Prevalence of Primary Headache Disease and Associated Factors with it among Rift Valley University Adama Campus Students, 2019

Background: Headache is a highly prevalent condition among University students than among other population groups but usually under-diagnosed and under-treated. Headache attacks lead to the loss of days of study and poor academic performance. However, the situation in Ethiopia is not well documented. Therefore, this research aimed to assess the prevalence of primary headache and associated factors among Rift Valley University Adama Campus Students. Methodology: Participants were selected using stratied random sampling from three faculties of Rift Valley University, Adama. An interviewer-administered questionnaire developed by reviewing related literature and headache-attributed restriction, disability, social handicap, and impaired participation (HARDSHIP) questionnaire and used to collect the data. STATA 12 was employed for data cleaning and analysis. Variables with a P-value of 0.25 and below on the bivariate logistic regression were considered for Multivariate analysis. Finally, a P-value of < 0.05 was considered as statistically signicant. Results: A total of 240 students participated in this research. The mean age of the students was 23.5 ± 2.4 years, 57.5% of them were female, 85.4 single, and 67.50% of them were urban dwellers. Almost all (97.9%) of the respondents experienced a headache in their lifetime and 61.3% within the last 30 days. Among those who experienced headache 69 (28.75%) had a primary type of headache. Forty-one (17.1%) of the respondent’s fullled the criteria for tension-type headache, 28 (11.7%) migraine, and 155 (64.58) had an unclassied type of headache. After controlling possible confounding effects of other covariates, age


Background
Headache is one of the most common neurological complaints encountered in clinical practice; most especially among the young population (1). It is one of the leading complaints seen in medical outpatient clinics and it is responsible for several visitations to the neurologist and general medical practitioners (2).
It is one of the most common neurological disorders (2) and accounts for multiple visits to the general physician and neurologist. Its lifetime prevalence is quite high (82.7-93%) in the general population (3).
Primary headache disorders, including migraine, tension-type, and cluster, are considered as major global health problems due to their high prevalence, chronicness and their substantial disability burden upon the sufferers (4,5).
Migraine and tension-type headache (TTH) are the two most common types of headaches. Various studies have shown the prevalence of migraines to be 2.4%-6% in males and 3.6%-15% in females and that of a tension-type headache the corresponding gures were 11.1%-63% in males and 11.8%-86% in females (3,6). Mostly migraine and tension-type headache (TTH), have emerged as major global public health concerns, lead to widespread health loss, impaired quality of life, and much loss of productivity (5,7,8). They often begin in adolescence and have a high risk of developing into a chronic condition and persisting into adulthood (9,10). Few studies have been done on speci c groups of the population like nurses and medical and university students which have found the prevalence of TTH to be between 12.2% and 22.64% and of migraine to be between 2.4% and 33.8% (11)(12)(13)(14).
Headache disorders, especially in student populations are usually under-diagnosed and under-treated conditions, and thus the headache attacks lead to losing days of study and worse academic performance (15). Absenteeism from school due to headaches has affected students and their academic performance.
A global study indicates that within 4 weeks, a fth of pupils with headaches, lose at least one complete day from school; another fth leave school early at least once, implying the loss of part of a day and almost half miss out on other school activities (16). Furthermore, students have di culty in maintaining attention during lessons and completing homework (11,17,18).
Several studies suggested different factors contributing to primary headaches. Among these sex being women to be signi cantly affected by headaches than men (14,(19)(20)(21), family history of headache was also found to be a common factor for headache in a study conducted among undergraduate Nigerian students (14), Brazilian undergraduate students (22) and study in Oman (11), consumptions of alcohol and smoking (23), stress and irregular sleep (24)(25)(26), sunshine and loud noise (27), lack of adequate vacation (28), low physical activity, and history of head trauma (29). In a study conducted in Northern India, Nausea/vomiting and scalp tenderness were the most common associated symptoms observed in students with recurrent headaches whereas migraineurs complained of photophobia/phonophobia along with nausea/vomiting, which is already documented associated symptoms con rming the diagnosis of migraine (30).
There is a scanty data on the prevalence of primary headaches in sub-Saharan Africa in general and Ethiopia in particular including in this study area. Therefore, this study is conducted to assess the prevalence of primary headache and associated factors among RVU Adama Campus students.

