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Year : 2023  |  Volume : 22  |  Issue : 1  |  Page : 11-17  

Quality of sleep and disability associated with headache: migraine versus tension-type headache: A comparative study

1 Department of Psychiatry, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India
2 Department of Psychiatry, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, Jammu and Kashmir, India
3 Department Mental Health, O/o Director General Health Services, Ambala, Haryana, India

Date of Submission24-Nov-2021
Date of Acceptance19-Oct-2022
Date of Web Publication24-Jan-2023

Correspondence Address:
Manish Bathla
782/Sector 13, Urban Estate, Karnal - 132 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aam.aam_241_21

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Background: One of the commonest and most frequently said, quoted and understood by even the least educated elements of our society is the neurological symptom of headache. The commonly diagnosed and studied headaches are Migraine and Tension type headache [TTH]. Headache has the power to reduce the very essence of a peaceful life and produce a disability in a person. Aims and Objectives: The aim of our study is to approach the subject with view of correlation of quality of sleep with the disability associated with migraine and compare it to TTH. Materials and Methods: For the same a cross-sectional study design was adopted and a consecutive sampling procedure was adopted. The sample was subjected to basic socio-demography, VAS, PSQI and HDI. Statistical analysis was done on the collected data. Results: Based on scales the results were evaluated using appropriate statistical methods. It was observed that there was a higher female preponderance in both migraine and TTH, there was severe disability associated and both headaches cause poor sleep quality. Conclusion: The current study concludes that headache is a debilitating illness which causes significant disability to a person.

Keywords: Headache disability inventory, headache, migraine, Pittsburgh sleep quality index, tension-type headache, visual analog scale

How to cite this article:
Singh AH, Bathla M, Gupta P, Bhusri L. Quality of sleep and disability associated with headache: migraine versus tension-type headache: A comparative study. Ann Afr Med 2023;22:11-7

How to cite this URL:
Singh AH, Bathla M, Gupta P, Bhusri L. Quality of sleep and disability associated with headache: migraine versus tension-type headache: A comparative study. Ann Afr Med [serial online] 2023 [cited 2023 Mar 21];22:11-7. Available from:

   Introduction Top

One of the most frequently said, quoted, and understood by even the least educated elements of our society is the neurological symptom of headache. The diverse clinical features, particularly the presentation, the parameters on which it could be assessed, and the diagnoses it could be fit into are ironically enough to give the clinician a headache. To understand headaches at a primal level, we must know that it consists of pain and/or discomfort from pain-sensitive structures in the head. These areas include extracranial structures such as skin, muscles, embedded blood vessels, and intracranial structures, including large blood vessels of Circle of Willis, the tremendous intracranial venous sinuses, parts of dura matter and its embedded arteries and cranial nerves.[1] The 3rd edition of the International Classification of Headache Disorders (ICHD) has provided us with diagnostic criteria to diagnose various headache syndrome varieties.[2]


Migraine is a common, neurovascular headache having multiple causative factors and is disabling in nature. It is a recurrent headache that affects approximately 15% of the population globally. The variety of triggers and complex symptomatology of migraines makes it challenging to thoroughly understand, diagnose, and treat.[3] ICHD defines it as a primary disabling headache disorder and has ranked it as the 3rd most prevalent disorder. Broadly it has been classified into two categories, which are migraine with aura and migraine without aura. Aura is defined as transient focal symptoms that are neurological and usually precede the headache and sometimes accompany it.

Tension-type headache

Tension-type headache (TTH) is typically a pressing or tightening type of pain with mild to moderate intensity. The recurrent episodes of headache that would last from minutes to weeks. It was earlier called as psychogenic headache, muscle contraction headache, stress headache, and psycho-myogenic headache. The description lies in the word tension-type, which specifies some kind of tension, either muscular, mental, or a combination playing a role in its pathogenesis. The exact path of physiology is yet to be ascertained.[4] TTH[3] is a common disorder with 30%–70% prevalence in the general population.

