and describes the incidence and prevalence of migraine disorder within this population, the direct and indirect costs for employers, and workplace challenges ...
Migraine Disorder Workplace Implications and Solutions by Peggy A. Berry, BSN, RN, COHN-S, SPHR
M
igraines have been described as chronic and debilitating with significant direct and indirect costs for the workplace due to absenteeism and presenteeism. Other costs may remain hidden due to selftreatment without a definitive diagnosis by a health care professional (Edmeads & Mackell, 2002). Although children experience migraines, this article focuses on adults and describes the incidence and prevalence of migraine disorder within this population, the direct and indirect costs for employers, and workplace challenges and solutions. Prior to 1988, health care providers had no systematic approach to diagnosing and classifying types of headaches or migraines, with or without aura. Without a classification system, researchers had no standardized method for diagnosing or identifying headache types for study purposes. The following research focuses primarily on migraine, with or without aura, as classified by the International Headache Society (IHS) (Headache Classification Subcommittee of the IHS, 2005). According to the IHS, a migraine without aura must meet the following diagnostic criteria: “recurrent headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and associated with nausea and/ or photophobia and phonophobia” (p. 29). At least five attacks, with no specific time frame, must occur with the above criteria for a diagnosis of migraine. The aura-associated migraine presents with reversible focal neurological symptoms. These symptoms are temporary, building gradually during 5 to 20 minutes and ceasing in less than 60 minutes. The classic migraine may or may not follow (Headache Classification Subcommittee of the IHS, 2005). Characteristics of an aura include visual, sensory, and speech symptoms, occurring independently or together gradually. For migraine with aura to be diagnosed, at least two attacks must occur with symptoms not attributable to any other disorder. In adAbout the Author
Ms. Berry is a master’s degree candidate in Occupational Health and Safety Nursing, University of Cincinnati College of Nursing, Cincinnati, OH.
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dition, auras may be present with hemiplegia or basilartype symptoms (e.g., dysarthria, vertigo, tinnitus, ataxia, or decreased level of consciousness). Table 1 lists informative migraine websites. Epidemiology of migraine disorder Migraine disorder is not country, gender, age, culture, or socioeconomic status specific. “Clinical episodes of headache were recorded as early as 700 B.C.” (Lofland & Lakhia, 2002, p. 489). The World Health Organization (2004) states that migraine disorder is 19th among all health-related causes for years lived with disability. Migraines are an all-inclusive disorder. The incidence and prevalence of migraine disorder are difficult to quantify. Incidence can be defined as “the rate of onset of new cases of a disease in a given population over a defined period” (Lipton, Bigal, Scher, & Stewart, 2003, p. S4). Prevalence is defined as “the proportion of a given population [with the disease] over a defined period” (Lipton et al., 2003, p. S4). Some researchers have attempted to determine incidence or prevalence rates for migraine disorder through health records. This has proven difficult, as analyses of population studies have determined that self-identified migraineurs do not always seek health care (Latin American Migraine Study Group, 2005; Lipton et al., 2003; Warshaw, Burton, Siberstein, & Lipton, 1997). Regarding the prevalence of migraine in Hungary, a survey conducted by Bank and Marton (2000) containing questions about the patient–physician relationship revealed that “only 43% of the migraineurs had consulted a physician about their migraines” (p. 166). In a Swedish study by Linde and Dahlof (2004), only 45% of self-identified migraineurs had seen a health care provider for diagnosis of their migraines. Manzoni and Torelli (2003) and Lipton and Bigal (2005) reviewed the literature to identify the incidence of migraine, finding only four relevant studies. All of these were conducted between 1991 and 1996 (Breslau, Chilcoat, & Andreski, 1996; Rasmussen, 1995; Stang et al., 1992; Stewart, Linet, Celentano, Van Natta, & Ziegler, 1991). Incidence rates varied widely between the studies, ranging from 1.5 to 2 per 1,000 person-years for men and approximately 3 to 6 per 1,000 person-years for women
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Table 1
Migraine Websites Organization
Web Address
Bandolier: Economics of Migraine
www.jr2.ox.ac.uk/bandolier/booth/Migraine/costsrev.html
International Headache Society
www.i-h-s.org
Job Accommodation Network
www.jan.wvu.edu/media/migr.htm
Medline Plus: Migraine
www.nlm.nih.gov/medlineplus/migraine.html
Merck Manual: Migraine
www.merck.com
National Headache Foundation
www.headaches.org/consumer
