Keywords
Headache, Primary headache, Migraine, Misan
Headache, Primary headache, Migraine, Misan
Migraine is the most common chronic inherited neurovascular disorder. The onset of migraine is typically between 15 and 24 years of age1, and the prevalence is highest in patients aged 35–45 years, 75% of whom have moderate to severe headaches2,3. Diagnosis is based on clinical features, together with radiology images4. The majority of migraine patients experience temporary disability that affects their work and daily activities and, thus, their productivity and quality of life5–7. Regarding pathophysiology, the constriction and then dilation of cerebral blood vessels was believed, until 25 years ago, to cause the neurologic symptoms associated with a migraine8. In approximately 60 - 70% of patients with a migraine, the onset of the headache is preceded by a non-specific malaise and irritable feelings, such as euphoria, depression, food cravings, fatigue, hypomania, cognitive slowing, dizziness, or asthenia. These symptoms are called the migraine prodromes and may occur as early as 24 hours before the actual migraine9–11, followed by the “aura”, which is a focal neurological sign, and then a severe, throbbing headache with photophobia and vomiting12. About 15 - 20% of migraine patients experience aura within one hour of, or simultaneously with a headache13. The migraine aura consists of neurologic abnormalities, including visual loss, hallucinations, numbness, tingling, weakness, or confusion. The aura is due to the cortical spreading depression, a wave of abnormal electrical discharges that travels across the brain's surface and short-circuits the brain14. Furthermore, migraine is best conceptualized as a triad of a paroxysmal headache, nausea and/or vomiting, and an aura of focal neurological events (visual events)15. Patients with these three signs have migraine with aura (or “classical migraine”), while those with a paroxysmal headache (with or without vomiting) but do not have aura are classified as migraine without aura (or “common migraine”)16,17.
The aim of this study was to observe migraines clinically, leading to infer causality behind this disease, risk factors and triggers. Evidence gathered from this study will enable diagnosis of migraine and its probability to occur in persons who have similarity to patients observed in this study. We believe that early detection of these manifestations correlates with time and money saving on unnecessary investigations and medications used in management and treatment.
Outpatient-based prospective cross-sectional study, which was conducted in the Al-Sadder Teaching Hospital, Misan Province, Iraq, over nine years from 23rd January 2010 to 14th July 2018.
The total number of patients included in this study was 1510 and included all those that attended to outpatient clinics.
The cases were aged 12–50 years, of both genders, suffering from migraine headaches according to the criteria of the International Classification of Headache Disorders (ICHD-III b version)4,5.
Inclusion criteria were: 1–8 attacks over four weeks, attacks fulfilling the International classification of Headache Disorders migraine diagnostic criteria, and absence of secondary causes of headaches.
Exclusion criteria: migraine onset at age >50, headaches attributable to underlying organic disorders, or no migraine attacks during the four weeks of assessment (this is made case by case for each patient from the point of diagnosis till the end of the study).
All data were collected from participant records.
For all patients a full medical history and family history of migraine headaches was obtained, and a thorough clinical examination performed, including general examination, assessment of vital signs, Glasgow Coma Scale (GCS), neurological and physical examinations (as per the Seattle Children’s Hospital Research Foundation migraine general assessment pathway).
All participants were assessed by a standard questionnaire from the Migraine Relief Center and a 4-week headache diagnostic diary procedure (as per the Migraine Trust guidelines)4,18. Disability due to acute migraine attacks was determined using the Migraine Disability Assessment Scale (MIDAS) questionnaire.
We implemented standard descriptive statistics and data analysis using IBM SPSS Statistics Software (version 20.0, SPSS, Inc., Chicago, Illinois, USA). All p-values < 0.05 were considered statistically significant for on-sample t-test. Mean and standard deviation were used to present data.
Written informed consent was obtained from the patients or the parents/guardians of minors for those below age of 18 years, for participating in this study, and was conducted according to the ethical standards established by the 1964 Declaration of Helsinki. The Medical Ethical Committee of Misan University approved this study (code:270000425).
A total of 1,412 patients with a migraine headache were included, including 1,100 women (77.9%) and 312 men (22.1%); women/men ratio of 3.5:1. Median age ±SD was 21 ± 5.42 years. The mean age at first attack was 17 ± 4.91 years. About 30 ± 15.79 mean±SD of the patients reported a family history of migraine (Table 1).
