Pain 79 (1999) 291–301

Validity of an illness severity measure for headache in a population

sample of migraine sufferers

Walter F. Stewart a ,*, Richard B. Lipton b , c , d, David Simon a,

Joshua Liberman a, Michael Von Korff e
a
Department of Epidemiology, The Johns Hopkins School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
b
Innovative Medical Research, Inc., 1001 Cromwell Bridge Road, Towson, MD 21285, USA
c
Department of Neurology, Albert Einstein College of Medicine and the Headache Unit, Montefiore Medical Center, Bronx, New York, USA
d
Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine and the Headache Unit,
Montefiore Medical Center, Bronx, New York, USA
e
Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, WA, USA

Received 29 September 1997; received in revised form 2 July 1998; accepted 2 September 1998

Abstract

The headache impact questionnaire (HImQ) is used to measure pain and activity limitations from headache over a 3-month recall period.
In a prior study, the test-retest reliability of the eight-item HImQ score was found to be relatively high (0.86). In the current study, we
examined the validity of the eight-item HImQ by comparing the overall score and individual items to equivalent measures from a 90-day
diary. Pain and activity limitations due to headache were assessed in a population-based sample of 132 migraine headache sufferers
enrolled in a 90-day daily diary study who completed the HImQ at the end of the study. The HImQ score was derived from four frequency-
based questions (i.e. number of headaches, missed days of work, missed days of chores, or missed days of non-work activity) and four
summary measures of average experience across headaches (i.e. average pain intensity, and average reduced effectiveness when having a
headache at work, during household chores, and in non-work activity). Diary based measures were used as the gold standard in evaluating
the HImQ score. Mean and median values of frequency-based HImQ items (e.g. number of headaches) were similar to equivalent diary
measures, indicating no systematic bias. In contrast, HImQ measures of average experience across attacks (e.g. average pain intensity)
overestimated equivalent diary measures and, in general, better approximated diary measures for migraine headaches, rather than all
headaches. The highest correlations between HImQ and diary items were observed for headache frequency and average pain intensity, the
two general headache measures, followed by measures of reduced effectiveness. Among frequency-based measures, the strength of the
correlation was directly related to the magnitude of the mean. The higher the mean value, the higher the correlation. The correlation
between the HImQ score and diary based score was 0.49. The HImQ score is moderately valid. Frequency-based items (e.g. number of
missed work days) were found to be unbiased and the highest correlation coefficients were observed for frequency-based items with
relatively high mean counts (number of headaches, number of missed non-work days). These findings have implications for measuring
severity of chronic episodic conditions like headache, asthma, back pain, arthritis, epilepsy, and panic disorder, which can cause limitations
to activities. The validity of illness severity measures may be improved by using frequency-based questions to assess both missed activity
days and days with significantly reduced effectiveness or productivity (e.g. by 50% or more). By combining the count for both missed days
and days where productivity is substantially reduced, the mean of the frequency-based measure will be increased, a factor which may
improve the overall validity of the item. A severity measure can be derived from such items by simple addition and provides a scale with
intuitively meaningful units.  1999 International Association for the Study of Pain. Published by Elsevier Science B.V.

Keywords: Diary; Validity; Migraine; Headache; Epidemiology

1. Introduction viduals (Stewart et al., 1996b). At one end of the spectrum,

migraine is truly a chronic condition with frequent attacks,
The severity of migraine varies considerably among indi- high levels of pain and disability during attacks, and
reduced levels of functioning between attacks. At the
* Corresponding author. Tel.: +1-410-955-3906; fax: +1-410-955-0863. other end of the spectrum, pain is moderate with little or

