DOI: 10.1590/1413-812320152011.

19272014 3477

Prevalence of headache in adolescents

article
and association with use of computer and videogames

Michelle Katherine Andrade Xavier 1

Ana Carolina Rodarti Pitangui 1
Georgia Rodrigues Reis Silva 1
Valéria Mayaly Alves de Oliveira 1
Natália Barros Beltrão 2
Rodrigo Cappato de Araújo 1

Abstract The aim of this study was to determine

the prevalence of headache in adolescents and its
association with excessive use of electronic devices
and games. The sample comprised 954 adoles-
cents of both sexes (14 to 19 years) who answered
a questionnaire about use of computers and elec-
tronic games, presence of headache and physical
activity. The binary and multinomial logistic re-
gression, with significance level of 5% was used
for inferential analysis. The prevalence of head-
ache was 80.6%. The excessive use of electronics
devices proved to be a risk factor (OR = 1.21) for
headache. Subjects aged between 14 and 16 years
were less likely to report headache (OR = 0.64).
Regarding classification, 17.9% of adolescents had
tension-type headache, 19.3% had migraine and
43.4% other types of headache. The adolescents
aged form 14 to 16 years had lower chance (OR
≤ 0.68) to report the tension-type headache and
other types of headache. The excessive use of dig-
ital equipment, electronic games and attending
the third year of high school proved to be risk fac-
tors for migraine-type development (OR ≥ 1.84).
1
Programa de Mestrado em
Hebiatria, Universidade de There was a high prevalence of headache in ad-
Pernambuco. R. Geraldo olescents and high-time use of electronic devices.
Estrela 100, Centro. 56300- We observed an association between excessive use
000 Petrolina PE Brasil.
michelle_katherineft@ of electronic devices and the presence of headache,
hotmail.com and this habit is considered a risk factor, especially
2
Departamento de for the development of migraine-type.
Educação Física,
Universidade Federal Rural Key words Headache, Adolescent, Computer,
de Pernambuco. Video games
3478
Xavier MKA et al.

Introduction characterized by focal neurological symptoms

that precede or accompany the headache. While
Daily activities related to work, education and the physiopathology of migraines is still not com-
leisure are changing due to the insertion of elec- pletely understood, it is known to be influenced
tronic devices into human life and society. This by genetic factors, eating habits, and physical and
process is affecting all age groups, including teen- psychological stress. These factors trigger a brain
agers, who are increasing their use of these de- dysfunction that in turn causes transient changes
vices1,2. Television, cell phones, video games and in neuronal activity that lead to pain10.
computers are among the media teenagers use Tension-type headache is the most common,
most, especially the latter two3, which are used and can be subdivided into episodic and chronic,
for socializing, leisure, learning, work, social in- the latter usually resulting in greater impact on
clusion and acceptance. quality of life. As with migraine, the pathophys-
In education, technological innovation is re- iology of tension-type headache is not well un-
lated to the prospect of continuous progress and derstood, although the mechanisms appear to be
improvement. Public policies have been devel- similar. Localized pain in the myofascial tissue is
oped to ensure digital inclusion for all students, capable of activating other pain pathways, there-
regardless of socioeconomic class. In many state by sensitizing and destabilizing the pain centers10.
public schools, laptops have been distributed to Studies have shown that headache has in-
teachers and students in an effort to enhance creased considerably in recent years, with a 70%
quality of education and the process of digital prevalence rate of at least one episode of head-
inclusion. This project has been implemented in ache every three months being observed among
various countries around the world, including teenagers. In Brazil, one population-based study
Brazil, where it is entitled Um Computador por conducted in the city of Campinas, in the south-
Aluno [One Laptop per Student]. Pernambuco, eastern state of São Paulo, showed that 24.83%
in the northeast, was the first Brazilian state to of adolescents complained of frequent headache,
adopt this policy and implement the program4. which is the second most reported health prob-
Digital inclusion programs increase the lem after allergy11.
time teenagers spend using electronic devices, Considering the high prevalence of headache
and some studies have shown that excessive use in adolescents and the risk factors that predispose
of electronic devices by teenagers is associated them to this condition, in particular frequent use
with reduced levels of physical activity, obesity, of electronic media, it is necessary to investigate
fatigue, stress, difficulty concentrating, develop- groups at risk for headache in order to formulate
ment of musculoskeletal pain, and headache5,6. policies that guarantee digital inclusion of teenag-
These data indicate that although the goal of ers that simultaneously protect their health. The
digital inclusion may be attained, the insertion present study aimed to verify the prevalence of
of digital technologies into the daily life of ado- headache in teenage students at public state high
lescents can cause adverse effects to the health of schools in the city of Recife, the capital of the
this population, and that it is a potential factor northeastern state of Pernambuco, as well as the
for the emergence of several health problems2,6. association of headache with excessive use of com-
Potential health complaints associated with puters, video games, and other associated factors.
excessive use of electronic devices among teen-
agers include headache6,7, one of the most im-
portant health problems worldwide due to its Methods
association with increased rates of depression
and anxiety8. There are several classifications for This was an epidemiological, descriptive, cor-
headache, and among the teenage population, relational, cross-sectional, school-based study.
the most prevalent is primary, which includes Sample size was calculated using the WinPepi
migraine and tension-type headaches9. software program, with an estimated population
Primary headache is defined as head pain of 55,058 students, according to 2012 data pro-
that does not present a temporal relationship vided by the Secretary of Education of the State
with any other disorder that could be considered of Pernambuco. A confidence interval of 95%
the cause. Migraine can be divided into two main was applied, along with a sample error of five
subtypes: migraine without aura, characterized percentage points, estimated prevalence of 50%,
by headache with specific characteristics and sample loss of 20%, and sample design effect set
associated symptoms; and migraine with aura, at twice the minimum sample size.
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Ciência & Saúde Coletiva, 20(11):3477-3486, 2015