Study area
Rift Valley University is a private higher learning institution that was established in October 2000 in Adama Town. It began to operate with 5 diploma programs of study, and about 154 evening students and ve part-time academic staff. The rst batch of students was graduated in August 2002. At present RVU Adama campus enrolled more than three thousand students in different elds both in Degree and Masters programs both in regular and extension.

Study design and period
An institution-based cross-sectional study was used to determine the prevalence of headache and associated factors among RVU Adama Campus students from October 7 to 14, 2019.

Sample size determination
The sample size calculation was done using single population proportion formula with the following assumption: 81.1% prevalence of headache in the last 12 months among Godar University Health Science students (28), a 5% precision, 95% level of con dence, and 10% non-response rate. Samples of 258 students were required for this study Sampling procedure In this study, by considering faculty of study and year of enrolment strati ed random sampling was used.
After obtaining the verbal informed consent each of the students was randomly selected when they were attending class.

Data collection
The data collecting tool was checked and evaluated for its appropriateness by doing a pre-test on 20 extension students of RVU. A half-day training given for data collectors, the objectives of the study and the diagnostic criteria of the International Headache Society (IHS) (31) data was collected from the randomly selected students under the supervision of the principal investigators using English version structured questionnaire. The rst part contains the sociodemographic characteristics of students. The second part of the questionnaire was about the presence of headaches, followed by questions speci c for headache sufferers like the number of headache episodes per time and the impact of headache on the daily activity of students. The third parts of the questionnaire were about triggering factors of headache.

Data processing and analysis
After proper cleaning, cross-checking, and coding of data descriptive as well as inferential statistics of the study were analyzed by using STATA 12. Bivariate and multivariate logistic regression was used to identify factors associated with the prevalence of headache among students. The variables with a pvalue of less than 0.25 in the bivariate analysis were entered into the multivariate model using the enter regression method. Model tness was checked using Hosmer and Lemeshow goodness of a t test.

Data quality control
Beyond Pretesting the questionnaire and training of the data collectors, the data collection process was closely monitored and supervised by the principal investigators. The collected data were reviewed and checked for completeness before data entry and incomplete data were discarded.

Result
Socio-demographic characteristics A total of 240 students from the RVU Adama Campus participated in this study. The majority of the patients 57.5% were females, 50.4% of them were in the age group between 17 to 22 years with the mean (SD) 23.51 ± 4.20 years. More than two-thirds of the participants, 67.5%% were from urban dwellers, 63.3% were from the Business and Social Science Department, the majority (85.4%) of them were single or never married and 65.8% of them were attended for less than two years in the University (Table 1)  Among respondents who had experienced headache about half 52.3% of them had unilateral, throbbing/pulsating, headache persists for hours (50.6%), the headache was quite bad for them when occurs (53.6%) and sometimes impaired their routine activities (53.2%) ( Table 2).  (Table 3).

Factors associated with headache
In bivariate analysis Age, place of birth, faculty in which they belong, respondents who had impaired daily activities, bothered by ashlight/daylight, noise, and reported nausea and or vomiting had a signi cant association with a primary headache at a P. value of 0.25. After controlling possible confounding effects of other covariates four factors remained as signi cant independent predictors of primary headache in multiple logistic regression adjustment: Age, faculty in which they belong, their place of birth, had nausea or vomiting, and bothered by ashlight had a signi cant association with primary headache (

