Neurol Sci (2014) 35 (Suppl 1):S27–S29 DOI 10.1007/s10072-014-1737-1
SESSION I HEADACHE AT WORK AND AT SCHOOL
Migraine in health workers: working in a hospital can be considered an advantage? M. Bartolini • G. Viticchi • L. Falsetti • A. Ulissi • M. Baldassari • A. Medori • S. Mattioli • F. Lombardi L. Provinciali • M. Silvestrini
•
Ó Springer-Verlag Italia 2014
Abstract Migraine is the most common form of headache, and is one of the most diffused pathologies in the world. Moreover, patients often lose years before obtaining a correct diagnosis. The aim of this study was to evaluate whether diagnostic delay differs between hospital workers, in theory more sensible to health problems, and common people. We compared our cohort of patients attending the headache center on which we put a diagnosis of migraine with and without aura with a sample of hospital workers investigated about headache presence and characteristics. Particularly, hospital workers were evaluated by IDmigraine test, a three-question test validated to formulate a migraine diagnosis. Continuous variables (age and diagnostic delay) were compared with t test for independent samples. Dichotomous and categorical variables were compared with Chi squared test. The mean difference between in-hospital workers and outpatients was analyzed with a GLM/multivariate model accounting for age and sex. The difference between the single subcategory of workers affected by migraine was explored with a GLM/ multivariate model accounting of age and sex. Five hundred and ninety-nine patients affected by migraine with and
without aura were enrolled. Demographical characteristics were comparable in the two study populations. In-hospital workers (99 patients) had a mean longer diagnostic delay (14.89 years; 95 % CI: 7.85–21.93 years) with respect to the outpatients (12.13 years; 95 % CI: 5.37–18.89 years). The difference resulted statistically significant at the multivariate model (p \ 0.05). Single subpopulations of inhospital workers did not have a statistically significant different delay in diagnosing migraine. Diagnostic delay was significantly longer in hospital workers with respect to outpatients. Then, we can conclude that our population of hospital workers did not present a particular attention to their headache, probably because of a tendency to selftreating. Moreover, we did not find differences among different typology of workers, underlining that different job experience and education did not contribute to a best management of headache. More information and informative initiatives are necessary to sensitize people about migraine, especially among hospital workers. Keywords
Migraine Diagnostic delay
Introduction M. Bartolini (&) G. Viticchi F. Lombardi L. Provinciali M. Silvestrini Neurologic Clinic, Politecnic University of Marche, Via Conca 1, 60020 Ancona, Italy e-mail: [email protected] L. Falsetti Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy A. Ulissi M. Baldassari A. Medori S. Mattioli Occupational Medicine Ward, Ospedali Riuniti Ancona, Ancona, Italy
Migraine is one of the most diffused pathologies in the world. In Europe up to 15 % of the population complains of this form of headache [1]. Diagnosis can be quite easily obtained according to the International Headache Society (IHS) guidelines [2] and no radiological or laboratory exams are usually necessary. Moreover, several studies showed that the diagnostic delay is very relevant in migraine, and very often patients need years for a correct definition of their problem [3, 4]. Our group investigated the diagnostic delay for migraine in general population and
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found a mean time to achieve a correct diagnosis of 10.7 years [5]. Moreover, we observed that the wasting time for diagnosis is proportional to the increasing number of instrumental examinations performed by patients [3, 6]. Hospital workers are expected to be more sensitized to health problems and more favored in the possibility of a medical consultation in order to clarify any suspected condition. This should be especially true for doctors, nurses and clinical workers. The large number of shift workers in the hospital staff makes this particular population at an increased risk for headache because frequent changes in work time involves sleepless nights. Hughes and colleagues investigated headache occurrence in people working in hospital focusing their attention on therapies and drugs employment [7]. Instead, no data are available about the diagnostic delay for migraine in hospital workers. The aim of this study was to evaluate if there is a difference in migraine diagnostic delay between hospital workers and common people. Moreover, we investigate if there were any differences among different typology of inhospital workers.
