The clinical properties of a Migrainous population in Eastern Turkey-Erzurum.

Objectives: The purpose of this study was to determine the clinical and demographic characteristics of patients with migraine headache, in the vicinity of Erzurum, Turkey.

Methods: A uniform questionnaire was given to 185 patients diagnosed as having migraine according to the International Headache Society diagnostic criteria between August 2001 and July 2002. One hundred forty five females (78.4%) and 40 males (21.6%) were included in the study. The male to female ratio was 1:3.2. The mean age of the cases was 32.4 [+ or -] 10.2 years and the mean age of onset was 22.8 [+ or -] 9.1 years.

Results: One hundred and thirty seven patients (74.6%) fulfilled the criteria for migraine without aura (MwA) whereas forty-eight patients (25.4%) fulfilled the criteria for migraine with aura (MA). The males had been suffering from migraine headaches for a mean of 8.3 [+ or -] 6.3 years versus a mean of 9.3 [+ or -] 7.6 years in females. More than half (61.4%) of the females were housewives, and 84.3% of the cases were living in urban areas. About half (48.7%) of them had at least 11 years of education, most (79.5%) reported low or medium income level. Also, 70.8% were married. There was a high rate of headache in family history (72.4%). A majority of patients (75.7%) complained of severe headaches. One fourth (24.9%) had more than three attacks per month. Headache was unilateral in 71.9% and was throbbing in 77.8%. In 117 patients (63.2%) the symptoms were aggravated by physical activity. Attacks were accompanied by nausea in 84.9%, vomiting in 50.3%, photophobia in 80.0%, and phonophobia in 78.4%. In 58% of the cases, the headache was severe enough to disturb daily activities.

Conclusions: This study showed that migraine is more commonly seen in urban areas, in females, and is associated with high education plus low income, and is comprised of a wide complex of symptoms.

Key Words: clinical properties, migraine, sociodemographic characteristics

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Migraine is a common disease. The life-term prevalence of migraine is 10% for males and 25% for females. (1-6) The purpose of this study was to determine the clinical profile of patients with migraine who live in the vicinity of Erzurum.

Materials and Methods

This prospective study was conducted on patients diagnosed as having migraine according to International Headache Society (IHS) diagnostic criteria, (7) and who were seen in the Neurology Department outpatient clinics of Ataturk University, Faculty of Medicine, between August 2001 and July 2002. The patients' histories were taken and physical examinations were performed. Auxiliary examinations were performed when necessary. A questionnaire was administered to determine the demographic characteristics (age of headache onset, sex, level of education and income, type of migraine), clinical features of the migraine (frequency, duration, localization, and quality of headache), and coexisting symptoms (nausea, vomiting, photophobia, and phonophobia).

Results

One hundred eighty-five patients with migraine were included; 145 (78.4%) were female and 40 (21.1%) were male. The male-to-female ratio was 1:3.2 and the age range was 8 to 64 years (mean age, 32.37 [+ or -] 10.16 years). Forty-seven (25.4%) were diagnosed as having migraine with aura (MA), and the remaining 138 (77.6%) as having migraine without aura (MwA). The mean age of headache onset was 21.9 [+ or -] 8.4 for MA and 23.1 [+ or -] 9.4 years for MwA (P > 0.05). The mean duration of migraine was 9.3 [+ or -] 7.6 years. There was no significant difference between MA and MwA groups in terms of age, sex, age of headache onset, and headache duration (Table 1).

The patients' sociodemographic characteristics are displayed in Table 2. It was observed that 37.3% of the females and 90% of the males had education for at least 11 years. Of all patients, 79.5% had low or medium income, and 20.5% had fair or high-income status. There was a significant difference between males and females according to the distributions of economic (P = 0.020), educational (P = 0.013), marital (P = 0.001), and occupational status (P = 0.000).

The clinical features of the headache attacks are presented in Table 3. Nausea was a significantly more frequent complaint reported by females than by males in the MwA group (P = 0.000). Again, when the males were compared among themselves, nausea (P = 0.012, MA > MwA) and vomiting (P = 0.009, MA > MwA) differed significantly. In the MA group, the auras were characterized as pure visual in 76.5%, both visual and sensorial in 23.5%, pure sensory in 5.9%, both visual and aphasic in 5.9%, and pure motor auras in 2.9%. The prodromal symptoms reported were unusual exhaustion (48%), mood alterations (47.4%), yawning (23.7%), and appetite for sweet foods (21.7%).

