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Prevalence of Headache Disorders, their Impact on the Daily Lifestyle of the Patients, and the Correlation of their Demographic and Clinical Features with Headache Impact Test 6

Article Information

Umar Farooque1*, Fahham Asghar1, Muhammad Talha Liaquat2, Bharat Pillai3, Sohaib Shabih4, Suchitra Muralidharan5, Ramsha Aqeel6, Muhammad Taimur6, Khadijah Sajid7, Omer Cheema6, Sundas Karimi8, Saurabh Kataria9 

1Department of Neurology, Dow University of Health Sciences, Karachi, Pakistan

2Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan

3Department of Neurology, Amrita Institute of Medical Sciences, Kerala, India

4Department of Internal Medicine, Patel Hospital, Karachi, Pakistan

5Department of Internal Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, India

6Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan

7Department of Internal Medicine, Shalamar Medical and Dental College, Lahore, Pakistan

8Department of General Surgery, Combined Military Hospital, Karachi, Pakistan

9Department of Neurology, University of Missouri Health Care, Columbia, United States

*Corresponding author: Umar Farooque, Department of Neurology, Dow University of Health Sciences, Karachi, Pakistan

Received: 21 August 2020; Accepted: 29 August 2020; Published: 07 September 2020

Citation: Umar Farooque, Fahham Asghar, Muhammad Talha Liaquat, Bharat Pillai, Sohaib Shabih, Suchitra Muralidharan, Ramsha Aqeel, Muhammad Taimur, Khadijah Sajid, Omer Cheema, Sundas Karimi, Saurabh Kataria. Prevalence of Headache Disorders, their Impact on the Daily Lifestyle of the Patients, and the Correlation of their Demographic and Clinical Features with Headache Impact Test 6. Archives of Internal Medicine Research 3 (2020): 195-205.

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Abstract

Introduction: Headache disorders are common among people of all ethnic groups. Primary headache disorders include migraine, tension-type headache, cluster headache, and chronic daily headache syndrome. Secondary headaches include medication overuse headache. The aim of this study is to evaluate the prevalence of various types of headaches disorders, their impact on the daily lifestyle of the patients, and the correlation of their demographic and clinical features with Headache Impact Test 6 (HIT-6).

Materials and methods: This prospective study was conducted at a tertiary care hospital in Karachi for a period of six months. 198 patients who came in the outpatient (OPD) department and had a diagnosis of headache were included in this study irrespective of their age and gender. The demographic features, clinical features, and the final diagnoses made by the attending physician using the International Classification of Headache Disorders II (ICHD-II) were recorded. The impact of headaches on the daily lifestyle of the patients was determined by using a six-item HIT-6 questionnaire. For continuous variables, the means and standard deviations were calculated. Whereas for categorical data, frequencies and percentages were calculated. Effect modifiers like demographic and clinical features were controlled through stratification, Fischer’s exact test was used and a p-value of ≤0.05 was taken as significant.

Results: The mean age of the patients was 34.39±15.58 years. Age distribution showed 90 (45.45%) patients of eight to 30 years, 84 (42.42%) patients of 31-50 years, and 24 (12.12%) patients of 51-75 years of age. There were 69 (34.8%) male and 129 (65.2%) female patients. The unmarried patients were 81 (40.9%) and married patients were 117 (59.1%). The lower-class patients were 94 (47%), the working-class patients were 87 (43.9%), the middle-class patients were 15 (7.6%), and the upper-class patients were three (1.5%). Primary headache was diagnosed in 150 (75.8%), and the secondary headache was diagnosed in 48 (24.2%) patients. 45 (22.7%) patients had throbbing, 87 (43.9%) had stabbing, and 66 (33.3%) had pressing headache quality. Unilateral headache was in 108 (54.5%), and the bilateral headache was in 90 (45.5%) patients. Pulsatile headache was in 102 (51.5%), and the non-pulsatile headache was in 96 (48.5%) patients. 51 (25.8%) patients had approximately one hour, 42 (21.2%) patients had more than four hours, and 105 (53%) patients had a continuous headache. The frequency was two to three times per week in 51 (25.8%), daily in 81 (40.9%), and variable in 66 (33.3%) patients. The headache occurred in the morning in 39 (19.7%), in the afternoon in 12 (6.1%), in the evening in 24 (12.1%), in the night in 30 (15.2%), and variably in 93 (47%) patients. Headache was mild in 36 (18.2%), moderate in 93 (47%), and severe in 69 (34.8%) patients. Aura, nausea, vomiting, photophobia, phonophobia, runny nose, and lacrimation were also present in many patients. 78 (39.4%) patients had a tension-type headache, and 60 (30,3%) had a migraine while others had several different conditions. The average HIT-6 score was 65.86±7.506. The severe impact was found in 168 (84.8%) patients, substantial impact in nine (4.5%), some impact in 12 (6.1%), and no impact in nine (4.5%) patients. Stratification showed a significant relationship with age, marital status, socioeconomic status, quality of headache, site of headache, pulsatile/non-pulsatile feature, frequency of headache, the severity of headache, and nausea.

