Migraine awareness, prevalence, triggers, and impact on university students: a cross-sectional study

Abstract

Background

Migraine is a public health concern, and university students have been found to be particularly susceptible to stress and other factors that trigger migraines. The objective of this study was to determine the prevalence, awareness, and impact of migraine on University of Sharjah students.

A cross-sectional study was conducted using a self-administered questionnaire. The diagnosis of migraine was made according to the International Headache Society (IHS) criteria and the impact on life was calculated through the Migraine Disability Assessment (MIDAS) score.

Results

The overall migraine prevalence was 26.35% with 25.3% of migraineurs were unaware of having migraine. The most common reported symptoms during a migraine headache attack were one side headache (82.7%) and pulsating headache (66%). Sleep deprivation (74.7%), stress (58%), and hunger or skipping meals (57.3%), were the most common triggering factors. Almost 60% of the migraineurs had a disability ranging from moderate to severe and hospital admission was needed by 30%.

Conclusions

The prevalence of migraine was high among university students, wherein some students might be unaware of having migraines. Migraine has a deleterious impact on students’ productivity and wellbeing. Well-designed interventions such as screening programs might be needed to help in proper diagnosis and management of migraine attacks as well as special educational programs to raise awareness about migraine.

Background

Headaches are widespread and can be defined as a disabling condition that may result in a lower quality of life and poor academic performance. According to the World Health Organization (WHO), half to three-quarters of adults aged 18–65 years in the world have had headache, which includes tension-type headaches, migraines, and cluster headaches [1]. Almost one-third of headache cases in adults are migraines [1]. Migraine is a neurovascular disorder characterized by recurrent throbbing headache that typically affects one side of the head and is often associated with nausea and disturbed vision [2]. It is noted that some factors might aggravate a migraine headache such as stress, sleep deprivation, and routine physical activity [3]. On the other hand, being in a dark, quiet room reduces the severity of a migraine episode [3].

Migraine headaches are a common health issue among university students. This is due to the significant prevalence, as well as the related morbidities, disability, and poor academic performance [4]. Several countries in the middle east including Saudi Arabia, Kuwait and Egypt have done studies regarding migraine [5]. Despite its high prevalence and disabling nature, migraine has continued to be under recognized and under‐treated, even in developed countries [6]. However, in the United Arab Emirates, we identified only one study conducted in 1998 to estimate prevalence of headache and migraine in schoolchildren [7]. Therefore, it is crucial to report an updated estimate of the prevalence of migraine among other populations in the country. Moreover, being aware of the prevalence, triggers, and effects of migraines may aid in preventing attacks or prompting early treatment.

The aim of this study was to determine the prevalence of migraine among university students based on International Headache Society (IHS) [8]. An additional aim was to describe awareness level, triggers, and impact of migraine on university students.

Methods

The present cross-sectional community-based study was conducted in the University of Sharjah during the academic year 2019/2020. The study population included university students from all majors ranging from the first year to sixth year. Those students were diverse regarding their age (17–27 years), gender, and nationality.

The sample size for this study was calculated to be a minimum of 400 students based on a sample size formula for cross-sectional study design {n = [Z² P (1 − P)]/d²}. Parameters used for sample size estimate: 95% confidence interval and a marginal error of not more than 5%. 570 subjects were approached to compensate for missing data and nonresponse. The study participation selection was based on nonprobability quota sampling, stratified based on their gender.

Data were collected using self-administered questionnaire (Additional file 1) with Arabic and English versions. Participants were asked to read and sign a consent form indicating their approval to participate. All students received an invitation through email through the official university portal. The online invitations made clear that participation was optional, that participants might revoke their consent at any moment, and that all data would be kept private. Each participant provided their online consent before filling the questionnaire. If participants wanted to clear up any questions they had concerning this study, appropriate contact information was supplied on the first page of the survey. Students who experienced headaches related to flu, cold, or head injury in the past 12 months were excluded from the study. The questionnaire consisted of 19 questions focusing on demographics, pain characteristics, accompanying factors, triggers, and knowledge about migraine. It was standardized in accordance to International Headache Society (IHS) criteria and the Migraine Disability Assessment Score (MIDAS). The Arabic version of MIDAS has been found to be reliable, with Cronbach’s alpha of 0.81 [8]. The alpha reliability value of this study is 0.79.

