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PII: S0022-510X(16)30774-2
DOI: doi: 10.1016/j.jns.2016.11.071
Reference: JNS 14983
To appear in: Journal of the Neurological Sciences
Received date: 22 September 2016
Revised date: 19 November 2016
Accepted date: 29 November 2016
Please cite this article as: Yohannes W. Woldeamanuel, Robert P. Cowan , Migraine
affects 1 in 10 people worldwide featuring recent rise: A systematic review and meta-
analysis of community-based studies involving 6 million participants. The address for
the corresponding author was captured as affiliation for all authors. Please check if
appropriate. Jns(2016), doi: 10.1016/j.jns.2016.11.071
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Title
Migraine affects 1 in 10 people worldwide featuring recent rise: a systematic review and meta-
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Author names and affiliations
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Yohannes W. Woldeamanuela,*
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a
Stanford Headache and Facial Pain Program, Department of Neurology and Neurological
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Sciences, Stanford University School of Medicine, 213 Quarry Road, Palo Alto, CA 94304, USA
email: ywoldeam@stanford.edu
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Robert P. Cowanb
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b
Stanford Headache and Facial Pain Program, Department of Neurology and Neurological
Sciences, Stanford University School of Medicine, 213 Quarry Road, Palo Alto, CA 94304, USA
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email: rpcowan@stanford.edu
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Abstract
Objective: To study the weighted average global prevalence of migraine at the community level.
Study Design and Setting: A systematic review using advanced search strategies employing
PubMed/MEDLINE, Scopus, and Web of Science was conducted for community-based and non-
clinical studies by combining the terms „„migraine‟‟, „„community-based‟‟, and names of every
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country worldwide spanning all previous years from January 1, 1920 until August 31, 2015.
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Methods were in accordance with PRISMA and MOOSE guidelines. A meta-analysis with
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subgroup analysis was performed to identify pooled migraine prevalence and examine cohort
heterogeneity.
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Results: A total of 302 community-based studies involving 6,216,995 participants (median age
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35 years, male-to-female ratio of 0.91) were included. Global migraine prevalence was 11.6%
(95% CI 10.7-12.6%; random effects); 10.4% in Africa, 10.1% in Asia, 11.4% in Europe, 9.7%
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in North America, 16.4% in Central and South America. When the pooled cohort was stratified,
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the prevalence was 13.8% among females, 6.9% among males, 11.2% among urban residents,
8.4% among rural residents, and 12.4% among school/college students. Our result showed a
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Conclusion: Migraine affects one in ten people worldwide featuring recent rise. Higher
analysis; Prevalence
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Highlights
Global migraine prevalence was 11.6% (95% CI 10.7-12.6%; random effects); 10.4%
in Africa, 10.1% in Asia, 11.4% in Europe, 9.7% in North America (NA), 16.4% in
When the pooled cohort was stratified, the prevalence was 13.8% among females,
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6.9% among males, 11.2% among urban residents, 8.4% among rural residents, and
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12.4% among school/college students.
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There was a pattern of rising global migraine prevalence.
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It can be deduced that rapid urbanization is associated with the recent rise in migraine
prevalence; higher student and urban affliction can lower academic and economic
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performance.
Improving awareness, early treatment access-points, research and training, and healthy
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urban lifestyles are important to tackle this costly prevalence rising worldwide.
