Characteristics and Gender Differences of Headache in the Veterans Health Administration: A National Cohort Study, Fiscal Year 2008-2019

doi:10.1212/WNL.0000000000200905

. 2022 Oct 31;99(18):e1993-e2005.

doi: 10.1212/WNL.0000000000200905.

Characteristics and Gender Differences of Headache in the Veterans Health Administration: A National Cohort Study, Fiscal Year 2008-2019

Jason Jonathon Sico¹, Elizabeth K Seng², Kaicheng Wang², Melissa Skanderson², Emmanuelle A D Schindler², John P Ney², Nancy Lorenze², Addison Kimber², Hayley Lindsey², Amy S Grinberg², Deena Kuruvilla², Donald S Higgins², Glenn Graham², Friedhelm Sandbrink², Joel Scholten², Robert E Shapiro², Richard B Lipton², Brenda T Fenton²

Affiliations

¹ From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY. jason.sico@yale.edu.
² From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY.

PMID: 36100437
PMCID: PMC9651459
DOI: 10.1212/WNL.0000000000200905

Characteristics and Gender Differences of Headache in the Veterans Health Administration: A National Cohort Study, Fiscal Year 2008-2019

Jason Jonathon Sico et al. Neurology. 2022.

. 2022 Oct 31;99(18):e1993-e2005.

doi: 10.1212/WNL.0000000000200905.

Authors

Affiliations

¹ From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY. jason.sico@yale.edu.
² From the Neurology Service (J.J.S., E.A.D.S.), Clinical Epidemiology Research Center (CERC) (J.J.S.), Pain Research (J.J.S., M.S., N.L., A.K., H.L., B.T.F.), Informatics, and Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven; Departments of Neurology (J.J.S., N.L., A.K., H.L., E.A.D.S.), Internal Medicine (J.J.S.), Center for Neuroepidemiological and Clinical Neurological Research (J.J.S., E.A.D.S.), Yale Center for Analytic Sciences (K.W.), Yale School of Medicine, New Haven, CT; Veterans Health Administration Headache Centers of Excellence (HCoE) Research and Evaluation Center (J.J.S., E.K.S., K.W., M.S., E.A.D.S., J.P.N., N.L., A.K., H.L., A.S.G., D.K., B.T.F.), Department of Veterans Affairs, Orange, CT; Yeshiva University (E.K.S.), New York City, NY; Neurology Service (J.P.N.), Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA; Department of Neurology (J.P.N.), Boston University School of Medicine, MA; Westport Headache Institute (D.K.), Westport, CT; Albany Stratton VA Medical Center (D.S.H.), NY; Department of Neurology (G.G.), George Washington University, Washington, DC; Department of Neurology (G.G.), University of California San Francisco School of Medicine, Specialty Care Services (G.G.), Veterans Health Administration Pain Management (F.S.), Opioid Safety and PDMP Program, Department of Veterans Affairs, Washington, DC; Departments of Neurology (F.S.), Physical Medicine and Rehabilitation (J.S.), Veterans Affairs Medical Center, Washington, DC; Department of Neurology (R.E.S.), University of Vermont Medical Center, Burlington, VT; Department of Neurology (R.B.L.), Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (R.B.L.), Montefiore Medical Center, Bronx, NY.

PMID: 36100437
PMCID: PMC9651459
DOI: 10.1212/WNL.0000000000200905

Abstract

Background and objectives: To determine gender differences in headache types diagnosed, sociodemographic characteristics, military campaign and exposures, and health care utilization among US veterans in the Veterans Health Administration (VHA).

Methods: This study used a retrospective cohort design to examine VHA electronic health record (EHR) data. This cohort includes veterans who had at least 1 visit for any headache between fiscal years 2008 and 2019. Headache diagnoses were classified into 8 categories using International Classification of Disease, Clinical Modification codes. Demographics, military-related exposures, comorbidities, and type of provider(s) consulted were extracted from the EHR and compared by gender. Age-adjusted incidence and prevalence rates of medically diagnosed headache disorders were calculated separately for each type of headache.