The common precipitating factors are listed in Table 4. The most common factors were stress/tension (70.8%), disturbances of sleep (48.6%), disturbances of eating (41.6%), and foods/drinks (32.9%). Also, during the pain-free periods, there was sensitivity to noise (42.2%) and glare (31.9%). Headache was precipitated during the menstrual periods in 31% of the female cases. In both sexes, fatigue was significantly more common in the cases without aura (P = 0.009, MwA > MA).

The onset of headache was during the awake state in 77%. Patients also had pain in the face and eye (40.8%) and in the neck (44.1%). Daily activities were disturbed by the headache "always" in 57.9%, and "occasionally" in 25% of the cases. In addition, 40.1% required bed rest (44.1% in cases of MA versus 39% in MwA, and 40.8% in the females versus 37.5% in the males).

Patients tried to cope with the headaches by taking analgesics (75.7%), attempting to sleep in a dark, silent place (63.2%), physical/mental relaxation (44.1%), and massaging (19.1%).

Discussion

Migraine is a neurologic disease with a high prevalence. (1-6,8,9) A predominance of females is evident among those afflicted. (10) In our series, the male-to-female ratio was 1:3.2. A change of the sex distribution with age can be seen. Until puberty, the prevalence of migraine in boys is equal to that of girls. Over 12 years of age, the prevalence is greater in females, reaching a peak between 25 to 40 years. Later, this ratio drops. The increase of migraine prevalence in females soon after menarche suggests a possible initiator role of female sex hormones. (1,2,6,11-13) A similar female predominance has also been reported in field or outpatient clinic-based studies performed in our country. (8,9,14,15) This predominance is explained with a more common admission rate of females due to headache as a primary complaint. Also, it has been suggested that females are more sensitive and responsive to pain. (16)

The age of onset of migraine headaches is frequently (90%) lower than 50 years. There is a tendency to start at an earlier age in MA than MwA and in males than females. (11) In the childhood period, the peak age of onset is between 10 to 12 years in males and 14 to 16 years in females. (17,18) Steiner et al (19) have found the onset to be after the age of 40 in 8% of 479 patients, and they have reported that when headache starts after the age of 40, other potential causes should be excluded. In our study, the mean age of headache onset was 22.8 [+ or -] 9.1 years, and after the age of 40 it was only 3.9%. These cases did not have any other causes of headache.

MA was detected in 48 (25.4%) versus MwA in 137 (74.6%) patients. Several series have reported that in about one fourth of the cases, an aura precedes the headaches. (11,18,20) The most commonly encountered aura type is visual, followed by sensorial, aphasic, and motor auras, respectively, which are rarely encountered alone but rather accompany visual aura. (11,18,20,21) In our cases, visual auras were the most common, followed (in descending order of frequency) by visual-sensorial (23.5%), pure sensorial, and visual-aphasic auras; motor auras were the least-often encountered (2.9%).

The majority of patients (84.3%) were living in urban areas. The rural-to-urban area ratio was 1:5.3. About half of the cases (48.7%) had a history of education for more than 11 years. Contrary to the old beliefs, recent studies have shown an inverse correlation of migraine prevalence with income. (1,5,6) In their studies, Stewart et al (1) found a strong relation between low income levels and migraine prevalence. They especially have reported a high risk for females 30 to 49 years of age with low income. Outpatient clinic studies conducted in our country have also revealed similar ratios. (14,15) Likewise, in our study, 79.5% had low-medium income levels. In a population-based study, migraine headache rates were reported to be significantly higher in married, educated females living in urban areas. (9) The majority of our patients (70.8%) were married. When the cases were distributed according to their professional status, housewives constituted the highest rate (48.1%); however, this high rate can result from the fact that most females living in our region are house-wives.

Migraine is an inherited disease. Migraineurs usually report headaches in their family histories in rates varying from 45% to 70%. (11,22,23) In our study, a family history of headache was found to be at a rate of 72.4%, and the majority of these headaches (56.7%) were defined as migraine.

In the medical histories of our cases, childhood-age vomiting attacks and traveling sickness were reported as a rate of 31.9%. In one study, cyclic vomiting and traveling sickness is reported to be present in 45% of childhood migraineurs, and is suggested as an additional and reliable minor criterion. (24) Lanzi et al (25) have suggested that the combination of vomiting and traveling sickness is 3 to 6 times more frequently seen in children with migraine than in control subjects.

