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Characteristics in patients with headache in an outpatient clinic in Japan

Characteristics in patients with headache in an outpatient clinic in Japan Background: Little is known about the prevalence of primary and secondary headache in clinics in Japan. The aim of this study is to characterize patients with headache in an outpatient unit where primary care physicians are working in Japan. Methods: Consecutive outpatients who newly visited the Department of General Medicine, Asahikawa Medical College Hospital, Asahikawa, Japan between April 2005 and March 2009 were analyzed. Each parameter such as age, sex or diagnosis was investigated. Results: Out of 4693 patients, 418 patients visited to our department because of headache. Primary headache was found in 167 patients (39.9%). The rate of tension-type headache (TTH) (30.8%) was highest, followed by migraine (9.1%). Approximately 3 times higher rate of migraine was observed in female patients when compared with male patients. In female patients, migraine was observed more frequently in younger patients. On the other hands, TTH was observed in almost all aged patients in males and females, and the rate of TTH peaks between the ages of 40 and 49 years in both sex. The present study also demonstrated that 8.4% of patients who chiefly complained of headache had been diagnosed as depression while 1.7% of remained patients had been diagnosed as depression, indicating 5-times higher rate of depression in patients with headache. Conclusion: All these results suggest that primary headache, especially TTH, is highly observed and depression should be considered in patients with headache in an outpatient clinic where primary care physicians are working in Japan. Background headache in outpatient setting where primary care phy- Headache is the most prevalent neurological symptom sicians are working in Japan. The aim of this study is and is experienced by almost everyone [1]. Population- therefore to characterize patients with headache in based epidemiological studies on primary headache have Japan who seek medical treatment. been carried out in many countries [2]. Stovner et al. have described in the review article that there exists a Methods regional differences in the prevalence of primary head- We analyzed consecutive outpatients who newly visited ache [2]. For example, the prevalence of tension type at Department of General Medicine, Asahikawa Medical headache (TTH) in the adults in Europe is much higher College Hospital. In Japan, almost everyone is covered than other regions including North America and Asia, by national health insurance. Patients generally have the and the prevalence of migraine in Asia is lower than freedom to choose the health care provider that feel Europe and North America. Although there are two best fits their needs without concerns regarding costs. reports on the prevalence of primary headache such as Therefore, there might be no big difference between migraine in general population in Japan [3,4], little is patients who visit the department of General Medicine known about the prevalence of not only primary head- in Asahikawa Medical College hospital and ones who ache such as migraine and TTH but also secondary visit clinics or smaller hospitals. The total number of patients during April 2005 and March 2009 evaluated in * Correspondence: okumurat@asahikawa-med.ac.jp this study was 4693. As reported previously [5,6], Asahi- Department of General Medicine, Asahikawa Medical University, Asahikawa, kawa Medical College Hospital is located in Asahikawa Japan © 2010 Okumura et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Okumura et al. Asia Pacific Family Medicine 2010, 9:10 Page 2 of 5 http://www.apfmj.com/content/9/1/10 City which has a population of approximately 350,000 in as depression. When we wonder if the patient may be the middle of the Hokkaido Island, the most northern depression because we observed appetite loss, sleep dis- part of Japan. The hospital consists of 602 beds in turbance, unexplained body weight loss, recent suicide which approximately 250 doctors are working to cover attempt, our feeling “He/She looks depressive” and so almost all of medical problems. Among them, 5 or 6 on, final diagnosis of depression have been done accord- primary care physicians are working at the Department ing to DSM-IV. Statistical analysis was made using c of General Medicine. New patients who come to the square test using IBM SPSS statistics software for Win- hospital by an ambulance are always admitted to the dows version 18.0 (SPSS Inc., Chicago, USA). A level of emergency unit in this hospital. Therefore, such patients p < 0.05 was considered to be statistically significant. are not admitted in the department of General Medi- cine. Out of new walk-in patients who visited to outpati- Results ent departments in our hospital, the patients who have a Out of 4693 patients, 418 (8.9%) patients visited because letter from other doctors to a specific department such of headache. CT scan or MRI imaging to detect or as the department of Dermatology go to directly to the exclude brain disorders was performed in 85 patients department. On the other hand, patients who have no (20. 