Parameters | Type of a migraine *ICHD-3b Code | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
1.1 | 1.2 | A.1.3.2 | A.1.1.1 | 1.2.1 | 8.2 | A.1.3 | **Other | A.1.6 | 1.2.1.2 | Total | ||
Number (%) | 980(69.4) | 127(9) | 92(6.5) | 57(4) | 45(3.2) | 37(2.6) | 35(2.5) | 17(1.2) | 12(0.8) | 10(0.7) | 1412(100) | |
Age, years median ±SD | 23±7.01 | 19±1.93 | 28± 5.98 | 18±1.46 | 20±2.13 | 24±3.51 | 31±5.40 | 18±3.81 | 12±1.0 | 22±2.57 | 21±5.42 | |
Age at onset, years mean | 18 | 16 | 24 | 14 | 26 | 16 | 10 | 18 | 12 | 18 | 17±4.91 | |
Gender | Female | 780 | 94 | 66 | 57 | 25 | 27 | 7 | 26 | 12 | 6 | 1100(77.9) |
Male | 200 | 33 | 26 | 0.0 | 20 | 10 | 5 | 9 | 5 | 4 | 312(22.1) | |
Family history of migraine (%) | 40 | 60 | 30 | 2 | 30 | 20 | 30 | 20 | -- | 30 | 30±15.79 | |
Frequency days per month | 2 | 2 | 4 | 1 | 1 | 15 | 0.5 | 1 | -- | 0.5 | 2±4.63 | |
Duration of attack, hours median | 24 | 24 | 72 | 48 | 24 | 24 | 12 | 72 | -- | 4 | 24 | |
Nausea and vomiting (%) | 20 | 30 | 10 | 15 | 30 | 10 | 10 | 15 | 15 | 30 | 15 | |
Photophobia (%) | 15 | 20 | 20 | 5 | 30 | 20 | 15 | 20 | 15 | 30 | 20 | |
Other nonspecific symptoms (%) | 10 | 20 | 15 | 5 | 20 | 5 | 10 | 10 | 20 | 15 | 12.5 | |
Aura (%) | 0 | 70 | 20 | 2 | 50 | 20 | 2 | 20 | 2 | 60 | 27 |
*International classification of headache disorder-3 version beta 2013
1.1= Migraine without aura
1.2= Migraine with aura
1.2.1= Migraine with typical aura
1.2.1.2 =Typical aura without headache
A.1.3.2 Chronic migraine with continuous pain
A.1.3 Chronic migraine (alternative criteria)
8.2 Medication-overuse headache (MOH)
A.1.1.1 Pure menstrual migraine without aura
A.1.6 Episodic syndromes-Childhood periodic syndromes
**Other subtypes (Ophthalmoplegic ‘migraine’ Retinal migraine, Familial hemiplegic migraine (FHM), Sporadic hemiplegic migraine, Basilar-type migraine, Abdominal migraine, Benign paroxysmal vertigo of childhood)
Migraine without aura was the most common (69.4%) subtype. The mean frequency of attacks was 2 ± 4.63 days per month. The mean duration of attack was 24 hours. Nausea and vomiting, photophobia and other nonspecific symptoms were experienced by 15%, 20%, and 12.5% of the patients respectively, while the remaining patients experienced non-specific prodromes 1–1.5 hours before the attacks (Table 1). About 27% of the patients in this study experienced aura during the period of study, the most common being migraine with aura, but also aura without a headache and aura with migraine (Table 1).
Migraine prevalence rates per year in this study are shown in Table 2; migraine without aura was the highest recorded in 2016 as 73%, which is common subtype with the mean 67.6 ± 2.934. Migraine with aura, in 2012 recorded 10.2%. Chronic migraine with continuous pain presented in 7.5% in 2013, whereas prevalence of chronic migraine (alternative criteria) in 2014 was 3.4%. In 2013, migraine with typical aura recorded a high rate as 4.3%, but in 2010, it was reported 1.2% had typical aura without headache. The medication-overuse headache reported a high rate in 2013 as 3.7%. Pure menstrual migraine without aura, and episodic syndromes-childhood periodic syndromes reported high rates in 2018 as 5.5% and 1.8%, respectively. Finally, others subtypes of migraine present in 2017 with a high prevalence rate 2.3%.
