Headache Syndromes in the Eastern Province of Saudi Arabia
Saad AI-Rajeh, M.D., Olajide Bademosi, M.D., FRCP (Lond), Hassan Ismail, M.D. MRCP (UK), and Adnan Awada, M.D.
Department of Neurology, King Faisal University, Dammam, Saudi Arabia. Reprint requests to: Dr. Saad AI-Rajeh, Department of Neurology, Colleges of Medicine and Medical Sciences, King Faisal University, P.O. Box 2114, Dammam 31451, Saudi Arabia. Accepted for Publication: March 27, 1990. SYNOPSIS
The pattern of headache syndromes in 222 subjects (142 Saudi nationals, 80 non-Saudis) seen at AI-Khobar, Saudi Arabia is presented. Headaches were common, and accounted for 13% of all neurological outpatients. They affected mainly young adults, with a peak frequency in the third decade for Saudis and the fourth for non-Saudis. They were rare in those under 10 and above 50 years old. Among Saudis, females outnumbered males especially in the second and fifth decades, while non-Saudi males were more frequent than females in all age groups except the second decade. The main types were tension headache (66%) and migraine (22%). Acute/chronic sinusitis was an uncommon cause of headache. Tension headache affected mainly individuals between 21 and 40 years of age (69%). It showed a female preponderance in Saudis aged 11-20 and above 40 years, unlike the male predilection in non-Saudis. Migraine showed a definite female predilection only in Saudis in the fourth decade (female to male ratio of 4:1 ). A positive family history for headache was present in 10% of the cases. The major precipitating factor for headaches was stress related to family or working conditions. Other triggers included hunger and prolonged exposure to excessive heat or sunlight. The pattern of headaches in Saudi nationals may be related to the prevalent sociocultural factors, and the differences observed between them and non-Saudis probably reflect the demographic status of non-Saudis in the Kingdom as a consequence of governmental recruitment policy. (Headache 30:359-362, 1990) INTRODUCTION
Headache is one of the most frequent and distressing of human discomforts. It is a symptom of diverse clinical entities, and may be precipitated by physical and environmental stimuli. Information on headache syndromes in the Arab peninsula has been limited to pseudotumour cerebri.1 This communication describes our experience of headache syndromes in the Eastern Province of Saudi Arabia. MATERIALS AND METHODS
All the patients with headache as the primary reason for their hospital visit for evaluation by the Department of Neurology, King Fahd Hospital of the University (KFHU), AI-Khobar, between December 1983 and November 1988 formed the basis of the study. Patients were excluded from the study on any of the following criteria: i. when headache was not the main presenting symptom that necessitated the visit to the hospital, ii. when the headache was a non-dominant component of other presenting symptoms of the clinical picture; i.e.: secondary to causes such as cerebrovascular disorders (cerebral haemorrhage, ischemic cerebrovascular disease, transient ischemic attacks), meningitis, brain tumours, subdural hematoma, acute head trauma, and arterial hypertension, iii. headache related to previous head injury; i.e. post-traumatic headache syndrome. Apart from routine investigations such as hematologic indices and biochemical tests, other tests included radiographs of the skull, brain computerized axial tomography (CT Scan) with and withouut enhancement, and electroencephalography (EEG). Lumbar puncture to measure the cerebrospinal fluid (CSF) entry pressure and obtain CSF for microscopy and biochemistry, and blood and CSF serology, were performed when indicated. For this study, headache was defined as pain or discomfort involving any part of the head including the face, and upper aspects of the neck. The headache syndromes were classified as: a. Migraine: recurrent episodic throbbing or pulsatile headache lasting 2-72 hours with total freedom between attacks; the headache, commonly unilateral, may be associated with visual, gastrointestinal or autonomic disturbances.2 b. Tension (Muscular, Psychogenic) headache: continuous, often persistent, chronic headache, usually generalised, occipital or vertex in location, with or without associated symptoms such as palpitations, dizziness, difficulty in concentration, and other features of anxiety or depression, c. Benign raised intracranial pressure: when the headache was associated with elevated CSF entry pressure at lumbar puncture (>200 mm water) and papilledema on funduscopy but without other clinical or