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1. Introduction
accurate representation of estimating true incidence and prevalence of public health burdens. 1
Such studies serve as a crucial source of information for planning, policy-making, and research
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risk and prognostic factors, identify comorbidities and correlates, and stratify phenotyping.2, 3
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These studies allow sociodemographic subanalysis of population characteristics such as age-
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disorders has been assessed utilizing neuroepidemiological studies.5 Capturing such big data
allows researchers to conduct longitudinal prospective studies to identify causal factors. While
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longitudinal prospective studies provide the best evidence base for data accrual, repeated cross-
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sectional studies can be regarded as quasilongitudinal providing less costly but useful
epidemiologic clues.6
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Migraine is a common cause of public health and socioeconomic burden worldwide; it is under-
or misdiagnosed and under- or mistreated.7-9 It can negatively affect quality of life and
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productivity both at work and at home.5 When not appropriately managed, migraine is a
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progressive neurological disorder that has the potential to chronify.5 Migraine is more common
among the productive workforce segment of the population.4, 10 Many countries in the Global
South are at the crossroads of rapidly improving socioeconomic mobility and shifting disease
greater numbers of people are living longer.1, 4 Thus, morbidity and disability causing disorders
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developing countries, the health care delivery system is designed to tackle infectious diseases,
and has not yet adapted to accommodate the growing health demands of chronic conditions such
as migraine.11, 12
Since the 1930‟s, beginning with classic studies by Balyeat13 and later by Valqhuist14, large
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number of community-based studies have been conducted in different countries worldwide to
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study migraine prevalence. The 2010 Global Burden of Disease (GBD) Study revealed that
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global years lived with disability (YLD) for migraine has steadily increased since 1990, making
primary headache disorders the leading causes of sequelae of up to 35.5% (10.7% in males,
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18.8% in females for migraine).1, 11 However, to the best of our knowledge, there is no study that
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combined data from all community-based studies to present a weighted average global migraine
prevalence. We are now able to analyze these accruing results and identify important time series
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trends. Using a comprehensive systematic review and meta-analysis, we studied the global
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migraine prevalence at the community level, examine population cohorts with varying
2. Methods
A combination of the following search strategies using different search databases was employed
migraine prevalence. Clinical or healthcare facility-based studies were excluded because clinical
population is made of convenience sampling where cohorts are created by recruiting only those
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Systematic Reviews on the PubMed Clinical Queries tool combining the terms
„„AND‟‟ was applied to connect the search terms. The Clinical Studies Category was
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“Therapy” and the scope of the search was made specific to „„Broad‟‟ to enable
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sensitivity and specificity search values of 99% and 70% (63), respectively.16
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2. A second PubMed/MEDLINE® search was employed without using the Clinical Queries
Tool. Search terms used were „„community- or population-based studies AND migraine
prevalence.‟‟
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3. Advanced PubMed/MEDLINE® search was used by implementing search builder of auto-
4. A Web of ScienceTM Advanced Search was employed by using the field tag „„TS‟‟ for
topic, the Boolean operator „„AND,‟‟ and parentheses to create our query as „„TS =
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were refined to MEDLINE®, Web of ScienceTM Core Collection, and Current Contents
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Connect®. Results included all languages, all Countries/Territories, all Research Areas,
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6. A PubMed/MEDLINE search was employed using the words “migraine, country”. For
“country”, the name of every country worldwide (196 countries) was entered, for e.g.
“migraine, China”.
7. Scientific abstracts and a relevant reference hand search were exhaustively conducted
using Google and Google Scholar. This enabled us to locate and capture unpublished
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studies from the gray literature (e.g. conference abstracts) on our topic of interest.
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A PRISMA17 (Preferred Reporting Items for Systematic Reviews and Meta-analysis: the
PRISMA Statement) flowchart depicting the selection of studies is shown on Figure 1a. Methods
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were in accordance with MOOSE18 (Meta-analysis of Observational Studies in Epidemiology
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guidelines) (Appendix A). Community-based and non-clinical studies were included. Clinical-
based studies and studies not related to our primary interest, i.e. migraine prevalence, were
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excluded. All language publications were included, and non-English articles were translated
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using the assistance from scientific colleagues with respective first languages. The search
spanned all studies which are available in the medical literature in previous years from January 1,
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1920 up to August 31, 2015. YWW (first author in this study) is an expert on literature search
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strategies and has previously contributed several related publications of systematic reviews and
meta-analysis.4, 19, 20
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The following data were extracted from each included study: first author, year of publication,
country of origin, average age of total participants, total sample size, number of female
participants, number of male participants, number of migraineurs. Prevalence and 95% CI were
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obtained for the overall pooled data, and stratified data for sex, study setting (urban, rural,
school-based), time period for prevalence (3-months, 6-months, one-year, two-years, lifetime),
method of migraine diagnosis (Ad Hoc Criteria 196221, ICHD criteria22-24, ID-Migraine25,
clinical interview and examination by clinicians and/or neurologists), method of data collection
(door-to-door, telephone interview, mail of self-reported questionnaires), and responder rate. The
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studies were stratified according to region of origin i.e. Africa, Asia, Europe, North America
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(NA), and Central and South America (CSA). The studies were tabulated in chronological order
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in order to observe time series trend and intergenerational differences.
