Assessment of Self-Medication and Disease Awareness about Migraine in Local Community of Multan, Pakistan

Introduction

According to the current Global Burden of disease survey conducted in 2016, Neurological complaints are considered the second most prominent sources that resulted in years wasted with debility [1]. Among such neurological disorders (primary and secondary types), the rank of Migraine is 3rd in such disorders (a major type of primary headache disorders) [2].

The continuous severe attacks of headache occur on half side of the head that is most difficult to bear for any person with associated indications that may continue up to 3 days is known as Migraine [3, 4]. The most prominent indications with migraine attacks are Sickness, Vomiting, and having feelings of sensitivity to bright light, strong smells, and knocking sounds [3]. In this modern Medical Era, Doctors are not still able to understand its exact Mechanism behind that [3]. The most commonly accepted theory behind that is the Cortical Spreading Depression Theory. In that, complex electrical impulses are produced in the brain stem that resulted in three major problems e.g sensory, visual, and motor nerves related problems [5]. It mostly consists of 4 major phases (Prodrome phase, Aura phase, Pain phase, and Postdrome phase). It has 2 types, one is Migraine with Aura, and the other is Migraine without Aura. It has strong hereditary relationships with Parents as shown in a similar study in Jalandhar (India) [6].

It has the highest global prevalence ratio than any other acute and chronic diseases in developed and underdeveloped countries. Its High prevalence is estimated from the fact that around about 1 in every 7 people in the whole world is affected by that horrible disease and it has the highest prevalence ratio in women than men [7].

Despite its high prevalence and high disability effects in Pakistan and even in Developed countries, this disease is still managed in a poor healthy manner, and the affected people in that disease mostly find its treatment in Self-Medication practice due to its very low poor awareness and also its Self-Medication practice is very highest. A practice of being using Medicines without a doctor’s prescription to treat disease Indications is known as Self-Medication [8]. Various studies have been conducted regarding the assessment of Self-medication and disease awareness about Migraine in Pakistan.

In a same recent study conducted in Rawalpindi among Medical students in 2016 about (95.3%) participants have done the practice of Self-Medication and the major disease’s indications behind that were Headache Disorders (69.5%). Also in that study Analgesics were the most Self-medicated medicines (74.5%) as shown in our research study [9]. A survey conducted in Jalandhar (India) in 2017 showed that overall awareness of migraine among people was about (85%) but there were not well aware of its proper treatment (23%) [6]. There is also an increasing trend of Self-medication practice among people of Multan’s city for various health disorders as shown in a study conducted among students of Bahauddin Zakariya University, such practice was found to be 75% [8].

Multan is the Central Hub of Punjab province and is known as the big city of Punjab province after Lahore. It is famous for its longest hot climate season. We already know that hot Climate season act as a very good environmental trigger for the generation of Migraine’s related symptoms. Thus keeping in view the hot climate season of Multan, the high prevalence of Migraine globally, and as well as its Low Awareness in Pakistan, we conducted a Cross-Sectional survey study about the assessment of Self-Medication practice and disease awareness of Migraine in Multan’s Community. In our Questionnaire, Migraine was assessed by the ID-migraine Screening test and Migraine Disability Assessment score.

Results

The whole target (n=306) took part in our study.Out of

306 participants, (n=130, 42.4%) were Males and (n=176, 57.5%) were Females.Our overall mean age was 23 years with Standard Deviation 6.88. We distributed the Demographic data of participants by Gender to get more differences and probabilities. The distribution of Demographic data according to Gender with P values having target n=306 is shown in Table 1.

As mentioned in above Table 1, the P value for Age’s status is very lower than 0.0 so its result is significant (but p values for Qualification and Social status are greater than standard p values e.g 0.20 and 0.97 so the results of both variables are Non-significant. In Age’s status Males were lesser (n=96, 31.37%) than Females (n=123, 40.19%). Also in Qualification females were a higher number in number (n=138) than males (n=84) in the undergraduate variable. In Social status, females were also greater in number (n=127) than males (n=89) in the upper Middle class.

For assessment of major signs and symptoms of migraine patients e.g Nausea, Light Bothering and Limited ability to do work, we used ID-Migraine Screening Test (questionnaire) whose results are shown concerning Gender with n=306 in Table 2.

As in Table 2, the three p values are obtained as they are two different variables (Yes and No) for each Question (0.061, 0.585, and 0.338), also note that the females’ ratio was greater in every three questions.

Then we determined the disability of Migraine’s Symptoms (low disability to highest disability) by the Help of Migraine Disability Assessment Score with Grades whose results concerning Males are shown in Table 3.

Please note that in Table 3, the p-value is greater than 0.05 so the results of the Migraine Disability Assessment Score are non-significant for Males. Also mostly males (n=48,

15.68%) were in Grade IV (severe disability) that showed migraine is more common in Multan’s Community also in Males.

Note that in above Table 4, the resulted p value is greater than 0.05, so the results of the Migraine Disability Assessment Score for females (n=176) are non-Significant. Also note that most of the Females (n=67, 21.89%) were also in Grade IV (severe disability) that showed migraine is more common in Multan’s Community also in Females.

We also apply the Mann-Whitney U test On Migraine Disability Assessment Score to check whether there is a significant relationship between Gender and That Questionnaire. Please note that the Gender case for that test is kept as Independent Variable. The results of the Mann- Whitney U test on our Questionnaire are shown in Table 5.

To evaluate the difference between Male and Female gender for Migraine Disability Assessment Score we used the Mann-Whitney U test. The test revealed a non-significant difference for the Migraine Disability Assessment Score for Males (Median=3, n=130) and Females (Median=3, n=176), U=1137.00, z=-1.41, p=0.888, r=0.08 so the hypothesis for a significant relationship is not so supported.