0304-3959/99/$ - see front matter  1999 International Association for the Study of Pain. Published by Elsevier Science B.V.
PII: S03 04-3959(98)001 81-X
292 W.F. Stewart et al. / Pain 79 (1999) 291–301
no limitation to functioning. This variability in the sever-
ity of illness has implications for treatment; individuals at
the severe end of the spectrum have much greater treat-
ment needs than those at the mild end of the spectrum
(Lipton et al., 1994). Unfortunately, physicians and
patients often do not effectively communicate about func-
tional limitations, a critical element to understanding the
severity of disease. We reasoned that a measure of head-
ache severity might facilitate doctor-patient communica-
tion and help guide treatment decisions. The headache
impact questionnaire (HImQ) was developed for this pur-
pose. The HImQ severity score is derived as a composite
of average pain intensity for headaches and lost time in
work outside the home, in household work, and in non-
work (family, social, and recreational) activities, over a 3-
month period.
In a separate study, HImQ items were found to be
highly reliable (Stewart et al., 1998), with a test-retest
correlation of 0.86 from the overall score. We also
found support for previous work indicating that measures
of pain intensity and disability comprising the HImQ
score were hierarchically related (Von Korff et al.,
1992; Stewart et al., 1994; Von Korff et al., 1994). In
general, individuals with mild to moderate headache
pain and little disability had low HImQ scores; individuals
with high levels of disability from their headaches had
high HImQ scores.
To be useful for clinical practice, the HImQ would
also have to be valid. Previous studies of the validity
of retrospective reporting of pain and disability have
been mixed (Hunter et al., 1979; Linton and Melin,
1982; Linton and Götestam, 1983; Kent, 1985; Roche
and Gijsbers, 1986; Means et al., 1989; Basilicato et
al., 1992; Solovey et al., 1992). Studies have varied
considerably in content and design, making it difficult
to accurately summarize patterns of recall bias. The out-
come measure of interest (i.e. pain vs. the behavioral
consequences of pain) has varied. Evidence suggests
that recall of pain experience may be more prone to
error (Means et al., 1989). However, studies differ in
the recall period used (e.g. 5 days–1 month), the nature
of the pain experience (e.g. acute episodic vs. chronic
pain), and the source of study subjects (e.g. specialty
care patients vs. volunteers). Finally, in most validation
studies a relatively small number of subjects have been
examined, limiting confidence in study findings.
In the present study, we examined the validity of HImQ
items and the overall HImQ score in a population-based
sample of migraine headache sufferers participating in a
3-month diary, a period of time that was the same as the
recall interval used for the HImQ. The daily diary method,
often viewed as the most valid method for collecting symp-
tom data, was used as the reference for evaluating the valid-
ity of HImQ items and the overall severity score. Finally,
the format of diary questions was the same as that used for
the HImQ.
2. Methods
The following procedures were involved in assessing the
validity of the HImQ. Potential migraine sufferers were
identified from a population-based telephone interview sur-
vey. Study participants completed the HImQ, in person,
after which they were examined by a clinician to confirm
migraine status. After the initial clinic visit, daily diaries
were completed for 90 days. Within 2 weeks of completing
the diary study, a second HImQ was completed. Finally,
validity of HImQ items and the overall score were assessed
by comparison to equivalent measures summarized from the
90-day diary.
2.1. Population sample and survey
The method for selecting subjects from the population is
described in detail elsewhere (Stewart et al., 1996a). In
brief, a telephone survey was conducted in Northern Balti-
more County, MD, in a demographically diverse popula-
tion. Phone numbers were called in a random order
between February and May, 1994. At the time of the initial
telephone contact, efforts were made to interview all age
eligible (18–65) subjects in each household. Subjects who
participated gave informed consent and were subsequently
interviewed about their different types of headaches using a
clinically validated computer-assisted telephone interview
(CATI). A total of 5071 interviews were completed for a
participation rate of 71.5% (Stewart et al., 1998).
Initial migraine status was determined from responses to
the CATI, using an algorithm based on the International
Headache Society (IHS) criteria (Headache Classification
Committee of the International Headache Society, 1988)
and subsequently confirmed by clinical diagnosis of each
study participant.
2.2. Clinical assessment
Of the 5071 completed telephone interviews, 800 sub-
jects from 770 households met IHS criteria for migraine
and had one or more migraine attacks in the year before
the interview. A random sample of 438 individuals meeting
these criteria were invited to participate in the diary study.
Only one migraine sufferer per household was selected. A
total of 239 (55%) individuals invited to participate gave
written informed consent, completed the HImQ in person at
the clinic, and were examined and interviewed by a clini-
cian. Headache diagnosis was made using IHS criteria. Of
the 239 subjects examined, 226 (95%) met IHS criteria for
migraine.
2.3. Diary
The HImQ asked subjects to report on headaches experi-
enced over the previous 3 months. As a gold standard, a 3-
month daily diary was selected for validating the HImQ-
 W.F. Stewart et al. / Pain 79 (1999) 291–301
based measures. Summary measures of frequency (e.g. days
with headache, days of missed work) were validated by a
count of the actual number of days from the dairy. Measures
