Assessing the Relationship between Migraine and Sino-Nasal Symptoms and Diseases Among Syrian Private University Students: A Case-Control Study

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Assessing the Relationship between Migraine and Sino-Nasal Symptoms and Diseases Among Syrian Private University Students: A Case-Control Study

https://doi.org/10.21203/rs.3.rs-2370915/v1

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Background: Migraine is a common chronic and disabling condition, diagnosed late in most patients. Furthermore, Sino- nasal diseases are severe stressing conditions that can correlate with headaches and migraine. This study aimed to assess the relationship between migraine and Sino- nasal diseases among Syrian private university students.

Methods: A case-control study was conducted among students of the Syrian Private University in Damascus, and written informed consent was obtained from all participants. A self-administered and completed Arabic questionnaire on migraine and its relationship to Sino- Nasal diseases was used in previous studies. The study included 963 students, of whom 417 were students who had migraines, and 546 were controls who did not have migraines. The Chi-square test was used to assess the relationship between cases and controls and study variables. P value was considered at < 0.05.

Results: Out of 963 students, 30.7% were male, and 69.3% were female. With an average age of 23.8. Most of the students were from the Faculty of Human Medicine, 27.1%, and were in their final years of study 24%. Most Sino- nasal diseases were related to migraine including nasal obstruction, the need to blow to empty, ear pain, pressure, or pain in facial bones. Sino- nasal Score was significantly related to migraine. The severity of Sino- nasal symptoms were significantly associated with migraine.

Conclusions: The results of this study indicate that the diseases and symptoms of the nose and sinuses are significantly associated with migraine. Healthcare providers must raise awareness about this relationship to evaluate it and provide appropriate advice and treatment at an early onset.

Otorhinolaryngology

Neurology

otolaryngology

migraine

headache

nasal symptoms

nasal disease

syrian private university

Migraine is a chronic nervous disorder characterized by attacks of severe headache accompanied by autonomic and nervous symptoms such as nausea and sensitivity to light and noise, and in some patients, it is a breath that includes neurological symptoms (1). Aura is defined by the International Headache Society (IHS) as a recurrent disorder characterized by attacks of neurological symptoms that develop progressively within 5–20 minutes and last for less than 60 minutes (2). A migraine can occur with or without a headache. Importantly, the typical no-headache aura (TAH), also formerly known as cerebral, migraine-equivalent, or accompanying migraine, is neither accompanied nor followed by a headache of any kind (2). In one year, the incidence of migraine headaches in the United States of America and Western Europe is 11% in adults, including 6% in men and 15–18% in women. The disabilities associated with migraines can be severe and impose significant burdens on the patient and society. Acute migraines have been classified by the World Health Organization (WHO) as one of the most disabling chronic diseases along with quadriplegia, psychosis, and dementia (1).

There are various nasal conditions all combined with common symptoms. The most common nasal diseases that may contribute to migraines are nasal septal deviation, sinusitis, allergic rhinitis, Turbinate hypertrophy, and Nasal polyps. Nasal septal deviation plays a critical role in nasal obstruction symptoms, the aesthetic appearance of the nose, increased nasal resistance, and sometimes snoring (3). Symptoms and signs of acute and chronic sinusitis are similar, but the difference is in the etiology. Sinusitis may be caused by infection - nasal polyps - edema of the lining of the sinuses. Symptoms of sinusitis include a runny nose and headache, nasal congestion and difficulty breathing, facial pain and swelling, poor smell and taste, and otalgia (4). Allergic rhinitis is an atopic health condition that results from an IgE-stimulated immune response against inhaled antigens followed by a subsequent engagement of Leukotriene (5). Turbinate hypertrophy is observed in various conditions, including allergic rhinitis, vasomotor rhinitis, and infectious rhinitis (6). Nasal polyps are benign lesions that arise from the mucous membrane of the paranasal sinuses. It is associated with several diseases such as asthma - allergies - frequent infections - immune disorders (7).

