Rethinking headache as a global public health case model for reaching the SDG 3 HEALTH by 2030.

The 2030 Agenda for Sustainable Development sets out, through 17 Sustainable Development Goals (SDGs), a path for the prosperity of people and the planet. SDG 3 in particular aims to ensure healthy lives and promote well-being for all at all ages and includes several targets to enhance health. This review presents a "headache-tailored" perspective on how to achieve SDG 3 by focusing on six specific actions: targeting chronic headaches; reducing the overuse of acute pain-relieving medications; promoting the education of healthcare professionals; granting access to medication in low- and middle-income countries (LMIC); implementing training and educational opportunities for healthcare professionals in low and middle income countries; building a global alliance against headache disorders. Addressing the burden of headache disorders directly impacts on populations' health, as well as on the possibility to improve the productivity of people aged below 50, women in particular. Our analysis pointed out several elements, and included: moving forward from frequency-based parameters to define headache severity; recognizing and managing comorbid diseases and risk factors; implementing a disease management multi-modal management model that incorporates pharmacological and non-pharmacological treatments; early recognizing and managing the overuse of acute pain-relieving medications; promoting undergraduate, postgraduate, and continuing medical education of healthcare professionals with specific training on headache; and promoting a culture that favors the recognition of headaches as diseases with a neurobiological basis, where this is not yet recognized. Making headache care more sustainable is an achievable objective, which will require multi-stakeholder collaborations across all sectors of society, both health-related and not health-related. Robust investments will be needed; however, considering the high prevalence of headache disorders and the associated disability, these investments will surely improve multiple health outcomes and lift development and well-being globally.

Clinical presentation and assessment of older patients presenting with headache to emergency departments: A multicentre observational study.

OBJECTIVE: To describe the characteristics, assessment and management of older emergency department (ED) patients with non-traumatic headache. METHODS: Planned sub-study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non-traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. RESULTS: A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). CONCLUSIONS: Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non-traumatic headache.

The Global South political economy of health financing and spending landscape - history and presence.

The Global South nations and their statehoods have presented a driving force of economic and social development through most of the written history of humankind. China and India have been traditionally accounted as the economic powerhouses of the past. In recent decades, we have witnessed reestablishment of the traditional world economic structure as per Agnus Maddison Project data. These profound changes have led to accelerated real GDP growth across many LMICs and emerging countries of the Global South. This evolution had a profound impact on an evolving health financing landscape. This review revealed hidden patterns and explained the driving forces behind the political economy of health spending in these vast world regions. The medical device and pharmaceutical industry play a crucial role in addressing the unmet medical needs of rising middle class citizens across Asia, Latin America, and Africa. Domestic manufacturing has only been partially meeting this ever rising demand for medical services and medicines. The rest was complemented by the participation of multinational pharmaceutical industry, whose focus on investment into East Asia and ASEAN nations remains part of long-term market access strategies. Understanding of the past remains essential for the development of successful health strategies for the present. Political economy has been driving the evolution of health financing landscape since the establishment of early modern health systems in these countries. Fiscal gaps these governments face in diverse ways might be partially overcome with the spreading of cost-effectiveness based decision-making and health technology assessment capacities. The considerable remaining challenges ranging from insufficient reimbursement rates, large out-of-pocket spending, and lengthy lag in the introduction of cutting-edge technologies such as monoclonal antibodies, biosimilars, or targeted oncology agents, might be partially resolved only in the long run.

Disparities in Care and Outcome of Stroke Patients from Culturally and Linguistically Diverse Communities in Metropolitan Australia.

BACKGROUND: Acute stroke is a time-critical emergency where diagnosis and acute management are highly dependent upon the accuracy of the patient's history. We hypothesised that the language barrier is associated with delayed onset time to thrombolysis and poor clinical outcomes. This study aims to evaluate the effect of language barriers on time to thrombolysis and clinical outcomes in acute ischemic stroke. Concerning the method, this is a retrospective study of all patients admitted to a metropolitan stroke unit (Melbourne, Victoria, Australia) with an acute ischemic stroke treated with tissue plasminogen activator between 1/2013 and 9/2017. Baseline characteristics, thrombolysis time intervals, length of stay, discharge destination, and in-hospital mortality were compared among patients with and without a language barrier using multivariate analysis after adjustment for age, sex, stroke severity, premorbid modified Rankin Scale (mRS), and Charlson Comorbidity Index (CCI). Language barriers were defined as a primary language other than English. A total of 374 patients were included. Our findings show that 76 patients (20.3%) had a language barrier. Mean age was five years older for patients with language barriers (76.7 vs. 71.8 years, p = 0.004). Less non-English speaking patients had premorbid mRS score of zero (p = 0.002), and more had premorbid mRS score of one or two (p = 0.04). There was no statistically significant difference between the two groups in terms of stroke severity on presentation (p = 0.06). The onset to needle time was significantly longer in patients with a language barrier (188 min vs. 173 min, p = 0.04). Onset to arrival and door to imaging times were reassuringly similar between the two groups. However, imaging to needle time was 9 min delayed in non-English speaking patients with a marginal p value (65 vs. 56 min, p = 0.06). Patients with language barriers stayed longer in the stroke unit (six vs. four days, p = 0.02) and had higher discharge rates than residential aged care facilities in those admitted from home (9.2% vs. 2.3%, p = 0.02). In-hospital mortality was not different between the two groups (p = 0.8). In conclusion, language barriers were associated with almost 14 min delay in thrombolysis. The delay was primarily attributable to imaging to needle time. Language barriers were also associated with poorer clinical outcomes.

Epidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study.

OBJECTIVE: To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). BACKGROUND: Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. METHODS: An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. RESULTS: We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526). CONCLUSION: Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.

Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost.

BACKGROUND: Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection. METHODS: Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (mRS). Individual patient expected survival and net difference in Disability/Quality-adjusted life years (DALY/QALY) up to 15 years from stroke were modeled using age, sex, 90-day mRS, and utility scores. Level of care within the first 90 days was prospectively measured and used to estimate procedure and inpatient care costs (US$ reference year 2014). RESULTS: There were 70 patients, 35 in each arm, mean age 69, median NIHSS 15 (IQR 12-19). The median (IQR) disability-weighted utility score at 90 days was 0.65 (0.00-0.91) in the alteplase-only versus 0.91 (0.65-1.00) in the endovascular group (p = 0.005). Modeled life expectancy was greater in the endovascular versus alteplase-only group (median 15.6 versus 11.2 years, p = 0.02). The endovascular thrombectomy group had fewer simulated DALYs lost over 15 years [median (IQR) 5.5 (3.2-8.7) versus 8.9 (4.7-13.8), p = 0.02] and more QALY gained [median (IQR) 9.3 (4.2-13.1) versus 4.9 (0.3-8.5), p = 0.03]. Endovascular patients spent less time in hospital [median (IQR) 5 (3-11) days versus 8 (5-14) days, p = 0.04] and rehabilitation [median (IQR) 0 (0-28) versus 27 (0-65) days, p = 0.03]. The estimated inpatient costs in the first 90 days were less in the thrombectomy group (average US$15,689 versus US$30,569, p = 0.008) offsetting the costs of interhospital transport and the thrombectomy procedure (average US$10,515). The average saving per patient treated with thrombectomy was US$4,365. CONCLUSION: Thrombectomy patients with large vessel occlusion and salvageable tissue on CT-perfusion had reduced length of stay and overall costs to 90 days. There was evidence of clinically relevant improvement in long-term survival and quality of life. CLINICAL TRIAL REGISTRATION: http://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).