radiologic evidence, including brain CT scan, of other intracranial pathology such as tumor, intracranial hemorrhage, or cerebral infarct, and subdural collection (haematoma, abscess etc.), d. Miscellaneous: includes conditions such as sinusitis, malocclusion of the temporomandibular joints, ocular disorders, atypical facial pain, and sub-arachnoid hemorrhage. The presence of subarachronic hemorrhage was accepted only in the presence of uniformly bloodstained CSF, characteristic brain CT Scan findings, as well as absence of brain CT changes of other forms of cerebrovascular disorders such as parenchymal hemorrhage and infarct. The diagnosis of brain tumor was accepted on findings at exploratory craniotomy and histologic confirmation of biopsy specimen obtained at operation, skull radiographs and brain CT scan. RESULTS
During the period of study, 222 patients consisting of 142 Saudi nationals and 80 non-Saudis satisfied the selection criteria and constituted the study population. Headache syndromes accounted for 13% Of neurological outpatient clinic attendances and constituted 1/1,000 of total hospital consultations. The age and sex distributions of the patients are shown in Table 1. Headache, most frequent in the third decade (36.0%), affected mainly young adults and was uncommon in children and those more than 50 years old. Sixty-nine percent of the cases were between 21 and 40 years old, and 81% were under 40 years old. The peak prevalence of headache in Saudis was in the third decade, but was a decade later for non-Saudis (Tables 3 and 4). There was no definite overall sex preponderance although females outnumbered males in the second and fifth decades and also in those more than 50 years old. The frequency of the various types of headache syndromes related to nationality is shown in Table 2. Tension headache (67%) was most common and showed equal sex distribution. Migraine, seen in 28% affected males more than females irrespective of nationality with a male to female ratio of 1.4:1. Table 3 shows the age and sex distribution of Saudis with headache syndromes. Females outnumbered males particularly in those under 20 years and above 40 years old with a female:male ratio of 2:1 and 3:1 respectively. Among non-Saudis, headache syndromes were most frequent in the fourth decade, and males were more affected than females in all the age groups except in the second decade (Table 4). Benign raised intracranial pressure was diagnosed in 6 patients (5 Saudis, 1 non-Saudi; all females, aged between 12 and 42 years). Other conditions encountered included cerebral arteriovenous malformation 2 cases,* and 1 case each of atypical facial Table 1 Age and Sex Distribution of Subjects with Headache Syndromes Age in Years Male Female Total Percentage - 10 0 1 1 0.5 11 - 20 9 16 25 11.3 21 - 30 50 36 86 38.7 31 - 40 37 31 68 30.6 41 - 50 14 20 34 15.3 > 50 3 5 8 3.6 TOTAL 113 109 222 100.0 PERCENTAGE 51.0 49.0 100.0 Table 2 Types of Headache Syndromes Related to Sex and Nationality *Headache Type Male Female Total Percentage Migraine 36 27 63 (100.0) 28.0 Saudi 21 18 39 ( 62.0) Non-Saudi 15 9 24 ( 38.0) Tension Headache 75 74 149 (100.0) 67.0 Saudi 42 53 95 ( 64.0) Non-Saudi 33 21 54 ( 36.0) Others 3 9 12 (100.0) 5.0 Saudi 1 8 9 ( 75.0) Non-Saudi 2 1 3 ( 25.0) *Benign
Intracranial Hypertension
6
Acute/Chronic Sinusitis 4 Atypical Facial Pain; Intracranial Tumor; 1 Each Table 3 Age and Sex Distribution of Saudi Subjects with Headache Syndromes Age in Years Male Female Total Percentage - 10 0 1 1 0.7 11 - 20 6 11 17 12.0 21 - 30 36 28 64 45.1 31 - 40 13 20 33 23.2 41 - 50 8 15 23 16.2 > 50 1 3 4 2.8 TOTAL 64 78 142 100.0 PERCENTAGE 45.0 55.0 100.0 Table 4 Age and Sex Distribution of Non-Saudi Subjects with Headache Syndromes Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 3 5 8 10.0 21 - 30 13 7 20 25.0 31 - 40 24 11 35 43.8 41 - 50 7 6 13 16.2 > 50 2 2 4 5.0 TOTAL 49 31 80 100.0 PERCENTAGE 61.0 39.0 100.0
