159

ORIGINAL ARTICLE
Frequency, character and predisposing factor of headache among students of
medical college of Karachi
Tooba Noor,1 Ali Sajjad,2 Anoosha Asma3

Abstract
Objective: To evaluate the frequency, predisposing factors and symptomatology of headache among medical
students.
Methods: The cross-sectional study was conducted from September to December 2013 and comprised students of
two medical colleges of Karachi. International Classification of Headache Disorder-II criterion was used to diagnose
and classify headache. SPSS 17 was used for statistical analysis.
Results: Of the 413 medical students studies, 326(79%) had tension type headache, and 87 (21%) had migraine.
Headache was more frequent among females than males, with a ratio of 6.5:1. Both types of headache were
significantly associated with self-reported disturbed sleep pattern, stress and various triggering factors (p<0.05
each). Both types greatly influenced individual's daily life with significant association with avoiding academics,
extra-curricular activities, family and friends (p<0.05 each). High self-medication rate of 400(96.9%) was observed.
Conclusion: The prevalence of headache among medical students was high with female predominance. Infrequent
consultation needs to be addressed through awareness programmes.
Keywords: Headache, Migraine, Medical students, Tension-type headache, Frequency. (JPMA 66: 159; 2016)

Introduction 40.17%7 with the prevalence of TTH ranging from 12.2%6

Headache, or its medical term "cephalgia", is one of the to 44.16%.8
common medical ailments that is not only considered a As the mechanisms of migraine and TTH are still ill-
nuisance but also has a negative impact on the quality of defined, epidemiological studies on specific populations
life, making the person too ill to perform his routine daily are needed to help clinicians and researchers find the
activities properly.1 World Health Organisation (WHO) has origin, several associated factors, characteristics and
ranked headache among the top 10 disabling conditions, pattern influencing the frequency of headache as well as
worldwide. The global prevalence of active headache various options of management.5 In addition, a high level
disorder is 47% with Tension Type Headache (TTH) of self-medication with small percentage of patients
contributing 38%, migraine 10% and chronic headache visiting consultants is also found among headache
3%.2 Moreover, headache is the leading neurological patients, particularly younger generation in several
complaint presented by patients to general practitioner studies.4
and neurologists.3
Severe and frequent episodes of headache have a greater
Although headache is a prevalent disorder, especially impact on academic performance and quality of life, thus
among adolescents and young adults,4 but it is also bringing about limitation to daily activities and work, as
counted as the most common presenting complaints of well as significantly influencing students' personal and
medical students, predictably due to various physical and professional behaviour and ultimately academic records.9
psychological stress factors which medical students are Therefore, some studies have been conducted suggesting
more prone to facing as opposed to general population the contribution of headache in reducing student's
and other groups of specific population.5 Considering this academic performance, but many factors co-exist,
fact, medical students have been the target of several interfering with student's academic performance at
epidemiological surveys dealing with headache and its professional level. However, it is important to rule out if
high prevalence among the population. The estimated headache is associated with worse academic
prevalence rate for migraine ranged from 12.2%6 to performance due to widespread prevalence in this
population.10
1,2Civil Hospital Karachi, Dow University of Health Sciences, 3Medical Student, Though distribution of different types of headache varies
Sind Medical College, Jinnah Sindh Medical University, Karachi. with environmental, socio-demographic, lifestyle and
Correspondence: Tooba Noor. Email: dr.toobanoor@gmail.com genetic aspects, very little data is available on headache

