The burden of headache and a health-care needs assessment in the adult population of Mali: a cross-sectional population-based study

The burden of headache and a health-care needs assessment in the adult population of Mali: a cross-sectional population-based study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The burden of headache and a health-care needs assessment in the adult population of Mali: a cross-sectional population-based study Youssoufa Maiga, Seybou H Diallo, Oumar Sangho, Leon Samuel Moskatel, and 27 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4450595/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background. Our recent studies have shown headache disorders to be very common in the central and western sub-Saharan countries of Benin and Cameroon. Here we report headache in nearby Mali, a strife-torn country that differs topographically, culturally, politically and economically. The purposes were to estimate headache-attributed burden and need for headache care. Methods. We used cluster-random sampling in seven of Mali’s eleven regions to obtain a nationally representative sample. During unannounced household visits by trained interviewers, one randomly selected adult member (18–65 years) from each household was interviewed using the structured HARDSHIP questionnaire, with enquiries into headache in the last year and, additionally, headache yesterday (HY). Headache on ≥ 15 days/month (H15+) was diagnosed as probable medication-overuse headache (pMOH) when associated with acute medication use on ≥ 15 days/month, and as “other H15+” when not. Episodic headache (on < 15 days/month) was recorded as such and not further diagnosed. Burden was assessed as impaired participation (days lost from paid and household work, and from leisure activity). Need for headache care was defined by criteria for expectation of benefit. Results. Data collection coincided with the SARS-CoV-2 pandemic. The participating proportion was nonetheless extremely high (99.4%). The observed 1-year prevalence of any headache was 90.9%. Age- and gender-adjusted estimates were 86.3% for episodic headache, 1.4% for pMOH and 3.1% for other H15+. HY was reported by 16.8% with a mean duration of 8.7 hours. Overall mean headache frequency was 3.5 days/month. Participants with pMOH lost more days from paid (8.8 days/3 months) and household work (10.3 days/3 months) than those with other H15+ (3.1 and 2.8 days/3 months) or episodic headache (1.2 and 0.9 days/3 months). At population level, 3.6–5.8% of all time was spent with headache, which led to a 3.6% decrease in all activity (impaired participation). Almost a quarter (23.4%) of Mali’s adult population need headache care. Conclusion. Headache is very common in Mali, as in its near neighbours, Benin and Cameroon, and associated with substantial losses of health and productivity. Need for headache care is high – a challenge for a low-income country – but lost productivity probably translates into lost gross domestic product. headache medication-overuse headache epidemiology burden of disease health policy Mali sub-Saharan Africa Global Campaign against Headache Figures Figure 1 BACKGROUND Recent studies from the Global Campaign against Headache have shown that headache disorders are very common in Benin [ 1 ] and Cameroon [ 2 ], with prevalence estimates for migraine and tension-type headache (TTH) exceeding global averages (14–15% and 26% [ 3 – 5 ]). Also common are disorders characterized by headache on ≥ 15 days/month (H15+), important among which (from a public-health perspective) is medication-overuse headache (MOH). These countries are in West and West-Central sub-Saharan Africa (SSA) respectively. Both are classified by the World Bank as lower-middle income countries [ 6 ]. Mali is an interior Western African country bordered by Algeria, Niger, Guinea, Senegal, Cote d’Ivoire and Burkina Faso [ 7 ]. It has no coastline; its northern part extends far into the Sahara desert [ 7 , 8 ]; it is one of the hottest countries in the world [ 8 ]. The overwhelming majority of the population live in the southern savannah, with the greatest density along the border with Burkina Faso [ 7 ]. The population, presently near 23 million [ 9 ], is expected to double by 2035: although infant, child and maternal mortality rates are among the highest in SSA [ 7 ], the fertility rate (5.5 children per woman) is fourth highest in the world. Meanwhile, less than half the population are aged 18 years or over. Mali is a low-income country [ 10 ] with extreme poverty increasing rapidly [ 10 – 12 ]. The political situation has been unstable and characterized by conflicts since the military coup in 2012 [ 10 ]. The findings in Benin and Cameroon cannot be extrapolated to Mali. The aims of this study were two-fold. First was to estimate the burdens attributed to headache in the adult population of Mali. The underlying question was: in a country so environmentally, economically and politically challenged, how much did headache contribute to population ill-health? The second, recognizing these challenges, was to assess need for headache care. METHODS Ethics and approvals The study was approved by the ethics committee of the Faculty of Medicine and Dentistry at the University of Technical Sciences and Technologies, Bamako, under the number 2020/209/CE/FMOS/FAPH. It was conducted in accordance with the Declaration of Helsinki [ 13 ]. All participants gave verbal consent to inclusion. Data were gathered anonymously, and managed in accordance with data protection legislation. Study design The study was a cross-sectional survey among adults in the general population of Mali, adopting the standardized sampling methodology of the Global Campaign against Headache [ 14 ]. Trained interviewers, visiting randomly selected households unannounced, employed a structured questionnaire during face-to-face interviews. Sampling The study was conducted from January to October 2021. Through multistage cluster sampling with random selection, we aimed to generate a representative sample of the adult general population (aged 18–65 years). Firstly, we selected seven of the country’s eleven regions to reflect its ethnic and cultural diversities: (1) Kayes and (2) Koulikoro in the west, (3) Bamako in the southwest, (4) Sikasso in the south, (5) Mopti and (6) Tombouctou (Timbuktu) in the central region, and (7) Gao in the east. Secondly, from these regions, we randomly selected health districts: from Bamako (Mali's most populous city and the country's Capital), four urban districts, two from each side of the Niger river, which divides Bamako into left and right banks; from Sikasso (the second most populous region), the urban district of Koutiala and rural district of Sélingué; from Mopti (the third most populous city), the urban district of Djenné and rural district of Badiangara; and from each of the less populated regions, a single district: Koniacary from Kayes and Maracacoungo from Koulikoro (both rural), the urban district of Tombouctou, and, for security reasons (rural areas being unsafe), the urban district of Gao. Thirdly, from health-district official lists, interviewers randomly selected four villages or city areas in each district, then one or more blocks or circumscribed areas within each village or city area. Within each block, they systematically visited consecutive dwellings (omitting empty properties and commercial premises), unannounced in the first instance (“cold-calling”). Fourthly, at each selected dwelling, the interviewer first identified the number of families living there (a family was defined as a group of people living together and sharing a kitchen). The head of each biologically unrelated family was asked to list all adult members (aged 18–65 years) living within that household. From this list, one person (the selected participant) was randomly selected for interview by the lottery method. Those refusing were counted, but not replaced from that household, in accordance with published guidelines [ 14 ]. If the selected participant was not present, another time was arranged for interview. If this and one further appointment were not kept, he or she was considered to be withholding consent and counted as a non-participant. When the door to a selected dwelling was not answered at first visit, the dwelling was replaced by the next. This continued until the required number of participants was achieved in each selected village or city, and in the study overall. We aimed for a minimum sample size of N = 2,000, again in accordance with guidelines [ 14 ]. Enquiry The eight interviewers were physicians or final-year medical students trained for the purpose, selected for their knowledge of the principal local languages of Mali. The study employed modules from the Global Campaign’s Headache-Attributed Restriction, Disability, Social Handicap, and Impaired Participation (HARDSHIP) questionnaire [ 15 ], translated into Central African French in the version previously used in Cameroon [ 2 ] and Benin [ 1 ]. The interviewers first gathered demographic information, then enquired into headache with neutral screening questions ("Have you ever had a headache?" and "Have you had a headache during the last year?"). Participants who answered positively to both were asked further questions enquiring into frequency, acute medication use and attributable burden. The last included impaired participation (lost time from paid and household work and from social or leisure activities, utilizing the Headache-Attributed Lost Time [HALT] questionnaire [ 16 ]), willingness to pay [WTP] for effective headache treatment, and quality of life (QoL) using the WHOQoL-8 questionnaire [ 17 ]. These enquiries were supplemented by questions about headache on the previous day ("headache yesterday" [HY]), its characteristics (duration and intensity) and its impact on activities. Participants reporting no headache in the preceding year were asked only about their QoL, to provide normative data. There was no diagnostic enquiry beyond establishing frequency and, in those reporting H15+, identifying probable medication-overuse headache (pMOH: H15 + associated with acute medication use on ≥ 15 days/month). Data entry and verification All data were entered using an electronic platform for data capture (ONA, datafax or Redcap). At the end of each day the team coordinator assessed the day’s data for completeness, inconsistencies and wrong or missed entries. Following this review, the data were downloaded and kept secure at the University of Technical Sciences and Technologies, Bamako. Analysis Demographics Gender was recorded as male or female. Age was recorded as a continuous variable, then categorized for further analyses as 18–25, 26–35, 36–45, 46–55 or 56–65 years. The distributions of these variables were compared with those of the national population aged 18–65 years. Marital status was recorded as single, married, widowed, separated or divorced, the last three analysed as a single category. Educational level was recorded and analysed as none, primary school, secondary school or college+. Household income was recorded in West African francs (XOF) in four categories (50,000). Headache Participants were classified as having no headache (no headache in the last year), episodic headache (reported frequency < 15 days/month), pMOH or other H15+. Headache-attributed burden was analysed overall and for each of these three types. Symptom burden was estimated in participants with HY from the symptoms associated with HY. Headache intensity was reported on a 3-point scale (1 = mild, 2 = moderate, 3 = severe), with means calculated as though these were continuous data. Time spent in the ictal state (TIS) was calculated as a product of duration of HY (assuming this to be typical for the participant) and headache frequency (in days/month), and reported as a proportion of total time (pTIS). These estimates, adjusted for frequency, were extrapolated to the whole sample. Headache-attributed impaired participation recalled by participants over the preceding 3 months (HALT-90) was analysed according to established procedure: “nothing achieved” and “less than half achieved” were counted as entire days lost; to counterbalance, “more than half achieved” was reckoned as no loss, along with “everything achieved” [ 16 ]. There were separate enquiries for income-generating work (“worktime”), household chores and leisure/social activities. For those with HY, impaired participation yesterday was analysed in similar manner by counting “less than half achieved” as “nothing achieved” and “more than half achieved” as “everything achieved”. WTP was recorded in XOF/month (at the time of the study, USD 1.00 ~ XOF 590) and categorized as 50,000. QoL scores (in the range 8–40) were derived by summation of responses to the eight items (each on a scale of 1–5), higher scores signifying better QoL. An assessment of headache-care need was carried out using criteria for expectation of benefit from care: 1) having pMOH or other H15+; 2) having episodic headache and either or both of a) pTIS > 3.3% and/or b) losing ≥ 3 work and/or household days over the preceding 3 months. Statistics In descriptive analyses, we used means with standard deviations (SDs) or standard errors of means (SEMs) and medians as appropriate. We estimated 1-year prevalences of any headache, episodic headache, pMOH and other H15 + as percentages (%) with 95% confidence intervals (CIs). We adjusted observed values for age and gender according to their distributions in the national population aged 18–65 years [ 9 ]. Point prevalence of headache was calculated from reported HY, and predicted point prevalence from observed 1-year prevalence and mean reported headache frequency in days/month. In the association analyses, demographic and social status variables were considered as independent variables and headache type as dependent. Unadjusted odds ratios (ORs) were calculated in bivariate analyses, and adjusted ORs (aORs) in multivariate analyses, each with 95% CIs. We evaluated associations between gender and symptom burden (headache frequency and duration of HY) and lost time using ANOVA. Intensity and impaired participation with HY were compared between genders using chi-squared tests. WTP and WHOQoL by headache type were analysed using ANOVA, and WHOQoL data were also displayed graphically. Population-level estimates of pTIS, and of impaired participation in the preceding 3 months and yesterday, were derived by factoring in age- and gender-adjusted 1-year or 1-day prevalences as appropriate. Significance was set at p < 0.05. We used Microsoft Excel to calculate adjusted prevalences and SPSS version 28 for all other analyses. RESULTS Data collection coincided with the SARS-CoV-2 pandemic. Description of sample A total of 2,105 participants