Prevalence of Migraine Headache in Saudi Arabia: A Systematic Review and Meta-Analysis

Background: Migraine is an important healthcare concern that silently affects diverse populations globally. The rising prevalence of migraine affects the quality of life of individuals, the economic burden of a nation, and work productivity. This study was designed to determine the prevalence of migraine in Saudi Arabia. Methodology: A systematic data search was designed, and scientific data were collected from leading databases, including PubMed, The Cochrane Library, Web of Science, Ovid, and Google Scholar. Results: Thirty-six studies, comprising 55061 study participants based on defined inclusion criteria, were statistically analyzed using StatsDirect software. The pooled proportion of migraine in Saudi Arabia among all 36 selected studies was 0.225617 (95% confidence interval (CI) = 0.172749 to 0.28326). The study was grouped into four categories: general population, students (of both genders), studies based on females only, and healthcare professionals in primary health care (PHC). The migraine pooled proportion among all four groups using random effects (DerSimonian-Laird) was 0.213822 (95% CI = 0.142888 to 0.294523), 0.205943 (95% CI = 0.127752 to 0.297076), 0.345967 (95% CI = 0.135996 to 0.593799), and 0.167068 (95% CI = 0.096429 to 0.252075), respectively. Conclusion: The estimated pooled proportion of migraine in Saudi Arabia is 0.225617, which is comparable to or even higher than other parts of the Middle East region. Migraine has a great impact on quality of life, productivity, and economic capacity, and increases the healthcare burden. Early detection and necessary lifestyle measures are necessary to minimize this number.


Introduction And Background
Migraine is described as a frequent, chronic, episodic neurological disorder presented by diverse and variable clinical symptoms, including headache, light sensitivity, dizziness, anxiety, nausea, vomiting, etc. [1,2]. The statistical data of the World Health Organization reported "migraine" as the third most frequent and second most damaging pathological condition, troubling more than one billion people worldwide [1]. Migraine involves the trigeminovascular system and emerges due to a disorder of sensory processing in the brain. There are many genetic and environmental factors involved in the development of this disorder, which significantly affects the quality of life (QoL) due to functional impairment leading to therapeutic interventions and is ranked as the 19th most disabling disorder globally [1,3,4]. The QoL is significantly deficient in patients with associated comorbidities such as diabetes mellitus, hypertension, and arthritis [4]. Moreover, females were reportedly more susceptible to migraine, especially those under 45 years of age; one in five women globally suffered from migraine, with a female-to-male ratio of 4:1 [4,5,6].
The prevalence of migraine is comparatively higher in Saudi Arabia than the worldwide average, with a higher rate in the female population. Saudi Arabia had approximately a 77.2% prevalence of all types of headaches, with a 25% prevalence of migraines [7]. The Global Summary of the Eastern Mediterranean Region, 1990-2016, reported that Saudi Arabia had the highest rising trend in age-standardized years lived with disability (YLD) rates of migraine and tension-type headache (TTH) [8].
The QoL of migraine patients is greatly affected by physiological and psychological involvement. The productivity and competence of migraine patients are reduced in all fields: academically, socially, occupationally, functionally, and emotionally. The financial burden is another aspect because of therapeutic demand [7]. Migraine is also associated with disability and is reportedly the eighth-highest disease linked with disability [7,8]. There are many risk factors associated with migraines and their progressions, such as anxiety, depression, family history, gender, age, higher academic standing, obesity, stress, poor sleep hygiene, eating habits, etc. [6,7,9]. Caffeinated drinks, alcohol consumption, junk food, poor sleeping, and eating patterns [10] can trigger migraine attacks. The link between migraine and demographic altitude was also reported in scientific studies in Saudi Arabia [5]. Several epidemiological studies of migraine from Saudi Arabia report its predictors, symptoms, and impacts, yet no comprehensive study has reported the prevalence of migraine headaches in Saudi Arabia. We designed this systematic review and meta-analysis to identify the prevalence of migraine headaches in the Kingdom of Saudi Arabia.

Data Search Strategy
Two authors of the research team were assigned to perform an identical data search. A comprehensive search of scientific articles and studies was performed. Well-known scientific databases were used, including the National Center for Biotechnology Information (NCBI)/PubMed, The Cochrane Library, Google Scholar, and Web of Science. Ovid was also used for data searches to conduct a comprehensive and systematic metaanalysis. Data were extracted with no time restriction, age, gender, or population groups to get all the possible scientific studies of migraine prevalence from Saudi Arabia.
The broad data extraction strategy was designed to avoid data loss from migraine studies in Saudi Arabia. The extracted data were critically analyzed for study selection, and selected articles were thoroughly inspected, especially the reference section, to check for data loss.

