European Journal of Cardiovascular Medicine

Headache is one of the most common neurological symptoms encountered in clinical practice. It is a frequent cause of outpatient visits and missed days at work, leading to significant individual and societal burden. The Global Burden of Disease Study [1] has consistently ranked migraine among the leading causes of years lived with disability worldwide. Headaches are generally classified as primary or secondary according to the International Headache Society (IHS). Primary headaches, which include migraine, tension-type headache (TTH), and trigeminal autonomic cephalalgias (TACs), are not attributable to other medical conditions.

Migraine, in particular, is a highly disabling neurological condition characterized by episodic attacks of throbbing head pain, often accompanied by nausea, photophobia, and phonophobia. TTH, the most prevalent primary headache type, presents as a bilateral, band-like pressure that, while generally less severe, can be chronic and disabling. Cluster headaches, though rare, are intensely painful and can cause profound disruption in affected individuals.

Despite their widespread prevalence, the subjective nature of headaches makes them challenging to assess and manage. The concept of health-related quality of life (HRQoL) has emerged as a crucial metric in evaluating the broader impact of chronic conditions. The SF-36 questionnaire, a validated tool, allows for systematic evaluation across physical, emotional, and social domains.

This study was designed to examine the clinical profile of patients with primary headache disorders and quantify their impact on HRQoL using the SF-36 in a tertiary care setting in India. By characterizing these conditions comprehensively, we aim to provide insights for better diagnosis, management, and patient education.

Primary headaches are frequently underestimated due to their non-life-threatening nature. However, their cumulative impact over time results in significant economic and social consequences. In low-resource settings, underdiagnosis and under-treatment of primary headaches are especially prevalent due to poor health-seeking behavior, lack of awareness, and limited access to neurological care.

The interplay between headache and psychological comorbidities further complicates management. Depression, anxiety, and sleep disorders are commonly coexistent, particularly among chronic migraine sufferers. These comorbid conditions not only affect headache frequency but also diminish treatment efficacy and patient adherence.

By focusing on both clinical and QoL dimensions, this study aims to bridge the gap between symptom control and holistic patient wellbeing.

Migraine is consistently ranked among the top 20 causes of disability worldwide, as identified by the Global Burden of Disease Study [1]. The prevalence of migraine is particularly high in females, often attributed to hormonal fluctuations and genetic predisposition [17]. It has been demonstrated that up to one-third of migraineurs have a family history of the condition [17,18]. The inclusion of SF-36, a validated quality of life tool, allows a comprehensive assessment of the patient’s daily function a...

This was a cross-sectional, observational study conducted at the Department of Neurology, S.C.B. Medical College, Cuttack, from October 2019 to September 2021. A total of 302 patients, aged 17 years and above, presenting with primary headache disorders as defined by the ICHD-3 classification were included. Patients with secondary headache disorders, those younger than 17 years, or unwilling to provide informed consent were excluded.

Participants were classified into three groups based on diagnosis: Group M (Migraine), Group T (Tension-type headache), and Group C (Cluster headache). Data collection involved a structured questionnaire that captured demographic details, clinical presentation, headache characteristics (duration, location, nature, triggering factors), and family history. Each patient’s quality of life was evaluated using the Medical Outcomes Study Short Form (SF-36) questionnaire.

The SF-36 assesses eight dimensions: physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH). Scores in each domain range from 0 to 100, with higher scores reflecting better quality of life.

Data were analyzed using SPSS version 22. Descriptive statistics were used to summarize patient demographics and clinical features. One-way ANOVA and chi-square tests were applied to assess the differences in HRQoL scores between the three groups. A p-value of less than 0.05 was considered statistically significant.

The study adhered to the principles of the Declaration of Helsinki. All participants provided informed consent prior to inclusion. Clinical interviews and examinations were conducted by trained neurologists to ensure diagnostic accuracy. The questionnaire was administered in the local language when necessary to maximize comprehension and accuracy.

Patients were also asked to report on their work productivity and social limitations, although these were not included in the SF-36 scoring. To minimize reporting bias, caregivers were allowed to corroborate responses when appropriate.

Statistical methods also included post hoc Tukey’s HSD test for multiple comparisons to determine specific group differences when ANOVA was significant.

