doi:10.1111/j.1468-2982.2007.01507.

The prevalence of headache among elderly in a low-income area

of São Paulo, Brazil
IM Benseñor1,2, PA Lotufo1,2, AC Goulart3, PR Menezes1,2 & M Scazufca1
1
Hospital Universitário, 2School of Medicine and 3Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil

Benseñor IM, Lotufo PA, Goulart AC, Menezes PR & Scazufca M. The prevalence
of headache among elderly in a low-income area of São Paulo, Brazil. Cephala-
lgia 2008; 28:329–333. London. ISSN 0333-1024
There are scarce data about headache prevalence and its characteristics among
elderly people. The aim was to carry out a cross-sectional study to determine the
1-year prevalence of tension-type and migraine headaches in people >65 years
old in the city of São Paulo, Brazil. All 1615 people living in the study catchment
area who agreed to participate in the study answered a questionnaire based in
the International Headache Society criteria. Prevalence (mean and 95% confi-
dence interval) of any type of headache in the last year was 45.6% (43.2, 48.0).
Prevalence of tension-type headache in the last year was 33.1% (30.8, 35.4): 28.1%
(24.6, 31.6) for men and 36.4% (33.4, 39.4) for women; for migraine headaches,
prevalence in the last year was 10.6% (9.1, 12.1): 5.1% (3.4, 6.8) for men and 14.1%
(11.9, 16.3) for women. One-year prevalence rates of headaches, and especially of
migraine headaches, are very high among the elderly in Brazil. 䊐 Brazil, headache,
migraine, prevalence, questionnaire
Isabela M. Benseñor, Av. Lineu Prestes, 2565, São Paulo, SP, CEP: 05508-900,
Brazil. Tel. + 55 11 3091 9300, fax + 55 11 3091 8004, e-mail isabensenor@hu.usp.br
Received 28 February 2007, accepted 12 October 2007

of urban communities. However, most of the

Introduction
Headache is less frequent in older than in younger
age groups. However, the increasing number of the
aged makes headache a more common complaint
among the elderly (1, 2). Solomon et al. (3), in 1990
estimated that 66% of all headaches in elderly
people would be classified as primary headaches:
tension-type and migraine headaches. Migraine
headaches are a common medical problem, espe-
cially among women, with as many as one in six
women having at least one migraine headache a
year (4, 5). Despite many data on migraine in
women, information about migraine prevalence
and characteristics in an elderly sample of men and
women is sparse, as is information about tension-
type headache.
Only few studies have evaluated the prevalence
of primary headaches in the elderly worldwide,
most of them in Europe (6, 7). Morillo et al. have
evaluated the prevalence of migraine in Latin
America in a randomly selected population sample
sample consisted of individuals 20–49 years of age,
with only a very small number of individuals
>60 years old (8). A survey performed in Brazil by
Queiroz et al. (9) has estimated the 1-year preva-
lence of headache in a sample of 625 subjects, aged
15–64 years, with a preponderance of migraine in
females, divorced or widowed, at a low socioeco-
nomic level.
To address the epidemiology of migraine and
tension-type headache among the elderly, we
studied the 1-year prevalence of migraine and
tension-type headache in a population sample of
65-year-old men and women living in a low-income
area in the city of São Paulo, Brazil.
Methods
A cross-sectional population-based study was
carried out with residents of an economically
deprived area of São Paulo, Brazil as part of a
collaborative investigation in Brazil, Cuba and the

© Blackwell Publishing Ltd Cephalalgia, 2007, 28, 329–333 329

330 IM Benseñor et al.

UK., whose main objectives were the study of envi-
ronmental and genetic risk factors for dementia in
admixed populations in Brazil and Cuba. The study
was approved by the Institutional Review Board.
Sample
The study was carried out in 66 predetermined
census sectors (catchment areas) in the area of
Butantã, located on the Western side of the city of
São Paulo. In the catchment areas in which there
were shanty towns (‘favelas’), or by the census
sectors covered by the Family Health Program—
with the lowest income in the area. The sample size
calculation was based on the expected association
between general dementia and individual racial
admixture, the main objective of the study, includ-
ing nearly 2000 people.
All residents ⱖ65 years old were included. They
were identified through systematic door knocking
on 21 727 households within the catchment-area
boundaries, totalling 2266 people. Of these, 2072
agreed to participate. However, the questionnaire
concerning headache had just begun to be applied
when 457 people had already been interviewed, so
1615 people answered this questionnaire.
Procedures
The study was conducted over a 3-year period,
from May 2003 to April 2005. Recruitment and
interviewing of the participants were carried out by
a group of interviewers trained to work in the
present study. All those aged 65 and in the study
catchment area who accepted to participate were
interviewed. This meant that in households with
two or more elderly people, all were invited to
participate. All participants were assessed for
dementia, socioeconomic characteristics, lifestyle
and cardiovascular risk factors. A headache ques-
tionnaire using the International Headache Society
(IHS-2004) criteria (10), previously validated in
Brazil, was applied as part of the main question-
naire (11). Age was classified in four age strata:
65–69, 70–74, 75–79 and >80 years. Race was classi-
fied by the interviewer into four categories: White,
Black, Mixed and Asian. Education was classified
according to the number of school years into three
categories: none, 1–3 and >4 years. Income per
month (transformed from Brazilian currency to
US Dollars) was classified in four categories: <110;
111–163, 164–318 and >319.
Data analysis
Data entry was carried out twice using the program
EPIDATA 3.0, and the validity check was carried
out to identify and correct data entry errors. Data
were analysed using SPSS 14.0 (SPSS Inc., Chicago,
IL, USA). One-year prevalence of headaches or
headache subtypes is presented as the number of
cases per 100 persons. Ninety-five percent confi-
dence intervals were also presented for prevalence.
c2 tests were used for comparison when appropri-
ate. c2 for linear trend analysis was used to measure
the age effects of headache prevalence. A P-value
<0.05 was considered to be statistically significant.
Results
Of the 1615 people in the study, 45.6% referred
headache in the last year. Of these, 71.2% were
women. Prevalence of any type of headache in the
last year was 33.7% for men and 53.1% for women
(Table 1). Prevalence of headache was higher in
women than in men (P < 0. 001).
Tension-type headache (including all subtypes)
was the most common type of headache in this