Migraines are often misdiagnosed as being caused by nasal diseases and vice versa because many nasal diseases are associated with a headache similar to a migraine (8). Conversely, inflammation of the presence may not be diagnosed when it is present, as sphenoid sinusitis is difficult to diagnose. Sinus infections are less common now than they were in the era before the discovery of antibiotics, but to this day it is misdiagnosed. Acute sinusitis is diagnosed with a clear runny nose and pain pointing to the site of the infection (4).

Acute sinusitis is diagnosed as a cause of headaches because it is believed that pain above the sinuses must be associated with them, but in fact, frontal headaches are often caused by migraines and tension headaches, and there is still debate about whether a stuffy nose will cause a headache (4).

A study has proven that the sinuses themselves are insensitive to pain and the pain associated with sinusitis is caused by inflammation and swelling of the nasal structures: the frontal nasal ducts - the corneas - the orifices - the upper nasal spaces. Sinusitis headaches are deep and dull, accompanied by a feeling of fullness and heaviness (4).

There is a misconception that sinusitis may induce migraines, as the entire complex of symptoms is vascular, in addition to the accompanying nasal congestion caused by the expansion of the vessels of the nasal mucosa, which is part of the vascular event. This was shown by nasal endoscopy and sinus imaging (9).

Some symptoms of migraine and sinus headaches that because headaches are very similar, symptoms such as heaviness in the head that intensifies when bending forward, runny nose, severe pressure in the facial muscles, and chest congestion are usually noted in both cases (9). A study indicates that headaches caused by nasal diseases are often secondary to prolonged mucosal contact points and sinus hypoxia following ischemia or pressure caused by the growth of nasal polyps (10).

Nasal migraine is closely related to allergic rhinitis. Facial pain or headache related to the nose is classified as a secondary headache disorder, making a clear distinction between it and migraine. Therefore, not every headache associated with nasal symptoms is a migraine (11).

This study aims to assess the relationship between migraine and symptoms and nasal diseases among a sample of students at the Syrian Private University.

Study design and participants:

This is case-control study was conducted among students of the Syrian Private University in Damascus and written informed consent was obtained from all participants. They were informed that all of their responses were anonymously recorded and that responding to all questions was not mandatory. The inclusion criteria included students studying at the Syrian Private University, 18 years and over. The objectives of the study were explained to the students in the written form attached to the questionnaire. The sample size of 357 was calculated based on a 5% margin of error and a 95% confidence factor, for a population of 5,000 students using the sample size calculator. Using the Migraine Screening Scale, the students were classified into two groups: Where the study included 963 students, of whom 417 were students who had migraines (migraine), and 546 were controls who did not have migraines (migraine).

Questioner:

A self-administered and completed Arabic questionnaire was published by students on migraine (migraine) and its relationship to ENT diseases, which was used in previous studies.

The questionnaire consists of two parts:

1- Demographic information and social habits: it included questions about age, gender, college, year of education, and questions about social habits such as smoking and alcohol consumption.

2- Migraine Screening Questionnaire (MSQ) of 5 items:

It is a questionnaire validated using the Cronbach α test with a score of 0.83, which is used to investigate the presence of migraine headaches. It consists of 5 questions about headache severity and duration of headaches. It also assesses the presence of nausea symptoms, the severity of the effect of light and noise, and the impact of headaches on working life.

3- The 14-item Sino-nasal Outcome Test (SNOT) results in scale:

Participants answered the SNOT scale, which is used to determine the severity of nasal and sinus disease, and assesses nasal symptoms, auricular and facial symptoms, and sleep quality. The severity of these diseases is determined by choosing several answers from these options (no problem, very mild problem, mild problem, moderate problem, severe problem, very severe problem).

Statistical Analysis:

The data were analyzed using the SPSS Statistical Package for Social Sciences version 25.0, showing numbers and percentages (for categorical variables), or averages and standard deviations, SD (for continuous variables). The Migraine Screening Scale (MSQ) was calculated, where each yes answer to the five items of the scale = 1. A total of 4 or more points would diagnose a migraine headache (migraine). The Sino-nasal Outcome Test (SNOT) scores scale was also calculated, whereby each student would rate each option from 0 to 5, according to the severity of symptoms. The Chi-Square independence test was used to test the independence of qualitative variables, and the T-test was used to assess the relationship between the SNOT scale with cases and controls. A p-value < 0.05 was adopted as statistical significance.

