Cross-sectional, hospital-based analysis of headache types using ICHD-3 criteria in the Middle East, Asia, and Africa: the Head-MENAA study
Authors: Genc H. , Baykan B. , Bolay H. , Uluduz D. , Unal-Cevik I. , Kissani N. , Luvsannorov O. , Togha M. , Ozdemir A. A. , Ozge A. ,   on behalf of Head-MENAA study group, Cakan M. , Ak AK , Celik F , Orun MO , Seker D , Kucuk A , Ozkan S , Kiraz M , Sirin TC , Ocal R , Hakyemez HA , Yener MO , Serim VA , Cinar N , Unal ED , Domac FM , Ates MF , Turkoglu BG , Gursoy G , Cekic S , Aslan SK , Agircan D , Oktar AC , Demirel EA , Gelener P , Ibrahim EAA , Evlice A , Gorken G , Sanli ZS , Bayır BRH , Tepe N , Okluoglu T , Demir TG , Badr MY , Vuralli D , Jafari E , Polat B , Ermis A , Khanmammadov E , Yolcu O , Kul B , Sakadi F , Ulutas S , Akturk T , Ketema MT , Lala S , Cedric APSA , Velioglu SK , Kirbasoglu O , Moustafa RR , Nowar AG , Kabay SC , Gumanovna VK , Yifru YM , Nasergivehchi S , Azizova I , Kizek O , Ekizoglu E , Orhan EK , Melka D , Alemayehu B 
Published: March 2023

Abstract
Background
Headaches are frequent neurological disorders that are yet to be unveiled and treated comprehensively worldwide. Bearing in mind that the distribution of headache subtypes in neurology clinics (NC) is essential for planning appropriate diagnostic and therapeutic approaches, the primary goals of this multi-centric study are to carry out inter-regional comparisons by using current diagnostic criteria with evaluations of neurologists to delineate headache burden.

Methods
A cross-sectional study between April 1 and May 16, 2022 was conducted with the participation of 13 countries from the Middle East, Asia, and Africa. Patients were included in the study on a specific day each week during five consecutive weeks. All volunteers over the age of 18 and whose primary cause for admission was headache were examined. The patients admitted to NC or referred from emergency services/other services were evaluated by neurologists by means of the International Classification of Headache Disorders (ICHD-3) criteria.

Results
Among the 13,794 patients encountered in NC, headache was the primary complaint in 30.04%. The headache patients’ mean age was 42.85 ± 14.89 (18–95 years), and 74.3% were female. According to the ICHD-3 criteria, 86.7% of the main group had primary headache disorders, 33.5% had secondary headaches, 4% had painful cranial neuropathies along with other facial and headaches, and 5.2% had headaches included in the appendix part showing some overlapping conditions. While the most common primary headache was migraine without aura (36.8%), the most common secondary headache was medication-overuse headache (MOH) (9.8%). Headaches attributed to COVID-19, its secondary complications, or vaccines continue to occur at rates of 1.2%-3.5% in current neurology practice. Pain severity was significantly lower in Ivory Coast and Sudan than in Türkiye, Turkish Republic of Northern Cyprus, Iran, Egypt, Senegal, Tatarstan, and Azerbaijan (p < 0.001).

Conclusions
The study showed that migraine is still the most common motive for admissions to NC in different regions. Furthermore, MOH, an avoidable disorder, is the most common secondary headache type and appears to be a significant problem in all regions. Remarkably, pain perception differs between regions, and pain intensity is lower in Africa than in other regions.