Clinical Profile of Tension Type Headache in a Medical College with Special Emphasis on Triggering Factors
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.359261
Source of Support: None, Conflict of Interest: None
Keywords: Headache, tension type headache, trigger factors
Headache is one of the commonest neurological disorders. According to the Global Burden of Disease Study, updated in 2013, it has been estimated that almost half of the adult population has had a headache at least once within the last year.,,,, A headache affects work, social and leisure activities and has a tremendous impact on a person's life. The focus of research on primary headache includes both the general population and specific population such as adolescents, college undergraduates, people in the workplace and also individuals with potentially related comorbidities such as epilepsy and psychiatric illnesses.,,
Tension type headache (TTH) is one of the costliest primary headaches. In the International Headache Society Classification (ICHD II), TTHs have been divided into two forms, episodic (ETTH) and chronic (CTTH). Data on epidemiology of TTH in Asian subcontinent is virtually non-existent. There are no large studies looking at the prevalence, clinical profile of TTHs in India. Danish epidemiological study conducted by Lyngberg et al. (2005) reported 79–87% lifetime prevalence of TTH. Considering the importance of recognizing triggers and the prevalence, which will help in improving TTH management, we have undertaken this study to evaluate the prevalence and the triggering factors associated with TTH in healthcare professionals in a medical college setup.
This is a prospective cross-sectional study conducted in a tertiary super speciality teaching hospital in Bangalore. Approval for the study protocol was obtained from the institutional health research and ethics committee. All subjects were screened for a headache using questionnaires and subjects who satisfied inclusion criteria were included in the study with prior informed and written consent. Subjects in the age range of 18–70 years with a primary headache were included in the study while diagnosed cases of a secondary headache and individuals not willing to participate were excluded. Questionnaire on socio-demographic details, clinical profile, the Visual Analogue Scale (VAS), Migraine Disability Assessment Scale (MIDAS) was presented in order. The investigator clarified the doubts and provided the queries regarding the study sought by the subjects. Subjects included undergraduate students in medicine, dentistry and nursing, residents in all departments, teaching/non-teaching staff associated with the institution. The analysis was undertaken using the SAS system (version 9.2).
Demographic and clinical characteristics
The sample comprised 2050 participants and included subjects of both the genders. Our study sample was from a medical college set up consisting of MBBS (44.3%), BDS (15.7%), nursing (13%), postgraduates and staff (26.8%).
The study group consisted of 2050 participants, the mean age of the sample was 23.56 ± 6 years. The incidence of TTH was highest in the age group of 18–25 (16.8%) followed by 26–35 years (3.9%) [Table 1]. The study group had 1274 females and 776 males of whom 269 females and 195 males had TTH [Table 2]. Prevalence of TTH was 40.5% (188) in MBBS students while it was 28.4% (132) among postgraduate students and staff. Nursing and dental students accounted for 9.9% (46) and 21.1% (98), respectively [Table 3].
Clinical data of tension type headache characteristics
In the study group, 32.4% of them had the headache of 1–3 months duration followed by >12 months in 25.5%, 3–6 months among 24.8%, 9.3% reported of 6–12 months duration and 7.8% reported <1 month duration of headache. About 86% of the subjects reported that each episode lasts for 4–12 h of duration, while 10.1% reported 12–24 h, 1.8% reported 24–48 h and 1.4% reported 48–72 h. When asked about the frequency of these episodes over a month, 88.6% were experiencing 5–10 attacks in a month. About 8.1% of them reported 10–15 attacks and 3% of them reported >15 attacks per month. Around 35% of the participants felt that their attack was sudden in onset, while 64.9% reported a gradual onset of each attack. With respect to timing of headaches during the time of the day, 149 (32.2%) of them reported that the attack of a headache occurred mostly during afternoons while 125 (26.9%) reported evening, 93 (20%) reported morning, 82 (17.6%) reported mixed/varied and only 15 (3.2%) of them reported nocturnal headaches. The commonest characteristic of headache was found to be pulsating which was seen in 51.6% of the participants followed by more than one type in 21.9%, throbbing in 18.5%, bursting type was reported in 3.4%, 3% reported band like and 1.4% reported shooting type. Seeking medical advice for headache attacks suggests the severity and morbidity of headache. With respect to medication use in our study, 67.5% of participants used nonsteroidal anti-inflammatory drugs (NSAIDs) (over the counter), 2.4% used opioids, 2% used triptans and 0.4% used homoeopathy. Only 7.7% of them used prophylactic medications. Among subjects with TTH, 90% of the individuals used NSAIDS, 8% used opioids. Rest 2% used homoeopathy medications.
The severity of pain determines the effect of these episodes on daily activities, this was assessed based on the VAS and morbidity was calculated based on the MIDAS. About 77.1% of participants reported moderate intensity (VAS 5–7) of pain on a VAS, 13.8% of them reported mild (VAS 0–4) and 9.1% of them reported of severe intensity (VAS 8–10). About 68.4% participants in our study reported a headache-related disability, i.e. MIDAS score of Grade I, 14.2% had Grade II, 12.5% had Grade III and 4.9% had Grade IV [Table 4].
Relieving and trigger factors
About 71.1% of them reported sleep as a relieving factor, while 58.3% of them reported of rest as a relieving factor, 26.9% reported massage, 9.4% of them reported entertainment, 6.3% reported vomiting and 2.5% of them reported change of posture as a relieving factor [Table 5].