Migraine and sleep quality

Sleep is one of the most intimate, important, and basic requirements of every individual. It ranks equally with needs such as food, a place to stay, wearing clothes, and physical needs. The antichrist relationship between sleep and headache is being studied for a long time.[5] Migraine patients have short sleep duration with increased latency, poor daytime functioning, daytime sleepiness, poor sleep efficiency, and overall poor sleep quality.[6] There is an increasing prevalence of impaired sleep quality, especially insomnia, snoring, and daytime sleepiness, in migraine patients compared to the general population.[7] Another fact that holds its weight in water is that migraine, along with the comorbidities it carries in the form of anxiety, depression, physical pain, etc., are also the reasons for patients to have poor sleep quality.

Tension-type headache and sleep quality

The most understandable fact explaining the role of TTH in sleep disturbance is the stress which triggers and precipitates the TTH and leads to sleep disturbances. The stress of any kind, emotional, physical, or even combination, leads to psycho-myogenic changes that lead to TTH. The complex interaction of emotional stress is studied and is concluded to have a more significant effect on TTH and, thus, sleep quality. Thus, emotional stress increases the frequency of TTH, and that has a longitudinal relationship with impaired sleep quality.[8] Rains et al.[9] conducted a research review to evaluate and investigate for unearthing the manifestation, declaring a bidirectional association between TTH and declined sleep quality in patients. The researchers explained that in its most severe exacerbation TTH in 2%–3% of the populace causes a very debilitating effect on sleep quality, conjunction, sleep deregulation, and potency to instigate an episodic TTH.

Disability caused by migraine

Migraine and disability of quality of life

According to the World Health Organization, quality of life (QOL) is defined as “the individual's perception of their position in life in the context of the culture and value systems in which they live and to their goals.”[10] The facts state that migraine has arisen from its debut at number 19th of the Global Burden of Disease (GBD) study of 2000 to 7th in GBD in 2010, 6th in GBD in 2013 and 2nd in GBD of 2016. The study took into consideration the Years Lived with Disability.[11] About as much as 76.2% of migraine-diagnosed patients in the general population suffered from neck pain and sought medical attention solely for it. The burden estimate of the study was about 173 billion Euros a year in Europe only.[12] Putting facts with figures, even a layperson would point out the dysfunction caused by a migraine on the physical domain of QOL and the huge expenditure done to ameliorate the said dysfunction. The health-related outcomes of migraine and psychiatric comorbidities have revealed that patients likely have a 2-week disability, restriction of activities, and poorer QOL.[13]

Disability caused by tension-type headache

Tension-type headache and disability of quality of life

As already described, a person able to fulfill his physical, social, and psychological needs is a person having good QOL. It is not hard to speculate a negative association of TTH with QOL. In India, a prevalence of 35.1% of TTH in the general population is estimated. The burden of TTH was also estimated–the lost productive time was measured through missed work, lost work time, and decreased work output. A fair assumption can be made that a decreased household work output is also there, along with professional decline. The social needs of a person are compromised, and in severe cases, they become a lost cause because of TTH.[14] The sufferer of TTH tends to stay alone, avoid interaction with people, avoid social situations, and avoid any stressor or perceived stressor in a bid to avoid triggering TTH. One can argue that these factors lead to the development of a phobia concerning exposure of the patient and triggering of TTH, and the psychological comorbidity of depression worsens.[15]

Having explained headache as a symptom to the classification of it to the most common primary types (migraine and TTH) and having understood the effect on sleep quality and disability of QOL, with this background, this study was planned and aimed to approach the subject with the view of correlating quality of sleep with the disability associated with migraine and compare it to TTH.

   Materials and Methodology Top

The study was cross-sectional by design. A consecutive sampling procedure was adopted. Patients aged more than 18 years and willing to give informed consent, educated in local languages to know Hindi, Punjabi, or English language and diagnosed with TTH or Migraine were included.

Patients with a history of any comorbid psychiatric disorder (depression, substance use, anxiety, etc.), with a history of any comorbid organic disorders (hypertension, ophthalmological disorders, trauma, thyroid, etc.), with mental retardation, who are taking prescribed medications (example – nitroglycerine, sildenafil, estrogen progesterone contraceptive pills, etc.) known to cause a headache as a side-effect were excluded.

