Modern characteristics of the epidemiology of the most common primary headaches in students of higher educational institutions

Introduction

Headache (HA) is a non-specific symptom that can accompany a fairly wide range of somatic and other pathologies. It is important to understand that HA in some cases is also an independent nosology, particularly when it comes to so-called primary benign headaches [1, 2]. In this review, we decided to examine the prevalence characteristics among students of two main pathologies from the primary HA group — tension-type headache (TTH) and migraine — due to their highest frequency in the population compared to other types of HA [3].

Headache has always been and remains an extremely significant medical and socio-economic problem. Despite the fact that this symptom often represents a benign condition that does not lead to significant health harm or death, it causes many people to suffer regularly, reducing their work capacity and learning ability, sometimes even leading to hospitalization and undoubtedly causing severe economic damage [4].

In the case of the social group we are considering — students of higher educational institutions — headache can reduce attentiveness in class, information retention, the quality and quantity of completed academic tasks, and lead to other, sometimes completely unpredictable, consequences, including, for example, the emergence of psychiatric disorders.

In Russian literature, there are no current reviews that fully examine the problem of HA prevalence in students, taking into account the modern realities of education, whose system is actively changing every year not only organizationally but also technologically; furthermore, the attitude of students themselves to study is also transforming due to a number of social and mental factors and processes [5, 6]. In general, the problem of suffering from headaches among students is characteristic not only of the Russian Federation or CIS countries; foreign students are equally susceptible to this ailment [7]; however, differences in educational systems in various countries and parts of the world should also be taken into account.

The relevance of the issue does not diminish over time also because, in our opinion, administrative structures to this day have not taken sufficient measures aimed at preventing the aggravation and solving this medico-social problem, which dictates the need to again draw public attention to it, characterizing it in the context of the present day.

Objective

The objective of this review is a comprehensive analysis of existing Russian and foreign literature, including studies, on the epidemiological features of tension-type headache and migraine in university students in order to determine the prevalence of both forms of HA among student groups divided according to several criteria, the key factors predisposing to HA, as well as comorbid disorders and anamnesis features associated with HA manifestations. It is also necessary to consider the characteristic consequences of the conditions under consideration in students, as well as the most commonly used therapeutic approaches applied to existing HA in this social group.

Key terms and concepts

Primary (benign) headaches are HAs that are etiopathogenetically unrelated to any identifiable organic pathology of various anatomical and functional brachycephalic structures (brain, head and neck vessels), and cannot be associated with a specific systemic pathology [1, 2].

According to the ICHD-3 of 2018 [8], the following types of primary HA are distinguished:

1. Tension-type headache.

2. Migraine:

   • With aura

   • Without aura.

3. Trigeminal autonomic cephalalgias (including cluster headache).

4. Other primary HAs.

Tension-type headache (TTH) is a type of primary HA that typically has the following clinical characteristics: bilateral, pressing, mild to moderate intensity, not accompanied by nausea or vomiting, rarely accompanied by photophobia, phonophobia, or loss of appetite, not aggravated or provoked by routine physical activity, lasting from thirty minutes to several days [1, 2].

Migraine is a type of primary HA that typically has the following clinical characteristics: unilateral, pulsating in nature, with pronounced and characteristic photophobia and phonophobia, often accompanied by nausea and vomiting, lasting from 4 to 72 hours [1, 2].

Migraine aura refers to transient neurological symptoms preceding the actual migraine HA (auditory, visual, speech, and other symptoms) [1, 2].

General epidemiological characteristics of headaches in students

Data on the prevalence of headache among university students vary significantly overall, but one common trend is evident — HA in general and its individual types occur frequently in students. For example, a study conducted among university students from all over Italy in 2021 and published in 2022 [9] surveyed 4926 students using an online questionnaire. It was found that 55% of respondents suffered from HA symptoms (without specifying the time frame), and furthermore, headache in this case caused quite significant damage to the ability to study and exam results (the study was conducted during the examination session). This study was conducted during the pandemic, which could have distorted the results (low physical activity, long hours spent in front of electronic device screens, and other factors), but, among other things, it showed how much HA is underestimated primarily by those who suffer from it: a small number of students (27%) attempted any drug therapy, and even fewer (19%) consulted a specialist or a headache center.