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Frequency, character and predisposing factor of headache among students of medical college of Karachi 160
epidemiology in Pakistan, especially in the light of recent examination or imaging was done.
classifications and definitions of International Headache
Society (HIS). Thus, the current study was planned as an Data collected was managed and analyzed using SPSS 17.
epidemiological survey with the aim of evaluating the Mean and Standard deviation were evaluated for
frequency of TTH and migraine headache among medical continuous data, and for categorical data frequency and
students with comparison in predisposing factors, percentage were calculated. Correlations among variables
symptomatology, health seeking behaviour and relation were explored using Chi square test. Multiple response
with studies. analysis was used in some variables due to multiple
choice queries (MCQs) in the questionnaire. Threshold of
Subjects and Methods significance was set at 0.05.
The cross-sectional study was conducted from September
to December 2013 and comprised medical students at
Results
two medical colleges of Karachi; Dow Medical College Initially, 430 medical students were enrolled. There were
(DMS) and Sindh Medical College (SMC). The sample size 372(86.5%) females and 58(13.4%) males with a female-
was estimated through Open Epi Version 2.3.1, keeping to-male ratio of 6.5:1. The overall mean age was
anticipated frequency 61% and was found to be 366 at 20.64±1.68 years (range: 17-26 years). Applying ICHD-2
95% Confidence Interval (CI).11 Study population was criteria, 326(79%) were diagnosed as TTH and 87(21%) as
raised using convenient sampling technique, from migraine. Of the total, 17(4%) were atypical and could not
medical students of First to Final year who had at least one be classified as either TTH or migraine, and were excluded,
episode of headache during the preceding six months. leaving the final study sample to be 413(96%); 238(57.6%)
from SMC and 175(42.4%) from DMC; and 111(26.9%),
A semi-structured questionnaire was developed to record 43(10.4%), 63(15.25%), 93(22.5%) and 103(24.9%)
demographic details, headache pattern, associated students from First, Second, Third and Final years. Overall,
factors, family history, prior illness, relation with studies 118(28.57%) students had suffered recurrent headache
and management. The International Classification of i.e. more the 5 episodes in the preceding six months.
Headache Disorder (ICHD) Version 2 for TTH and migraine
was used for diagnosis.12 Subjects who did not fall under Both types of headache were found more frequent in
one of the two categories were excluded. Diagnoses were females with 280(85.9%) having TTH and 77(89.5%)
based on headache characteristics. No physical migraine. Gender and age, however, had statistically

Table-1: Headache Characteristics.

Variables Overall (n = 413) Tension (n = 326) Migraine (n = 86)

Gender Male 55 (13.3%) 46 (14.1%) 9 (10.5%)

Female 358 (86.7%) 280 (85.9%) 77 (89.5%)
Symmetry Unilateral 272 (65.9%) 220 (67.5%) 53 (61%)
Bilateral 141 (34.1%) 106 (32.5%) 34 (39%)
Nature Persistent 73 (17.7%) 35 (10.8%) 38 (43.2%)
Temporary 340 (82.3%) 290 (89.2%) 50 (57.8%)
Severity Mild 107 (26%) 97 (30.7%) 10 (13.7%)
Moderate 237 (57.4%) 194 (61.4%) 34 (46.6%)
Severe 69 (16.7%) 25 (8.3%) 29 (39.7%)
Location* Right temporal 150 (20.3%) 110 (34.2%) 36 (41.9%)
Left temporal 133 (18%) 98 (30.4%) 31 (36.0%)
Parietal 97 (13.1%) 78 (24.2%) 18 (20.9%)
Frontal 247 (33.4%) 180 (55.9%) 55 (64.0%)
Occipital 67 (9.1%) 50 (15.5%) 12 (14.0%)
Face jaw 23 (3.1%) 17 (5.3%) 4 (4.7%)
Cervical 22 (3.0%) 17 (5.3%) 4 (4.7%)
Quality* Throbbing 112 (26.2%) 72 (22.1%) 37 (43.0%)
Aching 84 (19.8%) 70 (21.5%) 13 (15.1%)
Dull 135 (31.7%) 121 (37.1%) 14 (16.3%)
Sharp 42 (9.9%) 27 (8.2%) 6 (7.0%)
Tight band 53 (12.4%) 36 (11.0%) 16 (18.6%)
*Multiple response analysis used - individual response may not sum up to actual sample size.

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161 T. Noor, A. Sajjad, A. Asma

Table-2: Risk factors. Table-5: Academic problems.

