LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
Medical Academy
Psychiatry Department
Sarina Shimonov
Anxiety, depression, and other factors associated with headache in medical
students
.Master’s Thesis
Thesis supervisor
Assoc. prof. V. Steibliene
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TABLE OF CONTANT
1. SUMMARY ... 3
2. ACKNOWLEDGMENTS ... 6
3. CONFLICT OF INTEREST... 7
4. CLEARANCE ISSUED BY THE ETHICS COMMITTEE ... 8
5. ABBREVIATION LIST ... 9
6. TERMS ... 10
7. INTRODUCTION ... 11
8. AIM AND OBJECTIVE OF THE THESIS ... 12
9. LITERATURE REVIEW ... 13
9.1 Problem of Headache in general population ... 9.2 Relations among Anxiety, its severity and headache ... 9.3 Associations among Depression , it’s severity and headache ... 9.4 Other factors associated with headache... 9.4.1 Age 9.4.2 Gender 9.4.3 Smoking and alcohol 9.4.4 Exercise 10. RESEARCH METHODOLOGY ... 17 10.1 Participants... 10.2 Procedure ... 10.3 Instrument ... 10.4 Analysis ... 11. RESULTS and DISCUSSION ... 19
12. CONCLUSIONS ... 29
13. PRACTICAL RECOMMENDATIONS ... 29
1. SUMMARY
Author: Sarina Shimonov
Title: Anxiety, depression, and other factors associated with headache in medical students. Background:
Aim: To evaluate the relations between severity of anxiety and depressive symptoms and characteristics of headache among undergraduate medical students of Lithuanian University of Health Sciences.
Methodology: the participants in this study were 191 medical students of Lithuanian University of Health All study participants answered to authors, created questionnaire about symptoms of headache. The Hospital Anxiety and Depression Scale was used to evaluate severity of anxiety and depressive symptoms.
Results: The majority of study participants suffered from headache (86%), more than 37.4% reported symptoms non-constant symptoms of headache, but period more than 6 months not constant Headache started before18 years old was most common (78.2%). 60.2% of students with headache were foreign (p=0.0367).
The most common severity of headache scale was 5-7 (60%). 82.6 % of those who suffer from headache were females.
Evaluation with HAD scale showed that the most of the students reported mild to moderate severity of anxiety symptoms (59.2%); had no depressive symptoms (64.8%) or reported mild to moderate depressive symptoms (34.5%).
The relations among use of alcohol and lower severity of depressive symptoms; the relations among higher severity of anxiety and higher severity of depressive symptoms (P<0.001; r= 0.374); the relations among lower depressive symptoms (p=0.013; r= -0.207) and more severe headache; more severe anxiety symptoms (p<0.001; r=0.37) and more severe headache were found.
Headache >6 months mostly related to female gender (p=0.004), to higher anxiety (p=0.018), menstruation period (p=0.018) and irregular sleep (p=0.044).
Conclusions: At least 4/5 of medical students suffer from headache and one third of students suffer from headache for period longer than >6 months; beginning of headache in majority of the students was under the age of eighteen years old. The frequency of headache in one thirds of the students was once/twice per week and in one thirds of the students was once/twice per month. Headache was more frequent among foreign students and females. Two third of students reported mild to moderate severity of anxiety symptoms. One third of students reported mild to moderate severity of depressive symptoms.
Higher severity of anxiety symptoms was related to female gender, more intensity symptoms of headaches, duration of headache longer > 6 month and more severe depressive symptoms.
4 Lower depressive symptoms related to more headaches and alcohol use; headache in duration longer than 6 months related to more severe anxiety and irregular sleep, female gender and menstruation period among females.
Practical recommendations: manage your schedule, sleep enough hours, if you need any professional help, do not afraid to seek help, it will decrease your suffering during the studies. Medical studies are long and exhausting, take care of your mental health.
1. SANTRAUKA
Autorius: Sarina Shimonov
Pavadinimas: Nerimas, depresija ir kiti veiksniai susiję su galvos skausmu tarp medicinos studentų. Tikslas: Nustatyti ryšį tarp nerimo, depresijos simptomų sunkumo ir galvos skausmo pobūdžio tarp LSMU medicinos studentų
Metodai: Tyrime dalyvavo 191 LSMU medicinos studentas. Visi tyrimo dalyviai atsakė į autorių sudaryto sociodemografinio klausimyno klausimus bei klausimus apie galvos skausmų pobūdį, trukmę ir kitus parametrus. Nerimo ir depresijos simptomų sunkumui įvertinti naudota Hospitalinė nerimo ir depresijos skalė (HADS).