The sample selection procedure followed a uipamentos Medicos Ltda. brand, model Wood-
sequence of steps, in an attempt to obtain a rep- WCS, Brazil). These data were used to calculate
resentative sample of students, distributed ac- body mass index (BMI) and classify overweight
cording to geographic region and size of schools. and obese students according to the criteria sug-
In the first step, the total number of schools with gested by Cole et al.13
high school grades was observed. The schools The questionnaire was developed and adapt-
were then divided into each of the educational ed with the aim of assessing socio-demographic
management regions in the state, with the city variables (age, sex, level of education, presence of
of Recife divided into northern and southern remunerated professional activity, family income
regions. With the aim of assisting the sampling in minimum wages), data on the use of comput-
plan, the schools were divided into three catego- ers and video games, presence of musculoskeletal
ries according to size: small (200 students or less), pain and level of physical activity.
medium (201 to 499 students) and large (more For measurement of use of computer and
than 500 students)12. video games and the presence of musculoskel-
In the second step, cluster sampling was car- etal pain, questions were adopted from a ques-
ried out in two stages, considering school and tionnaire on musculoskeletal syndromes and
grade as sampling units in the first and second injuries in children and adolescents and their
stages, respectively. In the first stage of the second relationship with computers and video games14.
step, the stratification criterion was applied con- The short version of the International Physical
sidering the proportionality of schools by size. Activity Questionnaire15 was used to assess level
In the second stage of the second step, the strat- of physical activity.
ification criterion was applied considering the To diagnose headache, the questionnaire
proportionality of grade size12. After all steps, the developed by Lima et al.16 was applied. This in-
minimum number of 23 schools and 96 classes, strument assesses the presence of headache, and
totaling 954 teenagers, was attained. classifies headache according to the criteria of the
Study participants were teenage students International Classification of Headache Disor-
from the selected schools, aged between 14 and ders (ICHD)10.
19 years. A free and informed consent form Nine independent variables (sex, age, socio-
(FICF) was obtained from each participant, and economic status, occupation, level of physical
when under the age of 18 years, the FICF was activity, nutritional status, computer use time,
signed and dated by a legal guardian. Exclusion electronic gaming time, and total screen time
criteria were inadequate filling out of the ques- use) were evaluated along with one dependent
tionnaire, absence on the date of application of variable (presence of headache). For differentia-
the instrument, and/or refusal to undergo an- tion of different types of headaches, three more
thropometric measurements. Pregnant teenage dependent variables were considered: migraine,
girls and students who had musculoskeletal pain tension-type and others.
or injuries from recent infectious, hematological,
oncological or genetic diseases or trauma were
also excluded from the study. The study was ap- Data analysis
proved by the Human Research Ethics Commit-
tee of the University of Pernambuco. Data analysis was performed using the soft-
Data were collected by means of a question- ware Statistical Package for the Social Sciences
naire and anthropometric measurements. Just (SPSS) version 20. Descriptive analysis included
prior to application of the questionnaire, the stu- frequency distribution (relative and absolute)
dents were instructed on how to properly fill it for categorical variables and confidence inter-
out and the meaning of some terms, in an effort vals (95%) for proportions. Values of mean and
to ensure their understanding and its proper use. standard deviation were calculated for numeric
The questionnaire was then applied by a re- variables.
searcher and filled out by students during school Bivariate logistic regression models were
hours. The students then individually underwent built to test the isolated association between the
anthropometric assessment by means of a porta- dependent variables and each independent vari-
ble electronic personal weight scale (Camry Elec- able, in addition to analyzing those that entered
tronic brand, model G-THEC- Glass 6, China) into the model, exploring possible confounding
with a capacity of 150 kilograms (kg), and a por- factors and identifying the need for statistical
table stadiometer (Cardiomed Comercio de Eq- adjustment of analyses. Multiple logistic regres-
3480
Xavier MKA et al.