Variables Tension N (%) Migraine N (%) p-value Variables Tension N (%) Migraine N (%) p-value

Sleep disturbed Yes 33 (10.12%) 19 (22.1%) 0.003 Feel absent minded in class Yes 189 (58.0%) 63 (73.3%) 0.009
No 293 (89.88%) 67 (77.9%) No 137 (42.0%) 23 (26.7%)
Stress Yes 173 (53.6%) 35 (40.7%) 0.03 Bunk class due to headache Yes 63 (19.3%) 28 (32.6%) 0.008
No 150 (46.4%) 51 (59.3%) No 263 (80.7%) 58 (67.4%)
Weakness in eyesight Yes 167 (51.2%) 52 (60.5%) 0.126 Academic performance
No 159 (48.8%) 34 (39.5%) towards downfall Yes 45 (13.8%) 21 (24.4%) 0.017
Family history Yes 73 (22.5%) 27 (31.4%) 0.08 No 280 (86.2%) 65 (75.6%)
No 252 77.5% 59 68.6% Avoid Extracurricular activities Yes 14 (4.3%) 11 (12.8%) 0.003
No 312 (95.7%) 75 (87.2%)
Retake exam due to headache Yes 15 (4.6%) 6 (7.0%) 0.519*
Table-3: Triggering factors. No 311 (95.4%) 80 (93%)
*Via Fischer exact test, but insignificant.
Variables Tension N (%) Migraine N (%) p-value

Loud Noise Yes 79 (24.2%) 34 (39.5%) 0.004

No 247 (75.8%) 52 (60.5%)
Bright light Yes 31 (9.5%) 18 (20.9%) 0.003
No 295 (90.5%) 68 (79.1%)
Anxiety Yes 105 (32.2%) 38 (44.2%) 0.037
No 221 (67.8%) 48 (55.8%)
Hot weather Yes 123 (37.7%) 36 (41.9%) 0.484
No 203 (62.3%) 50 (58.1%)
Exams Yes 107 (32.8%) 32 (37.2%) 0.440
No 219 (67.2%) 54 (62.8%)
Menstrual cycle (females only) Yes 28 (10.0%) 7 (9.1%) 0.812
No 252 (90.0%) 70 (90.9%)

Table-4: Social factors.

Variables Tension N (%) Migraine N (%) p-value

Social / extracurricular
activity affected Yes 61 (18.7%) 39 (45.3%) <0.001 Figure: Treatment preferences.
No 265 (81.3%) 47 (54.7%)
Avoid extracurricular activities Yes 14 (4.3%) 11 (12.8%) 0.003
No 312 (95.7%) 75 (87.2%)
Avoid family and friends Yes 15 (4.6%) 10 (11.6%) 0.015 or pulsating type of pain 37(43%) and severe in intensity
No 311 (95.4%) 76 (88.4%) 29(39.7%) (Table-1).
Want to stay alone Yes 42 (12.9%) 29 (38.2%) < 0.001
While estimating predisposing factors, statistically
No 284 (87.1%) 57 (66.3%)
Avoid parties Yes 18 (5.5%) 7 (8.1%) 0.365 significant association of type of headache was found
No 308 (94.5%) 79 (91.9%) with disturbed sleep pattern and social stress (p<0.05
each) but not in terms of family history and eyesight
weakness (p>0.05 each) (Table-2). Several triggering and
social factors related to headache were also analysed and
insignificant associations with the types of headache significant association was found in relation to noise,
(p>0.05 each). Most frequent attributes of headache were light, anxiety, and extra-curricular activities (p<0.05 each)
unilateral 272(65.9%), temporary in nature 340(82.3%) (Table-3)
and moderate in intensity 237(57.4%). Using multiple
response analysis (due to overlapping response) results In terms of quality of social life, significant association was
also yielded headaches to be more frequently dull in found between headache type and all the parameters
135(31.7%) students, frontal in location 247(33.4%). evaluated (p<0.05 each) except when it came to avoiding
Students with migraine had more commonly throbbing parties (p>0.05) (Table-4).