Migraine ICHD-3B* Code | 2010 n= 169 (%) | 2011 n=170 (%) | 2012 n=157 (%) | 2013 n=161 (%) | 2014 n=175 (%) | 2015 n=172 (%) | 2016 n=160 (%) | 2017 n=174 (%) | 2018 n=109 (%) | Mean±SD |
---|---|---|---|---|---|---|---|---|---|---|
1.1 n=980 | 65 | 70.5 | 66 | 67 | 67 | 70 | 73 | 66 | 64 | 67.6±2.934 |
1.2 n=127 | 10 | 8 | 10.2 | 8.7 | 7.4 | 8.7 | 7.5 | 9.2 | 9.2 | 8.7±1.041 |
A.1.3.2 n=92 | 6.5 | 5.9 | 5 | 7.5 | 7.4 | 5.2 | 6 | 6.3 | 7.3 | 6.4±0.982 |
A.1.1.1 n=57 | 3.6 | 3.5 | 4.5 | 3.1 | 4.6 | 3 | 3.8 | 4.6 | 5.5 | 3.96±0.890 |
1.2.1 n=45 | 2.6 | 2.6 | 3.8 | 4.3 | 1.7 | 2.3 | 3 | 4 | 3.7 | 3.0±0.90 |
8.2 n=37 | 3 | 1.8 | 2.5 | 3.7 | 2.9 | 1.7 | 1.8 | 3 | 2.8 | 2.58±0.682 |
A.1.3 n=35 | 2.4 | 1.8 | 3.2 | 1.2 | 3.4 | 1.7 | 1.8 | 2.3 | 2.8 | 2.179±0.737 |
**Others n=17 | 1.2 | 0.6 | 0.64 | 1.3 | 0.6 | 1.7 | 1.3 | 2.3 | 1.8 | 1.271±0.594 |
A.1.6 n=12 | 1.2 | 0.6 | 0.64 | 0 | 1.5 | 1.2 | 0.6 | 0.6 | 1.8 | 0.84±0.558 |
1.2.1.2 n=10 | 1.2 | 0.6 | 0.64 | 1.3 | 0.6 | 0 | 0.6 | 0.6 | 0.9 | 0.71±0.294 |
Total n=1412 | 99.7 | 100 | 99.62 | 99.8 | 100 | 99.6 | 99.4 | 99.6 | 99.8 | 99.72±0.197 |
*International classification of headache disorder-3 version beta 2013
1.1= Migraine without aura
1.2= Migraine with aura
1.2.1= Migraine with typical aura
1.2.1.2 =Typical aura without headache
A.1.3.2 Chronic migraine with continuous pain
A.1.3 Chronic migraine (alternative criteria)
8.2 Medication-overuse headache (MOH)
A.1.1.1 Pure menstrual migraine without aura
A.1.6 Episodic syndromes-Childhood periodic syndromes
**Others subtypes (Ophthalmoplegic ‘migraine’ Retinal migraine, Familial hemiplegic migraine (FHM), Sporadic hemiplegic migraine, Basilar-type migraine, Abdominal migraine, Benign paroxysmal vertigo of childhood)
Visual aura was the most common (50%), while unilateral sensory symptoms, being second in frequency (42.17%). The transient dysphasic speech disturbance was the third most frequent (4.82%). Motor symptoms were very rare (0.6%), especially with a hemiplegic migraine (Table 3).
The duration (hours) and frequency (days per month) for migraine without aura, migraine with aura and chronic migraine with continuous pain exhibited are shown in Table 4. We also considered disabling symptoms, systemic blood pressure, changes in consciousness level (assessed by GCS in adult and pediatric groups, and trigger factors in relation to migraine without aura, migraine with aura and chronic migraine with continuous pain (Table 4).
