DOI: https://doi.org/10.21203/rs.3.rs-2618433/v3
Background: The aim of this study was to evaluate the frequency and duration of migraine among medical students following matriculation into medical school compared to frequency and duration prior to matriculation. This study also evaluated the relationship of post-matriculation frequency and duration of migraine with potential triggers including perceived stress, average hours of sleep per night, and daily water consumption.
Methods: This study employed a cross-sectional survey design and included 78 participants enrolled at the Alabama College of Osteopathic Medicine (ACOM) in Dothan, Alabama for the 2022-2023 academic year. Data was collected from participants’ self-reporting answers to each survey item and analyzed using two factor ANOVA, paired two sample t-test, and Chi-square test of independence.
Results: Participants demonstrated increased duration of migraine (p value = .03), increased water consumption (p value = .008), and increased perceived stress post-matriculation (p value < .001). Increased migraine duration post-matriculation was not found to be associated with the increase in perceived stress. Migraine frequency did not increase post-matriculation. However, participants who reported less hours of sleep were more likely to have increased frequency of migraine post-matriculation (p = .007). Female participants were more likely to have increased frequency (p = .002) and duration (p = .003) of migraine post-matriculation. Participants with family history of migraine were also more likely to have increased frequency (p = .046) and duration (p = .001) of migraine post-matriculation.
Conclusions: This study revealed greater duration of migraine among medical students following matriculation into medical school compared to duration of migraine pre-matriculation.
Migraine is a neurological disorder that can be classified as either episodic or chronic and with or without the presence of an aura [1]. Each episode of migraine may span several hours up to several days, often with debilitatingly painful headache and accompanying nausea and sensitivity to light, sound, and/or smell [2]. The global consequences of migraine symptoms are significant, as evidenced by its rank second among major worldwide causes of disability and an estimated 39 million individuals in the United States alone suffering with migraine [2,3]. Migraine has also been shown to be associated with several risk factors, the most predominant of which is stress, as well as poor sleep hygiene, and poor nutrition, all of which are especially prevalent among medical students [3,4]. Previous studies have suggested medical students in fact experience higher levels of psychological distress than both the general population and age-matched peers [5]. However, the existing literature provides limited data regarding stress, the additional aforementioned risk factors for migraine, as well as migraine prevalence specifically among medical students [5,6].
Migraine prevalence worldwide is approximately 15% with the lowest prevalence in China at 9% and highest prevalence in southeast Asia at 25-35% [7]. Prevalence in the United States is similar to the global prevalence at an estimated 12-13%[7]. Migraine prevalence has also been demonstrated as lower in children and elderly compared to middle adulthood, with the peak prevalence reportedly among both males and females aged 35-39 years old[7]. However, prior studies also suggest a gender-specific migraine prevalence presenting significantly higher in females than males, with 15-17% prevalence among women and 6% prevalence among men [8]. Few studies have investigated migraine prevalence among medical students specifically, but current literature reports this range anywhere from 11-40% among medical students globally [6].
Several theories have been hypothesized as causes of migraine. Such theories include cortical spreading depression, activation of the trigeminovascular system, sensitization of neurons, as well as genetic components involving the KCNK18 and CSNK1D genes and familial hemiplegic migraine of which several subtypes exist [3]. Several precipitating factors have also been identified in previous literature regarding migraine onset, the most commonly reported being stress, with an especially strong correlation between migraine and depression and anxiety disorders [3,7]. Additional triggers of migraine include poor nutrition, poor sleep hygiene, alcohol, smoke, odors, neck pain, and increased risk with co-morbid conditions such as obesity [3,7]. Medical students especially face several of these risk factors throughout their education, and have demonstrated higher rates of perceived stress, anxiety, depression, and burnout [3-5]. The prevalence of risk factors for migraine among medical students therefore suggests a possible increased prevalence of migraine among medical students compared to age-matched peers and general population.
Prior studies have shown individuals suffering with migraine to have impaired cognitive function compared to healthy controls, especially in terms of memory and attention, but the number and scope of these studies are limited, requiring further longitudinal investigation to further understand the long term effects of migraine [9,10]. Current literature suggests various other consequences of migraine as well, such as impaired personal relationships, lifestyle compromises, and loss of productivity [7]. Migraine among medical students therefore may contribute to worsening academic performance when combined with the other stressors present throughout medical education. The global consequences of migraine are also evident in the costs attributed to migraine with an estimated $11 billion in direct costs and $12 billion indirect costs in the United States in 2007, as well as an estimated €50 billion to €111 billion in Europe in 2011 [7]. Despite the evident global burden of migraine, limited research and education regarding migraine prevalence, risk factors, treatment, and prevention continues to persist [7].