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Extracted data were pooled to combine prevalence data into one weighted magnitude. StatsDirect
v2.7.9 (StatsDirect Ltd., Altrincham, Cheshire, UK) was used to analyze the results, develop
pooled prevalence rates and prepare forest plots. Pooled prevalence rates and 95% CIs were
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heterogeneity was explored using I2 and 95% CI.27 By virtue of being robust to outliers and to
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nonparametric distribution, median and its interquartile range was selected to describe
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continuous data. Where available, subgroup analysis was made to compare prevalence
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differences among male-female, rural-urban, students, and among different diagnostic methods
and prevalence periods. Subgroup analysis was also performed by comparing prevalence results
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for studies using ICHD diagnostic criteria against all included studies, and similarly for studies
with prevalence period of lifetime and one-year against all studies. In order to statistically test
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the differences among the subgroups, Cochran‟s chi-square or Q-test was applied using a
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significance p-value level of 0.05. Correlation analysis was conducted between the prevalences
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and the study years to identify if there was a trend of migraine prevalence change among the
different regions and overall globally. Statistical analysis of correlation was appropriately
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region; Pearson‟s r and Spearman‟s rho (with 95% CI and p-values) were selected for parametric
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and non-parametric data, respectively. Missing data were excluded from the final analysis.
Microsoft Excel (Version 15.18 (160109) Microsoft, Redmond, WA, USA, 2015) was utilized
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3. Results
302 studies involving 6,216,995 participants were included (Figure 1b, Appendix B). Median age
was 35 years (Interquartile Range or IQR 30.2-38.9). Male-to-female ratio among total number
of participants was 0.91 (47.6% males, 52.4% females); male-to-female ratio among non-
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responders was not available. The geographic distribution of the studies was as follows: 33
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(10.9%) studies were from Africa involving combined sample size of 178382, 63 (20.9%) from
Asia involving combined sample size of 4331237, 44 (14.6%) from CSA involving combined
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sample size of 72893, 22 (7.3%) from NA involving combined sample size of 825734, and 140
(46.3%) from Europe involving combined sample size of 808749 (Figure 2a, Appendix B).
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Ninety-two studies (30.5%) were school-based. Eighty-seven % (263) studies were from the
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post-ICHD era (International Classification of Headache Disorders 1988), and 82% (216) of
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these studies applied ICHD criteria. Seventy (23.2%) studies were from urban setting and 24
(8%) studies were from rural setting; the rest 94 (68.8%) studies were either mixed urban-rural.
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Data were mostly collected using door-to-door or face-to-face questionnaire method or through
postal mails of self-administered questionnaires. Telephone interviews were also used by some
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studies. Some studies used physician or neurologist assessment along with questionnaires.