pain and intracranial tumour. Acute and/or chronic sinusitis was the primary cause of headache in 4 patients but was an associated finding in 3% of the cases. Tables 5 and 6 show the age and sex distributions of the Saudi and non-Saudi subjects with migraine. In Saudis, migraine was most frequently encountered in the third decade (41.0%), and showed a definite female predilection only in the fourth decade when the female:male ratio was 4:1. For non-Saudis, migraine was most common in the fourth decade (35.0%) and showed a consistent male preponderance in all the age groups (Table 6). Sixty-six of the 95 Saudi patients (69.5%) with tension headache were between 21 and 40 years old (Table 7). Females outnumbered males in the groups under 20 years old and above 40 years old; the female:male ratios were 3.5:1 and 4:1 respectively. However, males marginally outnumbered females in the 21-40 year old stratum with a male to female ratio of 1.2:1. Table 8 shows the age and sex distribution of non-Saudi patients with tension headache. The peak frequency was in the fourth decade, and 69% of them were between 21 and 40 years old. Non-Saudi males were more frequently affected than females in all age groups except the second decade where there was a reversal with a male to female ratio of 1:5. Twenty percent of the individuals with migraine had associated tension headache. A positive family history of headache in at least one close relation was Table 5 Age and Sex Distribution of Saudi Subjects with Migraine Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 4 2 6 15.4 21 - 30 10 6 16 41.0 31 - 40 2 8 10 25.6 41 - 50 5 2 7 18.0 > 50 0 0 0 0.0 TOTAL 21 18 39 100.0 PERCENTAGE 54.0 46.0 100.0 Table 6 Age and Sex Distribution of Non-Saudi Subjects with Migraine Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 2 0 2 8.3 21 - 30 5 1 6 25.0 31 - 40 6 5 11 45.8 41 - 50 2 2 4 16.7 > 50 0 1 1 4.2 TOTAL 15 9 24 100.0 PERCENTAGE 62.5 37.5 100.0
obtained in 27 patients (20 Saudis, 7 non-Saudis), and was more frequent in those with migraine (17 cases) than with tension headache (7 cases). Depression was an associated feature in 11 patients with tension headache. The main precipitating factors for both migraine and tension headache were emotional and family stress (103 cases) associated mainly with anxiety about work, or problems with or within the family. Other factors included hunger (6 cases), prolonged exposure to heat and sunlight (3 cases), and food items especially any form of cheese or chocolate (3 cases). Migraine attacks were related to menstrual cycle in 15 females, induced by oral contraceptive pills in 6 females, and was related to sexual activity in a 17-year-old girl. DISCUSSION
This study shows that headache is common in this predominantly Arab community, and its frequency in both hospital and neurological outpatient attendance is similar to the described pattern from other clinical settings.3,4 The relative rarity of headache in children is however in contrast to the experience of others.5-7 It may be related to the apparent inability of children in general to express themselves explicitly, or unawareness of their symptoms by parents and relations since the diagnosis of headache syndromes is most often made retrospectively in the majority of cases.8 The high frequency of tension headache in this series is similar to the reported range of 60-80% of Table 7 Age and Sex Distribution of Saudi Subjects with Tension Headache Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 2 7 9 9.5 21 - 30 25 20 45 47.4 31 - 40 11 10 21 22.1 41 - 50 3 13 16 16.8 > 50 1 3 4 4.2 TOTAL 42 53 95 100.0 PERCENTAGE 44.0 56.0 100.0 Table 8 Age and Sex Distribution of Non-Saudi Subjects with Tension Headache Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 1 5 6 11.1 21 - 30 10 6 16 29.6 31 - 40 15 6 21 38.9 41 - 50 5 3 8 14.8 > 50 2 1 3 5.6 TOTAL 33 21 54 100.0 PERCENTAGE 55.0 45.0 100.0
