be one

of the major health problems resulting in deterioration in

the quality of life (QoL), social life and work capacity of

sufferers and is an important economic burden on society

[68]. Headache sufferers were reported to experience

more restriction of their daily activities than patients with

depression, osteoarthritis, diabetes or hypertension [9].

Migraine, quadriplegia, psychosis and dementia are

accepted to be the most disabling diseases, which cause

maximum functional loss in patients life, by the World

Health Organization [10]. In a population survey, it was

found that half of migraine and TTH sufferers discontinued

normal activities during their attacks and most of them

required bed rest, preventing them from going to work or

working efficiently [11]. Headache sufferers are mostly at

their most productive ages. Migraine has its peak prevalence between 20 and 40 years of age. Such a common disorder in these very productive ages causing more disability and restriction of life than many other severe diseases

has an important effect on the patients themselves, on society and the economy as well. A number of studies in West

European and North American countries have shown this

effect, particularly the economic part [1215]. In a large

epidemiological survey in France, total annual direct

healthcare costs were estimated to be 128 per individual

with migraine in 1999 and the total annual direct cost of

other forms of episodic headache was much lower at 28 per

individual [12]. Besides direct cost, indirect costs such as

lost productivity have been shown to be an important economical burden on societies [16, 17]. As headache is such

a prevalent disorder, even the smallest economic loss per

person might have a great impact on the countries

economies. This economic loss means a lot more to a

developing country than a developed country. The economic burden of headache has mostly been investigated in

Western European or North American countries. This study

aimed to investigate the economic burden of headache on

the patient and the society in tertiary care headache centres

in a developing country.Patients and methodsThis was a cross-sectional epidemiological survey performed in

university hospitals located in the seven main geographical

regions of Turkey, between December 2001 and August 2002.

All centres started recruitment on different dates according to

the convenience of their schedules and the study was terminated

on 31 August. Different numbers of patients (30120) were

recruited from headache centres.All patients with a diagnosis of primary headache according

to the International Classification of Headache Disorders I [18]

were recruited randomly from outpatient headache clinics and

questioned for the profile of patients and headache according to

IHS criteria [18], treatment approaches and methods used for

diagnosis during the last year, QoL of patients and socioeconomic impact of headache on the patients and society. The study

questionnaire was applied to the patients face to face by trained

research assistants at outpatient headache clinics. Before administering the questionnaire patients were asked if they had a

headache or not. Patients who had a headache were called on a

headache-free day in order to form a unique group and prevent

the effects of headache on patients cooperation.This paper represents the results of the economic impact of

primary headaches on the patients and indirectly on the Turkish

economy.The study data were collected using a questionnaire that contains 50 questions. Details were given in the Patients and meth-77ods section of the first part of this study. Direct costs of

headache and cost of loss of productivity were the parameters

evaluated for this study.Statistical methods for economic analysisFive types of direct costs were used: primary care physician cost, cost for diagnostic work-up, specialist outpatient care cost, drug treatment and hospital costs. These

were added to come up with the total direct cost of

headache for each patient. Primary care physician and

specialist outpatient care costs were calculated on the

basis of physician visits. Annual drug treatment costs

were calculated on the basis of monthly average analgesic

consumption and if a patient had received a prophylactic

treatment then the cost was added. Prophylactic treatment

was calculated according to the duration of the treatment

and prescribed drug cost. Indirect cost of headache was

calculated by the means of the loss of work days and loss

of efficiency at work. The total cost of headache to the

patient and the society was the sum of direct and indirect

costs. The ratio of total cost of headache per patient to

Gross National Product per capita estimated from the

Turkish State Institute of Statistics (3383 USD) was used

to calculate the ratio of costs to average income. The foreign exchange conversion rate of the Ministry of Finance

as of 1 March 2004 (1 USD: 1 314 825 Turkish Lira (TL))

was used to convert expenditure into United States

Dollars on which date the drug prices for 2004 were

released by the Ministry of Health. The applicable charges

for the same date for hospital stay, outpatient visits and

diagnostic work-up were retrieved from the price list

declared by the Ministry of Finance.The indirect cost calculations used the current daily

minimum wage of 14.08 USD, announced by the government officially twice a year, as the cost of the loss of a

work day. Two inefficient days at work were regarded as

a day absent from work.Outcome data were classified according to types of

headache and several patient characteristics. Cost analysis

excluded one patient without adequate financial data.