3%) out of the 418 patients. Final diagnosis of 418 letter from other doctors and do not know “I should patients was shown in Table 1. The present results visit to what department” come first to the Department demonstrated that cerebrovascular disorders had been of General Medicine. In our recent paper [5], evaluated rarely observed in patients who complained of headache outpatients who visited the Department of General as shown in Table 1. Primary headache was found in Medicine were classified into the major ICD-10. Thus a 167 patients (39.9%). The rate of TTH was highest, fol- large variety of patients visited to the Department of lowed by migraine. Secondary headache was found as in Medicine, Asahikawa Medical College Hospital, Japan. Table1.These includesystemicinfection such as influ- All data were drawn from medical records and Com- enza and common colds, rhino sinusitis or depression. puterized Physician Order Entry System in the hospital. Psychiatric disorders other than depression include schi- Each parameter such as age, sex and diagnosis was zophrenia and, neurotic and somatoform disorders. investigated from the source. All patients who accepted When systemic infection is excluded, the rate of primary for examination of laboratory test, we measured routi- headache such as TTH and migraine out of all patients nely urine and blood samples. These include complete with headache is 49.4% (167/338), and the prevalence of blood count, liver function, renal function, C-reactive primary headaches and depression is approximately protein and TSH. To exclude the secondary headache, 60.0% (202/338). patients who complained of symptoms such as headache with increasing intensity, sudden onset and/or headache that had been never experienced before, were received Table 1 Diagnosis of patients who had headache brain CT scan to rule out brain diseases. Rapid test for ICHD-II diagnosis Number (%) influenza virus, blood test for detection of EB virus or culture tests that had been considered to be necessarily Migraine 38 9.1 for differential diagnosis was performed in patients who Tension-type headache 129 30.8 had obvious signs of acute infection, like fever of ≥ 37.0° C within a couple of days. The International Classifica- cerebrovascular disorder 3 0.7 tion of Headache Disorders version 2 (ICDH-II) [7] was non-vascular intracranial disorder 2 0.5 applied to each patient who complained of headache. systemic infection (bacterial or viral) 80 19.1 Depression and other psychiatric disorders were diag- disorder of homoeostasis thyroid 3 0.7 nosed according to DSM-IV [8]. Due to the clinical lim- hypertension 5 1.2 itation, DSM-IV classification did not apply for all eyes, ears, nose, sinuses, structures acute 1 0.2 glaucoma patients. For instance, patients with acute fever, abdom- rhinosinusitis 11 2.6 inal pain and watery diarrhea were diagnosed as acute psychiatric disorder depression 35 8.4 enterocolitis without DSM-IV classification. As one may others 29 6.9 speculate, we could not exclude the possibility if the Cranial neuralgias and central causes of herpes 7 1.7 patient might be depression then. Thus, there was a facial pain zoster clinical limitation when the patients visited to our clinic. In fact, DSM-IV classification was applied to patients Others 75 17.9 who complained headache chronically. On the other hands, it is certain that a part of patients who com- Total 418 plained symptoms other than headache were diagnosed Okumura et al. Asia Pacific Family Medicine 2010, 9:10 Page 3 of 5 http://www.apfmj.com/content/9/1/10 Table 2 Gender and age distribution of migraine, tension Table 3 Incidence of depression in patients who type headache and depression complained of headache or others Age Total patient Tension type (A) Chief symptom (B) Depression (B/A %) Migraine Headache Depression Hadache 418 35 (8.4%) Male Others 4275 71 (1.7%) 10-19 112 0 0 0 20-29 331 4 (1.2%) 6 (1.8%) 3 (0.9%) Total 4693 106 (2.3%) 30-39 330 3 (0.9%) 10 (3.0%) 3 (0.9%) *, p < 0.001, when compared with others. 40-49 203 0 8 (3.9%) 5 (2.5%) 50-59 268 0 6 (2.2%) 2 (0.7%) 60-69 313 0 3 (1.0%) 0 Table 3 shows the incidence of depression in patients 70-79 249 0 5 (2.0%) 2 (0.8%) who complained of headache. As demonstrated, 8.4% of 80- 93 0 1 (1.0%) 0 patients who chiefly complained of headache had been diagnosed as depression while 1.7% of remained patients all 1930 7 (0.4%) 39 (2.0%) 15 (0.8%) had been diagnosed as depression. The rate of depres- sion was significantly high in patients with headache. Female Discussion 10-19 165 3 (1.8%) 7 (4.2%) 1 (0.6%) Out of 4693 patients, headache was the chief complaint 20-29 476 9 (1.9%) 19 (4.0%) 3 (0.6%) in 418 patients (8.9%), indicating that diagnosis and 30-39 480 9 (1.9%) 15 (3.1%) 4 (0.8%) treatment for headache is one of the most important 40-49 289 4 (1.4%) 14 (4.8%) 2 (0.7%) clinical issues in outpatient units in Japan. 