|Year : 2016 | Volume
| Issue : 1 | Page : 24-32
Prevalence of recurrent headache and its association with academic performance among King Khalid University male medical students
Abdullah S Abdullah1, Hassan M A. Al-Musa2
1 Family Medicine Resident, Family Medicine Program, Aseer Region, Abha, K.S.A
2 Associate Professor, &Consultant, Family and Community Medicine Dept., College of Medicine, King Khalid University, Abha, K.S.A
|Date of Web Publication||7-Aug-2020|
MD, ABFM Hassan M A. Al-Musa
Family and Community Medicine Department, College of Medicine, King Khalid University, P.O. Box 641, Abha
Source of Support: None, Conflict of Interest: None
Objectives: To identify the magnitude and risk factors of headache among male university students in medical colleges, King Khalid University, Abha, Kingdom of Saudi Arabia. Subjects and Methods: A cross-sectional questionnaire-based study was implemented included a representative sample of male students registered and regularly attending in colleges of Medicine, Pharmacy, Dentistry and Applied Medical Sciences for the academic year 1434-1435 H. A stratified sampling technique with proportional allocation was adopted. The data were collected through filling a self-administered questionnaire include demographic data and details of headache using Headache Assessment Questionnaire. Results: The prevalence rate of headache during the last 12 months was 70.4%. According to the criteria of the International Headache Society (IHS) for diagnosis of different types of headache, the prevalence of tension-type headache was 17.7% while that of migraine was 8.5%. Smokers and students of college of medicine were at higher risk for headache. Almost a quarter of medical students with history of headache visited physicians seeking for treatment. Regarding type of medication taken by medical students for treatment of their headache, acetaminophen and ibuprofen were taken by 33.5% and 22% of them. Academic performance of the medical students, based on their grade point average (GPA) in the last term, was significantly associated with their history of headache during the last year (p=0.009). Conclusions: Headache is a high-prevalence condition among medical students at King Khalid University. Headache is of greater prevalence than migraine and tension-type headache. Most university students rely on non-prescription simple analgesics for headache relief. Students who report headache have worse academic performance.
Keywords: Headache; Migraine; Prevalence; Academic performance; Medical students; Saudi Arabia
|How to cite this article:|
Abdullah AS, A. Al-Musa HM. Prevalence of recurrent headache and its association with academic performance among King Khalid University male medical students. King Khalid Univ J Health Scii 2016;1:24-32
|How to cite this URL:|
Abdullah AS, A. Al-Musa HM. Prevalence of recurrent headache and its association with academic performance among King Khalid University male medical students. King Khalid Univ J Health Scii [serial online] 2016 [cited 2020 Nov 28];1:24-32. Available from: https://www.kkujhs.org/text.asp?2016/1/1/24/291596
| Introduction|| |
It is well established that headache causes substantial disability worldwide and is among the most commonly reported neurological disorders in primary care. Because of their high prevalence and their disabling nature, tension-type headache (TTH), migraine and medication-overuse headache are three disorders collectively responsible for the majority of headache-attributed burden.,,,
It is estimated that globally, among the adult population, 46% have headache in general, 11% have migraine, 42% have TTH, and 3% have chronic daily headache.
The quality of life for individuals with headaches can be compromised by several factors. These factors include the presence of physical and emotional limitations, an impact on professional and academic activities and a drop in labor productivity. A headache patient’s social and family life can also be compromised since headache may limit the victim’s activities. Such factors can represent a high cost to society. Annual indirect costs related to migraine in the United States were estimated between US$ 1.4 and 17 billion. In Brazil, it is estimated that migraine alone is responsible for 4,016,076 consultations in primary care settings, 3,887,504 in secondary care and 93,103 in tertiary care per year, generating an annual direct medical cost of approximately US$ 140 million.