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Median responder rate was 83.4%. Prevalence period used ranged from lifetime prevalence in 73
(28.5%) studies, one-year prevalence in 149 (58.2%) studies, two-year prevalence in 4 (1.6%)
studies, 6-month prevalence in 18 (4.7%) studies, 3-month prevalence in 12 (7%) studies (Figure
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Pooled crude migraine prevalence was found to be 11.6% (95% CI 10.7-12.6%; random effects);
10.4% in Africa, 10.1% in Asia, 11.4% in Europe, 9.7% in NA, 16.4% in CSA (Figure 2b,
Appendix C). There was a statistically significant difference between the prevalence in CSA
compared to all the other regions; there was no statistically significant difference among the
other four regions (Table 1). When the pooled-cohort was stratified by sex, the prevalence was
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13.8% among females (Appendix D), 6.9% among males (Appendix E); this difference was
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statistically significant (p = 0.0001). When the pooled-cohort was stratified by area of residency
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(urban vs rural setting), the prevalence was 11.2% among urban residents (Appendix F), 8.4%
among rural residents (Appendix G), and 12.4% among school/college students (Appendix H).
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Urban-rural and school-rural prevalence difference was statistically significant at p = 0.002 and p
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= 0.001, respectively.
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Subgroup analysis showed similar random-effects weighted prevalence (p = 0.31) between the
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studies that applied ICHD criteria (11.2%) and all included studies (11.6%). Similarly, subgroup
prevalence between studies that used one-year period (11.9%) and all included studies (11.6%).
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There was observable increase in migraine prevalence within the last decade in the African,
European and South American regions. Inter-study heterogeneity was found to be moderate with
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Global migraine prevalence changes between the years 1930 and 2015 showed the regions of
Europe (Figure 3d), Asia (Figure 3b), CSA (Figure 3c), and Africa (Figure 3a) to have
statistically significant increment (in a descending order), i.e. migraine prevalence increased as
the years progressed. The NA region (Figure 3e) did not show statistically significant increase.
Overall, the global migraine prevalence (Figure 3f) showed statistically significant increase.
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4. Discussion
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Overall, migraine affects 11.6% people worldwide. When this crude estimate was stratified to
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different sociodemographic cohorts, female gender, school/college goers and urban residents
decreasingly were more affected compared to male gender, rural residents and the overall
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population. Urban residents were 1.3 times more likely to have migraine compared to rural
residents. Migraine was twice as common among females compared to males. These results were
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in agreement with most previous studies on migraine epidemiology. With a total sample size of
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more than 6 million people globally, this study provided the largest sample size and study power
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presently available; it can be assumed that 1 in 1000 people were crudely represented globally,
given the global population of 7 billion28 and a sampling fraction of 0.1%. However, the
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different years when the studies were conducted has to be taken into account as the global
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population has progressively increased. Our study was representative of all continents
worldwide. Male-to-female ratio of participants (0.91) was similar to that of the global (1.01)
population gender ratio estimates.28 The median age of 35 was comparable to current global
median age of 30 years.28 Migraineurs were slightly younger with a median age of 32 years; this
was in accordance to literature evidence that migraine primarily affects the younger and
productive demographic. The 2010 GBD study estimated global prevalence of migraine in both
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sexes to be 14.7% (10.7% in males, 18.8% in females); this was marginally higher than what we
found in our study. The reason for this disparity could be the fact that GBD data sources included
a mixture of published studies, disease registries, hospital discharge data, household surveys,
other surveys, and cohort studies1; in our study, we strictly used community-based and non-
clinical studies to provide a closer approximate to the true prevalence of migraine. According to
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the 2010 GBD, disability caused by migraine in terms of DALYs (Disability-adjusted Life
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Years) have increased by 20% from the year 2000 (15 million) to 2012 (18 million).1
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With regards to geography, the Asian region had the highest sample size of 4,331,237
participants with 20.9% of the total number of studies included (Figure 1b, Figure 2a). Given that