This study was conducted in the Department of Psychiatry at M. M. Institute of Medical Sciences and Research, Mullana, Ambala. For the current study, the sample was divided into two groups. Group A: patients with Migraine (75) and Group B: patients with TTH (75).

Method of data collection

A Primary Researcher Angad harsh bir (AHB) saw a patient under the supervision of a consultant Manish Bathla (MB). After that, the patient was to be reviewed by the consultant in charge (MB). The final diagnosis was made according to the ICHD 3rd edition. The cases were only be enrolled after an in-depth explanation of the study's nature explained to them in their native language. Written informed consent was obtained before enrolling them in the study. Ethical committee approval was obtained before data collection.

Instruments used

The sociodemographic datasheet format was structured to give the socio-demographic profile of a patient at a glance. The sociodemographic data sheet included variables such as age, gender, marital status, qualification, job profile, religion, and family construct. An updated version of Kuppuswamy's socioeconomic scale was used for the appropriate collection of data about the socioeconomic status of an individual or the family.[16]

Visual analog scale for pain measurement

A scale designed to be simple and effective with easy administration and interpretation. This scale is based on the fact that a patient can recognize the degree of discomfort they have. With the idea to let patients assess their feeling in the form of a visual scale Dr. RCB Atiken[17] initially came up with a scale, and later on, J W Woodforth used this concept to make a visual analog scale for pain measures.

Pittsburgh sleep quality index

Pittsburgh sleep quality index (PSQI)[18] was given by Buysse in 1988 to assess sleep disorders properly. It is a self-reported scale that helps determine sleep quality and disorders, mainly for a 1-month gap. It takes 5–10 min to apply the scale. It includes 19 items on a series of 4 items Likert scale from 0 to 3. It leads to 7 component scores, including latency, daytime problems, duration, quality, efficiency, use of sleeping drugs, and other disorders of sleep. A total score of 5 or more suggests sleep disorders indicating poor quality of sleep. The score of PSQI >5, suggestive of poor sleep quality, has 89.6% sensitivity and 86.5% specificity. (The permission to use the scale was obtained through E-mail from [email protected]; dated September 10, 2018).

Headache disability inventory

The scale was developed and used for the sole purpose of quantifying the problematic experience caused by the headache. The scale has items sub-grouped into functional and emotional subscales. A 25-item headache disability inventory (HDI)[19] scale is being used. The test-retest reliability of the scale is acceptable, and the functional and emotional subscale scores are also valid.

Statistical analysis

A descriptive analysis using mean and standard deviation (SD) was done to evaluate the variables recorded under sociodemographic data and clinically recorded. An analysis was conducted which commented on the frequency and percentages for the discontinuous sociodemographic data and the clinically found variables. This analysis will be descriptive. For the comparison of variables discrete in nature, an array of nonparametric tests would be applied (Chi-square test, etc.).

   Results Top

[Table 1] shows that the mean age of the migraine study population was 33.25 years with a SD of ± 10.73 and while that of the TTH group was 35.36 years with an SD of ± 11.65. The P = 0.251, which was not significant. The mean visual analog scale (VAS) score was 6.91, with an SD of ± 1.19 for 75 cases of migraine. The mean VAS score was 6.73, with an SD of ± 1.03 for 75 cases of TTH. The P value of the data was 0.341, which was statistically not significant.
Table 1: Mean age and Visual Analogue Scale score and its comparison in migraine and headache

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[Table 2] shows that 22 males and 25 females had a score <5 indicative of good sleep quality, and 28 males and 75 females had a score of more than five, indicative of poor sleep quality. The data had a Chi-square value of 5.593 and a P = 0.025, which is statistically significant.
Table 2: Pittsburgh sleep quality index score and its sociodemographic distribution

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[Table 3] shows the PSQI score, along with the type of headache. It is observed that 29.3% of migraine cases had good sleep quality than 33.3% of TTH cases. The data had a Chi-square value of 0.279 and a P = 0.597, which is statistically not significant.
Table 3: Pittsburgh sleep quality index score and type of headache

