Scientific studies have produced increasing evidence that the modern lifestyle in industrialised countries impacts the occurrence and effects of headache . This phenomenon has been named “21st century headache” (Fig. 1). Unhealthy diet, stress and poor posture have long been recognised as risk factors not only for obesity and fatigue but also for headache. Another important trigger factor recently added, was increased use of digital technology. The COVID-19 pandemic has made the situation even worse: not only stress and nervous tension increased, but also the time that people spend seated in front of a screen, with poor posture, participating in business meetings remotely and maintaining virtual social contacts for long hours.
Better understanding of “21st century headache” via real-world data
Headache triggers in modern life
Fig. 1. “21st century headache”: causes and effects
Negative headache impact on daily life and high level of suffering
The effects of the latest increase in headache - especially in those aged 15 to 49 - are many and varied: concentration, attention, motivation and social contacts decrease, whereas unfitness to work, presenteeism (presence at the workplace despite being unwell) and absenteeism increase (Fig. 1). Even though effective treatments exist, 60% of migraine sufferers and 80% of tension type headache (TTH) sufferers never go to the doctor and rely on self-medication for symptom relief. Until now, little was known about the actual negative impact in addition to the level of pain experienced by this group of sufferers, or about their self-treatment methods. This so-called ‘non-doctor treated headache’ (NDH) phenomenon is the reason why randomized controlled trials (RCTs) targeting the NDH population are not possible as they only address professionally diagnosed headache. Therefore, real-word data e.g., from apps are needed to learn more about these NDH sufferers.
Real-world data from self-treating app users
To shed more light on this problem, Goadsby et al.  used an app-based study collecting real-world data from 60,474 people from five countries. The retrospective cross-sectional study analysed the self-reported data from “Migraine Buddy” app* smartphone users over 25 months. This population was not selected or recruited, but existing users of the app were offered the chance to opt out of data collection. The data of all users who did not opt out and who had used the app at least 45 days during the study period were included in the analysis. The data associated with headache are shown in Figure 2.
Fig. 2. Real-world data from an app-based study on the frequency of headache and its impact on daily life 
Most suffers experience headache or migraine episodes up to 4 times per month
Transnationally, 57–67% of users reported they had fewer than 2 episodes of headache per month, whereas 29–36% suffered from headache between 2 and 5 times per month (Fig. 2A). The average reported pain intensity on a scale of 0 to 10 was about 5, but was slightly lower in Japan. Overall, the most frequently mentioned triggers were neck pain, stress and lack of sleep. Roughly half of all subjects reported nausea or vomiting associated with headache, except in Japan where the figure was only 14.5%. 35–64% of subjects reported that their everyday activities at home or at work were slower, 32–56% had difficulties to concentrate, 7–25% missed out on social activities and 13–21% on time with their family (Fig. 2B). The most common non-pharmacological interventions for relief were sleep, drinking water, spending time indoors or in a darkened room, and drinking coffee.
* Migraine Buddy App = smartphone application to track headache and migraine, available at https://migrainebuddy.com/
- Goadsby PJ, Lantéri-Minet M, Michel MC, Peres M, Shibata M, Straube A, Wijeratne T, Ebel-Bitoun C, Constantin L, Hitier S. 21st century headache: mapping new territory. J Headache Pain 2021;22:19. doi: 10.1186/s10194-021-01233-7.
- Goadsby PJ, Constantin L, Ebel-Bitoun C, Igracki Turudic I, Hitier S, Amand-Bourdon C, Stewart A. Multinational descriptive analysis of the real-world burden of headache using the Migraine Buddy application. Eur J Neurol 2021;28(12):4184-4193. doi: 10.1111/ene.15037.
Conflict of interest: Luminita Constantin, Marion Eberlin and Iva Igracki Turudic are employees of Sanofi-Aventis. Martin Michel is a consultant of Sanofi-Aventis.
Disclosure: Medical writing and publication funded by Sanofi-Aventis Deutschland GmbH.