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the Asian region housed the largest target population of over 4.4 billion 28, the Asian sample size
within this study had a sampling fraction of around 0.1% similar to the overall global sampling
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fraction (Figure 1b). Although nearly half of the studies included in this study were from Europe,
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the European sample size (808,749) had a similar sampling fraction of 0.1% - given its target
population of over 742.5 million (Figure 1b).28 The NA sample size (825,734) had the highest
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sampling fraction of 0.23% to its target population of over 355 million (Figure 1b) , despite
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having the lowest number of studies. The African sample size (178,382) had a sampling fraction
of 0.016% to its target population over 1.1 billion (Figure 1b).28 The CSA sample size (72,893)
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had the lowest sampling fraction of 0.011% to its target population of over 626 million (Figure
1b).28 These differences created unintentional overrepresentation where some regions were
overpowered while others were underpowered. In order to control for this effect, we stratified the
results into the different regions. Overall, regional prevalence ranged from 9.7% in NA to 16.4%
in CSA; the other regions of Africa, Asia, and Europe had a comparable prevalence of 10.1-
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11.4%. It was noteworthy to find higher regional prevalence in CSA region compared to other
regions; factors explaining this disparity need to be examined. However, one reason could be the
fact that the combined sample size of the CSA region is at least twice less than the second
combined sample size in Africa. The Asian region featured the highest combined sample size
involving more than 4 million participants. Europe and NA had similar combined sample size of
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around 800,000 participants. Considering the fact that Africa and CSA both feature a growing
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population of around 1 billion, the combined sample sizes for these two regions found in this
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study were under-representative compared to the other three regions ratio of sample size to
regional population size. In Africa, Asia, Europe, and CSA, the increase of migraine prevalence
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was indicative of either genuine intergenerational differences in prevalence or in pain perception
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and tolerance or in increasing awareness and accurate diagnosis. Another plausible reason might
to our results. However, it has to be noted that none of the previously published studies
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employed weighted average; all previously published results were produced by using arithmetic
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averages. Besides, our study is up-to-date with recent studies. For instance, one previously
published study showed arithmetic average migraine prevalence of 11% globally, 5% in Africa,
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9% in Asia, 22% in Australia, 9% in CSA, 15% in Europe, and 13% in NA; the data from
Australia comprised of females only, and all these prevalences included time period of 1 year, 3
months, and „time frame not stated‟.29 For a lifetime prevalence, the same study showed
Europe, 13% in NA, and 16% in CSA.29 Our study‟s overall 11.6% global prevalence, 6.9%
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prevalence in men, and 13.8% prevalence in women were comparable to 11%, 6%, and 14%
published in the aforementioned study29, respectively. The higher African prevalence in our
study was because of the weight from our inclusion of recently published studies with prevalence
of up to 22%30; this increasing prevalence was not due to ascertainment bias because the
majority of the studies (75%) in the African region were conducted door-to-door. The higher
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CSA prevalence from our study compared to that in the aforementioned study could be because
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of our study‟s inclusion of 14 recent studies with prevalence as high as 51%31 and probably
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because the latter study separated lifetime results unlike our study. Another point is that
Australia was included under the Asian region in our study unlike the above-mentioned study
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which reported Australian data distinctly from the Asian region. A graphical representation
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comparing these results to our results is displayed on Figure 4.
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Close to a third of the studies included were school-/college-based. Results from these were also
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had higher migraine prevalence than the overall general prevalence. This suggests migraine‟s
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potential burden on academic performance, because migraine attacks are associated with
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compared to urban residents. This may be associated with the disparity between lifestyles (sleep
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schedules, exercise, stress levels, and meal schedules) in urban versus rural settings.