50-59 413 5 (1.2%) 10 (2.4%) 3 (0.7%) According to this study, approximately 50% or 60% if 60-69 401 1 (0.2%) 13 (3.2%) 1 (0.2%) systemic infection was excluded out of patients with 70-79 375 0 7 (1.9%) 4 (1.1%) headache were diagnosed as primary headache such as 80- 143 0 3 (2.1%) 2 (1.4%) TTH and migraine, and depression. We should there- fore consider the three disorders, TTH, migraine, and all 2763 31 (1.1%) 88 (3.2%) 20 (0.7%) depression, as major causes of headache in this particu- lar clinical setting in Japan. Total 4693 38 (0.8%) 134 (2.9%) 35 (0.7%) With regard to the prevalence of primary headache such as migraine and TTH, a number of reports have been published in many countries. Murtaza et al. [9] Table 2 summarized the data on the gender and age have demonstrated that out of 255 consecutive patients distribution of migraine, TTH and depression who com- who presented to a headache clinic at a tertiary care plained of headache in the present study. Based on the hospital in Pakistan, migraine was the most common Table 2, the rate of migraine and TTH in all patients disorder (206 patients) followed by TTH (58 patients). was 0.8 or 2.9%, respectively, indicating TTH is the According to a report by a Brazilian tertiary-care center highest prevalence in this study. With regard to the rela- [10], the prevalence of diagnosis in patients with head- tionship between sex or age, and the number of patients ache were migraine (38%) and TTH (22%), respectively. with migraine and TTH, there was a significant gender Thus, in Pakistan and Brazil, migraine is the highest difference in the frequency of migraine in all aged prevalence in patients with headache. However, in a patients (male vs. female, 0.4% vs 1.1%), indicating a large majority of countries, TTH is the highest preva- higher rate of migraine in female patients. It was also lence in patients with headache [2]. shown that migraine was limited to patients aged 20-39 A population-based survey in Japan (the Disen study) years old in male patients. In female patients, migraine revealed the 1-year prevalence of migraine and TTH was observed more frequently in patients aged 20-39 was 6.0% and 21.7%, respectively (4). A nationwide sur- years old. There were significant numbers of migraine vey in Japan by Sakai et al. [3] have demonstrated that olderthan40years in womenbut notinmen.Onthe overall prevalence of migraine and TTH was 8.4% and other hands, the rate of TTH was 1.6 times higher in 22.4%, respectively. The present findings obtained from female than male. Although TTH was observed in an outpatient clinic-based study revealed migraine and almost all aged patients in males and females, the rate TTH was diagnosed in 9.1% and 30.8% out of patients of TTH peaksbetween theagesof40and 49 yearsin who complained of headache, respectively. These results men and women. suggest approximately 3 times higher prevalence of Okumura et al. Asia Pacific Family Medicine 2010, 9:10 Page 4 of 5 http://www.apfmj.com/content/9/1/10 TTH than migraine not only in general population but One may speculate whether diagnosis of depression also in outpatient units in Japan. was performed adequately in this study. We have Jensen et al. [2] have demonstrated that the male: recently published a paper on patients with prescription female ratio for migraine among adults varies from 1:2 of selective serotonin reuptake inhibitor (SSRI)s, anti- to 1:3. A nationwide survey of migraine in the general depression drugs, in our clinic [5]. As described in the population in Japan [3], the male: female ratio was paper, SSRIs were prescribed to 126 (2.7%) patients out 1: 3.6. The present study showed that male: female ratio of all 4670 patients during 4 years. The percentage for migraine was 1: 2.75, supporting the higher risk of might be acceptable because major depression is seen by migraine in female than male. primary care physicians with a prevalence of approxi- It has been demonstrated in the recent review that the mately 5% in adult patients in western countries [11-13]. male: female ratio for TTH is 4: 5, indicating that unlike We would therefore suggest the ability of accurate diag- for migraine, women are only slightly more affected nosis of depression would not be far from the estimated than men [2]. In the present study, male: female ratio percentage of depression in our clinic. for TTH was 1: 1.6, furthermore supporting that women The present study revealed that 8.4% out of patients are only slightly more affected by TTH than men, when who chiefly complained of headache were diagnosed as compared with migraine. depression. On the other hand, 1.7% out of remained With regard to the relation of age and the prevalence patients who chiefly complained of symptoms other of migraine, it has been shown that the highest preva- than headache were depression, suggesting approxi- lence of migraine was in women in their 30’s, in whom mately 5 times higher prevalence of depression in oneinfivesufferedmigraine[1].The presentstudy patients with headache. Marlow et al. [14] have reported similarlyshowedthatmigrainewas observedhigherin that 32% of patients with headache were depression womenin20’sand 30’s. On the other hand, the rate of whereas 12% patients without headache were depression, TTH peaks between the ages of 40 and 49 years in men indicating 3-times higher prevalence of depression in and women. These results suggest that there are gender patients with headache, supporting our present results. and age-dependent differences in the prevalence of Chung et al. [15] have demonstrated that patients who between migraine and TTH. presented with a chief complaint of headache in the out- Takeshimaetal. [4]have demonstratedthat1-year patient family