Prevalence of headache among university students varies from 33 to 98.5%.,,,,,,,,, The prevalence of migraine varies from 2.4 to 46.3%.,,,,,,,, and for TTH from 9.5 to 60%. ,,,,
A previous study reported that 62.7% of migraine-suffering students claimed a reduction in academic performance during a headache attack. This research reported a mean of 5.8 days that students did not study at home and of 1.6 days that they missed classes because of headache in 6 months. A total of 24.4% TTH-suffering students reported a reduction of their academic performance during headache episodes. There was a mean of 1.5 days that they did not study at home and of 0.3 days that they missed classes because of headache during the 6 months prior to the study.
In Brazil, a study of students at a college of medicine showed that headaches exert greater influence over academic performance than sex, state of origin, smoking habits, consumption of alcoholic beverages, practice of extracurricular activities, work and stress. There was association between headache and the need to do recovery exams.
Inevitably, many factors exist that can interfere with the academic performance of university students. It is important to verify if headache is associated with a poor academic performance, given that it has a high prevalence in the Saudi population and is a condition that can undergo abortive and prophylactic treatment . A better understanding of the influence over academic performance could deliver a potential improvement to student well-being.
This study aimed to identify the magnitude and risk factors of headache among male university students in medical colleges, King Khalid University, Abha, KSA.
| Subjects and Methods|| |
This study was conducted, following a cross-sectional study design at the medical colleges of King Khalid University (KKU) in Abha City, KSA. There are around 70,000 male students at KKU and has 14 colleges for males.
The total number of male students registered in medical colleges of KKU for the academic year 1433-1434 H was approximately 3200 students distributed as follows: College of Medicine “1200 students”, College of Pharmacy “500”, College of Dentistry “500 students” and College of Applied Medical Sciences “1000 students”. The sample size was calculated by using the single proportion equation in Raosoft software package, as 267 students at 95% confidence intervals (expected prevalence of 36%,  and an accepted error margin of 5%). The sample was increased to 300 to compensate for possible drop outs.
By applying a stratified sampling technique with proportional allocation, the sample size was divided along the 4 medical colleges and was determined as a percentage proportionally related to the total number of the students in the different colleges as follows: 19 students from each of the six academic years of the College of Medicine; 10 students from each of the five academic years of the College of Pharmacy; 10 from each of the five academic years of the College of Dentistry; and 20 students from each of the five academic years of the College of Applied Medical Sciences. However, due to absence of few selected students on the day of data collection, participants were 114 students from the College of Medicine; 46 students from the College of Pharmacy; 46 students were from the College of Dentistry; and 96 students from the College of Applied Medical Sciences. All students were selected by simple random technique from a list of their names at each college administration.
For the classification of headache, the researchers applied the operational diagnostic criteria of the International Headache Society (IHS), which is a hierarchically constructed classification. Migraine was defined as recurrent headache (lasting 4 to 72 hours) with at least 2 to 4 of the following quality of pain features: unilateral, pulsatile, or throbbing; moderate to severe headache; exacerbating on movement; and associated with gastrointestinal symptoms (either nausea or vomiting) or photophobia/phonophobia. No attempt was made to differentiate between the different forms of migraine.
Data was collected using a self-administered questionnaire that included demographic data and details of headache using the “Headache Assessment Questionnaire”  throughout the last year. The filled questionnaire sheets were collected by the researcher after 2 days. Students’ grade point average (GPA) was categorized into four categories: <2.75 (fair); 2.75-<3.75 (good); 3.75-<4.5 (very good); ≥4.5 (excellent).
Tension-type headache was defined as mild or moderate bilateral or vertex tightness or pressure-like feeling in the absence of gastrointestinal discomfort (nausea or vomiting) and photophobia/phonophobia.