Rezultatai: Dauguma studentų patiria galvos skausmus (86 proc.), iš jų 37,4 proc. atžymi nepastovų, tačiau lėtinį skausmą, trunkantį virš 6 mėnesių. 78,2 proc. tiriamųjų nurodo galvos skausmo atsiradimą iki 18 metų amžiaus. Iš visų tiriamųjų, patiriančių galvos skausmą, 60,2 proc. - užsienio studentai (p=0,0367). Dažniausias skausmo įvertis - 5-7 balai iš 10 (60 proc.). 82,6 proc. tiriamųjų, patiriančių galvos skausmą, yra moterys. Dauguma tiriamųjų nurodo patiriantys lengvą-vidutinį nerimą pagal HADS (59,2 proc. tiriamųjų), neturėjo depresijos simptomų (64,8 proc. tiriamųjų); o lengvus-vidutinius depresijos simptomus nurodo 34,5 proc. tyrimo dalyvių. Nustatyti ryšiai tarp alkoholio vartojimo ir žemesnio depresijos sunkumo; stipresnio nerimo ir sunkesnės depresijos (P<0.001; r= 0.374); lengvesnės depresijos ir stipresnio galvos skausmo (p=0.013; r= -0.207) ; stipresnio nerimo ir stipresnio galvos skausmo (p<0.001; r=0.37). Galvos skausmas, trunkantis daugiau nei 6 mėnesius, labiausiai susijęs su moteriška lytimi (p=0.004), sunkesniu nerimu (p=0.018), menstruacijomis (p=0.018) ir nereguliariu miegu (p=0.044).
Išvados: Mažiausiai 4 iš 5 medicinos studentų patiria galvos skausmą ir trečdalis jį jaučia virš 6 mėnesių; šie simptomai dažnesni moterims bei užsienio studentams. Du trečdaliai studentų nurodo jaučiantys lengvą ar vidutinį nerimą. Trečdalis – nesunkius depresijos simptomus. Stipresnis nerimas susijęs su moteriška lytimi, stipresniu galvos skausmu, trunkančiu daugiau nei 6 mėnesius bei labiau išreikštais depresijos simptomais. Lengvesni depresijos simptomai susiję su sunkesniu galvos skausmu ir alkoholio vartojimu. Galvos skausmas virš 6 mėnesių susijęs su sunkesniu nerimu bei nereguliariu miegu, moteriška lytimi ir menstruacijomis.
Praktinės rekomendacijos: Turėti aiškią dienotvarkę, miegoti pakankamą valandų skaičių, esant nerimui ar depresijos simptomams- nebijoti kreiptis pagalbos, rūpintis psichine sveikata.
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2. ACKNOWLEDGMENTS
I would like to thank the participants in the survey who supported my work and helped me getting high quality results. I am also grateful to assoc. prof. Vesta Steiblienė, for her patience and support in overcoming numerous obstacles I was facing throughout my research. I am also grateful to Shir Tiger a medical student who graduated last year for helping me organizing my paper. I would like to thank my friends for expecting me to be nothing less than excellence. I would like to thank my family for supporting me spiritually now and forever.
3. CONFLICT OF INTEREST
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4. CLEARANCE ISSUED BY THE ETHICS COMMITTEE
5. ABBREVIATION LIST
MMD- major depressive disorder BMI- Body Mass Index
IHS- International Headache Society
HADS- Hospital Anxiety and Depression Scale TTH-tension type headache
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6. TERMS
Anxiety- A chronic condition characterized by an excessive and persistent sense of apprehension, with physical symptoms such as sweating, palpitations, and feelings of stress.
Depression- negatively affects how you feel, the way you think and how you act. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.
7. INTRODUCTION
Headache is the one of the most common complaints among the general population, and in particularly common among medical students 41%-98%, many other researches was confirming this [23].
There is many factors as gender, family status, age, smoking, alcohol, exercise, sleeping hours that related to headache, which can exacerbate and on the opposite can relieve the headache as, lying down, or to be in dark quiet room, massages or ice/ cold compresses.
In this research, we would like to evaluate the relations between severity of anxiety and severity of depression with symptoms of headache in undergraduate medical students of Lithuanian University of Health Sciences.
Among the headaches, the most common is TTH and migraine. [24].
In the general population, the Migraine suffering people have 25% increase in depression and 50% anxiety. [25]
Anxiety shown to be more prominent in medical students with headache. [26]
As a big part of the research medical students answered a questionnaire about sociodemographic details, headache related questions, depression, and anxiety.
By analyzing the questionnaires, we will try to find the relations between each of the factors and evaluate the significance of them in medical students in LUHS, who suffer from headache and its relation to anxiety and depression.
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8. AIM AND OBJECTIVE OF THE THESIS
Aim: To evaluate the relations between severity of anxiety and severity of depression with symptoms of headache in undergraduate medical students of Lithuanian University of Health Sciences.
Objectives:
1. To determine the frequency and severity of headache in undergraduate medical students. 2. To determine and evaluate the severity of anxiety among undergraduate medical students. 3. To determine and evaluate the severity of depressive symptoms among undergraduate medical
students.
