Study design and time frame
A cross-sectional study was carried out on female students at Taif University in the period from February to June 2017.
Sampling
Multistage sampling methodology was carried out where Taif University was chosen. The university community of the female section of Taif University was the sampling frame. The university includes four medical colleges and seven non-medical colleges for females. The target population included all female students of the eleven colleges.
The total number of female students registered in the eleven colleges in the academic year 2016–2017 was 1733. A total coverage was done, and all students in the 11 colleges in all grades and classes were contacted. For each college, the Office of Student Affairs was contacted and a student list was obtained for every grade. With the help of the coordinator and the leader of every grade, questionnaire copies equal to the students’ number in every grade were distributed by the researchers in the self-study session of students where they were free from any academic duty. After excluding non-respondents, and those who met the exclusion criteria (those with a past history of head or neck injury, nasal allergy or inflammation, headache of secondary neurological disorders, or systematic disease and pregnant students), the response rate was 77.3%, and the total number of participants in the study was 1340 students.
The number of the eligible participants from each faculty was as follows: Faculty of Medicine (198 students), Faculty of Pharmacy (183), Faculty of Applied Medical Sciences (180), Faculty of Dentistry (157), Faculty of Science (85), Faculty of Literature (80), Faculty of Sharia and Law (96), Faculty of Education (86), Faculty of Design and Home Economics (94), Faculty of Computing and Information Technology (93), and Faculty of Managerial And Financial Sciences (88).
Study instrument
The study instrument was a pre-designed self-administered questionnaire that gathered information about age, college type, marital status, and educational grade. A stepwise approach was carried out to assess the prevalence of different types of headache, where a questionnaire to screen “headache” that contained three sections was used. The first section included a question to screen headache students, the second section included three questions to screen migraineurs, and the third section included four questions to screen students with TTH.
Step 1: For the determination of students with headache, an initial screening was carried out, where students who replied “yes” to this question: “Did you have two or more headaches in the last 3 months?” were the subjects with headache under consideration (916 students).
Step 2: For the screening of students who have migraine, students of positive answers in step 1 (916 students) were asked the three-item screening questions of the identification of migraine (ID Migraine™ screening tool): During the last 3 months, (1) Did you feel nauseated or sick in your stomach with your headaches? (2) Did light bother you when you had a headache (a lot more than when you do not have headaches)? and (3) Did your headache limit your ability to work, study, or do what you needed to do for at least 1 day? A test-diagnosis of migraine headache required at least two positive responses (436 students) [20].
The ID Migraine™ is a widely used screening tool for migraine that has showed good validity for diagnosis of migraineurs at primary health care services, as it investigates the major aspects of migraine headache, which are nausea, photophobia, and disability [20]. This tool was developed and validated by Lipton et al. and can be applied quickly to large numbers of populations [21]. Sensitivity, specificity, and positive predictive value of this test in primary care were estimated to be 81%, 75%, and 93%, respectively [22]. This test was also validated to be applied to adolescent students with a sensitivity of 62.1% and specificity of 71.1% [20,21,22]. In addition, it was used in studies done on university students in Arab countries and in Saudi Arabia [10, 19, 23].
For measuring migraine severity, pain intensity was measured on a 4-point scale ranged from 0 to 3, where 0 = no pain, 1 =mild, 2 = moderate, and 3 = severe headache. This scale was recommended by the International Headache Society [22]. For assessing migraine triggers, a list of triggers was provided in the questionnaire and included stress or anxiety, irregular sleep, much reading, exams, smoking, menstruation, exposure to sun, and noise. The students were instructed about the possibility to give more than one answer.
Step 3: For the diagnosis of TTH, the criteria of the International Headache Society (IHS) was used, where students screened positive in step 1, and did not fulfill the headache criteria of step 2, were asked if headache is (1) of pressing (non-pulsating) quality, (2) of mild or moderate intensity (may inhibit but does not prohibit activities), (3) of bilateral location, and (4) not aggravated by climbing stairs or similar routine physical activity. Diagnosis of TTH required at least two positive answers to the previous four questions (396 students) [24].
In the second and third sections, questions on frequency of headache, family history, medical consultation for headache, medications used, frequency of analgesic use, increase in headache frequency after analgesic use, and increasing analgesic dose used over time were presented. For students who reported having headache but who did not fulfill any of the migraine or TTH criteria, they were classified as students with unknown headache (84 students).
To assess the prevalence of depression among students, Beck Depression Inventory (BDI) was used. It is a 21-item scale where each item was scored from 0 to 3 according to the symptom severity, with a total score ranging from 0 to 63. It was possible to give an answer with a score that ranged from 0 to 3 (absent, mild, moderate, and severe). The patient was diagnosed as normal if having a score less than 26, mild depression if the score ranged from 26 to 38, moderate if ranged from 39 to 55, and severe depression if ranged from 56 to 63 [25].
Statistical analysis
The data were coded, tabulated, and analyzed using the Statistical Package for the Social Sciences (SPSS, version 20; IBM Corp., Armonk, NY, USA). Qualitative data were expressed as numbers and percentages, and the chi-square (χ2) test was used to test the relationship between variables. Quantitative data were expressed as mean and standard deviation (mean ± SD). A p value of < 0.05 was considered as statistically significant.