The present study was conducted in the medical students enrolled in the Faculty of Medicine, in the 2017–2018 academic year.
The curricula in the Faculty of Medicine require continuous effort, hard work, and concentration, and, thus, evaluation and management of headaches among medical students are of great importance [7].
Migraine frequency in our questionnaire-based study according to the international classification of headache disorders [3] was 17.9% (12.5% in males versus 23.1% in females).
The prevalence of migraine among medical students was variable worldwide. We found that the prevalence of migraine in our study was higher compared to some other studies. The prevalence was reported to be 14.2% in Isfahan, Iran [11]; 13.4% in the USA [12]; 13.1% in Nigeria [13]; and only 7.9% in Southeast China [14].
In contrast, other studies have revealed higher migraine prevalence than our study; the prevalence was 40.2% in Sao Paulo, Brazil [15]; 38.3% in Peshawar, Pakistan [16]; 28% in India [17]; 27.9% in Kuwait [7]; and 26.3% in Saudi Arabia, at King Abdulaziz University, Jeddah [18].
Many factors can explain the difference between the results of our study and the abovementioned studies regarding migraine prevalence: first, the number of subjects included from each gender. For example, in the study conducted by Ojini and colleagues, the ratio of female to male participants was lower than the ratio in our study. Moreover, the prevalence of migraine in females in their study was 10.9% while 3.2% in males. These factors made their total migraine prevalence 6.4% compared to 17.9% in our study [19].
Second, the difference in methodology, self-reporting questionnaires used, and the duration of the study differed between various studies. In the studies by Menon and Kinnera [17], for example, they assessed one year prevalence of migraine while in our study we assessed the last 3 months prevalence of migraine. Also, the studies conducted during stressful periods such as midterms, end of clinical rounds, or final exams were expected to find higher migraine prevalence.
Third, the difference in prevalence can also be explained by racial differences. Stewart and colleagues [20] studied the prevalence of migraine in Asian Americans, African-Americans, and Caucasians in the USA and found a significant difference in migraine prevalence between distinct racial groups. Nutritional habits and variation in weather and climate are also contributing factors.
Migraine prevalence among medical students in this study was higher compared to migraine prevalence in the Egyptian general population which was 10.5% in Kandil and colleagues, a study conducted in Assiut Governorate, Egypt [21].
Many studies have agreed that migraine is highly prevalent among university students compared to general populations [9]. The higher prevalence in our population study is expected due to their young ages and stressful academic life.
In this study, migraine prevalence was 1.9 times more common in females than males which is almost in agreement with the literature and previous studies [7, 11, 18].
This difference may be explained in part by the effects of estrogen hormone. Estrogen stimulates the synthesis and release of NO and calcitonin gene-related peptide, which in turn activate and transmit pain signals to the trigeminal nerve and trigger migraine. Also, estrogen may increase neuronal excitation and induce migraine by creating an imbalance in the levels of Mg2+ and Ca2+ [22].
Migraine has a well-known genetic component. Most of migraine patients have a first-degree relative with a history of migraine. Moreover, the risk of migraine has increased 4-folds in relatives of people who have migraine with aura [23].
In the present study, positive family history of headache for students with migraine was 67.4% which is almost in accordance to other studies where Balaban and colleagues [24] found that 72% of medical students with migraine had positive family history of headache respectively. Other studies have revealed less positive family history of headache prevalence among medical students with migraine, whereas the prevalence was 20.6% in the study conducted by Ghorbani and colleagues [11].
In this study, the prevalence of migraine without aura was higher than migraine with aura (59.2% and 40.8%, respectively). The most prevalent aura was visually followed by sensory (67.4% and 23.9%, respectively).
The findings of our study are in line with the results of many studies which found that the prevalence of migraine without aura was more than migraine with aura [11, 25, 26]. However, the prevalence of migraine with aura is relatively higher, and the prevalence of visual aura is relatively lower in our study compared such studies. These findings may have genetic or racial basis. Also, high proportions of subjects with both migraine with and without aura may be expected in headache-prone populations as medical students reported in several previous clinical studies [27,28,29]. In addition, inaccuracy in the diagnosis of aura symptoms may be a serious problem in both clinical and population-based studies. The aura symptoms may be extremely difficult to describe. The retrospective character of the present study may induce bias due to problems of recall of aura symptoms [30].