Data were entered into a personal computer and was analyzed using the Statistical Package for Social Sciences (SPSS version 20). Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative categorical variables, and means and standard deviations for quantitative variables (only age). Analytic statistics using Chi Square tests (χ2) to test for the association and/or the difference between two categorical variables (history of hypertension in the last 12 months and possible associated factors) were applied. Fischer exact test was utilized instead of chi-square test for small frequencies. P-value equal or less than 0.05 was considered statistically significant.
| Results|| |
As described in [Table 1], out of 302 distributed questionnaire sheets, 233 students responded, with an overall response rate was 77.2%. The highest rate was reported among students of the College of Pharmacy (89.1%), while the lowest rate was observed among students of the College of Medicine (70.2%).
|Table 1: Response rate of male medical students according to their college|
Click here to view
[Table 2] shows that more than one third of students (38.6%) were 21 years old or less, about one fourth of them (26.6%) were 22 years old, about one fifth of them (20.2%) aged 23 years and 14.6% aged 24 years or more. Third academic year represents 22.3% of students while fifth and sixth years represent 16.7% and 4.3% of them, respectively. Slightly more than half of them (50.6%) were from rural areas. The fathers of almost a quarter of them (24%) were government employees while the fathers of 19.7% and 18.5% of them were professionals and business men, respectively. The family income was more than 10,000 SR/month among 47.2% of them. The majority of participant students (86.3%) reported history of habitually drinking coffee, while current smoking was reported by 18.9% of them, i.e., some smokers were also habitually drinking coffee. Based on students’ GPA during the previous semester, almost half of students (50.6%) got good degree whereas 38.2% and 7.7% got very good and excellent grades, respectively.
[Table 3] shows that prevalence of recurrent headache throughout the past year among participants was 70.4%. The frequency of headache attacks was 10 and more among almost half of them (49.4%). Family history of headache reported among 56.8% of them. Daily attacks were reported among 8% of the participants while monthly attaches were reported among 60.2% of them.
|Table 3: Headache characteristics of medical colleges' students, King Khalid University (n=164)|
Click here to view
Regarding type of headache, pulsatile/throbbing, sharp/stabbing and tightness/pressing feeling were reported by 30.2%, 26.1% and 25% of them, respectively. Attacks of headache lasted between one and four hours among almost half of them (48.9%).
Headache attacks were accompanied by nausea, vomiting, loss of appetite or preceded by photophobia, phonophobia among 30.1% of the respondents with history of headache. Regarding its location, it was unilateral, alternating or frontal among 25%, 57.9% or 18.2% of them, respectively. Mild form was reported by 46% of them whereas severe form and daily activities suspended were reported by 6.3% and 1.7% of them, respectively.
According to the criteria of the International Headache Society (IHS) for diagnosis of different types of headache, the prevalence of tension headache was 17.7% while that of migraine was 8.5%.
[Table 4] shows that almost a quarter of medical students (24.4%) with history of headache visited physicians seeking for treatment. More than half of respondents with history of headache (55.5%) reported self-medication for headache, whereas 15.2% and 12.8% reported prescribed and traditional medication for headache, respectively, while 16.5% reported receiving no medication at all for their headache. Regarding type of medication taken by medical students for treatment of their headache, acetaminophen and Ibuprofen were taken by 33.5% and 15.2% of students, respectively. Among those who reported history of medication for headache (n=116), 50% of them reported that they improved sometimes with medication whereas 36.2% reported that they always improved and 13.8% reported no improvement with medication.
|Table 4: Headache medication characteristics of male medical students, King Khalid University|
Click here to view
[Table 5] shows that the commonest precipitating or aggravating factors for headache as mentioned by medical college students were Lack of sleep (52.4%), too much/excessive or long working hours (36%) and lack of rest (20.7%). Regarding relieving factors, sleep, rest and take medications were reported by 45.7%, 38.4% and 32.3% of the students who had history of headache, respectively.