Patients who suffer from more than one headache type

(other than combined headache) were excluded from the

cost analysis of the subgroups of headaches that they were

suffering from. Those patients have been analysed under

the heading of other headaches, which included cluster

headache, paroxysmal hemicrania, other infrequent primary headaches and multiple headache diagnosis. Chronic

daily headache was used for chronic migraine, 15 or more

migraine days in a month.The differences between different patient subgroups

for cost and loss of productivity were analysed using the

Mann-Whitney U-test for dichotomous groups while

Kruskal-Wallis and Jonckheere-Terpstra tests were used

for groups with nominal and ordinal categories, respectively. The level of statistical significance was defined as

p<0.05 for global comparisons. With the region and

headache type variables pairwise comparisons were performed using Bonferroni correction which pushed the p-value level of significance down to 0.00341 for multiple

comparisons.The corresponding authors university ethics committee approved the study and all patients gave informed consent prior to their inclusion in the study.ResultsPatients profileA total of 937 patients (81.5% female and 71% over 30

years of age) were included in the study. One patient was

excluded because of inadequate data. The headache profile

and QoL of patients were summarised in the first part of

this study. The frequency of severe headache was highest in

chronic daily (5 attacks/week and 16 attacks/month) and

chronic tension-type (5 attacks/week and 14 attacks/month)

headache. The number of headache days in a month were

20 days for chronic daily headache, 17 days for chronic

TTH and 13 days for combined headache sufferers.Diagnosis and treatment of headacheThe most common diagnostic tests were blood tests(53.2%), plain X-ray (50.0%) and cranial CT scan(44.5%) followed by cranial MR (21.1%).

Only 4% of the patients had been hospitalised for treatment of headache. Over 93% of the subjects used analgesics when they had headache, while 18% of all subjects

used analgesics regularly and 28% of all subjects used a

prophylactic agent regularly prescribed by a doctor in addition to the analgesics. The most common analgesic used for

headache attacks was naproxen sodium (77.0%). Naproxen

and paracetamol were also the most common analgesics

used regularly (26.4% and 17.4% respectively) (Table 1).

The most common prophylactic agents prescribed were

amitriptyline HCl (31.0%) and sertraline (21.0%).About one-tenth (9%) of the whole study population

preferred alternative therapies to relieve headache. These

therapies included herbal drugs (33%), physiotherapy/regular massage (24%), acupuncture (18%), seeking help from

religious sources (16%) and relaxation techniques (14%).78Direct and total costsAs shown in Table 2, the average total direct cost per

patient was found to be 162.0 USD with a median of 88.0

USD (range: 7.61748.2). The average total cost (both

direct costs and indirect costs) was 242.2 USD with a

median of 160.7 USD (range: 7.61908.5). The average

ratio of total cost per patient to Gross National Product per

capita for Turkey, which is 3383 USD for 2003, is 7.2%

with a median of 4.7% (range: 0.2%56.5%). The drug

treatment cost was the highest item (mean: 124.4 USD)

followed by the specialist outpatient care (mean: 18.1

USD) and diagnostic work-up (mean: 17.6 USD) costs. In

Table 3 all costs used to calculate direct and indirect costs

are given in detail.Subgroup analysis showed that the direct costs significantly differed by the type of headache and region of residence. Age group, gender and education level differences

