|Year : 2017 | Volume
| Issue : 3 | Page : 148-154
Prevalence of migraine, its effect, and some comorbid psychiatric disorders among female medical students at Al-Azhar University in Cairo
Eman Saif1, Reda El-Belbasy2, Zeinab El-Sayed Hammour2, Mahasen Mohamed2
1 Department of Neurology, Faculty of Medicine (For Girls), Al-Azhar University, Cairo, Egypt
2 Department of Community Medicine, Faculty of Medicine (For Girls), Al-Azhar University, Cairo, Egypt
|Date of Submission||06-Sep-2017|
|Date of Acceptance||03-Dec-2017|
|Date of Web Publication||22-Feb-2018|
Dr. Reda El-Belbasy
Community Medicine Department, Faculty of Medicine (For Girls), Al-Azhar University, Nasr City, Cairo, 1074
Source of Support: None, Conflict of Interest: None
The study on the importance of being mentally, socially, and physically healthy as a medical student is a deficient area in the scientific research in developing countries. Migraine has a negative effect on the general health as well as educational performance. Medical students, especially females, may be at a higher risk to manifest migraine associated with anxiety and/or depression.
The aims of this study were to determine the prevalence of migraine headache, to investigate its effect, and to assess some comorbid psychiatric disorders (anxiety and depression) among female medical students at Al-Azhar University in Cairo.
Participants and methods
A cross-sectional study was carried out on 599 female medical students from grade 1 to grade 6 at Faculty of Medicine for Girls, Al-Azhar University, Cairo, over a period of 1 month during the academic year 2014–2015. The studied female medical students were 18–26 years old. Through a self-administrated questionnaire, sociodemographic data were reported. In students without migraine with aura symptoms, the effects of migraine on daily activities, sleeping pattern, seeking of medical care, educational attendance, and influence on career decision were investigated. For each student, the reported migraine neurological symptoms were verified through meeting the International Headache Society (IHS) criteria for diagnosis, whereas comorbid psychiatric evaluation was assessed through the valid and reliable version of Neuropsychiatric Assessment by Hospital Anxiety and Depression Scale.
The reported migraine prevalence among the studied female medical students was 35.8%. The mean age of students having migraine was significantly higher than those without migraine (21.09±1.98 vs. 20.61±1.91 years) (P<0.05). Among the students having migraine, 70.2% reported reducing their usual daily activities during migraine episode, 53.5% reported poor sleeping pattern, and 58.6% were found to be felt obliged to attend educational activities despite their migraine symptoms. Seeking medical care was reported by only 20.0% of migraine students. The reported mean episodes of migraine per month was 5.11±4.47. Stress, noise, and menses were the most common triggers of migraine, as recorded by 83.7%. The prevalence of anxiety, depression, and mixed psychiatric disorders among students with migraine was found to be 23.3, 7.4, and 15.4%, respectively, as compared with 20.3, 4.4, and 7%, respectively, among nonmigraine group, without statistically significant differences between them (P>0.05).
Conclusion and future vision
The prevalence of migraine is considered high among the studied female medical students. It is found to be an important health problem because of its negative effect on diminishing students’ performance, disrupting their sleep, and implied stress. Anxiety and/or depression among medicals students with migraine as well as those without are urgent burdens that should be investigated more and targeted by health care providers. Curriculum should include stress-coping tools, counseling, and psychosocial support to reduce distress and severe effect of migraine on students’ well-being.
Keywords: depression, effect, medical students, migraine, prevalence, psychiatric comorbidity anxiety
|How to cite this article:|
Saif E, El-Belbasy R, Hammour ZE, Mohamed M. Prevalence of migraine, its effect, and some comorbid psychiatric disorders among female medical students at Al-Azhar University in Cairo. Al-Azhar Assiut Med J 2017;15:148-54
|How to cite this URL:|
Saif E, El-Belbasy R, Hammour ZE, Mohamed M. Prevalence of migraine, its effect, and some comorbid psychiatric disorders among female medical students at Al-Azhar University in Cairo. Al-Azhar Assiut Med J [serial online] 2017 [cited 2018 Oct 19];15:148-54. Available from: http://www.azmj.eg.net/text.asp?2017/15/3/148/226050
| Introduction|| |
Migraine is a common and major public health problem particularly among women of reproductive age . According to the WHO, migraine is ranked 19th among all diseases causing disability  and it is the 12th leading cause of years lived with disability among females of all ages worldwide .