practice setting were found to have a high prevalence of migraine was 6.0%, but less than 10% of prevalence of depression. These evidence suggest that migraine had consulted a physician in Japan. According headache would be a marker of depression in the pri- to the report by Sakai et al. [3], nationwide survey of mary care setting also in Japan. migraine was performed in Japan and demonstrated that the overall prevalence of migraine in the past year was Conclusion 8.4% while doctor attendance rate was very low and As shown in this study, a majority of patients who vis- approximately 70% with migraine had never consulted a ited to our outpatient unit because of headache were physician for headache. The present study showed that diagnosed as TTH and migraine, and depression. The migraine was diagnosed in only 0.8% out of all patients. epidemiological characteristics may help our daily clini- Although there is a much difference in the prevalence cal practice in outpatient units where primary care of migraine in between the general population (6.0% physicians are working in Japan. and 8.4%) reported previously and outpatients (0.8%) examined in this study, the difference might be Acknowledgements explained by the evidence that only a small part of We would like to thank Dr. Y. Saijo (Department of Health Science, migraine consult or seek medical service as described in Asahikawa Medical University, Japan) for asistance of statistical analysis. above at least in Japan. Authors’ contributions The present results also demonstrated that cerebrovas- TO conceptualized, designed, collected and analyzed data and drafted the cular disorders had been rarely observed in patients who manuscript. ST, MO, ST and TN contributed to collection and analysis of data. All authors read and approved the final manuscript. complained of headache. The reason may come from the features in this hospital that a large majority of Competing interests patients with severe headaches who might have cranial The authors declare that they have no competing interests. vascular diseases visited to our hospital by ambulance. Received: 5 August 2010 Accepted: 18 November 2010 Doctors in emergency room take care of the patients Published: 18 November 2010 who come by ambulance. In this study, we analyzed the data of walk-in patients in this outpatient department. References 1. Jensen R, Stovner LJ: Epidemiology and comorbidity of headache. Lancet These are the reasons why cranial vascular diseases Neurol 2008, 7:354-361. were rare in this study. Okumura et al. Asia Pacific Family Medicine 2010, 9:10 Page 5 of 5 http://www.apfmj.com/content/9/1/10 2. Stovner L, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, Steiner T, Zwart JA: The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007, 27:193-210. 3. Sakai F, Igarashi H: Prevalence of migraine in Japan: a nationwide survey. Cephalalgia 1997, 17:15-22. 4. Takeshima T, Ishizaki K, Fukuhara Y, Ijiri T, Kusumi M, Wakutani Y, Mori M, Kawashima M, Kowa H, Adachi Y, Urakami K, Nakashima K: Population- based door-to-door survey of migraine in Japan: the Daisen study. Headache 2004, 44:8-19. 5. Tanno S, Ohhira M, Tsuchiya Y, Takeuchi T, Tanno S, Okumura T: Frequent early discontinuation of SSRI prescribed by primary care physicians in young males in Japan. Intern Med 2009, 48:1263-1266. 6. Okumura T, Tanno S, Ohhira M, Tanno S: Prevalence of functional dyspepsia in an outpatient clinic with primary care physicians in Japan. J Gastroenterol 2010, 45:187-194. 7. Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders. Cephalagia;, 2 2004:24(Suppl 1):9-160. th 8. International Classification of Diseases 10 edition (ICD-10) codes. International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Version for; 2007 [http://www.who.int/ classifications/apps/icd/icd10online/]. 9. Murtaza M, Kisat M, Daniel H, Sonawalla AB: Classification and clinical features of headache disorders in Pakistan: a retrospective review of clinical data. PLoS One 2009, 4:e5827. 10. Felício AC, Bichuetti DB, Santos WA, Godeiro Junior Cde O, Marin LF, Carvalho Dde S: Epidemiology of primary and secondary headaches in a Brazilian tertiary-care center. Arq Neuropsiquiatr 2006, 64:41-44. 11. Williams JW Jr, Mulrow CD, Kroenke K, Dhanda R, Badgett RG, Omori D, Lee S: Case-finding for depression in primary care: randomized trial. Am JMed 1999, 106:36-43. 12. Simon GE, Vonkoff M: Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995, 4:99-105. 13. Whooley MA, Avins AL, Miranda J, Browner WS: Case-finding instruments for depression, two questions are as good as many. J Gen Intern Med 1997, 12:439-445. 14. Marlow RA, Kegowicz CL, Starkey KN: Prevalence of depression symptoms in outpatients with a complaint of headache. J Am Board Fam Med 2009, 22:633-637. 15. Chung MK, Kraybill DE: Headache: a marker of depression. J Fam Pract 1990, 31:360-364. doi:10.1186/1447-056X-9-10 Cite this article as: Okumura et al.: Characteristics in patients with headache in an outpatient clinic in Japan. Asia Pacific Family Medicine 2010 9:10. 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Characteristics in patients with headache in an outpatient clinic in Japan

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Springer Journals
