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Migraine among Egyptian medical students: prevalence, disability and psychological distress-cross sectional study

The Egyptian Journal of Neurology, Psychiatry and Neurosurgery volume 59, Article number: 62 (2023) Cite this article

Abstract

Background

Migraine is one of the most prevalent and disabling primary headache disorders. Migraine has many triggers factors as stress and irregular sleep pattern. Medical study in Egypt is so stressful with great psychological and physical burden; hence medical students are vulnerable to migraine. This study aims to determine the prevalence, characteristics, degree of disability, and psychological stress associated with migraine among medical students at different Egyptian universities.

Results

The overall prevalence of migraine was 17.27%, more in female (76.86%) than male. Sleeping disturbance and stress were the most common triggering factors associated with migraine (94.4%, 81.4% respectively). The majority of students with migraine (89.65%) had high psychological distress as measured by Kessler Psychological Distress Scale (K10) with moderate to severe disorder, while 76.8% had moderate to severe disability as assessed by Migraine Disability Assessment Score (MIDAS). Female gender was a potential predictor associated with higher psychological distress. There is negative correlation between degree of disability and academic performance.

Conclusion

Migraine is prevalent among medical students, with female predominance. It is associated with high level of psychological stress, moderate to severe disability, and negative impact on lifestyle and academic performance of the students.

Background

According to the International Classification of Headache Disorders 3rd edition (ICHD-3); headache is pain experienced either above the orbitotemporal, the nuchal line, or both [1]. There are primary and secondary types of headaches. The most common primary headaches are migraine, tension-type headache, and trigeminal autonomic cephalalgias [1]. Secondary headache may be attributed to head trauma, cranial or cervical vascular disorder, non-vascular intracranial disorder, substance abuse or its withdrawal, disorders of the cranium or sinuses, or psychiatric disorders [1].

Although migraine is highly prevalent in late adolescence, it is under-estimated among undergraduates [2]. Medical students have higher reliability for migraine [3]. Among US medical students, migraine prevalence was 35% for females and 14.1% for males in 2014 [4]. In Egypt, Oraby et al. in 2020, stated the prevalence as 17.9% among medical students [5].

The most common headache-triggering factors are stress, fatigue, sleep disturbances, prolonged exposure to excessive sunlight or heat, and hunger [6].

Recent study reported moderate migraine disability among Egyptian medical students; either caused by migraine or the psychological stress associated with it [5]. The prevalence of psychological stress is higher among migraineurs [7]. Rafique et al. in 2020, found that migraineurs female had higher psychological distress than non-migraineurs female [8].

This study aimed to determine the prevalence, characteristics, degree of disability, and psychological stress associated with migraine among medical students at the Faculty of Medicine of different Egyptian universities.

Methods

This is a cross sectional multicenter study conducted online via Google form. The study population included medical students and intern doctors from five different Egyptian Universities.

For data collection, we used medical students and intern doctors’ groups on Facebook as sample frame, from which we randomly selected 1627 students from all grades with age range from 18 to 24 years. The study was approved by the ethical review board, Approval code: MKSU 46-12-21. Each participants gave a virtual consent before submitting their response.

Our questionnaire was divided into five sections as shown in Fig. 1. In the first section we collected demographic data, family history for migraine, smoking, and other medical causes of headache. Students with secondary cause of headache as history of head trauma, sinusitis, neurological disorders, or systematic disease causing headache were excluded from further analysis.

Fig. 1
figure 1

Flowchart of survey responses

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The second section consisted of Migraine Screen Questionnaire (MS-Q) [9]. This questionnaire consists of five questions about the frequency and characteristics of headaches, as well as the presence or absence of migraine symptoms for this, a score of 0 was obtained for each negative answer (NO), and 1 for each positive answer reply (YES). A cutoff point indicating suspicion of migraine was established at 4 points, while a score less than 4 indicated no suspicion of migraine. Students MS-Q ˂4 were excluded from further analysis.

The third section consisted of the diagnostic criteria of migraine according to 3rd edition of the International Classification of Headache Disorders (ICHD-III) to confirm diagnosis of migraine [1]. It includes questions about the attacks’ frequency, duration, intensity, character, site, aura, interference with daily activities and associations of migraine headache. Also, students were asked about triggering factors of headache attacks—including noise, anxiety, sleeping disturbances, physical activity, exposure to sun, heat, annoyance, intense light, studying for exams, emotional upset, eating habits, and menstruation (in female students). Also, they were asked if they had previous diagnosis of migraine by medical staff.