sion analysis was used by estimating the odds who reported high weekly use of video games
ratio, and 95% confidence intervals were used to and other electronic devices, were more likely to
express the degree of association between inde- report symptoms of migraine.
pendent variables and the presence of headache, For other types of headache, it was observed
and adjusting for potential confounding factors. that high use of electronic devices is a risk factor,
In addition, a multinomial multiple regression and that younger subjects were likely to report
model was used to verify the association of in- symptoms (Table 5).
dependent variables and different types of head-
ache.
After obtaining the predictive variables, the Discussion
occurrence of interaction was tested on both
models. In the final multiple model, variables This study initially aimed to determine the prev-
with a significance of p less than 0.20 in the alence of headache in adolescents. The results
univariate regression were selected. In all tests showed that 80.6% of students from state public
applied, a p value of <0.05 was considered sta- high schools in Recife reported the presence of
tistically significant. Considering the sampling headache. These data corroborate the findings
design used in the study (cluster sampling in two of Blaschek et al.17, who found a prevalence of
stages), it was decided to perform inferential sta- 83.1% among subjects in the age range of 12 to
tistics in the complex sample mode of SPSS in 19 years. Straube et al.18 found a lower rate, rang-
order to apply the correction of estimates for the ing between 66% and 71%; however, the subjects
design effect. evaluated in this study were between 12 and 15
years, and can be characterized as young teenag-
ers. Considering the results of the present study,
Results which showed that younger subjects had a lower
chance of presenting headache, it is possible that
the lower rate of prevalence reported in the study
Initially, 1020 adolescents were included in this by Straube et al.18 is explained by the age of the
study, however, 66 subjects were excluded due sample.
to filling out questionnaires incorrectly or not According to the literature, tension-type and
completely. Thus, the final sample of this study migraine are the most common types of primary
was 954 adolescents. Sociodemographic, anthro- headache among teenagers17. The present study
pometric, and nutritional data of the study par- found a prevalence of 17.9% of adolescents with
ticipants, as well as data on their level of physical tension-type, 19.3% with migraine, and 43.4%
activity and occupation, are shown in Table 1. with other types of headache, regardless of sex. In
Table 2 presents data relating to the subjects’ the literature, the prevalence reported is distinct.
use of electronic devices. Data on the presence of Genizi et al.19 found a prevalence of 44% for
complaints of headache and their classification migraine and 47.7% for tension-type headache
are presented in Table 3. among individuals aged between 6 and 18 years,
By multiple regression analysis, the variables as well as a positive association of migraine-type
age, grade, socioeconomic status, occupation, headache with the female sex. Yet Tonini and Fre-
computer use time and total sreen time remained diani20 found 45% of individuals with migraine
in the final model. However, only age (p = 0.029) and 27% with tension-type among teenagers
and total screen time use (p = 0.042) were signifi- aged between 17 and 20 years. The variation of
cantly associated, and younger subjects were less rates of prevalence of the different types of head-
likely to have headache, whereas the high use of ache found in literature are probably due to dif-
electronic devices proved to be a risk factor for ferences in the population studied, sampling cri-
complaint of headache (Table 4). teria and diagnostic parameters adopted by each
Multinomial regression analysis showed that study21.
only the variable age was associated with ten- In the evaluation of the use of electronic de-
sion-type headache, and younger subjects (14-16 vices, it was observed that 88.7% of the teenage
years) were less likely to have this type of head- subjects confirmed computer use, and 63.4%
ache. Migraine was associated with the variables used electronic games. Specifically in regard to
grade, use of video games and total screen time computer use, the prevalence, although high,
use. In this case, it was possible to observe that confirms previous findings14,22-24. These data
teenagers in the third year of high school, and demonstrate that technological and economic
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Ciência & Saúde Coletiva, 20(11):3477-3486, 2015