The basic diagnostic criteria of migraine include headache of throbbing-unilateral character, an attack period lasting 4 to 72 hours, exacerbation with routine physical activity, and combination of nausea, photophobia, and phonophobia. (11,14,15,19,20,26-28) Although a unilateral headache is considered specific for migraine, it is a criterion with a low sensitivity. (20) Nausea, photophobia, and phonophobia are more specific features.

A severe functional impairment defined as needing bed rest was observed in 40.1% of our cases. This rate was 44.1% in cases of MA versus 39% in cases of MwA and 40.8% in females versus 37.5% in males.

Conclusion

Our study reveals that migraine comprises a wide complex of symptoms, causes functional impairment, and is more frequently seen in urban areas, in females, and in subjects with higher education plus lower income.

Table 1. Mean values of some parameters in the migraine patients

                         Males and females   Females

Mean age at
  consultation (yr)      32.4 [+ or -] 10.2  32.9 [+ or -] 10.0
Mean age onset
  of headache (yr)       22.8 [+ or -] 9.1   22.9 [+ or -] 9.3
Mean duration of
  migraine history (yr)   9.3 [+ or -] 7.6    9.6 [+ or -] 7.9

                             Males           P value

Mean age at
  consultation (yr)      30.5 [+ or -] 10.5  0.830
Mean age onset
  of headache (yr)       22.2 [+ or -] 8.7   0.238
Mean duration of
  migraine history (yr)   8.3 [+ or -] 6.3   0.667

t tests, P [less than or equal to] 0.05; all others nonsignificant.

Table 2. Sociodemographic characteristics of migraine cases (a)

                            Males and females     Females
                            Frequency     %    Frequency  %

Number of cases                 185    100         145    78.4
Types
  MA                             48     25.4        39    26.9
  MwA                           137     74.6       106    73.1
Education
  None                           17      9.2        17    11.7
  Graduate school                78     42.2        74    51
  Some college                   41     22.2        24    16.6
  High school or less            49     26.5        30    20.7
Economic level
  Low                            26     14.1        20    13.8
  Average                       121     65.4        99    68.3
  High                           38     20.5        26    17.9
Marital status
  Single                         54     29.2        36    24.8
  Married                       131     70.8       109    75.2
Occupation
  Housewife                      89     48.1        89    61.4
  Student                        32     17.3        20    13.8
  Civil servant                  18      9.7         6     4.1
  Others                         46     24.9        30    20.7
Residence
  Urban                         156     84.3       122    84.1
  Rural                          29     15.6        23    15.9
Family history of headache
  Migraine history               76     41.1        53    36.6
  Others headache                58     31.3        51    35.2
Patient's life history
  None                           98     53          73    50.3
  Allergy                        33     17.9        26    17.9
  Motion sickness                59     31.9        49    33.8

                                 Males
                            Frequency  %

Number of cases                 40     21.6
Types
  MA                             9     22.5
  MwA                           31     77.5
Education
  None                          ...    ...
  Graduate school                4     10
  Some college                  42.5   42.5
  High school or less           47.5   47.5
Economic level
  Low                            6     15
  Average                       22     55
  High                          12     30
Marital status
  Single                        18     45
  Married                       22     55
Occupation
  Housewife                     ...    ...
  Student                       12     30
  Civil servant                 12     30
  Others                        16     40
Residence
  Urban                         34     85
  Rural                          6     15
Family history of headache
  Migraine history              23     57.5
  Others headache                7     17.5
Patient's life history
  None                          25     62.5
  Allergy                        7     17.5
  Motion sickness               10     25

Values are frequency and percentages.
(a) MwA, migraine without aura; MA, migraine with aura.

Table 3. Clinical characteristics of headache attacks (a,b)

                                       Males (%)         Females (%)
                                    MwA       MA       MwA        MA
                                  (N = 31)  (N = 9)  (N = 106)  (N = 39)