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Copyright © 2010 by Okumura et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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1447-056X
DOI
10.1186/1447-056X-9-10
pmid
21083939
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Abstract

Background: Little is known about the prevalence of primary and secondary headache in clinics in Japan. The aim of this study is to characterize patients with headache in an outpatient unit where primary care physicians are working in Japan. Methods: Consecutive outpatients who newly visited the Department of General Medicine, Asahikawa Medical College Hospital, Asahikawa, Japan between April 2005 and March 2009 were analyzed. Each parameter such as age, sex or diagnosis was investigated. Results: Out of 4693 patients, 418 patients visited to our department because of headache. Primary headache was found in 167 patients (39.9%). The rate of tension-type headache (TTH) (30.8%) was highest, followed by migraine (9.1%). Approximately 3 times higher rate of migraine was observed in female patients when compared with male patients. In female patients, migraine was observed more frequently in younger patients. On the other hands, TTH was observed in almost all aged patients in males and females, and the rate of TTH peaks between the ages of 40 and 49 years in both sex. The present study also demonstrated that 8.4% of patients who chiefly complained of headache had been diagnosed as depression while 1.7% of remained patients had been diagnosed as depression, indicating 5-times higher rate of depression in patients with headache. Conclusion: All these results suggest that primary headache, especially TTH, is highly observed and depression should be considered in patients with headache in an outpatient clinic where primary care physicians are working in Japan. Background headache in outpatient setting where primary care phy- Headache is the most prevalent neurological symptom sicians are working in Japan. The aim of this study is and is experienced by almost everyone [1]. Population- therefore to characterize patients with headache in based epidemiological studies on primary headache have Japan who seek medical treatment. been carried out in many countries [2]. Stovner et al. have described in the review article that there exists a Methods regional differences in the prevalence of primary head- We analyzed consecutive outpatients who newly visited ache [2]. For example, the prevalence of tension type at Department of General Medicine, Asahikawa Medical headache (TTH) in the adults in Europe is much higher College Hospital. In Japan, almost everyone is covered than other regions including North America and Asia, by national health insurance. Patients generally have the and the prevalence of migraine in Asia is lower than freedom to choose the health care provider that feel Europe and North America. Although there are two best fits their needs without concerns regarding costs. reports on the prevalence of primary headache such as Therefore, there might be no big difference between migraine in general population in Japan [3,4], little is patients who visit the department of General Medicine known about the prevalence of not only primary head- in Asahikawa Medical College hospital and ones who ache such as migraine and TTH but also secondary visit clinics or smaller hospitals. The total number of patients during April 2005 and March 2009 evaluated in * Correspondence: okumurat@asahikawa-med.ac.jp this study was 4693. As reported previously [5,6], Asahi- Department of General Medicine, Asahikawa Medical University, Asahikawa, kawa Medical College Hospital is located in Asahikawa Japan © 2010 Okumura et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Okumura et al. Asia Pacific Family Medicine 2010, 9:10 Page 2 of 5 http://www.apfmj.com/content/9/1/10 City which has a population of approximately 350,000 in as depression. When we wonder if the patient may be the middle of the Hokkaido Island, the most northern depression because we observed appetite loss, sleep dis- part of Japan. The hospital consists of 602 beds in turbance, unexplained body weight loss, recent suicide which approximately 250 doctors are working to cover attempt, our feeling “He/She looks depressive” and so almost all of medical problems. Among them, 5 or 6 on, final diagnosis of depression have been done accord- primary care physicians are working at the Department ing to DSM-IV. Statistical analysis was made using c of General Medicine. New patients who come to the square test using IBM SPSS statistics software for Win- hospital by an ambulance are always admitted to the dows version 18.0 (SPSS Inc., Chicago, USA). A level of emergency unit in this hospital. Therefore, such patients p < 0.05 was considered to be statistically significant. are not admitted in the department of General Medi- cine. Out of new walk-in patients who visited to outpati- Results ent departments in our hospital, the patients who have a Out of 4693 patients, 418 (8.9%) patients visited because letter from other doctors to a specific department such of headache. CT scan or MRI imaging to detect or as the department of Dermatology go to directly to the exclude brain disorders was performed in 85 patients department. On the other hand, patients who have no (20. 