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Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study

BMJ 2011; 343 doi: (Published 25 August 2011) Cite this as: BMJ 2011;343:d5076
  1. Kathleen R Merikangas, senior investigator1,
  2. Lihong Cui, biostatistician1,
  3. Amanda Kalaydjian Richardson, epidemiologist1,
  4. Hansruedi Isler, clinical neurologist2,
  5. Suzan Khoromi, clinical neurologist1,
  6. Erin Nakamura, research coordinator1,
  7. Femke Lamers, epidemiologist1,
  8. Wulf Rössler, psychiatrist3,
  9. Vladeta Ajdacic-Gross, sociologist and statistician3,
  10. Alex Gamma, statistician3,
  11. Jules Angst, clinical psychiatrist3
  1. 1National Institutes of Health, National Institute of Mental Health, Intramural Research Program, Genetic Epidemiology Research Branch, Bethesda, MD, 20892-3720, USA
  2. 2Hochhaus zur Schanze, Zürich, Switzerland 8032
  3. 3Zürich University Psychiatric Hospital, Zürich
  1. Correspondence to: K R Merikangas Kathleen.Merikangas{at}
  • Accepted 22 June 2011


Objective To determine the prevalence, impact, and stability of different subtypes of headache in a 30 year prospective follow-up study of a general population sample.

Design Prospective cohort study.

Setting Canton of Zurich, Switzerland.

Participants 591 people aged 19-20 from a cohort of 4547 residents of Zurich, Switzerland, interviewed seven times across 30 years of follow-up.

Main outcome measures Prevalence of headache; stability of the predominant subtype of headache over time; and age of onset, severity, impact, family history, use of healthcare services, and drugs for headache subtypes.

Results The average one year prevalences of subtypes of headache were 0.9% (female:male ratio of 2.8) for migraine with aura, 10.9% (female:male ratio of 2.2) for migraine without aura, and 11.5% (female:male ratio of 1.2) for tension-type headache. Cumulative 30 year prevalences of headache subtypes were 3.0% for migraine with aura, 36.0% for migraine without aura, and 29.3% for tension-type headache. Despite the high prevalence of migraine without aura, most cases were transient and only about 20% continued to have migraine for more than half of the follow-up period. 69% of participants with migraine and 58% of those with tension-type headache manifested the same predominant subtype over time. However, the prospective stability of the predominant headache subtypes was quite low, with substantial crossover among the subtypes and no specific ordinal pattern of progression. A gradient of severity of clinical correlates and service use was present across headache subtypes; the greatest effect was for migraine with aura followed by migraine without aura, and then tension-type headache and unclassified headaches.

Conclusions These findings highlight the importance of prospective follow-up of people with headache. The substantial longitudinal overlap among subtypes of headache shows the developmental heterogeneity of headache syndromes. Studies of the causes of headache that apply diagnostic nomenclature based on distinctions between discrete headache subtypes may not capture the true nature of headache in the general population.


  • Contributors: KRM and JA designed the questions covered in the publication and wrote the manuscript. HI, SK, EN, and LC created and reviewed the diagnostic algorithms for headache syndromes. JA and WR designed and supervised the Zurich Cohort Study. HI and KRM developed the questions for the headache section of the interview. LC did the primary statistical analyses. VA-G and AG developed the diagnostic algorithms for many of the diagnostic sections of the interview. AKR, VA-G, AG, and FL contributed to the interpretation of the statistical analyses. All authors have reviewed, edited, and approved the final version. KRM and JA are the guarantors.

  • Funding: This work was supported by grant 3200-050881.97/1 of the Swiss National Science Foundation and National Institute of Mental Health, Intramural Research Program grant No ZIAMH002807-07 for collaborative analyses of the Zurich Cohort Study. FL is supported by a Rubicon fellowship from the Netherlands Organisation for Scientific Research (NWO). The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organisations, agencies, or US government.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The Zurich Cohort Study was approved by the ethics committee of the University of Zurich.

  • Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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