were included from the seven regions: Bamako 10.0%, Gao 10.0%, Kayes 9.5%, Koulikoro 10.4%, Mopti 20.2%, Sikasso 29.9%, Tombouctou 10.0%. There was a small preponderance of females (52.9%) compared to the general population aged 18–65 years (49.4%; chi-squared = 10.4, p = 0.001 [ 9 ]). The mean age of the sample was somewhat higher than in this population (35.9 vs 33.6 years; p < 0.001 [ 9 ]). There were only 12 refusals (participating proportion 99.4%). Headache Lifetime and one-year prevalences Lifetime prevalence of headache (headache ever) was very high (97.3%), with no difference between males (97.7% [95% CI: 96.5–98.5]) and females (97.0% [95.9–98.0]). Observed 1-year prevalence was also very high (90.9%), and similar between genders (males 90.7%; females 91.1%). Table 1 shows the observed 1-year prevalence of each headache type, overall and by gender. H15 + was reported by 4.8% of participants, and diagnosed as pMOH in one third (1.6%). More females than males had pMOH (2.1% vs 1.0%; aOR = 2.6; p = 0.04) and other H15+ (3.9% vs 2.5%; aOR = 2.7; p = 0.01). Adjustments for age and gender slightly increased the prevalence estimate for episodic headache (86.3% [84.7–87.7]) and decreased those for pMOH (1.4% [1.0–2.0]) and other H15+ (3.1% [2.4-4.0]), but made little difference to the estimate for any headache (90.8% [89.4–92.0]). Table 1 Observed one-year prevalence of each headache type, overall and by gender Overall Male Female % [95% confidence interval] Any headache 90.9 [89.6–92.1] 90.7 [88.7–92.5] 91.1 [89.3–92.7] All episodic headache 86.1 [84.5–87.5] 87.2 [84.8–89.2] 85.1 [82.9–87.1] pMOH 1.6 [1.1–2.2] 1.0 [0.5–1.9] 2.1 [1.3–3.1] Other H15+ 3.3 [2.6–4.1] 2.5 [1.6–3.7] 3.9 [2.9–5.3] pMOH: probable medication-overuse headache; H15+: headache on ≥ 15 days/month Associations No associations were found in bivariate analyses between any headache type and gender, educational level or household income (Table 2 ). Both pMOH and other H15 + increased with age and were most prevalent among those aged 46–55 years (OR = 3.6 [p = 0.02] and OR = 3.4 [p = 0.003] respectively), whereas episodic headache was significantly least prevalent in this age group (OR = 0.6; p = 0.02). Being widowed, separated or divorced was positively associated with pMOH (OR = 7.6; p = 0.009) and other H15+ (OR = 3.1; p = 0.03) and negatively associated with episodic headache (OR = 0.3; p < 0.001) (Table 2 ). In multivariate analyses adjusting for all other demographic variables (Table 3 ), gender associations emerged with all three headache types: being female positively with pMOH (aOR = 2.6; p = 0.04) and other H15+ (aOR = 2.7; p = 0.01), and negatively with episodic headache (aOR = 0.6; p = 0.003). The positive association between age and H15 + remained significant (Table 3 ). Some associations with marital status were significant, particularly being married with migraine (aOR = 1.9; p = 0.003). There were variations but no clear trends with household income (Table 3 ). Attributed burden Table 4 shows frequency by headache type. Mean headache frequency was 2.9 days/month overall, significantly higher in females (3.3 days/month) than males (2.6 days/month; p < 0.001). Frequency of episodic headache (2.4 days/month overall) was also significantly higher in females (2.7 days/month) than males (2.0 days/month; p < 0.001). Inevitably, frequencies were much higher for pMOH (28.9 days/month) and other H15+ (20.3 days/month), both similar between males and females. Table 2 Bivariate analyses of associations between headache type and demographic variables Variable Episodic headache pMOH Other H15+ Odds ratio [95% confidence interval] Gender male (n = 991) reference reference reference female (n = 1,114) 0.84 [0.7–1.1] p = 0.17 2.1 [1.0-4.4] p = 0.06 1.6 [1.0-2.6] p = 0.07 Age (years) 18–25 (n = 622) reference reference reference 26–35 (n = 549) 1.1 [0.8–1.5] p = 0.72 0.8 [0.2–2.7] p = 0.66 2.1 [1.0-4.4] p = 0.05 36–45 (n = 429) 0.9 [0.6–1.3] p = 0.50 1.5 [0.5–4.5] p = 0.52 2.0 [0.9–4.4] p = 0.08 46–55 (n = 263) 0.6 [0.4–0.9] p = 0.02 3.6 [1.3–10.3] p = 0.02 3.4 [1.5–7.4] p = 0.003 56–65 (n = 242) 0.7 [0.5–1.1] p = 0.09 3.5 [1.2–10.2] p = 0.02 1.9 [0.8–4.8] p = 0.17 Marital status single (n = 363) reference reference reference married (n = 1,675) 1.2 [0.9–1.7] p = 0.24 1.9 [0.6–6.3] p = 0.30 1.0 [0.5-2.0] p = 0.94 widowed, separated or divorced (n = 67) 0.3 [0.2–0.6] p < 0.001 7.6 [1.7–34.9] p = 0.009 3.1 [1.1–8.8] p = 0.03 Education level none (n = 1,135) 0.7 [0.4–1.2] p = 0.17 2.5 [0.3–18.5] p = 0.38 1.1 [0.4–3.2] p = 0.84 primary (n = 522) 0.6 [0.3–1.2] p = 0.14 2.2 [0.3–17.5] p = 0.46 0.8 [0.3–2.4] p = 0.67 secondary (n = 322) 0.6 [0.3–1.2] p = 0.16 0.4 [0.0-6.3] p = 0.51 1.2 [0.4–3.7] p = 0.78 college+ (n = 126) reference reference reference Household income (XOF/month) < 10,000 (n = 188) 1.1 [0.7–1.8] p = 0.73 0.7 [0.1–6.6] p = 0.75 0.1 [0.0-1.1] p = 0.06 10,000–20,000 (n = 1,056) 1.3 [1.0-1.8] p = 0.10 2.6 [0.8–8.8] p = 0.12 0.8 [0.4–1.5] p = 0.51 20,001–50,000 (n = 473) 0.9 [0.6–1.3] p = 0.68 2.2 [0.6–8.4] p = 0.24 1.4 [0.7–2.7] p = 0.37 > 50,000 (n = 388) reference reference reference pMOH: probable medication-overuse headache; H15+: headache on ≥ 15 days/month; significant values are emboldened. Table 3 Multivariate analyses of associations between headache type and demographic variables Variable Episodic headache pMOH Other H15+ Adjusted odds ratio [95% confidence interval] Gender male reference reference reference female 0.6 [0.4–0.8] p = 0.003 2.6 [1.0-6.4] p = 0.04 2.7 [1.5–4.9] p = 0.01 Age (years) 18–25 reference reference reference 26–35 0.9 [0.6–1.4] p = 0.71 0.8 [0.2–3.2] p = 0.76 2.5 [1.1–5.6] p = 0.03 36–45 0.7 [0.5–1.1] p = 0.12 1.7 [0.5–6.1] p = 0.43 2.7 [1.1–6.8] p = 0.03 46–55 0.5 [0.3–0.9] p = 0.01 4.0 [1.2–13.6] p = 0.03 4.0 [1.6–10.3] p = 0.004 56–65 0.6 [0.4–1.1] p = 0.09 4.1 [1.1–15.7] p = 0.04 2.4 [0.8–7.2] p = 0.13 Marital status single reference reference reference married 1.9 [1.2–2.9] p = 0.003 0.7 [0.2–2.9] p = 0.61 0.4 [0.1.0] p = 0.04 widowed, separated or divorced 0.7 [0.3–1.5] p = 0.34 1.0 [0.1–7.4] p = 0.96 0.8 [0.2–3.1] p = 0.78 Education level none 0.6 [0.3–1.1] p = 0.10 1.3 [0.2–11.1] p = 0.79 1.5 [0.5–4.7] p = 0.47 primary 0.5 [0.3-1.0] p = 0.07 1.6 [0.2–13.3] p = 0.69 1.1 [0.3–3.5] p = 0.92 secondary 0.6 [0.3–1.2] p = 0.14 0.3 [0.0-4.6] p = 0.37 1.4 [0.4–4.7] p = 0.57 college+ reference reference reference Household income (XOF/month) < 10,000 1.5 [0.8–2.6] p = 0.20 0.4 [0.0-4.7] p = 0.49 0.1 [0.0-0.7] p = 0.02 10,000–20,000 1.7 [1.2–2.6] p = 0.006 1.8 [0.5–6.8] p = 0.41 0.6 [0.3–1.2] p = 0.13 20,001–50,000 1.0 [0.7–1.5] p = 0.98 1.9 [0.5–7.6] p = 0.33 1.3 [0.6–2.6] p = 0.53 > 50,000 reference reference reference pMOH: probable medication-overuse headache; H15+: headache on ≥ 15 days/month; significant values are emboldened. Table 4 Symptom burden and impaired participation attributed to headache at individual level, overall and by gender Overall Male Female Male vs female Frequency (days/month) Any headache pMOH Other H15+ Episodic headache 3.5±0.1; 2.0 28.9±0.8; 30.4 20.3±1.3; 20.0 2.4±0.1; 2.0 2.8±0.2; 1.0 27.0±2.3; 30.4 20.9±2.0; 20.0 2.0±0.1; 1.0 4.1±0.2; 2.0 29.7±0.7; 30.4 20.0±1.6; 20.0 2.7±0.1; 2.0 F(1, 1793) = 25.0; p < 0.001 F(1, 29) = 2.0; p = 0.17 F(1, 65) = 0.1; p = 0.72 F(1, 1780) = 38.6; p < 0.001 Days lost in preceding 3 months (mean±SEM; median) HALT 1 + 2 Any headache pMOH Other H15+ Episodic headache 1.4±0.1; 0.0 8.8±2.7; 4.0 3.1±0.7; 0.0 1.2±0.1; 0.0 1.1±0.1; 0.0 5.2±1.8; 3.5 2.3±1.3; 0.0 1.0±0.1; 0.0 1.7±0.2; 0.0 10.3±3.8; 5.0 3.6±1.1; 1.0 1.5±0.1; 0.0 F(1, 1912) = 11.3; p < 0.001 F(1, 31) = 0.8; p = 0.39 F(1, 67) = 0.7; p = 0.40 F(1, 1810) = 7.1; p = 0.008 HALT 3 + 4 Any headache pMOH Other H15+ Episodic headache 1.1±0.1; 0.0 10.3±3.1; 3.0 2.8±0.9; 0.0 0.9±0.1; 0.0 0.4±0.1; 0.0 2.5±1.1; 1.0 0.5±0.3; 0.0 0.4±0.1; 0.0 1.7±0.2; 0.0 13.7±4.3; 4.0 4.0±1.3; 1.0 1.3±0.1; 0.0 F(1, 1912) = 38.8; p < 0.001 F(1, 31) = 2.9; p = 0.10 F(1, 67) = 6.0; p = 0.02 F(1, 1810) = 29.1; p < 0.001 HALT 5 Any headache pMOH Other H15+ Episodic headache 0.3±0.0; 0.0 3.7±1.4; 0.0 0.4±0.2; 0.0 0.2±0.0; 0.0 0.2±0.0; 0.0 1.5±0.9; 0.0 0.1±0.1; 0.0 0.2±0.0; 0.0 0.4±0.1; 0.0 4.7±1.9; 0.0 0.6±0.2; 0.0 0.3±0.0; 0.0 F(1, 1939) = 11.0; p < 0.001 F(1, 31) = 1.1; p = 0.30 F(1, 67) = 2.2; p = 0.14 F(1, 1810) = 7.6; p = 0.006 pMOH: probable medication-overuse headache; H15+: headache on ≥ 15 days/month; HALT: headache-attributed lost time: questions 1 and 2 relate to work time, 3 and 4 to household chores (see text), and 5 to social or leisure activity; significant values are emboldened. Table 5. Symptom burden of headache yesterday and impaired participation yesterday at individual level, overall and by gender Overall Male Female Male vs female Duration (hours) (mean±SEM; median) 8.7±0.6, 4.0 7.9±+0.9; 3.0 9.2±0.7; 5.0 F(1, 273)=1.3; p=0.26 Intensity (n) 1 (mild): 11 2 (moderate): 465 3 (severe): 102 mean* 6 284 63 2.2 5 181 39 2.2 X 2 (2, N=353)=1.1; p=0.58 What done yesterday (n) Everything: 178 More than half: 95 Less than half: 30 Nothing: 50 76 27 8 17 102 68 22 33 X 2 (3, N=353)=7.0; p=0.07 What done yesterday (dichotomized) (n) Everything: 273 Nothing: 80 103 25 170 55 X 2 (1, N=353)=1.1; p=0.18 *Treating the numerical ratings as though continuous data. Table 4 also shows impaired participation (lost time from paid work [HALT 1 + 2], household chores [HALT 3 + 4] and social or leisure activity [HALT 5]). For headache overall, mean estimated lost time from paid work was 1.4 days/3 months. For episodic headache, mean lost work days were 1.2, or 1.8% assuming a 5-day working week, significantly higher among females (1.5 days) than males (1.0 days; p = 0.008) (Table 4 ). Much higher losses arose from pMOH: 8.8 days/3 months, reportedly higher among females (10.3 days) than males (5.2 days) although the difference was not significant (p = 0.39). For other H15+, mean lost work days were 3.1, or 4.8% assuming a 5-day working week. Estimated losses from household work were much lower than from paid work among males but not females (Table 4 ). For episodic headache, 1.1 days/3 months were lost (males 0.4 days; females 1.3 days; p < 0.001); for pMOH, 10.3 days (males 2.5 days; females 13.7 days; not significant [p = 0.10] with small numbers); for other H15+, 2.8 days (males 0.5 days; females 4.0 days; p = 0.02) (Table 4 ). Reported losses from social or leisure activities were lower than from work (paid or household). For episodic headache, 0.2 days/3 months were lost, significantly more among females (0.3) than males (0.2; p = 0.006); for pMOH, 3.7 days and other H15 + 0.4 days, with no significant differences between genders (Table 4 ). Headache yesterday HY was reported by 16.8% (95% CI: 15.2–18.4) of all participants, by 15.3% of those with episodic headache but by 90.3% of those with pMOH (implying daily headache for most) and 59.4% of those with other H15+. Based on the observed 1-year prevalence of 90.9% and the mean recalled headache frequency of 3.5 days/month, the predicted point prevalence of any headache was 10.6%. The mean duration of HY was 8.7±0.6 hours (Table 5 ), not significantly different between males (7.9 hours) and females (9.2 hours; p = 0.26). Intensity (overall mean 2.2, equating to moderate [with very few participants reporting mild headache]) was also similar between the genders (p = 0.58). pTIS was calculated as 4.2% (the product of mean duration and mean headache frequency divided by total available time [(8.7*3.5)/(24*30)]). With regard to impaired participation with HY (Table 5 ), 50.4% reported doing everything as normal, 26.9% more than half, 8.5% less than half and 14.2% nothing. There were no significant differences between males and females. Quality of life and willingness to pay There was a significant association between headache status and QoL (p < 0.001; Table 6 ), with a clear (non-overlapping 95% CIs) declining gradient from 30.6±0.3 in those with no headache through 28.4±0.1 for episodic headache, 26.5±0.7 for other H15 + and 23.1±1.0 for pMOH (Table 6 ; Fig. 1 ). Table 6 Quality of life (WHOQoL-8) and willingness to pay for effective headache treatment by headache type WHOQoL-8 score (range 8–40) (mean ± SEM; median) Probable medication-overuse headache Other headache on ≥ 15 days/month Episodic headache No headache 23.1±1.0; 23.0 26.5±0.7; 26.0 28.4±0.1; 29.0 30.6±0.3; 30.0 F(3, 2,101) = 38.7; p < 0.001 Willingness to pay (XOF/month) (mean ± SEM; median) Probable medication-overuse headache Other headache on ≥ 15 days/month Episodic headache 9,986±2,975; 4,000 5,118±1,462; 1,000 6,214±887; 1,000 F(2, 1,811) = 0.3; p = 0.77 Significant value is emboldened. The data on WTP were heavily skewed, as indicated by the medians. There were no significant differences between the headache types regarding WTP (Table 6 ). However, descriptive statistics showed that those with pMOH were willing to pay, per month, far more (XOF 9,985 [USD 16.92]) than those with other H15+ (XOF 5,118 [USD 8.67]) or episodic headache (XOF 6,214 [10.53]). Headache-care needs assessment According to our criteria, 24.7% (519/2,105) of our sample were likely to benefit from headache care (Table 7 ). Adjusted for age and gender, the proportion of adults judged in need of care was 23.4%: 4.5% because of H15+, the remaining 18.9% because of episodic headache. Table 7 Headache-care needs assessment Criterion fulfilled Proportion of sample Estimated proportion of adult population* n % % [95% CI] a Headache on ≥ 15 days/month (pMOH or other) 102 4.8 4.5 [3.7–5.5] b Episodic headache and pTIS > 3.3% 236 11.2 10.9 [9.6–12.3] c Episodic headache and ≥ 3 lost work and/or household days/3 months 343 1 16.3 15.1 [13.6–16.7] One or more of criteria a-c 519 24.7 23.4 [21.6–25.3] *Age- and gender-adjusted; pMOH: probable medication-overuse headache; pTIS: proportion of time in ictal state; 1 Of whom 81 also fulfilled criteria b Population-level estimates Table 8 shows age- and gender-adjusted population-level estimates of pTIS and impaired participation, each estimated in two ways. Based on 1-year prevalence, headache frequency and duration of HY (assuming this to be average duration for the responding participant), an estimated 3.6% of all time was spent with headache, more with episodic headache (2.3%) than with H15+ (1.4%). Based on prevalence and duration of HY, the estimate was substantially higher: 5.8% of all time. Headache led to estimated losses, per 3 months, of 1.2 days from paid work, 0.9 days from household work and 0.3 days from social or leisure activity per person in the population (with or without headache) (Table 8 ). Most of this was again caused by episodic headache (1.0 workdays, 0.7 household days, 0.2 social or leisure days). According to HY data, all headache caused 3.6% of all activity to be lost. Table 8. Proportion of