3%) out of the 418 patients. Final diagnosis of 418 letter from other doctors and do not know “I should patients was shown in Table 1. The present results visit to what department” come first to the Department demonstrated that cerebrovascular disorders had been of General Medicine. In our recent paper [5], evaluated rarely observed in patients who complained of headache outpatients who visited the Department of General as shown in Table 1. Primary headache was found in Medicine were classified into the major ICD-10. Thus a 167 patients (39.9%). The rate of TTH was highest, fol- large variety of patients visited to the Department of lowed by migraine. Secondary headache was found as in Medicine, Asahikawa Medical College Hospital, Japan. Table1.These includesystemicinfection such as influ- All data were drawn from medical records and Com- enza and common colds, rhino sinusitis or depression. puterized Physician Order Entry System in the hospital. Psychiatric disorders other than depression include schi- Each parameter such as age, sex and diagnosis was zophrenia and, neurotic and somatoform disorders. investigated from the source. All patients who accepted When systemic infection is excluded, the rate of primary for examination of laboratory test, we measured routi- headache such as TTH and migraine out of all patients nely urine and blood samples. These include complete with headache is 49.4% (167/338), and the prevalence of blood count, liver function, renal function, C-reactive primary headaches and depression is approximately protein and TSH. To exclude the secondary headache, 60.0% (202/338). patients who complained of symptoms such as headache with increasing intensity, sudden onset and/or headache that had been never experienced before, were received Table 1 Diagnosis of patients who had headache brain CT scan to rule out brain diseases. Rapid test for ICHD-II diagnosis Number (%) influenza virus, blood test for detection of EB virus or culture tests that had been considered to be necessarily Migraine 38 9.1 for differential diagnosis was performed in patients who Tension-type headache 129 30.8 had obvious signs of acute infection, like fever of ≥ 37.0° C within a couple of days. The International Classifica- cerebrovascular disorder 3 0.7 tion of Headache Disorders version 2 (ICDH-II) [7] was non-vascular intracranial disorder 2 0.5 applied to each patient who complained of headache. systemic infection (bacterial or viral) 80 19.1 Depression and other psychiatric disorders were diag- disorder of homoeostasis thyroid 3 0.7 nosed according to DSM-IV [8]. Due to the clinical lim- hypertension 5 1.2 itation, DSM-IV classification did not apply for all eyes, ears, nose, sinuses, structures acute 1 0.2 glaucoma patients. For instance, patients with acute fever, abdom- rhinosinusitis 11 2.6 inal pain and watery diarrhea were diagnosed as acute psychiatric disorder depression 35 8.4 enterocolitis without DSM-IV classification. As one may others 29 6.9 speculate, we could not exclude the possibility if the Cranial neuralgias and central causes of herpes 7 1.7 patient might be depression then. Thus, there was a facial pain zoster clinical limitation when the patients visited to our clinic. In fact, DSM-IV classification was applied to patients Others 75 17.9 who complained headache chronically. On the other hands, it is certain that a part of patients who com- Total 418 plained symptoms other than headache were diagnosed Okumura et al. Asia Pacific Family Medicine 2010, 9:10 Page 3 of 5 http://www.apfmj.com/content/9/1/10 Table 2 Gender and age distribution of migraine, tension Table 3 Incidence of depression in patients who type headache and depression complained of headache or others Age Total patient Tension type (A) Chief symptom (B) Depression (B/A %) Migraine Headache Depression Hadache 418 35 (8.4%) Male Others 4275 71 (1.7%) 10-19 112 0 0 0 20-29 331 4 (1.2%) 6 (1.8%) 3 (0.9%) Total 4693 106 (2.3%) 30-39 330 3 (0.9%) 10 (3.0%) 3 (0.9%) *, p < 0.001, when compared with others. 40-49 203 0 8 (3.9%) 5 (2.5%) 50-59 268 0 6 (2.2%) 2 (0.7%) 60-69 313 0 3 (1.0%) 0 Table 3 shows the incidence of depression in patients 70-79 249 0 5 (2.0%) 2 (0.8%) who complained of headache. As demonstrated, 8.4% of 80- 93 0 1 (1.0%) 0 patients who chiefly complained of headache had been diagnosed as depression while 1.7% of remained patients all 1930 7 (0.4%) 39 (2.0%) 15 (0.8%) had been diagnosed as depression. The rate of depres- sion was significantly high in patients with headache. Female Discussion 10-19 165 3 (1.8%) 7 (4.2%) 1 (0.6%) Out of 4693 patients, headache was the chief complaint 20-29 476 9 (1.9%) 19 (4.0%) 3 (0.6%) in 418 patients (8.9%), indicating that diagnosis and 30-39 480 9 (1.9%) 15 (3.1%) 4 (0.8%) treatment for headache is one of the most important 40-49 289 4 (1.4%) 14 (4.8%) 2 (0.7%) clinical issues in outpatient units in Japan. 