Our medical students with migraine had experienced mean frequency of attacks 5.96 per month which is higher than previous studies. The mean attack frequency per month was 4.2 among medical students of Kuwait University [7] and 4.6 among medical students at King Abdulaziz University [18].
Regarding headache characteristics, 94.6% of our medical students with migraine had moderate to severe intensity of their attacks which is higher than that found in other studies [18, 31].
Some students have more than one trigger factor. Menstruation was a trigger factor among 41.9% of our female cohorts. This finding is in accordance with many other studies [14, 31].
As a result of biochemical changes related to the physiological stress response, stress has a negative impact on individuals predisposed to migraine attacks by enhancing the release of corticotrophin-releasing hormone or by the changes induced by psychological response to stressors [32].
In the present study, stress during studying and exams, psychological stress, irregular sleep, and fasting were the most common triggers of migraines. The findings of our present study are in agreement with the results of previous studies [33, 34]. Our results are also consistent with Timothy and colleagues, who concluded that migraine can be triggered by exams, diet, hunger, sleep deprivation, and physical and emotional stress [35].
These findings raise the importance of teaching stress management in the medical curricula so that medical students can learn how to deal with and alleviate stresses [14].
The impact of migraine on the lives of medical students could be measured by the Migraine Disability Assessment (MIDAS) questionnaire which includes five questions regarding days of activity limitations in work or scholastic performance, household work, and social, family, and leisure activities [10].
In this study, 37.2% and 23% of medical students with migraine had moderate and severe disability, respectively, according to The MIDAS scoring. In the study by Balaban and colleagues, MIDAS scoring was 19.3% for moderate disability and 22% for severe disability [24]. Hence, it is clear that our medical students had more disability because of their migraines.
Despite medical students were expected to be more aware regarding the importance of consultation for health problems, yet they reported low consultation rates. In this study, only 35.4% of medical students with migraine sought medical advice for their headache; 32.5% of them visited a neurologist, 25% visited an ophthalmologist, and 22.5% visited an internist.
In the USA, Johnson and colleagues [12] reported that half of medical students with migraine had consulted a physician for their headaches. This rate of consultation is higher than that of our study despite the fact that the Faculty of Medicine is affiliated with a teaching hospital that runs a neurologic outpatient clinic at least twice a week.
In Brazil, Da Costa and colleagues [36] revealed that 33.6% of the patients had consulted physicians which comes in agreement with our study. Other study has shown very low consultation rates [14, 31]. These findings could be explained by a relatively light severity of headache. Also, over-the-counter analgesics are easily available.
Fifty eight percent of our medical students with migraine administered medications without prescriptions, which was significantly higher than those who took medications with prescriptions (25.7%) (p value is < 0.00001). It is important to shed light on this malpractice because of its effect on migraine transformation from episodic to chronic due to analgesics overuse [37].
Not only was there a significant difference between females and males regarding migraine prevalence with higher females predominance (p value is 0.0006), but also there were differences regarding migraine-related disability. Female students with migraine had moderate to severe disability more than males with significant difference (p value is 0.0013). This is consistent with the findings of other studies [38, 39].
Differences between males and females in migraine are likely due to combination of biologic and psychosocial factors. Biologic explanations include genetic factors, fluctuations in sex hormones, and receptor binding [40].
In a study by Maleki and colleagues, high-field magnetic resonance imaging was performed in subjects with and without migraine (interictally for migraineurs). Females with migraine were found to have thicker posterior insula and precuneus cortices compared with males with migraine and healthy controls of both sexes [41].
Furthermore, psychosocial factors such as social role expectations, coping strategies, and affective variables may play a role in the observed gender-related differences in migraine headache [42].
By using logistic regression, female students and those with positive family history of headache had higher risk for migraine. These findings are in line with the findings of previous studies [23].
We have found a significant positive correlation between migraine severity and frequency with low academic performance (p values were 0.003 and < 0.001 respectively) in medical students. This was also observed in other studies [43]. It is possible that proper management of headaches improves the academic achievement of students [44].