National Migraine Association
www.migraines.org
World Health Organization
www.who.int/mediacentre/factsheets/fs277/en
(Manzoni & Torelli, 2003). However, these studies only examined the incidence of migraines in men and women younger than 30. Breslau et al. (1996) also examined the comorbidity of neuroticism associated with migraine, finding a higher incidence of migraine with depression. Although studies of incidence are limited, population-based prevalence research has examined the extent of migraine relative to age, gender, ethnicity, and socioeconomic status. Although these studies followed different designs and approaches, all used the International Headache Classification for migraine, with or without aura (Headache Classification Subcommittee of the IHS, 2005). For the purpose of this article, large population studies in the United States, Hungary, England, France, Croatia, Latin America, Turkey, Sweden, and Austria were reviewed to describe prevalence rates for age and gender (Table 2). Other studies provide additional information regarding direct and indirect costs, comorbidity relationships, and lack of diagnosis by a health care provider. Prevalence appears highest during the peak employment years (ages 25 to 55). Whereas Table 2 provides overall population prevalence rates, segmentation of data indicates a higher prevalence from 25 to 59 years (7.2% to 9.7% for men and 21.5% to 27.3% for women) in the United States (Lipton, Stewart, Diamond, Diamond, & Reed, 2001). In the England (Steiner et al., 2003) and Austria (Lampl, Buzath, Baumhackl, & Klingler, 2003) studies, the age range was 30 to 49 years. In both studies, prevalence was higher than in the general population for individuals 30 to 49 (10.9% to 11.9% for men and 19.1% to 21.8% for women in England, and a combined migraine with or without aura for 2.7% of men and 19% of women in Austria). Celik, Ekuklu, Tokuc, and Utku (2005) reported that 75.5% of those diagnosed as migraineurs in the Turkish study were age 21 to 50 and prevalence decreased with age. Women had a higher prevalence of migraine disorder than men throughout these studies. The male-to-female ratio varied from approximately 1:2 to 1:3 in the studies listed in Table 2. The World Health Organization (2004)
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suggests this is hormonally driven, as an estimated 60% of all U.S. female migraineurs (approximately 24 million) experience migraines in association with menstrual periods (Broner & Lay, 2005). Broner and Lay (2005) state it is believed that menstrual migraines are “triggered by the steep drop in estrogen levels just prior to the onset of bleeding” (p. 4). In addition, women with endometriosis have a significantly higher prevalence of migraine, with and without aura (15.1% to 38.3%), than women without endometriosis (Ferro et al., 2004). Although migraine disorder has been shown to affect all populations, the World Health Organization (2004) lists lower prevalence rates for African (3% to 7%) and Asian (female, 10%; male, 3%) populations. In one of the first prevalence studies in Taipei, Taiwan, the migraine prevalence rate was 14.2% for women and 4.6% for men (Wang, Fuh, Young, Lu, & Shia, 2000). Lipton et al. (2001) reported a higher crude prevalence rate for Whites (female, 18.3%; male, 6.5%) than Blacks (female, 15%; male, 4.6%). Molgaard, Rothrock, Stang, and Golbeck (2002) compared the prevalence of migraine for middleage and older ethnic groups in San Diego, California. The prevalence rate for Mexican Americans was lower than that for Whites (9.2% to 14.2%), but higher than that for Blacks (6.6%). A socioeconomic association with migraine disorder appears to exist in North America and England. Lipton et al. (2001) segmented prevalence rates by income. A higher prevalence of migraine disorder was associated with decreased income in the United States (female, 20.3%; male, 10.2%). Similarly, Molgaard et al. (2002) found increasing prevalence with decreased income for Mexican American (11.8%) and White (21%) populations. However, the prevalence rate inverted for the Black population, increasing from 5.9% for incomes of $0 to $9,900 to 9.1% for incomes of $10,000 to $19,000 (Molgaard et al., 2002). In England, the prevalence of migraine was higher for men with lower incomes, but no difference existed for women (Steiner et al., 2003). A connection between lower socioeconomic status and migraine is not observed in European studies (Lipton & Bigal, 2005). The
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Table 2
Prevalence of Migraine in the General Population Prevalence (%) Study
Year
Country
Lipton, Stewart, Diamond, Diamond, & Reed
2001
United States
Zivadinov et al.*
2001
Steiner et al.
Age (y)
Study Design
Men
Women
> 12
Mail questionnaire
6.5
18.2
Croatia
15–65
Face-to-face interview
14.8
22.9
2003
England
16–65
Telephone survey
7.6
18.3
Lampl, Buzath, Baumhackl, & Klingler
2003
Austria
> 15
Face-to-face
4.1
11.1
Celik, Ekuklu, Tokuc, & Utku*
2005
Turkey
> 14
Face-to-face
19.9
29.3
Morillo et al.