Another study, aimed at examining the epidemiology of both HA in general and its individual types (migraine with aura, migraine without aura, and episodic TTH) in students, in relation to a number of comorbid disorders and associated factors (internet addiction, insomnia), was conducted using a semi-structured questionnaire and published in 2021 [7]. It revealed new, even more attention-grabbing patterns: 95% of respondents had suffered from HA symptoms in the past year. Migraine was detected in 63.1% of respondents, migraine with aura in 43.3%, and TTH in 28.3%. It is worth noting that an association was found between migraine with aura and internet addiction. The study was not conducted on a very large sample (420 people), but it showed quite interesting results, including regarding the scientifically debated question of the link between HA and internet addiction.

A study of HA epidemiology via questionnaires among medical college students (471 people) in the Vidarbha region (India), conducted in 2023 [10], in addition to the overall prevalence of headache (80%), also showed an association with gender (87% in women, 71% in men) and a reliable association of the pathology with several psychosocial factors, such as dissatisfaction with academic performance, irritability, conflicts with others, work overload, and poverty (poor material and social status). Only headache in general (as a symptom) and TTH (as a diagnosis established according to ICHD-3) were considered. TTH was recognized as the most common type of HA, predominant in females (76% in women, 64% in men, 71% in all students). Furthermore, it was found that HA was associated with depression, but only in men, while anxiety and stress were associated with HA only in women. The limitations of this study include the modest sample size and the specificity of the results to a single educational institution, which reduces the reliability of projecting these results onto, for example, all of India.

A systematic review published in 2020 on the epidemiology of migraine in Arab countries [11] presents several data points that are attention-grabbing primarily because they are presented concerning different social groups, not just medical students. Among the general population, migraine prevalence varies from 2.6% to 32%, while among students of medical higher education institutions, this indicator ranged from 12.2% to 27.9%, suggesting a higher frequency of migraine suffering among representatives of this specific group.

Also in 2022, a fairly large systematic review and meta-analysis was published, dedicated to studying migraine in university students [12], according to which the overall prevalence of migraine among the studied social group was 19%, with significant gender differences in this indicator: 23% for women and 12% for men. It was noted that the consequences of HA were pronounced: from deterioration in academic performance to psychological comorbid disorders.

Interesting results are also presented by a study on the association between headache and tinnitus (subjective ear noise) in medical students, published in 2021 [13]. According to data collected via an online questionnaire, HA affected mostly women, Caucasians, aged 21-25 years. Regarding the sequence of symptoms, HA more often appeared before tinnitus. It is worth noting that the study was conducted on medical students from a single academic center.

In 2022, a study aimed at assessing the epidemiological characteristics of migraine among medical college students in western China was published [14]. This work features a large sample size (8783 people), despite the geographical and administrative narrowness (one medical college). Overall, the prevalence of migraine among students was 6.57%, with 5.9% among men and 6.77% among women, significantly higher among junior students. Moreover, migraine was found to be quite strongly associated with hereditary predisposition, acute respiratory viral infection (ARVI), psycho-emotional stress, sleep disturbances, and late awakening. It is worth noting that in this study, respondents underwent multi-stage testing (including in-person medical examination), and the diagnosis of "Migraine" was established quite reasonably (according to ICHD-3).

Epidemiological and clinical characteristics of HA in medical students at a medical college were also studied in Nepal in 2022 [15]. This work showed that the overall prevalence of HA was 26.86%, with TTH being the most common at 69.23%. The most significant provoking factors in this case were recognized as psycho-emotional stress and anxiety, and furthermore, the majority (63.09%) of the studied subjects noted that HA significantly disrupted their daily routine. It was more often detected in first- and fourth-year students (total of 5 years). The majority of respondents resorted to self-medication, mainly using non-steroidal anti-inflammatory drugs. The study was conducted via questionnaires but does not have an outstanding sample size (242 students).

In a study evaluating the association of HA, neck pain, stress, depression, and anxiety with prolonged viewing of electronic device screens [16], a direct association was found between a significant increase in HA intensity and smartphone use for 7 hours or more. 226 students were surveyed via an online questionnaire.

In 2018, a Russian study on the prevalence, structure, and provoking factors of headache in students was published [17]. It was conducted via questionnaires among students of Chuvash State University. Its results indicate an extremely high prevalence of HA among students in general — 88.1%, which corresponds more closely to the results of only the following works reviewed above: the 2021 study aimed at examining the epidemiology of HA in general, migraine, and episodic TTH [7], and the study by Indian colleagues [10]. HA in general was more common in women; an association was present between HA and a history of traumatic brain injury or mild concussion. A number of the most common clinical characteristics of headache in students were also identified: temporal localization, pressing in nature and moderate intensity, lasting up to 12 hours and occurring less than once a month. Headache often led to sleep disturbances and was accompanied by additional symptoms that reduce quality of life (specifically regarding intense pressing HA): tinnitus, nausea and dizziness, palpitations. The study has good detail but was conducted on a modest sample (420 students).