The SF-36 questionnaire [7] was chosen due to its extensive validation across diverse populations. Previous studies have used this tool to assess chronic conditions including hypertension, diabetes, and depression [7]. The ICHD-3 classification was used as the diagnostic reference standard [6]. Observations were made in accordance with ethical guidelines, and study methodology was consistent with prior large-scale epidemiological investigations [1,6].

Among the 302 participants, 211 (69.86%) had migraine, 85 (28.14%) had TTH, and 6 (1.98%) were diagnosed with cluster headache. A notable female predominance was seen in migraine and TTH groups, with 74.4% and 74.1% being women, respectively. In contrast, cluster headaches were predominantly observed in males (83.33%). (Table 1)

Age distribution varied across groups: the majority of migraine patients were in the 21–30 age group, whereas TTH cases peaked in the 31–50 age range. Cluster headaches were mostly seen in the 31–50 age bracket. A positive family history was significantly associated with migraine (57.1%) and TTH (20.2%), while none of the cluster headache patients reported similar history.

Migraine patients predominantly reported unilateral, throbbing pain typically located in the temporal and frontal regions. TTH patients experienced bilateral, band-like pressure mainly in the frontal region. Cluster headache cases presented with severe, unilateral pain primarily in the fronto-temporal region and associated with autonomic symptoms such as lacrimation and nasal congestion.

SF-36 domain scores varied significantly across headache types. Migraine patients had the lowest scores in bodily pain (mean score ~42), role limitations due to emotional problems (~38), and vitality (~45), indicating substantial functional impairment. (Table 2) TTH patients also reported reduced QoL, but to a lesser degree, with moderate impairment in mental health and vitality domains. Cluster headache patients, though few, reported severe pain-related impairment but relatively better scores in physical functioning due to short attack durations.

Statistical analysis revealed significant differences (p < 0.05) in SF-36 scores among the three groups across most domains, validating the discriminative power of the questionnaire. (Figure 1)

A significant portion of migraine patients (35.24%) reported headache duration between 12–24 hours, while cluster headache attacks were notably shorter, often under 6 hours. Migraine attacks were frequently aggravated by routine physical activity, while TTH patients did not report such associations.

The presence of aura was reported by 18.4% of migraine patients, with visual disturbances being the most common form. Photophobia and phonophobia were prominent in migraine, whereas TTH showed minimal sensory hypersensitivity.

Among those with chronic headache patterns (defined as ≥15 days/month for ≥3 months), quality of life scores were significantly lower across all SF-36 domains. Particularly in the migraine group, chronicity was associated with an even greater drop in mental health and emotional role scores.

Additionally, employment status and educational level were examined. Patients with higher education levels reported marginally better coping scores, while unemployed patients had significantly lower vitality and mental health scores, regardless of headache type.

Migraineurs most frequently reported sensory disturbances like photophobia and phonophobia [8]. A minority (18.4%) also experienced visual auras. These findings are in line with earlier studies showing sensory hypersensitivities and aura in significant subsets of patients [9]. Quality of life domains such as bodily pain and emotional functioning showed significant impairment in migraine and cluster headache patients [11].

The chronic migraine subgroup demonstrated severe scores across all SF-36 domains, particularly in vitality and mental health, echoing prior findings on migraine transformation [11,12]. Among TTH patients, the most common descriptors were mild to moderate bilateral pain, often band-like, which aligns with existing literature [6]. Cluster headache patients, though fewer in number, reported severe disabling pain that required acute interventions, consistent with reports by Cohen et al. [19] and Capobianco [20].

This study reinforces the considerable burden posed by primary headache disorders, particularly migraine, which emerged as the most prevalent and disabling type. The demographic and clinical characteristics align with global epidemiological trends, wherein migraine is more common in females and peaks in early adulthood. The higher prevalence in women is often attributed to hormonal influences, stress, and genetic predisposition.

The impact of these disorders extends far beyond pain alone. Migraine patients, especially those with frequent or chronic episodes, experience limitations in daily activities, poor sleep quality, and increased risk of anxiety and depression. The low SF-36 scores in emotional role and vitality dimensions among migraineurs in our study echo findings from other research indicating psychological distress and fatigue as major contributors to poor QoL.