A diagnosis of migraine was assigned based on the IHS criteria, 2018 [9] for migraine. Migraine was identified if a respondent reported at least five headache attacks lasting 4–72 h with at least two of the four following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravated by routine physical activity. In addition, experiencing at least one of the two following symptoms, either nausea, vomiting, or phonophobia with photophobia. If these criteria were not met, the respondents were classified as having headache [9].

MIDAS survey was applied to determine the impact of migraine on the patient’s quality of life. This instrument is a five-item questionnaire determining days lost at work or school, loss of productivity at work, and missed family, social, or leisure activities due to headache in the past 3 months.

The MIDAS score was obtained by adding the scores of the 5 questions. A score between 0 and 5 represented degree I, Little or No Disability; a score of 6–10 represented degree II, Mild Disability; a score of 11–20 represented degree III, Moderate Disability; and a score of 21 or higher represented degree IV, Severe Disability [10].

Descriptive statistics were used to describe the demographic characteristics of the study participants. Mean and standard deviation (SD) are reported for continuous variables. Frequencies with proportions were reported for categorical variables. The data analysis was conducted using the Statistical Package for Social Sciences (SPSS) V.25.0 (IBM, New York, USA).

Results

There were 600 subjects invited to participate in the study, of whom 569 (94.8%) had completed the survey. The mean age of the participants was 19.7 years old (Standard deviation ± 1.6 years). There were 464 (81.5%) of the participants had experienced headache in the past 12 months not related to flu, cold, or head injury. Table 1 shows the demographics of the study participants’ and the characteristics of migraine. The majority of the participants, 60.3% (343/569), were females, with Emiratis accounting for 25.8% (147/569) and medical students accounting for 53.6% (305/569). The prevalence of migraine headache was 26.3% (150/569) in the overall study group with over half of migraine sufferers, 50.7% (76/150), had five or more attacks in the last 3 months (Table 1). Over a third, 36% (54/150) of the migraineurs in the study experienced severe pain intensity, with pain scores ranging from 7 to 10 on a 0–10 pain scale (Table 1). Furthermore, 41.3% (62/150) of students with migraine sought medical advice, and 20% (30/150) of those with migraine required hospital admission (Table 1). Figure 1 displays the flow chart of the study participants. Among 464 participants with headache, 32.3% (150/464) had migraine with 25.3% (38/150) having no idea they had migraine and being identified using the IHS criteria (Fig. 1). Figure 2 illustrates the most common reported symptoms during a migraine headache attack, which were one side headache (82.7%), pulsating headache (66%), phonophobia (60%) and photophobia (56%). Sleep deprivation (74.7%), stress (58%), hunger or skipping meals (57.3%), loud sounds (54%), and fatigue (52%) were the most common triggering factors as depicted in Fig. 3. Figure 4 demonstrates the most frequently used factors in relieving a migraine attack were sleeping (90%), being in a dark room (69%), and head massage (64%). MIDAS questionnaire addressed the impact of migraine on the student’s quality of life. Out of 150 migraine sufferers, 58.7% (88/150) reported moderate to severe disability as a result of migraine headache attacks (Table 2). Bivariate analyses showed statistically significant associations between migraine and age, academic year and family history of migraine (Additional file 2, Table 1). However, an adjusted analysis of binary logistic regression revealed that family history of migraine was the only predictor of migraine headache (Additional file 2, Table 2).