reported as a summary among headaches (average pain
intensity, average reduced effectiveness at work) were vali-
dated by computing actual averages among attacks experi-
enced during the 3-month diary period (Table 1).
Each clinically confirmed migraine case was instructed to
complete a daily diary at the same time each day, if possible,
preferably at night. Participants were also told that it was
important to record the actual date that they completed the
diary, even if it was not possible on the assigned day. Each
diary booklet covered a 1-week period and was divided into
two parts. The first part (see Appendix A), containing two
pages for each day, was used to record information about
work (worked or not, percent of usual effective at work),
chores (did chores and percent of usual effectiveness), use
of medications, mood and stress, and whether a headache
occurred and the time it began and ended. The second part
of the diary (see Appendix A), completed on days with
headache, was comprised of two pages of questions on
pain intensity, the need for bed rest, pain features and asso-
ciated symptoms1 (used to define the type of headache),
missed work or school and reduced ability to work, reduced
ability to complete housework or chores, reduced ability to
participate in non-work activities, and medications used to
treat the headache. While each subject received 2 weekly
diaries at a time, they were asked to return completed diaries
by mail each week for 13 weeks. Follow-up calls were made
to those who failed to return their diaries on time. During the
follow-up contact, a supplemental interview was completed
to collect data about each headache that occurred during the
week covered by the corresponding diary. Subjects received
5.00 US $ for each completed diary.
Of the 226 study subjects initially enrolled in the diary
study, 54 were excluded from the analysis for the following
reasons: serious health problems (n = 1); withdrawal
(n = 1); moving without leaving a forwarding address or
phone number (n = 3) and inadequate data (i.e. subjects
who completed fewer than 10 weekly diaries n = 49).
While supplemental interviews were routinely adminis-
tered, most participants later returned the diary correspond-
ing to the week covered by the interview; only 44
supplemental interviews were administered where the cor-
responding diary was not returned.
2.4. The HImQ and HImQ score
The HImQ was completed at the beginning and end of the
1
Questions were asked about all relevant IHS migraine headache symp-
toms except exacerbation with routine physical activity; the latter was
inadvertently omitted. In a review of the screening questionnaire data,
only 9 of the diary study participants met criteria for migraine specifically
because they had headaches with exacerbation; 92 subjects did not report
exacerbation; the remaining 129 reported exacerbation along with at least
two other quality of pain features.
293
3-month diary period. Details regarding the development of
the HImQ questionnaire and the HImQ score are described
elsewhere (Stewart et al., 1998). In brief, a questionnaire,
based in part, on previous work (Von Korff et al., 1992;
Stewart et al., 1994; Von Korff et al., 1994), was reviewed
and modified by a group with expertise in headache and pain
management. More questions were included in the final
version of the HImQ then were intended for use in deriving
a severity measure. Questions captured information on mea-
sures of impairment (frequency and duration of headaches,
pain experience, nausea, photophobia and phonophobia),
functional limitations (need for bedrest), and disability
which itself was expressed by reported limitation to activ-
ities in three general domains (work, household chores, and
non-work activities).
Factor analysis supported previous research suggesting
that measures of pain intensity and disability could be com-
bined into a single composite score. Based on pre-defined
item specific criteria (response rate, ceiling or floor effects,
inter-item correlations) and the factor analysis, eight of 16
items (see Table 2) were selected to derive the HImQ sever-
ity score as the sum of two component measures: average
pain intensity (pain intensity) and total lost time, expressed
as lost days, in each of the three domains of activity. The
latter was derived as the sum of actual missed days (i.e.
missed chore days + missed non-work days + missed
work days) plus reduced effectiveness day equivalents in
each activity domain due to headaches (i.e. average reduced
effectiveness in doing the specific activity with a headache
times the number of days with headache, excluding missed
days).
Items selected for deriving the HImQ score fall into two
broadly defined categories: frequency-based measures
(headache frequency, missed chore days, missed non-work
days, missed work days) which are simply a count of the
number of days with headache or disability, and a mean
estimate of experience across multiple attacks (pain inten-
sity, percent reduced effectiveness at work, in doing chores,
and in non-work activities). This distinction is noteworthy
since the accuracy and predictive validity of HImQ items
varied by type of measure.
2.5. Validity of the HImQ
The primary purpose of this study was to evaluate the
validity of the HImQ score and the items that comprise it.
The reference measures for assessing validity were derived
from the 90-day diary. The HImQ questions and corre-
sponding definition of equivalent diary measures are
described in Table 2. Validity was assessed in reference to
the HImQ completed at the end of the diary study period
(i.e. a 3-month recall interval coinciding with the period
over which the diaries were completed). A total of 132 of
the 172 diary participants completed the HImQ at the end of
the diary period.
Validity was evaluated by comparison of HImQ and diary
294 W.F. Stewart et al. / Pain 79 (1999) 291–301