Among the triggering factors, hunger, hot water bath, head bath, stress, noise, decreased sleep, odour, chocolate consumption, flickering lights, watching TV/laptops, menstruation, emotional factors, weather changes, travel, reading, irregularity in food intake and excessive work were statistically significant (P = <0.0001) [Figure 1]. Stress, decreased sleep and hunger were the commonly reported triggering factors in females [Figure 2].
The frequency of triggering factors among different courses
Among dental students, stress, decreased sleep and hunger were the commonest triggering factors reported with a migraine. Among medical students also, stress, hunger and decreased sleep were the commonly reported triggering factors. However, nursing students reported hunger as the commonest triggering factor followed by stress and emotional factors. Postgraduates and staff also reported stress as the commonest triggering factor followed by environmental changes and decreased sleep.
Tension headache is one of the most prevalent, costliest subtypes of a primary headache and a benign neurological disorder.,,,, The present study was aimed at identifying the prevalence, triggering factors and their frequency. The study was also aimed at highlighting the importance of awareness and avoidance of potential trigger factors. The study consisted of 2050 participants, the cross-sectional assessment was done both by the structured and unstructured clinical interview using a specially designed proforma. The questionnaire comprised of socio-demographic details, the VAS for pain and the MIDAS. Out of 2050 patients, 464 (22.63%) participants had TTH according to the International Headache Society Criteria.
The study subjects were recruited on a purposive basis and their socio-demographic background showed that majority were females 269 (57%). The mean age of the subjects recruited here has been 23.5 ± 6.0 [Table 1]. Our study showed that out of 464 subjects who had TTH, 57.9% were females compared to 42% males indicating that TTH is only slightly more common in females [Table 2]. The higher frequency of a TTH was found in MBBS students 188 (40.5%) followed by postgraduates and staff 132 (28.4%), 98 (21.1%) in BDS and 46 (9.9%) in nursing students, respectively [Table 3].
With respect to the duration of a headache, 32.4% of participants reported that they had the headache of 1–3 months of duration while 25.5% reported headache of >12 months duration. TTH was divided into frequent and chronic type TTH. The episodic form was subdivided into infrequent and frequent type in ICHD (beta version). In our study, we found that 88% of participants had less than five episodes per month and can be classified under infrequent episodic TTH which is the most common type of TTH. About 3% of individuals reported >10 headache days in a month. This is in concordance with the Danish study conducted by Lyngberg et al. (2005) which reported a similar prevalence. Furthermore, 86.5% people reported that each episode of a headache lasts for around 4–12 h. Majority of the participants reported a gradual onset of a headache (64.9%) episode. Around 32.2% of the individuals had a headache in the afternoon which could be related to exposure to sun and skipping of meals. About 26.9%, however, reported evening onset headaches. The intensity of headache was reported using the VAS for pain. About 77.1% (358) of the individuals reported moderate amount of pain during the attacks.
Individuals were also asked to report about any relaxation techniques which they found beneficial in reducing the duration of attack/aborting the attack or which reduced the frequency of further attacks [Table 5]. About 71.1% of the individuals reported sleep to be the single most effective strategy followed by rest (58.3%). About 26.9% felt that head massage reduced the intensity of the headache. Self-medication is extremely common in general population and also among people involved in healthcare. In our study group, 67.5% of individuals reported the use of NSAIDs during the attack. One of the striking observations was that only 7.7% of individuals with a headache were on some kind of prophylactic medication. This is fairly low for a population who have easy access to healthcare services. MIDAS score gives a fair representation of disability due to a headache. In our study 68.4% [Table 4] subjects had a MIDAS score of Grade I, 14.2% had Grade II, 12.3% had Grade III and 4.8% had Grade IV. This reflects that if the headache is very severe, other aetiologies must be considered and ruled out before diagnosing a patient with TTH. It is important to note that 18% of the participants with TTH had to take time off from work because of the headache, while 30% reported that it had a significant impact on their efficiency at work., Identification of the triggering factors in patients with TTH is quintessential in order to prevent further attacks. Almost all the patients with TTH identify these triggers and find a way to avoid it. The results in our study group [Figure 1] revealed that most individuals had multiple trigger factors responsible for the onset of headache and also in increasing the severity of the headache. Stress was the commonest triggering factor (74.1%) in our study group, while some other studies have reported weather change to be the most common triggering factor. Other factors reported mainly were decreased sleep (49.4%), hunger (44.3%), excessive work (35%), emotional factors (31.8%), noise (27.1%) and reading (29.1%).,, Most participants also reported susceptibility to environmental and hormonal triggers like, head bath (22%), irregularity in food intake (20.6%), hot water bath (6.9%), watching TV/laptop (27.6%), flickering lights (6.3%), weather changes (12%), travel (19.3%), odour (13.1%) excessive relaxation (6%), head and neck movement (5.5%) and menstruation (16%). This finding is consistent with other studies.,,,,,,, Only a few participants reported susceptibility to dietary factors like chocolate (5%), Chinese food (0.1%), spicy food (0.1%), sweets (0.1%), consumption tea/alcohol/coffee (1.1%) and fruits like grapes and pineapple (0.1%).
TTH has a significant impact on overall quality of life. Stress is the most common triggering factor in healthcare setting followed by lack of sleep.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]