Tension-type headache, although traditionally considered less severe, was not devoid of impact. Chronic TTH patients reported reduced mental health and social functioning, indicating that persistent, even mild pain can lead to significant distress over time. The underreporting and undertreatment of TTH may further exacerbate its burden.

Cluster headache, although rare in our cohort, demonstrated a profound impact in terms of pain intensity and autonomic symptoms. These patients often report fear of recurrence and disruption of normal routines. Despite the low prevalence, healthcare providers must remain vigilant for this diagnosis due to its unique management needs.

One of the strengths of this study lies in the use of a standardized, validated instrument (SF-36) to quantify the subjective experience of headache-related disability. However, limitations include the relatively small number of cluster headache patients and the cross-sectional nature of the study, which precludes causal inference. Furthermore, the reliance on self-report may introduce recall bias.

Despite these limitations, this study underscores the necessity of individualized management strategies and public health awareness campaigns. Early diagnosis, lifestyle modification, preventive pharmacotherapy [12], and psychological counseling [13] are integral to improving patient outcomes.

In line with international findings, the data from our study indicate that migraine remains the leading primary headache disorder in terms of prevalence and impact. The observation that migraine peaks in young adults suggests a direct economic burden through reduced workforce participation and productivity loss.

The inclusion of SF-36 as a QoL metric allowed for nuanced understanding beyond clinical symptoms. Our results reiterate that symptom frequency alone does not predict impact; instead, the intensity and functional limitations imposed are more relevant to the patient’s lived experience.

This study also highlights the need for comprehensive headache services in public healthcare settings. In particular, training of primary care physicians in headache classification and treatment guidelines could result in earlier diagnosis and intervention.

Non-pharmacological strategies, including behavioral therapy, cognitive counseling, and structured patient education, should be integrated into treatment protocols. The mental health dimension of QoL was substantially affected across all primary headache types, underlining the need for a multidisciplinary approach.

Future research could benefit from longitudinal designs, tracking QoL changes over time and in response to treatment. Additionally, community-based studies may reveal higher prevalence and underreporting, further substantiating the need for public health initiatives.

Neuroimaging and pathophysiological studies have previously shown altered pain processing and cortical excitability in migraine patients [3,10]. Functional MRI studies reveal that during migraine episodes, there is hypoactivation in brainstem regions responsible for pain inhibition [10]. These changes support the need for central sensitization-targeted therapies.

Botulinum toxin therapy has shown promising results in chronic migraine, backed by the PREEMPT trials [4]. Non-pharmacological modalities, such as cognitive behavioral therapy and nerve stimulation devices, have also been recommended [5,14]. Furthermore, calcium channel blockers and antidepressants have been effective in select patients [12,13].

Recent genetic studies suggest that familial clustering of migraine and cluster headache may involve autosomal dominant inheritance with incomplete penetrance [17]. Preventive therapies using topiramate, valproate, and beta-blockers have demonstrated efficacy in reducing attack frequency and improving QoL [12,13,14]. This study validates those observations in an Indian clinical setting, highlighting the global relevance of standardized headache management guidelines.

Primary headache disorders are common neurological conditions with distinct clinical profiles and a significant impact on quality of life. Migraine, being the most prevalent in our cohort, had the most detrimental effect across multiple domains of SF-36. TTH, while often underdiagnosed, carries a substantial burden, especially in its chronic form. Cluster headaches, although infrequent, were associated with intense pain and autonomic symptoms.

This study highlights the importance of using patient-reported outcomes like SF-36 to comprehensively assess headache burden. Incorporating QoL assessment in routine clinical practice can help tailor therapeutic strategies and improve patient satisfaction. Future research should focus on longitudinal studies and interventional trials to evaluate the effect of various treatments on HRQoL in headache patients.

Table 1

Table 1 depicts general parameters for Migraine, tension type headache and cluster headache groups

Table 2

Table 2 Depicts SF36 domain mean with standard deviation and p value (ANOVA) among migraine, tension type headache and cluster headache groups

Graph 1

Graph 1 depicts over all SF 36 score among migraine, tension type headache and cluster headache groups

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