were found to be statistically insignificant. Total direct

cost per patient was highest at 178.7 USD in the age group

of 2029 years. Migraine with and without aura had the

highest average total direct costs per patient, which were

250.5 USD and 225.6 USD respectively. TTH groups

(episodic and chronic) had lower costs when compared to

both migraine with aura (MA) and migraine without aura

(MO). Southeastern Anatolia had higher costs when compared to the other regions (Table 2).The loss of productivityThe loss of productivity was studied with the lost and

inefficient work or school days in the last year. Loss of

work/school days ranged between 0 and 45 while

decreased work/school efficiency was reported to range

from 0 to 100 days for one year. The loss of work/school

days was highest in MO, CDH and combined headache

(migraine and TTH) groups. It was shown that loss of

work/school days was higher for MO when compared

with the episodic and chronic TTH groups.The differences in inefficient work or school days

among groups were only statistically significant

between the episodic TTH and combined headache

groups, the former causing the least and the latter causing the highest number of inefficient work/school days

(Table 3).DiscussionIn the second part of this large university hospital based

cross-sectional survey investigating tertiary care

headache patients profile, characteristics of primary

headaches and the effects of headaches on QoL, we primarily focused on the economic impact of headache on

patients and society.Although there is a great heterogeneity of costs of

work/school days in Turkey, we calculated the indirect

costs of headache as loss of productivity and loss of

work/school days/year, regarding minimum wage in

Turkey, which is approximately 14.08 USD/work day,

announced by the government officially twice a year. We

calculated the direct cost of headache, which is the sum of

subcomponents like primary care physician costs, cost for

diagnostic work-up, specialist outpatient care costs, drug

treatment costs and hospital costs.The average total direct cost per patient was found to

be 162.0 USD, with a median of 88.0 USD (range:7.61748.2). Von Korff et al. [19] defined the cost of

headache in a good-outcome group as 307 USD and in a

poor-outcome group as 750 USD per patient per year.

When compared to a French study, our total direct cost

for migraine is nearly two times higher [12]. In Spain,

another Mediterranean country, both direct and indirectTable 1 The analgesics used by patients for individual headache attacks and on a regular basis, either prescribed by physicians or obtained

by patients themselves (n=936)Analgesic Used only for individual headache attacks (%) On a regular basis (%)Naproxen Na 77.0 26.4

Paracetamol 74.0 17.4

Metamizol Na 35.0 15.5

Flurbiprophen 16.0 18.6

Ergotamine 15.0 11.8

Acetyl salicylic acid 12.0 13.7

Diclofenac Na 12.0 16.8

Nimesulid 11.0

Sumatriptan 17.0 13.7

Zolmitriptan 15.679Table 2 Total direct costs by patient subgroupsn Mean (SD) Median (range) SignificanceAll patients 936 162.0 (225.9) 88.0 (7.61748.2)Age group <20 53 101.1 (124.9) 31.5 1(7.6566.3) p=0.42, Jonckheere-Terpstra

test for trend2029 247 178.7 (265.1) 88.0 (7.61450.1)3039 277 164.5 (203.4) 95.1 (7.61219.0)4049 246 156.9 (206.5) 92.4 (7.61490.0)5059 93 162.3 (276.4) 56.8 (7.61748.2)6064 20 146.8 (152.2) 100.8 1(7.6647.9)Gender Female 763 165.5 (227.5) 91.3 (7.61748.2) p=0.17, Mann-Whitney U-test

Male 173 146.8 (218.9) 79.0 (7.61450.1)Geographical Southern 129 125.6 (184.5) 53.2 (7.61108.3) p<0.001, Mann-Whitney

regions U with Bonferroni correction*Southeastern 124 222.6 (154.2) 258.8 1(7.6833.7)

Northwestern 335 165.8 (250.0) 83.5 (7.61748.2)

Western 148 140.3 (216.6) 73.0 (7.61207.0)

Central 130 200.9 (288.5) 96.2 (7.61490.0)