Table 1
Percent distribution of migraine cases who completed the diary study by selected demographic and headache features obtained during the baseline telephone
interview compared with the sample of all population based migraine cases eligible for the diary study

Variable Category Completed diary studya Eligible migraine casesb

Gender Female 77.1 75.6

Male 22.9 24.4
Race Caucasian 83.9 77.7
Other 16.1 22.3
Age 18-25 10.0 18.7
26-35 29.2 29.4
36-45 33.1 32.8
46+ 27.7 19.2
Education ,12th Grade 3.0 32.9
High school diploma 21.4 32.9
Some post HS training 29.0 29.7
College degree 25.2 19.2
Graduate training 21.4 12.1
Frequency of most severe headache (per year) ,6 32.1 29.2
6–12 26.7 25.5
13–24 13.0 12.5
25+ 28.2 32.8
Average pain with most severe headache ,5 3.8 3.0
(0–10 scale)
5–6 6.9 13.3
7–8 45.8 42.9
9–10 43.5 40.8
Average duration of most severe headache (h) ≤4 12.2 11.5
5–24 38.9 34.6
25+ 48.9 53.9
Nausea with most severe headache Never or rarely 21.4 29.7
Less than half the time 16.8 14.6
Half the time or more 61.8 55.7
Sensitivity to light with most severe headache Never or rarely 13.7 11.6
Less than half the time 3.8 6.6
Half the time or more 82.5 81.7
Sensitivity to sound with most severe headache Never or rarely 19.8 15.6
Less than half the time 6.9 5.6
Half the time or more 73.3 78.7
Unilateral pain with most severe headache Never or rarely 34.4 34.8
Less than half the time 9.2 8.8
Half the time or more 56.4 56.4
Exacerbating pain with most severe headache Never or rarely 43.5 39.7
Less than half the time 3.1 3.8
Half the time or more 53.4 56.5
Pulsatile pain with most severe headache Never or rarely 19.1 14.1
Less than half the time 4.6 7.1
Half the time or more 76.3 78.7
a
Includes the 132 cases who completed ten or more weekly diaries and completed the HImQ at the end of the study.
b
All active migraine sufferers (i.e. at least one migraine per year)identified during the baseline telephone interview.