Sample characteristics:

Out of 963 students, 30.7% were male, and 69.3% were female. With an average age of 23.8. Most of the students were studying at the Faculty of Medicine, 27.1%, and were in their senior year, 24%.

352 (36.6%) of the sample declare their smoking habit and 73 (7.6%) alcohol consumption.

Characteristics of migraine headaches in students:

31.9% of the students stated that they had suffered from a migraine before. 54.9% reported experiencing severe and frequent headaches, 49.9% reported a headache lasting more than 4 hours, 38.8% felt nausea accompanying a headache, 67.5% felt disturbed by light when experiencing a headache attack, and 70.4% reported that headaches were reducing their intellectual or practical activity.

The average number of days the students had headaches was 2.3. in addition, 13.5% on a scale of 0 to 10 expressed the severity of their headaches during the past two weeks as 5.

Medical and surgical history of students:

20.9% of the sample mentioned having a history of nose surgery, compared to 79.1% who did not. Regarding the history of diseases of the nose and sinuses, 359 (37.3%) reported that they don’t have any account of nasal conditions. the ones that mention a history of nasal diseases are 288 (29.9%) with nasal septum deviation, 197 (20.5%) with turbinates hypertrophy, 302 (31.4%) with Seasonal allergies, 298 (30.9%) with acute or chronic sinusitis, 23 (2.4%) with nasal polyps.

Possible nasal symptoms in the past two weeks:

The students answered a set of questions related to the appearance of nasal and paranasal symptoms during the past two weeks as follows:

18.2% of the students reported experiencing a moderate need to blow their nose for release, compared to 38.6% who did not.

19.5% and 17.8% reported suffering to a slight degree from sneezing and stuffy nose, compared to 32.2% and 32.4% who did not suffer from that, respectively.

The majority reported having the following symptoms to a very mild degree: runny nose 19.4%, loss or decreased sense of smell or taste 11.7%, coughing 18.7%, post nasopharyngeal rhinorrhea 16.7%, sticky nasal discharge 16.6%, nosebleed 6.9%, snoring 11.5%, A sense of ear blockage 22.7%, a feeling of imbalance 19.6%, ear pain 15.8%, and the presence of pressure or pain in the face 14.3%.

Case-control investigation:

When studying the relationship between cases and controls with demographic factors, the results showed a statistically significant relationship between them, most of the students who suffered from migraine headaches were 79.9% female, compared to 20.1% male. (p< 0.001), most of those who suffered from migraines were less than 25 years old, 57.1% compared to 42.9% of those aged 25 years or older. (p< 0.001). most of those who suffered from headaches were from engineering colleges, 25.7% compared to the rest of the university colleges. (p< 0.001)

When studying the relationship between cases and controls with medical and surgical history, the results showed a statistically significant relationship between them as follows, most of the students who had migraines had a history of acute or chronic sinusitis, significantly 38.8% compared to the controls 24.9%. (p< 0.001) most of the students who did not suffer from migraines had no antecedents, significantly 40.8% compared to 32.9%. (p=0.009), most of the students who had migraines had a prominently diagnosed migraine history 61.2% compared to the 9.5% controls. (p< 0.001), most of the students who experienced migraines had a significant headache lasting more than a week 19.9% compared to 6.2% controls. (p< 0.001), most of the students who had migraine headaches had headaches of intensity greater than or equal to 5 out of 10 (92.9%) compared to the controls (43.4%). (p< 0.001)

When studying the relationship between students in the case and control group with nasal symptoms, the results showed a statistically significant relationship between them as follows, the students who had migraine headaches had a significant need to blow the nose to empty it to a severe/very intense 12.2%, significantly compared to the 9.5% controls. In contrast, the students in the control group did not suffer from the need to blow their nose to empty it at 39.7% compared to 37.2% of the students in the condition group. (p=0.017)

The students who had migraine headaches had severe/very severe nasal obstruction significantly 19.4% compared to the 11.5% controls. In contrast, the students in the control group did not suffer from nasal obstruction, and 35.5% of the students in the case group did not suffer from nasal obstruction, compared to 28.3% of the students in the condition group. (p=0.001)