In this study we hypothesized migraine frequency and duration among medical students increase upon matriculation into medical school versus before matriculation into medical school because of decreased sleep, decreased water consumption, and increased perceived stress. We also hypothesized female medical students and medical students with a family history of migraine were more likely to have increased frequency and duration of migraine following matriculation into medical school versus before matriculation into medical school.
This study employed a cross-sectional survey design conducted on the students enrolled at the Alabama College of Osteopathic Medicine (ACOM) in Dothan, Alabama. An email containing the link to the Qualtrics survey was sent to all students enrolled at ACOM for the 2022-2023 academic year. The total number of students enrolled at ACOM for the 2022-2023 academic year is 720. 82 students (11.4%) filled out the survey. All participants were informed they may withdraw from the study at any point and survey results would remain anonymous. Consent was obtained within the survey by participants selecting the answer choice indicating their understanding of the survey and providing their consent. The survey opened on October 26th, 2022 and closed November 16th, 2022. Data was collected from participants’ self-reporting answers to each item in the survey. After data collection was complete, 78 participants (10.8%) were included in the study, and 4 participants were excluded due to incomplete survey responses.
The survey consisted of 16 items including demographic information such as age, sex, race, and family history of migraine, as well as Likert-type scale items to evaluate the frequency and duration of migraines, perceived stress, hours of sleep, and water consumption before and after matriculation.
The first item asked participants when they first experienced a migraine, with options to select never, younger than 12 years old, 12-17 years old, 12-17 years old, 18-24 years old, 25-30 years old, 31-40 years old, 40-49 years old, or 50+ years old.
The next set of questions asked participants how often they experienced migraine before starting medical school and after starting medical school, with options to select never, 1-3 per year, 4-6 per year, 1-2 per month, 3-4 per month, or 5+ per month.
The third set of questions asked participants how long their migraine typically lasted before starting medical school and after starting medical school, with options to select less than 1 hour, 1-4 hours, 5-10 hours, or 10+ hours.
The fourth set of questions asked participants how many hours of sleep on average they had
before starting medical school and after starting medical school, with options to select less than 4 hours,
4-7 hours, 8-12 hours, or more than 12 hours.
The fifth set of questions asked participants how much water per day they consumed before starting medical school and after starting medical school, with options to select less than 1 cup, 1-3 cups, 4-7 cups, 8-10 cups, or 10+ cups.
The sixth set of questions asked participants to rank their daily stress on a scale of 1-10 before starting medical school and after starting medical school, 1 indicating little to no stress and 10 indicating very high stress.
The last set of questions asked participants about their demographic information including age, race, and sex, and if they have an immediate family history of migraines with options to select no, yes mother, yes father, or yes both mother and father.
Two factor ANOVA without replication was used to examine frequency of migration occurrence before matriculation into medical school versus after matriculation into medical school, duration of migration before matriculation into medical school versus after matriculation into medical school, average number of hours of sleep before matriculation into medical school versus after matriculation into medical school, and cups of water consumption before matriculation into medical school versus after matriculation into medical school. Paired two sample t-test for means was used to examine perceived stress among participants before matriculation into medical school versus after matriculation into medical school. Chi-square test of independence was used to examine the relationship between frequency of migraine occurrence following matriculation into medical school and age at first migraine, the relationship between frequency of migraine occurrence following matriculation into medical school and average hours of sleep per night following matriculation into medical school, the relationship between frequency of migraine occurrence following matriculation into medical school and amount of water consumption following matriculation into medical school, the relationship between frequency of migraine occurrence following matriculation into medical school and perceived stress following matriculation into medical school, the relationship between frequency of migraine occurrence following matriculation into medical school and presence of family history of migraine, and the relationship between frequency of migraine occurrence following matriculation into medical school and gender. Chi-square test of independence was also used to examine the relationship between duration of migraine following matriculation into medical school and age at first migraine, the relationship between duration of migraine following matriculation into medical school and average hours of sleep per night following matriculation into medical school, the relationship between duration of migraine following matriculation into medical school and amount of water consumption following matriculation into medical school, the relationship between duration of migraine following matriculation into medical school and perceived stress following matriculation into medical school, the relationship between duration of migraine following matriculation into medical school and presence of family history of migraine, and the relationship between duration of migraine following matriculation into medical school and gender.