Frequency (per month)
  [less than or equal to]1 d        19.4      11.2      20.7      19.4
  1-3 d                             54.8      55.5      57.6      42.1
  4-6 d                             25.8      33.3      20.8      33.4
  [greater than or equal to]6 d     ...       ...        0.9       5.1
Duration
  [less than or equal to]4 h        19.5      22.2      10.4      20.5
  4-24 h                            64.5      55.6      64.2      38.5
  24-72 h                            9.6      22.2      19.8      30.7
  [greater than or equal to]72 h     6.4      ...        5.6      10.3
Intensity
  Mild                              ...       11.1       6.6      ...
  Moderate                          16.2      11.1      17        15.4
  Severe                            80.6      77.8      71.7      82.1
  Unbearable                         3.2      ...        4.7       2.5
Location
  Unilateral                        74.2      44.4      74.5      69.2
  Bilateral                         25.8      55.6      25.5      30.8
Quality
  Pulsatile                         80.6      66.7      75.5      84.6
  Others                            19.4      33.3      24.5      15.4
Aggravation by routine physical
  activity                          61.3      44.4      63.2      69.2
Associated symptoms of headache
  Nausea                            54.8     100        90.6      89.7
  Vomiting                          29        77.8      52.8      53.8
  Photophobia                       67.7      88.9      78.3      92.3
  Phonophobia                       77.4      88.9      76.4      82.1

                                  Males and females (%)
                                    MwA        MA
                                  (N = 137)  (N = 48)

Frequency (per month)
  [less than or equal to]1 d        20.4      18.7
  1-3 d                             56.9      43.8
  4-6 d                             21.9      33.3
  [greater than or equal to]6 d      0.8       4.2
Duration
  [less than or equal to]4 h        12.4      20.8
  4-24 h                            64.2      41.6
  24-72 h                           17.5      29.2
  [greater than or equal to]72 h     5.9       8.4
Intensity
  Mild                               5.1       2.1
  Moderate                          16.8      14.5
  Severe                            73.7      81.3
  Unbearable                         4.4       2.1
Location
  Unilateral                        74.5      64.6
  Bilateral                         25.5      35.4
Quality
  Pulsatile                         76.6      81.3
  Others                            23.4      18.7
Aggravation by routine physical
  activity                          62.8      64.6
Associated symptoms of headache
  Nausea                            82.5      91.6
  Vomiting                          47.4      58.3
  Photophobia                       75.9      91.6
  Phonophobia                       76.6      83.3

(a) MwA, migraine without aura; MA, migraine with aura.
(b) Values are percentages.

Table 4. Self-reported precipitating factors for migraine (a)

                     Males and females (%)      Females (%)
                        MwA        MA          MwA        MA
                     (N = 137)  (N = 48)    (N = 106)  (N = 39)

Stress/tension          71.5       68.1        71.7       71.8
Changes in sleep        48.2       50          44.3       51.3
Noise                   43.8       37.5        43.3       38.4
Missing a meal          43.8       35.4        40.6       35.9
Some food or drinks     31.4       37.5        31.1       33.3
Glare                   30.7       35.4        28.3       30.8
Menstruation (b)        33         25.7        33         25.6
Strong odors            27.7       20.8        30.2       17.9
Fatigue                 26.3        8.3        26.4       10.3
Weather changes         18.2       14.6        19.8       12.8

                          Males (%)
                        MwA       MA
                     (N = 31)  (N = 9)

Stress/tension          71       55.6
Changes in sleep        61.3     44.4
Noise                   45.2     33.3
Missing a meal          54.8     33.3
Some food or drinks     32.3     55.6
Glare                   38.7     55.6
Menstruation (b)        ...      ...
Strong odors            19.4     33.3
Fatigue                 25.8     ...
Weather changes          9.7     22.2

Values are percentages.
(a) MwA, migraine without aura; MA, migraine with aura.
(b) Women only.

Accepted June 22, 2004.

References

1. Stewart WF, Lipton RB, Celantano DD, Reed ML. Prevalence of migraine headache in the United States: relation to age, income, race and other sociodemographic factors. JAMA 1992;267:64-70.

2. Stewart WF, Schechter A, Rasmussen BK. Migraine prevalence: a review of population-based studies. Neurology 1994;44(suppl 4):17-23.

3. Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in general population: a prevalence study. J Clin Epidemiol 1991;44:1147-1157.

4. Russell MB, Rasmussen BK, Thorvaldsen P, Olesen J. Prevalence and sex-ratio of the subtypes of migraine. Int J Epidemiol 1995;24:612-618.

5. Martin BC, Dorfman JH, McMillan CA. Prevalence of migraine headache and association with sex, age, race, and rural/urban residence: a population-based study of Georgia Medicaid recipients. Clin Ther 1994;16:854-872.

6. Lipton RB, Stewart WF, Diamond S, et al. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache 2001;41:646-657.

7. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8(suppl 7):1-96.

