When stretch’d on one’s bed
With a fierce-throbbing head
Which precludes alike thought or repose
How little one cares
For the grandest affairs
That may busy the world as it goes! – Jane Austen
We all get headaches every so often, and the stanza from Austen’s classic poem When Stretch’d On One’s Bed wonderfully describes its impact when things are particularly bad.
Migraines can be particularly horrid, and although we colloquially use the word for a bad headache, it is far more than that.
Some patients lose control over limbs, many are unable to focus on the simplest of matters due to the adverse sensory intrusion that is associated with migraines.
The Global Burden of Disease (GBD) Study 2021 estimates that 1.2 billion people worldwide live with migraine, making it one of the most prevalent conditions on the planet.
More strikingly, it ranks among the leading global causes of years lived with disability, and for people under 50 it is a leading cause of disability outright.
This is not a fringe complaint.
It is a mass phenomenon that peaks precisely during our most economically and socially productive years.
The severity is easy to underestimate if you have never had one.
Don’t underestimate its debilitating effects
A migraine attack is not a headache with the volume turned up.
It is a neurological event, frequently accompanied by nausea, vomiting and disabling sensitivity to light and sound, that can last for days.
In the short term, an attack removes a person from functional life entirely.
In the long term, the picture is more insidious: episodic migraine can transform into chronic migraine, defined as headache on 15 or more days a month, and this brings well-documented comorbidities.
Migraine travels with sleep disorders, anxiety and depression, and the causal arrows almost certainly run in both directions, creating a reinforcing cycle that is difficult to break.
Migraine also rarely arrives alone.
It interacts with other physiological drivers in ways clinicians must untangle.
The most important is hormonal.
After puberty, migraine becomes two to three times more common in women than in men, and the pattern tracks reproductive milestones across a woman’s life.
The dominant explanation is the estrogen withdrawal hypothesis: the premenstrual fall in estrogen appears to trigger attacks, which is why up to 60% of women with migraine report an association with menstruation, and these menstrual attacks are often more severe, longer lasting and more resistant to treatment than others.
Cervicogenic contributors matter, too.
Neck pathology, including disc prolapse and degenerative change, can generate or amplify head pain through the trigeminocervical complex, which is why a proper assessment looks beyond the skull to the spine.
Unable to work
The economic impact is where this stops being a purely clinical conversation.
Productivity loss from migraine comes in two forms: absenteeism, days lost entirely, and presenteeism, the reduced output of someone at their desk but functioning at a fraction of capacity.
The counter-intuitive finding, replicated across studies, is that presenteeism causes more financial loss than absenteeism.
A rigorous workplace study conducted with the World Health Organization estimated presenteeism-related productivity loss from migraine at US$21.3bil (RM87.1bil) per year in Japan alone.
This should reframe how employers think.
The visible cost, the empty chair, is the smaller problem.
The larger cost is invisible, sitting in plain sight and quietly underperforming.
This is not an abstract concern for us.
A Malaysian study of banking-sector employees found the average annual loss from presenteeism was 3.5 times more than absenteeism, and among the most frequent sufferers, presenteeism loss reached MYR25,691 per person.
Multiply that across a workforce and the numbers become material to any chief financial officer.
Newer medicines
On therapeutics, the field has been transformed.
Alongside established acute treatments and older preventives, we now have drugs targeting the calcitonin gene-related peptide (CGRP) pathway: the monoclonal antibodies and the oral “gepants”.
The United States Food and Drug Administration approved the first CGRP monoclonal antibody, erenumab, in 2018, and in trials these agents reduce monthly migraine days by 50% or more in roughly 40 to 50% of patients, with tolerability good enough that 2024 consensus guidance now supports them as first-line prevention in appropriate cases.
But as always there’s a caveat – the cost.
Economic analyses suggest they are cost-effective in chronic migraine but harder to justify in episodic disease unless prices fall or indirect costs are counted.
That caveat leads directly to the hardest policy question.
In a health system with a fixed budget, every ringgit spent subsidising CGRP therapy is a ringgit not spent on oncology, cardiac care, or dialysis, all of which carry louder advocacy constituencies and more visible mortality.
Migraine’s burden is disability, not death, and disability is chronically underweighted in budget politics.
Any honest case for investment has to win that argument on its merits, which means quantifying the productivity return, not just the clinical one.
Suggestion for policy-makers
Policy-makers can focus on a few things.
First, recognition: migraine remains, in the GBD authors’ own words, underrecognised in health policy and funding relative to its burden, and closing that gap starts cheaply, with better primary-care diagnosis rather than expensive drugs.
Second, workplace policy: because presenteeism dominates, the intervention is cultural as much as clinical, moving away from rewarding sick employees for showing up and toward flexible arrangements and manager awareness.
This is where the productivity return is largest and the fiscal cost to the state is near zero.
Third, access: newer therapeutics work, but efficacy is meaningless if only the affluent can afford them.
So reimbursement deserves an evidence-led answer, most likely a stratified one that funds the high-cost agents for chronic, treatment-refractory patients where the cost-effectiveness case is strongest, rather than a blanket yes or no.
This is particularly true for coverage by insurance companies.
Austen wrote her lines despite the throbbing head, but a life less burdened by disease is one with far more room for poetry, and for living.
Dr Helmy Haja Mydin is a consultant respiratory physician and Social & Economic Research Initiative chairman. For further information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