Table 1 Demographics of the study participants’ and characteristics of migraine

Fig. 1

Flowchart of the study participants. *Not related to flu, cold, or head injury

Fig. 2

Symptoms experienced by study participants during a migraine attack

Fig. 3

The top ten migraine attack triggers in the study participants

Fig. 4

Factors that relieve migraine attacks in the study participants

Table 2 The impact of migraine on students’ quality of life based on the MIDAS score, n = 150

Discussion

This is a cross-sectional study estimating the prevalence of headache and migraine among university students. In our study, 81.5% of people had a headache in the previous 12 months, which was similar to 83.6% in Oman and 72.5% in Qatar [11]. Whereas the prevalence of migraine headache among our participants was 26.35%, which agrees with recent similar studies from Saudi Arabia, 26.3% [12], Kuwait 27.9% [13], Turkey 21.9% [14] and USA 24.8% [15]. However, lower migraine rates were reported among the general population including 10.4% in Africa, 10.1% in Asia, 11.4% in Europe, and an overall worldwide prevalence of 11.6% [16]. Higher prevalence among students could be related to various triggers experienced by students such as study pressure, sleep deprivation during exams, missing a meal, and loud noises during students’ events [17].

Over three-quarters of our participants experienced more than 2 headache attacks during the three months preceding the study. This result matches with a study done among university students from Saudi Arabia [12]. The most reported triggering factors of migraine were sleep deprivation, stress, and hunger/skipping meals, which is supported by previous studies in Saudi Arabia [12] and Iran [16]. Our students and Saudi Arabian students [3] had similar relieving variables, with the most common behaviors being laying down and sleeping, followed by being in a dark quiet room [18]. The most reported pain intensity was described as moderate to severe pain, which was similar to previous studies [13, 19]. In addition to pain, accompanying symptoms were present; our study was in line with other studies reporting phonophobia, photophobia, nausea, and vomiting being the most common [20].

Based on MIDAS score, our study showed that almost 60% of participants reported moderate to severe disability (MIDAS grades III and IV). This was consistent with a systematic review which stated that 8 of the 13 studies that reported MIDAS grades found that more than half of the migraineurs were moderately to severely disabled by their headaches [21].

Medical consultation for migraine management was considered moderate as it was only sought by 41% of the students suffering from migraine, much better than 12% reported by a study conducted in Saudi Arabia [22]. According to multiple research [22,23,24], one likely reason for poor medical consultation for migraine is that a large percentage of students use over-the-counter medications. The majority of the medicines taken by students were simple pain killers that were not specifically designed to treat migraine [25]. Students with migraine may take excessive amounts of over-the-counter analgesics due to the severity of pain, which may cause serious health harm. Therefore, there is a pressing need to raise student awareness and urge medical consultation o properly manage migraines. Twenty percent of students with migraine needed hospital admission, some participants may have viewed obtaining overnight treatment in the emergency room. However, a recent study from the United Kingdom has also noted a high percentage (17.4%) of hospitalizations among emergency visitors due to migraine [26]. This shows the physical and mental burden of migraine on students, which may have an impact on their productivity.

To the best of our knowledge, this is the first study to evaluate the prevalence, awareness, and impact of migraine among students in the UAE. However, this study is not free of some limitations. The use of a self-administered questionnaire might introduce a potential recall bias. Another limitation was that participants were not interviewed by a neurologist for confirmation of the migraine diagnosis. Moreover, comprehensive information on the usage of analgesic drugs as a migraine relief factor was not gathered in this study. In addition, the generalizability of our findings is limited because this is not a population-based study.

Conclusions

The study concluded that the prevalence of migraine was high among university students, wherein some students might be unaware of having migraines. Migraine has a deleterious impact on the students’ productivity and wellbeing. Stress, sleep deprivation, and fatigue were reported to be the most common triggering factors.

Future studies should focus on identifying headache and migraine subtypes among university students. Well-designed interventions such as screening programs should be implemented to help in proper diagnosis and management of migraine attacks. Additionally, special educational programs for students are required to promote awareness of migraine.