Methods We evaluated the occurrence of headache in the hospital employers during their legal visits for ability to work, as routinely concerned by the law. Time of onset of headache symptoms was the core of our investigation. Moreover, we checked if headache patients had ever undergone a specialist visit. Particularly, we evaluated headache presence by a self-questionnaire including the ID-migraine test (a three-question test validated to formulate a migraine diagnosis) [8]. Moreover, we investigated the specific characteristics of the job activity including the work time and the demographic characteristics. We compared this sample of hospital workers with our database of headache center about all patients of the last 5 years on which we put a first diagnosis of migraine with and without aura according to IHS criteria [2]. These patients performed a complete visit with a physical examination, a complete anamnesis about their clinical history and finally a complete questionnaire about headache characteristics. In the statistical analysis, we recorded for each patient the number of years from symptoms onset to migraine diagnosis, age and sex. Age and diagnostic delay were treated as continuous variables, sex was treated as binary. The subgroups of workers were synthesized as ordinal variables. Continuous variables were compared with t test for independent samples. Dichotomous and categorical
123
Neurol Sci (2014) 35 (Suppl 1):S27–S29
variables were compared with Chi squared test. The mean difference between in-hospital workers and outpatients was analyzed with a GLM/multivariate model accounting of age and sex. The difference between the single subcategory of workers affected by migraine was explored with a GLM/ multivariate model accounting of age and sex. Statistical analysis was performed with SPSS 13.0 for Windows systems.
Results We considered a total of 639 hospital workers from September 2013 to February 2014: 377 subjects complained headache, but only 99 of them referred symptoms consistent with migraine with or without aura. In this subgroup, 16 (2.7 %) were doctors, 53 (8.8 %) were nurses, 3 (0.5 %) were sanitary operators, 6 (1 %) were technicians, 14 (2.3 %) were administrative employees, 8 (1.3 %) covered other positions. Five hundred subjects (83.3 %) were outpatients coming from our headache center. Finally, a total of 599 patients affected by migraine with and without aura were enrolled. Mean age of in-hospital workers was 40.24 years (±9.72 years), mean age of our outpatients’ population was 39.02 years (±13.60 years). t test showed a non-significant difference (p = 0.393) between the two subpopulations. Female sex was represented in 81 % of in-hospital workers and 78 % of the outpatients, and this difference did not result as statistically significant at Chi squared statistics (p = 0.740). In-hospital workers (99 patients) had a mean longer diagnostic delay (14.89 years; 95 % CI: 7.85–21.93 years) with respect to the outpatients (12.13 years; 95 % CI: 5.37–18.89 years), and this difference resulted statistically significant at the multivariate model (p \ 0.05) (Fig. 1). Single subpopulations of in-hospital workers did not have a statistically significant different delay in diagnosing migraine: doctors (13.81 years; 95 % CI: 5.38–22.45 years), nurses (13.87 years; 95 % CI: 6.57–21.17 years), Sanitary operators (15.39 years; 95 % CI: 1.93–28.84 years), technicians (13.88 years; 95 % CI: 2.55–25.20 years), administratives (17.14 years; 95 % CI: 8.52–25.76 years) and other (20.16 years; 95 % CI: 10.32–30.00 years) showed a nonsignificant difference at multivariate model (Fig. 1).
Discussion Our data showed that diagnostic delay for migraine is surprisingly longer in hospital workers with respect to an outpatient population. These findings were largely unexpected because, as reasonably assumed, people working in a general hospital should be more sensitized about health
Neurol Sci (2014) 35 (Suppl 1):S27–S29
S29
Fig. 1 Migraine diagnostic delay: hospital workers presented a significant major delay in respect to out-patients. There are no significant differences among different sub-groups of in-hospital workers
problems and have more opportunities to undergo to medical evaluations or to obtain neurological consults. A further interesting information from our study is that no significant differences in diagnostic delay derived from different job activities. In this respect, it was surprising that medical doctors and nurses shared the same diagnostic delay of the other workers who did not experience clinical activities. This finding is difficult to interpret. One hypothesis is that clinicians are inclined to use symptomatic therapies for a non-life-threatening condition without consulting a specialistic colleague. There are many studies about all the risks linked to uncontrolled use of symptomatic therapies [9, 10]. First of all, a non-specific treatment of migraine attacks tends to increase the risk of chronicization. Moreover, a relevant use (often till to a real abuse) of NSAIDs could cause severe consequences for health. This study has two major limits: the first one is that the data of hospital workers were drawn by a self-questionnaire and not by a face-to-face visit. This fact could produce a possible bias, so we are planning to visit all these selected subjects in a second time to validate our data. The second limitation concerns the concept of delay: we considered the time between the day of our clinical diagnosis and the onset of symptoms as a diagnostic delay index. We recognize that it is an arbitrary assumption. However, we can underline that each of the 99 hospital workers have never had a previous diagnosis of migraine in spite of the fact that they presented typical symptoms from several years and usually they used symptomatic therapies. So, the gap between our assessment and the large amount of years with an unrecognized headache could be a reliable index for the waste of time. In conclusion, our study demonstrates that for a fast recognition and effective management of migraine a strong
engagement is still necessary. On the other hand, diagnostic work is essential for a rational therapeutic management in order to an uncorrected use of symptomatic drugs and useless investigations. More informative initiatives are necessary to sensitize people, including hospital workers about migraine. Conflict of interest I certify that there is no actual or potential conflict of interest in relation to this article.