means and medians to assess systematic bias, and by Pear-
son’s correlation coefficient to assess the extent to which the
HImQ items and score severity explained variance in
equivalent diary measures (Table 2). In evaluating work
related measures, analysis was limited to subjects who
worked 3 or more days per week (n = 82). A total of ten
subjects who completed the second HImQ were excluded
from the analysis because they did not respond to the ques-
tion regarding total number of headaches in the past 3
months. One additional subject was excluded because he
did not complete most of the questions on the HImQ. In
deriving correlation coefficients, bivariate plots of HImQ
and equivalent diary measures were examined for outliers.
Details regarding the effect of removing outliers are sum-
marized in the footnotes to Table 2.
3. Results
3.1. Study participants versus migraineurs in the
population
The 132 subjects who completed both the diary study and
second HImQ tended to differ on demographic but not head-
 W.F. Stewart et al. / Pain 79 (1999) 291–301
ache characteristics when compared with the total popula-
tion sample of migraineurs identified in the initial telephone
survey (Table 1). Specifically, compared to all migraineurs,
diary participants were similar in gender, but were more
likely to be Caucasian, older and better educated. In con-
trast, diary study participants closely resembled all migrai-
neurs in headache frequency (45 vs. 41% had .1 headache/
month), frequency of occurrence of each migrainous symp-
toms with headache, total number of symptoms, average
headache duration (54 vs. 49% with an average duration
.24 h), disability (73. vs. 75% reported frequent need to
lie down), and severe average pain score (44 vs. 41% had
pain scores of 9 or 10 on a 0–10 scale).
3.2. Systematic bias in the HImQ versus the diary
To assess systematic bias we compared mean and median
values of HImQ items with equivalent diary measures. In
ascending order, mean and median values for HImQ items
were greater than equivalent diary measures for reduced
effectiveness at chores, in non-work activities, and at
work, followed by average pain intensity. For these HImQ
items, which provide a summary of experience across
attacks, the mean and median values appear to better
approximate diary based measures for migraine headaches
(data not shown), rather than all headaches. For example,
the median pain intensity for migraine headaches from the
diary was 7.0 compared with a median average pain inten-
sity for all headaches of 7.0 from the HImQ.
Mean and median HImQ values of reduced effectiveness
varied by the type of activity, with the highest values
observed for chores (60 and 44%) followed in order by
reduced effectiveness in non-work activities (40 and 42%)
and at work or school (30 and 36%). In contrast, measures of
reduced effectiveness derived from the diary did not vary by
type of activity.
No consistent pattern of systematic bias was observed for
frequency-based measures (i.e. number of headaches, lost
days of work, household chores, and non-work activities).
Mean HImQ and diary values were similar for the number of
days with headache (15.1 vs. 15.5), missed work days (0.8
vs. 0.9), missed chore days (3.8 vs. 3.7), and to a lesser
extent for missed non-work days (3.1 vs. 3.8). On the
other hand, median HImQ values for three of the four fre-
quency-based items tended to be lower than the equivalent
diary measure, suggesting a modest degree of under report-
ing by some subjects.
Lost time in a specific domain was expressed as a lost day
measure and was the sum of actual missed days plus reduced
effectiveness day equivalents. The latter was the product of
the average reduced effectiveness in a defined domain times
the number of days with headache, excluding missed days in
the specific domain due to headache. HImQ measures of lost
time overestimate their diary based counterpart, due in large
part to the overestimation of percent reduced effectiveness,
previously noted. Overestimation bias was greatest for the
295
HImQ measure of lost work time, since the reduced effec-
tiveness day equivalents measure had to be calculated as the
product of the average reduced effectiveness at work times
number of days with headache and not the number of days at
work with a headache. In contrast, the diary based measure
of the reduced effectiveness day equivalents for work was
by definition the sum of the percentage reduced effective-
ness at work on days when a headache occurred at work.
3.3. Correlation between the HImQ and diary
Before estimating correlation coefficients, each variable
was examined for outliers in univariate and bivariate plots.
Frequency-based measures (e.g. number of headaches, num-
ber of missed chore days) were consistently skewed right as
indicated by a median value that was less than the mean
value (Table 2). This same pattern was not observed for the
summary measures. In general, few outliers were identified
(Table 2, footnote).
Pearson’s correlation coefficients between HImQ and
diary measures (Table 2) ranged from a low of 0.25 (number
of days kept from work or school for at least half the day) to
a high of 0.74 for number of headaches in the past 3 months.
The highest correlations were observed for headache fre-
quency and average pain intensity, the two global measures
of headache severity. Relatively high correlations were also
observed for measures of reduced effectiveness, particularly
in the work and chores domains.
Among frequency-based measures, it appears that the
correlation is directly related to the magnitude of the
mean. The higher the mean value, the higher the correlation.
For example, the correlation for number of headaches was
0.67 for which the diary based mean value was 15.5 days. In
contrast, the correlation and mean for missed chore days
was 0.39 and 3.7 days, and for missed workdays the values
were 0.25 and 0.9 days, respectively.
The correlation between the HImQ score and equivalent
diary measure was 0.49 (Fig. 1). Outliers tended to be more
common for the HImQ severity score compared with the