Our result showed a pattern of increasing global migraine prevalence; when this result was
stratified among the different regions, Europe, Asia, CSA, and Africa had significant rise. There
was no statistically significant change in the NA region; this could be a genuine pattern or due to
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the lower number of studies available in the NA region. The migraine prevalence rise in Asia,
CSA, and Africa should be regarded within the context of the general increase in non-
communicable diseases in these regions which are home to the majority of developing
economies; this correlates with the rapid urbanization rates occurring within these regions33
accompanied by unfavorable lifestyle changes such as low levels of physical activity and sleep
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dysregulation, both of which lower threshold for a migraine attack.34 The European prevalence
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increment could be due to a combination of inadequate attention and suboptimal prioritization
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given to public health policy changes with regards to headache awareness and management,
substandard headache care resource utilization and ineffective strategies, and unfavorable
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lifestyle changes mentioned above.35 Implementing such public health policy changes requires
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the participation of an inter-disciplinary team at different levels of every community, and
actively involving governments and authorities.36 These temporal changes and disparities also
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indicate the need for healthy and favorable lifestyle modification as important self-management
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tools to lower migraines prevalence, particularly in the urban setting.34 Self-management tools
not only help lower prevalences but also return the locus of control back to the sufferer.37
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The claim of increasing prevalence in our study is in line with other recent reports such as that
from the Global Burden Disease (2015) which revealed statistically significant increment of
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global migraine prevalence from 14.7% in 2005 to 15.3% in 201538. The 2015 GBD study
similarly reported that migraine was among the top ranking conditions with age-specific years
lived with disability in adolescents and young adults. The recent rise of migraine needs to be
viewed within the context of the recent rise in non-communicable diseases worldwide; increasing
prevalence in chronic health conditions such as chronic pain, sleep disorders, depression, and
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multimorbidity between migraine and these chronic health conditions39-41. Biobehavioral factors
such as increasing stress levels also contribute to migraine prevalence42. Migraine and
common health problem worldwide38. A rise in one of these health conditions can fuel an
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increment in migraine prevalence. Studies show that pain reporting and pain-related traits such as
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hyperalgesia and pain thresholds are heritable phenotypes43, 44. In addition, epigenetic interaction
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with different environmental stimuli can increase pain susceptibility39, 44. Most of the risk factors
responsible for the increment in migraine prevalence are modifiable. Active pain-coping
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strategies such as exercise were found to be three times more powerful in lowering pain-related
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disability45.
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The number of school-based studies found from North American region was low, suggesting
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unmet need to adequately measure and address the costly burden of migraine in school environs.
National surveillance reports from the NHIS (National Health Interview Survey)26 in USA did
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not use valid and accurate migraine diagnostic criteria; this underscores the importance of
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applied were in accordance to ICHD criteria in the majority of studies. A door-to-door approach
was used to reach participants, and this is recognized as the best modality to examine community
prevalence. Nearly 60% of studies assessed prevalence data of a one-year period. While recall
bias cannot be completely eliminated, a one-year recall fares better than a lifetime recall.
Previous studies have shown that the difference in recall bias between a one-year, a 6-month, and
a 3-month period is not significant.46 Lifetime prevalence is preferably used when studying more
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severe and rarer headache attacks such as cluster headache which is more likely not to be
remembered by the sufferer.46 The overall responder rate of more than 80% was remarkable and
this supported the representativeness of the final pooled results. That recruitment methods
sampling, random sampling, and stratified sampling provided a useful mixed method of
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sampling.
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When performing meta-analysis, fixed-effects model (inverse variance weighting) assumes one
true effect size underlying all studies included.47 Fixed-effects model accepts that there is no real
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difference between studies other than that from pure random error or chance.47 Fixed-effects
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model does not recognize heterogeneity factors such as study settings, studies done in different
years, studies involving different populations and countries; these factors can influence
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prevalence among the different studies included.47 Since heterogeneity makes a fixed-effect
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model implausible for our study, we selected random-effects meta-analysis model. Random-
effects model assumes that the combined study effect is from a distribution of study effects; by
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factoring of study design covariates from one study to another; it incorporates both within and
between study variance.26 Although both approaches were used in our study, we reported results
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from the latter to allow factoring of study variations within the meta-analysis.
Our study strengths include the undertaking and completeness of the first large-scale global
meta-analysis in headache research involving more than 6 million participants. Additionally, our
study provides the first ever weighted analysis of migraine prevalence worldwide. Our study
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delivers a valuable and landmark baseline foundation for conducting similar successive weighted
Our study not only offers data-driven approaches in understanding epidemiological variations in
migraine, but also can help identify risk factors and speculate intergenerational key differences
(e.g. low levels of physical activity, unhealthy rapid urbanization) that can be used to implement
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a public health policy change. Careful examination of repeated cross-sectional studies can
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provide an alternative to conducting highly costly prospective longitudinal studies.
