Patients characteristics
The sample analyzed consisted of 108 patients, 9 (8.3%) women and 99 (91.7%) men, aged between 22 and 76 years. Patient characteristics are shown in Table 1. The average age of men was 44.1 ± 11.8 years and of women was 36.2 ± 12.3 years. The age at onset of CH was 30 ± 11 years. According to the ICHD-III diagnostic criteria, 89 (82.4%) subjects had ECH and 19 (17.6%) had CCH. On average, patients had 2.3 ± 1.4 attacks per day (CCH: 2.2 ± 1.7, ECH: 2.4 ± 1.3) with a range from 0.4 (3 per week) to 6 attacks per day. The mean duration of bouts in the total population was 14.8 ± 17.9 weeks with a minimum of 1 week to a maximum of 12 months. The mean duration of bouts among ECH patients was 6.8 ± 5.1 weeks with a minimum of 1 week to a maximum of 6 months.
Specialist visits
Patients enrolled in the study consulted our outpatient headache centre with an average number of 3.0 ± 1.9 visits (range 1-9) during the CH period (Table 2). The average number of headache visits was higher for CCH (6.7 ± 1.5; range: 4-9) than ECH (2.2 ± 0.7, range 1-5; p <0.0001). A cardiologist was consulted by 13 (68.4%) CCH patients and by 23 (11.2%) ECH patients (p <0.0001).
The mean cost of specialist visits was €169 ± €114 (range: €53-527) per patient, covered by NHS for the 39%, and was significantly higher for CCH (€391 ± €77) than ECH (€122 ± €42; p <0.0001) (Table 3).
Diagnostic tests
The use of at least one diagnostic during the bout involved 71 (65.7%) patients (Table 2). Seventy-one (65.7%) patients received at least one electrocardiogram (ECG). Higher proportion of CCH patients had prescribed an ECG compared to ECH patients (94.7.% vs. 59.6%; p 0.002). The mean number of ECG per patient was higher for CCH (2.5 ± 1.2) than ECH (0.6 ± 0.7; p < 0.0001). Thirty-seven (34.3%) patients underwent to brain magnetic resonance imaging (MRI). Higher proportion of CCH patients received a prescription for a brain MRI compared to ECH patients (84.2% vs. 23.6%; p <0.0001). The mean number of brain MRI per patient was higher for CCH (0.8 ± 0.4) than ECH (0.2 ± 0.4; p < 0.0001).
The diagnostic tests had an average cost per patient of €204 ± €237 (range: €0-691), covered by the NHS for 82.4% (€168 ± €200). The cost was significantly higher for CCH (€520 ± € 188) than ECH (€137 ± €187; p < 0.0001) (Table 3).
ED visits
During a bout, 25 (23.1%) of 108 patients entered the ED because of CH attack (Table 2). Higher proportion of CCH patients visited the ED compared to ECH patients (57.9% vs. 15.7%; p <0.0001). The average number of ED visits per patient was higher for CCH (0.7 ± 0.7, range 0-2) than ECH (0.2 ± 0.6; range: 0-3; p < 0.0001).
The mean annual cost for the NHS relating to ED visits was €71 ± €145 (range: €0-723) per patient and the cost was higher for CCH (€165 ± €162) than ECH (€51 ± €133; p <0.0001) (Table 3).
Medications consumption
The allocation of intake of attack-aborting treatment and drugs is shown in Table 2. Regarding acute medications, CCH patients used significantly more sumatriptan 6 mg and oxygen than EEC patients (p = 0.030 and p = 0.038, respectively), while the use of zolmitriptan 5 mg did not differ between the two groups. Higher proportion of CCH patients used more than one medication to treat the headache (p = 0.007). Regarding preventive medications, CCH patients used significantly more topiramate than ECH patients (p = 0.048), while the use of verapamil did not differ between the two groups. Higher proportion of CCH patients used a combination of two drugs as prevention (p = 0.001). Similarly, the use of transitional treatments, both oral corticosteroids and steroid suboccipital injections, was significantly higher for CCH than ECH patients (p = 0.002 and p < 0.0001, respectively). CCH patients also used more melatonin than ECH patients (p < 0.0001).
The mean cost of acute medications for CH bout was €2,606 ± €4,236 (range: €14-25,024) per patient and was significantly higher for CCH (€8,314 ± €6,822) than ECH (€1,387 ± €1,938; p < 0.0001) (Table 3). The mean cost of preventive medications for CH bout was €102 ± €138 (range: €0-537) per patient and was significantly higher for CCH (€357 ± €74) than ECH (€48 ± €70; p < 0.0001). The mean cost of transitional treatments for CH bout was €20 ± €34 (range: €0-92) per patient and was significantly higher for CCH (€66 ± €35) than ECH (€10 ± €24; p < 0.0001).
Impact on work
The mean number of days off work within the bout due to CH was nearly 7 days. Statistically
the number of absence days due to headache was significantly larger among CCH patients (15.2 ± 11.8) than ECH patients (5.6 ± 7.9; p <.0001) (Table 4). On the contrary, the proportion of days off work respect to the bout duration was higher for ECH patients than CCH patients (10.3% vs. 4.2%, respectively; p <.0001), due to the longer duration of CCH bout. Overall, CH was responsible of nearly 16 days of work with reduced capacity. The impact of CCH was higher than that of ECH (46.3 ± 72.2 vs. 10.8 ± 14.0 days, respectively), but the difference was not significant. The reduction of productive capacity at work is shown in Figure 1. The reports of work changes due to CH are shown in Figure 2.
The mean cost of absences from work for CH bout was €434 ± €952 (range: €0-5,603) per patient and was higher for CCH (€879 ± €1,694) then ECH (€339 ± €680), but the difference was not significant (Table 4). The mean cost attributed to days with reduced productive capacity for CH bout was €792 ± €3,541 (range: €0-29,501) per patient and was higher for CCH (€2,659 ± €7,818) then ECH (€393 ± €1,352), but the difference was not significant.
Direct costs
The mean direct costs of a CH bout were €3,173 ± €4,609 (range: €66-26,626) per patient and was covered for the 94.8% (€3,006) by the NHS (Table 3). The main item of expenditure was represented by treatments that accounted for 86% (€2,728), followed by diagnostic tests for 6% (€204), specialist visits for 5% (€169) and ED visits for 3% (€71) (Figure 3). The mean direct costs of a CH bout were significantly higher for CCH (€9,812 ± €6,932) than ECH (€1,755 ± €2,110; p < 0.0001). There were small differences between the impact of the different expenditure items between CCH and ECH: 89% vs. 82% for treatments, 5% vs. 8% for diagnostic tests, 4% vs. 7% for specialist visits, and 2% vs. 3% for ED visits, respectively.
Indirect costs
The mean indirect costs for a CH bout were €1,226 ± €4,374 (€0-34,865) per patient and were higher for CCH (€3.538 ± €9,420) than ECH (€732 ± €1,928), but the difference was not significant (Table 4). Days with reduced production capacity impacted for the 64.6% (€792) of the total indirect costs.
Analysis of total costs
The mean total costs (direct + indirect) for a CH bout were €4,398 ± €7,724 (66-51,281) per patient and the direct costs accounted for 72.1% (€3,173) (Figure 4). The total cost of CCH (€13,350 ± €13,991; range 2,157-51,281) was 5.4 times higher than ECH (€2,487 ± €3,394; range 66-20,697; p < 0.001) and the difference in the total average costs of a CH bout between CCH and ECH was €10,863. The impact of direct costs on total expenditure was higher for CCH than ECH (73.5% vs. 70.6%), but the difference was not significant.