all headaches from other studies,9-11 The clinical presentation of tension headache in our patients conforms to the well-documented pattern and needs no further comments.11 The low frequency of tension headache in individuals under 20 years old, similar to the experience of others,12-14 probably reflects age-related psychologic differences as suggested by Levington and colleagues.15 The male preponderance observed in non-Saudis with tension headache is unlike the female predilection described in other series. It most likely reflects the sex stratification of non-Saudis in the Kingdom of Saudi Arabia where males outnumber females because of the recruitment policy.16 Despite the overall female preponderance of Saudi females in tension headache, it is interesting to note the peculiar sex distribution of the Saudi patients in the various decades in this study. The increased male frequency between the third and fourth decades probably reflects the added responsibility imposed by family and social factors. The female preponderance in those under 20 and above 40 years old is most likely related to the effect of socioeconomic and cultural influences including marriage and child bearing and rearing. The marked female predominance in Saudis with migraine in the fourth decade conforms to the pattern from other communities.4,5,17 The overall increased Saudi male frequency in migraine in this study is difficult to explain, and may possibly reflect differences in hospital attendance, as males commonly outnumber females in general outpatient clinic visits. It may, however, be associated with the type of migraine as atypical forms of migraine are commoner in males.5,15 Similarly, the predominance of males in non-Saudis with migraine, though unusual, probably mirrors the sex distribution of non-Saudis in the Kingdom, who constitute a selected population as a result of recruitment patterns. The low frequency of benign raised intracranial pressure and intracranial space occupying lesions in this series probably reflects selection and referral pattern bias: the majority of the individuals with these conditions in this environment are more likely to have been evaluated by the first contact physician, and subsequently sent directly to the neurosurgeons. However, it is interesting to note that the frequency of headache as the presenting symptom in all such cases in this study is similar to the 74-99% reported by others.18 REFERENCES
1.
Phadke JG, AI-Deeb S: Pseudotumor cerebri (benign intracranial pressure) in Saudi Arabia. Saudi Med J 8:391-395, 1987.
2.
Blau JN: Towards a definition of migraine headache. Lancet 1:444-445, 1984.
3.
Jamieson M: Headache. Brit Med J 288:1281-83, 1984.
4.
Bademosi O: Headache II: Common clinical types of headaches in Nigerians. Nig Med J 12:63-67, 1986.
5.
Selby H, Lance JW: Observations on 500 cases of migraine and allied vascular headache. J Neurol Neurosurg Psychiat 23:23-32, 1960.
6.
Congdon PJ, Forsythe WI: Migraine in children: A study of 300 children. Devl Med Chld Neurol 21:209-216, 1979.
7.
Hockaday JM: Headache in children. Br J Hosp Med 27:383-390, 1982.
8.
Lance JW, Curran D, Anthony M: Investigations into the mechanisms and treatment of chronic headache. Med J Aust 2:909-914, 1965.
9.
Osuntokun BO: Headache as a presenting symptom in Nigerians. J Nig Med Assoc 1:14-17, 1971.
10.
Kudrow L: Tension headache (scalp muscle contraction headache). In: O. Appenzeller (Ed.), Pathogenesis and Treatment of Headache. Spectrum Publications Inc., New York, 1976.
11.
Kudrow L: Muscle Contraction Headache: In: F Clifford Rose (ed.), Handbook of Clinical Neurology, Revised Series 4, Elsevier Science Publishers, Amsterdam, 1986, pp. 343-352.
12.
Rothner AD: Headaches in children: A review. Headache 18:169-175, 1978.
13.
Jay GW, Tumasi LG: Pediatric headaches: A one year retrospective analysis. Headache 21:5-9, 1981.
14.
Shinnar S, D'Souza B J: The diagnosis and management of headaches in childhood. Pediatr Clin North Am 20:79-93, 1981.
15.
Levington A, Warner VS, Bana D, Graham JR: Age-related headache characteristics. Arch Neurol 41:762-764, 1984.
16.
AI-Sharnubi MA: Population structure of the Kingdom of Saudi Arabia: Part 9: AI-Quabas 5972:9, 1988.
17.
Osuntokun BO, Bademosi O, Osuntokun O: Migraine in Nigerians. In: FC Rose (ed), Advances in Migraine Research and Therapy, Raven Press, New York, 1982.