4. To determine other risk factors related to anxiety, depressive symptoms and headache in undergraduate medical students.
5. To evaluate the relations among anxiety, depressive symptoms, age, gender, smoking, other factors and headache in undergraduate medical students.
9. LITERATURE REVIEW
9.1 Problem of Headache in general population.
Headache is a general term that refers to a persistent or lasting pain in the head region. [7] During medical studies, headache is the most common complain. [8, 29].
There is several types of headache:
1. Tension headaches- dull, aching sensation all over your head often triggered by stress. Bilateral, "band-like," "tight cap", no throbbing headache, not worsened by physical activity, Uncommon to have phonophobia or photophobia.
2. Cluster headaches- severe burning and piercing pain. They occur around or behind one eye or on one side of the face at a time. Sometimes swelling, redness, flushing, and sweating can occur on the side that is affected by the headache. Nasal congestion and eye tearing also often occur on the same side as the headache. 15 minutes to three hours. More common in men, onset typically 10 - 39 years old.
3. Migraines- intense pulsing from deep within your head. Can last for days. Pulsating/throbbing quality. Length usually 4-72 hours long, unilateral (usually), do not exclude migraine if headache is bilateral. Nausea/vomiting, debilitating, aura (~25% of cases). Often sensitive to light and sound (photophobia, phonophobia) [27]. [9] Migraine prevalence is higher in medical students especially the last two years of study. Migraine is associated with poor sleep quality [28].
To measure severity of headache can be done by frequency, severity and duration, by questionnaire, dairy or interview.
The IHS grading of headache intensity contains four steps, including the “zero” step: mild, moderate, and severe.
Severe, prohibits daily activities;
Moderate, inhibits daily activities but does not prohibit activities; And mild or moderate, may inhibit activities. [10].
Excessive amounts of stress in medical training predisposes students for difficulties in solving interpersonal conflicts, sleeping disorders, decreased attention, reduced concentration, temptation to cheat on exams, depression, loss of objectivity, increased incidence of errors, and improper behavior such as negligence. [32]
14 9.2 Relations among Anxiety and its severity, and headache.
A physiological, psychological, and emotional state results when we behave apprehensively. [1]Anxiety is a problem when symptoms interfere with a person's ability to sleep or otherwise function. [2] Can cause symptoms as palpitations, choking, chest pain, and fear of dying, nausea, vomiting and abdominal pain. Most people who suffer from anxiety also have headache.
Types of Disorders: [3] Panic disorder
Social anxiety disorder Specific phobias.
Generalized anxiety disorder.
It is important to differentiate between normal anxieties from pathological anxieties.
The anxiety is a result of the body response to stress, the sympathetic nervous system "fight and flight" that caused by release of adrenaline. [4]
Highly associated factors are Female sex, increasing age, overweight and obesity [33].
There is high coexistence of depressive and anxiety symptoms among medical students [30].
stress and pressure of getting good grades, the lack of sleep are a risk factors that medical students has, that make them to be prone to depression and anxiety. [37].
9.3 Relations among Depression, its severity and headache.
Felling of sadness, loss of interest, feeling of guilt, decreased energy, decreased concentration, appetite changes, psychomotor agitation and retardation, aches, pains, headaches, or cramps that won't go away, Suicidal thoughts or attempts.
If the symptoms last >2 weeks and more than five of the symptoms above it is MDD.
In medical students the risk for depression in higher as there is multiple factors in the academic and clinical studies in addition to time pressure and social adjustments.
Medical students are mostly type A personality, Students have described the link between perfectionism and depression in their files. [5]. medical students are three times more susceptible to mental health disorders than the average college students. However, they are the last ones to ask for help. [37].
A headache secondary to depression is usually considered a tension-type (muscle contraction) headache. Migraine linked to both depression and anxiety. In fact, people with migraine are about five times more likely to develop depression than someone without migraine [35].
Medical students had higher depression rates than the general population, and women students had higher
rates than men did. [34, 36]. Females are more prone to depression especially in their hormonal periods as
menstrual period. It found that dark and short days, when colder, the risk of depression are higher, as well when spend more time indoor. Poor nutrition also found to cause depression. Stressful life events can cause depression, by releasing high levels of cortisol. [36].
9.4 Other factors associated with headache
There is other factors that associated with headache as dissatisfaction with study, dissatisfaction with family life, dissatisfaction for personal reasons, bad financial situation, overwork, stress, not enough sleep, insomnia, depressed mood, anxiety, irritability, tendency towards conflicts and not being married [6, 28]
9.4.1 Age
In a researches that was done among medical student can see that more than 80% had headache TTH or migraine (60%) as the reason of the headache, the average age was 18-22 years old men and women. [11, 12].
9.4.2 Gender
Some studies of medical students from public universities have reported that female students experience more depression, anxiety, and stress compared to male students, while others have reported no gender difference in prevalence of depression [13, 14, 19,31].