Conclusions: Tension-type and migraine headaches are the most common headaches that mostly affect young to middle-aged married females of low socioeconomic status. Age, marital status, socioeconomic status, quality of headache, site of headache, pulsatile/non-pulsatile feature, frequency of headache, the severity of headache, and nausea are some of the determinants of the impact of headaches on daily life. Further studies are needed to validate these conclusions.

Keywords

Headache Disorders, Prevalence, Headache Impact Test, Impact on Lifestyle, Correlation, Demographic Features, Clinical Features, Humans

Headache Disorders articles, Prevalence articles, Headache Impact Test articles, Impact on Lifestyle articles, Correlation articles, Demographic Features articles, Clinical Features articles, Humans articles

Article Details

1. Introduction

Headache disorders are a common occurrence among people of all races, backgrounds, and ethnicities. It is believed that more than half of the adult human population has suffered from headaches accompanying these headache disorders at least once in their lifetimes [1]. Primary headache disorders include migraine, tension-type headache, cluster headache, and chronic daily headache syndrome [1, 2]. Medication overuse headache is a secondary headache disorder having a substantial medical impact [1]. Migraine is a one-sided headache usually starting at puberty and occurring in episodes once or twice a month [1, 3]. A migraine headache may or may not be accompanied by an aura. It is the second most common type of headache reported worldwide with over 10% of people affected [1, 3, 4]. The prevalence is three times higher in females [1, 5]. Tension-type headache is a stress-related headache having a musculoskeletal origin. It is described as a vice-like or band like ache around the neck and/or the forehead to the occiput [1]. Episodic tension-type headache is the most common type of headache reported worldwide, sometimes by 71% of the population of a region [1, 2]. Cluster headache is a primary headache disorder characterized by severe unilateral retro-orbital or periorbital pain. It involves tearing of the eyes and stuffy nose. It is not very common, affecting less than one in 1000 people [2].

Chronic daily headache syndrome is a descriptive term applied to a range of headache types occurring about 15 days a month. The headache may be tension-type, migraine, or even cluster headache. Medication overuse headache, as its name suggests, is a headache caused due to chronic excessive use of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) as well as other drugs [1]. This iatrogenic disorder is thought to affect more than 1% of the world’s population, up to 5% in some areas [2]. Headache disorders are ever-present, widespread, and disabling, and yet their recognition, diagnosis, and treatment are unsatisfactory worldwide [1]. The detrimental effects of headaches are not very well documented. A headache interferes with an individual’s physical performance, work efficiency, leisure activities, the standard of living, and psychosomatic well-being. Research has also shown that the level of disability differs according to the frequency of headache occurrences. The purpose of our study is to calculate the prevalence of the different types of headache disorders in people belonging to all social and economic backgrounds, their impact on the daily lifestyle of the patients, and correlation of their demographic and clinical features with Headache Impact Test 6 (HIT-6).

2. Materials and Methods

2.1 Study design and sampling

This prospective study took place at Dow University Hospital Karachi, from 10/01/2019 to 04/01/2020 (for six months). Inclusion criteria included any age, either gender, and diagnosis of headache. All other patients were excluded from the study.