time in ictal state and impaired participation at population level by headache type and by timeframe of enquiry (adjusted for age and gender) Headache type Estimated pTIS (%) Estimated impaired participation According to 1-year prevalence, average frequency, and duration of headache yesterday According to prevalence and duration of headache yesterday According to HALT data (lost days/3 months) According to headache yesterday Lost productivity Lost social or leisure Lost activity (%) Paid work Household work Any headache 3.6 5.8 1.2 0.9 0.3 3.6 pMOH 0.7 0.1 0.2 0.1 Other H15+ 0.7 0.1 0.1 0.0 Episodic headache 2.3 1.0 0.7 0.2 pTIS: proportion of time in ictal state; HALT: headache-attributed lost time; pMOH: probable medication-overuse headache; H15+: headache on ≥15 days/month. DISCUSSION This study, diverging from standard Global Campaign methodology, avoided the difficulties associated with epidemiological diagnosis of headache type [ 14 , 15 ] by looking simply at headache as a symptom associated with health and productivity losses, these being matters of interest to health and economic policy. It was not a purpose to make separate estimates for migraine and TTH, although we did for pMOH and other H15+, since the burdens associated with these highly frequent headaches were expected to be of a different order of magnitude. However, a consequence of this approach was that we could not assess what might have been secondary headaches. While in much of the world these are relatively uncommon, malaria is endemic and prevalent in Mali, and very much associated with headache as a symptom. It is highly likely that malaria contributed to the very high reported lifetime prevalence (97.3%) and 1-year prevalence (90.8% after age- and gender-adjustment). It was less likely that it greatly influenced survey estimates based on the preceding 3 months, and very improbably those based on HY (survey participants were fit enough to be interviewed). Furthermore, during the period of data collection, the SARS-CoV-2 pandemic was happening. Headache is very much a feature of this viral disease [ 18 ]. To the extent that either of these influenced findings, they would almost certainly be reflected in H15 + rather than episodic headache. H15 + was estimated to affect one in 22 people in Mali (4.5%), with most (3.1%) not further diagnosed. The relatively few with pMOH (1.4%) were testimony, perhaps, to limited access to acute medication. However, 1.4% is within the (imprecisely) estimated global mean of 1–2% for MOH [ 19 – 21 ]. All this said, it is clear that in Mali, beset by all its problems, headache is a major factor contributing to health and productivity losses. As for symptom burden, translating into lost health, most headache was rated of moderate intensity (assessed, with freedom from recall error) from HY. Mean duration of HY was 8.7 hours. Assuming HY was typical in its duration for each participant (but, in any case, on average across the group), and with a reported mean frequency of 3.5 days/month, we estimated pTIS for those with headache at 4.2%, which diluted to 3.5% per person (with or without headache) in the general adult population. However, the pTIS estimate derived solely from HY, without the likely error associated with recall of past headache frequency, was much higher: 5.8%. The difference is obviously important. Evidenced by the discrepancy between predicted (10.6%) and observed 1-day prevalence (16.8%), it appears that people substantially underestimate headache frequency. Also possible was that participants recalled and reported attacks rather than days with headache as instructed, in which case an attack extending into the next day would be counted as one day, not two. Either way, burden measures based on reported headache frequency appear to be unreliably low. Productivity losses were estimated at population level for all headache, both genders, at 0.9 household days per person per 3 months and at 1.2 days per person per 3 months of income-generating time, which, if this translates into gross domestic product (GDP) loss, is substantial (1.8%, assuming a 5-day working week). Total activity lost to headache, estimated from HY data, was 3.6%. In other words, this (3.6%) was the estimated proportion by which headache impaired participation in work or leisure activities throughout the adult population of Mali. Despite their very high burdens at individual level, pMOH (mean frequency 28.9 days/month; 8.8 days/3 months lost from paid work and 10.3 days from household work) and other H15+ (20.3 days/month; 3.1 days from paid work and 2.8 days from household work), had less impact on participation and productivity at population level (factoring in prevalence) than episodic headache. At this level, more time was spent with episodic headache (2.3% of all time) than with pMOH (0.7%) and other H15+ (0.7%) combined. QoL and WTP are regarded as all-encompassing measures, taking account of all aspects of lost wellbeing [ 17 ]. WHOQoL clearly differentiated between no headache and the various headache types, showing a gradient with pMOH, which is associated with the highest symptom burden and lost productivity, also associated with the lowest QoL. People with pMOH were, reportedly, also willing to pay most for effective treatment (almost XOF 10,000/month) than people with other headache (while this was evident in both mean and median values, the differences, with wide CIs and small numbers, were not statistically significant). In contrast WTP was almost the same for other H15+ (XOF 5,118/month) and episodic headache (XOF 6,214/month), despite QoL being lower in the former. As a measure, WTP is highly subjective, often poorly grounded in reality (HARDSHP employs the bidding-game method to address this [ 15 ]), and much influenced by ability to pay. It is worth noting that 59.1% of those who responded to the enquiry reported a monthly household income of ≤ XOF 20,000 (Table 2 ). Extremely high lifetime prevalences of headache were also found in previous Global Campaign studies in Benin in western SSA (95.2% [ 1 ]) and Cameroon in central SSA ( 94.8% [ 2 ]), with speculation in both cases, as here, that malaria was a likely contributor. From that perspective, the three studies were in alignment. In the present study, age- and gender- adjusted 1-year prevalence of headache was also very high (90.8%), far greater than in Benin (74.9% [ 1 ]) or Cameroon (77.1% [ 2 ]). If malaria also contributed to this, it should be noted that the study predated surveillance procedures instituted in Mali from 2021 onwards [ 22 ]. But, as noted, SARS-CoV-2 may also have contributed to the observed 4.8% with H15+. Almost one quarter of the adult population of Mali (24.7%) were judged to be in need of (likely to benefit from) headache care. Obviously this reflects the high prevalence, but the estimate was driven by attributed burden. Admittedly this estimate was derived by applying what might be considered arbitrary criteria. However, the proposition that all those with H15 + need health care is, we believe, uncontroversial. The two criteria pertaining to episodic headache (pTIS > 3.3% or ≥ 3 work and/or household days lost in 3 months) may be more questionable, but they are indicative of quite substantial lost health or productivity. The latter is likely to be with commensurate financial cost, making a very strong economic argument for investment in headache care, with the expectation of regaining at least some of this cost [ 23 , 24 ]. Strengths and limitations This cross-sectional study was performed in an adequately sized, representative sample of the general population drawn randomly from eight of Mali’s eleven regions, and used standardised engagement and enquiry methodology [ 14 ]. The participating proportion was very high. These were strengths. The principal limitation was that episodic headaches were not further diagnosed, but this did not hinder the study purposes: to estimate the burdens attributed to headache in the adult population of Mali and to assess need for headache care in this low-income and politically challenged country. Other limitations were those always associated with this type of cross-sectional research and its dependence on responses (some requiring recall over months) given at a single encounter. Enquiry into HY was a means of mitigating recall error [ 14 , 15 ]. CONCLUSION Headache is very common in Mali, as in its near neighbours, Benin and Cameroon, and is associated with substantial losses of health and productivity. Need for headache care is high – a challenge for a low-income country – but lost productivity probably translates into lost gross domestic product. These are important messages for health and economic policies in Mali. Abbreviations aOR: adjusted odds ratio; CI: confidence interval; d/m: days/month; GDP: gross domestic product; HARDSHIP: Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation questionnaire; MOH: medication-overuse headache; OR: odds ratio; QoL: quality of life; pMOH: probable MOH; SD: standard deviation; SEM: standard error of mean; SSA: sub-Saharan Africa; TTH: tension-type headache; USD: United States dollar; WHO: World Health Organization; XOF: West African franc. Declarations Ethics approval and consent to participation The study was approved by the ethics committee of the Faculty of Medicine and Dentistry at the University of Technical Sciences and Technologies, Bamako, under the number 2020/209/CE/FMOS/FAPH. All participants gave verbal consent to inclusion. Consent for publication Not applicable. Author contributions YM conceived the study, adapting the standardised protocol and questionnaire of the Global Campaign against Headache, and oversaw conduct of the study as principal investigator. All authors except TJS and AH contributed in data collection. AH performed the statistical analysis, with input into data interpretation from TJS. AH and TJS drafted the manuscript. All authors reviewed and approved the final version. Availability of data and materials The original data are held at University of Technical Sciences and Technologies, Bamako, Mali, and the analytical set at Norwegian University of Science and Technology, Trondheim, Norway. When analyses are completed, anonymised data will be available on request for academic purposes, in line with the policy of the Global Campaign against Headache. Funding The study was supported by Fondation SunStar. Competing interests TJS is a Director and Trustee of Lifting The Burden , and associate editor of The Journal of Headache and Pain . AH is a member of the Junior Editorial Board of The Journal of Headache and Pain . There were no other conflicts of interest. Acknowledgments We are grateful to Professor Callixte Kuate Tegueu, Department of Neurology, Hôpital Laquintinie de Douala, Douala, Cameroon, for making available the Central African French translation of the HARDSHIP questionnaire. References Adoukonou T, Agbetou M, Dettin E, Kossi O, Husøy A, Thomas H, Houinato D, Steiner TJ (2004) The prevalence and demographic associations of headache in the adult population of Benin: a cross-sectional population-based study. 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Lancet 396:1204–1222. 10.1016/S0140-6736(20)30925-9 World Bank Country and Lending Groups https://datahelpdesk.worldbank.org/knowledgebase/articles/906519 . Accessed August 10th 2023 The world factbook Mali. https://www.cia.gov/the-world-factbook/countries/mali/ . Accessed August 9th 2023 Mali (2023) https://en.wikipedia.org/wiki/Mali Mali P (2023) https://worldpopulationreview.com/countries/mali-population . Accessed August 9th 2023 The World Bank in Mali https://www.worldbank.org/en/country/mali/overview . Accessed August 9th 2023 Poorest Countries in the World https://wisevoter.com/country-rankings/poorest-countries-in-the-world/ . Accessed August 9th 2023 Poorest countries in the world 2023 https://worldpopulationreview.com/country-rankings/poorest-countries-in-the-world . Accessed August 9th 2023 World Medical Association (2013) World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. JAMA 310:2191–2194. 10.1001/jama.2013.281053 Stovner LJ, Al Jumah M, Birbeck GL, Gururaj G, Jensen R, Katsarava Z et al (2014) The methodology of population surveys of headache prevalence, burden and cost: principles and recommendations from the Global Campaign against Headache. J Headache Pain 15:5. 10.1186/1129-2377-15-5 Steiner TJ, Gururaj G, Andrée C, Katsarava Z, Ayzenberg I, Yu SY et al (2014) Diagnosis, prevalence estimation and burden measurement in population surveys of headache: presenting the HARDSHIP questionnaire. J Headache Pain 15:3. 10.1186/1129-2377-15-3 Steiner TJ, Lipton RB (2018) The Headache-Attributed Lost Time (HALT) Indices: measures of burden for clinical management and population-based research. J Headache Pain 19:12. 10.1186/s10194-018-0837-3 The WHOQOL Group (1998) Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med 28:551–558. 10.1017/s0033291798006667 Sampaio Rocha-Filho PA (2022) Headache associated with COVID-19: Epidemiology, characteristics, pathophysiology, and management. Headache 62:650–656. 10.1111/head.14319 Westergaard ML, Munksgaard SB, Bendtsen L, Jensen RH (2016) Medication-overuse headache: a perspective review. Ther Adv Drug Saf 7:147–158. 10.1177/2042098616653390 Ashina S, Terwindt GM, Steiner TJ, Lee MJ, Porreca F, Tassorelli C et al (2023) Medication overuse headache. Nat Rev Dis Primers 9:5. 10.1038/s41572-022-00415-0 Kristoffersen ES, Lundqvist C (2014) Medication-overuse headache: epidemiology, diagnosis and treatment. Ther Adv Drug Saf 5:87–99. 10.1177/2042098614522683 Tackling malaria in Mali through stronger surveillance (2023) https://www.afro.who.int/countries/mali/news/tackling-malaria-mali-through-stronger-surveillance World Health Organization Lifting The Burden (2011) Atlas of headache disorders and resources in the world, 2011. Geneva: World Health Organization Tinelli M, Leonardi M, Paemeleire K, Raggi A, Mitsikostas D, de la Ruiz E, Steiner TJ (2021) Structured headache services as the solution to the ill-health burden of headache. 3. Modelling effectiveness and cost-effectiveness of implementation in Europe: Findings and conclusions. J Headache Pain 22:90 Additional Declarations No competing interests reported. 