Headache is more prevalent in females than in males. TTH almost equally prevalent in females and males, but migraine more common in females (three times more) [15, 16].
9.4.3 Smoking and alcohol
Some of the studies did not find a significant association between headache and smoking and alcohol. [19, 20]
Other studies was found that there is higher risk of headache in people that smoke more than 10 cigarettes or passive smokers [21].
16 9.4.4 Exercise
Students with low physical activity are at risk of recurrent headaches. A recent study also concluded exercise as an alternative to prophylactic treatment of migraine [22].
During medical studies, headache is the most common complain. Anxiety and depression are very common mental disorder that increase with the years. From 1990-2013 there is increase in almost 50%. [17]
10. RESEARCH METHODOLOGY
10.1 Participants
The participants in this study were 142 medical students studying in LUHS. 10.2 Procedure
Firstly we decided which question be asked, secondly was agreement from the dean to use the LUHS students as a sample then we asked bioethical approval of Bioethics committee of LUHS (BEC MF 117, 2018/11/28) and finally I introduced my master thesis and asked the students when they were in the library or labs to their consent to participate and fill the survey in their free time. They had ample amount of time to complete the survey. The participant did not know that the questions were regarding anxiety and depression assessment, in order to be impartial, and avoid bias while felling the questioner. The survey was anonymous. Students were also informed that their results were not indicative of a clinical diagnosis. 10.3 Instrument
The survey instrument comprised a number of demographic items and questions relating to students if they are international student or local students, the year in which they are in, smoking and alcohol use habits, gender, faculty, age, faculty, exercise and sleeping hours.
For evaluation symptoms and severity of headache, we asked if they have headache in general, headache duration is more than 6 months, hours, frequency, intensity, site, quality of pain, nausea/ vomiting, photophobia, phonophobia, aura, eye tears, runny nose, if pain worsen with daily activity, what trigger and what relieve the pain.
For evaluation severity of anxiety and depression symptoms the Hospital anxiety and depression scale (HAD) was used. The HADS is self-rating instrument, used in general practice to determine the levels of anxiety and depression that a person is experiencing. Is a fourteen-item scale. Seven of the items relate to anxiety and seven relate to depression. Each item on the questionnaire is scored from 0-3 and this means that sum score a person can score between 0 and 21 for either anxiety or depression. For both scales, scores of less than 7 indicate non-cases, 8–10 Mild, 11–14 Moderate, 15–21 Severe symptoms.
18 10.4 Analysis
Data were processed using MS Excel 2010 and analyzed using IBM SPSS Statistics, version 22. Only completed surveys were included in the analysis. The descriptive analysis included the calculations of the prevalence, percentage, P values. Categorical data were presented as percentages (n, %). And I used the Chi square for the correlations.
We checked the correlations between different answers to find if there is a correlation at all by the P value, the correlations elected by the aims and objectives of our research.
The tables created to answer our considerations about the topic. To make an easier way to write the results and the conclusion and present the results simpler.
11. RESULTS AND DISCUSSION
11.1 Analysis of sample of medical students and symptoms of headache.
To analyze the characteristics and check the sample amount and the percentage of them we divided the table to three parameters, in each, we inserted the questions and their results.
Only the fully answered questionnaires inserted. In total was 191 students that answered, from them 49 did not answer the questionnaire fully and did not inserted to the results.
For the division of headache and its correlations with sociodemographic parameters the questions presented in table 1.
As shown in Table 1 62 (43.7%) local and 80 (56.3%) students participated in the research. the major sample from the research were 2nd course studentsfFrom 44 (31%), the other big sample is 29 students (20.4%) from 6th course, then 26 (18.3%) were 1st course. 20 (14.1%) were from 3th course. From 5th
course 12 students (8.5%). From 4th course 11 students (7.7%).
Of all- 96 (67.6%) were females, 46 (32.4%) were males. 67.6% of the participants were single, 71.8% did not smoke, 64.1% drinking alcohol. 54.2% are exercising. Most of the students 41.4% are sleeping 6-7 hours a night.
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Table 1. Socio-demographic parameters of study participants, n=142.
Characteristics N Percent
Local or foreign student Local Foreign 62 80 43.7 56.3 Course year 1st - 26 2nd- 44 3rd – 20 4th- 11 5th - 12 6th -29 18.3 31 14.1 7.7 8.5 20.4 Gender Male Female 46 96 32.4 67.6 Family status Single In a relationship Married 79 56 7 55.6 39.4 4.9 Smoking Yes No 40 102 28.2 71.8 Alcohol Yes No 91 51 64.1 35.9 Exercise Yes
How many days? 1-2 3-4 5-6 No 77 20 37 15 65 54.2 14.6 27 10.9 45.8 Sleep hours 5-6h 6-7h 7-8h 8-9h 16.2 40.8 33.8 7 16.4 41.4 34.3 7.1
As shown in Table 2. - from 142 students 123 (86.6%) reported having headache, students that had chronic headache >6 months not constant, but periodic, that started <18 years old is the most common (75%). The most common duration of headache in hours is 0-1 hours in 59 students (48.8%), 28 students (23.1%) complains that the duration of headache is too variable. 27 students (22.3%) marked that the duration is 1-6 hours.