This study was reviewed and approved by the Alabama College of Osteopathic Medicine Institutional Review Board.
Table 1 summarizes the demographic characteristics of the study participants. 78 participants were included in the study. 55 participants were female, 22 participants were male, and 1 participant chose the option “prefer not to answer.” The age of the participants ranged from 18 to 40 years old. 55 participants identified as White/Caucasian, 1 participant identified as Black/African American, 9 participants identified as Hispanic/Latino, 10 participants identified as Asian/Pacific Islander, 2 participants identified as multiracial/biracial, and 1 participant chose the option “prefer not to answer.” 40 participants denied family history of migraines, 32 participants had family history of migraines in mother only, 5 participants had family history of migraines in father only, and 1 participant had family history of migraines in both mother and father. 18 participants stated they have never experienced migraine, 13 participants experienced first migraine at younger than 12 years old, 25 participants experienced first migraine at 12-17 years old, 19 participants experienced first migraine at 18-24 years, and 3 participants experienced first migraine at 25-30 years old.
|
Table 1. Demographics of study participants |
||||||||
|
Age |
18-24 years old |
25-30 years old |
31-40 years old |
41-50 years old |
50+ years old |
|
||
|
22 |
48 |
8 |
0 |
0 |
||||
|
Race |
White/Caucasian |
Black/African American |
Hispanic/Latino |
Asian/Pacific Islander |
Native American/ Alaskan native |
Multiracial/biracial |
Not listed |
Prefer not to answer |
|
55 |
1 |
9 |
10 |
0 |
2 |
0 |
1 |
|
|
Gender |
Female |
Male |
Transgender female |
Transgender Male |
Gender variant/ Non-conforming |
Not listed |
Prefer not to answer |
|
|
55 |
22 |
0 |
0 |
0 |
0 |
1 |
||
|
Age at First migraine
|
Never |
Younger than 12 years old |
12-17 years old |
18-24 years old |
25-30 years old |
31-40 years old |
41-50 years old |
50+ years old |
|
18 |
13 |
25 |
19 |
3 |
0 |
0 |
0 |
|
Tables 2-6 summarize the data before and after matriculation of frequency of migraine occurrence, duration of migraine, average hours of sleep per night, amount of water consumption, and perceived stress. Two-factor ANOVA without replication demonstrated an increase in duration of migraine following matriculation into medical school (p value = .03) and an increase in water consumption following matriculation into medical school (p value = .008). Paired two sample t-test for means demonstrated and an increase in stress following matriculation into medical school (p value < .001).
|
Table 2. Frequency of migraine pre-matriculation vs post-matriculation |
||
|
Frequency of Migraine |
Pre-matriculation |
Post-matriculation |
|
Never |
24 |
23 |
|
1-3 per year |
16 |
13 |
|
4-6 per year |
20 |
6 |
|
1-2 per month |
9 |
22 |
|
3-4 per month |
5 |
5 |
|
5+ per month |
4 |
9 |
|
Table 3. Duration of migraine pre-matriculation vs post-matriculation |
||
|
Duration of Migraine |
Pre-matriculation |
Post-matriculation |
|
Less than 1 hour |
28 |
26 |
|
1-4 hours |
27 |
22 |
|
5-10 hours |
17 |
24 |
|
10+ hours |
6 |
6 |
|
Table 4. Hours of sleep pre-matriculation vs post-matriculation |
||
|
Hours of sleep |
Pre-matriculation |
Post-matriculation |
|
Less than 4 hours |
3 |
3 |
|
4-7 hours |
27 |
52 |
|
8-12 hours |
47 |
23 |
|
More than 12 hours |
1 |
0 |
|
Table 5. Water consumption pre-matriculation vs post-matriculation |
||
|
Water consumption |
Pre-matriculation |
Post-matriculation |
|
less than 1 cup |
1 |
1 |
|
1-3 cups |
14 |
22 |
|
4-7 cups |
33 |
26 |
|
8-10 cups |
22 |
22 |
|
10+ cups |
8 |
7 |
|
Table 6. Perceived stress on a scale of 1-10 pre-matriculation vs post-matriculation. 1 represents minimal to no stress. 10 represents very high, severe stress. |
||
|
Perceived Stress Scale 1-10 |
Pre-matriculation |
Post-matriculation |
|
1 |
1 |
1 |
|
2 |
8 |
0 |
|
3 |
12 |
1 |
|
4 |
20 |
2 |
|
5 |
17 |
2 |
|
6 |
11 |
11 |
|
7 |
6 |
10 |
|
8 |
2 |
31 |
|
9 |
0 |
10 |
|
10 |
1 |
10 |
A chi square test of independence was performed to examine the relationship between frequency of migraine occurrence following matriculation into medical school and hours of sleep per night following matriculation into medical school. The relationship was significant, x^2(3, N=78) = 24.356, p = .007. Participants who reported less hours of sleep were more likely to have increased frequency of migraine following matriculation into medical school.