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[Table 4] shows the frequency and severity of headaches as per HDI in the type of headache. The P value for the data was 0.427 for headache frequency and 0.704, respectively, for headache severity and statistically insignificant.
Table 4: Frequency and severity as per headache disability inventory in a type of headache

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[Table 5] shows the HDI severity and type of headaches. The Chi-square value of the data was 1.261, and P = 0.738, which is not statistically significant.
Table 5: Headache disability inventory severity score and type of headaches

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[Table 6] shows the correlation of PSQI, VAS, and HDI in migraine. It is observed that as the score of VAS increases, the score of PSQI and HDI. The score of PSQI increase is also associated with an increase in VAS and HDI. The score of HDI increase is associated with an increase in VAS and PSQI. The P = 0.000 for the association of VAS with PSQI and HDI, which is statistically significant.
Table 6: Correlations of pittsburgh sleep quality index, Visual Analogue Scale, and headache disability inventory in migraine

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[Table 7] shows the correlation of PSQI, VAS, and HDI in TTH. It is observed that as the score of VAS increases, the score of PSQI and HDI. The score of PSQI increase is also associated with an increase in VAS and HDI. The score of HDI increase is associated with an increase in VAS and PSQI.
Table 7: Correlations of pittsburgh sleep quality index, Visual Analogue Scale, and headache disability inventory in tension-type headache

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   Discussion Top

Our study observed that 66.7% of the cases were between the age group of 21 and 40 years. The finding is similar to Al-Hashel et al.[20] in Kuwait, where 38% of patients were <30 years of age, and 68% were in the age group 18–50 years. As Kulkarni et al.[21] reported, the data for the prevalence of headache in India's mean age was 38.1 ± 12.0 years for migraine and 36.9 ± 12.4 years for TTH, which is almost similar to the current study. The study observed an increased incidence of migraine in females, married populous with high school education. The findings were similar to data reported by various studies earlier.[20],[21],[22],[23] It was observed that migraine has a more deleterious effect on sleep quality as compared to TTH. The current observation was supported by the findings of Cheraghi et al.[24] and Duman et al.[25] While the research work of Verma et al.[26] and Andrijauskis et al.[27] reported more impairment in TTH in comparison to migraine.

The research infers that headache in itself is a disabling illness, with more than half having a severe disability; it was also inferred that migraine has a more disabling illness than TTH, but the data is not statistically significant. The inference was similar to Rammohan et al.,[28] Berardelli et al.,[29] and Ayele and Yifru.[30] A mean score of 6.82, indicating moderate pain, is observed for the sample, while for migraine, the mean score is 6.91 ± 1.19, and for TTH, the mean score is 6.73 ± 1.03. In the research conducted by Kim et al.,[31] it was observed that the mean VAS score for migraine cases was seven, which was corroborative with the current study.

It has been observed that for each type of headache, an increase in VAS score had a positive correlation with PSQI and HDI; similarly, an increase in PSQI was associated with increased scores of HDI and VAS, and an increase in HDI led to an increase in PSQI and VAS. The inference of which was that an increase in pain leads to disturbed sleep, leading to increased disability by headache, a disturbed sleep would cause more disabling headache and hence increased pain score, and an increased disabling headache would cause more disturbed sleep and increased pain score.

   Conclusion Top

Headache is a debilitating condition that affects the normal QOL of a person. The deleterious effects of headache include but are not imitated to disturbed the ability to work, increased disability in daily activities, poor sleep quality, etc. The current study attempted to study the effects of headache on sleep quality and its disabling effects on an individual's life. The current study evaluated sleep quality using PSQI and disability caused by headache using HDI. More than half of the participants had poor sleep quality. It was also observed that most of the participants had a severe disability due to headaches. A positive correlation was observed between the increase in the severity of the disability and poor sleep quality and increased pain intensity of headache.


  1. The study did not take into consideration any minimum duration of the headache
  2. Other types of headaches were not taken into consideration
  3. The effect of treatment on headache was not taken into consideration
  4. The sample size was small.


Acknowledging the ethics committee of Maharishi Markendeshwar Deemed University for encouraging and allowing the study to be undertaken. There was no financial help from anyone.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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