50-59 413 5 (1.2%) 10 (2.4%) 3 (0.7%) According to this study, approximately 50% or 60% if 60-69 401 1 (0.2%) 13 (3.2%) 1 (0.2%) systemic infection was excluded out of patients with 70-79 375 0 7 (1.9%) 4 (1.1%) headache were diagnosed as primary headache such as 80- 143 0 3 (2.1%) 2 (1.4%) TTH and migraine, and depression. We should there- fore consider the three disorders, TTH, migraine, and all 2763 31 (1.1%) 88 (3.2%) 20 (0.7%) depression, as major causes of headache in this particu- lar clinical setting in Japan. Total 4693 38 (0.8%) 134 (2.9%) 35 (0.7%) With regard to the prevalence of primary headache such as migraine and TTH, a number of reports have been published in many countries. Murtaza et al. [9] Table 2 summarized the data on the gender and age have demonstrated that out of 255 consecutive patients distribution of migraine, TTH and depression who com- who presented to a headache clinic at a tertiary care plained of headache in the present study. Based on the hospital in Pakistan, migraine was the most common Table 2, the rate of migraine and TTH in all patients disorder (206 patients) followed by TTH (58 patients). was 0.8 or 2.9%, respectively, indicating TTH is the According to a report by a Brazilian tertiary-care center highest prevalence in this study. With regard to the rela- [10], the prevalence of diagnosis in patients with head- tionship between sex or age, and the number of patients ache were migraine (38%) and TTH (22%), respectively. with migraine and TTH, there was a significant gender Thus, in Pakistan and Brazil, migraine is the highest difference in the frequency of migraine in all aged prevalence in patients with headache. However, in a patients (male vs. female, 0.4% vs 1.1%), indicating a large majority of countries, TTH is the highest preva- higher rate of migraine in female patients. It was also lence in patients with headache [2]. shown that migraine was limited to patients aged 20-39 A population-based survey in Japan (the Disen study) years old in male patients. In female patients, migraine revealed the 1-year prevalence of migraine and TTH was observed more frequently in patients aged 20-39 was 6.0% and 21.7%, respectively (4). A nationwide sur- years old. There were significant numbers of migraine vey in Japan by Sakai et al. [3] have demonstrated that olderthan40years in womenbut notinmen.Onthe overall prevalence of migraine and TTH was 8.4% and other hands, the rate of TTH was 1.6 times higher in 22.4%, respectively. The present findings obtained from female than male. Although TTH was observed in an outpatient clinic-based study revealed migraine and almost all aged patients in males and females, the rate TTH was diagnosed in 9.1% and 30.8% out of patients of TTH peaksbetween theagesof40and 49 yearsin who complained of headache, respectively. These results men and women. suggest approximately 3 times higher prevalence of Okumura et al. Asia Pacific Family Medicine 2010, 9:10 Page 4 of 5 http://www.apfmj.com/content/9/1/10 TTH than migraine not only in general population but One may speculate whether diagnosis of depression also in outpatient units in Japan. was performed adequately in this study. We have Jensen et al. [2] have demonstrated that the male: recently published a paper on patients with prescription female ratio for migraine among adults varies from 1:2 of selective serotonin reuptake inhibitor (SSRI)s, anti- to 1:3. A nationwide survey of migraine in the general depression drugs, in our clinic [5]. As described in the population in Japan [3], the male: female ratio was paper, SSRIs were prescribed to 126 (2.7%) patients out 1: 3.6. The present study showed that male: female ratio of all 4670 patients during 4 years. The percentage for migraine was 1: 2.75, supporting the higher risk of might be acceptable because major depression is seen by migraine in female than male. primary care physicians with a prevalence of approxi- It has been demonstrated in the recent review that the mately 5% in adult patients in western countries [11-13]. male: female ratio for TTH is 4: 5, indicating that unlike We would therefore suggest the ability of accurate diag- for migraine, women are only slightly more affected nosis of depression would not be far from the estimated than men [2]. In the present study, male: female ratio percentage of depression in our clinic. for TTH was 1: 1.6, furthermore supporting that women The present study revealed that 8.4% out of patients are only slightly more affected by TTH than men, when who chiefly complained of headache were diagnosed as compared with migraine. depression. On the other hand, 1.7% out of remained With regard to the relation of age and the prevalence patients who chiefly complained of symptoms other of migraine, it has been shown that the highest preva- than headache were depression, suggesting approxi- lence of migraine was in women in their 30’s, in whom mately 5 times higher prevalence of depression in oneinfivesufferedmigraine[1].The presentstudy patients with headache. Marlow et al. [14] have reported similarlyshowedthatmigrainewas observedhigherin that 32% of patients with headache were depression womenin20’sand 30’s. On the other hand, the rate of whereas 12% patients without headache were depression, TTH peaks between the ages of 40 and 49 years in men indicating 3-times higher prevalence of depression in and women. These results suggest that there are gender patients with headache, supporting our present results. and age-dependent differences in the prevalence of Chung et al. [15] have demonstrated that patients who between migraine and TTH. presented with a chief complaint of headache in the