Abstract
Background
Headache disorders are classified as primary or secondary; however, among the secondary headaches, those attributed to food ingestion are not well understood. Therefore, we conducted this study to describe and characterize a new headache entity that occurred during the holy month of Ramadan. This headache occurred within 4 h of breaking the fast.
Methods
This is a nationwide descriptive community-based cross-sectional study conducted during the last 10 days of Ramadan, based on a random sample of adults living in Saudi Arabia. The demographic data, headache symptomatology, nature and distribution of the pain, possible triggering and relieving factors, and patient management programs were analyzed.
Results
Completed questionnaires were obtained from 16,031 participants. Of those, 3147 (19.6%) reported headaches after breaking the fast in Ramadan. In 84.1% of cases, there was no previous diagnosis of headache or migraine. The characteristics of these postprandial fasting-related headaches mostly was episodic in nature (72%). The nature of the headache was variable, mostly heaviness or tightness (53.9%). Triggering factors included ingestion of fried food in (45%) and coffee (26.3%). Lying down and sleeping was found to be an important relieving factor (61%).
Conclusion
A new headache entity is being described. Appears to be quite common, occurs less than 2 h following the first meal, and is mostly of the heaviness and tension type.
Introduction
Headache is one of the most common reasons for neurological clinic visits. In some cases, despite all the diagnostic and treatment measures, the cause of the headache cannot be determined and only symptoms are treated (1).
Fasting, the act of willingly abstaining from all food and drink, is practiced to some extent by most religions. In Islam, fasting for a month is an obligatory practice during the holy month of Ramadan (2), from fajr (dawn) until maghrib (dusk). Muslims are prohibited from eating, drinking (including water), engaging in sexual activity, and smoking while fasting. Fasting in the month of Ramadan is one of the Pillars of Islam and is thus one of the most important acts of Islamic worship, and its health benefits has been studied (3,8,9).
All types of fasting including fasting during Ramadan have been studied by scientists and clinicians. Caloric deprivation decreases total body mass index, levels of glucose and triglycerides due to an increase in insulin sensitivity (8,9). Fasting induces neuroprotection by stimulating the release of brain-derived neurotrophic factor (BDNF) through stimulation of neuronal network activity, which is thought to improve cognitive function and energy expenditure acceleration (10). Caloric restriction is thought to contributes to expanding lifespan by exerting anti-aging effects, such as reducing the levels of diabetic metabolic markers, cardiovascular diseases, cancer, oxidative damage, and increasing cellular stress resistance (11).
Fasting can trigger a headache even in individuals without a previous history of headaches. It is a known trigger for migraine attacks (4,5). Previous studies have shown a direct relationship between the frequency of headache and the duration of fasting. Caloric deprivation can lead to fatigue, which can range from mild to severe (11), and it has been found that some Muslims experience headache during the first days of Ramadan and immediately before and after the breakfast time (Iftar), which could be related to changes in their lifestyle, hydration status, caffeine intake, smoking, and/or serum glucose level changes, but there is much to be further understood about the etiology of such headaches.
The International Classification of Headache, 3rd edition (ICHD-3, 2018), codes “headache attributed to fasting” as a separate entity (10.5 of ICHD-3) (4). Nevertheless, the ICHD-2 criteria define fasting headache only when the patient has been fasting for more than 16 h. The fasting time, or the time between dawn and sunset in Saudi Arabia (SA) during the study month is < 15 h, which by definition cannot be included in fasting headache. Postprandial headache (PPH) is classified as (8.1.5 of ICHD-3) (4); namely, headache induced by food and/or additive, which includes an episode of migraine triggered by a specific food or additive, is coded as the appropriate subtype of migraine or headache caused by ingestion of a food or an additive containing one or more specific substances, which may not be identified, to which the patient is sensitive, where headache has developed within 4 h of ingestion of the food or additive, has resolved within 72 h after ingestion of the food or additive, and has at least one of the following four characteristics: a) bilateral b) mild to moderate intensity c) pulsating quality d) aggravated by physical activity.
This study describes a type of headache that does not fulfil the criteria of fasting headache because the duration was less than 16 h and occurred after breaking the fast and does not fully fit the criteria of PPH because it did not occur after regular meals.
The aim of this study is to describe and characterize a new headache entity that occurred in the fasting month of Ramadan. This headache occurred within 4 h of breaking the fast.