18.
Rush JA: Pseudotumour cerebri. Brit J Hosp Med 28:320-325, 1983.
Saad AI-Rajeh, M.D., Olajide Bademosi, M.D., FRCP (Lond), Hassan Ismail, M.D. MRCP (UK), and Adnan Awada, M.D.
Department of Neurology, King Faisal University, Dammam, Saudi Arabia. Reprint requests to: Dr. Saad AI-Rajeh, Department of Neurology, Colleges of Medicine and Medical Sciences, King Faisal University, P.O. Box 2114, Dammam 31451, Saudi Arabia. Accepted for Publication: March 27, 1990. SYNOPSIS
The pattern of headache syndromes in 222 subjects (142 Saudi nationals, 80 non-Saudis) seen at AI-Khobar, Saudi Arabia is presented. Headaches were common, and accounted for 13% of all neurological outpatients. They affected mainly young adults, with a peak frequency in the third decade for Saudis and the fourth for non-Saudis. They were rare in those under 10 and above 50 years old. Among Saudis, females outnumbered males especially in the second and fifth decades, while non-Saudi males were more frequent than females in all age groups except the second decade. The main types were tension headache (66%) and migraine (22%). Acute/chronic sinusitis was an uncommon cause of headache. Tension headache affected mainly individuals between 21 and 40 years of age (69%). It showed a female preponderance in Saudis aged 11-20 and above 40 years, unlike the male predilection in non-Saudis. Migraine showed a definite female predilection only in Saudis in the fourth decade (female to male ratio of 4:1 ). A positive family history for headache was present in 10% of the cases. The major precipitating factor for headaches was stress related to family or working conditions. Other triggers included hunger and prolonged exposure to excessive heat or sunlight. The pattern of headaches in Saudi nationals may be related to the prevalent sociocultural factors, and the differences observed between them and non-Saudis probably reflect the demographic status of non-Saudis in the Kingdom as a consequence of governmental recruitment policy. (Headache 30:359-362, 1990) INTRODUCTION
Headache is one of the most frequent and distressing of human discomforts. It is a symptom of diverse clinical entities, and may be precipitated by physical and environmental stimuli. Information on headache syndromes in the Arab peninsula has been limited to pseudotumour cerebri.1 This communication describes our experience of headache syndromes in the Eastern Province of Saudi Arabia. MATERIALS AND METHODS
All the patients with headache as the primary reason for their hospital visit for evaluation by the Department of Neurology, King Fahd Hospital of the University (KFHU), AI-Khobar, between December 1983 and November 1988 formed the basis of the study. Patients were excluded from the study on any of the following criteria: i. when headache was not the main presenting symptom that necessitated the visit to the hospital, ii. when the headache was a non-dominant component of other presenting symptoms of the clinical picture; i.e.: secondary to causes such as cerebrovascular disorders (cerebral haemorrhage, ischemic cerebrovascular disease, transient ischemic attacks), meningitis, brain tumours, subdural hematoma, acute head trauma, and arterial hypertension, iii. headache related to previous head injury; i.e. post-traumatic headache syndrome. Apart from routine investigations such as hematologic indices and biochemical tests, other tests included radiographs of the skull, brain computerized axial tomography (CT Scan) with and withouut enhancement, and electroencephalography (EEG). Lumbar puncture to measure the cerebrospinal fluid (CSF) entry pressure and obtain CSF for microscopy and biochemistry, and blood and CSF serology, were performed when indicated. For this study, headache was defined as pain or discomfort involving any part of the head including the face, and upper aspects of the neck. The headache syndromes were classified as: a. Migraine: recurrent episodic throbbing or pulsatile headache lasting 2-72 hours with total freedom between attacks; the headache, commonly unilateral, may be associated with visual, gastrointestinal or autonomic disturbances.2 b. Tension (Muscular, Psychogenic) headache: continuous, often persistent, chronic headache, usually generalised, occipital or vertex in location, with or without associated symptoms such as palpitations, dizziness, difficulty in concentration, and other features of anxiety or depression, c. Benign raised intracranial pressure: when the headache was associated with elevated CSF entry pressure at lumbar puncture (>200 mm water) and papilledema on funduscopy but without other clinical or