2.2 Data collection

A total of 198 patients came in the outpatient (OPD) department who met the inclusion/exclusion criteria and were included in this study. All patients were informed about the study and both verbal and written informed consents were obtained. The demographic features (age, gender, marital status, socioeconomic status), and the clinical features (quality, site, pulsatile/non-pulsatile feature, duration, frequency, timing, severity, aura, nausea, vomiting, photophobia, phonophobia, runny nose, and lacrimation) were noted on a preformed proforma. The final diagnoses made by the attending physician in accordance with the International Classification of Headache Disorders II (ICHD-II) were also noted. A six-item HIT-6 questionnaire was used to determine the impact of headaches on the daily lifestyle of the patients.

2.3 Data analysis

Data were entered and analyzed on Statistical Package for the Social Sciences, version 19 (SPSS Statistics, Chicago, IL). Continuous data were presented as mean and standard deviation values. Whereas categorical data were presented in numbers and percentages. Stratification was done to see the effects of demographic and clinical features on the HIT-6 score, Fischer’s exact test was applied and a p-value of ≤0.05 was considered as significant.

3. Results

Mean age of the patients was 34.39 years with a standard deviation of 15.58 years. The youngest patient was eight years old while the oldest was 75 years old, as shown in Table 1. The distribution of age showed that 90 (45.45%) patients were from eight to 30 years, 84 (42.42%) patients were from 31-50 years, and 24 (12.12%) patients were from 51-75 years of age, as shown in Figure 1. 69 (34.8%) patients were male while 129 (65.2%) were female. 81 (40.9%) patients were unmarried while 117 (59.1%) were married. 94 (47%) patients belonged to the lower-class, 87 (43.9%) belonged to the working-class, 15 (7.6%) belonged to the middle-class while three (1.5%) belonged to the upper-class families. 150 (75.8%) patients presented with primary headaches while 48 (24.2%) with secondary headaches. The headache was described by 45 (22.7%) patients as throbbing, 87 (43.9%) as stabbing while 66 (33.3%) as pressing. 108 (54.5%) patients experienced unilateral while 90 (45.5%) experienced bilateral pain. 102 (51.5%) patients experienced pulsatile while 96 (48.5%) experienced non-pulsatile pain.

The duration of the headache of 51 (25.8%) patients was approximately one hour while 42 (21.2%) patients had more than four hours of duration and 105 (53%) patients had a continuous headache. 51 (25.8%) patients experienced headaches two to three times a week, 81 (40.9%) patients daily, and 66 (33.3%) patients experienced headache variably. 39 (19.7%) patients experienced a headache in the morning, 12 (6.1%) in the afternoon, 24 (12.1%) in the evening, 30 (15.2%) in the night while 93 (47%) patients experienced headache variably. 36 (18.2%) patients had mild, 93 (47%) had moderate while 69 (34.8%) had a very severe headache. Many of these patients were presented with different symptoms like aura, nausea, vomiting, photophobia, phonophobia, runny nose, and lacrimation. The frequencies and percentages of all the above stated demographic and clinical features are shown in Table 2. 78 (39.4%) patients were diagnosed by the attending physician with tension-type headache, 60 (30.3%) were diagnosed with migraine, and others were diagnosed with several different conditions, as shown in Table 3. The average HIT-6 score was 65.86 with a standard deviation of 7.506, as shown in Table 4. We assessed from our HIT-6 questionnaire that 168 (84.8%) patients were impacted to a severe degree, nine (4.5%) had a substantial impact, 12 (6.1%) were impacted to some extent, and nine (4.5%) patients were not impacted at all in their lives, as shown in Figure 2.

Stratification of HIT-6 score with the demographic and clinical features showed a statistically significant relationship with age (p-value= 0.001), marital status (p-value= 0.001), socioeconomic status (p-value= 0.001), quality of headache (p-value= 0.001), site of headache (p-value= 0.009), pulsatile/non-pulsatile feature (p-value= 0.002), frequency of headache (p-value= 0.02), the severity of headache (p-value= 0.001), and nausea (p-value= 0.049). Younger patients who were married, belonged to working or lower socioeconomic class, and had daily, moderate to severe intensity, stabbing, unilateral or pulsatile headaches in the absence of nausea had their daily lives more affected, as shown in Table 5.