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohamadou","middleName":"","lastName":"Sanogo","suffix":""},{"id":309551673,"identity":"084f33c7-d351-4705-808f-9c948c1882b4","order_by":26,"name":"Sekou Boiguilé","email":"","orcid":"","institution":"Gabriel Touré Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sekou","middleName":"","lastName":"Boiguilé","suffix":""},{"id":309551674,"identity":"a3479b19-1b06-48b8-ae74-05c7aebf323d","order_by":27,"name":"Julien Nizard","email":"","orcid":"","institution":"University of Nantes","correspondingAuthor":false,"prefix":"","firstName":"Julien","middleName":"","lastName":"Nizard","suffix":""},{"id":309551675,"identity":"3bf8e78e-16ad-4f8c-818b-189b739718e9","order_by":28,"name":"Robert Cowan","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Cowan","suffix":""},{"id":309551676,"identity":"1227bffd-8359-442f-89a1-f8f0323a32a2","order_by":29,"name":"Timothy J Steiner","email":"","orcid":"","institution":"Norwegian University of Science and Technology (NTNU)","correspondingAuthor":false,"prefix":"","firstName":"Timothy","middleName":"J","lastName":"Steiner","suffix":""},{"id":309551677,"identity":"198d0e3a-761f-4dfb-a259-a32750484bf5","order_by":30,"name":"Andreas Husøy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYDACCTBpA8SMjQdI0ZIG0tJAkpbDYJI4Lfyze4w/fGw7b7e2/TDQlhqbaMKW3DljJjmz7XbytjOJQC3H0nIbCOq5kWPGzAvUYnYAqIWx4TBhLfI3cow/87adSzY7/5BILQY3cgykedsO2JndINYWwxtpZZIzziUnmN0A2pJAjF/kbiRv/vChzM7e7Hz6wwcfamyI8D4IMLIxJIJVJhClHAz+MNgTr3gUjIJRMApGHAAAFIlInW4HCygAAAAASUVORK5CYII=","orcid":"","institution":"Norwegian University of Science and Technology (NTNU)","correspondingAuthor":true,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Husøy","suffix":""}],"badges":[],"createdAt":"2024-05-20 18:06:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4450595/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4450595/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57867588,"identity":"afa65e61-7462-45ab-b2e9-232049c91302","added_by":"auto","created_at":"2024-06-06 16:06:06","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":213186,"visible":true,"origin":"","legend":"\u003cp\u003eMean reported quality of life by headache status (WHOQoL-8: possible range 8-40)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4450595/v1/3ae4c066e7298578fee2c931.jpeg"},{"id":57868281,"identity":"2962b0ef-91d6-416a-bd80-02f8b0b5e4db","added_by":"auto","created_at":"2024-06-06 16:14:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1538263,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4450595/v1/7bd50b07-e430-4e2f-b2fc-8a6e5b6531f6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The burden of headache and a health-care needs assessment in the adult population of Mali: a cross-sectional population-based study","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eRecent studies from the Global Campaign against Headache have shown that headache disorders are very common in Benin [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and Cameroon [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], with prevalence estimates for migraine and tension-type headache (TTH) exceeding global averages (14\u0026ndash;15% and 26% [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]). Also common are disorders characterized by headache on \u0026ge;\u0026thinsp;15 days/month (H15+), important among which (from a public-health perspective) is medication-overuse headache (MOH).\u003c/p\u003e \u003cp\u003eThese countries are in West and West-Central sub-Saharan Africa (SSA) respectively. Both are classified by the World Bank as lower-middle income countries [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMali is an interior Western African country bordered by Algeria, Niger, Guinea, Senegal, Cote d\u0026rsquo;Ivoire and Burkina Faso [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It has no coastline; its northern part extends far into the Sahara desert [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; it is one of the hottest countries in the world [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The overwhelming majority of the population live in the southern savannah, with the greatest density along the border with Burkina Faso [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The population, presently near 23\u0026nbsp;million [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], is expected to double by 2035: although infant, child and maternal mortality rates are among the highest in SSA [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the fertility rate (5.5 children per woman) is fourth highest in the world. Meanwhile, less than half the population are aged 18 years or over. Mali is a low-income country [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] with extreme poverty increasing rapidly [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The political situation has been unstable and characterized by conflicts since the military coup in 2012 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The findings in Benin and Cameroon cannot be extrapolated to Mali.\u003c/p\u003e \u003cp\u003eThe aims of this study were two-fold. First was to estimate the burdens attributed to headache in the adult population of Mali. The underlying question was: in a country so environmentally, economically and politically challenged, how much did headache contribute to population ill-health? The second, recognizing these challenges, was to assess need for headache care.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEthics and approvals\u003c/h2\u003e \u003cp\u003eThe study was approved by the ethics committee of the Faculty of Medicine and Dentistry at the University of Technical Sciences and Technologies, Bamako, under the number 2020/209/CE/FMOS/FAPH. It was conducted in accordance with the Declaration of Helsinki [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. All participants gave verbal consent to inclusion.\u003c/p\u003e \u003cp\u003eData were gathered anonymously, and managed in accordance with data protection legislation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe study was a cross-sectional survey among adults in the general population of Mali, adopting the standardized sampling methodology of the Global Campaign against Headache [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Trained interviewers, visiting randomly selected households unannounced, employed a structured questionnaire during face-to-face interviews.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSampling\u003c/h2\u003e \u003cp\u003eThe study was conducted from January to October 2021.\u003c/p\u003e \u003cp\u003eThrough multistage cluster sampling with random selection, we aimed to generate a representative sample of the adult general population (aged 18\u0026ndash;65 years).\u003c/p\u003e \u003cp\u003eFirstly, we selected seven of the country\u0026rsquo;s eleven regions to reflect its ethnic and cultural diversities: (1) Kayes and (2) Koulikoro in the west, (3) Bamako in the southwest, (4) Sikasso in the south, (5) Mopti and (6) Tombouctou (Timbuktu) in the central region, and (7) Gao in the east.\u003c/p\u003e \u003cp\u003eSecondly, from these regions, we randomly selected health districts: from Bamako (Mali's most populous city and the country's Capital), four urban districts, two from each side of the Niger river, which divides Bamako into left and right banks; from Sikasso (the second most populous region), the urban district of Koutiala and rural district of S\u0026eacute;lingu\u0026eacute;; from Mopti (the third most populous city), the urban district of Djenn\u0026eacute; and rural district of Badiangara; and from each of the less populated regions, a single district: Koniacary from Kayes and Maracacoungo from Koulikoro (both rural), the urban district of Tombouctou, and, for security reasons (rural areas being unsafe), the urban district of Gao.\u003c/p\u003e \u003cp\u003eThirdly, from health-district official lists, interviewers randomly selected four villages or city areas in each district, then one or more blocks or circumscribed areas within each village or city area. Within each block, they systematically visited consecutive dwellings (omitting empty properties and commercial premises), unannounced in the first instance (\u0026ldquo;cold-calling\u0026rdquo;).\u003c/p\u003e \u003cp\u003eFourthly, at each selected dwelling, the interviewer first identified the number of families living there (a family was defined as a group of people living together and sharing a kitchen). The head of each biologically unrelated family was asked to list all adult members (aged 18\u0026ndash;65 years) living within that household. From this list, one person (the selected participant) was randomly selected for interview by the lottery method. Those refusing were counted, but not replaced from that household, in accordance with published guidelines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. If the selected participant was not present, another time was arranged for interview. If this and one further appointment were not kept, he or she was considered to be withholding consent and counted as a non-participant.\u003c/p\u003e \u003cp\u003eWhen the door to a selected dwelling was not answered at first visit, the dwelling was replaced by the next. This continued until the required number of participants was achieved in each selected village or city, and in the study overall.\u003c/p\u003e \u003cp\u003eWe aimed for a minimum sample size of N\u0026thinsp;=\u0026thinsp;2,000, again in accordance with guidelines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eEnquiry\u003c/h2\u003e \u003cp\u003eThe eight interviewers were physicians or final-year medical students trained for the purpose, selected for their knowledge of the principal local languages of Mali.\u003c/p\u003e \u003cp\u003eThe study employed modules from the Global Campaign\u0026rsquo;s Headache-Attributed Restriction, Disability, Social Handicap, and Impaired Participation (HARDSHIP) questionnaire [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], translated into Central African French in the version previously used in Cameroon [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and Benin [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The interviewers first gathered demographic information, then enquired into headache with neutral screening questions (\"Have you ever had a headache?\" and \"Have you had a headache during the last year?\"). Participants who answered positively to both were asked further questions enquiring into frequency, acute medication use and attributable burden. The last included impaired participation (lost time from paid and household work and from social or leisure activities, utilizing the Headache-Attributed Lost Time [HALT] questionnaire [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]), willingness to pay [WTP] for effective headache treatment, and quality of life (QoL) using the WHOQoL-8 questionnaire [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These enquiries were supplemented by questions about headache on the previous day (\"headache yesterday\" [HY]), its characteristics (duration and intensity) and its impact on activities. Participants reporting no headache in the preceding year were asked only about their QoL, to provide normative data.\u003c/p\u003e \u003cp\u003eThere was no diagnostic enquiry beyond establishing frequency and, in those reporting H15+, identifying probable medication-overuse headache (pMOH: H15\u0026thinsp;+\u0026thinsp;associated with acute medication use on \u0026ge;\u0026thinsp;15 days/month).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData entry and verification\u003c/h2\u003e \u003cp\u003eAll data were entered using an electronic platform for data capture (ONA, datafax or Redcap). At the end of each day the team coordinator assessed the day\u0026rsquo;s data for completeness, inconsistencies and wrong or missed entries. Following this review, the data were downloaded and kept secure at the University of Technical Sciences and Technologies, Bamako.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eGender was recorded as male or female. Age was recorded as a continuous variable, then categorized for further analyses as 18\u0026ndash;25, 26\u0026ndash;35, 36\u0026ndash;45, 46\u0026ndash;55 or 56\u0026ndash;65 years. The distributions of these variables were compared with those of the national population aged 18\u0026ndash;65 years.\u003c/p\u003e \u003cp\u003eMarital status was recorded as single, married, widowed, separated or divorced, the last three analysed as a single category. Educational level was recorded and analysed as none, primary school, secondary school or college+. Household income was recorded in West African francs (XOF) in four categories (\u0026lt;\u0026thinsp;10,000; 10,000\u0026ndash;20,000; 20,001\u0026ndash;50,000; \u0026gt;50,000).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eHeadache\u003c/h2\u003e \u003cp\u003eParticipants were classified as having no headache (no headache in the last year), episodic headache (reported frequency\u0026thinsp;\u0026lt;\u0026thinsp;15 days/month), pMOH or other H15+.\u003c/p\u003e \u003cp\u003eHeadache-attributed burden was analysed overall and for each of these three types. Symptom burden was estimated in participants with HY from the symptoms associated with HY. Headache intensity was reported on a 3-point scale (1\u0026thinsp;=\u0026thinsp;mild, 2\u0026thinsp;=\u0026thinsp;moderate, 3\u0026thinsp;=\u0026thinsp;severe), with means calculated as though these were continuous data. Time spent in the ictal state (TIS) was calculated as a product of duration of HY (assuming this to be typical for the participant) and headache frequency (in days/month), and reported as a proportion of total time (pTIS). These estimates, adjusted for frequency, were extrapolated to the whole sample.\u003c/p\u003e \u003cp\u003eHeadache-attributed impaired participation recalled by participants over the preceding 3 months (HALT-90) was analysed according to established procedure: \u0026ldquo;nothing achieved\u0026rdquo; and \u0026ldquo;less than half achieved\u0026rdquo; were counted as entire days lost; to counterbalance, \u0026ldquo;more than half achieved\u0026rdquo; was reckoned as no loss, along with \u0026ldquo;everything achieved\u0026rdquo; [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. There were separate enquiries for income-generating work (\u0026ldquo;worktime\u0026rdquo;), household chores and leisure/social activities. For those with HY, impaired participation yesterday was analysed in similar manner by counting \u0026ldquo;less than half achieved\u0026rdquo; as \u0026ldquo;nothing achieved\u0026rdquo; and \u0026ldquo;more than half achieved\u0026rdquo; as \u0026ldquo;everything achieved\u0026rdquo;. WTP was recorded in XOF/month (at the time of the study, USD 1.00\u0026thinsp;~\u0026thinsp;XOF 590) and categorized as \u0026lt;\u0026thinsp;10,000, 10,000\u0026ndash;20,000, 20,001\u0026ndash;50,000 or \u0026gt;\u0026thinsp;50,000. QoL scores (in the range 8\u0026ndash;40) were derived by summation of responses to the eight items (each on a scale of 1\u0026ndash;5), higher scores signifying better QoL.