|Table 5: Factors that precipitate or aggravate headache among medical colleges' students with headache|
Click here to view
[Table 6] shows that history of headache during the last 12 months was not significantly associated with student’s age (p=0.393). The highest prevalence rate of headache during the last 12 months was among students of college of medicine (80%) whereas the lowest rate was reported by students of the college of health sciences (61.1%). The association between student’s college and prevalence of headache during the last 12 months was statistically significant (p=0.041). The highest rate of headache during the last 12 months was reported among students of fourth academic year (89.5%) whereas the lowest rate was reported by students of the third academic year (57.7%). The association between student’s academic level and prevalence of headache during the last 12 months was statistically significant (p=0.030). The highest rate of headache during the last 12 months was reported among students whose fathers were professionals (80.4%), whereas the lowest rate was reported by students whose fathers were technical workers (56.5%). However, the association between father’s occupation and prevalence of headache during the last 12 months among medical students was not statistically significant (p=0.399). History of headache during the last 12 months was not significantly associated with student’s residence (p=0.491). Prevalence rate of headache during the last 12 months steadily increased with increasing in family’s income (ranged between 60.5% among those whose family’s income was ≤5000 SR/month and 78.2% among those whose family income was >1000 SR/month). This difference was statistically significant, (p=0.043).
|Table 6: Prevalence of headache among students according to their characteristics|
Click here to view
History of headache during the last 12 months was not significantly associated with drinking coffee among medical students, (p=0.843). Prevalence rate of headache during the last 12 months was significantly higher among smoker students compared to non-smokers (90.9% versus 65.6%, p<0.001). History of headache during the last 12 months was not significantly associated with wearing sunglasses among medical students (p=0.703).
Academic performance of the medical students, based on their GPA in the last term, was significantly associated with their history of headache during the last year. Three-quarters of students who got fair grade and 77.1% of those who got good grade compared to only 38.9% of those who got excellent grade had history of headache. This differences were statistically significant (p=0.009).
| Discussion|| |
In the present study, prevalence of headache among medical students was 70.4%. This prevalence lies within the range reported by other studies conducted among university students (from 33% to 98.5%).,,,,,,,,, Our prevalence of TTH of 12.4%, is within the variation range found in other studies, closer to the lower limit of that range (9.5% to 60%).,,,,,,,,
We reported a prevalence of 6% for migraine. This is again within the range of most studied conducted among university studies and also closer to the lower value of the range (from 2.4 to 48.5%),,,,,,,,,,,
Medical colleges’ students form a selected group and the prevalence figures for headache within this group will almost certainly not be applicable to the entire population of the country. The high prevalence of headache among medical colleges’ students may relate to the clustering of subjects genetically prone to headache attacks in the university as well as to a high level of “floating” tension and stress within the university and medical environments.
Cigarette smoking can contribute to headaches for both the smoker and the non-smoker. Nicotine, one of the components of tobacco, stimulates the blood vessels in the brain to constrict (narrow). Smoking also stimulates the nerves in the back of the throat, contributing to headache.  Usually, by removing the stimulus (nicotine), headaches will be relieved. Quitting smoking or reducing exposure to second-hand smoke is helpful for those with cluster headaches. In one study of people with cluster headaches, those who reduced their tobacco use by less than one-half pack of cigarettes per day found their headaches decreased by 50%. In accordance with this fact, our study revealed that smokers were at a higher risk for headache (prevalence rate of 90.9%) compared with non-smokers (prevalence rate of 56.6%).
Less than 25% of students with headache sought medical assistance during headache episodes. This is despite the fact that the medical school is near to a teaching hospital that runs a daily students and staff clinic. One possible reason for this low recourse to hospital treatment might be the relatively light headache burden. Most students had headache lasting less than 4 hours. Most studies ,,, have reported that despite the high prevalence of headache in university students, only a small percentage (5-23%) sought medical attention for headache.
Most students with headache in our study self-medicated with non-prescription over the-counter drugs. The range of drugs used was limited to simple analgesics such as paracetamol and the non-steroidal anti-inflammatory drug, ibuprofen. The same has been reported among Nigerian University students  and medical students at Sultan Qaboos University.
The low consultation rate and the rarity of usage of specific anti-headache drugs probably point to inadequacies in the management of headaches in our population. Sleep, either alone or in combination with analgesics and rest, was the most common non-drug headache-relieving strategy used by almost half of students. The same has been reported by others.