out- Takeshimaetal. [4]have demonstratedthat1-year patient family practice setting were found to have a high prevalence of migraine was 6.0%, but less than 10% of prevalence of depression. These evidence suggest that migraine had consulted a physician in Japan. According headache would be a marker of depression in the pri- to the report by Sakai et al. [3], nationwide survey of mary care setting also in Japan. migraine was performed in Japan and demonstrated that the overall prevalence of migraine in the past year was Conclusion 8.4% while doctor attendance rate was very low and As shown in this study, a majority of patients who vis- approximately 70% with migraine had never consulted a ited to our outpatient unit because of headache were physician for headache. The present study showed that diagnosed as TTH and migraine, and depression. The migraine was diagnosed in only 0.8% out of all patients. epidemiological characteristics may help our daily clini- Although there is a much difference in the prevalence cal practice in outpatient units where primary care of migraine in between the general population (6.0% physicians are working in Japan. and 8.4%) reported previously and outpatients (0.8%) examined in this study, the difference might be Acknowledgements explained by the evidence that only a small part of We would like to thank Dr. Y. Saijo (Department of Health Science, migraine consult or seek medical service as described in Asahikawa Medical University, Japan) for asistance of statistical analysis. above at least in Japan. Authors’ contributions The present results also demonstrated that cerebrovas- TO conceptualized, designed, collected and analyzed data and drafted the cular disorders had been rarely observed in patients who manuscript. ST, MO, ST and TN contributed to collection and analysis of data. All authors read and approved the final manuscript. complained of headache. The reason may come from the features in this hospital that a large majority of Competing interests patients with severe headaches who might have cranial The authors declare that they have no competing interests. vascular diseases visited to our hospital by ambulance. Received: 5 August 2010 Accepted: 18 November 2010 Doctors in emergency room take care of the patients Published: 18 November 2010 who come by ambulance. In this study, we analyzed the data of walk-in patients in this outpatient department. References 1. Jensen R, Stovner LJ: Epidemiology and comorbidity of headache. Lancet These are the reasons why cranial vascular diseases Neurol 2008, 7:354-361. were rare in this study. Okumura et al. Asia Pacific Family Medicine 2010, 9:10 Page 5 of 5 http://www.apfmj.com/content/9/1/10 2. Stovner L, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, Steiner T, Zwart JA: The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007, 27:193-210. 3. Sakai F, Igarashi H: Prevalence of migraine in Japan: a nationwide survey. Cephalalgia 1997, 17:15-22. 4. Takeshima T, Ishizaki K, Fukuhara Y, Ijiri T, Kusumi M, Wakutani Y, Mori M, Kawashima M, Kowa H, Adachi Y, Urakami K, Nakashima K: Population- based door-to-door survey of migraine in Japan: the Daisen study. Headache 2004, 44:8-19. 5. Tanno S, Ohhira M, Tsuchiya Y, Takeuchi T, Tanno S, Okumura T: Frequent early discontinuation of SSRI prescribed by primary care physicians in young males in Japan. Intern Med 2009, 48:1263-1266. 6. Okumura T, Tanno S, Ohhira M, Tanno S: Prevalence of functional dyspepsia in an outpatient clinic with primary care physicians in Japan. J Gastroenterol 2010, 45:187-194. 7. Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders. Cephalagia;, 2 2004:24(Suppl 1):9-160. th 8. International Classification of Diseases 10 edition (ICD-10) codes. International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Version for; 2007 [http://www.who.int/ classifications/apps/icd/icd10online/]. 9. Murtaza M, Kisat M, Daniel H, Sonawalla AB: Classification and clinical features of headache disorders in Pakistan: a retrospective review of clinical data. PLoS One 2009, 4:e5827. 10. Felício AC, Bichuetti DB, Santos WA, Godeiro Junior Cde O, Marin LF, Carvalho Dde S: Epidemiology of primary and secondary headaches in a Brazilian tertiary-care center. Arq Neuropsiquiatr 2006, 64:41-44. 11. Williams JW Jr, Mulrow CD, Kroenke K, Dhanda R, Badgett RG, Omori D, Lee S: Case-finding for depression in primary care: randomized trial. Am JMed 1999, 106:36-43. 12. Simon GE, Vonkoff M: Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995, 4:99-105. 13. Whooley MA, Avins AL, Miranda J, Browner WS: Case-finding instruments for depression, two questions are as good as many. J Gen Intern Med 1997, 12:439-445. 14. Marlow RA, Kegowicz CL, Starkey KN: Prevalence of depression symptoms in outpatients with a complaint of headache. J Am Board Fam Med 2009, 22:633-637. 15. Chung MK, Kraybill DE: Headache: a marker of depression. J Fam Pract 1990, 31:360-364. doi:10.1186/1447-056X-9-10 Cite this article as: Okumura et al.: Characteristics in patients with headache in an outpatient clinic in Japan. Asia Pacific Family Medicine 2010 9:10. 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Asia Pacific Family MedicineSpringer Journals

Published: Nov 18, 2010

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