\u003c/p\u003e \u003cp\u003eAn assessment of headache-care need was carried out using criteria for expectation of benefit from care: 1) having pMOH or other H15+; 2) having episodic headache \u003cem\u003eand\u003c/em\u003e either or both of a) pTIS\u0026thinsp;\u0026gt;\u0026thinsp;3.3% and/or b) losing\u0026thinsp;\u0026ge;\u0026thinsp;3 work and/or household days over the preceding 3 months.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eIn descriptive analyses, we used means with standard deviations (SDs) or standard errors of means (SEMs) and medians as appropriate.\u003c/p\u003e \u003cp\u003eWe estimated 1-year prevalences of any headache, episodic headache, pMOH and other H15\u0026thinsp;+\u0026thinsp;as percentages (%) with 95% confidence intervals (CIs). We adjusted observed values for age and gender according to their distributions in the national population aged 18\u0026ndash;65 years [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Point prevalence of headache was calculated from reported HY, and predicted point prevalence from observed 1-year prevalence and mean reported headache frequency in days/month.\u003c/p\u003e \u003cp\u003eIn the association analyses, demographic and social status variables were considered as independent variables and headache type as dependent. Unadjusted odds ratios (ORs) were calculated in bivariate analyses, and adjusted ORs (aORs) in multivariate analyses, each with 95% CIs. We evaluated associations between gender and symptom burden (headache frequency and duration of HY) and lost time using ANOVA. Intensity and impaired participation with HY were compared between genders using chi-squared tests. WTP and WHOQoL by headache type were analysed using ANOVA, and WHOQoL data were also displayed graphically.\u003c/p\u003e \u003cp\u003ePopulation-level estimates of pTIS, and of impaired participation in the preceding 3 months and yesterday, were derived by factoring in age- and gender-adjusted 1-year or 1-day prevalences as appropriate.\u003c/p\u003e \u003cp\u003eSignificance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. We used Microsoft Excel to calculate adjusted prevalences and SPSS version 28 for all other analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eData collection coincided with the SARS-CoV-2 pandemic.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDescription of sample\u003c/h2\u003e \u003cp\u003eA total of 2,105 participants were included from the seven regions: Bamako 10.0%, Gao 10.0%, Kayes 9.5%, Koulikoro 10.4%, Mopti 20.2%, Sikasso 29.9%, Tombouctou 10.0%. There was a small preponderance of females (52.9%) compared to the general population aged 18\u0026ndash;65 years (49.4%; chi-squared\u0026thinsp;=\u0026thinsp;10.4, p\u0026thinsp;=\u0026thinsp;0.001 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]). The mean age of the sample was somewhat higher than in this population (35.9 vs 33.6 years; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]).\u003c/p\u003e \u003cp\u003eThere were only 12 refusals (participating proportion 99.4%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eHeadache\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eLifetime and one-year prevalences\u003c/h2\u003e \u003cp\u003eLifetime prevalence of headache (headache ever) was very high (97.3%), with no difference between males (97.7% [95% CI: 96.5\u0026ndash;98.5]) and females (97.0% [95.9\u0026ndash;98.0]). Observed 1-year prevalence was also very high (90.9%), and similar between genders (males 90.7%; females 91.1%). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the observed 1-year prevalence of each headache type, overall and by gender. H15\u0026thinsp;+\u0026thinsp;was reported by 4.8% of participants, and diagnosed as pMOH in one third (1.6%). More females than males had pMOH (2.1% vs 1.0%; aOR\u0026thinsp;=\u0026thinsp;2.6; p\u0026thinsp;=\u0026thinsp;0.04) and other H15+ (3.9% vs 2.5%; aOR\u0026thinsp;=\u0026thinsp;2.7; p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eAdjustments for age and gender slightly increased the prevalence estimate for episodic headache (86.3% [84.7\u0026ndash;87.7]) and decreased those for pMOH (1.4% [1.0\u0026ndash;2.0]) and other H15+ (3.1% [2.4-4.0]), but made little difference to the estimate for any headache (90.8% [89.4\u0026ndash;92.0]).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eObserved one-year prevalence of each headache type, overall and by gender\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e% [95% confidence interval]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90.9 [89.6\u0026ndash;92.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.7 [88.7\u0026ndash;92.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.1 [89.3\u0026ndash;92.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll episodic headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86.1 [84.5\u0026ndash;87.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87.2 [84.8\u0026ndash;89.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85.1 [82.9\u0026ndash;87.1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epMOH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.6 [1.1\u0026ndash;2.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0 [0.5\u0026ndash;1.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.1 [1.3\u0026ndash;3.1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther H15+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.3 [2.6\u0026ndash;4.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.5 [1.6\u0026ndash;3.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.9 [2.9\u0026ndash;5.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003epMOH: probable medication-overuse headache; H15+: headache on \u0026ge;\u0026thinsp;15 days/month\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eAssociations\u003c/h2\u003e \u003cp\u003eNo associations were found in bivariate analyses between any headache type and gender, educational level or household income (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Both pMOH and other H15\u0026thinsp;+\u0026thinsp;increased with age and were most prevalent among those aged 46\u0026ndash;55 years (OR\u0026thinsp;=\u0026thinsp;3.6 [p\u0026thinsp;=\u0026thinsp;0.02] and OR\u0026thinsp;=\u0026thinsp;3.4 [p\u0026thinsp;=\u0026thinsp;0.003] respectively), whereas episodic headache was significantly least prevalent in this age group (OR\u0026thinsp;=\u0026thinsp;0.6; p\u0026thinsp;=\u0026thinsp;0.02). Being widowed, separated or divorced was positively associated with pMOH (OR\u0026thinsp;=\u0026thinsp;7.6; p\u0026thinsp;=\u0026thinsp;0.009) and other H15+ (OR\u0026thinsp;=\u0026thinsp;3.1; p\u0026thinsp;=\u0026thinsp;0.03) and negatively associated with episodic headache (OR\u0026thinsp;=\u0026thinsp;0.3; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn multivariate analyses adjusting for all other demographic variables (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), gender associations emerged with all three headache types: being female positively with pMOH (aOR\u0026thinsp;=\u0026thinsp;2.6; p\u0026thinsp;=\u0026thinsp;0.04) and other H15+ (aOR\u0026thinsp;=\u0026thinsp;2.7; p\u0026thinsp;=\u0026thinsp;0.01), and negatively with episodic headache (aOR\u0026thinsp;=\u0026thinsp;0.6; p\u0026thinsp;=\u0026thinsp;0.003). The positive association between age and H15\u0026thinsp;+\u0026thinsp;remained significant (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Some associations with marital status were significant, particularly being married with migraine (aOR\u0026thinsp;=\u0026thinsp;1.9; p\u0026thinsp;=\u0026thinsp;0.003). There were variations but no clear trends with household income (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eAttributed burden\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows frequency by headache type.\u003c/p\u003e \u003cp\u003eMean headache frequency was 2.9 days/month overall, significantly higher in females (3.3 days/month) than males (2.6 days/month; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Frequency of episodic headache (2.4 days/month overall) was also significantly higher in females (2.7 days/month) than males (2.0 days/month; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Inevitably, frequencies were much higher for pMOH (28.9 days/month) and other H15+ (20.3 days/month), both similar between males and females.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate analyses of associations between headache type and demographic variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpisodic headache\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epMOH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOther H15+\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eOdds ratio [95% confidence interval]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale (n\u0026thinsp;=\u0026thinsp;991)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale (n\u0026thinsp;=\u0026thinsp;1,114)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.84 [0.7\u0026ndash;1.1]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1 [1.0-4.4]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.6 [1.0-2.6]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e (years)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;25 (n\u0026thinsp;=\u0026thinsp;622)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u0026ndash;35 (n\u0026thinsp;=\u0026thinsp;549)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1 [0.8\u0026ndash;1.5]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.8 [0.2\u0026ndash;2.7]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.1 [1.0-4.4]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u0026ndash;45 (n\u0026thinsp;=\u0026thinsp;429)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9 [0.6\u0026ndash;1.3]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5 [0.5\u0026ndash;4.5]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0 [0.9\u0026ndash;4.4]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u0026ndash;55 (n\u0026thinsp;=\u0026thinsp;263)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.6 [0.4\u0026ndash;0.9]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3.6 [1.3\u0026ndash;10.3]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.4 [1.5\u0026ndash;7.4]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e56\u0026ndash;65 (n\u0026thinsp;=\u0026thinsp;242)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7 [0.5\u0026ndash;1.1]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3.5 [1.2\u0026ndash;10.2]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.9 [0.8\u0026ndash;4.8]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esingle (n\u0026thinsp;=\u0026thinsp;363)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emarried (n\u0026thinsp;=\u0026thinsp;1,675)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2 [0.9\u0026ndash;1.7]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9 [0.6\u0026ndash;6.3]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0 [0.5-2.0]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewidowed, separated or divorced (n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.3 [0.2\u0026ndash;0.6]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e7.6 [1.7\u0026ndash;34.9]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.1 [1.1\u0026ndash;8.8]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enone (n\u0026thinsp;=\u0026thinsp;1,135)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7 [0.4\u0026ndash;1.2]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5 [0.3\u0026ndash;18.5]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1 [0.4\u0026ndash;3.2]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eprimary (n\u0026thinsp;=\u0026thinsp;522)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.6 [0.3\u0026ndash;1.2]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.2 [0.3\u0026ndash;17.5]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8 [0.3\u0026ndash;2.4]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esecondary (n\u0026thinsp;=\u0026thinsp;322)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.6 [0.3\u0026ndash;1.2]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4 [0.0-6.3]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.2 [0.4\u0026ndash;3.7]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecollege+ (n\u0026thinsp;=\u0026thinsp;126)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold income\u003c/b\u003e (XOF/month)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10,000 (n\u0026thinsp;=\u0026thinsp;188)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1 [0.7\u0026ndash;1.8]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7 [0.1\u0026ndash;6.6]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1 [0.0-1.1]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10,000\u0026ndash;20,000 (n\u0026thinsp;=\u0026thinsp;1,056)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 [1.0-1.8]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6 [0.8\u0026ndash;8.8]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8 [0.4\u0026ndash;1.5]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20,001\u0026ndash;50,000 (n\u0026thinsp;=\u0026thinsp;473)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9 [0.6\u0026ndash;1.3]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.2 [0.6\u0026ndash;8.4]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4 [0.7\u0026ndash;2.7]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50,000 (n\u0026thinsp;=\u0026thinsp;388)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003epMOH: probable medication-overuse headache; H15+: headache on \u0026ge;\u0026thinsp;15 days/month; significant values are emboldened.