Discussion
The prevalence of migraine in our study was 17.6% (12.5% with aura and 5% without aura), in comparison with the prevalence of migraine worldwide which was 10%.5 We found that migraine prevalence among medical students was high. Several studies from Ethiopia,14 Saudi Arabia,16 Kuwait18 and Russia15 support our conclusion, but the difference in prevalence among the studies is due to the difference in the methodology, because we used a self-reported questioner and we did not confirm the diagnosis by clinical examination. Moreover, we did not include all types of headache. Sampling criteria and the diagnostic parameters should be considered.19 Emotional stress, poor sleeping and eating habits are all influencing medical students more than other people.18 Females have higher rate for migraine prevalence (21.4%) in comparison with males (13.2%), which is similar to the worldwide migraine prevalence and female medical students’ prevalence.5 16 TTH prevalence was 18.6% (17.2% episodic TTH and 1.5% chronic TTH), which is lower than TTH prevalence worldwide 38%1 5 ; we suspect that methodological differences could explain the difference result. Our results are close to the results of a Turkish study 20.35% (18.84% episodic TTH and 1.88% chronic TTH)20; probably because of geographical and cultural similarities between Turkey and Syria. Moreover, the methodology in the Turkish study was similar to our study.
Medical students have higher rate of headache 61% in comparison with pharmaceutical students 45.4% and dental students 46.3%; this could be due to stressful life of medical students and lack of free time. The medical system in Syria sorts students into clinical specialties according to their desires (based on their academic grades). Because of this system, there is high competition among students to get seats in clinical specialties, which make medical students in a permanent stress situation to study more and get higher marks. This competition does not exist in the faculties of pharmacy and dentistry.
The prevalence of headache according to students’ academic year is not compatible with the results of other studies16 18; this result is may be due to the differences among educational systems at other universities.
Employed students have lower rate of headache 44% in comparison with unemployed students 60.1%. This may be due to difficult economic situation in Syria. Employed students have better financial state and the poor economic state increase both migraine and TTH.15
Rural areas were associated with a lower prevalence of TTH (13.7%) in comparison with urban areas (19.1%), which reflects the effect of stressful life in the cities.
Smoker students are less likely to have TTH (10.5%) in comparison with non-smoker students (19.8%); smokers assume that smoking relieves stress.21
In migraine, 48.2% of the participants report a family history of headache and 33% of participants with TTH have a family history. Several studies have close results.8 14 16 20
93.7% and 86% of participants with migraine and TTH, respectively, report that headache interfered with their daily life activities. In a Saudi study, migraine affected on 85.1% of the participants, but TTH affected only 4.5% of participants.16 However, a Turkish study revealed that TTH affected on the educational performance of 12.4% of participants.20
89.3% of participants with migraine report about trigger factors and 79.5% of participants with TTH report about them. The most common trigger factors for migraine were noise, lack of sleep and exams. While for TTH: stress, lack of sleep and exams were the most common triggers. Stress, lack of sleep and emotional upset were the most common triggers in other studies.14 16 18 21 However, exams period often associates with stress. In general, lack of sleep, which associated with long time studying, and exams were the most common trigger factors for headache; these two factors are more common in medical students.
94.6% of the participants have accompanying psychological symptoms. The main psychological symptoms associated with both migraine and TTH are: depressed mood, anxiety, dissatisfaction with educational performance and stress. Kurt elucidates the relationship between headache and depression.21
15.9% of the participants seek for medical consultation (24% of participants with migraine and 13.8% of participants with TTH). We found a similarly low rate of medical consultations in other studies: 3.1% in Pakistan22 (11.9% in patients with migraine and 12.4% in patients with TTH) in Saudi Arabia16 and 23.3% in Oman8; therefore, a large number of students are unaware of their condition. This result may be due to the students' confidence in their medical information, which prompted them to try treat themselves without seeking medical consultation, in addition to easy access to over-the-counter medicines.
66.4% of the participants took over the counter analgesics for their headache, personal choice was the main reason (58.3%) to take them. Only 19.3% of participants took a medication after they seek for physician’s advice. About 80.3%, 47.6% and 41% of participants took a medication for the headache in Oman,8 Turkey20 and Pakistan,22 respectively. Anyway, more studies should be conducted to confirm the success of the treatment. Financial state might be the reason for avoiding medical consultation due to the high poverty rate because of crisis in Syria. Also, the health system in Syria has been affected by crisis which makes it difficult to access medical services.
81.6% of participants took the analgesic less than 7 days a month and only 26.7% of the participants raised the dose to control the headache which explains the low rate of medical consultations. Desouky et al found that the frequency of using analgesics was less than daily to weekly in 93.8% of patients with migraine compared with 38.9% in patients with TTH.16
Paracetamol was the most used analgesic (91.1%); other studies found similar result.14 16 18 A very low number of participants (3.2%) use a preventive medication. This was due to low rate of medical consultations. Most of our results are not statically significant, but that might be due to the difference in participants numbers in the three faculties.
Limitations and strengths
We relied on diagnostic criteria of ICHD-III to ensure the diagnosis of all patients with headache in the most optimal way. Furthermore, our study is considered the first Syrian study assessed headache among medical, dental and pharmaceutical undergraduate students. On the other hand, using self-reported questionnaire may lead to recall bias. We recommend to perform more longitudinal studies because our study is a cross sectional which means that there is no cause–effect relation among variables. Also, we depended on participants’ self-reports to determine psychological disorders such as: depression and anxiety without using strict criteria. There was no clinical examination to confirm the diagnosis of the headache. Another limitation was the heterogeneity of the participants among faculties, where the number of students was the largest in faculty of medicine, so we recommend to perform more studies with higher number of students from the other faculties.