A chi square test of independence was performed to examine the relationship between frequency of migraine occurrence following matriculation into medical school and presence of family history of migraine. The relationship was significant, x^2(3, N=78) = 25.284, p = .046. Participants with family history of migraine were more likely to have increased frequency of migraine following matriculation into medical school.
A chi square test of independence was performed to examine the relationship between frequency of migraine occurrence following matriculation into medical school and gender. The relationship was significant, x^2(2, N=78) = 28.519, p = .002. Female participants were more likely to have increased frequency of migraine occurrence following matriculation into medical school.
A chi square test of independence was performed to examine the relationship between duration of migraine following matriculation into medical school and presence of family history of migraine. The relationship was significant, x^2(3, N=78) = 21.715, p = .001. Participants with family history of migraine were more likely to have increased duration of migraine following matriculation into medical school.
A chi square test of independence was performed to examine the relationship between duration of migraine following matriculation into medical school and gender. The relationship was significant, x^2(2, N=78) = 20.29, p = .003. Female participants were more likely to have increased duration of migraine following matriculation into medical school.
This study evaluated the frequency and duration of migraine among medical students following matriculation into medical school compared to frequency and duration before matriculation. The relationship of various factors contributing to migraine frequency and duration among medical students were also evaluated, including sleep, hydration, stress, and demographic factors such as race, gender, family history of migraine, and age at first migraine.
Duration of migraine was demonstrated to increase following matriculation into medical school, but interestingly, frequency of migraine occurrence did not increase following matriculation into medical school. As hypothesized, perceived stress increased following matriculation into medical school. However, the amount of sleep was not shown to decrease following matriculation into medical school, and the amount of water consumption increased following matriculation into medical school.
In analysis of the factors contributing to the increased duration of migraine following matriculation into medical school, sleep, water consumption, nor stress were found to have a significant relationship with duration. Factors that did demonstrate a significant relationship with duration were female gender and presence of family history of migraine.
In addition, although frequency of migraine occurrence did not increase following matriculation into medical school, a significant relationship between frequency of migraine occurrence and average number of hours of sleep following matriculation into medical school was demonstrated. Similarly to duration of migration, frequency of migraine occurrence also had a significant relationship with both female gender and presence of family history of migraine.
Further research investigating frequency and duration of migraine among medical students following matriculation into medical school and the factors most significantly associated with both migraine frequency and duration is still needed. This research would provide further information regarding possible preventative measures students may take, health initiatives and programs medical institutions may implement, and more broad treatment options based on either frequency or duration of migraine. Migraine among medical students combined with factors such as increased stress following matriculation may ultimately be contributing to lower academic and professional performance and therefore calls for increased prioritization of research regarding migraine and wellness among medical students.
One of the limitations of this study include the low response rate of the medical students enrolled at ACOM to the survey. This resulted in a small sample size and the results therefore may not be generalizable to the medical students enrolled at other institutions. In addition, the presence of migraine was not assessed with a diagnostic tool and was only based on participants’ self-reported answer to the survey item asking if the participant has ever experienced a migraine and the subsequent survey items regarding the characteristics of the participants’ migraines.
Acknowledgements
Thank you to Lisa Ennis, MA, MS, MPH Director of Library & Learning Resources, Professor of Library
& Information Sciences, Division of Institutional Effectiveness at the Alabama College of Osteopathic Medicine for supervising, reviewing final manuscript, and providing guidance throughout the study. An additional thank you to all the students who participated and complete each item of the survey.
Funding
No funding was required for the current study.
Competing interests
The corresponding author states that there is no conflict of interest.
Ethics approval
This study was approved by the Alabama College of Osteopathic Medicine Institutional Review Board.
Consent to participate
All participants provided informed consent.
Consent for publication
Not applicable.
Availability of data and materials
All data generated or analyzed during the current study are included in this published article.
Code availability
Not applicable.
Authors’ contributions
A.R. conceived and designed the study, developed the survey, and analyzed and interpreted the data. A.R. authored the manuscript in its entirety.