equivalent diary based score. For example, six of the 132
subjects had HImQ scores .70. No such values were
observed for the diary based scores. More generally, we
examined individual differences between the HImQ score
(observed) and the diary score (expected) and found in
regression analysis that 71% of the difference was explained
by the estimated number of reduced effectiveness day
equivalents from work.
4. Discussion
This is the first study to assess the validity of a self admi-
nistered questionnaire (i.e. the HImQ) for assessing head-
ache severity in a population-based sample of migraineurs
using prospectively recorded diary measures as the gold
standard. Results from this study indicate that the HImQ
296 W.F. Stewart et al. / Pain 79 (1999) 291–301
Fig. 1. Correlations between the HImQ severity score and the equivalent
measure derived from the 90-day diary.
severity score is valid, but that validity is higher for ques-
tions based on frequency counts (e.g. missed non-work
days) rather than average headache experience (e.g. average
pain intensity). While other measures of the impact or qual-
ity of life in headache have been developed (Dahlof, 1990;
Richard et al., 1993; Babiak et al., 1994; Jacobson et al.,
1994; Cavallini et al., 1995; Hartmaier et al., 1995; Mushet
et al., 1995), none have been validated against diary based
measures. Moreover, while correlates (e.g. mood, coping
methods, fatigue, etc.) of daily diary measures of pain
have been examined in past studies (Jandorf et al., 1986;
Affleck et al., 1991; Affleck et al., 1992; Cruise et al., 1996;
Keefe et al., 1996; Affleck et al., 1998), none have specifi-
cally sought to validate a cross-sectional measure using
diary based summary measures as the gold standard. A
unique feature of this study is that data were collected in
the diary and the HImQ using a similar question format and
an equivalent scoring procedure. This type of work is parti-
cularly relevant to clinical practice, due to the logistical
advantages of using a simple brief questionnaire instead
of a long-term diary. Finally, most previous measures rele-
vant to headache and to pain, in general, have only been
examined in clinic-based patients. The HImQ was intended
for use in the general population, regardless of whether or
not a sufferer had sought care. For this reason, we concluded
that population-based sampling was essential to assessing
validity for the reference population of intended use.
The correlation between the HImQ score and equivalent
diary score was 0.49, a relatively strong correlation given
that we compared measures based on very different methods
of collecting data. While the HImQ severity score was
greater than the diary severity score, this bias was primarily
explained by overestimation for HImQ items of reduced
effectiveness and, in particular, for lost work time due to
reduced effectiveness at work. In contrast, overestimation
bias was not observed for the frequency-based HImQ items,
including the number of headaches and the number of lost
work days, missed chore days, and missed non-work days.
In comparing the HImQ to diary measures, the means and
the correlations provide different information. When the
means are comparable (e.g. headache frequency), this sug-
gests that, as a group, migraineurs provide accurate infor-
mation. In contrast, if the means differ, as they do for the
three measures of percent reduced effectiveness, migraine
headache sufferers either overestimate the severity of indi-
vidual attacks or selectively recall their more severe head-
aches. Overestimation of this kind was observed for average
pain intensity and measures of reduced effectiveness. This
type of selective recall needs to be considered when com-
bining information on reduced effectiveness from head-
aches and number of headache to estimate of lost time
from the survey data.
Frequency-based HImQ measures were not biased, a find-
ing which supports the accuracy of population-based survey
estimates of the burden of disease when frequency-based
questions are used. However, the strength of the correlation
between these HImQ and diary measures appears to be
directly related to the HImQ mean value for the fre-
quency-based measure. Frequency-based measures can
only vary by integers. When the mean count is low, as it
was for missed work days (e.g. 0.9 for lost workdays), var-
iation in reporting by a single integer (e.g. 0 vs. 1) results in
a relatively substantial reporting error.
This study has several limitations. HImQ information was
not obtained on the proportion of headaches that occurred at
work. In contrast, this information was explicitly reported in
the diary on each day that a headache occurred. As a con-
sequence, the HImQ summary measure for lost day equiva-
lents due to reduced effectiveness at work overestimates the
equivalent diary measure, in part, since the HImQ measure
of reduced effectiveness is multiplied by all headache days
and not simply workdays. In addition, since self-reported
reduced effectiveness tends to reflect migraine headaches or
the worst headaches, the overall estimate of lost work time
due to reduced effectiveness at work and in other roles will
also be overestimated if all headaches are used as a refer-
ence instead of severe headaches only. Finally, for the
HImQ work related measure, it was not possible to distin-
guish days on which headaches occurred at work versus
non-workdays. This resulted in more serious overestimation
bias. In the diary, by contrast, participants indicated which
days were workdays (whether or not they attended work).
As such, lost work time due to reduced effectiveness at work
could be directly calculated. For the HImQ, lost work time
from reduced effectiveness was derived as average reduced
effectiveness multiplied times number of days with head-
ache. Using data from the diary, we estimate that 35% of
days with headache did not occur on a work day. These
errors are likely to have had a significant effect on bias to
 W.F. Stewart et al. / Pain 79 (1999) 291–301 297