Table 1 Prevalence of primary headaches in a population sample of ageing men and women according to the 2004 criteria
of International Headache Society

Men (n = 629; 38.9%) Women (n = 986, 61.1%) Total (n = 1615, 100%)

N (%) 95% CI N (%) 95% CI N (%) 95% CI

Any type of headache 212 (33.7) 30.0, 37.4 524 (53.1) 50.1, 56.3 736 (45.6) 43.2, 48.0
All tension-type headaches (2) 177 (28.1) 24.6, 31.6 358 (36.3) 33.4, 39.4 535 (33.1) 30.8, 35.4
Tension-type headaches (2.1, 2.2 and 2.3) 150 (23.8) 20.5, 27.1 316 (32.0) 29.1, 34.9 466 (28.9) 6.7, 31.1
Probable tension-type headache (2.4) 27 (4.3) 2.7, 5.9 42 (4.3) 3.0, 5.6 69 (4.3) 0.3, 5.3
All migraine subtypes (1) 32 (5.1) 3.4, 6.8 139 (14.1) 11.9, 16.3 171 (10.6) 9.1, 12.1
Migraine with/without aura (1.2, 1.1) 9 (1.4) 0.5, 2.3 60 (6.1) 4.6, 7.6 69 (4.3) 3.3, 5.3
Probable migraine (1.6) 23 (3.7) 2.2, 5.2 79 (8.0) 6.3, 9.7 102 (6.3) 5.1, 7.5
Other headaches 3 (0.5) 0.01, 1.1 27 (2.7) 1.7, 3.7 30 (1.9) 1.2, 2.6