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Frequency, character and predisposing factor of headache among students of medical college of Karachi 162
When analyzing the relation of headache with studies, This might be due to the fact that prevalence of stress
191(46.2%) students reported that their headache got seemed to be high among medical students. Academic
worse after admission to medical school, while burden, workload, sleep deprivation and increased
182(44.1%) reported an increase in the frequency of psychological pressure are assumed to be major "stress
headache during exams. Duration of studying hours did factors" for medical students which not only affect their
not yield any significant association with either frequency medical performances, but also all aspects of health.
of headache or type of headache (p>0.05 each). Studies suggest that amount of disability associated with
TTH on a social level is much greater than that of
When it came to quality of academic life, statistically
migraine, especially when measured as absence from
significant relationship was in almost all variables (p<0.05
work.23 This might be the possibility that social stress and
each) except exam retake due to headache (p>0.05)
sleep deprivation were found to be the most common
(Table-5).
triggering factors with significant association in our study
Overall therapeutic aspect seemed to be very comparing it with other studies that also have similar
disappointing with high self-medication rate. Only 13 associations.13,14 Minimising stress, getting enough sleep,
(3.1%) of them sought medical advice and visited regular exercise, increasing awareness and improving the
consultants of the field, while 400 (96.9%) did not. None of quality of care are proved to be helpful for patients with
them sought emergency treatment (Figure). Analgesics TTH. Several triggering and social factors which a
remained the most preferable therapeutic choice in common man is readily exposed to in his routine life were
169(41.0%) cases, followed by tea/coffee/joshanda also analysed and found significant, but, surprisingly we
144(34.8%), massaging 74(18%) and specific medicine failed to find any comparable literature as most of studies
14(3.5%). have not highlighted the other side of the picture.

Discussion Our study demonstrated female students to have higher

Headache disorder is a common complaint among all age frequency of TTH compared to male.5,17 A large part of
groups and recurrent headaches cause significant female students' contribution in the sample size could be
problems to individual's life as well represent a burden on the possible reason for this. However, the prevalence of
society. It also affects student's social and academic life. migraine is compatible and supported by other
This is the first detailed study of frequency, characteristics studies14,18,21 and equally common among females as that
and pattern of headache disorder in Pakistan with its of TTH.
characteristics classified and diagnosed under ICHD-2
The study was unable to find any significant linkage of
among medical students.
headache with family history compared to other studies
Regarding estimated frequency of headache in local reporting strong association and high prevalence of
literature, prevalence of headache in the study population headache in family especially those of migraine.1,17 A
was 85.5%11 and 76.1%13 in earlier studies. Similarly, higher prevalence of family history among migraine
neighbouring countries reported the same result ranging patients highlights the role of genetics. Migraine is a
from 43.8%14 to 68%.15 Several studies that have chosen polygenic disease i.e. several genes have minor
medical students as a target population represented contributions to its pathophysiology and genetic
similar observations of high prevalence of headache predisposition combines with environmental triggers to
ranging from 46.0% to 96.8%.16-19 cause clinical symptoms. The search for genes that
predispose to migraine has not yielded uniform results to
As reported in most of the studies, a general as well as date most likely due to heterogeneity of patients studied
classification-based high frequency of headache among and lack of a reliable endophenotype to classify the
women is also reported in our study compared to their disease.24 A probable reason for insignificant association
male counterparts.18-20 TTH was found to be the more and relatively lower frequency of positive family history
common type of headache compared to migraine, again could be the higher prevalence of TTH which is actually
supported by many national and international studies. In associated with certain personal, psychological, social and
the current study, TTH accounted for 76%, which is environmental conditions. A wide-spectrum, multi-
comparatively higher than those in the majority of similar centred general population-based study is needed to
studies20,21 but comparable with the reported rates of explain any definite racial or genetic association.
56.3%13 and 64.7%22 among Brazilian medical students. A
study at Kenyatta National Hospital, Nairobi, reported it to An overall character of headache found in our study is
be 50%.16 comparable to that reported earlier,11 both having