48 of the students (38.1%) marked that the frequency of headache is one/twice per month, 39 (31%) marked that once/twice per week.
The most common severity in 1-10 scale is 5-7 with a mean of 20% each, but this is a subjective felling about the pain than we cannot conclude this results as a significant. Intensity of headache is also an individual and subjective. For people that tolerate pain more or less will answer differently. Data shows that 55 students (44.4%) had moderate intensity of headache without medication, 41 (33.1%) marked severe intensity, 24 (19.4%) mild headache and 4 (3.2%) incapacitating headache.
Most of the research students marked that there is no worsening of headache with daily activity, but in comparison to the beginning of modules/courses and week prior the exam, 64.8% felling worsening of headache.
Table 2. Symptoms of headache in undergraduate medical students. (n=123).
N %
Headaches ever Have
Does not have
123 19 86.6 13.4 Headache >6 month Yes No 46 77 37.4 62.6 Age of beginning of headache
<15 15-18 19-25 >25 36 39 24 3 35.4 38.2 23.5 2.9 Duration of headache 0-1h 1-6h 6-12h 12-24h Too variable 59 27 6 1 28 48.8 22.3 5.0 .8 23.1
22 Table 2. Continue
Frequency of headache
Once/twice per week Once/twice per month <1 in 3 months
>2 times per week
39 48 30 9 31 38.1 23.8 7.1 Intensity of headaches without meds
mild 24 19.4
moderate 55 44.4
severe 41 33.1
incapacitating 4 3.2
Headache worsened with daily activity
Yes 54 42.9
No 72 57.1
In comparison to the beginning of modules/courses and week prior the exam, do you feel any worsening?
Yes 81 64.8
11.2 Evaluation of anxiety symptoms among medical students
By Table 3 we can see that anxiety in medical students shown to be in different levels, almost 60% of the students are between mild and moderate anxiety severity, when 30.3% are 43 students with mild severity of anxiety and 28.9%, 41 students have moderate anxiety.
Table 3. Severity of anxiety in medical students
HADS anxiety N=142 Percent
0-7 normal 8-10 mild 11-14 moderate 15-21 severe 51 43 41 7 35.9 30.3 28.9 4.9
11.3 Evaluation of depressive symptoms among medical students
By Table 4 we can see that most of the medical students of LUHS are without depression 64.8%, 92 students from 142, the other big group are with mild and moderate depression with 49 students (34.5%).
Table 4. severity of depression in medical students in LUHS
HADS depression N Percent
0-7 normal 8-10 mild 11-14 moderate 15-21 severe 92 32 17 1 64.8 22.5 12 0.7
24 11.4 Factors and their relation to headache among medical students
From the table 5. We can see that students who have headache are mostly foreign, and students who do not have headache are mostly local. There is high correlation between them (P value =0.0367).
Medical Students who suffer from headache are also suffer mostly from mild anxiety and those who do not suffer from headaches are mostly with no any anxiety. (P value 0.037).
Table 5. Other factors and their relation to headache among medical students
Headache
Have
Total n=123
Does not have Total n=19 Difference between Groups N % N % Chi-square p-value Gender male 40 32.5 6 31.6 0.00 1.0000 female 83 67.5 13 68.4 Age 18-25 96 78.0 15 78.9 0.16 0.9249 26-30 26 21.1 4 21.1 >30 1 0.8 0 0.0
Course year 1st year 24 19.5 2 10.5 3.81 0.5770
2nd year 38 30.9 6 31.6
3rd year 16 13.0 4 21.1
4th year 8 6.5 3 15.8
5th year 11 8.9 1 5.3
6th year 26 21.1 3 15.8
Local or foreign local student 49 39.8 13 68.4 4.37 0.0367 foreign student 74 60.2 6 31.6
smoking yes 35 28.5 5 26.3 0.00 1.0000
no 88 71.5 14 73.7
alcohol yes 80 65.0 11 57.9 0.12 0.7283
no 43 35.0 8 42.1
HADS depression 0-7 normal 75 61 17 89.5 0.1
8-10 mild 30 24.4 2 10.5
11-14 moderate 17 13.8 0 0
15-21 severe 1 0.8 0 0
HADS anxiety 0-7 normal 39 31.7 12 63.2 0.037
8-10 mild 41 33.3 2 10.5
11-14 moderate 36 29.3 5 26.3
Continue of Table 5.