radiologic evidence, including brain CT scan, of other intracranial pathology such as tumor, intracranial hemorrhage, or cerebral infarct, and subdural collection (haematoma, abscess etc.), d. Miscellaneous: includes conditions such as sinusitis, malocclusion of the temporomandibular joints, ocular disorders, atypical facial pain, and sub-arachnoid hemorrhage. The presence of subarachronic hemorrhage was accepted only in the presence of uniformly bloodstained CSF, characteristic brain CT Scan findings, as well as absence of brain CT changes of other forms of cerebrovascular disorders such as parenchymal hemorrhage and infarct. The diagnosis of brain tumor was accepted on findings at exploratory craniotomy and histologic confirmation of biopsy specimen obtained at operation, skull radiographs and brain CT scan. RESULTS
During the period of study, 222 patients consisting of 142 Saudi nationals and 80 non-Saudis satisfied the selection criteria and constituted the study population. Headache syndromes accounted for 13% Of neurological outpatient clinic attendances and constituted 1/1,000 of total hospital consultations. The age and sex distributions of the patients are shown in Table 1. Headache, most frequent in the third decade (36.0%), affected mainly young adults and was uncommon in children and those more than 50 years old. Sixty-nine percent of the cases were between 21 and 40 years old, and 81% were under 40 years old. The peak prevalence of headache in Saudis was in the third decade, but was a decade later for non-Saudis (Tables 3 and 4). There was no definite overall sex preponderance although females outnumbered males in the second and fifth decades and also in those more than 50 years old. The frequency of the various types of headache syndromes related to nationality is shown in Table 2. Tension headache (67%) was most common and showed equal sex distribution. Migraine, seen in 28% affected males more than females irrespective of nationality with a male to female ratio of 1.4:1. Table 3 shows the age and sex distribution of Saudis with headache syndromes. Females outnumbered males particularly in those under 20 years and above 40 years old with a female:male ratio of 2:1 and 3:1 respectively. Among non-Saudis, headache syndromes were most frequent in the fourth decade, and males were more affected than females in all the age groups except in the second decade (Table 4). Benign raised intracranial pressure was diagnosed in 6 patients (5 Saudis, 1 non-Saudi; all females, aged between 12 and 42 years). Other conditions encountered included cerebral arteriovenous malformation 2 cases,* and 1 case each of atypical facial Table 1 Age and Sex Distribution of Subjects with Headache Syndromes Age in Years Male Female Total Percentage - 10 0 1 1 0.5 11 - 20 9 16 25 11.3 21 - 30 50 36 86 38.7 31 - 40 37 31 68 30.6 41 - 50 14 20 34 15.3 > 50 3 5 8 3.6 TOTAL 113 109 222 100.0 PERCENTAGE 51.0 49.0 100.0 Table 2 Types of Headache Syndromes Related to Sex and Nationality *Headache Type Male Female Total Percentage Migraine 36 27 63 (100.0) 28.0 Saudi 21 18 39 ( 62.0) Non-Saudi 15 9 24 ( 38.0) Tension Headache 75 74 149 (100.0) 67.0 Saudi 42 53 95 ( 64.0) Non-Saudi 33 21 54 ( 36.0) Others 3 9 12 (100.0) 5.0 Saudi 1 8 9 ( 75.0) Non-Saudi 2 1 3 ( 25.0) *Benign
Intracranial Hypertension
6
Acute/Chronic Sinusitis 4 Atypical Facial Pain; Intracranial Tumor; 1 Each Table 3 Age and Sex Distribution of Saudi Subjects with Headache Syndromes Age in Years Male Female Total Percentage - 10 0 1 1 0.7 11 - 20 6 11 17 12.0 21 - 30 36 28 64 45.1 31 - 40 13 20 33 23.2 41 - 50 8 15 23 16.2 > 50 1 3 4 2.8 TOTAL 64 78 142 100.0 PERCENTAGE 45.0 55.0 100.0 Table 4 Age and Sex Distribution of Non-Saudi Subjects with Headache Syndromes Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 3 5 8 10.0 21 - 30 13 7 20 25.0 31 - 40 24 11 35 43.8 41 - 50 7 6 13 16.2 > 50 2 2 4 5.0 TOTAL 49 31 80 100.0 PERCENTAGE 61.0 39.0 100.0