Methodology
This is a cross-sectional nationwide community-based study included adults of 18–50 years of age from both genders. Participants were recruited by convenient random sampling from the SA population during Ramadan between 23 April 2020 and 23 May 2020.
Tools
The tool consists of 40 selected response items with free response at the end. It consisted of several sections that enquired about demographic data, sleep (enquiring about sleep deprivation as perceived by the subject) and habits, symptomatology (including nature of headache, site of headache, duration, severity, seeking medical help, medications, family history, relationship to meal and fasting, relationship to Ramadan month, associated symptoms, interruption of work or study, and whether it led to breaking the fast), triggering factors, relieving factors and management sought, comorbidities (only those that have been confirmed by clinical diagnosis), and triggering food types. It was designed on Google forms by the researchers for the purpose of characterizing all descriptors and factors related to the headache entity.
Tool validation
Content validation of the tool was achieved by reviewing the literature (1–7) to include all items related to headache. In addition, a two-stage expert validation process was followed. Three neurologists were asked to evaluate the items on the tool separately. In the second stage, focus group discussion was used to reach consensus > 85.0% about every item.
Subject recruitment
The survey was posted on social media and responses were electronically entered in an Excel sheet from Google forms. Out of the positive group who reported fasting-related postprandial headache, a convenient random sample (>50%) was interviewed by a telephone call to confirm the responses.
Inclusion and exclusion criteria
Any subject who developed headache after fasting within 4 h was considered for inclusion. Exclusion criteria were subjects who were younger than 18 or older than 50 years, non-fasting subjects, and those who developed headache more than 4 h after breaking the fast.
Statistical analysis
The data were collected and analyzed using the IBM Statistical Package for the Social Sciences version for Windows, version 19 (IBM Corp., Armonk, N.Y., USA). Data were analyzed descriptively using simple statistical ratios consisting of frequency and percentages. Based on the “Qualtrics” sample-size calculator, the minimal sample size that should be recruited from the general population of SA should consist of 246 patients (taken from the global prevalence rate of headaches in Asia, affecting 20% of the population in 2018) (6), along with confidence intervals of 99% with a 2% margin of error.
Ethical approval
This study was ethically approved by Imam Abdulrahman Bin Faisal University Institutional Review Board committee. Written consent was provided by the participants. The study adheres to the principles of the Helsinki Declaration of 2008.
Data management
Each participant was given a specific code for the storage of data that was secured by a unique password access.
Results
The response rate to the questionnaire was 75.8%. Of the 16,027 participants, 3,147 reported having fasting-related postprandial (post-iftar) headache during Ramadan. The prevalence of fasting-related postprandial (post-iftar) headache during Ramadan was found to be 19.6% (95% CI).
The demographic characteristics of the study group are shown in Table 1. Age ranged from 18–50 years, and the sex distribution was fairly even (55.4% females, 44.6% males). Smoking was present in only 20.9% of the participants, and 43.9% reported sleep deprivation.
Demographic data of 3147 patients with postprandial headache after iftar.
In terms of comorbidities, sinusitis had the highest prevalence (10.4%), followed by anemia (7.3%), diabetes (6.3%), hypertension (6.2%), asthma (6.1%), gastrointestinal disease (5.2%), thyroid disease (2.9%), cardiac disease (1.7%), autoimmune diseases (1.1%), psychiatric disorders (1%), stroke (0.2%), and other diseases (8.6%), as shown in Table 2.
Chronic diseases.
Table 3 shows that most of the participants (84.1%) did not seek medical diagnosis or advice. A tension headache was diagnosed in 5.6%, migraine with aura in 4.7%, migraine without aura in 4.8%, and cluster headache in only 0.7% of the participants. Most participants (69.7%) had no family history of headache, while only 30.3% had a positive family history of headache, out of which 76.2% had a first degree relative with headaches.
Headache characteristics.
The number of meals the participants had during Ramadan was variable and ranged from one to more than four, but most participants (67.8%) had two meals. The onset of headache in most (59.2%) of the participants was in the first 10 days of Ramadan, followed by the second 10-day period (30.9%), followed by the third 10-day period (9.9%). The headache pattern was episodic in most participants (72%), on sporadic days (66.8%), and gradual in onset (45%). Time for the headache to reach its maximum was in minutes (55.4%) and it was resolved in 2 h (62%). The headache distribution was frontal (40.4%), frontal with eyes (36.2%), occipital (14.4%), occipital and back of neck (10.7%), and unilateral (28%). The nature of the headache pain was described as heaviness or tension (54%), tingling (35.1%), and pulsatile (10.9%), as shown in Table 3.