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate analyses of associations between headache type and demographic variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpisodic headache\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epMOH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOther H15+\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eAdjusted odds ratio [95% confidence interval]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.6 [0.4\u0026ndash;0.8]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.6 [1.0-6.4]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.7 [1.5\u0026ndash;4.9]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e (years)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9 [0.6\u0026ndash;1.4]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.8 [0.2\u0026ndash;3.2]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.5 [1.1\u0026ndash;5.6]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7 [0.5\u0026ndash;1.1]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7 [0.5\u0026ndash;6.1]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.7 [1.1\u0026ndash;6.8]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.5 [0.3\u0026ndash;0.9]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4.0 [1.2\u0026ndash;13.6]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e4.0 [1.6\u0026ndash;10.3]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e56\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.6 [0.4\u0026ndash;1.1]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4.1 [1.1\u0026ndash;15.7]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.4 [0.8\u0026ndash;7.2]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.9 [1.2\u0026ndash;2.9]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7 [0.2\u0026ndash;2.9]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.4 [0.1.0]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ewidowed, separated or divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7 [0.3\u0026ndash;1.5]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0 [0.1\u0026ndash;7.4]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8 [0.2\u0026ndash;3.1]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.6 [0.3\u0026ndash;1.1]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3 [0.2\u0026ndash;11.1]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5 [0.5\u0026ndash;4.7]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eprimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5 [0.3-1.0]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6 [0.2\u0026ndash;13.3]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1 [0.3\u0026ndash;3.5]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.6 [0.3\u0026ndash;1.2]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3 [0.0-4.6]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4 [0.4\u0026ndash;4.7]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecollege+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold income\u003c/b\u003e (XOF/month)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 [0.8\u0026ndash;2.6]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4 [0.0-4.7]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.1 [0.0-0.7]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10,000\u0026ndash;20,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.7 [1.2\u0026ndash;2.6]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8 [0.5\u0026ndash;6.8]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6 [0.3\u0026ndash;1.2]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20,001\u0026ndash;50,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0 [0.7\u0026ndash;1.5]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9 [0.5\u0026ndash;7.6]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.3 [0.6\u0026ndash;2.6]\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;50,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ereference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003epMOH: probable medication-overuse headache; H15+: headache on \u0026ge;\u0026thinsp;15 days/month; significant values are emboldened.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSymptom burden and impaired participation attributed to headache at individual level, overall and by gender\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMale vs female\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFrequency\u003c/b\u003e (days/month)\u003c/p\u003e \u003cp\u003eAny headache\u003c/p\u003e \u003cp\u003epMOH\u003c/p\u003e \u003cp\u003eOther H15+\u003c/p\u003e \u003cp\u003eEpisodic headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u0026plusmn;0.1; 2.0\u003c/p\u003e \u003cp\u003e28.9\u0026plusmn;0.8; 30.4\u003c/p\u003e \u003cp\u003e20.3\u0026plusmn;1.3; 20.0\u003c/p\u003e \u003cp\u003e2.4\u0026plusmn;0.1; 2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8\u0026plusmn;0.2; 1.0\u003c/p\u003e \u003cp\u003e27.0\u0026plusmn;2.3; 30.4\u003c/p\u003e \u003cp\u003e20.9\u0026plusmn;2.0; 20.0\u003c/p\u003e \u003cp\u003e2.0\u0026plusmn;0.1; 1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.1\u0026plusmn;0.2; 2.0\u003c/p\u003e \u003cp\u003e29.7\u0026plusmn;0.7; 30.4\u003c/p\u003e \u003cp\u003e20.0\u0026plusmn;1.6; 20.0\u003c/p\u003e \u003cp\u003e2.7\u0026plusmn;0.1; 2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eF(1, 1793)\u0026thinsp;=\u0026thinsp;25.0; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003eF(1, 29)\u0026thinsp;=\u0026thinsp;2.0; p\u0026thinsp;=\u0026thinsp;0.17\u003c/p\u003e \u003cp\u003eF(1, 65)\u0026thinsp;=\u0026thinsp;0.1; p\u0026thinsp;=\u0026thinsp;0.72\u003c/p\u003e \u003cp\u003e\u003cb\u003eF(1, 1780)\u0026thinsp;=\u0026thinsp;38.6; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDays lost in preceding 3 months\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(mean\u0026plusmn;SEM; median)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHALT 1\u0026thinsp;+\u0026thinsp;2\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAny headache\u003c/p\u003e \u003cp\u003epMOH\u003c/p\u003e \u003cp\u003eOther H15+\u003c/p\u003e \u003cp\u003eEpisodic headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.4\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003cp\u003e8.8\u0026plusmn;2.7; 4.0\u003c/p\u003e \u003cp\u003e3.1\u0026plusmn;0.7; 0.0\u003c/p\u003e \u003cp\u003e1.2\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003cp\u003e5.2\u0026plusmn;1.8; 3.5\u003c/p\u003e \u003cp\u003e2.3\u0026plusmn;1.3; 0.0\u003c/p\u003e \u003cp\u003e1.0\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u0026plusmn;0.2; 0.0\u003c/p\u003e \u003cp\u003e10.3\u0026plusmn;3.8; 5.0\u003c/p\u003e \u003cp\u003e3.6\u0026plusmn;1.1; 1.0\u003c/p\u003e \u003cp\u003e1.5\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eF(1, 1912)\u0026thinsp;=\u0026thinsp;11.3; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003eF(1, 31)\u0026thinsp;=\u0026thinsp;0.8; p\u0026thinsp;=\u0026thinsp;0.39\u003c/p\u003e \u003cp\u003eF(1, 67)\u0026thinsp;=\u0026thinsp;0.7; p\u0026thinsp;=\u0026thinsp;0.40\u003c/p\u003e \u003cp\u003e\u003cb\u003eF(1, 1810)\u0026thinsp;=\u0026thinsp;7.1; p\u0026thinsp;=\u0026thinsp;0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHALT 3\u0026thinsp;+\u0026thinsp;4\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAny headache\u003c/p\u003e \u003cp\u003epMOH\u003c/p\u003e \u003cp\u003eOther H15+\u003c/p\u003e \u003cp\u003eEpisodic headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003cp\u003e10.3\u0026plusmn;3.1; 3.0\u003c/p\u003e \u003cp\u003e2.8\u0026plusmn;0.9; 0.0\u003c/p\u003e \u003cp\u003e0.9\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003cp\u003e2.5\u0026plusmn;1.1; 1.0\u003c/p\u003e \u003cp\u003e0.5\u0026plusmn;0.3; 0.0\u003c/p\u003e \u003cp\u003e0.4\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u0026plusmn;0.2; 0.0\u003c/p\u003e \u003cp\u003e13.7\u0026plusmn;4.3; 4.0\u003c/p\u003e \u003cp\u003e4.0\u0026plusmn;1.3; 1.0\u003c/p\u003e \u003cp\u003e1.3\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eF(1, 1912)\u0026thinsp;=\u0026thinsp;38.8; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003eF(1, 31)\u0026thinsp;=\u0026thinsp;2.9; p\u0026thinsp;=\u0026thinsp;0.10\u003c/p\u003e \u003cp\u003e\u003cb\u003eF(1, 67)\u0026thinsp;=\u0026thinsp;6.0; p\u0026thinsp;=\u0026thinsp;0.02\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eF(1, 1810)\u0026thinsp;=\u0026thinsp;29.1; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHALT 5\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAny headache\u003c/p\u003e \u003cp\u003epMOH\u003c/p\u003e \u003cp\u003eOther H15+\u003c/p\u003e \u003cp\u003eEpisodic headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3\u0026plusmn;0.0; 0.0\u003c/p\u003e \u003cp\u003e3.7\u0026plusmn;1.4; 0.0\u003c/p\u003e \u003cp\u003e0.4\u0026plusmn;0.2; 0.0\u003c/p\u003e \u003cp\u003e0.2\u0026plusmn;0.0; 0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.2\u0026plusmn;0.0; 0.0\u003c/p\u003e \u003cp\u003e1.5\u0026plusmn;0.9; 0.0\u003c/p\u003e \u003cp\u003e0.1\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003cp\u003e0.2\u0026plusmn;0.0; 0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4\u0026plusmn;0.1; 0.0\u003c/p\u003e \u003cp\u003e4.7\u0026plusmn;1.9; 0.0\u003c/p\u003e \u003cp\u003e0.6\u0026plusmn;0.2; 0.0\u003c/p\u003e \u003cp\u003e0.3\u0026plusmn;0.0; 0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eF(1, 1939)\u0026thinsp;=\u0026thinsp;11.0; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003cp\u003eF(1, 31)\u0026thinsp;=\u0026thinsp;1.1; p\u0026thinsp;=\u0026thinsp;0.30\u003c/p\u003e \u003cp\u003eF(1, 67)\u0026thinsp;=\u0026thinsp;2.2; p\u0026thinsp;=\u0026thinsp;0.14\u003c/p\u003e \u003cp\u003e\u003cb\u003eF(1, 1810)\u0026thinsp;=\u0026thinsp;7.6; p\u0026thinsp;=\u0026thinsp;0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003epMOH: probable medication-overuse headache; H15+: headache on \u0026ge;\u0026thinsp;15 days/month; HALT: headache-attributed lost time: questions 1 and 2 relate to work time, 3 and 4 to household chores (see text), and 5 to social or leisure activity; significant values are emboldened.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 5. Symptom burden of headache yesterday and impaired participation yesterday\u003c/strong\u003e \u003cstrong\u003eat individual level, overall and by gender\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"917\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07742639040349%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.557251908396946%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.466739367502726%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.898582333696837%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale vs female\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07742639040349%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration\u003c/strong\u003e (hours) (mean\u0026plusmn;SEM; median)\u003c/p\u003e\n \u003cp\u003e8.7\u0026plusmn;0.6, 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.557251908396946%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.9\u0026plusmn;+0.9; 3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.466739367502726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.2\u0026plusmn;0.7; 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.898582333696837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eF(1, 273)=1.3; p=0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07742639040349%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntensity\u0026nbsp;\u003c/strong\u003e(n)\u003c/p\u003e\n \u003cp\u003e1 (mild): 11\u003c/p\u003e\n \u003cp\u003e2 (moderate): 465\u003c/p\u003e\n \u003cp\u003e3 (severe): 102\u003c/p\u003e\n \u003cp\u003emean*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.557251908396946%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;6\u003c/p\u003e\n \u003cp\u003e284\u003c/p\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.466739367502726%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;5\u003c/p\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.898582333696837%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cbr\u003e X\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e(2, N=353)=1.1; p=0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07742639040349%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat done yesterday\u0026nbsp;\u003c/strong\u003e(n)\u003c/p\u003e\n \u003cp\u003eEverything: 178\u003c/p\u003e\n \u003cp\u003eMore than half: 95\u003c/p\u003e\n \u003cp\u003eLess than half: 30\u003c/p\u003e\n \u003cp\u003eNothing: 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.557251908396946%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.466739367502726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.898582333696837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e(3, N=353)=7.0; p=0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07742639040349%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat done yesterday\u0026nbsp;\u003c/strong\u003e(dichotomized) (n)\u003c/p\u003e\n \u003cp\u003eEverything: 273\u003c/p\u003e\n \u003cp\u003eNothing: 80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.557251908396946%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.466739367502726%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.898582333696837%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e(1, N=353)=1.1; p=0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003e*Treating the numerical ratings as though continuous data.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e also shows impaired participation (lost time from paid work [HALT 1\u0026thinsp;+\u0026thinsp;2], household chores [HALT 3\u0026thinsp;+\u0026thinsp;4] and social or leisure activity [HALT 5]).\u003c/p\u003e \u003cp\u003eFor headache overall, mean estimated lost time from paid work was 1.4 days/3 months. For episodic headache, mean lost work days were 1.2, or 1.8% assuming a 5-day working week, significantly higher among females (1.5 days) than males (1.0 days; p\u0026thinsp;=\u0026thinsp;0.008) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Much higher losses arose from pMOH: 8.8 days/3 months, reportedly higher among females (10.3 days) than males (5.2 days) although the difference was not significant (p\u0026thinsp;=\u0026thinsp;0.39). For other H15+, mean lost work days were 3.1, or 4.8% assuming a 5-day working week.\u003c/p\u003e \u003cp\u003eEstimated losses from household work were much lower than from paid work among males but not females (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). For episodic headache, 1.1 days/3 months were lost (males 0.4 days; females 1.3 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); for pMOH, 10.3 days (males 2.5 days; females 13.7 days; not significant [p\u0026thinsp;=\u0026thinsp;0.10] with small numbers); for other H15+, 2.8 days (males 0.5 days; females 4.0 days; p\u0026thinsp;=\u0026thinsp;0.02) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eReported losses from social or leisure activities were lower than from work (paid or household). For episodic headache, 0.2 days/3 months were lost, significantly more among females (0.3) than males (0.2; p\u0026thinsp;=\u0026thinsp;0.006); for pMOH, 3.7 days and other H15\u0026thinsp;+\u0026thinsp;0.4 days, with no significant differences between genders (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eHeadache yesterday\u003c/h2\u003e \u003cp\u003eHY was reported by 16.8% (95% CI: 15.2\u0026ndash;18.4) of all participants, by 15.3% of those with episodic headache but by 90.3% of those with pMOH (implying daily headache for most) and 59.4% of those with other H15+. Based on the observed 1-year prevalence of 90.9% and the mean recalled headache frequency of 3.5 days/month, the predicted point prevalence of any headache was 10.6%.