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.

Table 1: Analysis of age.

Figure 1: Distribution of age.

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

Table 3: Attending physician’s diagnosis.

HIT- Headache Impact Test

Table 4: Analysis of HIT-6 score.

HIT- Headache Impact Test

Figure 2: Distribution of HIT-6 score.

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.

References

1. World Health Organization, Lifting The Burden. Atlas of Headache Disorders and Resources in the World 2011. WHO, Geneva (2011).
2. Arnold M. Headache classification committee of the international headache society (IHS) the International classification of headache disorders, 3rd edition. Cephalalgia 38 (2018): 1-211.
3. Stovner LJ, Hagen K, Jensen R, et al. The global burden of headache: documentation of headache prevalence and disability worldwide. Cephalalgia 27 (2007): 193-210.
4. Leonardi M, Steiner TJ, Scher AT, et al. The global burden of migraine: measuring disability in headache disorders with WHO's classification of functioning, disability and health (ICF). J Headache Pain 6 (2005): 429-440.
5. Merikangas KR, Cui L, Richardson AK, et al. Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study. BMJ 343 (2011): d5076.
6. Jensen R, Stovner LJ. Epidemiology and comorbidity of headache. Lancet Neurol 7 (2008): 354-361.
7. Ahmed A, Khan UA, Khan RF, et al. Clinical aspects of headache. Ann King Edward Med Coll 5 (1999): 315-316.
8. Murtaza M, Kisat M, Daniel H, et al. Classification and clinical features of headache disorders in Pakistan: a retrospective review of clinical data. PloS One 4 (2009): e5827.
9. Yu S, Han X. Update of chronic tension-type headache. Curr Pain Headache Rep 19 (2015): 469.
10. Robbins MS, Lipton RB. The epidemiology of primary headache disorders. Semin Neurol 30 (2010): 107-119.
11. Ferrante T, Manzoni G, Russo M, et al. Prevalence of tension-type headache in adult general population: the PACE study and review of the literature. Neurol Sci 34 (2013): 137-138.
12. Holstein BE, Andersen A, Denbæk AM, et al. Persistent socio?economic inequality in frequent headache among Danish adolescents from 1991 to 2014. Eur J Pain 22 (2018): 935-940.
13. Jelinski SE, Becker WJ, Christie SN, et al. Demographics and clinical features of patients referred to headache specialists. Can J Neurol Sci 33 (2006): 228-234.
14. Shin HE, Park JW, Kim YI, et al. Headache impact test-6 (HIT-6) scores for migraine patients: their relation to disability as measured from a headache diary. J Clin Neurol 4 (2008): 158-163.
15. Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. J Epidemiol Community Health 46 (1992): 443-446.
16. Edmeads J, Findlay H, Tugwell P, et al. Impact of migraine and tension-type headache on life-style, consulting behaviour, and medication use: a Canadian population survey. Can J Neurol Sci 20 (1993): 131-137.