Study Selection Criteria
Inclusion and exclusion criteria: The broad inclusion criteria were established without any date or duration for data extraction. The scientific articles and studies reported the prevalence of migraine in Saudi Arabia based on all age groups and population groups of both genders. All study designs from all population facilities are included in this systematic review and meta-analysis.
Non-conclusive or incomplete studies, scientific abstract presentations, review articles, letters to the editor, case reports, and non-English articles were excluded.

Primary Outcome Measures
Gaining an accurate estimation of the prevalence rates of migraine in Saudi Arabia .

Study Selection
Studies were screened and selected by both assigned authors independently based on the inclusion criteria. Any ambiguity and difference in study selection were finalized by consensus of the research team.

Data Extraction
The risk of bias and the possibility of data loss was avoided by performing duplicate data extraction independently [11].

Methodology Statement and Data Presentation
An overview of all identified and selected studies is presented in Table 1. Data extraction, screening, eligibility, and selection were followed by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). This is showcased in Figure 1 [12].

Study Selection Process
A total of 73209 studies were extracted after broad data extraction from scientific databases, including PubMed, Cochrane, Web of Science, Ovid, and Google Scholar. Fourteen studies were included in the extraction pool from the manual search. During the screening of articles, 1072 records were identified as duplicates. The data were screened based on the title and abstract, and 162 records were identified as eligible. Thirty-six studies were selected based on the defined inclusion criteria for this systematic review and meta-analysis; 126 records were excluded for not meeting the inclusion criteria. The PRISMA flowchart describes the complete data selection process, shown in Figure 1.

Cumulative Analysis
For all selected studies, the fixed effects (inverse variance) pooled proportion = 0.  Figure 2. The bias assessment plot evaluated the publication bias against the defined primary outcome of all selected studies, as shown in Figure 3. [6,

Group Analysis
Studies were grouped into the general population, students (both genders), female students only, and healthcare professionals of PHC. Figures 4-7 represent the forest plot presentations of the general population, students (both genders), female students only, and healthcare professionals of PHC. The cumulative group analysis was performed and presented in Figure 8.  Figure 4. [6, 13-15, 18, 23-24, 28,32-34, 37-38, 42-43, 45, 47]    category; female only (students) [19,22,29,31,46] [41,44] The overall representation of the cumulative prevalence of all selected studies and among all four groups, including the general population, students (both genders), female students only, and healthcare professionals, were presented in Figure 8

Data Findings
Thirty-six studies were selected to conduct a systematic review and meta-analysis of migraine prevalence in Saudi Arabia. All studies were extracted from well-reputed web sources and used reliable study design and methodology for migraine assessment. Table 1 summarizes the essential findings of selected studies.
The total number of study participants among all selected studies was 55061, and the pooled proportion of migraine among all selected studies using random effects (DerSimonian-Laird) was 0.225617 (95% CI = 0.172749 to 0.28326).
Selected studies were grouped into the general population, students, studies based on females only, and healthcare professionals in PHC. The pooled proportion of migraine cases among all four groups using random effects (DerSimonian-Laird) was 0.213822 (95% CI = 0.142888 to 0.294523), 0.205943 (95% CI = 0.127752 to 0.297076), 0.345967 (95% CI = 0.135996 to 0.593799), and 0.167068 (95% CI = 0.096429 to 0.252075) among the general population, students, studies based on only females, and healthcare professionals of PHC, respectively.