8. Turkish Headache Epidemiological Study Group. Headache Screening Survey. Piar-Gallup, Marketing

9. Talasho[??]glu A, Cetinkaya F, Koseo[??]glu E, Nacar M. The Epidemiological and Clinical Properties of Migraine Headaches in Adult Women in the Region of Kayseri Province. 37th National Annual Neurological Congress Program and Report Summary Book. October 31 to November 4, 2001, Turkey, pp 244.

10. Stewart AL, Greenfield S, Hays RD, et al. Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study. JAMA 1989;262:907-913.

11. Mathew NT. Migraine, in Evans RW, Mathew NT (eds): Handbook of Headache. Lippincott Williams & Wilkins, Philadelphia, 2000, pp 22-60.

12. Silberstein SD, Lipton RB. Headache epidemiology: emphasis on migraine. Neurol Clin 1996;14:421-434.

13. Russell MB, Rasmussen BK, Fenger K, Olesen J. Migraine without aura and migraine with aura are distinct clinical entities: a study of four hundred and eighty-four male and female migraineurs from the general population. Cephalalgia 1996;16:215.

14. Mavio[??]glu H, Karaca S, Yilmaz H, et al. The demographic and clinical profiles of headache patients admitted to outpatient clinics. J Psychiatry Neurologic Sci (Turkish) 2000;2:110-115.

15. Cakmak G, Yayla V, Muhan A, et al. Socio-demographic evaluations of migraine patients. J Turkish Soc Cerebrovasc Dis 1996;2:29-31.

16. Lautenbacher S, Strain F. Sex differences in pain and thermal sensitivity: the role of body size. Percept Psychophys 1991;50:175-183.

17. I Abu-Arefeh, G Russell. Prevalence of headache and migraine in school-children. BMJ 1994;309:765-769.

18. Ferrari MD. Migraine. Lancet 1998:4;351:1043-1051.

19. Steiner TF, Guha P, Capildeo R, Rose FC. Migraine in patients attending a migraine clinic: an analysis by computer of age, sex, and family history. Headache 1980;20:190-195.

20. Smetana GW. The diagnostic value of historical features in primary headache syndromes: a comprehensive review. Arch Intern Med 2000;160:2729-2737.

21. Russell MB, Olesen J. A nosographic analysis of the migraine aura in a general population. Brain 1996;119:355-361.

22. Russell MB, Fenger K, Olesen J. The family history of migraine: direct versus indirect information. Cephalalgia 1991;11:156-160.

23. Bener A, Uduman SA, Qassimi EM, et al. Genetic and environmental factors associated with migraine in schoolchildren. Headache 2000;40:152-157.

24. Barabas G, Matthews WS, Ferrari M. Childhood migraine and motion sickness. Pediatrics 1983;72:188-190.

25. Lanzi G, Balottin U, Ottolini A, et al. Cyclic vomiting and recurrent abdominal pain as migraine or epileptic equivalents. Cephalalgia 1983;3:115-118.

26. Stewart WF, Schechter A, Lipton RB. Migraine heterogeneity: disability, pain intensity, and attack frequency and duration. Neurology 1994;44(suppl 4):S24-S39.

27. deq Ueiroz LP, Rapopat AM, Sheftell FD. Clinical characteristics of migraine without aura. Ar Qneuropsiquiatr 1998;56:78-82.

28. Leira R, Lainez JM, Pascual J, et al. Spanish study of quality of life in migraine, I: profile of the patient with migraine attending neurology clinics. Neurologia 1998;13:287-291.

RELATED ARTICLE: Key Points

* Migraine is one of the most common primary episodic headache disorders, characterized by various combinations of neurologic changes.

* A history of migraine is present in perhaps 70% of first-degree relatives.

* About one third of migraineurs were severely disabled and needed bed rest during the attack.

* Migraine is predominately an affliction of young people, particularly females, and has a close association with high education plus low income.

Recep Aygul, MD, Orhan Deniz, MD, Nuri Kocak, MD, Asuman Orhan, MD, and Hizir Ulvi, MD

From the Department of Neurology, Ataturk University Faculty of Medicine, Erzurum, Turkey.

Reprint requests to Dr. Recep Aygul, Ataturk Universitesi, Tip Fakultesi, Noroloji Anabilim Dalt, 25240 Erzurum, Turkey. E-mail: [e-mail]