Headache
Have
Total n=123
Does not have Total n=19
Difference between Groups
Trigger factors N % N % Chi-square p-value
Menstruation ( women, n=84) Yes 30 36.6 1 50 0.698 No 52 63.4 1 50 Stress Yes 93 76.6 2 66.7 0.680 No 28 23.1 1 33.3 Exam Yes 57 47.5 1 33.3 0.627 No 63 52.5 2 66.7
Irregular sleep Yes 74 61.7 1 33.3 0.320
No 46 38.3 2 66.7
Much reading Yes 32 34 0 0 0.217
No 62 66 3 100
Headache that does not for long duration of life, there is no any correlation to trigger factors. Menstruation, stress, exam, irregular sleep and much reading does not influence on headache.
By Table 6, we can see that females who does have headache is 82.6%. In comparison to males who only 17.4%. From those values we conclude that there is relation between headaches duration >6 months and female gender (P=0.004). As was written in the literature that female has more complains of headache in our research also was approved.
26 Table 6. Duration of the headache >6 month among medical students and the relations with other factors
Headache > 6 months
Have Total n=46
Does not have Total n=77 Difference between Groups N % N % Chi-square p-value Gender male 8 17.4 33 42.9 0.004 female 38 82.6 44 57.1 Age 18-25 37 80.4 57 74 0.582 26-30 9 19.6 19 24.7 >30 0 0 1 1.3
Course year 1st year 8 17.4 15 19.5 0.521
2nd year 17 37 19 24.7
3rd year 5 10.9 12 15.6
4th year 2 4.3 7 9.1
5th year 6 13 6 7.8
6th year 8 17.4 18 23.4
Local or foreign Local student 16 34.8 32 41.6 0.456
Foreign 30 65.2 45 58.4
Smoking Yes 14 30.4 22 28.6 0.826
No 32 69.6 55 71.4
Alcohol use Yes 33 71.7 47 61 0.229
No 13 28.3 30 39 HADS depression 0-7 24 52.2 50 64.9 0.333 8-10 13 28.3 18 23.4 11-14 9 19.6 8 10.4 15-21 0 0 1 1.3 HADS anxiety 0-7 8 17.4 31 40.3 0.018 8-10 15 32.6 26 33.8 11-14 19 41.3 18 23.4 15-21 4 8.7 2 2.6
Continue of Table 6
Headache >6 months
Have Total n=46
Does not have Total n=77
Difference between Groups
Trigger factors N % N % Chi-square p-value
Menstruation, (women N=80) Yes 13 34.2 15 35.7 0.020 No 25 65.8 27 64.3 Stress Yes 33 71.7 59 59 0.249 No 11 28.3 14 14 Exam Yes 22 47.8 34 47.2 0.949 No 24 52.2 38 52.8
Irregular sleep Yes 34 73.9 40 55.6 0.044
No 12 26.1 32 44.4
Much reading Yes 11 35.5 20 32.8 0.796
No 20 64.5 41 67.2
Headaches that long in duration, >6 months enhanced by menstruation as a trigger factor. The relation between them is high as the P= 0.018. The data found that Females are more prone to depression especially in their hormonal periods as menstrual period. [36].
In addition, the irregular sleep of students is a trigger factor to headache as well. Students that respond that they have irregular sleep are also have headache. P=0.044. Irregular sleep is a trigger for headache especially migraine type. [32]. As we found in the literature anxiety, interfere with person's ability to sleep [2]. The data shows that some trigger factors related to headache, and on the opposite, we found that some are not related in LUHS students complains about stress, reading and exams.
Table 7. Significant relations among headache and anxiety, depression and other factors among medical students.
Headaches Relations P value
Local/foreign 0.019
HADS depression 0.013
28 Headache related to foreign students more than local (P value 0.019). Literature describe that colder place, when the days are short and dark, as in the winter in Lithuania the risk to develop depression are higher. The foreign students are more prone to depression in Lithuania as some come from warmth countries as Israel, Spain, Syria, Saudi Arabia and more. [36].
We found that as the headache starts earlier in life the duration is longer than 6 month and the headache longer in hours.
Those who had headache >6 months has more correlation with: Nausea and vomiting (P value 0.027), Worsening of headache with daily activity (P value 0.009) and anxiety (P value 0.002).
HADS depression Relations P value
Headaches 0.013
HADS anxiety 0.00
Depression is correlated with Headache (P value 0.013). Depression as well correlated with headache intensity without medications (P value 0.048). From our results we found that Students who drink Alcohol are depressed more (P value 0.05). I didn’t find a sifnificant correlation in the data about alcohol ad depression.
As written in the literature, depression and anxiety and comorbidities that comes together in most of the medical students [30].