Parameters n=1199 | Migraine without aura n= 980 | Migraine with aura n=127 | Chronic migraine with continuous pain n=92 | Mean±SD | P value | |
---|---|---|---|---|---|---|
% | ||||||
Duration, hours | 4-12 | 15 | 20 | 20 | 18.1±2.8 | < 0.019 |
12- <24 | 10 | 60 | 50 | 60±10 | < 0.053 | |
24-<48 | 10 | 18 | 20 | 15.3±5.3 | < 0.016 | |
48->72 | 5 | 2 | 10 | 4.64±4.04 | < 0.006 | |
Frequency, days per month | 2-4 | 98 | 95 | 90 | 94.27±4.04 | < 0.080 |
5-7 | 3 | 3 | 7 | |||
8-10 | 0.5 | 0.9 | 2 | |||
11-13 | 0.3 | 0.3 | 0.5 | |||
14-16 | 0.1 | 0.1 | 0.5 | |||
*Disabling Symptoms+ = limited your ability (reduced by half or more) to work, or do what you needed to do for at least one day? **(MIDAS) | Concentrating | 8 | 10 | 4 | 3.78±4.35 | < 0.005 |
Understanding instructions | 7 | 10 | 1 | |||
Dealing with others | 10 | 20 | 4 | |||
Lifting | 3 | 4 | 1 | |||
Walking | 2 | 4 | 1 | |||
Standing | 2 | 4 | 0.5 | |||
Studying | 4 | 6 | 0.5 | |||
Miss work days per 3 months | 5 | 10 | 8 | |||
Miss family, social, or leisure activities | 6 | 10 | 2 | |||
***Adult GCS Score | 15 | 99.8 | 99.5 | 100 | 99.76±0.25 | |
3-14 | 0.2 | 0.5 | 0 | 0.23±0.25 | ||
Pediatric GCS Score | 15 | 100 | 99.4 | 100 | 99.79±0.34 | |
3-14 | 0 | 0.6 | 0 | 0.2±0.34 | ||
Systemic blood pressure (BP/mmHg) | Systolic BP (≤ 90 mmHg) | 10 | 20 | 0 | 10.0±10.0 | < 0.011 |
Systolic BP (≥ 150mmHg) | 2 | 2 | 1 | 1.58±5.77 | < 0.003 | |
Trigger factors |
Emotional stress or release from stress | 50 | 40 | 10 | 34.19±15.27 | < 0.032 |
Sleep disturbance Too much or too little sleep | 10 | 20 | 5 | 7.29±19.05 | < 0.009 | |
Dietary factors | 2 | 2 | 1 | |||
Menstruation | 4 | 6 | 0.5 | |||
Fasting | 10 | 15 | 1 | |||
Hormonal therapy | 20 | 18 | 5.0 | |||
Exposure to bright lights, loud noises, and smoke | 60 | 70 | 20 | |||
Change in the weather | 4 | 12 | 0.5 |
Out of 1,412 patients with a migraine headache, enrolled in this study from 2010 to 2018, only a minority reported serious complications, such as chronic persistent headaches in 6.5% especially in migraine without aura and migraine with aura events (Table 5). The medication overuse headache 2.6% and thromboembolic stroke 0.7%, also recorded (Table 5).
Complications | Type of a migraine *ICHD.3b code | N (%)** |
---|---|---|
Chronic migraine | 1.1, 1.2 | 92(6.5) |
Headache attributed to the medication overuse | 8.2 | 37(2.6) |
Thromboembolic stroke | 1.2 | 10(0.7) |
Persistent aura without infarction | 1.2.1.2 | 5(0.35) |
Ischemic stroke | 1.2 | 4(0.3) |
Migraine triggered seizure | A.1.6 | 3(0.2) |
Status migrainosus | 1.2 | 2(0.14) |
Transient ischemic attack | 1.2,***FHM | 2(0.14) |
Total | 155 |
* (International classification of headache disorder-3 version beta 2013 )
**Mean age=10 years
1.1= Migraine without aura
1.2= Migraine with aura
1.2.1= Migraine with typical aura
1.2.1.2 =Typical aura without headache
A1.3.2 a Chronic migraine with continuous pain
A1.3 Chronic migraine (alternative criteria)
8.2 Medication-overuse headache (MOH)
A1.1.1 Pure menstrual migraine without aura
A1.6 Episodic syndromes-Childhood periodic syndromes, *Other subtype of migraine
***Others subtypes (Ophthalmoplegic ‘migraine’ Retinal migraine, Familial hemiplegic migraine (FHM), Sporadic hemiplegic migraine, Basilar-type migraine, Abdominal migraine, Benign paroxysmal vertigo of childhood)
In this study, 1,412 patients diagnosed with migraine headaches, according to established criteria4,19,20 were analyzed. Women were more affected (77.9%) than men (22.1%), and such a 3.5/1 female/male ratio is consistent with the results of large-scale studies6,10,12. This skewed sex ratio is mostly due to hormonal variation during menstruation and pregnancy, and to genetic predisposition1. The median age of first onset in this study was 21 ± 5.42 years, with range 12–45 years. Migraine without aura was the most common subtype (69.4%) in the sample. Childhood migraine prevalence was 0.8%, including migraine with aura and episodic syndromes/childhood periodic syndromes. The pediatric Glasgow Coma Scale (GCS) score in this subgroup ranged between 3 and 14, but this result was not significant. Patients experienced non-specific prodromes 1-1.5 hours before the attacks, including nausea, vomiting, and photophobia. About 27% of the patients in this study experienced transient aura during the study period. Visual aura was the most common (50%), while unilateral