Students who had migraine headaches had severe/very severe ear blockage sensation (pressure) of 10.1% significantly compared to controls 6.8%. On the other hand, 49.8% of the students in the control group did not suffer from a feeling of obstruction in the ear, compared to 33.8% of the students in the condition group. (p< 0.001)

The students who had migraine headaches (migraine) had a feeling of severe/very severe imbalance of 12.2%, significantly compared to the controls 5.5%. On the other hand, the students in the control group did not suffer from the feeling of imbalance 52.2% compared to 32.4% of the students in the condition group. (p< 0.001)

The students who had migraine headaches had severe/very severe earaches by 7.4% significantly compared to the 4% controls. On the other hand, 65.9% of the students in the control group did not suffer from ear pain compared to 52.3% of the students in the condition group. (p< 0.001) Of the students who had migraine headaches had severe/very severe facial bone pressure or pain in 17.3%, significantly compared to the 5.5% controls. On the other hand, the students in the control group did not suffer from the presence of pressure or pain in the facial bones, 64.1% compared to 36.7% of the students in the condition group. (p< 0.001)

Study of the relationship between cases and controls with the mean of the results of the nose and sinuses test (Sino-Nasal Outcome Test score):

When studying the relationship between cases and controls with the average nasal and sinus test results scale, the results showed a statistically significant relationship between them as follows, students who had migraine headaches 16.7 had a significantly greater mean SNOT score compared to students with a 12.7 control group. (p< 0.001). The students who had migraine (migraine) and had a history of nasal surgery 16.9 had a significantly greater mean compared to the students in the control group 13. (p = 0.017)

The students who had migraines and experienced the need to blow their nose to empty it had a significantly greater average of 20.9 compared to the students in the 17.4 control group. (p< 0.001)

The students who had migraine (migraine) and who experienced sneezing had a significantly greater mean of 20.2 compared to the students in the control group 16. (p < 0.001)

The students who had migraine (migraine) and who had a runny nose 21.9 had a significantly greater mean compared to the students in the control group 18.5. (p< 0.001) The students who had a migraine (migraine) and a stuffy nose 20.4 had a significantly greater mean compared to the students in the control group 17.2. (p< 0.001)

The students who had migraines and had a loss or decreased sense of smell or taste 26.2 had a significantly greater average compared to the students in the 21.4 control group. (p< 0.001)

The students who had migraines (migraine) and coughed 23.9 were significantly greater on average compared to the students in the control group 18.9. (p< 0.001)

The students who had migraine (migraine) and who had posterior rhinorrhea 22.4 averaged significantly greater when compared to the students in the control group 19.4. (p< 0.05)

The students who had migraine headaches and who had nasal discharge 23.9 had a significantly greater mean compared to the students in the 20.6 control group. (p< 0.05)

The students who had migraine (migraine) and who had epistaxis 26.9 had a significantly greater mean compared to the students in the control group 22.4. (p< 0.05)

The students who had migraines and snored 23.9 had a significantly greater average score compared to students in the 20.6 control group. (p< 0.05)

The students who had migraine (migraine) and who had earache 23.1 were significantly greater on average compared to the students in the control group of .720. (p=0.049)

A cross-sectional study of 30 migraine patients aged 18–55 years in Croatia demonstrated a reduced quality of life in these patients as well as worse overall health compared to normal (12). Worrying about the next migraine attack has negative effects on the family, social life, and work productivity of migraine patients and thus causes a decline in quality of life. The benefits of migraine prophylaxis are measured over time in terms of the frequency of acute attacks, the effect of acute medication on headache and recurrence within 24 hours, and the reduction in overall functional disability (13).

In a descriptive study conducted on 2058 adults in Saudi Arabia, it was found that the prevalence of migraine was 37.2%, and the rates were higher among females (81.1%) and the highest percentage found among students (43.3%). The most common presentation accompanying the sister was the fear of light (94.6%), and the most frequent seizure inducers were (sleep deprivation - anxiety - stress) (14).

Regarding the quality of life, the studies conducted in Saudi Arabia revealed a correlation between the low quality of life and migraine in the eight aspects of quality of life compared to the normal group. Determining the role of the individual due to physical health was the most affected aspect (14).