References 1. Stovner LJ, Andree C (2010) Prevalence of headache in Europe: a review for the Eurolight project. J Headache Pain 11(4):289–299 2. Headache Classification Committee of the International Headache Society (IHS) (2013) The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 33(9):629–808 3. Viticchi G, Bartolini M, Falsetti L et al (2013) Instrumental exams performance can be a contributing factor to the delay in diagnosis of migraine. Eur Neurol 71(3–4):120–125 4. Viticchi G, Silvestrini M, Falsetti L et al (2011) Time delay from onset to diagnosis of migraine. Headache 51(2):232–236 5. Viticchi G, Bartolini M, Falsetti L et al (2013) Diagnostic delay in migraine with aura. Neurol Sci 34(Suppl 1):S141–S142 6. Viticchi G, Silvestrini M, Falsetti L et al (2011) The role of instrumental examinations in delayed migraine diagnosis. Neurol Sci 32(Suppl 1):S143–S144 7. Hughes MD, Wu J, Williams TC et al (2013) The experience of headaches in health care workers: opportunity for care improvement. Headache 53(6):962–969 8. Cousins G, Hijazze S, Van de Laar FA, Fahey T (2011) Diagnostic accuracy of the ID migraine: a systematic review and meta-analysis. Headache 51(7):1140–1148 9. Cola´s R, Muno˜z P, Temprano R, Go´mez C, Pascual J (2004) Chronic daily headache with analgesic overuse: epidemiology and impact on quality of life. Neurology 62:1338–1342 10. Katic´ BJ, Krause SJ, Tepper SJ, Hu HX, Bigal ME (2010) Adherence to acute migraine medication: what does it mean, why does it matter? Headache 50:117–129
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SESSION I HEADACHE AT WORK AND AT SCHOOL
Migraine in health workers: working in a hospital can be considered an advantage? M. Bartolini • G. Viticchi • L. Falsetti • A. Ulissi • M. Baldassari • A. Medori • S. Mattioli • F. Lombardi L. Provinciali • M. Silvestrini
•
Ó Springer-Verlag Italia 2014
Abstract Migraine is the most common form of headache, and is one of the most diffused pathologies in the world. Moreover, patients often lose years before obtaining a correct diagnosis. The aim of this study was to evaluate whether diagnostic delay differs between hospital workers, in theory more sensible to health problems, and common people. We compared our cohort of patients attending the headache center on which we put a diagnosis of migraine with and without aura with a sample of hospital workers investigated about headache presence and characteristics. Particularly, hospital workers were evaluated by IDmigraine test, a three-question test validated to formulate a migraine diagnosis. Continuous variables (age and diagnostic delay) were compared with t test for independent samples. Dichotomous and categorical variables were compared with Chi squared test. The mean difference between in-hospital workers and outpatients was analyzed with a GLM/multivariate model accounting for age and sex. The difference between the single subcategory of workers affected by migraine was explored with a GLM/ multivariate model accounting of age and sex. Five hundred and ninety-nine patients affected by migraine with and
without aura were enrolled. Demographical characteristics were comparable in the two study populations. In-hospital workers (99 patients) had a mean longer diagnostic delay (14.89 years; 95 % CI: 7.85–21.93 years) with respect to the outpatients (12.13 years; 95 % CI: 5.37–18.89 years). The difference resulted statistically significant at the multivariate model (p \ 0.05). Single subpopulations of inhospital workers did not have a statistically significant different delay in diagnosing migraine. Diagnostic delay was significantly longer in hospital workers with respect to outpatients. Then, we can conclude that our population of hospital workers did not present a particular attention to their headache, probably because of a tendency to selftreating. Moreover, we did not find differences among different typology of workers, underlining that different job experience and education did not contribute to a best management of headache. More information and informative initiatives are necessary to sensitize people about migraine, especially among hospital workers. Keywords
Migraine Diagnostic delay
Introduction M. Bartolini (&) G. Viticchi F. Lombardi L. Provinciali M. Silvestrini Neurologic Clinic, Politecnic University of Marche, Via Conca 1, 60020 Ancona, Italy e-mail: [email protected] L. Falsetti Internal and Subintensive Medicine, Ospedali Riuniti Ancona, Ancona, Italy A. Ulissi M. Baldassari A. Medori S. Mattioli Occupational Medicine Ward, Ospedali Riuniti Ancona, Ancona, Italy
Migraine is one of the most diffused pathologies in the world. In Europe up to 15 % of the population complains of this form of headache [1]. Diagnosis can be quite easily obtained according to the International Headache Society (IHS) guidelines [2] and no radiological or laboratory exams are usually necessary. Moreover, several studies showed that the diagnostic delay is very relevant in migraine, and very often patients need years for a correct definition of their problem [3, 4]. Our group investigated the diagnostic delay for migraine in general population and