Northern 70 77.5 (87.5) 44.9 1(7.6373.8)Marital status Married 700 163.2 (220.3) 91.3 (7.61748.2) p=0.28, Kruskal-Wallis testSingle 199 164.3 (251.9) 77.6 (7.61450.1)

Divorced/widowed 37 128.6 (181.6) 53.2 1(7.6911.4)Education No formal education 59 200.3 (289.4) 125.5 (7.61748.2) p=0.53, Jonckheere-Terpstra

test for trendPrimary school 231 143.2 (211.9) 71.5 (7.61232.0)Secondary school 107 185.6 (232.6) 128.3 (7.61490.0)

Highschool 282 164.9 (219.7) 96.6 (7.61224.5)

University 248 158.3 (227.0) 84.6 (7.61450.1)Type of headache Episodic tension 159 93.0 (115.1) 39.1 1(7.6833.7) p<0.001, Kruskal-Wallis

test**Chronic tension 168 104.8 (122.3) 53.5 1(7.6833.7)

MA 72 225.6 (206.8) 183.3 1(7.6979.1)

MO 241 250.5 (290.4) 160.5 (7.61490.0)

Combined headache 126 197.4 (281.4) 109.8 (7.61219.0)

CDH 51 120.7 (110.7) 105.3 1(7.6566.3)

Other 119 97.8 (208.2) 22.8 (7.61748.2)SD, standard deviation; MA, migraine with aura; MO, migraine without aura; CDH, chronic daily headache

*p<0.001 for Southeastern vs. all other regions with Mann-Whitney U-test; **p<0.001 for episodic tension vs. MA, episodic tension vs.

MO, chronic tension vs. MA, chronic tension vs. MO; p=0.001 for MA vs. CDH; p=0.002 for episodic tension vs. combined headache with

Mann-Whitney U-testtotal costs were higher [20]. Badia et al. [20] reported

that the highest item in direct cost was primary care visits, but it was medication in our study. The relatively

lower direct costs of headache in our study might be

explained by the cheapness of the costs of diagnostic

and treatment tools in Turkey and general lower tendency of Turkish patients to seek medical care. The explanations for the large range of direct costs in this study

are the heterogeneity of severity of headache and probably socioeconomic level of the studied population.This hypothesis was supported by the findings of the

significant difference in the direct costs of headache

regarding the type of headache and region of residence.

Patients with MA and MO were defined to have higher

costs compared to TTH. The highest total cost for

headache was in the Southeastern region. The education

level in this region is the lowest in Turkey. This might

have resulted in inappropriate use of medication and

healthcare facilities, which might have resulted in higher costs. In the western part of Turkey, total cost is in the80U

-test) when compared with the corre-MO

,MA

, migraine with aura; Group total (

n

=936)162.0 (225.9)(7.61748.2)0.9 (4.2)(0.045.6)18.1 (19.4)(7.6220.6)17.6 (33.7)(0.0163.5)124.4 (217.1)(0.01474.8)(0.0117.1)(0.045.0)88.0 14.6 0.9 (8.0)1.5 (5.1)8.4 (17.5)(0.0100.0)0.0 7.6 0.0 0.0 0.0 0.0 (

n

=119)97.8 (208.2)(7.61748.2)Other 0.6 (2.5)(0.022.8)16.1 (16.7)(7.6121.7)20.0 (38.7)(0.0163.5)(177.7)(0.01383.9)1.4 (11.4)(0.0117.1)1.8 (6.2)(0.040.0)(0.090.0)22.8 0.0 7.6 0.0 59.8 8.2 (17.1)0.0 0.0 0.0 0.0 (110.7)CDH (

n

=51)a 105.3 (7.6566.3)120.71.1 (4.6)(0.027.4)25.1 (26.8)(7.6121.7)28.4 (42.3)(0.0153.6)a, m (0.0528.3)2.9 (14.6)(0.074.5)(0.020.0)0.0 15.2 7.9 (20.7)SD