It was found through a literature review study that chronic headaches and chronic headaches associated with increased use of analgesics are associated with a lower quality of life than normal, whereas chronic headaches are associated with lower productivity, greater disability, more medical consultations, longer hospitalization, and greater cost (15). In a cross-sectional study conducted in the Philippines, it was found that females who suffer from migraine constitute two-thirds of migraine cases and have a higher risk of disability due to migraine than men. Migraine triggers are prolonged looking at a computer screen. The best coping method was sleeping for enough hours and massages (16).

In a study conducted in Hungary, migraine patients were shown to have higher scores on BDI-II and T-STAI and were found to have undetected anxiety and depression before migraine. In addition, they had higher scores on SCI and consequently higher stress scores and disturbed coping styles. They also had lower scores on SF-36 and therefore lower quality of life (17).

A study conducted in Poland showed that 90% of headaches associated with sinusitis are caused by migraines (18), which agrees with the results of this study where most of the students who suffered from migraines had a history of acute or chronic sinusitis, significantly 38.8% compared to the controls 24.9%.

In a study conducted in Turkey on 214 sister patients, of whom 116 (54.2%) were previously diagnosed with sinusitis, 25% of them had an additional symptom, while 75% of them did not have any of the previous (19), This is consistent with our study where the students who had migraine headache had severe/very severe nasal obstruction 19.4% significantly compared to the controls 11.5%. In contrast, students in the control group did not suffer from nasal obstruction, and 35.5% of the students in the case group did not suffer from nasal obstruction, compared to 28.3% of the students in the condition group.

In a study conducted in Germany, it was found that facial pain formed 2.3% of patients with migraines (20), this is consistent with this study the increase in the percentage, where the students who suffered from migraine (migraine) had severe/very severe facial bone pressure or pain 17.3%, significantly compared to 5.5% controls. In contrast, the students in the control group did not suffer from the presence of pressure or pain in the facial bones, 64.1% compared to 36.7% of the students in the condition group.

A study showed that 64 out of 90 patients with ear pain accompanied the pain with migraines (21), and this is consistent with our study where the students who had migraine headaches had severe/very severe earaches by 7.4% significantly compared to the 4% controls. On the other hand, 65.9% of the students in the control group did not suffer from ear pain compared to 52.3% of the students in the condition group.

A study revealed that migraines are more common in females (22), this corresponds to our study in which it was found that 79.9% of the students who suffered from migraine headaches were female, compared to 20.1% of males. It was also shown in the same study that the majority of migraine cases occur at the ages of 30–60 years 32 and this contradicts our study in which most of those who suffered from migraine (migraine) were less than 25 years old 57.1% compared to 42.9% of those who were older or equal to 25 years.

Study'S Limitations:

The difficulty in providing the necessary tools to objectively assess the symptoms and nasal diseases among students in an objective way. The results of this study are limited to a sample of students from one university only, which may not be representative of all university students in Syria. The design of the case-control study is subject to recall bias and does not allow conclusions to be drawn about causation.

The results of this study indicate that the diseases and symptoms of the nose and sinuses are significantly associated with migraine. Healthcare providers must raise awareness about this relationship to evaluate it and provide appropriate advice and treatment at an early onset. We recommend Raising awareness about migraine-related nasal diseases and symptoms among university youth and urging them to review ENT doctors to assess these symptoms and prescribe appropriate treatment, conducting a study that includes samples from different universities that may provide a more comprehensive picture for Syrian university students, conducting a study aimed at evaluating nasal symptoms on a sample of migraine patients who attended the neurologist’s clinic.

Ethical approval:

Ethical approval was obtained from the Institutional Review Board (IRB), Faculty of Medicine, Syrian Private University.

Funding statement:

No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.

Availability of supporting data:

The data that support the findings of this study are available from the Corresponding author, upon reasonable request.

Competing interests:

The authors declare that they have no competing interests.

Acknowledgments:

Not applicable.

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Assessing the Relationship between Migraine and Sino-Nasal Symptoms and Diseases Among Syrian Private University Students: A Case-Control Study

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