Age (years)

N

Minimum

Maximum

Mean

Standard deviation

198

8

75

34.39

15.578

Table 1: Analysis of age.

fortune-biomass-feedstock

Figure 1: Distribution of age.

Variable

Category

N (%)

Gender

Male

69 (34.8%)

Female

129 (65.2%)

Marital Status

Unmarried

81 (40.9%)

Married

117 (59.1%)

Socioeconomic status

Lower class

94 (47%)

Working class

87 (43.9%)

Middle class

15 (7.6%)

Upper class

3 (1.5%)

Type of headache

Primary headache

150 (75.8%)

Secondary headache

48 (24.2%)

Quality of headache

Throbbing

45 (22.7%)

Stabbing

87 (43.9%)

Pressing

66 (33.3%)

Site of headache

Unilateral

108 (54.5%)

Bilateral

90 (45.5%)

Pulsatile/Non-pulsatile

Pulsatile

102 (51.5%)

Non-pulsatile

96 (48.5%)

Duration of headache

~1 Hour

51 (25.8%)

 >4 hours

42 (21.2%)

Continuous

105 (53%)

Frequency of headache

2-3 times/week

51 (25.8%)

Daily

81 (40.9%)

Variable

66 (33.3%)

Timing of headache

Morning

39 (19.7%)

Afternoon

12 (6.1%)

Evening

24 (12.1%)

Night

30 (15.2%)

Variable

93 (47%)

Severity of headache

Mild

36 (18.2%)

Moderate

93 (47%)

Severe

69 (34.8%)

Aura

Yes

69 (34.8%)

No

129 (65.1%)

Nausea

Yes

36 (18.2%)

No

162 (81.8%)

Vomiting

Yes

42 (21.2%)

No

156 (78.8%)

Photophobia/phonophobia

Yes

42 (21.2%)

No

156 (78.8%)

Runny nose

Yes

9 (4.5%)

No

189 (95.5%)

Lacrimation

Yes

18 (9.1%)

No

180 (90.9%)

Table 2: Analysis of demographic and clinical features of headaches.

Diagnosis

N (%)

Brain damage

3 (1.5%)

Cervical spondylosis

3 (1.5%)

Depression

3 (1.5%)

Epilepsy

15 (7.5%)

Increased intracranial pressure

3 (1.5%)

Mental impairment

3 (1.5%)

Mental retardation

3 (1.5%)

Migraine

60 (30.3%)

Parkinson’s disease

3 (1.5%)

Chorea

3 (1.5%)

Stress related

3 (1.5%)

Stroke

12 (6%)

Thyroid insufficiency

3 (1.5%)

Tension-type headache

78 (39.4%)

Vertigo

3 (1.5%)

Table 3: Attending physician’s diagnosis.

HIT-6 score

N

Minimum

Maximum

Mean

Standard deviation

198

43

78

65.86

7.506

HIT- Headache Impact Test

Table 4: Analysis of HIT-6 score.

HIT- Headache Impact Test

fortune-biomass-feedstock

Figure 2: Distribution of HIT-6 score.

Variables

HIT-6 score

p-value

<49

50-55

56-59

>60

Age (years)