© Blackwell Publishing Ltd Cephalalgia, 2007, 28, 329–333

 Headache among elderly people in Brazil 331

Table 2 Prevalence of tension-type and migraine headaches subjects >65 years old (47.4% women). Prevalence
according to age strata by gender of current migraine headache was 2.0% in women
Tension-type Migraine with no case in men; and of tension-type headaches,
headaches headaches 4.0% in women and 1.2% in men. In the same year,
N (%) N (%) Wang et al. (16), in a population sample of elderly
Chinese (ⱖ65 years; 56.4% women), demonstrated a
Men 1-year prevalence of migraine in men and women,
65–69 years 84 (26.1) 21 (6.5) respectively, of 0.7% and 4.7%; and of tension-type
70–74 years 49 (24.9) 7 (3.6) headache, respectively, of 20% and 46%. In 1999, the
75–79 years 23 (18.4) 1 (0.8) GEM Study (17) demonstrated a 1-year prevalence
ⱖ80 years 21 (20.6) 3 (1)
of migraine headaches in men and women
P for trend 0.80 0.09
ⱖ55 years old, respectively, of 5.6% and 12.4%.
Women
65–69 years 175 (39.8) 62 (14.1)
Henry et al. (18) in 2002 showed a prevalence of
70–74 years 91 (58.3) 47 (24) migraine headaches and migrainous disorder in
75–79 years 52 (24.4) 20 (9.4) France, for men and women aged >64 years, of
ⱖ80 years 40 (25) 10 (6.3) 1.5%, 2.0%, 2.5% and 7.0%. In 2003, Camarda and
P for trend 0.17 0.68 Monastero (6) studied prevalence of primary head-
aches in 1031 participants (54.3% women) in a
door-to-door survey of people ⱖ65 years old. One-
population, with a female:male ratio of 1.3 : 1. year prevalence rates for headache were 4.6% for
Migraine headaches were also more common in migraine, 16% for tension-type headaches and 1.3%
women, with a female:male ratio of 2.8 : 1, although for other headaches. In 2005, Prencipe et al. (7)
menopause had occurred in these women >10 years assessed in a population sample of elderly the
previously. Prevalence of tension-type headaches in 1-year prevalence of migraine headaches, 13.8% for
the last year was 33.1% for both genders: 28.1% for women and 7.4% for men. For tension-type head-
men and 36.4% for women. Prevalence of migraine ache, the 1-year prevalence was 55.1% for women
headaches in the last year was 10.6% for both sexes: and 30.9% for men.
5.1% for men and 14.1% for women. Our results have shown a higher 1-year preva-
For tension-type headaches, 87.1% (n = 466) were lence of migraine and tension-type headaches in
confirmed cases (IHS2.1, 2.2 and 2.3) and 12.9% (n = 69) our sample of elderly people. Several factors could
probable cases (IHS2.4). For migraine headaches, 69 explain our results. The population sample of
(40.4%) were confirmed cases (IHS1.1, 1.2, 1.5) and 102 ageing people who participated in the study was
(59.6%) were probable cases (IHS1.6). Of these, 90 selected from the area in the District of Butantã that
(88.2%) referred <4 h of pain. Using a modified has a lower income in the area. Almost 13% of the
criterion excluding duration of headache, as in pre- participants live in shanty towns, and 87.8% of the
vious papers (4, 5, 12–14), increased the number of heads of households had <1 year of schooling.
confirmed cases to 159 (159/171 = 93.0%). Of the Some studies have shown an association between
736 people reporting any kind of headache, 30 did low socioeconomic status and prevalence of
not fulfil criteria for tension-type or migraine head- migraine, including a previous study in Brazil (9,
aches and they were classified as having other 19–22), not confirmed in other studies (17, 23, 24).
headaches. However, it is plausible that the higher 1-year
Table 2 shows the prevalence of headaches prevalence of migraine headaches could be
according to age strata by gender. There was no explained by the low-income population in this
difference in the prevalence of headaches according sample compared with previous studies. Further-
to race, number of school years or mean income. more, Brazil is part of Latin America, and other
Frequency of tension-type and migraine headaches studies on headache in elderly people have been
decreased with age, but not statistically signifi- done in Europe and China. Cultural factors could
cantly so. explain the higher 1-year prevalence of headaches
in Brazil. Craig et al. (25) have studied the current
prevalence of migraine headaches in Mexican
Discussion Americans born in Mexico and the USA. Mexican
There are sparse data about prevalence of headache Americans born in Mexico have twice the current
in ageing people. Franceschi et al. (15) in 1997 prevalence of migraine headaches than Mexican
evaluated the prevalence of headache in 312 Americans born in the USA. In the same study, the

© Blackwell Publishing Ltd Cephalalgia, 2007, 28, 329–333

332 IM Benseñor et al.
current prevalence of migraine in men and women
ⱖ65 years old was 9.1%, more similar to the 1-year
prevalence of migraine headaches in our sample of
10.6%.
In our sample, the 1-year prevalence of tension-
type or migraine headaches did not change accord-
ing to age strata. Frequency decreased with age, but
statistically significantly so. Camarda and Monas-
tero (6) have described a significant decrease in
migraine headache prevalence with increasing age.
Wang et al. (16) have also described a decrease in
migraine headaches prevalence in men, but not in
women. One possible explanation for the difference
between our study and others could be the small
number of people aged ⱖ75 years in our sample
compared with Italy and even China. Of the 1615
participants in the present study, only 28.5% of the
sample were >75 years old.
In our study, some kind of misclassification is
possible, because headache diagnosis was done
using a questionnaire and not personal interviews
with a doctor. However, the questionnaire is based
on the IHS criteria and has been validated in a
previous study in a Brazilian low-income popula-
tion (11). Several epidemiological studies have used
lay interviewers in recent years with good results.
In the present study, we have not been able to
exclude symptomatic headache with certainty.
However, 90.3% of people complaining of headache
remembered the age in which headache began. Of
these, 80.7% referred the beginning of headache to
a mean age of 43.1 years (7, 24) (median 45 years;
mode 50 years), suggesting a history of primary
headaches of many years’ duration.
Brazilian studies about prevalence of headaches
have shown the high frequency of migraine head-
aches in our population. The recent study of
Morillo et al. (8) has shown a higher frequency of
migraine headaches in Brazil compared with other
countries in Latin America. Other studies in differ-
ent age strata and samples in Brazil have confirmed
the high prevalence of migraine headaches in this
country (9, 26–28).
Our findings support the conclusion of an exten-
sive and recent review of migraine in the elderly,
that stated that ‘migraine in older age groups has
been neglected’ and ‘even in these age groups,
effective treatment is available and careful manage-
ment can improve the quality of life’ (1). Our results
have confirmed in an ageing sample of men and
women that the prevalence of headaches, and espe-
cially of migraine headaches, is very high in Brazil.
Low income and cultural factors are a likely expla-
nation for these findings.
Acknowledgements
All authors are recipients of a scholarship from Conselho
Nacional de Pesquisa, CNPq, Brasília, Brazil. Grant research:
Wellcome Trust, London, UK.
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