Migraine is a complex neurological disorder characterized by recurrent episodes of headache, most often unilateral and in some cases associated with visual or sensory symptoms (aura). In most cases, however, migraine occurs as multifactorial inherited disorder. Therefore, different genes or loci may interact with factors intrinsic to the individual (e.g. the hormonal factor) and/or with exogenous factors (e.g. psychosocial stressors related to the family or to the working environment, geoclimatic changes, and certain foods) generating different clinical forms of the disease ,.
Since the establishment of the current diagnostic criteria of the IHS , several studies have shown that migraine is highly prevalent among university students, and it is associated with impaired academic performance and limited daily activities ,. Patients with migraine excessively report a lower quality of life than do those without migraine. Moreover, their physical health, mental health, and social functioning are also affected . Despite these adverse effects, available data about headache epidemiology in general are scarce, and migraine is underdiagnosed and undertreated in developing countries as well as in Egypt ,. So, studying some epidemiological aspects of migraine among medical students is of great importance, particularly with assessment of comorbid psychiatric conditions and by using valid self-reporting tools. We hypothesized that female medical students in Al-Azhar University may be at a higher risk of having migraine.
| Aims|| |
The main objectives of this study are as follows:
- Determine the prevalence of migraine headache among female medical students at Al-Azhar University in Cairo.
- Investigate its effect.
- Assess some comorbid psychiatric disorders (anxiety and depression) among the female medical students.
Participants and methods
A cross-sectional study was conducted in the Faculty of Medicine for Girls, Al-Azhar University, Cairo, during the academic year 2014–2015, and the data were collected over a period of 1 month. Based on a previous study ; sample size was calculated according to the following equation of Cochran .
where P is the prevalence of migraine=16.1% (according to a meta-analysis study , Z=1.96 (for 95% confidence level), D (design effect)=2, and L (limit of precision)=0.05. The resultant sample size was 413. To yield a more certain prevalence of migraine, the sample size was increased to 610 to represent 25% of the total number of female medical students (2338). They were selected randomly by a randomized stratified sampling technique and drawn by the sum of proportional allocation from every stratum (i.e. from grade 1 to grade 6).
A total of 599 students completed and returned the questionnaires, representing a response rate of 98.2%.
Inclusion and exclusion criteria
The following were the applied inclusion and exclusion criteria:
- The students who having a history of chronic medical conditions such as diabetes mellitus, hypertension, dental problems, sinusitis, and unrepaired refractions of errors were not included.
- Those diagnosed and/or under psychiatric condition treatment were also excluded.
- Otherwise, all female medical students at the Faculty of Medicine for Girls, Al-Azhar University in Cairo were eligible for the study.
Study tools and data collection
The following study tools to collect data were applied:
- A self-administered questionnaire focusing on the participant’s sociodemographic data. Effect of migraine on their educational attendance, daily activities, sleeping pattern, and medical career choice was assessed. Family history of migraine, duration of suffering, accompanying migraine triggers, seeking medical care, and medication use were also enquired.
- For diagnosis of migraine without aura, each student who reported migraine symptoms, her sheet was verified as meeting the IHS criteria for diagnosis , which was evaluated as highly reliable in previous studies ,,.
- For psychiatric comorbidities, separate assessments of anxiety and depression as well as comorbid psychiatric disorders (i.e. mixed anxiety and depression) were done by Hospital Anxiety and Depression Scale . The scale is from 0 (lowest) to 21 (highest).
The total score of the previous scale was classified as follows:
Normal score from 0–7.
Borderline score from 8–10.
Diseased or abnormal score from 11–21.
The validity and reliability of these questionnaires have been confirmed as they were used before in a previous study .
- All the selected female medical students were personally interviewed for explaining the nature and objectives of the study.
- They were requested to participate with strict confidentiality and based on voluntary consent.
- The study was approved by the ethical committee of the Faculty of Medicine for Girls, Al-Azhar University (Cairo, Egypt).
- The statistical package for the social sciences (version 16; SPSS Inc., Chicago, Illinois, USA) was used for data entry and analysis.
- Descriptive statistics were presented as numbers and percentages.
- To assess the significance in the observed differences between groups, χ2-test was used for qualitative data, whereas the independent t-test was used for quantitative data.
- Multiple logistic regression analysis was also used.
- P values were taken at a significance level of 0.05 and 95% confidence limit.
| Results|| |
According to the IHS classification, 215 of the 599 studied female medical students fulfilled the criteria for migraine, with a prevalence rate of 35.89%. Although 384 (64.11%) students had no migraine, they may have reported other forms of headache.