2004
Latin America Argentina
> 15
Face-to-face
3.5
5.6
Brazil
> 15
Face-to-face
7.3
16.7
Columbia
> 15
Face-to-face
5.0
14.2
Ecuador
> 15
Face-to-face
2.9
13.8
Mexico
> 15
Face-to-face
3.6
12.4
Venezuela
> 15
Face-to-face
4.8
12.2
Linde & Dahlof
2004
Sweden
18 to 74
Mail questionnaire
9.5
16.7
Lanteri-Minet, Valda, Geraud, Chautard, & Lucas
2005
France
> 18
Mail questionnaire
7.8
12.2
*Lifetime prevalence.
difference in sick leave policies and inability to terminate employment related to health absences in Europe may be the cause of this disparity. Lipton et al. (2003) suggest that migraine disability interferes with “educational and occupational function, causing a loss of income or the ability to rise from a low-income group” (p. S7). Workplace Implications Current research on the prevalence of migraine disorder has extended from community populations into the workplace. Because this disorder affects approximately 11% of the adult population of the Western world (Lipton & Bigal, 2005), epidemiology studies have moved from focusing on incidence and prevalence to focusing on direct and indirect economic burdens associated with migraines, particularly lost productivity in the workplace and at home. The highest prevalence of migraine is during peak employment years, contributing substantially to lost workdays and productivity (Lipton & Bigal, 2005). Direct costs associated with migraine involve medication, inpatient or outpatient care, and visits to health care providers. Indirect costs of migraine disorder are absenteeism and presenteeism (Pesa & Lage, 2004). Although migraineurs incur absences, presenteeism appears to encompass most of the indirect costs associated with
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migraine disorder. Presenteeism can be described as loss of productivity “that occurs when employees come to work but perform below par due to any kind of illness” (Levin-Epstein, 2005, p. 1). Steiner et al. (2003) estimated that in the United Kingdom, which has a population of 5.85 million migraineurs, at least 25 million lost work or school days occur each year from migraine disorder. In Sweden, the mean number of lost workdays from migraine attacks was 1.3 per month (Linde & Dahlof, 2004). In a multi-national study, Gerth, Carides, Dasbach, Wisser, and Santanello (2001) estimated that a total of 19.55 workdays per year were lost to absences and reduced productivity. Absent days related to migraine accounted for only 8.3 days, whereas reduced productivity days related to migraine accounted for 11.2 days. In a study of migraineur absenteeism among French workers, using a self-report survey on loss of productivity, Michel, Dartigues, Lindoulsi, and Henry (1997) found there were no more absences in the migraineur group than in a control group without migraine. However, productivity was greatly reduced in the migraineur group related to presenteeism. According to a study by Lipton et al. (2001), while 31% of migraineurs in the United States reported at least one missed day of work or school in the 3 months prior to the study, 51% reported loss of pro-
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ductivity while at school or work. Edmeads and Mackell (2002) estimated that two-thirds of the financial burden of migraine is related to indirect costs from lost productivity. Gerth et al. (2001) found the cost of absenteeism and presenteeism to employers to be approximately $3,309 per migraineur employee. Additional costs exist for employers and migraineurs besides work absence and productivity loss. Edmeads and Mackell (2002) questioned whether individuals with migraine incurred greater direct costs than a matched group without migraine. With the use of survey data from the National Health and Wellness Study performed in 1998 by Consumer Health Sciences, a sample of 1,087 self-reported migraineurs was matched according to age, gender, employment status, and number of comorbidities to a group of individuals with no history of migraine. The frequency and quantity of health care during a 6-month period was generally greater for the migraine group ($522 vs. $415 spent). Although direct costs can be measured through administrative data sets from health care use, undiagnosed migraineurs’ use of over-the-counter treatments with comorbid illness and the side effects of self-treatment remain hidden (Kolodner et al., 2004; Lipton & Bigal, 2005). Forty-five percent to 55% of those who would be diagnosed with migraine do not seek treatment from health care providers or secure prescriptive medication (Linde & Dahlof, 2004; Pop et al., 2002). In a study by Pop, Gierveld, Karis, and Tiedink (2002), 86.5% of those identified in a Dutch workplace only used over-the-counter medications in treating their migraines. Workplace Solutions and Challenges Recognizing and differentiating headache types are the first steps toward containing direct and indirect costs of migraine and increasing the quality of life of migraineurs. Migraine disorder is not an occupational illness but is present in the workplace due to the higher prevalence of migraine within the working population. Migraine triggers existing within the workplace include lighting, video display terminals, stress, smells, and noise. Although migraine disorder cannot be cured, it can be managed by ongoing collaboration between “a motivated and educated patient and a concerned and knowledgeable health profession” (Warshaw, Burton, & Schneider, 2001, p. 100). Research indicates that 45% to 55% of migraineurs are not diagnosed by health care providers and rely solely on over-the-counter medications to manage their symptoms. Thus, these migraineurs do not receive referral to neurologists and are not given therapeutic maintenance medications to prevent migraines (Lipton & Bigal, 2005). In the Dutch workplace study by Pop et al. (2002), only 13.5% of those diagnosed with migraine were receiving migraine-specific therapy. Given that this disorder is underdiagnosed, occupational health nurses may have the initial opportunity to refer employees for diagnosis and treatment. A simple questionnaire, similar to one developed by Marcus, Kapelewski, Jacob, Rudy, and Furman (2004), can be used to screen employees (Sidebar). The role of occupational health nurses also includes support for prevention and management of migraines.