In a study on the frequency of headache depending on physical activity in students, conducted in 2023 at the Ural State University of Physical Education [18], a direct dependence of HA occurrence on physical exertion was found (60% of respondents noted a link between their HA and sports activities). Moreover, 93% of respondents complained of HA, which generally aligns with several data points presented in other works reviewed above. Besides the above, this study reveals several other patterns interesting for the general epidemiological characteristics of headache in students: those suffering from HA often use a smartphone for more than 5 hours a day and note limitations in work capacity and academic activity; HA in the surveyed students was often accompanied by dizziness, frequently by increased blood pressure and a feeling of neck stiffness; 81% of respondents indicated a direct association between headaches and experienced psycho-emotional stress. Unfortunately, this work cannot boast a large sample size — only 41 students, which may harm the objectivity and representativeness of the obtained data.

In 2022, a Russian scientific inquiry was presented with a focus quite interesting for our research purposes — studying the association between the frequency of headaches in medical students and comorbid psychiatric disorders such as anxiety and depression [19]. As a result of comprehensive testing of 80 students from the Faculty of General Medicine, including a survey, clinical and neurological examinations, and even a laboratory research method — determining blood serotonin levels — it was found that those suffering from HA often had palpatory tenderness of the pericranial muscles, and among the factors that most often provoked HA, lack of sleep, overwork, and psycho-emotional tension (stress) were noted. The age of HA onset was reported as 17.8 years (this concerns the main group of students — those who experience headaches regularly). The majority of respondents complained of HA which, considering the obtained data, could be classified according to ICHD-3 as tension-type headache; however, migraine was also common. In general, HA most often manifested in the evening, often accompanied in several subjects by nausea, photophobia, phonophobia, and facial flushing. According to the assessment using the Hospital Anxiety and Depression Scale, the level of anxiety was significantly higher in those who frequently experience headaches, while no difference in the level of depression was found. The data from the above-mentioned laboratory study are noteworthy: the serum serotonin level was significantly lower in those suffering from HA, and there was an inverse correlation between the quantitative serotonin level and the severity of pain and anxiety disorders.

Relatively recently, in 2023, a study conducted at the Pacific State Medical University was published, aiming to investigate (via questionnaires) the main tenets of the etiology of primary cephalgias in the context of their epidemiological characteristics in medical students [20]. 70 medical students participated in the study. Among the results were the following data: tension-type headache was most common among students — 67.1%, equally distributed across all six years (migraine was present in 14.3% of respondents, predominantly in 1st and 6th-year students, while mixed HA, representing the presence of both TTH and migraine simultaneously, was observed in 18.6%); 81.4% of respondents noted lack of sleep and overwork as the main causes of HA. Other common provoking factors for headache included nervous strain (70%), anxiety (51.4%), and dissatisfaction with studies (18.6%).

Thus, the prevalence of headache in general among students according to different sources varies from 26.86% [15] to 95% [7]. The frequency of headaches in the general population according to a 2022 review was 52% [21], which, compared to the indicators described above, allows us to assert quite confidently that HA is more prevalent among students than in the entire human population. A wide range of data also exists for individual types of HA: the prevalence of tension-type headache is estimated from 28.3% to 74.36% [7, 10, 20], migraine — from 6.57% to 63.1% [7, 11, 12, 14, 20]. It is almost unanimously stated that tension-type headache epidemiologically predominates over other types of primary HA, and only one study demonstrates a radically opposite result — the prevalence of migraine was 63.1%, and TTH only 28.3% [7].

The pronounced heterogeneity of epidemiological indicators may be related to geographical, racial-ethnic, and administrative factors, as well as, most likely, the absence of a unified research methodology for this problem, the different designs, components, goals, and objectives of the described works.

Otherwise, the reviewed studies, systematic reviews, and meta-analyses provide many patterns of interest to us that do not have such pronounced contradictions: concerning the likely provoking factors of headache. 

Given the high pace of digitalization in the education system and life in general, it is worth highlighting significant and relatively new provoking factors for headaches, namely, long-term smartphone use (prolonged viewing of screens of any electronic devices > 5-7 hours) [16, 18] and internet addiction [7, 10]. The most frequent and socially important consequences of headaches according to the reviewed studies are sleep disturbances [17], deterioration in academic performance [12], formation/exacerbation of anxiety and depression [12], and, overall, a decrease in quality of life [15].