Table 2
Summary statistics and Pearson’s correlation coefficient for HImQ measures obtained at the end of the diary period and for equivalent measures derived from
the diary

Type of HImQ items HImQ HImQ Equivalent Diary Diary Correlation

measure median mean diary measure median mean between HImQ
and diary

Frequency On how many days in the last 3 months have 10.5 15.1 Number of days 13.9 15.5 0.67
you had a headache? (Headache frequency) with headache
Pain level How would you rate the pain from your head- 7.0 6.2 Average pain level 5.4 5.3 0.74
aches on a scale from 0 to 10 (0 is no pain at of all headaches
all and 10 is pain as bad as it can be)?
(Pain intensity)
Average pain from migraine headaches 7.0 6.8 0.50
Work When you have a headache, how often do 0 6.5 Percent of workdays 0 11.0 0.60a,b
you miss work or school for all or part of missed on workdays
the day where 0% is never and 100% is always? with headache
(Percent of time missing work)
How many days in the last 3 months have you 0 0.8 Number of days 0 0.9 0.25a
been kept from work activities (work or school) kept from work
for at least half of the day because of your for all or part
headaches? (Missed work days) of the day
When you have a headache while you work 30.0 35.7 Average of percent 22.4 26.6 0.62a,b
(work or school), how much is your ability to reduced effective-
work reduced? (0% is not reduced at all and ness for headaches
100% is unable to work)? (Percent reduced on full days at work
effectiveness at work)
Lost work time (sum of missed work days and 3.4 5.2 Lost work days dur- 1.9 2.5 0.48a
reduced effectiveness day equivalents at work) ing 3-month period
due to headache
Chores How many days in the last 3 months have 2.0 3.8 Number of days 2.8 3.7 0.39b
you been kept from doing housework or unable to do chores
chores for at least half of the day because for half the day or
of your headaches? (Missed chore days) more
When you have a headache, how much is your 60.0 44.2 Average of per- 21.1 27.3 0.45b
ability to do housework or chores reduced? cent reduced effec-
(Zero percent is not reduced at all and 100% tiveness at chores
is unable to work) (percent reduced on days with
effectiveness in chores) headache
Lost chore time (sum of missed chore days 5.3 8.2 Lost chore days 3.9 4.9 0.50
and reduced effectiveness day equivalents during 3-month
in chores) period due to
headache
Non-work How many days in the last 3 months have 2.0 3.1 Number of days 2.8 3.7 0.43
activities you been kept from non-work activities unable to do non-
(family, social, or recreational) because of work activities
your headaches? (Missed non-work days)
When you have a headache, how much is 40.0 42.8 Average of percent 20.0 26.5 0.36b
your ability to engage in non-work activities reduced effectiveness
(family, social, or recreational) reduced? at non-work activities
(Zero percent is not reduced at all and 100% for headaches
is unable to work) (percent reduced effective-
ness in non-work activities)
Lost non-work time (sum of missed 4.5 7.2 Lost non-work 4.3 5.2 0.52
non-work days and reduced effectiveness time during
day equivalents in non-work activities) 3-month period
from headache
Total score HImQ score 18.8 26.7 Diary score 14.8 17.3 0.49a
a
Restricted to subjects who worked 3 or more days per week.
b
Correlation coefficients displayed in the Table are after removal of outliers. Removal of one outliers each caused the correlation to decrease for percent
missed workdays (from 0.67 to 0.60) and missed chore days (from 0.48 to 0.39) and to an increase for percent reduced effectiveness at work (from 0.48 to
0.62) and in chores (from 0.37 to 0.45). Removal of three data points for percent reduced effectiveness in non-work activities increased the correlation from
0.25 to 0.36.
298 W.F. Stewart et al. / Pain 79 (1999) 291–301
the HImQ severity score. Overall, the measure of lost work
time from reduced effectiveness at work explained 71% of
