Prevalence of Tension-Type Headache among Medical Students in Tabuk University, Saudi Arabia

Background: Headaches disorders have a significant burden on the world. Tension Type Headache is the most common type among primary headaches. Since medical students are exposed to a lot of stress, and it is associated with a tension-type headache, the importance of this Original Research Article Mirghani et al.; JPRI, 33(51B): 1-10, 2021; Article no.JPRI.77366 2 study comes. This study aims to measure the prevalence of tension-type headache among medical students at Tabuk University 2020. Methodology: A cross-sectional study in Tabuk, Saudi Arabia was conducted. The study included medical students at the University of Tabuk in the academic years from 2 nd to 6 th grades during the calendar year of 2020. An adapted semi-structured self-administered questionnaire was retrieved from other validated questionnaires. The internal validity and reliability of the questionnaire were tested using Cronbach's alpha test and was highly reliable (25 items, α = .715). Both medical and research experts assessed the face and content validity. The data were coded, tabulated, and analyzed using the Statistical Package for the Social Sciences (SPSS, version 27). Results: The total number of the students was 380 (response rate, 78.6%). 55.22% were females, and 44.78% were males their mean age was 21.18 ± SD 1.78 years. Out of the 297 students, only 122 met the diagnostic criteria. The 1-year prevalence Tension Type Headache (TTH) included the three types: frequent TTH 67.2%, 18.0% infrequent TTH, and only 14.8% suffered from chronic TTH. The most common aggravating factors included studying stressors (82%), 68% of the participants reported daily activity interference, and 48.4% reported that headache aggravate with routine physical activities (e.g., walking or climbing stairs). The headache quality varied between throbbing/pulsating (54.9%), pressing/tightening (68.9%) and sharp/stabbing (10.7%). The median headache intensity was 5.25 at pain level score (IQR =2). Only 28% of the students sought counseling where the main analgesic used was Acetaminophen (74%). Many non-pharmacological therapies were practiced by the students to relieve headache, including sleep (60.7%), rest (63.1%) and caffeine (41.8%).23% of the medical students reported that they sought medical counseling to maintain their performance level. There was a statistically significant difference between the average age of medical students suffering from frequent and infrequent TTH, t(102) = 2.31, p = .023. Conclusion: Tension-type headache is a prevalent type of headache among Saudi medical students. Prevalence and aggravating factors in our study were comparable to previously reported literature. Future studies with large sample size may be required among all university students to define burden of the case in Saudi Arabia.


INTRODUCTION
Headaches disorders have a significant burden on the world. Apart from this, Headaches affect people of all ages, socioeconomic statuses, and races. Moreover, in neurology disorders, headaches considered to be one of the most prevalent complaints [1]. Additionally, headaches are the second most common condition in neurology clinics [2].
According to The International Classification of Headache Disorders 3rd edition International Classification of Headache Disorders (ICHD-3), the tension-type headache (TTH) is classified under primary headaches, which also include migraine, cluster, trigeminal autonomic cephalalgias and others [3]. TTH is the most common type among primary headaches [4].
Despite numerous clinical and neurophysiological studies, the exact cause of tension headache remains elusive. Detailed discussion on these studies is beyond the scope of this article. A distillate of the currently available data does however suggest that percranial myofascial mechanisms probably are of importance in episodic TTH, whereas sensitization of pain pathways in the central nervous system resulting from prolonged nociceptive stimuli from pericranial myofascial tissues seems to be responsible for the conversion of episodic to chronic TTH [4].
Vast majority of TTH patients do not seek medical attention. Only when ETTH attacks become frequent or the headache changes into chronic type (CTTH), patients seek treatment. Diagnosis of TTH is difficult as headache characteristics are non specific. Diagnosis is essentially clinical and based on negative associations and by exclusion. A typical case or those with abnormal neurological examination must be investigated thoroughly to exclude secondary headaches [3].
Since medical students are exposed to a lot of stress, and it is associated with a tension-type headache, the importance of this study comes [18]. Farthest we know there is a lack of studies regarding tension-type headache among medical students in Tabuk, Saudi Arabia. This study aims to measure the prevalence of tension-type headache among medical students among Tabuk University 2020.
A study was conducted at King Abdul-Aziz University, Jeddah, Saudi Arabia, to determine the prevalence of tension headache among medical students. The researchers distributed a self-administrated questionnaire to 4th to 6thgrade medical students (n=387). The study results show that the lifetime prevalence of tension headache was (66.4%). However, the one-year prevalence was (28.9%). Females were showing a significantly higher risk of tension headache than males. Moreover, sleeping less than 8 hours/night increases the risk of having a tension headache. Additionally, the most common factor that aggravates tension headache was studying stressors (83.3%) [6].
A study was performed in the Medical School of Zagreb University. The study sample was 314 students; the Participants were aged between 18 and 27. The study illustrated that tension-type headache (TTH) was (60.1%) for first-year students, and (57.7%) for sixth-year students. When they were asked about trigger factors, more than 50% of both first and sixth-year students mentioned that lack of sleep and stress were the main factors for the headache. Only 32 out of 220 suffered from headaches (14.5%) who had consulted a doctor about their headache. Furthermore, self-medication usage had a high percentage of sixth-year students (73.3%), while first-year students (59.8%). The most common medication was acetylsalicylic acid. (68.6%) stated that at the period of the headache, they could not perform well or perform at all [7].