Table 1. Sociodemographic and anthropometric characteristics, nutritional status, physical activity level, and
occupation of adolescents from state schools of Recife, stratified by sex.
Variables Male Female Total
Age (years) 16.61 (1.35) 16.40 (1.23) 16.5 (1.3)
Body Mass (kg) 64.68 (13.60) 56.15 (10.79) 59.45 (12.64)
Height (m) 1.71 (0.07) 1.60 (0.06) 1.64 (0.08)
Family Income
1 to 2 minimum wages 236 461 697
Over 2 minimum wages 94 91 185
Nutritional Status
Eutrophic 295 459 754
Overweight and Obese 73 127 200
Physical Activity Level
Active 282 441 723
Inactive 86 145 231
Occupation
Yes 64 106 170
No 304 480 784
Categorical dichotomous variables are presented with absolute frequency. Continuous numeric variables are presented with mean
and standard deviation.

Table 2. Characteristics of electronic devices use among adolescents from state schools of Recife, stratified by sex.

Variables Male Female Total

Computer Usage
Yes 331 515 846
No 37 71 108
Computer at home
Yes 281 431 712
No 87 155 242
Own computer
Yes 222 340 562
No 145 245 390
Notebook/Tablet owner
Yes 263 447 710
No 103 133 236
Electronic devices Usage
Computer 174 237 411
Notebook/Tablet 136 277 413
Other electronic devices 50 53 103
Starting using age (years) 11.29 ± 2.85 11.29 ± 2.45 11.30 ± 2.60
Computer usage frequency (days/weeks) 5.52 ± 2.13 5.53 ± 2.07 5.53 ± 2.09
Computer weekly usage time (minutes) 1.705.30 ± 1.358.85 1.742.73 ± 1.600.49 1.728.14 ± 1.511 ± 23
Electronic games usage
Yes 296 309 605
No 72 274 346
Electronic games owner
Yes 232 281 513
No 136 304 440
Electronic games usage frequency (days/weeks) 3.24 ± 2.55 1.82 ± 2.30 2.37 ± 2.50
Electronic games weekly usage time (minutes) 950.72 ± 1.145.17 354.58 ± 673.06 584.54 ± 931.35
Electronic devices weekly total usage time (minutes) 2653.21 ± 2125.98 2086.67 ± 1955.69 2369.94 ± 1957.54

Categorical dichotomous variables are presented with absolute frequency. Continuous numeric variables are presented with mean and
standard deviation.
3482
Xavier MKA et al.

Table 3. Absolut frequency description of headache development through the state-sponsored pro-
occurrence, and its classification among male and gram to encourage use of electronic equipment
female adolescents from state schools of Recife. in public high schools has enabled use of these
technologies by teenagers, whereas before they
Variables Male Female Total were only accessible to families of a higher socio-
(n) (n) (n)
economic status. Yet in regard to the use of elec-
Headache tronic games, the prevalence found was higher
Yes 303 466 769 than that reported in previous studies, which re-
No 65 120 185 ported rates varying between 27%5 and 50.3%23.
Headache classification Such differences may be explained by a possible
Tension-type 65 106 171
correlation between frequency of use of electron-
Migraine 73 111 184
ic devices among teenagers and the rate of eco-
Other types 165 249 414
Without headache 65 120 185
nomic and technological growth of Brazil.
Concomitant to this economic growth, there
n – Absolut values. is an accelerated process of urbanization of cit-