Traditional herbal remedies were not popular as headache-relieving medications in our participant students. Probably, this finding is due to the fact that our students learn only the classic non-traditional medicine in their university courses, but not due to the non-availability of effective headache-relieving traditional herbal remedies.
Several studies suggested that headache contributes to a reduction in academic performance.,,, Moreover, Falavigna et al. reported that headache may have a major impact on the undergraduate students’ lives and ultimately leads to educational failure. Catharino et al.  noted that headache is associated with learning difficulty complaints. Bigal et al.  added that 62.7% of migraine victims and 24.4% of tension-type headache sufferers, when in pain, complained of decreased productivity while studying.
The evaluation of the academic performance in university students in most published studies was carried out by the student’s self-reporting of absenteeism, need for re-taking exams, and the number of failures per subject. In the present study, we depended on the GPA of the last semester taken from the student’s themselves which could be subjected to memory bias. It was more accurate to take them from the academic records system of the university.
However, this was not possible since the questionnaire was anonymous for confidentiality. Anyhow, the impact of headache on academic performance was evident in our study.
Among possible limitations of the present study, the information about headaches and students’ performance outcomes was collected in a single moment in time through a cross-sectional study. Hence, it is not possible to affirm that there is a causal relation between headaches and a worse academic performance by the students. Another limitation is the conduction of the study among male students of medical colleges only, excluding female and other colleges’ students. This would limit free generalization of our results. Diagnosis of headache in our study was not confirmed by neurological examination as we depend on self-report by students which increase the possibility of over or under estimation of the prevalence.
| Conclusion|| |
Headache is a high-prevalence condition among medical students, KKU. Headache is of greater prevalence than migraine and tension-type headache. Students of College of Medicine and cigarette smokers are at higher risk for headache than others. Few students with headache seek medical consultation. Most of students rely on non-prescription simple analgesics for headache relief. Students who report headaches have worse academic performance.
University students should be encouraged to seek medical consultation for headache, especially for moderate and severe forms. Further studies that include female students and those from non-medical colleges are needed. Smoking-cessation interventions should be stressed among university students. Measures should be taken to reduce the misuse of analgesics since most university students rely on nonprescription medications.
| References|| |
World Health Organization. the World Health Report 2001. WHO, Geneva, 2001.
World Health Organization and the World Federation of Neurology. Atlas: Country resources for neurological disorders 2004. WHO, Geneva, 2004.
International Headache Society Classification Subcommittee. The International Classification of Headache Disorders, 2nd edition. Cephalalgia 2004; 24(suppl 1):1-160.
Silberstein SD, Lipton RB. Epidemiology of migraine. Neuroepidemiology 1993; 12:179-194.
Rasmussen BK. Epidemiology of headache in Europe. In: Olesen J (ed). Headache Classification and Epidemiology. Raven, New York, 1994; 231-237.
Wang SJ, Fuh JL, Lu SR, Liu CY, Hsu LC, et al. Chronic daily headache in Chinese elderly. Neurology 2000; 54:314.
Stovner LJ, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007; 27:193-210
Bigal ME, Lipton RB. The epidemiology, burden, and comorbidities of migraine. Neurol Clin. 2009; 27:321-334.
de Lissovoy G, Lazarus SS. The economic cost of migraine. Present state of knowledge. Neurology. 1994;44:S56-S62.
Bigal ME, Rapoport AM, Bordini CA, Tepper SJ, Sheftell FD, Speciali JG. Burden of migraine in Brazil: Estimate of cost of migraine to the public health system and an analytical study of the cost effectiveness of a stratified model of care. Headache 2003; 43:742-754.
Bicakci S, Over F, Aslan K, Bozdemir N, Saatci E, Sarica Y. Headache characteristics in senior medical students in Turkey. Tohoku J Exp Med. 2007;213: 277-282.
Bicakci S, Bozdemir N, Over F, Saatci E, Sarica Y. Prevalence of migraine diagnosis using ID migraine among university students in southern Turkey. J Headache Pain. 2008; 9:159-163.