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Our study limitations are those that are inherent in performing meta-analyses i.e. the
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heterogeneity aspects in variable methods of the studies included. Possible reasons for the
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moderate heterogeneity we found could be the regional differences, the different years, the
prevalence period variations, non-ICHD diagnoses (18%), and differing sample sizes. However,
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cohorts to create a more homogenous participant population. Other limitations include lack of
complete metadata for all studies, and we are aware of the unintended attrition bias related to
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this. All missing data were excluded from the final analysis; such data may be non-random
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missing data and it is known that analysis solely restricted to available data may tend to create
biased results.
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We recommend that future studies report complete sociodemographic and related characteristics
of their findings. Similar pooled meta-analysis studies on other types of headaches such as
tension-type, cluster, and other secondary headaches will shed more light into salient
neuroepidemiologic features. Few studies mentioned that their sample were biologically
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unrelated48, 49; accrued results from such efforts and similar twin studies will contribute to the
5. Conclusions
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Migraine affects one in ten people worldwide; it is twice common in females. Geographical
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variations were observed with Central and South American region featuring higher prevalence
compared to other regions with comparable prevalence; however, this has to be interpreted
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within the context of lower combined sample size within this region compared to other regions.
It can be deduced that rapid urbanization is associated with the recent rise in migraine
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prevalence. The significance of these and other factors to the evolution of the global migraine
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prevalence need to be examined prospectively. Higher student and urban affliction can lower
research and training, and healthy urban lifestyles are important to tackle this costly prevalence
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rising worldwide. Large-scale and centralized databases and data streaming need to exist for
more efficient community-based mega-data collection. Our study provides the first proper global
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estimation of migraine prevalence. By so doing, our study offers a granular detail of worldwide
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migraine prevalence at the community level. These are applicable for public health policy
changes such as increasing awareness of migraine prevalence and for early management; if not
properly managed, migraine can become chronic and disabling, and this can have wide
socioeconomic consequences.
Acknowledgements
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The authors are indebted to Associate Professor Tomomi Kawakami and Dr. Yuko Nakamura,
from Department of Pediatric Dentistry, The Nippon Dental University School of Life Dentistry
Funding
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This research received no specific grant from any funding agency in the public, commercial, or
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not-for-profit sectors.
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Method 6: n = 1960
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Records after duplicates removed
(n = 1975)
Screening
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Records excluded: studies not
Records screened related to our primary interest
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(n = 1975) i.e. migraine prevalence
(n = 1523)
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Eligibility
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(n = 452)
setting
(n = 150)
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Included
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Figure 1a. PRISMA Flow Diagram depicting the identification, screening, eligibility, and
inclusion stages. A total of 302 studies were included in the final quantitative meta-analysis.
