Headache Syndromes in the Eastern Province of Saudi Arabia Saad AI-Rajeh, M.D., Olajide Bademosi, M.D., FRCP (Lond), Hassan Ismail, M.D. MRCP (UK), and Adnan Awada, M.D. Department of Neurology, King Faisal University, Dammam, Saudi Arabia. Reprint requests to: Dr. Saad AI-Rajeh, Department of Neurology, Colleges of Medicine and Medical Sciences, King Faisal University, P.O. Box 2114, Dammam 31451, Saudi Arabia. Accepted for Publication: March 27, 1990. SYNOPSIS The pattern of headache syndromes in 222 subjects (142 Saudi nationals, 80 non-Saudis) seen at AI-Khobar, Saudi Arabia is presented. Headaches were common, and accounted for 13% of all neurological outpatients. They affected mainly young adults, with a peak frequency in the third decade for Saudis and the fourth for non-Saudis. They were rare in those under 10 and above 50 years old. Among Saudis, females outnumbered males especially in the second and fifth decades, while non-Saudi males were mo re frequent than females in all age groups except the second decade. The main types were tension headache (66%) and migraine (22%). Acute/chronic sinusitis was an uncommon cause of headache. Tension headache affected mainly individuals between 21 and 40 years of age (69%). It showed a female preponderance in Saudis ag ed 11-20 and above 40 years, unlike the male predilection in non-Saudis. Migraine showed a definite female predilection only in Saudis in the fourth decade (female to male ratio of 4:1 ). A positive family history for headache was present in 10% of t he cases. The major precipitating factor for headaches was stress related to family or working conditions. Other triggers included hunger and prolonged exposure to excessive heat or sunlight. The pattern of headaches in Saudi nationals may be related to the prevalent sociocultural factors, and the differences observed between them and non-Saudis probably reflect the demographic status of non-Saudis in the Kingdom as a consequence of gover nmental recruitment policy. ( Headache 30:359-362, 1990) INTRODUCTION Headache is one of the most frequent and distressing of human discomforts. It is a symptom of diverse clinical entities, and may be precipitated by physical and environmental stimuli. Information on headache syndromes in the Arab peninsula has been l imited to pseudotumour cerebri. 1 This communication describes our experience of headache syndromes in the Eastern Province of Saudi Arabia. MATERIALS AND METHODS All the patients with headache as the primary reason for their hospital visit for evaluation by the Department of Neurology, King Fahd Hospital of the University (KFHU), AI-Khobar, between December 1983 and November 1988 formed the basis of the study . Patients were excluded from the study on any of the following criteria: i. when headache was not the main presenting symptom that necessitated the visit to the hospital, ii. when the headache was a non-dominant component of other presenting symptoms of the clinical picture; i.e.: secondary to causes such as cerebrovascular disorders (cerebral haemorrhage, ischemic cerebrovascular disease, transient ischemic attacks), meningitis, brain tumours, subdural hematoma, acute head trauma, and arterial hypertension, iii. headache related to previous head injury; i.e. post-traumatic headache syndrome. Apart from routine investigations such as hematologic indices and biochemical tests, other tests included radiographs of the skull, brain computerized axial tomography (CT Scan) with and withouut enhancement, and electroencephalography (EEG). Lumbar puncture to measure the cerebrospinal fluid (CSF) entry pressure and obtain CSF for microscopy and biochemistry, and blood and CSF serology, were performed when indicated. For this study, headache was defined as pain or discomfort involving any part of the head including the face, and upper aspects of the neck. The headache syndromes were classified as: a. Migraine: recurrent episodic throbbing or pulsatile headache lasting 2-72 hours with total freedom between attacks; the headache, commonly unilateral, may be associated with visual, gastrointestinal or autonomic disturbances. 2 b. Tension (Muscular, Psychogenic) headache: continuous, often persistent, chronic headache, usually generalised, occipital or vertex in location, with or without associated symptoms such as palpitations, dizziness, difficulty in concentration, and o ther features of anxiety or depression, c. Benign raised intracranial pressure: when the headache was associated with elevated CSF entry pressure at lumbar puncture (>200 mm water) and papilledema on funduscopy but without other clinical or