Introduction

Headache is one of the most common neurological disorders with the estimated global prevalence in adults being around 50% [1]. It can affect people irrespective of age, sex, education, socioeconomic status and occupation [2]. Headache pain usually occurs due to peripheral nociceptors stimulation in response to tissue injury, damage or inappropriate activation of the pain-producing pathway of the central or peripheral nervous system, visceral distension, or other factors [3].

Broadly, all headaches fall under two subtypes: Primary headache and Secondary headache. Primary headache includes cluster, migraine and tension-type headache and secondary headache includes all those subtypes that result from underlying pathologies. A primary headache is, however, more common than a secondary headache [4].

The migraine headache is characterized by unilateral pulsatile or throbbing pain of moderate to severe intensity associated with nausea, vomiting, photophobia and phonophobia and lasting for about 4 to 72 hours if left untreated [5].

Similarly, tension-type headache is characterized by pain which is often described as “a band around the head”, pressing or tightening quality, mild to moderate in intensity, bilateral not affected by routine activity, and not associated with nausea and vomiting. Women are found to be at a greater risk to develop migraine and tension-type headaches. This could be because of the effect of female hormone levels, particularly estrogen [6].

Another subtype, cluster headache is defined by attacks of severe, unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15–180 minutes and occurring from once every other day to eight times a day. The pain is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, forehead and facial sweating, rhinorrhea, ptosis and/or eyelid oedema, restlessness or agitation [4]. The lifetime prevalence of cluster headache is 124 per 100,000 and 1-year prevalence is 53 per 100,000. The ratio of episodic vs chronic cluster headache is 6.0 [7].

Medical students are among the vulnerable groups to headache disorder [8]. It is highly prevalent among undergraduate medical students. In past studies, stress was found to be the most common cause of headaches with sleep being reported as the commonest relieving factor. The academic performance, reasoning capacities, mental functioning and overall quality of life of medical students can be severely impaired due to headaches [9].

There are very few studies conducted on headache disorders in medical students in developing countries like ours. There has been studies in the developed nations which cannot be generalized to the developing nation such as ours. The medical students are subjected to a higher level of stress, performance pressure, longer duration of education and a strong responsibility towards their career. Neurological problems like headaches are commonly ignored in a developing country like Nepal by adults and also, they undergo self-medication. So, our main objective was to find out the prevalence of headaches and their different types among students of a medical college. We have also studied the possible severity, precipitating and relieving factors, and treatment practices among medical studies concerning headache problems.

Material and methods

Sampling and sample size

Stratified random sampling followed by a simple random sampling technique was adopted.

Sample size:

Total population of MBBS students (N) = 540 Where,

1. E = margin of error, 5%
2. p = estimated proportion of the population which has attribute to the questions, taken as 50%
3. q = 1-p = 0.5
4. z = confidence interval at 95% = 1.96

Since the population was finite, the adjusted sample size was calculated as per Cochran’s formula [10]

100% of the randomly selected participants responded to our questionnaires. However, while calculating the minimum sample size, we had assumed a 5% non-response rate. That made our sample size 236. Yet, we took 242 cases finally for our study.

After calculation of sample size, a stratified sampling technique was employed using students’ academic year as a stratum. First, the total sample size was proportionally allocated for each stratum (MBBS first year to the fifth year), and then a simple random sampling method using random number generator software was applied.

Results

Among 242 students, 65 (26.86%) said that they were diagnosed with a headache disorder by a Neurologist or the General Physician. Out of the diagnosed ones, 45 (69.23%), 14 (21.54%) and 2 (3.08%) had tension, migraine and cluster headache respectively. Four (6.15%) of them had other types of headaches that included secondary causes like the common cold, sinusitis, and refractive error.

“Table 1” shows the prevalence of headaches across socio-demographic variables like age, gender, marital status and MBBS academic years. The median age was similar in both groups; having and not having diagnosed headache disorder (21.00 [20.00–23.00]). Out of the total, 175 (72.31%) were males and 67 (27.69%) were females. The headache was more prevalent in females (20, 29.85%) compared to males (45, 25.71%). The prevalence of headaches was highest among fourth-year students (14/37, 37.84%) followed by first-year students (21/63, 33.33%). But these were not statistically significant.

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Table 1. Prevalence of headache across different socio-demographic variables.

https://doi.org/10.1371/journal.pone.0277821.t001

Aetiology and precipitating factors

21 (32.31%) of them reported that the headache starts after an illness or infection or accident. The rest of the others had spontaneous onset of headache. ‘Anxiety/stress’ (49/65, 75.40%) was the most common precipitating factor followed by ‘too little sleep’ (30, 46.15%) and ‘loud noise’ (28, 43.07%). Other precipitants of headache are illustrated in “Table 2”.