Discussion
Our study results showed the prevalence of lifetime headache and headache in the last 12 months was 97.9% 84.2%, respectively. Which is higher than a study conducted among University of Gondar students, 81.11 and 67.22% respectively (32), in dental students of a tertiary care teaching dental hospital in Northern India, 63.9% (30) and Pharmacy Students, Al Ain University, Abu Dhabi which was 82.6% (33).
Among those experienced headaches in the last 12 months, only 28.8% (95% CI: 22.9, 34.6) ful lled the criteria of primary headache. This nding is similar to previously done researches in Addis Ababa among the Local community (34). However, this value is much lower than to the current global prevalence of 47% (35), Ojini et al. (14) reported 46% at a teaching hospital, Tertiary Health Facility in Lagos, Nigeria 39.3% (36), and a much higher prevalence of 74.5% had been documented among Brazilian undergraduates (22). While our nding was higher than a study conducted by Takele et. Al. (37) reported 16.4% among textile workers. The possible difference could be due to the study design and small population sizes in this study and cultural and environmental differences with the present study The prevalence of the subtypes of headache was also noted and 17.1% with 95% CI (12.5, 22.1), of them had TTH and 11.9% with 95% CI (7.5, 15.8) of them had a migraine. This nding is similar to a study conducted in Addis Ababa by Mihila et. Al. 17.7% and 20.6% for migraine and THA respectively (38). But lower compared with a study conducted in Egypt 24.5% of them had TTH and 17.3% migraine (39), In Euro-light Project (40,41), the mean prevalence of migraine in Europe was 14.7%, while the overall prevalence of TTH was 62.6%. In Georgia, the prevalence was 37.3% for TTH and 15.6% for migraine (42). This could be attributed to different methodologies and cultural diversity.
Our study documented a prevalence rate of migraines was 11.9% which is similar to a study in Benin among University students 11.3% (43), 12.4% among Turkey students (44), and 12.2% among students in Oman (11). But a considerably high compared to 'Ojini' 6.4% (14) and previous community-based studies in Ethiopia, 3-10% (25,34). However, the ndings of this study were very low compared with a study among Kuwaitis medical students 27.9% (45) and the study of Florianopolis in Brazil, which was 22.1% (46). The difference in the prevalence can be attributed to the racial, environmental, nutritional, psychological, and social factors of a particular population contributing to the headache. The other explanation could be due to the rigorous and strenuous medical program could account for the higher prevalence of headaches among medical students.
The prevalence rate of TTH in our study was 17.1%. This nding is much lower than the 47.7% documented in Zimbabwe (47), 25.5% by Quesada-V´azquez et al. in Cuba (48), and Russell reported 86% (49). There has been wide variations and differences in the epidemiology of TTH across different cultures (35). These variations may result from differences in study design, study population, inclusion or exclusion of cases of infrequent episodic TTH, and overlap with probable migraine, cultural and environmental differences, or even genetic factors (50).
Although, sex has no signi cant association with primary headache in this research the prevalence of primary headache was a little bit higher in women compared with men as has been previously reported (19)(20)(21). This has been attributed to the effect of female sex hormones speci cally estrogen, genetics, and differences in response to stress and pain perception or psychological burden on females.
The majority of respondents with primary headache in this study was with the age group of 23 and 28 years. This age group has a signi cant association with primary headaches. It is consistent with the ndings in the literature that locate the maximum of the migraine prevalence is at a younger age (23).
This may be explained by the fact that 90.8% of surveyed students are 16 to 29 years old.
The nding of this research the prevalence of primary headache was high among urban dwellers compared with rural and showed a signi cant association between respondents from urban and primary headaches. This is supported by a study conducted in Ethiopia in 2003 & 2008 (25, 37). This might be due to the magico-religious perception of diseases and opting for traditional healing in rural communities may hinder the reporting of headaches. It is also the rural people who have a greater tolerance for pain.
The most common trigger factor for headache in this study was the presence of nausea and vomiting and sunshine or ashlight but different kinds of the literature indicated stress and lack of sleep in nonmedical students were stress and loud noise (24)(25)(26)(27)30).

Limitation of the study
The limitations of this study included sample size, in terms of both the students who were participated and the facilities that were used, which thereby limited the general applicability of the results. All data is based on self-reporting hence the study might be affected by reporting bias. Also, the study is prone to recall bias since most of the questions require recalling past experiences.

Conclusion
Headache is a common complaint among Rift Valley University Adama Campus students. The lifetime prevalence of any headache was 97.9% and 28.8% of them ful lled the criteria of primary headache. Age, faculty in which they belong, their place of birth, had nausea or vomiting, and bothered by ashlight had a signi cant association with primary headache. Students need proper education and support about treatment to ease their suffering and forestall complications. The datasets generated and/or analyzed during the current study are not publicly available due to some privacy reasons, but part of the raw data set will be available from the corresponding author upon reasonable request.

Ethical Approval
An ethical approval letter was obtained from the institutional review board (IRB) of RVU. Each study participant was adequately informed about the purpose, method, anticipated bene t, and risk of the study by the data collectors. Verbal informed consent was obtained from study participants and anonymity was maintained to ensure con dentiality. The respondents' right to refuse or withdraw from participating in the interview was fully maintained and the information provided by each respondent kept strictly con dential.

Consent
The data collectors read and explain the consent form until the respondents understood all and once willing to participate the data collector sing for reading and asking consent before an interview Funding Tadesse Seda contributed to review, validation of the questionnaire, assisting in data analysis, revising the article and gave nal approval of the version to be published, and also agree to be accountable for all aspects of the work