, standard deviation; 0.0 63.3(108.5)12.0 1.8 (5.3)(0.090.0)0.0 0.0 0.0 and combined headache groups); n

=126)(281.4)Combined headache ((7.61219.0)(4.6)(0.027.4)(24.8)(7.6159.7)19.9 (34.0)e (0.0127.8)m (0.01178.7)(0.0106.5)(19.4)197.4109.8 e 1.9 (12.9)(0.030.0)(0.0100.0)e 22.715.2 0.0 151.5(269.6)1.425.2 1.8 (5.2)0.0 0.0 0.0 12.30.0 e n

=936)dMO (

n

=241)(7.61490.0)e, c, h, d e, c (5.0)0.9 (3.7)The direct costs and loss of productivity of patients for the different types of headache (250.516.3 (13.4)(7.691.3)p

<0.00341, Bonferroni adjustment for multiple comparisons with Mann-Whitney (290.4)160.5 (0.027.4)17.8 (34.3)(0.0163.5)(0.01474.8)0.0 15.2 214.8(283.1)132.5 0.5 (5.1)(0.074.5)e, c (0.030.0)8.7 (16.3)(0.0100.0)h0.0 0.0 1.80.0 0.0 sponding group (e.g., a superscript of ah shows significant difference between MA(

n

=72)(29.9)e, c, d 225.6(206.8)183.3 (7.697.1)d 2.7 (9.1)(0.045.6)(7.6152.1)(0.0136.9)(210.9)e 22.9 (38.4)(0.0971.5)(0.031.9)(0.015.0)6.8 (14.6)(0.090.0)MA0.0 26.715.2 173.00.4 (3.8)1.1 (3.2)m0.0 137.7 0.0 0.0 0.0 n

=168)a, m Chronic tension ((122.3)(7.6833.7)0.6 (3.8)(0.045.6)15.7 (12.1)(7.683.7)12.1 (25.1)(0.098.9)a, m (0.0826.1)(0.010.6)(5.5)(0.045.0)9.0 (20.0)(0.0100.0)m 104.853.5 0.0 76.2(121.8)12.0 0.1 (1.2)a7.6 0.0 0.0 1.20.0 0.0 e, c, a, m, h, d: statistically significant difference (Episodic tension (

n

=159)(19.7)(115.1)a, m, h (7.6833.7)(1.7)(0.018.3)a, h (7.6220.6)13.9 (30.2)(0.0153.6)a, m (109.2)(0.0826.1)0.5 (6.0)(0.074.5)(4.8)(0.040.0)(14.7)(0.0100.0)CDH

, chronic daily headache93.039.1 0.30.0 15.37.6 0.0 63.012.0 0.0 0.90.0 5.30.0 h m h cMean (SD)Median (range)Mean (SD)(range)Mean (SD)(range)Mean (SD)(range)Mean (SD)Median (range)Mean (SD) Median (range)Mean (SD) Median (range)Mean (SD) Median (range)eSuperscript for marking significance Direct costs Total direct costs (USD)Primary care physician costs (USD)Median Specialist outpatient care costs (USD)Median Diagnostic work-up costs Drug treatment Hospitalisation (USD)Median costs (USD)costs (USD)Loss of productivity Loss of work/school daysInefficient work/school daysmigraine without aura; Table 381middle range. These regions are the most developed

regions of Turkey. Education level is higher than other

regions. As seen in the education-total cost relation,

education has a decreasing effect on the total cost of

headache. Highly educated headache patients might

avoid trigger factors and might have received better

headache management.In this study, the drug treatment cost was the highest

item (mean: 124.4 USD) followed by the specialist outpatient care (mean: 18.1 USD) and diagnostic work-up

(mean: 17.6 USD) costs. This study was conducted in the

university hospitals tertiary-care headache outpatient

clinics. In Turkey, most of the patients of the university

hospitals are covered by social security institutions of the

state. The price list for the medical services of these university hospitals are determined by the Ministry of