\u003c/p\u003e \u003cp\u003eThe mean duration of HY was 8.7\u0026plusmn;0.6 hours (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e), not significantly different between males (7.9 hours) and females (9.2 hours; p\u0026thinsp;=\u0026thinsp;0.26). Intensity (overall mean 2.2, equating to moderate [with very few participants reporting mild headache]) was also similar between the genders (p\u0026thinsp;=\u0026thinsp;0.58). pTIS was calculated as 4.2% (the product of mean duration and mean headache frequency divided by total available time [(8.7*3.5)/(24*30)]).\u003c/p\u003e \u003cp\u003eWith regard to impaired participation with HY (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e), 50.4% reported doing everything as normal, 26.9% more than half, 8.5% less than half and 14.2% nothing. There were no significant differences between males and females.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eQuality of life and willingness to pay\u003c/h2\u003e \u003cp\u003eThere was a significant association between headache status and QoL (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e), with a clear (non-overlapping 95% CIs) declining gradient from 30.6\u0026plusmn;0.3 in those with no headache through 28.4\u0026plusmn;0.1 for episodic headache, 26.5\u0026plusmn;0.7 for other H15\u0026thinsp;+\u0026thinsp;and 23.1\u0026plusmn;1.0 for pMOH (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality of life (WHOQoL-8) and willingness to pay for effective headache treatment by headache type\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHOQoL-8 score (range 8\u0026ndash;40) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SEM; median)\u003c/p\u003e \u003cp\u003eProbable medication-overuse headache\u003c/p\u003e \u003cp\u003eOther headache on \u0026ge;\u0026thinsp;15 days/month\u003c/p\u003e \u003cp\u003eEpisodic headache\u003c/p\u003e \u003cp\u003eNo headache\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.1\u0026plusmn;1.0; 23.0\u003c/p\u003e \u003cp\u003e26.5\u0026plusmn;0.7; 26.0\u003c/p\u003e \u003cp\u003e28.4\u0026plusmn;0.1; 29.0\u003c/p\u003e \u003cp\u003e30.6\u0026plusmn;0.3; 30.0\u003c/p\u003e \u003cp\u003eF(3, 2,101)\u0026thinsp;=\u0026thinsp;38.7; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWillingness to pay\u003c/b\u003e (XOF/month) (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SEM; median)\u003c/p\u003e \u003cp\u003eProbable medication-overuse headache\u003c/p\u003e \u003cp\u003eOther headache on \u0026ge;\u0026thinsp;15 days/month\u003c/p\u003e \u003cp\u003eEpisodic headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9,986\u0026plusmn;2,975; 4,000\u003c/p\u003e \u003cp\u003e5,118\u0026plusmn;1,462; 1,000\u003c/p\u003e \u003cp\u003e6,214\u0026plusmn;887; 1,000\u003c/p\u003e \u003cp\u003eF(2, 1,811)\u0026thinsp;=\u0026thinsp;0.3; p\u0026thinsp;=\u0026thinsp;0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSignificant value is emboldened.\u003c/p\u003e \u003cp\u003eThe data on WTP were heavily skewed, as indicated by the medians. There were no significant differences between the headache types regarding WTP (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). However, descriptive statistics showed that those with pMOH were willing to pay, per month, far more (XOF 9,985 [USD 16.92]) than those with other H15+ (XOF 5,118 [USD 8.67]) or episodic headache (XOF 6,214 [10.53]).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eHeadache-care needs assessment\u003c/h2\u003e \u003cp\u003eAccording to our criteria, 24.7% (519/2,105) of our sample were likely to benefit from headache care (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Adjusted for age and gender, the proportion of adults judged in need of care was 23.4%: 4.5% because of H15+, the remaining 18.9% because of episodic headache.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHeadache-care needs assessment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eCriterion fulfilled\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eProportion of sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEstimated proportion of adult population*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e [95% CI]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeadache on \u0026ge;\u0026thinsp;15 days/month (pMOH or other)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.5 [3.7\u0026ndash;5.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpisodic headache and pTIS\u0026thinsp;\u0026gt;\u0026thinsp;3.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.9 [9.6\u0026ndash;12.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpisodic headache and \u0026ge;\u0026thinsp;3 lost work and/or household days/3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e343\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.1 [13.6\u0026ndash;16.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOne or more of criteria a-c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e519\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.4 [21.6\u0026ndash;25.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Age- and gender-adjusted; pMOH: probable medication-overuse headache; pTIS: proportion of time in ictal state; \u003csup\u003e1\u003c/sup\u003eOf whom 81 also fulfilled criteria b\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePopulation-level estimates\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e shows age- and gender-adjusted population-level estimates of pTIS and impaired participation, each estimated in two ways. Based on 1-year prevalence, headache frequency and duration of HY (assuming this to be average duration for the responding participant), an estimated 3.6% of all time was spent with headache, more with episodic headache (2.3%) than with H15+ (1.4%). Based on prevalence and duration of HY, the estimate was substantially higher: 5.8% of all time.\u003c/p\u003e \u003cp\u003eHeadache led to estimated losses, per 3 months, of 1.2 days from paid work, 0.9 days from household work and 0.3 days from social or leisure activity per person in the population (with or without headache) (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). Most of this was again caused by episodic headache (1.0 workdays, 0.7 household days, 0.2 social or leisure days). According to HY data, all headache caused 3.6% of all activity to be lost.\u003c/p\u003e \u003cp\u003eTable 8. Proportion of time in ictal state and impaired participation at population level by headache type and by timeframe of enquiry (adjusted for age and gender)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"936\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.23076923076923%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeadache type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.303418803418804%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated pTIS\u0026nbsp;\u003c/strong\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.465811965811966%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated impaired participation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.973544973544975%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccording to 1-year prevalence, average frequency, and duration of headache yesterday\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.78306878306878%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccording to prevalence and duration of headache yesterday\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.2962962962963%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccording to HALT data\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e(lost days/3 months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.947089947089948%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccording to headache yesterday\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.0755939524838%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLost productivity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.518358531317496%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLost social or leisure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.406047516198704%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLost activity\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"51.76470588235294%\" style=\"width: 12.3301%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePaid work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48.23529411764706%\" style=\"width: 12.4199%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.23076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003eAny headache\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.132478632478634%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.17094017094017%\" valign=\"bottom\"\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.102564102564102%\" valign=\"bottom\" style=\"width: 12.3301%;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.14102564102564%\" valign=\"bottom\" style=\"width: 12.4199%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.149572649572649%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.072649572649572%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.23076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003epMOH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.132478632478634%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.17094017094017%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.102564102564102%\" valign=\"bottom\" style=\"width: 12.3301%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.14102564102564%\" valign=\"bottom\" style=\"width: 12.4199%;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.149572649572649%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.072649572649572%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.23076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003eOther H15+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.132478632478634%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.17094017094017%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.102564102564102%\" valign=\"bottom\" style=\"width: 12.3301%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.14102564102564%\" valign=\"bottom\" style=\"width: 12.4199%;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.149572649572649%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.072649572649572%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.23076923076923%\" valign=\"bottom\"\u003e\n \u003cp\u003eEpisodic headache\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.132478632478634%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.17094017094017%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.102564102564102%\" valign=\"bottom\" style=\"width: 12.3301%;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.14102564102564%\" valign=\"bottom\" style=\"width: 12.4199%;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.149572649572649%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.072649572649572%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003epTIS: proportion of time in ictal state; HALT: headache-attributed lost time; pMOH: probable medication-overuse headache; H15+: headache on \u0026ge;15 days/month.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study, diverging from standard Global Campaign methodology, avoided the difficulties associated with epidemiological diagnosis of headache type [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] by looking simply at headache as a symptom associated with health and productivity losses, these being matters of interest to health and economic policy. It was not a purpose to make separate estimates for migraine and TTH, although we did for pMOH and other H15+, since the burdens associated with these highly frequent headaches were expected to be of a different order of magnitude.\u003c/p\u003e \u003cp\u003eHowever, a consequence of this approach was that we could not assess what might have been secondary headaches. While in much of the world these are relatively uncommon, malaria is endemic and prevalent in Mali, and very much associated with headache as a symptom. It is highly likely that malaria contributed to the very high reported lifetime prevalence (97.3%) and 1-year prevalence (90.8% after age- and gender-adjustment). It was less likely that it greatly influenced survey estimates based on the preceding 3 months, and very improbably those based on HY (survey participants were fit enough to be interviewed). Furthermore, during the period of data collection, the SARS-CoV-2 pandemic was happening. Headache is very much a feature of this viral disease [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. To the extent that either of these influenced findings, they would almost certainly be reflected in H15\u0026thinsp;+\u0026thinsp;rather than episodic headache. H15\u0026thinsp;+\u0026thinsp;was estimated to affect one in 22 people in Mali (4.5%), with most (3.1%) not further diagnosed. The relatively few with pMOH (1.4%) were testimony, perhaps, to limited access to acute medication. However, 1.4% is within the (imprecisely) estimated global mean of 1\u0026ndash;2% for MOH [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll this said, it is clear that in Mali, beset by all its problems, headache \u003cem\u003eis\u003c/em\u003e a major factor contributing to health and productivity losses.\u003c/p\u003e \u003cp\u003eAs for symptom burden, translating into lost health, most headache was rated of moderate intensity (assessed, with freedom from recall error) from HY. Mean duration of HY was 8.7 hours. Assuming HY was typical in its duration for each participant (but, in any case, on average across the group), and with a reported mean frequency of 3.5 days/month, we estimated pTIS for those with headache at 4.2%, which diluted to 3.5% per person (with or without headache) in the general adult population. However, the pTIS estimate derived solely from HY, without the likely error associated with recall of past headache frequency, was much higher: 5.8%. The difference is obviously important. Evidenced by the discrepancy between predicted (10.6%) and observed 1-day prevalence (16.8%), it appears that people substantially underestimate headache frequency. Also possible was that participants recalled and reported attacks rather than days with headache as instructed, in which case an attack extending into the next day would be counted as one day, not two. Either way, burden measures based on reported headache frequency appear to be unreliably low.\u003c/p\u003e \u003cp\u003eProductivity losses were estimated at population level for all headache, both genders, at 0.9 household days per person per 3 months and at 1.2 days per person per 3 months of income-generating time, which, if this translates into gross domestic product (GDP) loss, is substantial (1.8%, assuming a 5-day working week). Total activity lost to headache, estimated from HY data, was 3.6%. In other words, this (3.6%) was the estimated proportion by which headache impaired participation in work or leisure activities throughout the adult population of Mali.