Table 4. Absolut frequency values and association between independent variables and presence and absence of
headache among adolescents from state schools of Recife, PE.
Variables With Without OR Adjusted OR
Headache (n) Headache (n) [IC 95%] [IC95%]
Sex
Female 466 120 0.83 [0.35 – 1.99]
Male 303 65 1
Age
14 to 16 years 361 109 0.72 [0.19 – 2.79] 0.64 [0.34 – 0.98]*
17 to 19 years 403 81 1
Grade
1st Grade 261 63 0.86 [0.49 – 1.52] 1.05 [0.51 – 2.18]
2nd Grade 226 43 1.27 [0.43 – 3.76]
3rd Grade 282 79 1
Socioeconomic Status
Up to 2MW 555 142 0.73 [0.48 – 1.10] 0.72 [0.36 – 1.47]
More than 2 MW 156 29 1
Occupation
Woks 134 36 0.87 [0.70 – 1.10] 0.88 [0.76 – 1.09]
Does not work 635 149 1
Nutritional Status
Overweight and Obesity 161 39 0.99 [0.94 – 1.05]
Eutrophic 608 146 1
Physical Activity Level
Inactive 185 46 0.96 [0.46 – 1.99]
Active 584 139 1
Computer Use Time
Long Time (> 3 hours/day) 385 81 1.79 [0.20 – 8.29] 0.86 [0.53 – 1.08]
Short Time (< 3 hours/day) 384 104 1
Electronic Gaming Time Long Time
(> 1 hour/day) 398 79 1.44 [0.36 – 5.74]
Short Time (< 1 hour/day) 371 106 1
Total Screen Time
Long Time (> 4 hours/day) 401 76 1.96 [1.13 – 8.45] 1.21 [1.02 – 8.30]*
Short Time (< 4 hours/day) 368 109 1

n – Absolut frequency values. * Significant association - p < 0.05.

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Ciência & Saúde Coletiva, 20(11):3477-3486, 2015

Table 5. Factors associated to the occurrence of different types of headache among adolescents from state
schools of Recife - PE.
Variables OR [IC 95%] p
Tension-type Headache
Age (14 – 16 years) 0.44 0.10 – 0.97 0.041*
Socioeconomic Status (up to 2 MW) 0.63 0.26 – 1.50 0.148
Nutritional Status (Overweight/Obesity) 0.59 0.23 – 1.53 0.141
Computer Usage (High use) 0.88 0.63 – 1.29 0.067
Migraine Headache
Grade (3rd grade of secondary education) 1.84 1.02 – 3.13 0.031*
Socioeconomic Status (up to 2 MW) 0.74 0.39 – 1.41 0.183
Computer Use Time (High use) 0.78 0.43 – 1.24 0.123
Electronic Gaming Time (High Use) 1.86 1.01 – 3.67 0.037*
Total Screen Time (Long Time > 4 hours) 2.03 1.17 – 6.25 0.048*
Other types of headache
Age (14 – 16 years) 0.68 0.27 – 0.98 0.040*
Professional Activity (Works) 0.83 0.63 – 1.02 0.108
Nutritional Status (Overweight/Obesity) 1.34 0.75 – 2.40 0.165
Computer Use Time (High use) 0.74 0.41 – 1.33 0.160
Total Screen Time (Long Time > 4 hours) 1.42 1.02 – 2.03 0.049*
Reference variable for the multinomial model: No headache complaints. * Significant Association – p < 0.05.