123
S28
found a mean time to achieve a correct diagnosis of 10.7 years [5]. Moreover, we observed that the wasting time for diagnosis is proportional to the increasing number of instrumental examinations performed by patients [3, 6]. Hospital workers are expected to be more sensitized to health problems and more favored in the possibility of a medical consultation in order to clarify any suspected condition. This should be especially true for doctors, nurses and clinical workers. The large number of shift workers in the hospital staff makes this particular population at an increased risk for headache because frequent changes in work time involves sleepless nights. Hughes and colleagues investigated headache occurrence in people working in hospital focusing their attention on therapies and drugs employment [7]. Instead, no data are available about the diagnostic delay for migraine in hospital workers. The aim of this study was to evaluate if there is a difference in migraine diagnostic delay between hospital workers and common people. Moreover, we investigate if there were any differences among different typology of inhospital workers.
Methods We evaluated the occurrence of headache in the hospital employers during their legal visits for ability to work, as routinely concerned by the law. Time of onset of headache symptoms was the core of our investigation. Moreover, we checked if headache patients had ever undergone a specialist visit. Particularly, we evaluated headache presence by a self-questionnaire including the ID-migraine test (a three-question test validated to formulate a migraine diagnosis) [8]. Moreover, we investigated the specific characteristics of the job activity including the work time and the demographic characteristics. We compared this sample of hospital workers with our database of headache center about all patients of the last 5 years on which we put a first diagnosis of migraine with and without aura according to IHS criteria [2]. These patients performed a complete visit with a physical examination, a complete anamnesis about their clinical history and finally a complete questionnaire about headache characteristics. In the statistical analysis, we recorded for each patient the number of years from symptoms onset to migraine diagnosis, age and sex. Age and diagnostic delay were treated as continuous variables, sex was treated as binary. The subgroups of workers were synthesized as ordinal variables. Continuous variables were compared with t test for independent samples. Dichotomous and categorical
123
Neurol Sci (2014) 35 (Suppl 1):S27–S29
variables were compared with Chi squared test. The mean difference between in-hospital workers and outpatients was analyzed with a GLM/multivariate model accounting of age and sex. The difference between the single subcategory of workers affected by migraine was explored with a GLM/ multivariate model accounting of age and sex. Statistical analysis was performed with SPSS 13.0 for Windows systems.
Results We considered a total of 639 hospital workers from September 2013 to February 2014: 377 subjects complained headache, but only 99 of them referred symptoms consistent with migraine with or without aura. In this subgroup, 16 (2.7 %) were doctors, 53 (8.8 %) were nurses, 3 (0.5 %) were sanitary operators, 6 (1 %) were technicians, 14 (2.3 %) were administrative employees, 8 (1.3 %) covered other positions. Five hundred subjects (83.3 %) were outpatients coming from our headache center. Finally, a total of 599 patients affected by migraine with and without aura were enrolled. Mean age of in-hospital workers was 40.24 years (±9.72 years), mean age of our outpatients’ population was 39.02 years (±13.60 years). t test showed a non-significant difference (p = 0.393) between the two subpopulations. Female sex was represented in 81 % of in-hospital workers and 78 % of the outpatients, and this difference did not result as statistically significant at Chi squared statistics (p = 0.740). In-hospital workers (99 patients) had a mean longer diagnostic delay (14.89 years; 95 % CI: 7.85–21.93 years) with respect to the outpatients (12.13 years; 95 % CI: 5.37–18.89 years), and this difference resulted statistically significant at the multivariate model (p \ 0.05) (Fig. 1). Single subpopulations of in-hospital workers did not have a statistically significant different delay in diagnosing migraine: doctors (13.81 years; 95 % CI: 5.38–22.45 years), nurses (13.87 years; 95 % CI: 6.57–21.17 years), Sanitary operators (15.39 years; 95 % CI: 1.93–28.84 years), technicians (13.88 years; 95 % CI: 2.55–25.20 years), administratives (17.14 years; 95 % CI: 8.52–25.76 years) and other (20.16 years; 95 % CI: 10.32–30.00 years) showed a nonsignificant difference at multivariate model (Fig. 1).