Epidemiology of headaches in students depending on geographical location

According to data from a large-scale survey conducted by researchers in 2016 among students at the University of Hong Kong, sleep disturbances turned out to be a key factor provoking migraine [22, 23]. Almost all students with headaches (94%) noted lack of sleep as the main trigger, followed by disruptions in sleep patterns (83.1%) and increased noise levels (81.9%). The study predominantly involved girls — 534 people, while there were only 168 boys. The average age of respondents was about 21 years. Migraine pain was more often diagnosed in those whose relatives also suffered from this ailment, and in students with weakened health. One in eight students (11.8%) reported having migraine, and two-thirds of them experienced attacks monthly. A typical headache episode lasted about three hours with quite high intensity — 6.4 points out of 10 possible.

A large-scale online survey of more than 2,300 students at Rajshahi and Jahangirnagar universities in India revealed alarming statistics on headaches [23, 24]. Women proved to be more susceptible to this problem — almost 30% of female respondents complained of migraine, while among men the rate was only 12%. Overall, one in five students (21.4%) suffered from headaches. The main trigger for migraine turned out to be stress, characteristic of the university environment. Disruptions in sleep patterns, intense academic workload, and weather sensitivity also had a significant impact on the occurrence of attacks. The majority of migraine sufferers (more than 70%) experienced at least five serious attacks monthly, ranging from moderate to acute.

In the Turkish city of Sivas, a large-scale medical study was conducted covering more than one and a half thousand students at Cumhuriyet University [25]. It was found that the actual frequency of migraine occurrence among higher education students reached 10.6% (169 people), although according to students' self-reports this figure was higher — 13.7%. The final stage of the study included psychiatric diagnosis of migraine patients, based on the Structured Clinical Interview for DSM IV-R Axis I disorders. SCID-I diagnostics revealed the presence of current mental disorders in 23.1% of those examined (39 out of 169 migraine sufferers). According to SCID-I diagnostics, almost half of the surveyed students (43.2% or 73 people) received a lifetime psychiatric diagnosis.

In 2008, series of studies involving more than two thousand students (n=2023) revealed the presence of migraine in almost one in five students — 17.9% of respondents [26]. Even higher rates were obtained in the work by Bicakci S, where out of 1256 examined students, migraine was diagnosed in 21.9% of participants [27]. Meanwhile, the study by Demirkiran MK, covering 1029 students, showed a slightly lower prevalence — 12.4% [28].

A large-scale study of headaches among young people covered thousands of adolescents in North Trøndelag (Norway) [29]. The process included two stages of data collection: a written questionnaire on headache symptoms over the past year and a subsequent interview, in which 5847 students participated (out of more than 8,000 surveyed). The study showed gender differences in the frequency of headaches among young people. Girls proved to be more susceptible to all types of cephalgia regardless of age. Specifically, 84.2% of females reported having headaches in the past year, while among boys this figure was 69.4%. Analysis of headache types revealed the following distribution: migraine was observed in 7% of respondents, tension-type headaches in 18%, and unclassifiable headaches in 4.8% of respondents. Interestingly, age dynamics did not show significant changes in the frequency of recurrent cephalgias; however, gender differences turned out to be significant — females demonstrated a noticeably higher frequency of these somatic symptoms compared to males.

At the University of Lagos (Nigeria), a large-scale questionnaire survey revealed significant gender differences in the prevalence of cephalgia. The overall occurrence rate of headaches reached 46%, with women suffering from them almost twice as often as men (62.8% and 34.1% respectively) [30, 31]. The most common type is tension-type headache (18.1%), which affects both sexes almost equally: 17.3% of men and 19.2% of women. Migraine, occurring less frequently (6.4%), demonstrates pronounced gender specificity — women are three times more susceptible to it than men (10.9% vs. 3.2%).

Studies show varying prevalence of headaches in different regions of the world. In the university environment, this problem is particularly relevant among medical students. Statistics show that more than one-fifth of students (22%) have a hereditary predisposition to headaches. The majority of students (68.2%) prefer self-medication using over-the-counter analgesics instead of consulting specialists. Only 4.6% of students seek professional medical help [31]. Specialized medications for treating migraine and tension-type headache are practically not used in this group, indicating insufficient awareness of modern treatment methods even among future doctors.