Study Objective
This study aims to measure the prevalence of tension-type headache among medical students at Tabuk University 2020, to estimate the difference between gender regarding tension type headache, to assess the prevalence of analgesia use for headache, to assess the prevalence of student that seek medical and nonmedical attention, and to assess the association between Family history and tension type headache.

Subjects and Methods
A cross-sectional study in Tabuk, Saudi Arabia was conducted. The study included medical students at the University of Tabuk in the academic years from 2 nd to 6 th grades during the calendar year of 2020. All the students with chronic headache and who gave consent were approached, and then only those with tension headache were selected, other types of headaches were not included. The selection criteria that we followed was to exclude students who suffered from headache for less than 7 episodes occurring per year; their headache was accompanied by no more than one of the following symptoms: nausea or vomiting; and no more than one of photophobia or phonophobia. The sample size was 297 participants, and data was collected via online questionnaire. The total number of the students was 380 (response rate, 78.6%) An adapted semi-structured selfadministered questionnaire was retrieved from other validated questionnaires [6,14,15], which is divided into three sections: 1-Demographic profile (age, gender). 2-International classification of headache (ICHD-3) that inquired about the headache profile. 3. Factors that aggravate or relieve headache (Analgesics, non-pharmacological method to relieve the headache: Sleep, rest, caffeine).
Tension-type headache was defined as an individual who had experienced ten or more attacks of headache during the past year, and which had lasted for at least 30 minutes to 7 days each. The headache accompanied by at least two of the following four pain characteristics: bilateral location, non-pulsating (pressing or tightening), mild-to-moderate severity, and not aggravated by routine physical activity, in the absence of features that characterize migraine, such as nausea, vomiting, photophobia, and phonophobia. But could include either photophobia or phonophobia, but not both. The questionnaire was conducted in Arabic and it was handed to them during the period from March 2020 to June 2020.
The internal validity and reliability of the questionnaire were tested using Cronbach's alpha test and was highly reliable (25 items, α = .715). Both medical and research experts assessed the face and content validity.

Statistical Analysis
The data were coded, tabulated, and analysed using the Statistical Package for the Social Sciences (SPSS, version 27). Qualitative data were expressed as numbers and percentages, and the chi-square (χ 2 ) test was used to test the association between variables. Quantitative data were expressed as mean and standard deviation (mean ± SD). A p-value of < 0.05 was considered as statistically significant. Descriptive statistics were conducted in terms of frequency (n) and proportions (%). Bivariate analyses (Pearson chi-square) performed to study the association between the 1-year prevalence TTH (Y/N) and gender, medical grade and smoking covariates.

RESULTS
A total of 297 medical students were approached 55.22% were females, and 44.78% were males their mean age was 21.18 ± SD 1.78 years. Out of the 297 students, only 122 met the diagnostic criteria (41.1%) ( Table 1).
Headache usually was accompanied or preceded by nausea (15.6%), phonophobia (35.2), or photophobia (27.9%), and visual error (46.7%). The percentages of those who reported TTH headache with Aura symptoms as displayed in Table 3 are as follows: Visual (13.1%), Speech disturbances (0.8%), sensation disturbance (8.2%) and motor weakness (3.3%). Out of 122 participants, 54.9% reported having family history of headaches. Table 4 shows types of therapies and types of counseling among students who suffered from TTH, students stated that headache limited their daily activity as walking and climbing stairs (59%) and 89.3% reported that their headache was of moderate to severe intensity. Only 28% of the students sought counseling where the main analgesic used was Acetaminophen (74%) as explained in Table 4.
Analgesics were taken according to an advice from a family member (23%), and only 7% of them took analgesic according to an advice from a physician or a pharmacist (Fig. 2).
23% of the medical students reported that they sought medical counseling to maintain their performance level. The survey revealed that (61.5%) of the medical students' headaches got worse since they joined medical college.
There was a statistically significant difference between the average age of medical students suffering from frequent and infrequent TTH, To investigate whether study stressors is associated with the student grade in medical school chi-square statistic was conducted. Assumptions were checked and were met. The Pearson chi-square results and indicates that the student stressors is significantly associated with the student grade (χ 2 = 23.75. df= 4, N = 122, p < .001). Females are more likely than males expected under the null hypothesis to be affected by study stressors. Phi which indicates the strength of the association between the two variables, is .441.
Simultaneous multiple regression was conducted to investigate the best predictors of number of episodes per year. The combination of variables to predict TTH episodes per year from age, smoking, student year of study, family history, and gender was statistically significant. F (5,