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This can include referral for counseling or resources to help employees live healthier lives. It may also include educating and encouraging employees regarding physical conditioning, sleep, nutrition, dietary triggers, caffeine, alcohol, and nicotine, and environmental triggers or stress at work and home. Stress management, relaxation exercises, meditation, and biofeedback may be part of an employee wellness program (Warshaw et al., 2001). Occupational health nurses are an important resource for employers regarding workplace accommodation to prevent migraine disorder. This is especially true in recognizing and eliminating workplace triggers (e.g., lighting, computer screen glare, or noise). The Job Accommodation Network (www.jan.wvu.edu/media/atoz.htm) provides helpful information. Occupational health nurses’ assessment and management of employees’ migraine attacks at work can significantly decrease disability time. Treatment can be as simple as providing a dark, quiet room, over-the-counter medication, and ice packs for the area or administering prescription medication provided by the employee or under standing orders. If the intensity of the migraine requires removal from work, occupational health nurses may need to ensure safe travel arrangements (Warshaw et al., 2001). In addition to preventing and recognizing migraine, occupational health nurses are essential in managing absence counseling programs and participating as part of disability management teams (Solomon et al., 2002). Summary Migraine disorder is disabling, costly, underdiagnosed, and undertreated. It affects employees’ quality of life and ability to work or attend school, potentially decreasing their earning ability. Migraine disorder impacts the workplace substantially through absenteeism and presenteeism and increases health care costs. Although research on migraine disorder is expansive, no systematic research tool or design exists within population studies. This may account for the different prevalence rates seen, especially in African studies, which rely on verbal interviews instead of mail or telephone surveys. Women have a higher prevalence rate throughout the research, but they seek help more often than men. This may contribute to their higher rates, although hormones also play a role. Occupational health nurses can affect the outcome of migraine disorder for employees and employers. They can assist in identifying those employees with migraine disorder who are not diagnosed, those who have not investigated the various available medications, or the lifestyle changes that would decrease the intensity and frequency of migraine attacks. Research is needed to quantify the cost savings of workplace intervention in identifying employees with migraine disorder and its effect on absenteeism, presenteeism, and health care use. Occupational health nurses can determine the effectiveness of education by measuring motivation, lifestyle changes, and workplace modification against the intensity and frequency of migraine attacks. This, in turn, will yield measurable results in reducing absenteeism and presenteeism in the workplace.