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8 Sampling Fraction (of thousands)
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7 Sample Size (millions)
6 Population (billions)
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4
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3
2
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Africa Asia CSA NA Europe Global
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Figure 1b. Sample size, sampling fractions, and population size of the different regions. With a
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total sample size of more than 6 million people globally, this study provides the largest sample
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size and study power presently available; it can be assumed that 1 in 1000 people were crudely
represented globally, given the global population of 7 billion[28] and a sampling fraction of
0.1%. The Asian region had the highest sample size of 4,331,237 participants with 20.9% of the
total number of studies included. Given that the Asian region housed the largest target
population of over 4.4 billion [28], the Asian sample size within this study had a sampling
fraction of around 0.1% similar to the overall global sampling fraction. Although nearly half of
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the studies included in this study were from Europe, the European sample size (808,749) had a
similar sampling fraction of 0.1% - given its target population of over 742.5 million[28]. The NA
sample size (825,734) had the highest sampling fraction of 0.23% to its target population of
over 355 million [28], despite having the lowest number of studies. The African sample size
(178,382) had a sampling fraction of 0.016% to its target population over 1.1 billion.[28] The
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CSA sample size (72,893) had the lowest sampling fraction of 0.011% to its target population of
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over 626 million.[28]
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Study characterisitics
Three-month
Six-month
Two-year
One-year
Lifetime
School-based
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Mixed
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Urban
Rural
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ICHD used
Post-ICHD era
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Europe
NA
CSA
Asia
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Africa
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
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Figure 2. Characteristics of the studies included. Nearly 60% of the studies applied a one-year
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prevalence. Responder rate was over 80%. Seventy (23.2%) studies were from urban setting and 24 (8%)
studies were from rural setting; the rest 94 (68.8%) studies were either mixed urban-rural. Eighty-seven %
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studies were from the post-ICHD era (International Classification of Headache Disorders 1988), and 82%
of these studies applied ICHD criteria. The geographic distribution of the studies was as follows: 33
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(10.9%) studies were from Africa involving combined sample size of 178382, 63 (20.9%) from Asia
involving combined sample size of 4331237, 44 (14.6%) from CSA involving combined sample size of
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72893, 22 (7.3%) from NA involving combined sample size of 825734, and 140 (46.3%) from Europe
involving combined sample size of 808749. Pooled crude migraine prevalence was found to be 11.6%
(95% CI 10.7-12.6%; random effects); 10.4% in Africa, 10.1% in Asia, 11.4% in Europe, 9.7% in NA,
16.4% in CSA.
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Figure 3. Global migraine prevalence changes between the years 1930 and 2015. These
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results showed the regions of Europe (Figure 3d), Asia (Figure 3b), CSA (Figure 3c), and Africa
(Figure 3a) to have statistically significant increment (in a descending order), i.e. migraine
prevalence increased as the years progressed. The NA region (Figure 3e) did not show
statistically significant increase. Overall, the global migraine prevalence (Figure 3f) showed
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Stovner 2007
14%
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10%
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8%
6%
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4%
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2%
0%
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Figure 4. Comparison of our study results to previously published study[29]. The previously
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published study by Stovner et al. showed arithmetic average migraine prevalence of 11%
globally, 5% in Africa, 9% in Asia, 22% in Australia, 9% in CSA, 15% in Europe, and 13% in
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NA; the data from Australia comprised of females only, and all these prevalences included time
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period of 1 year, 3 months, and „time frame not stated‟.[29] For a lifetime prevalence, the same
Asia, 17% in Europe, 13% in NA, and 16% in CSA.[29] Our study‟s overall 11.6% global
prevalence, 6.9% prevalence in men, and 13.8% prevalence in women were comparable to 11%,
6%, and 14% published in the aforementioned study[29], respectively. The higher African
prevalence in our study was because of the weight from our inclusion of recently published
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studies with prevalence of up to 22%.[30] The higher CSA prevalence from our study compared
to that in the aforementioned study could be because of our study‟s inclusion of 14 recent studies
with prevalence as high as 51%[31] and probably because the latter study separated lifetime
results unlike our study. Another point is that Australia was included under the Asian region in
our study unlike the above-mentioned study which reported Australian data distinctly from the
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Asian region.
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Heterogeneity
Comparisons
Q-value p-value
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Africa vs. NA 0.006 0.937
Asia vs. CSA 7.080 0.008
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Asia vs. Europe 1.253 0.263
Asia vs. NA 0.053 0.818
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Europe vs. NA 1.652 0.199
Europe vs. CSA 10.009 0.002
NA vs. CSA 10.667 0.001
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Table 1. Statistical differences among the regional subgroups. There was a statistically
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significant difference between the prevalence in CSA compared to all the other regions; there
was no statistically significant difference among the other four regions. Cochran‟s chi-square or
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Q-test was applied using a significance p-value level of 0.05. Statistically significant differences
are displayed in bold.
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