The fourth section assessed psychological distress using Kessler Psychological Distress Scale (K10). K10 scale included 10 questions about emotional states with response scale from one (none of the time) to five (all the time). Scores of the 10 questions are summed and categorized as following: (10–19) is likely to be well, (20–24) is likely to have mild disorder, (25–29) is likely to have moderate disorder, (30–50) is likely to have severe disorder [10].

The fifth section consisted of Migraine Disability Assessment Score (MIDAS) to assess degree of disability. The test consisted of five questions. Total number of days is summed as MIDAS score and categorized as following: grade I (0–5) has little or no disability, grade II (6–10) has mild disability, grade III (11–20) has moderate disability, grade IV (21 or more) has severe disability [11].

The form responses were exported to Google sheets for data organization and cleansing. Then the collected data was analyzed using SPSS software version 20, qualitative data was described as frequency and percentage and expressed as, median and range while quantitative data was expressed as mean and standard deviation. The difference between two qualitative variables was calculated using Chi-square test and Anova was used for more than two groups. P-value less than 0.05 reflecting significant difference.

Results

A total of 1627 medical students and intern doctors from different universities in Egypt were enrolled in this study through an online structured questionnaire via Google form. Their mean age was 21.3 years with a standard deviation of 3.08 years. Table 1 illustrates the basic characteristics of the studied participants: 65.2% were female, and 34.8% were male. The majority were single (97.5%). Regarding residence, 61.4% and 38.6% lived in urban and rural areas respectively. The majority were non-smokers (96.3%) with no family history of migraine in 72.7%. Two hundred and sixty-five (16.3%) were suspected to have secondary headache.

Table 1 Socio-demographic characteristics of the studied participants (n = 1627)
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Among the study participants, 1362 were screened for migraine through (MS-Q) by answering five questions with total mean score (X ± SD = 2.29 ± 1.4). Of them, 315 (23.1%) had total score ≥ 4; probably having migraine (Table 2). Out of the 315; fourteen students did not complete the questionnaire and were considered missing data, 281 fit the criteria for migraine headache according to ICHD-3 with a prevalence of 17.27% as shown in Table 3. Among the 281 students diagnosed with migraine, 38.5% had about 1–4 attacks per month, 94.4% reported pulsating headache, the most common location of headache was unilateral 79.35%. In association with headache, 62.8% experienced photophobia or phonophobia while 32.55% experienced nausea or vomiting. The migraine attack was associated with aura in 31.2% of the students, most commonly visual aura (79.7%).

Table 2 Questions of Migraine Screen Questionnaire (MS-Q) (n = 1362)
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Table 3 Questions related to those diagnosed as migraine (n = 301)
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Table 4 shows sociodemographic characteristics of those diagnosed with migraine. It was found to be more in females (76.86%) than males, those living in urban areas (63.35%), academic grades 4th and 6th (23.11% and 23.11%); and regarding academic performance, 45.2% got excellent marks.

Table 4 Socio-demographic characteristics of those diagnosed with migraine (n = 281)
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Sleeping disturbance and stress were the most common triggering factors associated with migraine attacks among students (94.4%, 81.4% respectively). Menstruation was reported as a triggering factor in 29% of females with migraine as shown in Table 5.

Table 5 The frequency distribution of the main triggering factors of migraine
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Regarding psychological distress measured by Kessler Psychological Distress Scale (K10), most students with migraine (252) had high psychological distress with moderate to severe disability (25–50 points) with a percentage of 89.65%. Logistic regression analysis was done for the potential predictors of psychological distress in students with migraine, it showed that the female gender is a potential predictor associated with higher psychological distress with significant relation (p-value = .047) while other predictors showed no significant relations as shown in Table 6.

Table 6 Logistic regression analysis of potential predictors of psychological distress in patients with migraine (n = 281)
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In Table 7, by analysis of the degree of disability measured by MIDAS among migraineurs, 216 (76.8%) of students with migraine had moderate to severe disability. On studying different parameters associated with disability in migraine, the academic performance showed statistically significant relation with different grades of migraine with P-value 0.05. Among students with minimal disability, no cases reported fair academic performance while more than half of them had an excellent performance but cases with grade IV disability 6.87% had fair achievement and more than half ranging from good and very good. There is a negative correlation between the degree of disability and academic performance; the decrease in the degree of disability is associated with higher academic performance (R = − 0.118 P = .041).

Table 7 Relation between basic characteristics and migraine disability (Total = 281)
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Discussion

The present study was conducted on medical students and intern doctors from five different universities in Egypt. Google forms was used to structure and distribute the questionnaire. This is the first multicentric study in Egyptian universities to evaluate the prevalence of migraine, associated disability, and psychological distress—based on self-report. The curricula in the Faculty of Medicine demand continuous effort, hard work, and concentration; so evaluating and managing headache among medical students is critical.