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Migraine Assessment Tool* Subject: ______________ Date: _____________ Examiner: _____________ 1. Did the headaches start within 2 weeks of a head injury, trauma, or illness? Yes No (If no, proceed to the next question.) 2. Do you have any brain abnormality, like tumors or hydrocephalus? Yes No (If no, proceed to the next question.) 3. Do you have a headache everyday or take over-the-counter or prescription pain or headache medication (e.g., acetaminophen, aspirin, and caffeine)? Yes No (If no, proceed to the next question.) 4. Do you have an intermittent or constant headache? Constant Intermittent (If intermittent, proceed to the next question.) 5. How long does each individual headache episode last? < 2 hours > 2 hours (If > 2 hours, proceed to the next question.) 6. Do you have any of the following neurological symptoms immediately before or during your headache episode? _______ Visual scotoma (blind or black spots in the vision) _______ Visual hallucination (zigzag or wavy lines, colored lights or balls, shimmering patterns) _______ Weakness or numbness on one side of your body If yes, diagnose migraine. No further questions needed. If no, proceed to question 7. 7. Do you have at least 2 of the following symptoms with your headache? _____Pain is on one side of the head during a headache episode _____Pain feels like throbbing or pulsing sensation _____Pain limits, restricts, or interferes with routine activities _____Pain is made worse by performing routine activities, such as stair climbing No (Stop! No diagnosis of migraine.) Yes (If yes, proceed to the next question.) 8. Do you have at least 1 of the following symptoms with your headache? _____Nausea or vomiting _____Markedly increased sensitivity to BOTH normal room lighting AND conversational speech. (You need to turn down or off lights, close curtains or blinds, turn down or off radio or television, or need to retreat to a dark, quiet room.) If yes, then diagnose migraine. If no, no diagnosis of migraine. *Reprinted with permission from Marcus, D., Kapelewski, C., Jacob, R., Rudy, T., & Furman, J. (2004). Validation of a brief nurseadministered migraine assessment tool. Headache, 44(4), 328-332 © 2004 Blackwell Publishing.
Occupational health nurses can spread this information through employees to their families. As more undiagnosed and undertreated individuals with migraine become educated and pursue diagnosis, treatment, and lifestyle changes, a measurable decrease in health care use and costs may occur. The economic impact of migraine disorder, in terms of workplace absenteeism and presenteeism and increased health care use by employees, continues to be of great
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concern. This impact may motivate employers to support workplace interventions that educate, screen, and refer migraineurs to appropriate care. Employers may also be motivated to request that a managed care model for migraine be included in health and welfare programs, which would allow for assignment of a nurse case manager with automatic referral to a neurologist. The workplace is an ideal environment for identifying and referring migraine sufferers who only self-treat
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IN SU M M ARY
Migraine Disorder Workplace Implications and Solutions Berry, P. A. AAOHN Journal 2007; 55(2), 51-56.
1
Migraine disorder is prevalent throughout the world and seen in all ages, both genders, and all races. Prevalence rates appear highest during peak years of employment and among females.
2
Almost half of those suffering from migraine disorder have not sought health care treatment and rely on over-the-counter medications to manage symptoms.
3
Occupational health nurses can increase the quality of life for employees with migraines and decrease the associated costs to employers by providing education about the disorder.
4
In the workplace, migraine symptoms can be decreased by removing or modifying migraine triggers and providing appropriate first aid.
for symptoms. Prompt and effective treatment, in and out of the workplace, will decrease the frequency and intensity of migraine attacks and increase the quality of life. References
Bank, J., & Marton, M. (2000). Hungarian migraine epidemiology. Headache, 40(2), 164-169. Breslau, N., Chilcoat, H., & Andreski, P. (1996). Further evidence on the link between migraine and neuroticism. Neurology, 47(3), 663667. Broner, S., & Lay, C. (2005). Menstrual migraine. NHF Headlines, 146, 4-5. Celik, Y., Ekuklu, G., Tokuc, B., & Utku, U. (2005). Migraine prevalence and some related factors in Turkey. Headache, 45(1), 32-36. Edmeads, J., & Mackell, J. (2002). The economic impact of migraine: An analysis of direct and indirect cost. Headache, 42(6), 501-509. Ferro, S., Pretta, S., Bertoldi, S., Anserini, P., Remorgida, V., Del Sette, M., et al. (2004). Increased frequency of migraine among women with endometriosis. Human Reproduction, 19(12), 2927-2932. Gerth, W., Carides, G., Dasbach, E., Visser, H., & Santanello, N. (2001). The multinational impact of migraine symptoms on health care utilization and work loss. Pharmacoeconomics, 19(2), 197-206. Headache Classification Subcommittee of the International Headache Society. (2005). The international classification of headache disorders (ed. 2, p. 29) [Electronic version]. Oxford: Blackwell Publishing. Kolodner, K., Lipton, R., Lafata, J., Leotta, C., Liberman, J., Chee, E., et al. (2004). Pharmacy and medical claims data identified migraine sufferers with high specificity but modest sensitivity. Journal of Clinical Epidemiology, 57, 962-972. Lampl, C., Buzath, A., Baumhackl, U., & Klingler, D. (2003). One-year prevalence of migraine in Austria: A nation-wide survey. Cephalalgia, 23(4), 280-286. Lanteri-Minet, M., Valda, D., Geraud, G., Chautard, M., & Lucas, C.
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