Discussion Our data showed that diagnostic delay for migraine is surprisingly longer in hospital workers with respect to an outpatient population. These findings were largely unexpected because, as reasonably assumed, people working in a general hospital should be more sensitized about health
Neurol Sci (2014) 35 (Suppl 1):S27–S29
S29
Fig. 1 Migraine diagnostic delay: hospital workers presented a significant major delay in respect to out-patients. There are no significant differences among different sub-groups of in-hospital workers
problems and have more opportunities to undergo to medical evaluations or to obtain neurological consults. A further interesting information from our study is that no significant differences in diagnostic delay derived from different job activities. In this respect, it was surprising that medical doctors and nurses shared the same diagnostic delay of the other workers who did not experience clinical activities. This finding is difficult to interpret. One hypothesis is that clinicians are inclined to use symptomatic therapies for a non-life-threatening condition without consulting a specialistic colleague. There are many studies about all the risks linked to uncontrolled use of symptomatic therapies [9, 10]. First of all, a non-specific treatment of migraine attacks tends to increase the risk of chronicization. Moreover, a relevant use (often till to a real abuse) of NSAIDs could cause severe consequences for health. This study has two major limits: the first one is that the data of hospital workers were drawn by a self-questionnaire and not by a face-to-face visit. This fact could produce a possible bias, so we are planning to visit all these selected subjects in a second time to validate our data. The second limitation concerns the concept of delay: we considered the time between the day of our clinical diagnosis and the onset of symptoms as a diagnostic delay index. We recognize that it is an arbitrary assumption. However, we can underline that each of the 99 hospital workers have never had a previous diagnosis of migraine in spite of the fact that they presented typical symptoms from several years and usually they used symptomatic therapies. So, the gap between our assessment and the large amount of years with an unrecognized headache could be a reliable index for the waste of time. In conclusion, our study demonstrates that for a fast recognition and effective management of migraine a strong
engagement is still necessary. On the other hand, diagnostic work is essential for a rational therapeutic management in order to an uncorrected use of symptomatic drugs and useless investigations. More informative initiatives are necessary to sensitize people, including hospital workers about migraine. Conflict of interest I certify that there is no actual or potential conflict of interest in relation to this article.
References 1. Stovner LJ, Andree C (2010) Prevalence of headache in Europe: a review for the Eurolight project. J Headache Pain 11(4):289–299 2. Headache Classification Committee of the International Headache Society (IHS) (2013) The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 33(9):629–808 3. Viticchi G, Bartolini M, Falsetti L et al (2013) Instrumental exams performance can be a contributing factor to the delay in diagnosis of migraine. Eur Neurol 71(3–4):120–125 4. Viticchi G, Silvestrini M, Falsetti L et al (2011) Time delay from onset to diagnosis of migraine. Headache 51(2):232–236 5. Viticchi G, Bartolini M, Falsetti L et al (2013) Diagnostic delay in migraine with aura. Neurol Sci 34(Suppl 1):S141–S142 6. Viticchi G, Silvestrini M, Falsetti L et al (2011) The role of instrumental examinations in delayed migraine diagnosis. Neurol Sci 32(Suppl 1):S143–S144 7. Hughes MD, Wu J, Williams TC et al (2013) The experience of headaches in health care workers: opportunity for care improvement. Headache 53(6):962–969 8. Cousins G, Hijazze S, Van de Laar FA, Fahey T (2011) Diagnostic accuracy of the ID migraine: a systematic review and meta-analysis. Headache 51(7):1140–1148 9. Cola´s R, Muno˜z P, Temprano R, Go´mez C, Pascual J (2004) Chronic daily headache with analgesic overuse: epidemiology and impact on quality of life. Neurology 62:1338–1342 10. Katic´ BJ, Krause SJ, Tepper SJ, Hu HX, Bigal ME (2010) Adherence to acute migraine medication: what does it mean, why does it matter? Headache 50:117–129
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