[Table 1] shows the sociodemographic characteristics and migraine family history of the studied sample.
|Table 1 Sociodemographic characteristics and migraine family history of the studied sample|
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The criteria of migraine were fulfilled by 215 students of the total studied sample, representing a prevalence rate of 35.89%. The mean age of students with migraine was higher (21.09±1.98 years) than those without (20.61±1.91 years), signifying that older age students were more affected among the migraine group. Those aged more than 21 years to less than 24 years represented 41.4% of migraine group versus 35.4% of students without migraine, and those who were 24 years and older accounted for 13% in the migraine group versus 8.6% students without migraine.
Regarding the distribution by educational grades, more than one-third (36.7%) of students who fulfilled the migraine criteria were in the more advanced grades (the grades 5 and 6) as compared with 23.2% of those without migraine, and early grade students (grades 1 and 2) represented 35.4% of those with migraine compared with 44.5% of those without. The presence of family history of migraine was reported among 63.7% of students with migraine versus 50% of those without.
The differences between migraine and nonmigraine groups were statistically significant regarding age, educational grade, and family history (P<0.05). However, marital status and residence did not show statistically significant differences between both the groups (P>0.05).
[Table 2] illustrates some related effects of migraine. Overall, 70.2% of students with migraine reported inhibited daily activities. Students seeking medical care for migraine illness formed 20% of the migraine group and those taking prescribed specific drugs represented only 10.2%, whereas 70.3% of all students in the migraine group were on NSAID. Traditional medication was used by 19.5% of the students in migration group. Moreover, poor sleeping pattern was recorded among 53.5%. Moreover, 58.6% of students were keen to attend their educational activities despite experiencing migraine. Medical career choice was recorded by only 26% as a result of their migraine experience.
[Table 3] reveals some comorbid psychiatric disorders among the studied sample. Migraine group reported relatively high borderline and diseased anxiety scores, 40 and 23.3%, respectively, as compared with 34.1 and 20.3%, respectively, among the nonmigraine group. Depression (borderline and diseased) scores were found to be 26.1 and 7.4%, respectively, among migraine group as compared with 24.5 and 4.4%, respectively, among the nonmigraine group. Mixed cases of anxiety and depression constituted 15.4% of students with migraine compared with 7% of nonmigraine group. These observed differences between both groups were statistically insignificant (P>0.05).
[Table 4] presents the data about triggers and factors that worsen migraine, and it reveals that 83.72% of migraine group had triggers, in the form of stress, menses, noise, and certain foods, that worsened migraine. Moreover, routine physical activity worsened migraine in 83.25%. Mean attack duration of migraine was 4.82±15.89 h, and the mean numbers of episodes per month was 5.11±4.47.
|Table 4 Triggers and factors aggravating migraine and episode description among migraine group|
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[Table 5] reveals that age, routine physical activities, and migraine family history were important significant predictors of migraine among the studied female medical students (P<0.05).
|Table 5 Multiple logistic regression analysis of factors affecting migraine|
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| Discussion|| |
The current study was conducted on 599 female medical students in the faculty of medicine for girls, Al-Azhar University, Cairo. The reported migraine prevalence was 35.89%. A similar prevalence rate was reported among American female medical students (35%) . Even though migraine prevalence has great variation from 11 to 46% among medical students worldwide ,, similar prevalence rates, close to ours, of 25.7, 28.7, and 27.9% were reported among medical students in Saudi Arabia, Al-Kuwait, and Nigeria, respectively ,,. However, migraine prevalence rate in a meta-analysis study  was only 16.1%.
These variations may be attributed to several factors, including composition of the study group, which in the current study was entirely females, who predominantly have a high migraine prevalence rate, which might be related to hormonal factors ,; the high awareness of migraine among medical students, which may result in an increased self-reporting of migraine symptoms; and diverse methodologies used . However, a study done in Al-Quseir City (Red Sea Governorate, Egypt) reported a prevalence rate of only 2.8% in the general population older than 8 years , and it was speculated that headache in general is still underestimated and under-recognized in Egypt .
Effect of migraine and factors aggravating its occurrence
The results of this study support that migraine has a combination of negative effects on the medical students, as two-thirds (70.2%) of the students with migraine reported inhibition of their daily activities. In agreement, Smitherman et al.  found that more than 80% of the medical students had reduced productivity during episodes. Migraine was ranked among the top ten causes of disabilities that interfered with activities of daily living and caused lifestyle restrictions . Moreover, migraine was also associated with a profound negative effect on educational performance .