Note that in Table 6, the p values for Duration of taking pain medicines, Pain Alleviation by taking medicines, Seeking help from medical doctors for treatment of Migraine are greater than standard p values (0.105, 0.098, 0.586) than standard p value 0.05, so these results are not significant. But in the case of regarding migraine as an illness, the p value is less than the standard p value e.g 0.03 so its result is significant.

In above Table # 7, the Chi-Square test is not so applicable. Also note that Panadol is the most self-medicated drug (n=40, 13.071%) being used by females than Males (n=39, 12.745%). The Ratio of Self-Medication Practice for Migraine

In Table 8, the level of significance for Levene’s test for equality of Means is less than 0.05.

In above table 9, the degree of freedom is about 304, and the level of significance is 0.305

Confounding Questions

From the participants, we also asked some extra questions called Confounding questions other than our required questionnaire. These are those questions that affect the positive and negative outcomes of a Study. These questions were about Reasons behind Self-Medication Practice, Symptoms leading to Self-Medication Practice, Sources behind Self-Medication Practice, and others. Not any test is applied to them. The various reasons behind Self- medication practice by gender n=306 are shown in Table 10.

As shown in Table 10, Females pointed out the most reason for the High Doctor’s fee (n=32) than Males (n=29). Similarly prescribing of high potent drugs by the doctors to their Patients showed a big reason for Self-Medication practice in males (8.82%) than females (7.51%) after High Doctor’s Fee.

In Table # 11, we listed some of the symptoms leading to Self-medication Practice, Sources behind Self-Medication practice as shown below.

In Table 11, Females had the greatest incidence of Headache symptoms (38.56%) than males (26.47%). Similarly, also in table 11, Influence by advertisement campaigns given by the Pharmaceutical companies is greatest among females (15.68%) than males (12.09%).

In Table 12, Females have a greater awareness ratio (88.06%) than males (73.07%). So we get a greater awareness of Migraine in Multan’s Community.

In Table 13, the various Food triggers of Migraine concerning Gender n=306 which is shown below.

In above table 13, the major food trigger both for females and males was Caffeine withdrawal (32.35%) and (23.20%). Similarly, Diet food trigger was highest for males (6.20%) after chocolate items.

In Table 14, the strong smells ratio was greater for females (12.74%), but in Males, the ratio of loud noises was greater (15.68%) than Females.

In Table 15, the Stress ratio was greater for Females (12.74%) whereas in Males also the ratio of Stress was greater (10.13%). The females also reported Disturbances in the Menstrual cycle (10.13%).

Limitations

There are various kinds of limitations connected with our Cross-sectional study. As our study is a cross-sectional study, so the temporary connections of different nature may not be recognized efficiently. Another limitation is that we only survey Multan’s Community people so it is not considered to be a global-based community survey. Due to Corona Outbreak in Multan, we in the end collected our Patients’ Data from the Students of different colleges and universities in Multan city which were well aware of the causes, its Self- medication practices as well as management of migraine’s treatment plans that do not match with our required cross-sectional study fundamental requirements. In our study, we do not include such questions regarding the onset of diagnosis, duration as well as frequencies of Migraine Aura and Migraine without Aura like symptoms. Moreover, our study is also limited due to its small sample size and lack of randomization.

Discussion

Our study aimed to assess the Self-medication practice and disease awareness about Migraine in Multan’s Community. In our study, we have shown that up to (61%) males do not consult any physicians while (87%) females do not consult any doctors for their proper treatment of disease. While also self-medication Practice among males and females were very highest. Now we discuss these parameters stepwise.

Conclusion

Migraine cases as well as Self-Medication practice ratio were the most common among females than males (Table 7). Since most of the patients in our study are in Grade IV (severe disability) of (Migraine Disability Assessment Score) which have affected the healthy lifestyle standards as well as academic results of patients (Tables 2-4). Despite its high prevalence globally, patients most of the time do not seek help from medical professionals due to low awareness (Table 12). Therefore, it is the need of time not only to discuss the exact reasons behind Migraine problems with the patients but also to improve the healthy lifestyle (Physical and Mental) and their Academic performances in their educational fields. Findings of this study strongly recommend that there should be Efficient, Reliable, and Standard Awareness campaigns made by Federal Health care facilities to be made and implemented all over the country according to National and International Guidelines by the World Health Organization that should exactly find out the Sources that resulted in severe symptoms of Migraine in healthy persons. Proper Educational Counselling Sessions must be developed by Neuro physicians that should be mandatory for each patient to attend if he/she faces the severe symptoms of Migraine in his/her healthy life span years. Moreover, Neurological Management Treatment Plan courses should be made and must be included in medical fields’ syllabus according to Standard Treatment Guidelines so that any Health care physician, as well as Pharmacists, could easily manage as well as counsel the patients of Migraine and also aware their patients in an Efficient Manner. Moreover, there should be large good descriptive studies to support good strong evident data.

Recommendations

There are two types of interventions. First, is the Psychotherapeutic Interventions and second is the Institutional Interventions. In Psychotherapeutic Interventions, such interventions should be included that showed positive outcomes with Patients’ healthy status with the help of Neuro physicians, Pharmacists, Physicians, Nurses, and others. In such interventions, Patients’ health care plans should be made by reviewing the National and International Treatment Guidelines and Counselling sessions should be planned and arranged so that Physicians and Patients could easily participate in them. By that, Physicians could understand this highly prevalent deadly disease efficiently and also give awareness to their patients in a most suitable manner.

In Institutional interventions, Medical Institutions should take responsibility to include Current Management Headache Plans in their respective syllabus by giving the efficient Policy guidelines to the Higher Education Commission of Pakistan.