HADS anxiety Relations P value, R value
gender 0.02, 0.253
HADS depression 0.00, 0.374
From the literature found that anxiety has a correlation with headache [2], by the research we found that Anxiety correlated with Headache scale 1-10 (P value 0.046), as well anxiety correlated with Headache worsening (P value 0.029). Headache worsening in comparison to the beginning of modules/courses and week prior the exam (P value 0.001) also correlated with anxiety. Headache worsen with daily activity (P value 0.005) is highly correlated anxiety.
Anxiety correlated with Aura (P value 0.008) , Phonophobia (P value 0.032) [27], Headache (P values 0.0497), Depression (P values 0.00), Headache intensity with/ without medications (P value 0.012/0.000), Gender (P values 0.0023) females more than males, in the literature there was some that found that there is a prevalent gender and some are not [13,14,19].
13. CONCLUSION
1. At least 4/5 of medical students suffer from headache and one third of students suffer from headache for period longer than >6 months; beginning of headache in majority of the students was under the age of eighteen years old. The frequency of headache in one thirds of the students was once/twice per week and in one thirds of the students was once/twice per month. Headache was more frequent among foreign students and females.
2. Two third of students reported mild to moderate severity of anxiety symptoms. 3. One third of students reported mild to moderate severity of depressive symptoms.
4. Higher severity of anxiety symptoms was related to female gender, more intensity symptoms of headaches, duration of headache longer > 6 month and more severe depressive symptoms.
5. Lower depressive symptoms related to more headaches and alcohol use; headache in duration longer than 6 months related to more severe anxiety and irregular sleep, female gender and menstruation period among females.
14. PRACTICAL RECOMMENDATIONS
In light of the findings in this study, we would like to recommend the university to implant policies of mental health services for international students, which are accessible and affordable. This includes both, private consultations and special programs, where students can get their emotional and social support not only from trained university personal, such as psychologists, but also from their fellow students.
Motivation is an important factor to help medical students maintain a healthy balance between study demand and personal well-being.
To manage the individual schedule to have enough sleep per night. Can decrease the risk to have headaches and decrease the risk to anxiety and depression.
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15. REFERENCES
[1] Jim Folk, Marilyn Folk, BScN. What is anxiety? What causes anxiety? Medscape. March 9, 2017 [2] Anxiety. By The medical news today Editorial Team. 5 January 2016
[3] What Are Anxiety Disorders? WebMD 12 June 2017
[4] By the MNT Editorial Team. Anxiety: Causes, symptoms, and treatments. December 2017. [5] Fiona Moir, Jill Yielder, Jasmine Sanson, and Yan Chen. Depression in medical students: current insights. 2018 May.
[6] Lebedeva ER, Kobzeva NR, Gilev DV, Kislyak NV, Olesen J. Psychosocial factors associated with migraine and tension-type headache in medical students. PubMed. Cephalalgia. Epub 2016 Nov 12 [7] Migraine and Headache Glossary WebMD Medical Reference (2017).
[8] J Res Med Sci. Prevalence and clinical characteristics of headache among medical students, Isfahan, Iran 2013 March.
[9] Judith Marcin, MD 10 Types of Headaches and How to Treat Them. On July 10, 2017
[10] Sjaastad, O., Fredriksen, T. A., Petersen, H. C., & Bakketeig, L. S. (2002). Grading of headache intensity. A proposal. Journal of Headache and Pain, 3(3), 117–127. https://doi.org/10.1007/s101940200029
[11] Zarea, K., Rahmani, M., Hassani, F., & Hakim, A. (2017). Epidemiology and associated factors of migraine headache among iranian medical students: A descriptive-analytical study. Clinical
Epidemiology and Global Health, 6(3), 109–114. https://doi.org/10.1016/j.cegh.2017.10.002
[12] Noor, T., Sajjad, A., & Asma, A. (2016). Frequency, character and predisposing factor of headache among students of medical college of Karachi. Journal of the Pakistan Medical Association, 66(2), 159–164.
[13] Saravanan, C., Wilks, R., Saravanan, C., & Wilks, R. (2014). Medical Students’ Experience of and Reaction to Stress: The Role of Depression and Anxiety. The Scientific World Journal, 2014, 1–8. https://doi.org/10.1155/2014/737382
[14] Lúcia Damásio Moutinho, I., De Castro, N., Maddalena, P., Kleinsorge Roland, R., Lamas Granero Lucchetti, A., Helena Cerrato Tibiriçá, S., … Lucchetti, G. (2017). Depression, stress anD anxiety in meDical stuDents: a cross-sectional comparison between stuDents from Different semesters Depression, stress and anxiety in medical students: A cross- -sectional comparison between students from different semesters. Rev Assoc Med Bras, 63(1), 21–28. https://doi.org/10.1590/1806- 9282.63.01.21
[15] FI Ojini, Nu Okubadejo, MA Danesi. (April 2009). Prevalence and Clinical Characteristics of Headache in Medical Students of the University of Lagos, Nigeria.