In the present study, 281 (17.27%) of 1,627 medical students and intern doctors were established as migraineurs based on ICHD-3. This was similar to a recent Egyptian study conducted in one university—which reported migraine among 17.9% of medical students [5]. Migraine prevalence in this study is close to another study in Brazil with migraine prevalence 22% [12].

The prevalence of migraine was so variable among international studies on university students. Some studies reported lower prevalence as 14.1% in Nigeria [13], 13.1% in Southeast Nigeria [14], 12.6% in Turkey [15], 12.2% in Oman [16] and 7.14% in the Southeast of Iran [17]. While other studies reported higher prevalence as 40.2% in Sao Paulo, Brazil [18]; 38.3% in Peshawar, Pakistan [19].

Many studies have found that migraine is more common among university students than in the general population, because of their young ages and stressful academic lives [20]. In addition, most of the participants of questionnaire were females with higher prevalence of headache generally and migraine especially. Also, this study was conducted during stressful periods (midterms and the end of clinical rounds) with more students experiencing migraine attacks.

For migraine prevalence, a higher prevalence was reported among females than males (76.86%, 23.13% respectively) which was in agreement with the literature and previous studies [13, 21, 22]. This could be attributed to hormonal differences related to menstrual cycles, a condition referred to as estrogen-withdrawal headache by the International Classification of Headache Disorders (ICHD) [1]. Estrogen stimulates the synthesis and release of NO and calcitonin gene-related peptide, which activates and transmits pain signals to the trigeminal nerve, resulting in migraine. Furthermore, estrogen may cause neuronal excitation and migraine by causing an imbalance in Mg2+ and Ca2+ levels [23].

The results of this study showed that 34.87% of migraineur students have positive family history of migraine. Ghorbani et al. reported a lower percentage (20.6%) [24], while another study reported a higher percentage (72%) [15]. This could be justified by the study of Bigal et al. which revealed that personal or family economic status may contribute to migraine attacks due to financial stress in patients without the strong influence of genetic factors [25].

This study revealed that 38.5% of migraineur students experienced 1–4 attacks per month, 55.5% with duration last from 4 to 72 h, most of them (91.7%) with moderate to severe in the intensity, 94.4% was pulsating, 79.35% was unilateral, 93.2% interfered with daily activity. These results are consistent with the study of Kurt et al. [26].

This study found that most of migraineurs experienced migraine without aura (68.8%) and it is consistent with a previous study which reported that 63.9% had migraine without aura, 17.9% had migraine with aura, and 13.1% had migraine both with and without aura [27]. In consistent with many other studies, 31.2% of migraineurs experienced aura mostly in the form of visual disturbances (79.7%) [24, 28, 29]. However, inaccurate diagnosis of aura symptoms may be a serious issue in both clinical and population-based studies as aura symptoms can be difficult to describe. The current study's retrospective nature may introduce bias due to recall issues with aura symptoms [30].

The most triggering factors of migraine were sleeping disturbances (94.4%), anxiety (81.4%), emotional upset (80.1%), and studying for exams (79.7%). Sauro et al. have suggested that stress can not only trigger an acute attack, but also predispose to migraine [31]. Another study examined the relationship between stress and migraine in a longitudinal and bidirectional manner, indicating that stress is a risk factor for migraine [32]. Furthermore, patients with primary chronic headache, including tension type headache and migraine, reported a significant increase in stressful life events in the year preceding the onset of headache [33].

These findings may be explained by the fact that the hypothalamic-pituitary-adrenocortical axis is stimulated in response to stress, resulting in the activation of corticotrophin releasing hormone and, as a result, changes in serotonin receptors. This causes degranulation of mast cells near the trigeminal nerve endings, resulting in the release of vasoactive and inflammatory mediators that cause migraine [34, 35].

In contrast, studies in Africa in particular, reported sun and heat exposure as the most significant triggering factors for migraine [36, 37]. In this study, menstruation was reported as a triggering factor in 29.9 percent of female students, which was slightly higher than other studies that reported proportions ranging from 10 to 19% [16, 26, 38]. Differences in triggering factors may explain some of the disparities in migraine prevalence between developed and developing countries.

An important finding of this study was that migraineurs had higher psychological stress levels (89.65%). This finding is consistent with earlier findings from international research on medical students [17, 21, 39, 40]. Emotional stress, anxiety, poor lifestyle, and other risk factors for headache among medical students were found to be significant. The high degree of psychological distress they endure is a result of exams, high-level performance, and many years of study and training are all risk factors [39]. Lipton et al. found that the stress levels were not generally associated with migraine occurrence. However, stress reduction from one day to the next is linked to migraine onset the next day [41]. Hashizume et al. discovered that increased stress of daily annoyances had no significant impact on the intensity of migraine [42]. These partially contradictory outcomes can be explained by the varying ages of the subjects, the sample size, or the application of different stress scales.