ies that is often accompanied by increased rates be related to the lack of control of intervening
of violence, which, over the years, have reshaped variables that can trigger a headache, and, in the
the lifestyle and leisure activities of children and study by Shantakumari et al., to the high age
adolescents, and made use of electronic games range of subjects assessed (17 to 31 years), since
increasingly common, especially in large urban the greater age increases the prevalence of head-
centers3. The predominance of the use of video ache.
games by male subjects was also observed, and The present study also showed no association
affected the total time of use of electronic equip- between the presence of headache and excessive
ment by these participants, thereby corroborat- use of electronic games (> 1 hour/day). Howev-
ing previous results23,25. er, in analyzing the different types of headache,
As a second objective, this study sought to the results revealed that the excessive use of elec-
verify the association between headache and ex- tronic games was associated with the presence of
cessive computer use and video games and other migraine-type headache, and is considered a risk
associated factors. It was found that excessive use factor that increases the chance of this affliction
of electronic devices (>4 hours/day) was asso- in teenagers by about two times. Although there
ciated with the presence of headache. It is likely is a paucity of data on the influence of electron-
that the high amount of time spent using these ic games on the symptoms of headache, the data
devices leads to reduced free time for leisure ac- from this study underscore the findings in the
tivities, encourages maintaining unhealthy body literature, which report that the excessive use of
postures for prolonged periods, and increases videogames is one of the main triggers of epi-
overload of the visual system as a result of the sodes of migraine in children and teenagers28.
high screen time, which trigger episodes of head- In this study, it was possible to observe that
ache2,7,26. in the bivariate analysis, although several vari-
Association was not verified between the ables presented association with the presence of
variables sporadic computer use and headache. headache, only age (14-16 years) and total screen
Although these data corroborate the results of time use remained in the final statistical models.
Smith et al.26, they disagree with the findings of These data indicate that younger individuals who
Torsheim et al.6 and Shantakumari et al.27. In the are usually in the first years of high school are less
study by Torsheim et al.6, the differences may likely to complain of headache. In addition, in the
3484
Xavier MKA et al.

analysis of specific types of headache, it was veri- had low socioeconomic status (up to 2 monthly
fied that studying in the third year of high school minimum salaries).
and excessive use of digital equipment are risk In summary, the results of this study suggest
factors for migraine. These results are supported that technological development and changes of
by the findings of Neutrino et al.28, who demon- behavior in society can have significant effects,
strated association between headache and stress and constant monitoring of health indicators
in children and adolescents, and that this is the and their associated factors is necessary. It is im-
main cause of bouts of migraine. Thus, younger portant to note, however, that the fact that the
students, as is the case of those in the first year of study was carried out in only one Brazilian capi-
high school, by being subject to a lower level of tal city, and that only public school students were
stress in comparison to those in their final years29, evaluated, hinders generalization of the data. In
have a chance to express complaints of headache. addition, the use of self-applied questionnaires to
Alternatively, students in the third year of high diagnose headache may have submitted the mea-
school or pre-entry college examination courses surement to memory bias.
tend to have higher levels of stress because they Finally, it is suggested that further studies be
are in the process of choosing and preparing for undertaken to longitudinally assess the impact of
their profession29, which is most likely reflected the use of electronic devices and its relationship
in the higher rate of headache in this age group. with the presence of headache. Clarification of
In addition, depression and anxiety disorders, such questions will enable taking advantage of
frequent among older teenagers, are among the the full potential of these resources to facilitate
major neurological diseases and psychiatric dis- processes of education, communication and lei-
orders associated with migraine30. sure, without necessarily being associated with
The other variables, including nutritional adverse effects to the health of teenagers.
status, occupation, socioeconomic status and
level of physical activity, were not relevant to the
main findings of this study. Although population Conclusion
studies have identified an association between
being obese or overweight and31,32 headache, this The results of this study showed a high preva-
study found no association between the presence lence of headache among the teenage subjects,
of headache (and its different types) and being with the most prevalent primary type being mi-
overweight or obese. This result can be explained graine, followed by tension. Furthermore, it was
by the fact that the majority of the sample (79%) observed that most adolescents evaluated spend
was classified as eutrophic. Similarly, the litera- an excessive amount of time using electronic de-
ture points to physical inactivity24 and low socio- vices, and this behavior is higher in boys due to
economic levels33 as risk factors for the presence their increased use of electronic games.
of headache. However, no association was iden- Excessive use of electronic devices was shown
tified between the factors physical inactivity, low to be associated with the presence of headache,
socioeconomic status and presence of headache. especially migraine and other types, considered a
Again, these results may have been influenced risk factor for development. On the other hand,
by the characteristics of the population studied the variable age proved to be a mitigating factor
in the present study, in which 75.8% of subjects for the presence of headache. The other variables
were classified as active or very active, and 73.1% analyzed showed no significant associations.
 3485

Ciência & Saúde Coletiva, 20(11):3477-3486, 2015

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