the difference between the HImQ and diary based severity
scores.
Selection bias could have influenced the validity esti-
mates. A random sample of 438 of the 800 population
based sample of eligible migraine sufferers were invited
to participate in the diary study. While 239 subjects agreed
to participate, only 132 subjects were included in the final
analysis. An important strength of this study is that selection
bias could be evaluated since the baseline data were col-
lected on potentially eligible population based cases. Data
from Table 1 indicates that the demographic profile of the
132 participants is different in some respects from the total
sample of 800 migraineurs. However, no notable differ-
ences were observed in headache features between the
132 diary participants and the population sample.
The HImQ was administered after participation in the 90-
day diary study. It is possible that keeping a diary might
improves the accuracy of reporting on the HImQ and, artifi-
cially increasing the validity correlation. While it is difficult
to evaluate the influence of diary on accuracy of recall, the
only study designed to examine this issue suggests that it is
not a significant concern. Solovey et al. (1992) randomized
107 chronic pain sufferers to groups that did and did not
keep diaries of pain experience and pain related behavior.
Study participants responded to an advertisement but were
not seeking medical care at the time. One-month recall of
average pain intensity and pain related behaviors did not
differ between those who did and did not keep a diary.
However, keeping a diary may influence recall if the diary
period is relatively short (Basilicato et al., 1992).
In assessing validity of self-reported symptoms we exam-
ined the influence of outliers. Outliers were identified
visually from bivariate plots. A data point was qualitatively
defined as an outlier if its removal substantially influenced
the estimated correlation coefficient. In two instances,
removal of outliers caused the correlation to decrease and
in three instances removal of outliers caused the correlation
to increase. While we identified selected data points as out-
liers, we reported results with and without outliers so that
readers could judge for themselves.
It is possible that study participants completed their
weekly diaries once a week. Several steps were taken to
minimize this problem. Subjects were asked to complete
their diary every day, if possible, and to mail the weekly
diary once a week. In addition, whether or not the daily
diary was completed on the assigned day, study participants
were asked to record the actual date that they completed the
diary. For the most part, diaries were completed on the
assigned day. A total of 99% of the diaries were completed
on the assigned day (92.5%) or within 1 day of the assigned
day (6.5%).
The findings from this study have implications for clin-
ical history taking. In taking histories, clinicians tend to
focus on the headache symtomatology over an undefined
period of time. The present study suggests that questions
about number of headaches and days with activity limita-
tions in the past 3 months will provoke accurate and reliable
recall in clinical practice. Since pain and disability from
headaches vary widely among patients and are directly rele-
vant to treatment choices, we would encourage clinicians to
ask patients about their experience in these specific
domains.
From a public health perspective, the HImQ was devel-
oped to help identify headache sufferers with the greatest
need for medical care. The results of this study suggest that
a simple, brief, self-administered questionnaire can ade-
quately capture information relevant to rating the severity
of a patient’s pain experience.
Acknowledgements
This research was supported by Glaxo-Wellcome, Inc.
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Appendix A.
W.F. Stewart et al. / Pain 79 (1999) 291–301 301