On studying correlation of psychological distress and different characteristics of the migraineurs, female gender has positive correlation with psychological stress. This could be attributed to the fact the females have a higher prevalence of psychiatric disorders due to hormonal and serotonin effects [43, 44]. Furthermore, the Arab Community places greater limits on girls' actions than on boys’ and has lower expectations for females' competences and achievements [45].

The Migraine Disability Assessment questionnaire (MIDAS) could be used to assess the impact of migraine on the lives of medical students; by asking about days of activity limitations in work or scholastic performance, household work, and social, family, and leisure activities [11].

In this study, 19.9% and 56.9% of medical students with migraine had moderate to severe disability respectively. In a previous study on Egyptian medical students, 37.2 percent and 23 percent of medical students with migraine had moderate and severe disability respectively [5]. In the Balaban et al. study, the MIDAS scoring was 19.3 percent for moderate disability and 22 percent for severe disability [15]. As a result, our medical students were more disabled because of their migraines.

Migraine is one of the top diseases causing disability. Since its inclusion in Global Burden of Diseases (GBD), migraine has risen through the ranks of the top causes of Years Lived of Disability (YLDs) worldwide, from 19th in GBD 2000 [46] to sixth in GBD 2013 [47]. Steiner et al. reported that migraine is the third cause of disability under 50 s [48]. This persistent rise does not imply an increase in prevalence, it follows the collection and incorporation of all data into GBD and improved data with new population-based studies [49].

In this study, there was a significant positive correlation between migraine and low academic performance in medical students which was also observed in other studies [25]. It is possible that proper headache management improves students' academic performance [40].

One of the study's limitations was the use of self-reported questionnaires for data collection, which were prone to recall bias. Another limitation was that the study was cross-sectional, which demonstrated the relationship between variables without concluding a cause-effect relationship. Longitudinal studies should be encouraged to determine the relationship between variables.

Conclusion

Migraine is prevalent among medical students, with a female predominance. It is associated with high level of psychological stress and moderate to severe disability with impact on lifestyle and academic performance of the students.

Recommendations

The Faculty of Medicine should conduct student-led campaigns to raise awareness of the high prevalence of migraine, its diagnosis, and its impact on academic performance. Stress management programs should be developed so that students can learn the proper methods of stress relief. We also recommend assessment of depression and anxiety among Egyptian migraine students as it could be an area of further research.

Availability of data and materials

The data will be available on the editor request through communication with the corresponding author.

Abbreviations

GBD:

Global Burden of Diseases

ICHD-3:

International Classification of Headache Disorders-3rd edition

K-10:

Kessler Psychological Distress Scale

MIDAS:

Migraine Disability Assessment questionnaire

MS-Q:

Migraine Screen Questionnaire

YLDs:

Years Lived of Disability

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Acknowledgements

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Author information

Authors and Affiliations

  1. Department of Neuropsychiatry, Faculty of Medicine, Kafrelsheikh University, El-Geish Street, Kafrelsheikh, Egypt

    Salma Ragab & Shimaa Elgamal

  2. Department of Family Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt

    Nahla Zaitoun

  3. Department of Neuropsychiatry, Faculty of Medicine, Minia University, Minya, Egypt

    Ahmed Elrafie

  4. Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt

    Hussien el-Ansarey & Azza Srour

  5. Faculty of Medicine, Alexandria University, Alexandria, Egypt

    Nada Nabil

  6. Faculty of Medicine, Ain-Shams University, Cairo, Egypt

    Yasmin Elshoura

  7. Department of Ophthalmology, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt

    Mohamed Elshafei

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  1. Salma Ragab
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  4. Hussien el-Ansarey
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  7. Yasmin Elshoura
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  8. Mohamed Elshafei
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  9. Shimaa Elgamal
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Contributions

AE, HE, AS, NN and YE were concerned with data collection from different universities, NZ did the statistical analysis of the data, SR and SE were the major contributor of writing manuscript and AE participated in data analysis and final editing of the paper. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Salma Ragab.

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Ethics approval and consent to participate

The study was approved by the ethical review board in faculty of medicine, Kafrelsheikh University. Approval code: MKSU 46-12-21. Each participants gave a virtual consent before submitting their response.

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Not applicable.

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The authors declare that they have no competing interests.

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Ragab, S., Zaitoun, N., Elrafie, A. et al. Migraine among Egyptian medical students: prevalence, disability and psychological distress-cross sectional study. Egypt J Neurol Psychiatry Neurosurg 59, 62 (2023). https://doi.org/10.1186/s41983-023-00665-z

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