Symptoms associated with the headache, shown in Table 4, were as follows: Phonophobia (35%), mood changes (33.3%), dizziness and sleepiness (37%): photophobia (31%), nausea (19.9%), disturbed concentration (16%), increased lacrimation (7.2%), tingling in one limb (6.6%), or vomiting (4.9%). Most had mild to moderate pain (65.1%), A high percentage of subjects (44.3%) stated that the headache interfered with their daily function. Only 6.5% had to break their fast because of the headache.
Associated symptoms.
Table 5 shows the relief measures and treatments that the patients sought during the headache episode. Relief activities included lying down and sleeping (61%), head massage (26.2%), sitting in a dark quiet room (21.9%), nothing (21.3%), using a head bandage (16.9%), and motor activity (5.3%). Pharmacological treatment of the headache included paracetamol (53.7%), nothing (36.4%), ibuprofen (12%), injection of Xefo (2.4%) or naproxen (2.3%) in the ER.
Relieving factors and treatments.
Triggering foods were found to consist of fried food (45%), stimulants like coffee or tea (26.3%), sweetened food and drinks (27.2%), grilled food (6.4%), or other kinds of food (21.8%), as shown in Table 6.
Triggering foods.
The minimum number of days that the patients suffered from postprandial (post-iftar) fasting-related headache was 1 day and the maximum was 30 days, with a mean of 5 days, as shown in Figure 1.
Days with a postprandial headache after iftar during Ramadan.
Discussion
This is the first large-scale population-based study among adults in SA to measure the prevalence of Ramadan fasting-related postprandial (post-iftar) headaches based on a validated questionnaire. This study showed that headache related to fasting during the month of Ramadan is common (32.9%). Out of 16,037 respondents, 3144 reported fasting-related postprandial headache following Iftar time – (19.5%) comprised the majority.
Thus, the prevalence of headache related to fasting in SA is higher than the prevalence reported elsewhere, such as in Turkey (16.9%) and Denmark (19.0%) (5). In a global study conducted by Rigmor Jensen, headache prevalence was found to be highest in Europe, followed by North America, South and Central America, and Asia. The severity of the attacks in our study were more varied and severe cases (3.9%) were less when compared to the Turkish study (54.2%).
Chronic conditions associated with headache like sinusitis were of lower rate in our study (10.4%) than in the Turkish study (15.3%), and hypertension rates were almost twice as common in in our study than in Turkey or Denmark. With regards to headache characteristics, the prevalence of tension headaches was similar to that in Turkey, but lower than in Denmark (5.6% vs. 5.1% in Turkey, 20.5% in Denmark), while migraines were much less prevalent (9.5% vs. 28.8% in Turkey, 20.5% in Denmark). The nature of the headache revealed a less pulsatile character in our group than in Turkey (10.9% vs. 81.6%). Associated symptoms revealed less nausea and vomiting (24.8% vs. 80.8%), phonophobia (35% vs. 85.2%), and photophobia (31% vs. 82.5%) among our participants.
This study helps to increase awareness about headache occurrence during the holy month of Ramadan. Fasting-related postprandial headaches were the most common type. In conclusion, the present study sought to assess the most common types of headache related to fasting during the month of Ramadan, revealing that a unique entity was discovered that is related to fasting but occurred after meals in the majority of participants. Neurologists should consider this type of headache prevalence during this time of the year before adjusting a patient’s headache treatment regimen.
Limitations
Complete randomization was difficult because of the large sample. Trigger foods, sleep deprivation, and relieving factors were considered according to subjective perception by the candidates.
Clinical implications
Most post-iftar headaches in Ramadan are of the heaviness and tension type and were related to the type of food eaten in the first meal. Physician awareness of this headache entity should be achieved to avoid unnecessary changes or commencement of headache medication.
Footnotes
Acknowledgment
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethics/IRB approval
The ethical approval was taken from Institutional Board Review committee at Imam Abdulrahman Bin Faisal University (IRB-2020-618-Med).