Bigal ME, Bigal JM, Betti M, Bordini CA, Speciali JG. Evaluation of the impact of migraine and episodic tension-type headache on the quality of life and performance of a university student population. Headache 2001; 41:710-719.
Sanvito WL, Monzillo PH, Peres MF, et al. The epidemiology of migraine in medical students. Headache. 1996;36:316-319.
Ojini FI, Okubadejo NU, Danesi MA. Prevalence and clinical characteristics of headache in medical students of the University of Lagos, Nigeria. Cephalalgia. 2009; 29:472-477.
Catharino AMS, Catharino FMC, Alvarenga RMP, Fonseca RL. Cefaléia: Prevalência e relaçao com odesempenho escolar de estudantes de medicina. Migrâneas E Cefaléias. 2007; 10:46-50 [English Abstract].
Deleu D, Khan MA, Humaidan H, Al Mantheri Z, Al Hashami S. Prevalence and clinical characteristics of headache in medical students in Oman. Headache. 2001; 41:798-804.
da Costa MZ, Soares CB, Heinisch LM, Heinisch RH. Frequency of headache in the medical students of Santa Catarina’s Federal University. Headache. 2000;40:740-744.
Mitsikostas DD, Gatzonis S, Thomas A, Kalfakis N, Llias A, Papageoergiou C.An epidemiological study of headaches among medical students in Athens. Headache. 1996; 36:561-564.
Adoukonou T, Houinato D, Kankouan J, et al. Migraine among university students in Cotonou (Benin). Headache. 2009; 49:887-893.
Kurt S, Kaplan Y. Epidemiological and clinical characteristics of headache in university students. Clin Neurol Neurosurg. 2008; 110:46-50.
Galinovic I, Vukovic V, Troselj M, Antic S, Demarin V. Migraine and tension-type headache in medical students: A questionnaire study. Coll Antropol. 2009; 33:169-173.
Monteiro JM, Matos E, Calheiros JM. Headaches in medical school students. Neuroepidemiology. 1994; 13:103-107.
Demirkirkan MK, Ellidokuz H, Boluk A. Prevalence and clinical characteristics of migraine in university students in Turkey. Tohoku J Exp Med. 2006; 208:87-92.
Benamer HT, Deleu D, Grosset D. Epidemiology of headache in Arab countries. J Headache Pain. 2010;11(1):1-3.
Mitsikostas DD, Gatzonis S, Thomas A, Kalfakis N, IIias A, Papageoergiou C. An epidemiological study of headaches among medical students in Athens. Headache. 1996; 36(9):561-564.
Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia. 1988; 8(suppl. 7):1-96.
Deleu D, Khan MA, Humaidan H, Al Mantheri Z, Al Hashami S. Prevalence and clinical characteristics of headache in medical students in Oman. Headache. 2001;41:798-804.
Souza-e-Silva HR, Rocha-Filho PAS. Headaches and Academic Performance in University Students: A Cross-Sectional Study. Headache 2011; 51:1493-1502
Ferri-de-Barros JE, Alencar MJ, Berchielli LF, Castelhano Junior LC. Headache among medical and psychology students. Arq Neuropsiquiatr. 2011 Jun; 69(3):502-508.
Amayo EO, Jowi JO, Njeru EK. Headache associated disability in medical students at the Kenyatta National Hospital, Nairobi. East Afr Med J. 2002 Oct; 79(10):519-523.
Payne TJ, Stetson B, Stevens VM, Johnson CA, Penzien DB, Van Dorsten B. The impact of cigarette smoking on headache activity in headache patients. Headache 1991; 31(5):329- 332.
Falavigna A, Teles AR, Velho MC, Vedana VM, da Silva RC et al. Prevalence and impact of headache in undergraduate students in Southern Brazil. Arq Neuro-Psiquiatr 2010; 68(6):873-877.
Bigal ME, Bigal JM, Betti M, Bordini CA, Speciali JG. Evaluation of the impact of migrane and episodic tension type headache on the quality of life and performance of a university student population. Headache 2001; 41:710-719.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]