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163 T. Noor, A. Sajjad, A. Asma

moderate pain on frontal location and less than 3 despite the fact that each medical school is affiliated with
episodes of headache as a leading presentation. As a teaching hospital that runs a daily outpatient
defined by IHS, migraine is commonly unilateral, department. A relatively light severity of headache could
pulsating and moderate to severe in intensity and is be the possible reason for this as most of the students
associated with nausea and photophobia and experienced headache of mild to moderate intensity. Also,
phonophobia. TTH is characterised as bilateral, analgesics and over-the-counter drugs are very easily
pressing/tightening in quality, mild or moderate in available and frequently self-abused by amateur doctors.
intensity and is usually not aggravated by routine physical Likewise, in other studies,1,17 analgesics remained the
activities. Almost, two-third of patients (60.5%) of most preferable choice amongst medical students
migraine in our study reported unilateral headache, with (42.0%) followed by non-medical therapeutics. Less than
43% of them having throbbing pain with moderate to 4% participants used specific drugs for headache. The rare
severe intensity almost parallel with IHS criteria and usage of specific medicines or analgesics and rare
supported by one study.14 Similarly, dull pain with consultation visits among one of the most educated
moderate intensity of TTH patients in our study was classed of society point to a non-serious and careless
according to IHS , but unilateral location in two-third of attitude towards health and inadequacies in the
patients is contrary to ICHD-2. The finding, however, is management of headache in our study population.
supported by prior studies.1,14 Hence, variations are Similar observations are expected in different specific
expected irrespective of target population, sample size populations of society. Educational programmes are,
and place of study. therefore, required for patients to recognise the
importance of effective migraine treatment.
Several studies suggest that there is a reduction in
academic performance with headache. We found Headache disorders deserve more attention. Adequate
comparable results with regard to absenteeism, academic primary prevention, timely diagnosis and appropriate
performance and headache interfering with treatment would be helpful to reduce the burden. These
daily/extracurricular activities with significant relation strategies can be assessed by examining frequency
with absenteeism and academic performance as distribution, identifying probable predisposing factors,
proposed earlier.10 But, we could not find any significant duration, intensity and headache-related disability.
association with number of failures or retake exams due Apart from possible cultural, regional and genetic
to headache as found by an earlier study.10 What were differences in the prevalence of headache, the study
actually associated in our study with student's academic design and methodology affected its reported
problems were the type, intensity and frequency of prevalence. One of the limitations of our study was the
headache, not the repercussions which is contrary to the self-reported questionnaire-based survey strictly using
earlier study10 which reported, "the greater is the diagnostic criteria of IHS without physical examination
repercussions, the greater is the absenteeism". As a matter and imaging. Moreover, the questionnaire did not take
of fact, information about headache and student's into account headaches other than migraine and TTH and
academic problems in our study were collected in a single those with more than one form of headache. This could be
moment in time. Therefore, it is not logical to affirm a the reason of high frequency of TTH in the study
causal relation between headache and student's worse population. Also, the migraine was not further classified
academic performance, but still further work-up in the as defined by IHS and represented the data of both
subject is needed to be done. The study also probable and definite migraine combined.
demonstrates that despite high frequency of headaches,
daily life activities continued, but the reasons for Our study represents the headache frequency of only two
continuation of activities were not evaluated and could large medical schools of Pakistan and may not represent
not be established. The reason may be higher proportion the entire community. Further epidemiological studies on
of TTH which had moderate severity and high use of small and specific populations as well as general
analgesic to relieve the headaches. population surveys are recommended.

With high prevalence and high rate of disability due to Conclusion

headache, a very high rate of self-medication is also There was a high frequency of headache among the
prevalent. A very little portion i.e. 3.1% visited consultants medical students. TTH was more common than migraine.
for medical advice. It was comparable to 2%13 and 5%1 Social stress and sleep deprivation were significant
prevalence of medical assistance for headache reported, factors. A large majority of students indulged in self-
but much lower than 23.3% students of Oman.17 This is medication. The results of the study should be used to

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Frequency, character and predisposing factor of headache among students of medical college of Karachi 164
improve the knowledge of treating headache in medical Students at Fatima Memorial College, Lahore Pak J Med Health Sci.
schools. 2010; 4: 542-3.
12. Headache Classification Subcommittee of the International
Headache Society. The international classification of headache
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