DISCUSSION
Tension-type headache (TTH) is the most common primary headache disorder, with a worldwide lifetime prevalence of 46% to 78%. TTH causes greater disability and accounts for more missed work days than migraine. The etiology of TTH is thought to be multifactorial, involving genetic and environmental factors [3].
In our study, the 1-year prevalence TTH included the three types: frequent TTH 67.2%, 18.0% infrequent TTH, and only 14.8% suffered from chronic. Lower results were reported in KSA as history of headache was reported in (92%) of students; the tension headache was seen in (58%) [12]. A study was conducted in Umm Al-Qura college of medicine, Makkah, Saudi Arabia, reported one-year headache prevalence was (89.6%), the most common diagnosis among both genders was frequent tension-type headache (31%) [15]. Another study in Riyadh, among medical students showed that (53.78%) of participants had a headache, and (41.66%) had TTH [8]. A study in Taif University, show that (29.5%) of female students experienced TTH [14]. Another reported lower results as (46%) of students suffered from recurrent headaches.

Fig. 2. Counselling type among medical students
The careful monitoring of the trigger factors of headache could be an important step in treatment, because their avoidance may lessen the frequency and severity of attacks. Furthermore, they may provide a clue to the etiology of headache [14]. In our study, the most common aggravating factors included studying stressors (82%), 68% of the participants reported daily activity interference, and 48.4% reported that headache aggravate with routine physical activities (e.g., walking or climbing stairs). A study in KSA reported the main trigger for migraine attacks was stress or anxiety, and 18.3% of migraineurs reported the presence of more than one trigger. Most of the migraineurs (43.6%) reported that the frequency of migraine attacks per month was fewer than daily to weekly, and 86.6% reported a family history of migraine [14]. This result is going with those revealed from other national and international studies [20][21][22] Stress at study or work were reported in another study as (93.6%) was the most reported trigger factor, followed by lack of sleep (92.3%) and change in time of sleep (87.2%). Almost three quarters of the migraineurs reported environmental triggers, including sudden change in temperature (79.5%) and noise (76.9%) [23,24]. Another study reported an association between type of headache, disturbed sleep pattern, and social stress [11]. This was comparable to a study reported stress (24.9%), irregular sleep (20.8%), and substantial reading (18.5%) were the most common triggers for headache followed by exams (11.1%), smoking (5.8%) and fasting (25%). Lack of sleep, followed by excessively long hours of work were reported in another Saudi study [13].
Another study on medical students reported that effect on daily activities was higher in chronic tension headache (96.7%) and migraine without aura (94.6%) than migraine with aura (91.3%) and episodic tension headache (85.1%) [25].
In our study, out of 122 participants, 54.9% reported having family history of headaches. This was higher than reported in previous literature as positive family history of headache was found in 6.1% of students with TTH, and there was statistically significant association between positive family history and the type of headache (P < 0.001) [16]. Consistently with this report, 10% of students with headache had a positive family history being less than that reported by Ojini et al. (22%) [26]. This is less than those reported previously [27][28][29]. The reason for a relatively lower frequency of positive family history of headache in our study is elusive, though, the high prevalence of TTH, which is actually associated with certain individual, psychosocial, and environmental conditions, might be regarded as an explanation [16]. In another study, 86.6% of migraineur students and 61.1% of students with TTH reported having a family history [14], A finding consistently found in previous studies and may highlight the role of genetics in this concern [30][31][32].
Most medical students in our study (66.4%) reported taking different types of analgesics as a self-medication mainly Panadol (60.7%). Many non-pharmacological therapies were practiced by the students to relieve headache, including sleep (60.7%), rest (63.1%) and caffeine (41.8%).
Another study reported that majority of TTH students reported no increase in headache frequency after analgesic use or increase in the analgesic dose used over time. The main analgesic used was paracetamol (46.5%), followed by ibuprofen, acetaminophen, aspirin, and diclofenac sodium (33.8%, 13.9%, 3%, and 2.8%, respectively) [14]. The popularity of paracetamol and acetaminophen was explained in the previous studies by their low price, safety, and less GIT side effects, in addition to their availability as an over-the-counter medication [27]. Another Saudi study reported that headache relief by taking medication was reported in over one-third of respondents. Also, sleep was effective (28.2%) of the respondents. The rest was effective in (19.7%) of the respondents [13].

CONCLUSION
Tension-type headache is a prevalent type of headache among Saudi medical students. Prevalence and aggravating factors in our study were comparable to previously reported literature. Awareness of seeking medical advice and relieving stress for management of this case is required among medical students in Saudi Arabia. Future studies with large sample size may be required among all university students to define burden of the case in Saudi Arabia.

CONSENT AND ETHICAL APPROVAL
A letter of approval was obtained from the Institutional Review Board of the Faculty of Medicine, Tabuk University; the participants gave a verbal consent and then responded to the questionnaire. Participants' privacy and confidentiality will be assured, no identities will be collected.