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Table 2. Precipitating factors, characteristics and severity of headache.

https://doi.org/10.1371/journal.pone.0277821.t002

Discussion

In our study, the headache was found to be fairly common among medical students, with a prevalence of 26.86%. This is considerably lower than reported in studies by Kurt et al. (41.0%), Ojini et al. (46.0%), Ghorbani et al. (58.7%), and Bakhshi et al. (87.8%), and Anaya et al. (81.8%) [11–15]. The prevalence was higher in females (29.85%) than in males (25.71%). This is consistent with studies were done by Ojini et al. and Bakhshi et al. which showed a higher prevalence rate in females than males [12, 15]. The studies done on the general population have also shown a higher prevalence of headaches in women than men [16, 17]. Tension-type headache was found to be the most common headache with a prevalence of 69.23% which is significantly higher than the global prevalence. However, this value is similar to the findings in several other studies conducted in Ukraine (58.7%), Palestine (59.8%), Nigeria (18.1%), Iran(44.2%), and Nairobi (50%) [11, 12, 15, 18]. Similarly, in our study, tension headache (69.23%) was most common followed by migraine (21.54%). It is in line with the findings of a study conducted in Ukraine (9.1%). The prevalence of migraine headaches in our case is higher as compared to the global prevalence and a study in Ukraine (9.1%) [19, 20].

In our scenario, the prevalence of headaches was lower in third-year MBBS students (19.15%) compared to other academic years. This may be because the students in the third year have to study fewer subjects compared to other academic years as per the curriculum of the university. Fewer subjects and exams, and thus reduced stress can explain this finding. Similar findings have been seen in a study done in Palestine by Anaya et al. which found differences in basic and clinical years [11]. Also, fourth-year students had a higher prevalence of headaches, perhaps owing to multiple subjects that needed to be studied in a year. A study done in Iran by Ghorbani et al. also found a higher prevalence in the third year which was associated with highly stressful Basic Science exams [13].

In our result, 10.77% of those diagnosed with headaches had a positive family history. This is similar to the study done by Ghorbani et al. (10.0%) in Iran but less than that reported in studies by Ojini et al. (22%) and Deleu et al. (57.6%) done in Nigeria and Oman respectively [13, 15, 21]. This could be due to the racial and genetic differences between different populations for which separate population-based studies may be required.

Our study shows that anxiety/stress (75.38%) related to exams was the major precipitating factor for headaches followed by too little sleep (46.15%). This finding is similar to the studies conducted in Ukraine (36%) and Indonesia (20%), which also showed anxiety to be the most common cause of headaches [19, 22]. The major site of headache in our setting was the forehead (29.23%) followed by “all around the head” (24.62%). This finding is different from the study conducted in Saudi Arabia which showed the most common headache location to be bilateral [23]. The major characteristic of headache was found to be the dull type (26.15%) followed by throbbing/pounding in nature (18.46%). This finding also differs from the finding of the study conducted in Indonesia which showed more than half of the cases to be pulsatile and one-third with a sensation of tightness around the headache [22].

Our study showed most of the headache is accompanied by sensitivity to light (35.38%) followed by nausea (33.85%). This finding is comparable to an Indonesian study, which showed nausea (18.1%) to be the most common accompanying symptom [22]. Our study depicted that 63.08% of those having headaches couldn’t perform their regular activities, and about 35.38% were found to miss their work or school. This finding is significantly higher than in Indonesia which showed only 41.5% of the participants to have severe debilitating headaches and around 41.3% to have difficulty in performing daily activities [22].

In our study, 80% of the participants with headaches had spontaneous resolution of symptoms. Among those not having a spontaneous resolution, 53.85% were found to do self-medication. This is much lower than the findings from the study conducted in Oman (80.3%) but higher than the findings of studies conducted in Turkey (47.6%) and Pakistan (41%) [21, 24, 25]. Among those who practised self-medication, non-steroidal anti-inflammatory drug (40%) was found to be the most commonly used medicine. However, a study by Mohamad Shadi Alkarrash et al, depicted that 91.1% of the students used Acetaminophen for self-medication purposes [26]. The reason behind this may be NSAIDs and Acetaminophen being easily available over-the-counter drugs.

There are some limitations of this study to be mentioned. This is a single center study and the results of this study may not be representative. Since it was conducted with a Semi-structured questionnaire distributed through an online platform, there might have been some information bias. Some of the medical students had class tests or presentations at the time of data collection so it could have impacted headache development and characteristics. Also, the students were engaged in online education during the past year due to COVID-19 which itself could be perceived as stressful and overwhelming to some students. In this study, we have considered only diagnosed cases to have a headache disorder, so there might have been missing cases that were not diagnosed yet. These cases need to be examined by the Neurologist or the General Physician. The cause of secondary headaches is also not properly addressed. Also, treatment for headaches is not described in detail as this study is more focused on describing characteristics rather than treatment. So, further studies need to be conducted in future to get the real picture. However, this study is relevant to describing the load and characteristics of headaches in medical students.

Conclusion

One-fourth of the medical student had headache disorder, with tension headache being the most common type. The fourth- and first-year students were most commonly affected, and anxiety/stress was their commonest precipitant. The problem of headaches stopped the majority of them from doing regular activities. Half of the students reported practising self-medication in case of non-resolution of pain. Therefore, this problem should be properly looked into by the concerned authority and the guardians. Further multicenter studies are required to study the complete clinical characteristics of headaches among medical students in Nepal.

Supporting information

Acknowledgments

We would like to acknowledge all the participants who were involved in this cross-sectional study.