Finance, which the university hospitals have to obey. In

order to lower the medical expenses, the Ministry of

Finance generally declares lower prices for medical services. The price list of medical drugs is also declared by

the official authorities. However, drug prices are relatively very high when compared to the medical services given

in the university hospitals. Therefore, the costs of specialist outpatient care and diagnostic work-up were nearly

one-seventh of drug treatment cost. Social security institutions cover a great percentage of health expenses in

Turkey. The reimbursement rate for hospitalisation, investigation and doctor visits is 100%. For medication this is

80% for working patients and 100% for retired patients.

Therefore, these high reimbursement rates increase the

economic burden on society.It has been found that headache is a considerable

economic burden regarding loss of productivity [16]. In

this study, the mean loss of work/school days was1.55.1 days/year/patient and the mean inefficient

work/school days was 8.417.5 days/year/patient.

Compared to the study of Stewart et al. [17], which

reported lost productive time for patients with headache

as 3.50.1 h/week, our results indicated very much less

loss of productivity. In a population-based diary study,

migraineurs experienced an average of 3.0 lost work

days/year, which was also higher than our findings[21]. Bigal et al. [22] reported the mean number of total

lost working hours per month due to migraine as 6.5 in

a public Brazilian hospital. These variabilities might be

explained by the different designs of studies and sociocultural differences between populations. The work

attendance of Turkish patients despite headache seems

higher. The great difference between lost and inefficient work/school days supports this suggestion. In a

study on Swedish patients the ratio of going to work

despite headache among patients with headache was

50% [23].As expected, chronic TTH costs were higher than

episodic headaches. The higher loss of productivity in

chronic TTH had an important effect on the total cost. It

was shown that indirect costs as loss of productivity at

work/school days were higher for MO when compared

with the episodic and chronic TTH groups, which was

similar to the difference for direct cost. Mean total direct

cost in the MO group was higher than in MA. However,

this difference was insignificant. The differences in inefficient work/school days among groups were only statistically significant between the episodic tension-type and

combined headache groups, the former causing the least

and the latter causing the highest number of inefficient

work/school days.If indirect costs, calculated regarding minimum wage

in Turkey (14.08 USD/day), were added to direct cost, the

average total cost of migraine was found to be 242.2 USD,

with a median of 160.7 USD (range: 7.61908.5). Many

previous studies have investigated the direct and indirect

costs of headache [1215, 24]. These studies demonstrated that the indirect costs of headache were more than the

direct costs. In this study, the direct cost of migraine

seems higher than indirect costs, which might be

explained by the low minimum wage in Turkey.In order to overcome comparison difficulties between

studies and to reach a standard value to overcome the low

prices in Turkey, we calculated the average ratio of total

cost of headache per patient to Gross National Product per

capita for Turkey, which is 3383 USD for 2003. The average ratio was 7.2%, with a median of 4.7% (range:0.2%56.5%), which is strikingly high.

This study showed that headache, particularly

migraine, might have an important economic impact on

the patient and society. Therefore, in order to reduce the

economic burden of migraine, proper diagnosis and treatment of migraine becomes even more important.

Unfortunately, only 31% of migraineurs had sought help

in their lifetime. Of those, 73% were properly diagnosed

as migraine and 46% had a prescription medication [25].

Therefore, increasing awareness about migraine and proper diagnosis and treatment of migraine not only improves

the patients quality of life but helps to alleviate the economic burden as well.As a conclusion, the results of this study, which is the

first large university hospital based study investigating the

direct and indirect costs of headache in Turkey, showed

that headache has a considerable economic impact on

headache sufferers and society. Therefore, it should be

regarded as a public health problem and measures should

be taken to reduce its impact on patients and society.Acknowledgement Merck Sharpe Dohme, Turkey, provided

financial support to this study82References1. Stewart W, Celentano D, Ziegler D,Sprecher M (1989) An epidemiologic

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