In an analysis covering 806 future doctors from Palestine, female students comprised 59% (476 people) [32]. The study revealed that lack of sleep, physical exertion, and sleep pattern disturbances are key triggers of headaches. Among junior students, the highest frequency of both migraine (22%) and TTH (59.8%) cases was observed. Gender analysis showed a predominance of females over males in a ratio of 1.67:1 for both types of cephalgia.

In a medical study at the Ural State Medical University, lasting from March to November 2013, 1042 students participated, predominantly women (719 people). The average age of respondents was 20.6 years, ranging from 17 to 40 years, with no significant gender differences [31]. The study involved 1042 students, of whom 92.9% (968 people) reported headaches during the past year. Women constituted the majority — 684 versus 284 men.

In the week before the survey, headaches were noted in 46% of students, predominantly in women. Monthly statistics showed an increase to 68.5% of cases. Over the annual perspective, more than one thousand headache episodes were recorded among students, with some suffering from several types simultaneously. Three-quarters of all cases were episodic TTH; chronic forms were rare — only in 3.1% of cases.

Thus, there is no clear dependence of headache epidemiology on geographical location. All differences are explained by varying age, health status, gender, cultural differences, survey sampling, and imperfections in research methodology.

The epidemiology of headaches in students may vary depending on the field of study

In Kazan, an epidemiological study of headache in students was conducted in 2022. Junior students suffer from headaches more often (36.6±1.6%) than senior students (19.4±2.4%) [33]. This is associated with difficulties in adapting to the new university environment after school. The frequency of cephalgia is especially high in technical higher education institutions, where exact sciences predominate. The study revealed a relationship between headaches in students and their academic schedule. In different higher education institutions, the situation varied: from 23.7% in a veterinary university to 38.3% in a technical university. Among all students, 1.8% took academic leave due to neurological problems, where headache was the main reason. In the majority of students, headaches occurred during preparation for studies due to lack of sleep, fatigue, and a sedentary lifestyle. The problem of cephalgia among students requires attention when planning the educational process, especially considering that almost half of those suffering from it are smokers with 1 to 3 years of experience.

In 1.3% of the examined individuals (21 people), different types of migraine were diagnosed: the simple form was identified in 14 patients (0.8%), ophthalmic migraine in 4 (0.3%), and associated migraine in 3 (0.2%). Neurological departments of hospitals confirmed all cases before the start of higher education. The onset of the disease in the majority of patients occurred during puberty, and in 78% of cases, migraine was associated with the onset of menstruation. More than half of the cases (58%) were accompanied by hereditary arterial hypotension.

During diagnosis, various causes of tension-type headaches were identified. The dominant factor was spinal pathology (4.3%). Less common were moderate to high degree vision problems (2.1%), neuroses (0.7%), and cervical sympathetic syndrome (0.4%).

Examination of the muscular system showed that the majority of patients (72.2%) had myofascial pain syndrome. Many had painful lumps in the muscles of the head and neck (68%), as well as referred pain (72.2%). One-third of patients had trigger points, and 43% had limited neck mobility. Radiography revealed osteochondrosis (23.6%) and spondyloarthrosis (8.3%).

In 82 students (56.9%), headaches occurred periodically, while in 62 (43.1%) they were constant. The pain was moderate — about 2-2.5 points — and its specific characteristics depended on the underlying disease. Prolonged static tension during studies (up to 83% of the time) caused spasm of the muscles of the head and shoulder girdle. At the same time, electromyographic examination of 15 patients with tension-type cephalgia showed no pathology of peripheral motor neurons.

Conclusion

As a result of the literature review on this problem, a large number of important patterns are revealed concerning the modern epidemiology of primary headaches in students; data on provoking factors, comorbid disorders, and consequences of HA, and prevalence across different years and types of higher education institutions are clarified. However, there is pronounced heterogeneity in the main epidemiological indicators, which is most likely associated with the absence of a unified theme and methodology for studying the epidemiology of headache both in general and in particular. All this undoubtedly significantly complicates the scientific and public assessment of the problem under consideration.

The high prevalence of headaches among medical students requires special attention to this social group. Considering the increased complexity of the information mastered during the educational process and the natural difficulties in eliminating provoking factors, this category of patients likely needs early selection of preventive therapy for attacks to prevent pain chronification and the development of medication-overuse headache.

Particularly interesting for further research is the impact of modern digital technology use on the frequency and clinical features of headaches. In the context of an increasing proportion of distance education in the training of students of all specialties, including medical students, this issue becomes even more relevant.