\u003c/p\u003e \u003cp\u003eDespite their very high burdens at individual level, pMOH (mean frequency 28.9 days/month; 8.8 days/3 months lost from paid work and 10.3 days from household work) and other H15+ (20.3 days/month; 3.1 days from paid work and 2.8 days from household work), had less impact on participation and productivity at population level (factoring in prevalence) than episodic headache. At this level, more time was spent with episodic headache (2.3% of all time) than with pMOH (0.7%) and other H15+ (0.7%) combined.\u003c/p\u003e \u003cp\u003eQoL and WTP are regarded as all-encompassing measures, taking account of all aspects of lost wellbeing [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. WHOQoL clearly differentiated between no headache and the various headache types, showing a gradient with pMOH, which is associated with the highest symptom burden and lost productivity, also associated with the lowest QoL. People with pMOH were, reportedly, also willing to pay most for effective treatment (almost XOF 10,000/month) than people with other headache (while this was evident in both mean and median values, the differences, with wide CIs and small numbers, were not statistically significant). In contrast WTP was almost the same for other H15+ (XOF 5,118/month) and episodic headache (XOF 6,214/month), despite QoL being lower in the former. As a measure, WTP is highly subjective, often poorly grounded in reality (HARDSHP employs the bidding-game method to address this [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]), and much influenced by ability to pay. It is worth noting that 59.1% of those who responded to the enquiry reported a monthly household income of \u0026le;\u0026thinsp;XOF 20,000 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExtremely high lifetime prevalences of headache were also found in previous Global Campaign studies in Benin in western SSA (95.2% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]) and Cameroon in central SSA ( 94.8% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]), with speculation in both cases, as here, that malaria was a likely contributor. From that perspective, the three studies were in alignment. In the present study, age- and gender- adjusted 1-year prevalence of headache was also very high (90.8%), far greater than in Benin (74.9% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]) or Cameroon (77.1% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]). If malaria also contributed to this, it should be noted that the study predated surveillance procedures instituted in Mali from 2021 onwards [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. But, as noted, SARS-CoV-2 may also have contributed to the observed 4.8% with H15+.\u003c/p\u003e \u003cp\u003eAlmost one quarter of the adult population of Mali (24.7%) were judged to be in need of (likely to benefit from) headache care. Obviously this reflects the high prevalence, but the estimate was driven by attributed burden. Admittedly this estimate was derived by applying what might be considered arbitrary criteria. However, the proposition that all those with H15\u0026thinsp;+\u0026thinsp;need health care is, we believe, uncontroversial. The two criteria pertaining to episodic headache (pTIS\u0026thinsp;\u0026gt;\u0026thinsp;3.3% \u003cem\u003eor\u003c/em\u003e \u0026ge;\u0026thinsp;3 work and/or household days lost in 3 months) may be more questionable, but they are indicative of quite substantial lost health or productivity. The latter is likely to be with commensurate financial cost, making a very strong economic argument for investment in headache care, with the expectation of regaining at least some of this cost [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was performed in an adequately sized, representative sample of the general population drawn randomly from eight of Mali\u0026rsquo;s eleven regions, and used standardised engagement and enquiry methodology [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The participating proportion was very high. These were strengths.\u003c/p\u003e \u003cp\u003eThe principal limitation was that episodic headaches were not further diagnosed, but this did not hinder the study purposes: to estimate the burdens attributed to headache in the adult population of Mali and to assess need for headache care in this low-income and politically challenged country. Other limitations were those always associated with this type of cross-sectional research and its dependence on responses (some requiring recall over months) given at a single encounter. Enquiry into HY was a means of mitigating recall error [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eHeadache is very common in Mali, as in its near neighbours, Benin and Cameroon, and is associated with substantial losses of health and productivity. Need for headache care is high \u0026ndash; a challenge for a low-income country \u0026ndash; but lost productivity probably translates into lost gross domestic product. These are important messages for health and economic policies in Mali.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eaOR: adjusted odds ratio; CI: confidence interval; d/m: days/month; GDP: gross domestic product; HARDSHIP: Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation questionnaire; MOH: medication-overuse headache; OR: odds ratio; QoL: quality of life; pMOH: probable MOH; SD: standard deviation; SEM: standard error of mean; SSA: sub-Saharan Africa; TTH: tension-type headache; USD: United States dollar; WHO: World Health Organization; XOF: West African franc.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participation\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the ethics committee of the Faculty of Medicine and Dentistry at the University of Technical Sciences and Technologies, Bamako, under the number 2020/209/CE/FMOS/FAPH. All participants gave verbal consent to inclusion.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAuthor contributions\u003c/h3\u003e\n\u003cp\u003eYM\u0026nbsp;conceived the study, adapting the standardised protocol and questionnaire of the Global Campaign against Headache, and oversaw conduct of the study as principal investigator. All authors except TJS and AH contributed in data collection. AH performed the statistical analysis, with input into data interpretation from TJS. AH and TJS drafted the manuscript. All authors reviewed and approved the final version.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe original data are held at University of Technical Sciences and Technologies, Bamako, Mali, and the analytical set at Norwegian University of Science and Technology, Trondheim, Norway. When analyses are completed, anonymised data will be available on request for academic purposes, in line with the policy of the Global Campaign against Headache.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThe study was supported\u0026nbsp;by Fondation SunStar.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eTJS is a Director and Trustee of \u003cem\u003eLifting The Burden\u003c/em\u003e, and associate editor of\u0026nbsp;\u003cem\u003eThe Journal of Headache and Pain\u003c/em\u003e.\u0026nbsp;AH is a member of the Junior Editorial Board of \u003cem\u003eThe Journal of Headache and Pain\u003c/em\u003e.\u0026nbsp;There were no other conflicts of interest.\u003c/p\u003e\n\u003ch3\u003eAcknowledgments\u003c/h3\u003e\n\u003cp\u003eWe are grateful to Professor Callixte Kuate Tegueu, Department of Neurology, H\u0026ocirc;pital Laquintinie de Douala, Douala, Cameroon, for making available the Central African French translation of the HARDSHIP questionnaire.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdoukonou T, Agbetou M, Dettin E, Kossi O, Hus\u0026oslash;y A, Thomas H, Houinato D, Steiner TJ (2004) The prevalence and demographic associations of headache in the adult population of Benin: a cross-sectional population-based study. 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Ther Adv Drug Saf 5:87\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2042098614522683\u003c/span\u003e\u003cspan address=\"10.1177/2042098614522683\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTackling malaria in Mali through stronger surveillance (2023) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.afro.who.int/countries/mali/news/tackling-malaria-mali-through-stronger-surveillance\u003c/span\u003e\u003cspan address=\"https://www.afro.who.int/countries/mali/news/tackling-malaria-mali-through-stronger-surveillance\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization \u003cem\u003eLifting The Burden\u003c/em\u003e (2011) Atlas of headache disorders and resources in the world, 2011. Geneva: World Health Organization\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTinelli M, Leonardi M, Paemeleire K, Raggi A, Mitsikostas D, de la Ruiz E, Steiner TJ (2021) Structured headache services as the solution to the ill-health burden of headache. 3. Modelling effectiveness and cost-effectiveness of implementation in Europe: Findings and conclusions. J Headache Pain 22:90\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-journal-of-headache-and-pain","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tjhp","sideBox":"Learn more about [The Journal of Headache and Pain](https://thejournalofheadacheandpain.biomedcentral.com/)","snPcode":"10194","submissionUrl":"https://submission.nature.com/new-submission/10194/3","title":"The Journal of Headache and Pain","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"headache, medication-overuse headache, epidemiology, burden of disease, health policy, Mali, sub-Saharan Africa, Global Campaign against Headache","lastPublishedDoi":"10.21203/rs.3.rs-4450595/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4450595/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground.\u003c/h2\u003e \u003cp\u003eOur recent studies have shown headache disorders to be very common in the central and western sub-Saharan countries of Benin and Cameroon. Here we report headache in nearby Mali, a strife-torn country that differs topographically, culturally, politically and economically. The purposes were to estimate headache-attributed burden and need for headache care.\u003c/p\u003e\u003ch2\u003eMethods.\u003c/h2\u003e \u003cp\u003eWe used cluster-random sampling in seven of Mali\u0026rsquo;s eleven regions to obtain a nationally representative sample. During unannounced household visits by trained interviewers, one randomly selected adult member (18\u0026ndash;65 years) from each household was interviewed using the structured HARDSHIP questionnaire, with enquiries into headache in the last year and, additionally, headache yesterday (HY). Headache on \u0026ge;\u0026thinsp;15 days/month (H15+) was diagnosed as probable medication-overuse headache (pMOH) when associated with acute medication use on \u0026ge;\u0026thinsp;15 days/month, and as \u0026ldquo;other H15+\u0026rdquo; when not. Episodic headache (on \u0026lt;\u0026thinsp;15 days/month) was recorded as such and not further diagnosed. Burden was assessed as impaired participation (days lost from paid and household work, and from leisure activity). Need for headache care was defined by criteria for expectation of benefit.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e \u003cp\u003eData collection coincided with the SARS-CoV-2 pandemic. The participating proportion was nonetheless extremely high (99.4%). The observed 1-year prevalence of any headache was 90.9%. Age- and gender-adjusted estimates were 86.3% for episodic headache, 1.4% for pMOH and 3.1% for other H15+. HY was reported by 16.8% with a mean duration of 8.7 hours. Overall mean headache frequency was 3.5 days/month. Participants with pMOH lost more days from paid (8.8 days/3 months) and household work (10.3 days/3 months) than those with other H15+ (3.1 and 2.8 days/3 months) or episodic headache (1.2 and 0.9 days/3 months). At population level, 3.6\u0026ndash;5.8% of all time was spent with headache, which led to a 3.6% decrease in all activity (impaired participation). Almost a quarter (23.4%) of Mali\u0026rsquo;s adult population need headache care.\u003c/p\u003e\u003ch2\u003eConclusion.\u003c/h2\u003e \u003cp\u003eHeadache is very common in Mali, as in its near neighbours, Benin and Cameroon, and associated with substantial losses of health and productivity. Need for headache care is high \u0026ndash; a challenge for a low-income country \u0026ndash; but lost productivity probably translates into lost gross domestic product.\u003c/p\u003e","manuscriptTitle":"The burden of headache and a health-care needs assessment in the adult population of Mali: a cross-sectional population-based study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-06 16:06:01","doi":"10.21203/rs.3.rs-4450595/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-08T00:07:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-07T07:55:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"11519251668745568876367829167874844631","date":"2024-06-07T07:25:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-02T08:16:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59805205662505739759468035408344097551","date":"2024-05-27T21:56:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50227418896471923335524546825814655293","date":"2024-05-24T15:52:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106049421041317821406784863603236163339","date":"2024-05-21T21:18:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-21T10:23:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-21T09:07:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-21T09:07:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Journal of Headache and Pain","date":"2024-05-20T18:02:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-journal-of-headache-and-pain","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tjhp","sideBox":"Learn more about [The Journal of Headache and Pain](https://thejournalofheadacheandpain.biomedcentral.com/)","snPcode":"10194","submissionUrl":"https://submission.nature.com/new-submission/10194/3","title":"The Journal of Headache and Pain","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7353f245-b7af-4a41-a3c1-2ad748a22f22","owner":[],"postedDate":"June 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-12T09:14:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-06 16:06:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4450595","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4450595","identity":"rs-4450595","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}