sensory symptoms, tingling and numbness was the second most frequent type of aura and transient dysphasic speech disturbance was the third, while motor symptoms were very rare. Aura occurs because of the spreading of a wave of depolarization (cortical spreading depression)20, and is associated first with a reduction, and then an increase in blood flow, and affects the parieto-occipital cortex10. The mean frequency of acute migraine attacks was 2 ± 4.63 days per month; in very few patients (0.5%) the frequency of the attacks was 14–16 days per month, especially in patients suffering from migraine with aura and chronic migraine. The mean duration of acute attacks was 12–24 hours in 60% of the patients. The severity of acute attacks depends on their frequency, duration and disabling symptoms; in general, most of the acute attacks were moderate to severe12. In our study about 8% of migraine patients suffered from debilitating, disabling and incapacitating symptoms. Symptoms were considered disabling, if they reduced by half or more the patient’s ability to work, or more generally to do what needs to be done, or at least 24 hours, thus impairing quality of life2,11,18. In this study about 10% of the patients had acute attacks associated with systemic hypotension (systolic blood pressure (BP) < 90 mmHg), especially in a migraine with aura, and women. Furthermore, systolic hypertension (≥ 150 mmHg) was found in 1.5% of the patients, especially in women. We found variation in the estimates of migraine prevalence and clinical characteristics symptoms, depending on the stage of the migraine (prodrome, aura, acute attack, and postdrome). One third of patients had a family history of migraine, showing that migraine is an inherited condition accompanied by episodic symptoms arising in the brain10,19–21. In our study chronic migraine with continuous pain and chronic migraine (according to alternative criteria) represented about 9% of the total sample, and had a detrimental influence on the patients’ lives, impacting socioeconomic functioning and quality of life. It usually develops from an episode of migraine, with or without aura, which turns into a continuum, with an undetermined annual conversion rate20,22. Another important subtype of a migraine is medication-overuse headache (MOH), which represented about 2.6% of the whole sample.
The limitation of this study were that it was a single center, local, regional, monophasic study and there was high financial cost involved. Therefore, for future studies we recommend a multi-centric, national, and diphasic study to obtain more information and data to help advance management of migraine.
In our study, we observed that migraine causes a headache resulting in episodes of temporary functional disability and women suffered more than men (ratio of 3.5:1). The mean age at first attack was a young age, and a family history of migraine highly altered distribution. Migraine without aura was the most common type, and symptoms including nausea and vomiting and photophobia were experienced by patients, which were used to diagnose migraines. Experienced aura was the most common migraine with aura, but also aura without a headache and aura with migraine were prevalent; therefore, it is important to differentiate between migraine subtypes. Visual aura was the most common aura, while motor symptoms were very rare. Chronic persistent headaches were a common complication recorded. These features provide evidence for the creation of screening tools in migraine prevention migraine.
F1000Research: Dataset 1. Excel sheet file of 1412 citizens from Misan province, Iraq whom suffer from migraine from 2010 to 2018., https://doi.org/10.5256/f1000research.16854.d22986123
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Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Is the work clearly and accurately presented and does it cite the current literature?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Migraine observational studies, cardiovascular risk in migraine, stroke epidemiology
Is the work clearly and accurately presented and does it cite the current literature?
Partly
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Neuroscience, Neuropharmacology, pain, headache
Alongside their report, reviewers assign a status to the article:
Invited Reviewers | |||
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