However, in the present study, 58.6% of the students with migraine were keen to attend their educational activities despite their migraine. The mean episodes of migraine per month was 5.11±4.57. In accordance to this finding, a study reported that 76% of medical students felt forced to attend educational classes regardless of their severity of symptoms, which impaired performance . Moreover, a recent study demonstrated that most participant students reported that their educational performance and ability to attend sessions were affected during migraine attacks .
Moreover, choice of medical career was not influenced by migraine headache in 74% of students with migraine in the present study. This finding was supported by an earlier study , in the sense that students do not let the pain direct their career decision. Furthermore, poor sleeping pattern owing to migraine attacks was existent among 53.5% of the studied students with migraine, which could precipitate migraine episodes in a vicious circle. Beside lack of sleep, augmented stress and/or excessive exposure to triggers such as noise, certain food, and menses were the most common triggers worsening migraine. In the current study, at least one trigger was reported among migraine students (83.7%), which coincides with the literature studies ,,,. They showed that approximately 50–72% of medical students with migraine reported stress and/or lack of sleep as specific triggers. This could be explained by the fact that medical students face the challenges of the medical education, including the rigidity of the educational program, and emotionally tense experiences, such as dealing with illness, disease, and dying . On the contrary, the current study revealed a significant increased migraine family history among migraine group (63.7%) as compared with the nonmigraine group (50%).
A family history of migraine was also found to be the most potent and consistent risk factor for migraine, with two- to three-fold greater risk of migraine among relatives of people with migraine compared with controls ,,. In the present study, multiple regression analysis further confirmed that age, routine physical activities, and family history of migraine were significant predictors of migraine. Furthermore, the current results revealed undertreatment of migraine, as only 20% were keen to seek medical care, and 70.3% depended on analgesics, with the NSAI drugs being the most frequently used. However, 19.5% preferred rest and traditional medicine. Similar findings were reported as medical students with migraine were self-treated, mainly by simple analgesics, whereas specific drugs for migraine and tension-type headache were rarely used . Moreover, only 4.6% sought medical assistance, whereas 68.2% took nonprescription drugs . This scenario is especially alarming given the fact that they being medical students probably have knowledge of illness and easy access to self-medication.
The present study revealed unexpected results toward psychiatric disorders, that is, anxiety and depressive manifestations alone or mixed depression-anxiety disorders and borderlines. These comorbidities were found among students with migraine as well as those without migraine, with no statistically significant differences. Contradictory with this finding, was the increased risk of anxiety in migraine patients, which is even stronger than that between migraine and depression. This association has been observed in both clinic and community-based populations. Compared with individuals without migraines, migraineurs are at four to five times greater risk for generalized anxiety disorder ,,. Shared etiological factors and common determinants explain the co-occurrence of both entities . However, the prominent psychiatric symptoms among the students without migraine could be explained by the fact that medical students routinely have a combination of triggers, especially stress regarding examinations, high level of performance, and many years of education.
| Limitations|| |
This study has some limitations, including participant sample from only one medical university, which does not represent all female medical students; reliance on self-diagnosis of migraine; the subjective nature of some items; and inability to examine the students by a neuropsychiatrist.
| Conclusion|| |
The prevalence of migraine is high among female medical students. It has no influence on their medical career decision. Migraine substantially diminishes students’ performance, which worsens when associated with anxiety and/or depression. Psychiatric disorders were common among the studied female medical students with or without migraine.
- Owing to its negative effect, migraine should be targeted as an important health problem in research area among all medical students especially among those having psychiatric comorbidities.
- Migraine must be of concern among health care providers in a multidisciplinary context.
- Medical curriculum should include preventive approaches such as stress-coping tools, healthy lifestyle habits, and trigger management.
- Counseling and psychosocial support are needed to reduce suffering and serious effect on student well-being.
Deep appreciation for all the female medical students-Al Azhar University in Cairo who participate in the study. Without their approval to share, this work cannot be done.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bigal ME, Liberman JN, Lipton RB. Age-dependent prevalence and clinical features of migraine. Neurology 2006; 67:246–516.
World Health Organization and Lifting The Burden. Atlas of headache disorders and resources in the world 2011. Geneva: WHO; 2011.
Murray CJ, Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C et al.
Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the global burden of disease study. Lancet 2012; 380:2197–2223.
Kathleen R. Merikangas: contributions of epidemiology to our understanding of migraine. Headache 2013; 53:230–246.