Discussion
The prevalence of migraine is significantly higher in Saudi Arabia than the global average and is still underestimated and neglected [34]. The Global Summary Report of the Eastern Mediterranean Region, 1990-2016, published that among 22 countries, Saudi Arabia and Libya had the highest escalation rates of agestandardized "years lived with disability (YLD)" of migraine and tension-type headache (TTH) [8]. Among all Arab countries, the migraine prevalence was reportedly high; young adults reportedly have a 12% prevalence rate [10,48]. Despite its high and escalating prevalence, the lack of knowledge about migraine is seen not only in the general population but also among healthcare providers [1,49]. Saudi studies also reported the significantly negative impact of migraine on quality of life, competence, and work productivity [1]. There are many reasons associated with its increased prevalence, i.e., increased urbanization, use of medicines, and high altitude [5,34]. Despite the high prevalence of migraine documented in different studies, no study is yet designed to report the cumulative "prevalence of migraine in Saudi Arabia." As per the literature search, there is no systematic review and meta-analysis from Saudi Arabia on "migraine prevalence." Our study reported a 0.225617 pooled proportion of migraine among the Saudi population, based on 36 selected studies and 55061 total study participants of all age groups. A systematic review based on 357 publications reported the global prevalence of migraine at 14% [50]. Our findings are also comparable to these global numbers. Iran, a Middle Eastern country, reported a 14% prevalence of migraine based on a systematic review and meta-analysis of 30 studies' outcomes [51]. Different global regions have different migraine prevalence rates: the USA reported 11.7% [52], Germany 10.6% [53], Turkey 16.4% [54], India 22.8% [55], and the UK 14.3% [56]. The UK study also reported that migraine is estimated to affect 5.85 million adult people aged between 16 and 65 years. People undergo 190,000 migraine attacks daily, which significantly affect productivity, resulting in a loss of 25 million working days [56].
Scientific evidence has reported that gender is strongly associated with migraine prevalence, its characteristics, associated symptoms, and clinical presentation [51,57]. Among the 36 selected studies, 17 belong to the student group, of which twelve were based on both genders and five included only female students for the migraine study. In female students, the migraine prevalence was significantly high, i.e., 0.345967%. Many students support the increased prevalence of migraine in students because of educational pressure and stressful conditions [51,57]. Our findings also support the evidence of a 0.205943 pooled proportion of migraine in student-based studies of both genders. Selected studies also support the evidence of female predominance, except for one study by Akour et al. (2018) [26], which did not find a significant difference between genders. The main migraine predictors of student-based studies were functional gastrointestinal disorders (FGIDs), family history, lifestyle, female gender, and academic pressure for the next year. The most common migraine triggers were examination stress, phonophobia, use of bright light, and irregular sleep; see Table 1. However, one study finds out that poor sleep is not linked with migraine [31]. Excessive consumption of coffee and caffeinated items is also significantly linked with migraine prevalence in students [46]. Only one study was based on school students (ages six to 18) [16] and reported a sharp increase in the prevalence rate of around 2%-9% in the age group of 10-11 years in both genders, while all the other studies of students were based on the adult age group.
The pooled proportion of migraine in the general population is 0.213822, based on 17 studies. The first study reported by Al-Rajeh S in 1990 supports a female preponderance aged between 11 and 20 years with a 4:1 female-to-male ratio [6]. This study was based on Blau's definition from 1984 [6]. Later on, all general population-based studies supported female predominance. A study by Jabbar MA et al. of 5891 general population participants found that migraine prevalence was higher among professionals, possibly due to high stress [15]. Muayqil T et al. supported the notion that migraine prevalence is associated with multiple comorbidities [23]. Stress and poor sleep were reportedly the most common triggering factors [28,33]. Al-Garni MA et al. reported an additional fact that in migraine cases, most MRI tests showed normal results [32]. Al Jumah M et al. found a negative link between migraine and individuals over 45 years of age [34]. The severity of migraine was also evaluated in some student-based and general population-based studies and was predominantly seen among females [20,24,36]. Two selected studies based on a cross-sectional design evaluated migraine prevalence in healthcare professionals using the Migraine Disability Assessment (MIDAS) test, scoring a 0.167068 pooled proportion of migraine [41,44]. As per the MIDAS grade of disability, mild disability was seen in 45 individuals, moderate in 50, and severe in 46 healthcare professionals. This study found that males may encounter mild and moderate disabilities, whereas females are affected by little to severe disabilities [41]. Migraine prevalence was higher among older age groups and more experienced female physicians [44].
This systematic review and meta-analysis is a valuable contribution to the scientific literature because of its huge sample size, which represents the overall prevalence of migraine in Saudi Arabia across all regions. The limitations of the study are that not all studies used the same study design and diagnostic criteria, which impacts heterogeneity among studies. Another limitation is that this systematic review and meta-analysis did not portray the prevalence of migraine in every region of Saudi Arabia because of the unavailability of studies.

Conclusions
We designed this systematic review and meta-analysis to identify the prevalence of migraine headaches in the Kingdom of Saudi Arabia. The estimated pooled proportion of migraines in Saudi Arabia is 0.225617, which is alarmingly high and difficult to control. This study helps identify the necessary measures to reduce this number. These include lifestyle modifications, stress reduction, and minimal use of caffeinated drinks. However, more studies need to be conducted in all regions of Saudi Arabia to find out a more precise outcome.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.