[16] Sanya, E., Desalu, O., Aderibigbe, S., Kolo, P., Mustapha, A., & Adeyanju, O. (2017). Prevalence and clinical characteristics of headaches among undergraduate students in three tertiary institutions in Ilorin, Nigeria. Nigerian Journal of Clinical Practice, 20(11), 1411. https://doi.org/10.4103/njcp.njcp_383_16
[17] WHO. Investing in treatment for depression and anxiety leads to fourfold return. April 2016. [18] Migraine and Headache Glossary WebMD Medical Reference (2017).
[19] Iqbal, S., Gupta, S., & Venkatarao, E. (2015). Stress , anxiety & depression among medical undergraduate students & their socio- demographic correlates. The Indian Journal of Medical
Research, (March), 72–75. https://doi.org/10.4103/0971-5916.156571
[20] Balaban, H., Semiz, M., Senturk, I. A., Kavakci, O., Cinar, Z., Dikici, A., & Topaktas, S. (2012). Migraine prevalence, alexithymia, and post-traumatic stress disorder among medical students in turkey. Journal of Headache and Pain, 13(6), 459–467. https://doi.org/10.1007/s10194-012-0452-7
[21] A. H. Aamodt L. J. Stovner K. Hagen G. Bråthen J. Zwart (October 2006). Headache prevalence related to smoking and alcohol use. The Head‐HUNT Study.
[22] Bindu Menon and Neeharika Kinnera (2013) Prevalence and characteristics of migraine in medical students and its impact on their daily activities.
[23] Bakhshi, S. K., Naim, H., Salman, A., Imran, M., & Ashraf, J. (2016). The Frequency , Classification and Characteristics of Headache Among Medical Students of Karachi , 6(3), 78–83.
32 [24] Lebedeva, E. R., Kobzeva, N. R., Gilev, D. V., Kislyak, N. V., & Olesen, J. (2017). Psychosocial factors associated with migraine and tension-type headache in medical students. Cephalalgia, 37(13), 1264– 1271. https://doi.org/10.1177/0333102416678389
[25] Study, M. A. C., Chu, H., Liang, C., Lee, J., & Yeh, T. (2017). Research Submissions Associations Between Depression / Anxiety and Headache, (325). https://doi.org/10.1111/head.13215
[26] Yasa, I., Kedokteran, F., Udayana, U., & Widyadharma, E. (2015). ANXIETY CORRELATED WITH TENSION-TYPE HEADACHE IN MEDICAL, (August), 3–7.
[27] Llop, S. M., Frandsen, J. E., Digre, K. B., Katz, B. J., Crum, A. V, Zhang, C., & Warner, J. E. A. (2016). Increased prevalence of depression and anxiety in patients with migraine and interictal photophobia. The Journal of Headache and Pain. https://doi.org/10.1186/s10194-016-0629-6 [28] Walters, A. B., Hamer, J. D., & Smitherman, T. A. (2014). Research Submission Sleep Disturbance
and Affective Comorbidity Among Episodic Migraineurs, 116–124. https://doi.org/10.1111/head.12168
[29] Ghorbani A, Abtahi SM, Fereidan-Esfahani M, et al. Prevalence and clinical characteristics of headache among medical students, Isfahan, Iran. J Res Med Sci. 2013;18(Suppl 1):S24–S27.
[30] Mayer, F. B., Santos, I. S., Silveira, P. S. P., Helena, M., Lopes, I., Regina, A., … Almeida, R. (2016).
Factors associated to depression and anxiety in medical students : a multicenter study. BMC Medical
Education, 1–9. https://doi.org/10.1186/s12909-016-0791-1
[31] Iqbal S, Gupta S, Venkatarao E. Stress, anxiety and depression among medical undergraduate students and their socio-demographic correlates. Indian J Med Res. 2015;141(3):354–357.
[32] Arabia, S. (2017). Prevalence , predictors and triggers of migraine headache among medical students and interns in, 33(2).
[33] Yousif, W., Wahed, A., & Hassan, S. K. (2017). Alexandria University Faculty of Medicine Prevalence and associated factors of stress , anxiety and depression among medical Fayoum University students. Alexandria Journal of Medicine, 53(1), 77–84. https://doi.org/10.1016/j.ajme.2016.01.005
[34] Yousif, W., Wahed, A., & Hassan, S. K. (2017). Alexandria University Faculty of Medicine Prevalence and associated factors of stress , anxiety and depression among medical Fayoum University students. Alexandria Journal of Medicine, 53(1), 77–84. https://doi.org/10.1016/j.ajme.2016.01.005 [35] Dawn Buse, Ph.D., the Director of Behavioral Medicine at the Montefiore Headache Center and an associate professor in the Department of Neurology at Albert Einstein College of Medicine in New York.
[36] Schimelpfening, B. N. (2019). 9 Most Common Causes of Depression.