pain and intracranial tumour. Acute and/or chronic sinusitis was the primary cause of headache in 4 patients but was an associated finding in 3% of the cases. Tables 5 and 6 show the age and sex distributions of the Saudi and non-Saudi subjects with migraine. In Saudis, migraine was most frequently encountered in the third decade (41.0%), and showed a definite female predilection only in the fourth decade when the female:male ratio was 4:1. For non-Saudis, migraine was most common in the fourth decade (35.0%) and showed a consistent male preponderance in all the age groups (Table 6). Sixty-six of the 95 Saudi patients (69.5%) with tension headache were between 21 and 40 years old (Table 7). Females outnumbered males in the groups under 20 years old and above 40 years old; the female:male ratios were 3.5:1 and 4:1 respectively. However, males marginally outnumbered females in the 21-40 year old stratum with a male to female ratio of 1.2:1. Table 8 shows the age and sex distribution of non-Saudi patients with tension headache. The peak frequency was in the fourth decade, and 69% of them were between 21 and 40 years old. Non-Saudi males were more frequently affected than females in all age groups except the second decade where there was a reversal with a male to female ratio of 1:5. Twenty percent of the individuals with migraine had associated tension headache. A positive family history of headache in at least one close relation was Table 5 Age and Sex Distribution of Saudi Subjects with Migraine Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 4 2 6 15.4 21 - 30 10 6 16 41.0 31 - 40 2 8 10 25.6 41 - 50 5 2 7 18.0 > 50 0 0 0 0.0 TOTAL 21 18 39 100.0 PERCENTAGE 54.0 46.0 100.0 Table 6 Age and Sex Distribution of Non-Saudi Subjects with Migraine Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 2 0 2 8.3 21 - 30 5 1 6 25.0 31 - 40 6 5 11 45.8 41 - 50 2 2 4 16.7 > 50 0 1 1 4.2 TOTAL 15 9 24 100.0 PERCENTAGE 62.5 37.5 100.0
obtained in 27 patients (20 Saudis, 7 non-Saudis), and was more frequent in those with migraine (17 cases) than with tension headache (7 cases). Depression was an associated feature in 11 patients with tension headache. The main precipitating factors for both migraine and tension headache were emotional and family stress (103 cases) associated mainly with anxiety about work, or problems with or within the family. Other factors included hunger (6 cases), prolonged exposure to heat and sunlight (3 cases), and food items especially any form of cheese or chocolate (3 cases). Migraine attacks were related to menstrual cycle in 15 females, induced by oral contraceptive pills in 6 females, and was related to sexual activity in a 17-year-old girl. DISCUSSION
This study shows that headache is common in this predominantly Arab community, and its frequency in both hospital and neurological outpatient attendance is similar to the described pattern from other clinical settings.3,4 The relative rarity of headache in children is however in contrast to the experience of others.5-7 It may be related to the apparent inability of children in general to express themselves explicitly, or unawareness of their symptoms by parents and relations since the diagnosis of headache syndromes is most often made retrospectively in the majority of cases.8 The high frequency of tension headache in this series is similar to the reported range of 60-80% of Table 7 Age and Sex Distribution of Saudi Subjects with Tension Headache Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 2 7 9 9.5 21 - 30 25 20 45 47.4 31 - 40 11 10 21 22.1 41 - 50 3 13 16 16.8 > 50 1 3 4 4.2 TOTAL 42 53 95 100.0 PERCENTAGE 44.0 56.0 100.0 Table 8 Age and Sex Distribution of Non-Saudi Subjects with Tension Headache Age in Years Male Female Total Percentage - 10 0 0 0 0.0 11 - 20 1 5 6 11.1 21 - 30 10 6 16 29.6 31 - 40 15 6 21 38.9 41 - 50 5 3 8 14.8 > 50 2 1 3 5.6 TOTAL 33 21 54 100.0 PERCENTAGE 55.0 45.0 100.0