Results: Of the 1,524,960 veterans with headache diagnoses included in the cohort, 82.8% were men. Compared with women, men were more often White (70.4% vs 56.7%), older (52.0 ± 16.8 vs 41.9 ± 13.0 years), with higher rates of traumatic brain injury (2.9% vs 1.1%) and post-traumatic stress disorder (23.7% vs 21.7%), and lower rates of military sexual trauma (3.2% vs 33.7%; p < 0.001 for all). Age-adjusted incidence rate of headache of any type was higher among women. Migraine and trigeminal autonomic cephalalgia rates were most stable over time. Men were more likely than women to be diagnosed with headache not otherwise specified (77.4% vs 67.7%) and have higher incidence rates of headaches related to trauma (3.4% vs 1.9% [post-traumatic]; 5.5% vs 5.1% [postwhiplash]; p < 0.001 for all). Men also had fewer headache types diagnosed (mean ± SD; 1.3 ± 0.6 vs 1.5 ± 0.7), had fewer encounters for headache/year (0.8 ± 1.2 vs 1.2 ± 1.6), and fewer visits to headache specialists (20.8% vs 27.4% p < 0.001 for all), compared with women. Emergency department utilization for headache care was high for both genders and higher for women compared with men (20.3% vs 22.9%; p < 0.001).

Discussion: Among veterans with headache diagnoses, important gender differences exist for men and women veterans receiving headache care within VHA regarding sociodemographic characteristics, headache diagnoses, military exposure, and headache health care utilization. The findings have potential implications for providers and the health care system caring for veterans living with headache.

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Figures

**Figure 1. Baseline Age Distribution of Veterans in the VHA HCoE Administrate Data Cohort by Gender**

Figure 2. Age-Adjusted Headache Incidence of Distinct Headache Types Encountered Within the Veterans Health Administration, Stratified by Gender and Standardized to the US Population (2010), Fiscal Year 2009–2019

See this image and copyright information in PMC

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References

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[1] Saylor D, Steiner TJ. The global burden of headache. Semin Neurol. 2018;38:182-190. - PubMed

[2] Saylor D, Steiner TJ. The global burden of headache. Semin Neurol. 2018;38:182-190. - PubMed

[3] Stovner L, Hagen K, Jensen R, et al. . The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27:193-210. - PubMed

[4] Stovner L, Hagen K, Jensen R, et al. . The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27:193-210. - PubMed

[5] Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: updated age, sex, and socioeconomic‐specific estimates from government health surveys. Headache. J Head Face Pain. 2021;61:60-68. - PubMed

[6] Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: updated age, sex, and socioeconomic‐specific estimates from government health surveys. Headache. J Head Face Pain. 2021;61:60-68. - PubMed

[7] Lipton R, Scher A, Steiner T, et al. . Patterns of health care utilization for migraine in England and in the United States. Neurology. 2003;60:441-448. - PubMed

[8] Lipton R, Scher A, Steiner T, et al. . Patterns of health care utilization for migraine in England and in the United States. Neurology. 2003;60:441-448. - PubMed

[9] Lipton RB, Manack Adams A, Buse DC, Fanning KM, Reed ML. A comparison of the chronic migraine epidemiology and outcomes (CaMEO) study and American migraine prevalence and prevention (AMPP) study: demographics and headache-related disability. Headache. 2016;56:1280-1289. - PMC - PubMed

[10] Lipton RB, Manack Adams A, Buse DC, Fanning KM, Reed ML. A comparison of the chronic migraine epidemiology and outcomes (CaMEO) study and American migraine prevalence and prevention (AMPP) study: demographics and headache-related disability. Headache. 2016;56:1280-1289. - PMC - PubMed

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Characteristics and Gender Differences of Headache in the Veterans Health Administration: A National Cohort Study, Fiscal Year 2008-2019

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Characteristics and Gender Differences of Headache in the Veterans Health Administration: A National Cohort Study, Fiscal Year 2008-2019

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