8-30

9

6

9

66

0.001

31-50

0

6

0

78

51-75

0

0

0

24

Gender

Male

3

3

6

57

0.204

Female

6

9

3

111

Marital Status

Unmarried

6

9

9

57

0.001

Married

3

3

0

111

Socioeconomic status

Lower class

3

3

3

84

0.001

Working class

3

6

6

72

Middle class

3

0

0

12

Upper class

0

3

0

0

Type of headache

Primary headache

6

9

6

129

0.823

Secondary headache

3

3

3

39

Quality of headache

Throbbing

0

0

3

42

0.001

Stabbing

9

3

3

72

Pressing

0

9

3

54

Site of headache

Unilateral

6

9

9

84

0.009

Bilateral

3

3

0

84

Pulsatile/Non-pulsatile

Pulsatile

6

0

6

90

0.002

Non-pulsatile

3

12

3

78

Duration of headache

~1 Hour

3

6

0

42

0.077

 >4 hours

6

6

6

87

Continuous

0

0

3

39

Frequency of headache

2-3 times/week

0

3

6

42

0.020

Daily

3

6

3

69

Variable

6

3

0

57

Timing of headache

Morning

0

3

0

36

0.098

Afternoon

0

0

0

12

Evening

3

0

0

21

Night

3

3

3

21

Variable

3

6

6

78

Severity of headache

Mild

6

6

0

24

0.001

Moderate

0

6

6

81

Severe

3

0

3

63

Aura

Yes

3

3

3

60

0.900

No

6

9

6

108

Nausea

Yes

0

0

0

36

0.049

No

9

12

9

132

Vomiting

Yes

0

0

3

39

0.077

No

9

12

6

129

Photophobia/phonophobia

Yes

3

0

0

39

0.077

No

6

12

9

129

Runny nose

Yes

0

0

0

9

0.641

No

9

12

9

159

Lacrimation

Yes

0

0

0

18

0.316

No

9

12

9

150

HIT- Headache Impact Test

Table 5: Association of demographic and clinical features of headaches with HIT-6 score.

4. Discussion

This study is a glimpse of the characteristics of headache disorders classified and diagnosed according to ICHD-II. Our study also depicts the impact of headaches on daily life using a standardized HIT-6 questionnaire. The majority of the patients were female. Previous studies have also shown more prevalence of headache disorders in females. Jensen at el. reported male to female ratios of 1:3 and 4:5 in migraine and tension-type headache respectively [6]. Other studies from our region also reported that most types of headaches are more common among females [7, 8]. Migraine and tension-type headaches are the two most frequent headaches reported in our study. Tension-type headache was the most frequently diagnosed headache type in our study. Statistical evidence also suggests that tension-type headache is the most common cause of primary headaches [3, 9]. However, epidemiological data on the prevalence of tension-type headache has been heterogeneous [10, 11]. The wide variations of estimated prevalence might be due to the differences in the age profiles, racial backgrounds, environment, and data collection methodology. Other explanations for this disparity include under-recognition of tension-type headache as a ‘real disease’ by patients and health practitioners, lower individual morbidity of tension-type headache, and lack of medical referral system in our country. More epidemiological data are needed to test these explanations. The majority of the patients reporting headaches belonged to lower socioeconomic groups. This is consistent with the findings of Holstein et al. who thoroughly studied the association between socioeconomic status and the frequency of headaches among adolescents. The prevalence of frequent headaches among adolescence increased with decreasing socioeconomic status [12]. However, the association between socioeconomic status and headaches is still an understudied issue. More studies are needed to establish a statistical interaction between the frequency of headaches and socioeconomic factors.

Assessments from the HIT-6 score showed that most of the patients were affected to a severe degree [13, 14]. The literature review also suggests that the amount of disability associated with tension-type headache is much higher than with migraine especially when measured as absence from work [15]. Similarly, Edmeads et al. in their population survey, reported that at least three-quarters of both migraine and tension-type headache sufferers had impaired relationships with their families and partners. About 50 % of the subjects in this study believed that headaches influenced their families, and 35 % of the sufferers indicated that headaches influenced their social plans [16]. Increasing awareness and improving the capability of primary care physicians to manage tension-type headache and migraine is likely to help decrease the associated burden. Stratification of HIT-6 score with various clinical and demographic features like age, marital status, socioeconomic status, quality of headache, site of headache, pulsatile/non-pulsatile feature, the frequency of headache, the severity of headache, and nausea showed a statistically significant relationship. Similar results were reported by Jelinksi et al. They conducted a study across five headache centers throughout Canada with a sample size of 865 patients. They concluded that the average age of the patients was 40 years with the majority of them being females. Most of the patients had headaches every day and the majority of the patients were diagnosed with either migraine or tension-type headache [13].

5. Conclusions

Patients seeking medical advice for headaches are mostly young to middle-aged married females of low socioeconomic status. Tension-type and migraine headaches are the most common clinical presentations of headaches. The impact of headaches on daily activities is associated the patient’s age, marital status, socioeconomic status, quality of headache, site of headache, pulsatile/non-pulsatile feature, frequency of headache, the severity of headache, and nausea. Follow-up studies to describe the epidemiology and burden of headaches and to find out the actual relationship of the aforementioned factors with HIT-6 score is still needed.

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