all headaches from other studies,9-11 The clinical presentation of tension headache in our patients conforms to the well-documented pattern and needs no further comments.11 The low frequency of tension headache in individuals under 20 years old, similar to the experience of others,12-14 probably reflects age-related psychologic differences as suggested by Levington and colleagues.15 The male preponderance observed in non-Saudis with tension headache is unlike the female predilection described in other series. It most likely reflects the sex stratification of non-Saudis in the Kingdom of Saudi Arabia where males outnumber females because of the recruitment policy.16 Despite the overall female preponderance of Saudi females in tension headache, it is interesting to note the peculiar sex distribution of the Saudi patients in the various decades in this study. The increased male frequency between the third and fourth decades probably reflects the added responsibility imposed by family and social factors. The female preponderance in those under 20 and above 40 years old is most likely related to the effect of socioeconomic and cultural influences including marriage and child bearing and rearing. The marked female predominance in Saudis with migraine in the fourth decade conforms to the pattern from other communities.4,5,17 The overall increased Saudi male frequency in migraine in this study is difficult to explain, and may possibly reflect differences in hospital attendance, as males commonly outnumber females in general outpatient clinic visits. It may, however, be associated with the type of migraine as atypical forms of migraine are commoner in males.5,15 Similarly, the predominance of males in non-Saudis with migraine, though unusual, probably mirrors the sex distribution of non-Saudis in the Kingdom, who constitute a selected population as a result of recruitment patterns. The low frequency of benign raised intracranial pressure and intracranial space occupying lesions in this series probably reflects selection and referral pattern bias: the majority of the individuals with these conditions in this environment are more likely to have been evaluated by the first contact physician, and subsequently sent directly to the neurosurgeons. However, it is interesting to note that the frequency of headache as the presenting symptom in all such cases in this study is similar to the 74-99% reported by others.18 REFERENCES
1.
Phadke JG, AI-Deeb S: Pseudotumor cerebri (benign intracranial pressure) in Saudi Arabia. Saudi Med J 8:391-395, 1987.
2.
Blau JN: Towards a definition of migraine headache. Lancet 1:444-445, 1984.
3.
Jamieson M: Headache. Brit Med J 288:1281-83, 1984.
4.
Bademosi O: Headache II: Common clinical types of headaches in Nigerians. Nig Med J 12:63-67, 1986.
5.
Selby H, Lance JW: Observations on 500 cases of migraine and allied vascular headache. J Neurol Neurosurg Psychiat 23:23-32, 1960.
6.
Congdon PJ, Forsythe WI: Migraine in children: A study of 300 children. Devl Med Chld Neurol 21:209-216, 1979.
7.
Hockaday JM: Headache in children. Br J Hosp Med 27:383-390, 1982.
8.
Lance JW, Curran D, Anthony M: Investigations into the mechanisms and treatment of chronic headache. Med J Aust 2:909-914, 1965.
9.
Osuntokun BO: Headache as a presenting symptom in Nigerians. J Nig Med Assoc 1:14-17, 1971.
10.
Kudrow L: Tension headache (scalp muscle contraction headache). In: O. Appenzeller (Ed.), Pathogenesis and Treatment of Headache. Spectrum Publications Inc., New York, 1976.
11.
Kudrow L: Muscle Contraction Headache: In: F Clifford Rose (ed.), Handbook of Clinical Neurology, Revised Series 4, Elsevier Science Publishers, Amsterdam, 1986, pp. 343-352.
12.
Rothner AD: Headaches in children: A review. Headache 18:169-175, 1978.
13.
Jay GW, Tumasi LG: Pediatric headaches: A one year retrospective analysis. Headache 21:5-9, 1981.
14.
Shinnar S, D'Souza B J: The diagnosis and management of headaches in childhood. Pediatr Clin North Am 20:79-93, 1981.
15.
Levington A, Warner VS, Bana D, Graham JR: Age-related headache characteristics. Arch Neurol 41:762-764, 1984.
16.
AI-Sharnubi MA: Population structure of the Kingdom of Saudi Arabia: Part 9: AI-Quabas 5972:9, 1988.
17.
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