Montagna P. Migraine genetics. Expert Rev Neurother 2008; 8:1321–1330.
Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 2nd edition. Cephalgia 2004; 24(Suppl 1):9–160.)
Al-Tayel S. Effect of migraine headache on academic performance and quality of life of female students at King Saud University, Kingdom of Saudi Arabia. Bull Alex Fac Med 2008; 44:503–509.
Al-Hashem JY, Ahmed SF, Raed A, Goadsby PJ. Migraine among medical students in Kuwait University. J Headache Pain 2014; 15:26.
Smitherman TA, McDermott MJ, Buchanan EM. Negative impact of episodic migraine on a university population: quality of life, functional impairment, and co-morbid psychiatric symptoms. Headache 2011; 51:581–589.
Mateen FJ, Dua T, Steiner T, Saxena S. Headache disorders in developing countries: research over the past decade. Cephalalgia 2008; 28:1107–1114.
El-Tallawy H, Farghaly W, Metwally N, Rageh T, Shehata GA, Badry R et al.
Prevalence of neurological disorders in Al Quseir, Egypt: methodological aspects. Neuropsychiatr Dis Treat 2013; 9:1295–1300.
Cochran WG. Sampling techniques. 2nd ed. New York, NY: John Wiley and Sons, Inc.; 1963.
Wang XH, Zhou JM, Sun YH, Xing YH, Zhu YL, Zhao YS. The prevalence of migraine in university students: a systematic review and meta analysis. Eur J Neurol 2016; 23:464–475.
Murat S, aysegul K, Onder K. Prevalence of migraine and the co-morbidity of psychiatric disorders among students at Cumhuriyet University. J Headache Pain 2013; 14:34.
Wade DC. Measurement of emotion and social interaction. In: Wade DC, editor. Measurement in neurological rehabilitation. Oxford, UK: Oxford University Press; 1992. pp. 261–263.
El-Mously L, El-Sawy M, Ekram F, Saif E. Clinical biogenetic neuro-physiological approach to idiopathic epilepsy among egyptian families [Thesis]. Egypt: Faculty of Medicine for Girls, Al-Azhar University; 2002.
Johnson H, Guhl G, Arora J, Walling A. Migraine in students of a US Medical School. Fam Med 2014; 46:615–619.
Ojini FI, Okubadejo NU, Danesi MA. Prevalence and clinical characteristics of headache in medical students of the University of Lagos, Nigeria. Cephalalgia 2009; 29:472–477.
Ferri-de-Barros JE, Alencar MJ, Berchielli LF. Headache among medical and psychology students. Arq Neuropsiquiatr 2011; 69:502–508.
Balarabe SA, Yunusa MA. Prevalence of migraine among medical students in Sokoto, North-Western Nigeria. Eur J Pharm Med Res 2016; 3:604–608.
Naglaa A, Mohamed M, Nevin M, Hatem S. Prevalence of primary headache disorders in Fayoum Governorate, Egypt. J Headache Pain 2015; 16:85.
Smitherman TA, Burch R, Sheikh H, Loder E. The prevalence, impact, and treatmentof migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache 2013; 53:427–436.
Leonardi M. Burden of migraine: what should we say more? Neurol Sci 2015; 36(Suppl 1):1–3.
Ibrahim NK, Alotaibi AK, Alhazmi AM, Alshehri RZ. Prevalence, predictors and triggers of migraine headache among medical students and interns in King Abdulaziz University, Jeddah, Saudi Arabia. Pak J Med Sci 2017; 33:270–275.
Elzubeir MA, Elzubeir KE, Magzoub ME. Stress and coping strategies among Arab medical students: towards a research agenda. Educ Health 2010; 23:355.
] [Full text]
Dzoljic E, Vlajinac H, Sipetic S, Marinkovic J, Grbatinic I, Kostic V. A survey of female students with migraine: what is the influence of family history and lifestyle? Int J Neurosci 2014; 124:82–87.
Sandra WH, Richard B, Lipton M. Psychiatric comorbidity of migraine. Headache 2006; 46:1327–1333.
Semiz M, Şentürk İA, Balaban H, Yağız A, Kavakçı Ö. et al.
.. Prevalence of migraine and co-morbid psychiatric disorders among students of Cumhuriyet University. J Headache Pain 2013; 14:34.
Evans RW, Rosen N. Migraine, psychiatric comorbidities and treatment. Headache 2008; 48:952–958.
Radat F, Swendsen J. Psychiatric comorbidity in migraine: a review. Cephalalgia 2005; 25:165–178.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]